Anterior cruciate ligament reconstruction
Year: 2016
Type: article
Abstract: Anterior cruciate ligament (ACL) reconstruction is a common procedure performed by orthopaedic surgeons, particularly in association with sports-related injuries. Over the past 10 years, a renewed interest in the native anatomy of the ACL has facilitated a progression from non-anatomic to more anatomic reconstruction techniques. The anatomic and individualised ACL reconstruction concept attempts to closely reproduce the patient's individual anatomy with the goal of reproducing the native ACL characteristics and improving patient outcomes. Measurements of the patient's anatomy help determine graft choice and whether anatomic reconstruction should be performed with an single-bundle or double-bundle technique. The bony landmarks and insertions of the ACL are preserved to assist with anatomic placement of both tibial and femoral tunnels. Long-term outcomes for anatomic ACL reconstruction are unknown and future research, considering biomechanics and clinical outcomes, should be focused on this area. Future studies may yield important information with regard to the potential progression to osteoarthritis after ACL reconstruction, including factors affecting or preventing it. In this State of the art review, we have attempted to summarise the best available evidence addressing ACL injury diagnostics, treatment, surgical techniques, complications, tips, pitfalls and geographical differences, following our primary goal of improving medical care and outcomes for patients who suffer an ACL injury. Anterior cruciate ligament (ACL) reconstruction is a common procedure performed by orthopaedic surgeons, particularly in association with sports-related injuries. Over the past 10 years, a renewed interest in the native anatomy of the ACL has facilitated a progression from non-anatomic to more anatomic reconstruction techniques. The anatomic and individualised ACL reconstruction concept attempts to closely reproduce the patient's individual anatomy with the goal of reproducing the native ACL characteristics and improving patient outcomes. Measurements of the patient's anatomy help determine graft choice and whether anatomic reconstruction should be performed with an single-bundle or double-bundle technique. The bony landmarks and insertions of the ACL are preserved to assist with anatomic placement of both tibial and femoral tunnels. Long-term outcomes for anatomic ACL reconstruction are unknown and future research, considering biomechanics and clinical outcomes, should be focused on this area. Future studies may yield important information with regard to the potential progression to osteoarthritis after ACL reconstruction, including factors affecting or preventing it. In this State of the art review, we have attempted to summarise the best available evidence addressing ACL injury diagnostics, treatment, surgical techniques, complications, tips, pitfalls and geographical differences, following our primary goal of improving medical care and outcomes for patients who suffer an ACL injury. What this paper adds•The gold standard of ACL reconstruction is known as the anatomic and individualised ACL reconstruction concept.•Following this concept, anatomic SB or DB reconstruction is performed with the goal of reproducing the patient's individual knee anatomy and restore its normal kinematics, focused on protecting long-term knee health.•Future research, considering biomechanics and clinical outcomes, should be focused on this area. •The gold standard of ACL reconstruction is known as the anatomic and individualised ACL reconstruction concept.•Following this concept, anatomic SB or DB reconstruction is performed with the goal of reproducing the patient's individual knee anatomy and restore its normal kinematics, focused on protecting long-term knee health.•Future research, considering biomechanics and clinical outcomes, should be focused on this area. Anterior cruciate ligament (ACL) injury is one of the most frequent sports injuries, with an incidence of 35/100 000 people per year,1Gianotti SM Marshall SW Hume PA et al.Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study.J Sci Med Sport. 2009; 12: 622-62710.1016/j.jsams.2008.07.005Abstract Full Text Full Text PDF PubMed Scopus (478) Google Scholar This injury, without appropriate treatment, results in increased joint laxity, instability of the knee, reduced physical activity and decreased sports participation.2Meuffels DE Favejee MM Vissers MM et al.Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes.Br J Sports Med. 2009; 43: 347-35110.1136/bjsm.2008.049403Crossref PubMed Scopus (144) Google Scholar This is particularly important in physically active patients, allowing them to return to daily activities, including sports, and reducing their risk of developing degenerative knee changes at 10 years.3Ajuied A Wong F Smith C et al.Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis.Am J Sports Med. 2014; 42: 2242-225210.1177/0363546513508376Crossref PubMed Scopus (297) Google Scholar In this review, a critical assessment of the evidence for diagnosis and treatment of the primary ACL rupture in adults is provided, including detailed descriptions of surgical techniques, patient management strategies and clinical outcomes. The first ACL repair is attributed to the English surgeon Arthur William Mayo Robson in 1895. In 1934, the Italian surgeon Riccardo Galeazzi described a technique for ACL reconstruction using the semitendinosus tendon, and in 1935, Willis Campbell, from the USA, described the first use of a patellar tendon graft and fixation through tunnels in the femur and tibia. In the 1970s, extra-articular ACL reconstruction techniques came into favour, even though primary ACL repair was commonly performed. In the 1980s, intra-articular ACL reconstruction developed. John Insall is often given credit for the early intra-articular reconstructions using a band of fascia lata. A free patellar tendon graft came shortly thereafter with Clancy establishing the first step of the current standard of practice: using a free tendon graft through tunnels in the tibia and femur along the course of the native ACL. Since the development of the arthroscopically assisted reconstruction that was initially performed by Dandy in 1980, arthroscopic techniques for ACL reconstruction became increasingly popular. The transtibial (TT) single-bundle (SB) technique, in which the femoral tunnel is drilled inside-out through the tibial tunnel was, and probably still is, the most common ACL reconstruction technique. As early as 1836, ACL anatomy has been described in detail as two functional bundles (anteromedial, AM, and posterolateral, PL, according to the tibial insertion site position). In spite of this, reconstruction techniques initially restored only one bundle. It was not until 1982 that the an open method of double-bundle (DB) ACL reconstruction was described and published by Mott, and not until 1994, when Rosenberg described the arthroscopic method later popularised in Japan. Modifications of this technique have been described by a number of authors, and research into this area continues. Nowadays, the gold standard of ACL reconstruction is known as the anatomic ACL reconstruction concept. This concept is rooted in anatomy, aiming to restore the native ACL according to each patient's characteristics, and is described in detail in this review.4Fu FH van Eck CF Tashman S et al.Anatomic anterior cruciate ligament reconstruction: a changing paradigm.Knee Surg Sports Traumatol Arthrosc. 2015; 23: 640-64810.1007/s00167-014-3209-9Crossref PubMed Scopus (121) Google Scholar Knowledge of the evolution of ACL reconstruction is invaluable to those who continue to try to improve the outcomes of the procedure and to keep progressing in this area. In the past 10 years, almost 250 systematic reviews and more than 60 meta-analyses have been published about the ACL. The most recent evidence-based clinical practice guideline on the management of ACL was published according to a systematic review that considered the most important topics about this injury.5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar The highest quality studies, related to diagnosis, treatment, rehabilitation and return to sports (RTS), were reviewed and most of them were included in this article. Historically, the most cited papers related to ACL reconstruction focus on biomechanics and outcomes evaluation, which have been the basis of all clinical studies. The 10 most cited papers about ACL reconstruction are summarised in table 1.Table 1Ten most cited papers about anterior cruciate ligament (ACL) reconstructionRankAuthor/Journal/YearArticleCitations*Reference1Tegner et al Clin Orthop Relat Res 1985Rating systems in the evaluation of knee ligament injuries14596Tegner Y Lysholm J Rating systems in the evaluation of knee ligament injuries.Clin Orthop Relat Res. 1985; 198: 43-49Crossref PubMed Scopus (3345) Google Scholar2Lysholm et al Am J Sports Med 1982Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale12797Lysholm J Gillquist J Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale.Am J Sports Med. 1982; 10: 150-15410.1177/036354658201000306Crossref PubMed Scopus (1998) Google Scholar3Noyes et al J Bone Joint Surg Am 1984Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions7168Noyes FR Butler DL Grood ES et al.Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions.J Bone Joint Surg Am. 1984; 66: 344-352Crossref PubMed Scopus (1162) Google Scholar4Hewett et al Am J Sports Med 2005Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes7019Hewett TE Myer GD Ford KR et al.Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study.Am J Sports Med. 2005; 33: 492-50110.1177/0363546504269591Crossref PubMed Scopus (2185) Google Scholar5Daniel et al Am J Sports Med 1994Fate of the ACL-injured patient: a prospective outcome study65310Daniel DM Stone ML Dobson BE et al.Fate of the ACL-injured patient. A prospective outcome study.Am J Sports Med. 1994; 22: 632-64410.1177/036354659402200511Crossref PubMed Scopus (1032) Google Scholar6Rodeo et al J Bone Joint Surg Am 1993Tendon healing in a bone tunnel. A biomechanical and histological study in the dog63411Rodeo SA Arnoczky SP Torzilli PA et al.Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog.J Bone Joint Surg Am. 1993; 75: 1795-1803Crossref PubMed Scopus (956) Google Scholar7Hewett et al Am J Sports Med 1999The effect of neuromuscular training on the incidence of knee injury in female athletes—a prospective study63212Hewett TE Lindenfeld TN Riccobene JV et al.The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.Am J Sports Med. 1999; 27: 699-706Crossref PubMed Scopus (1151) Google Scholar8Butler et al J Bone Joint Surg Am 1980Ligamentous restraints to anteroposterior drawer in the human knee—biomechanical study61813Butler DL Noyes FR Grood ES Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study.J Bone Joint Surg Am. 1980; 62: 259-270Crossref PubMed Scopus (906) Google Scholar9Shelbourne et al Am J Sports Med 1990Accelerated rehabilitation after anterior cruciate ligament reconstruction57714Shelbourne KD Nitz P Accelerated rehabilitation after anterior cruciate ligament reconstruction.Am J Sports Med. 1990; 18: 292-29910.1177/036354659001800313Crossref PubMed Scopus (947) Google Scholar10Girgis et al Clin Orthop Relat Res 1985Cruciate ligaments of knee joint—anatomical, functional and experimental analysis56215Girgis FG Marshall JL Monajem A The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis.Clin Orthop Relat Res. 1975; 106: 216-23110.1097/00003086-197501000-00033Crossref PubMed Google Scholar*August 2015. Open table in a new tab *August 2015. During the past 10 years, more than 15 'current concepts' reviews and two 'state of the art' reviews have been published.16Murawski CD Wolf MR Araki D et al.Anatomic anterior cruciate ligament reconstruction: current concepts and future perspective.Cartilage. 2013; 4: 27S-37S10.1177/1947603513486557Crossref PubMed Scopus (23) Google Scholar, 17Voigt C Schönaich M Lill H Anterior cruciate ligament reconstruction: state of the art.Eur J Trauma. 2006; 32: 332-33910.1007/s00068-006-6118-xCrossref Scopus (15) Google Scholar, 18Fu FH Schulte KR Anterior cruciate ligament surgery 1996. State of the art?.Clin Orthop Relat Res. 1996; 325: 19-2410.1097/00003086-199604000-00004Crossref PubMed Scopus (75) Google Scholar This article is the first 'state of the art' review on ACL reconstruction that discusses the diagnostics, treatment, surgical techniques, complications, pitfalls, regional or geographical differences, and future directions, based on the best available evidence. A detailed medical history, physical examination and imaging are vital in the diagnosis of an ACL injury, and can also provide useful information regarding the adequate treatment options. Strong evidence supports the use of the history and physical examination as effective diagnostic tools for ACL injury.5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar The history gives an idea of the patient's activity level and mechanism of injury, and the physical examination has been shown to be as sensitive and specific as imaging modalities.19Benjaminse A Gokeler A van der Schans CP Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis.J Orthop Sports Phys Ther. 2006; 36: 267-28810.2519/jospt.2006.2011Crossref PubMed Scopus (264) Google Scholar Physical examination should include range of motion (ROM), the Lachman test, the pivot shift test, and evaluation of concomitant ligamentous, meniscal and neurovascular injuries.5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar According to the most recent meta-analysis of ACL tear diagnosis, the Lachman and the pivot shift tests have a sensitivity of 0.77 and 0.28, respectively, and a specificity of 0.53 and 0.81, respectively, without anaesthesia (positive likelihood ratio (LR) 4.50 and 5.5, negative LR 0.22 and 0.84, respectively). 5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar 20van Eck CF van den Bekerom MPJ Fu FH et al.Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia.Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1895-190310.1007/s00167-012-2250-9Crossref PubMed Scopus (95) Google Scholar The pivot shift test should be standardised to avoid interindividual and intraindividual variability and improve measurement accuracy.21Hoshino Y Araujo P Ahldén M et al.Standardized pivot shift test improves measurement accuracy.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 732-73610.1007/s00167-011-1850-0Crossref PubMed Scopus (79) Google Scholar Additionally, instrumented measurements (KT-arthrometer) can objectively evaluate the anteroposterior (AP) tibial translation, and allows the evaluation of the postoperative results.22van Eck CF Loopik M van den Bekerom MP et al.Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of instrumented knee laxity tests.Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1989-199710.1007/s00167-012-2246-5Crossref PubMed Scopus (35) Google Scholar A complete X-ray series of the knee can give information about any fractures or subtle signs of a rotational injury, such as the Segond or reverse Segond capsular lesion. In addition, the status of the physes or any arthritic changes should be noted and compared with the contralateral side. Long cassette films should be obtained for any patient with knee malalignment on examination, or if any arthritic changes are noted on the knee series. MRI can confirm the diagnosis of the ACL injury. A recent meta-analysis showed that MRI has a sensitivity of 0.92 and a specificity of 0.96 for ACL injury (LR+ 23.8; LR− 0.08).5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar More importantly, it allows the surgeon to also examine the rupture pattern, measure the native ACL insertion site, evaluate for other ligamentous or bony injuries, and assess the meniscus and cartilage status. It can also provide information about potential autograft options, such as the quadriceps and patellar tendons. With access to special MRI cuts, such as the coronal oblique and sagittal oblique, the ACL bundles can be evaluated with higher sensitivity. Several studies indicate that ACL reconstruction decreases pathological knee laxity and the incidence of subsequent injuries, including meniscal tears and degenerative changes.3Ajuied A Wong F Smith C et al.Anterior cruciate ligament injury and radiologic progression of knee osteoarthritis: a systematic review and meta-analysis.Am J Sports Med. 2014; 42: 2242-225210.1177/0363546513508376Crossref PubMed Scopus (297) Google Scholar 5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar 23Frobell RB Roos EM Roos HP et al.A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-34210.1056/NEJMoa0907797Crossref PubMed Scopus (568) Google Scholar 24Laxdal G Kartus J Ejerhed L et al.Outcome and risk factors after anterior cruciate ligament reconstruction: a follow-up study of 948 patients.Arthroscopy. 2005; 21: 958-96410.1016/j.arthro.2005.05.007Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar These findings have defined ACL reconstruction surgery as the standard treatment for ACL injuries. The ideal patient for ACL reconstruction is a young patient (<40 years) with an active lifestyle and an acute ACL injury.5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar Knee instability is the main indication for surgical treatment and it should be evaluated subjectively (history, symptoms) and objectively (physical examination and instrumented side-to-side differences). ACL reconstruction is contraindicated in patients with partial tears, minimal instability and no joint laxity on examination. It is also contraindicated in elderly, low-demand patients with minimal instability, patients with knee malalignment and associated comorbidities that make surgical intervention unsafe (eg, active infection). Relative contraindications, which should be evaluated case by case, include patients with open physes (Tanner stage ≤3, males ≤16 years, or females ≤14 years), radiographic evidence of degenerative joint disease (Kellgren-Lawrence grade ≥3), a sedentary or inactive lifestyle, and an unwillingness or inability to comply with the required postoperative rehabilitation protocol. Considering contraindications to surgical treatment and a patient's preferences, there are some patients for whom non-operative treatment is indicated. Some studies have shown that non-operative treatment does provide satisfactory results.25Moksnes H Risberg MA Performance-based functional evaluation of non-operative and operative treatment after anterior cruciate ligament injury.Scand J Med Sci Sports. 2009; 19: 345-35510.1111/j.1600-0838.2008.00816.xCrossref PubMed Scopus (74) Google Scholar 26Grindem H Eitzen I Engebretsen L et al.Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL cohort study.J Bone Joint Surg Am. 2014; 96: 1233-124110.2106/JBJS.M.01054Crossref PubMed Scopus (121) Google Scholar In a Norwegian study,25Moksnes H Risberg MA Performance-based functional evaluation of non-operative and operative treatment after anterior cruciate ligament injury.Scand J Med Sci Sports. 2009; 19: 345-35510.1111/j.1600-0838.2008.00816.xCrossref PubMed Scopus (74) Google Scholar the treatment between non-operative and ACL reconstruction was chosen by the patients. At a 1-year or 2-year follow-up examination, no differences were detected between the two groups with regard to the ability to resume preinjury activity level, muscle strength or functional performance. Another Norwegian study26Grindem H Eitzen I Engebretsen L et al.Nonsurgical or surgical treatment of ACL injuries: knee function, sports participation, and knee reinjury: the Delaware-Oslo ACL cohort study.J Bone Joint Surg Am. 2014; 96: 1233-124110.2106/JBJS.M.01054Crossref PubMed Scopus (121) Google Scholar reported that there were few differences between the clinical courses following non-surgical and surgical treatment of ACL injury, highlighting the potential for good outcomes with non-operative care following ACL injury. Roughly a third of the entire study population experienced good function and low reinjury rates with non-operative treatment. However, one-third of the patients of the non-surgical group crossed over to the surgical group, presumably because of reinjury, unacceptable function or limitations imposed by the treatment protocol. Additionally, good outcomes of this study were most likely due to careful screening, followed by a personalised rehabilitation programme, and close follow-up monitoring for at least 2 years. Similarly, a randomised study reported that an ACL reconstruction could be avoided in 61% of the patients, without compromising the results evaluated at 2 years after injury, by initially providing a structured rehabilitation followed by an optional delayed ACL reconstruction, instead of directly performing an early reconstruction.23Frobell RB Roos EM Roos HP et al.A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-34210.1056/NEJMoa0907797Crossref PubMed Scopus (568) Google Scholar Nevertheless, the frequency of meniscal resections was greater in the delayed surgery group than in the early surgery group (70% vs 48%, respectively). These data might demonstrate that menisci may be saved by an early surgical have been described to the individualised of treatment after the ACL injury. et al L A prospective trial of a patient management and examination for active with anterior cruciate ligament J Sports Med. 36: PubMed Scopus Google Scholar active patients Knee level I or with good knee early after ACL using tests and knee outcome Knee of These potential which of the population of ACL-injured patients in this good potential to be with physical over a to protocol. However, after the rehabilitation programme, of the required ACL The other patients who not surgery could return to preinjury sports and were with this choice at the follow-up Nevertheless, study showed that patients with instability can by sports more than ACL reconstruction patients and DM Stone ML Dobson BE et al.Fate of the ACL-injured patient. A prospective outcome study.Am J Sports Med. 1994; 22: 632-64410.1177/036354659402200511Crossref PubMed Scopus (1032) Google Scholar The most recent systematic review reported that there is evidence to non-surgical even in active patients with KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar In of the patients with including ACL reconstruction or meniscal KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar the to with the operative treatment of an ACL rupture is of the procedure an important to and quadriceps strength have been as factors that can the of ACL following ACL and Orthop PubMed Scopus Google Scholar I I Risberg MA quadriceps strength is a of knee function two years after anterior cruciate ligament J Sports Med. 2009; 43: PubMed Scopus Google Scholar and have been related to the development of after following ACL and Orthop PubMed Scopus Google Scholar quadriceps strength of have been shown to the 2-year functional outcomes of ACL reconstruction with I I Risberg MA quadriceps strength is a of knee function two years after anterior cruciate ligament J Sports Med. 2009; 43: PubMed Scopus Google Scholar intervention is to be delayed until any knee has knee has been quadriceps control is and and that the patient is physically and for surgery and a postoperative physical some studies have not reported differences in and clinical outcomes between early versus ACL reconstruction A A G et al.A of early and delayed reconstruction of the anterior cruciate ligament using Bone Joint Surg 2010; PubMed Scopus Google Scholar most recent based on quality surgery at to after injury.5Shea KG Carey JL Richmond J et al.The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries.J Bone Joint Surg Am. 2015; 97: 672-67410.2106/JBJS.N.01257Crossref PubMed Scopus (58) Google Scholar this is associated with knee higher activity level and knee function when compared with reconstruction after DM Stone ML Dobson BE et al.Fate of the ACL-injured patient. A prospective outcome study.Am J Sports Med. 1994; 22: 632-64410.1177/036354659402200511Crossref PubMed Scopus (1032) Google Scholar 23Frobell RB Roos EM Roos HP et al.A randomized trial of treatment for acute anterior cruciate ligament tears.N Engl J Med. 2010; 363: 331-34210.1056/NEJMoa0907797Crossref PubMed Scopus (568) Google Scholar et al.Outcome of arthroscopic single-bundle versus double-bundle reconstruction of the anterior cruciate a 2-year prospective 2010; Full Text Full Text PDF PubMed Scopus Google Scholar
Language: Spanish
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,000
OpenAlex ID: W2290358747