4-24-19.pdf Published September 5, 2014. Management of Anterior Cruciate. Ligament Injuries. Evidence-Based Clinical Practice Guideline. Adopted by:.

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Please cite this guideline as: American Academy of Orthopaedic Surgeons Management of Anterior Cruciate Ligament Injuries Evidence-Based Clinical Practice Guideline. https://www.aaos.org/globalassets/quality-and-practice- resources/anterior-cruciate-ligament-injuries/anterior -cruciate-ligament-injuries- clinical-practice-guideline- 4-24-19.pdf Published September 5, 2014 Management of Anterior Cruciate Ligament Injuries Evidence-Based Clinical Practice Guideline Adpted by: The American Academy of Orthopaedic Surgeons Board of Directors September 5, 2014 Endorsed by:

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ii Disclaimer This Clinical Practice Guideline was developed by an AAOS multidisciplinary volunteer Work Group based on a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be clinical circumstances. Disclosure Requirement In accordance with AAOS policy, all individuals whose names appear as authors or contributors to Clinical Practice Guideline filed a disclosure statement as part of the submission process. All panel members provided full disclosure of potential conflicts of interest prior to voting on the recommendations contained within this Clinical Practice Guidelines. Funding Source This Clinical Practice Guideline was funded exclusively by the American Academy of Orthopaedic Surgeons who received no funding from outside commercial sources to support the development of this document. FDA Clearance Some drugs or medical devices referenced or described in this Clinical Practice Guideline may not have been cleared by the Food and Drug Administration (FDA) or may have been cleared for a specific use only. The FDA has stated that it is the responsibility of the physician to determine the FDA clearance status of each drug or device he or she wishes to use in clinical practice. Copyright All rights reserved. No part of this Clinical Practice Guideline may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the AAOS. Published 2014 by the American Academy of Orthopaedic Surgeons 6300 North River Road Rosemont, IL 60018 First Edition Copyright 2014 by the American Academy of Orthopaedic Surgeons

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iii I.SUMMARY OF RECOMMENDATIONS The following is a summary of the recommendations of the AAOS clinical practice guideline on the Management of Anterior Cruciate Ligament Injuries. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, and other healthcare practitioners. Strength of Recommendation Descriptions Strength Overall Strength of Evidence Description of Evidence Strength Strength Visual Strong Strong strength studies with consistent findings for recommending for or against the intervention. Moderate Moderate strength studies wit h consistent findings, study for recommending for or against the intervention. Limited Low Strength Evidence or Conflicting Evidence strength studies with consistent findings or evidence from a single study for recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention. Consensus* No Evidence There is no support ing evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion. Consensus recommendations can only be created when not establishing a recommendation could have catastrophic consequences.

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iv ACL HISTORY AND PHYSICAL Strong evidence supports that the practitioner should obtain a relevant history and perform a musculoskeletal exam of the lower extremities, because these are effective diagnostic tools for ACL injury. Strength of Recommendation: Strong Description: recommending for or against the intervention. ACL RADIOGRAPHS In the absence of reliable evidence, it is the opinion of the work group that in the initial evaluation of a person with a knee injury and associated symptoms [giving way, pain, locking, catching] and signs [effusion, inability to bear weight, bone tenderness, loss of motion, and/or pathological laxity] that the practitioner obtain AP and lateral knee xrays to identify fractures or dislocations requiring emergent care. Strength of Recommendation: Consensus Description: There is no supporting evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion. Consensus recommendations can only be created when not establishing a recommendation could have catastrophic consequences. ACL MAGNETIC RESONAN CE IMAGING (MRI) Strong evidence supports that the MRI can provide confirmation of ACL injury and assist in identifying concomitant knee pathology such as other ligament, meniscal, or articular cartilage injury. Strength of Recommendation: Strong Description: recommending for or against the intervention. ACL PEDIATRIC There is limited evidence in skeletally immature patients with torn ACLs, but it supports that the practitioner might perform surgical reconstruction because it reduces activity related disability and recurrent instability which may lead to additional injury. Strength of Recommendation: Limited Description: or evidence from a single study for recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention. ACL YOUNG ACTIVE ADU LT Moderate evidence supports surgical reconstruction in active young adult (18-35) patients with an ACL tear. Strength of Recommendation: Moderate Description:

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v ACL MENISCAL REPAIR There is limited evidence in patients with combined ACL tears and reparable meniscus tears, but it supports that the practitioner might repair these meniscus tears when combined with ACL reconstruction because it improves patient outcomes. Strength of Recommendation: Limited Description: or evidence from a single study for recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention. ACL RECURRENT INSTABILITY There is limited evidence comparing non-operative treatment to ACL reconstruction in patients with recurrent instability, but it supports that the practitioner might perform ACL reconstruction because this procedure reduces pathologic laxity. Strength of Recommendation: Limited Description: or evidence from a single study for recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention. ACL CONSERVATIVE TREATMENT There is limited evidence to support non-surgical management for less active patients with less laxity. Strength of Recommendation: Limited Description: or evidence from a single study for recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention. ACL SURGERY TIMING When ACL reconstruction is indicated, moderate evidence supports reconstruction within five months of injury to protect the articular cartilage and menisci. Strength of Recommendation: Moderate Description: g for or against the intervention. ACL COMBINED MCL There is limited evidence in patients with acute ACL tear and MCL tear to support that the practitioner might perform reconstruction of the ACL and non-operative treatment of the MCL tear. Strength of Recommendation: Limited Description: or evidence from a single study for recommending for or against the intervention or diagnostic test or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention.

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vi ACL LOCKED KNEE In the absence of reliable evidence, it is the opinion of the work group that patients with an ACL tear and a locked knee secondary to a displaced meniscal tear have prompt treatment to unlock the knee in order to avoid a fixed flexion contracture. Strength of Recommendation: Consensus Description: There is no supporting evidence. In the absence of reliable evidence, the work group is making a recommendation based on their clinical opinion. Consensus recommendations can only be created when not establishing a recommendation could have catastrophic consequences. ACL SINGLE OR DOUBLE BUNDLE RECONSTRUCTION Strong evidence supports that in patients undergoing intra-articul ar ACL reconstruction the practitioner should use either single bundle or double bundle technique, because the measured outcomes are similar. Strength of Recommendation: Strong Description: nt findings for recommending for or against the intervention. ACL AUTOGRAFT SOURCE Strong evidence supports that in patients undergoing intra-articular ACL reconstruction using autograft tissue the practitioner should use bone-patellar tendon-bone or hamstring- tendon grafts, because the measured outcomes are similar. Strength of Recommendation: Strong Description: recommending for or against the intervention. ACL AUTOGRAFT VS ALLOGRAFT Strong evidence supports that in patients undergoing ACL reconstructions, the practitioner should use either autograft or appropriately processed allograft tissue, because the measured outcomes are similar, although these results may not be generalizable to all allografts or all patients, such as young patients or highly active patients. Strength of Recommendation: Strong Description: recommending for or against the intervention. ACL FEMORAL TUNNEL TECHNIQUE Moderate evidence supports that in patients undergoing intra-articular ACL reconstruction the practitioner could use either a tibial independent approach or transtibial approach for the femoral tunnel, because the measured outcomes are similar. Strength of Recommendation: Moderate Description: ention.

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1 Table of Contents I.Summary of Recommendations . .. iii ACL History and Physical .. . iv ACL Radiographs . iv ACL Magnetic Resonance Imaging (MRI) .. iv ACL Pediatric . iv ACL Young Active Adult .. .. iv ACL Meniscal Repair .. v ACL Recurrent Instability.. v ACL Conservative Treatment . . v ACL Surgery Timing .. . v ACL Combined MCL .. v ACL Locked Knee vi ACL Single or Double Bundle Reconstruction . vi ACL Autograft Source .. . vi ACL Autograft vs Allograft .. .. vi ACL Femoral Tunnel Technique . . vi ACL Post-Op Functional Bracing . .. vii ACL Prophylactic Braces .. . vii ACL NeuroMuscular Training Programs vii ACL Post-Op Physical Therapy. .. vii ACL Return to Sports .. . vii II.Introduction 12 Overview .. 12 Goals and rationale . 12 Intended Users .. 12 Patient Population & Scope of Guideline 13 Burden of Disease 13 Etiology . 13 Incidence and Prevalence .. .. 13 Risk Factors 13 Potential Benefits, Harms, and Contraindications .. 13 III.Methods .. 14 Formulating Preliminary Recommendations . 15 Study Selection Criteria .. . 15 Best Evidence Synthesis .. 16 Minimally Clinically Important Improvement.. 17 Literature Searches.. 17 Methods for Evaluating Evidence . .. 18 Studies of Intervention/Prevention 18 Studies of Screening and Diagnostic Tests 20 Studies of Prognostics .. 22 Final Strength of Evidence. 23 Defining the Strength of the Recommendations .. 24

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2 Wording of the Final Recommendations . 25 Applying the Recommendations to Clinical Practice .. . 25 Voting on the Recommendations . 26 Statistical Methods .. 26 Peer Review 27 Public Commentary .. . 28 The AAOS Guideline Approval Process . 28 Revision Plans 29 Guideline Dissemination Plans . 29 AAOS Clinical Practice Guideline Development Process Overview .. 30 IV.Recommendations .. .. 31 Overview of Study Quality Per Recommendation.. 31 ACL History and Physical .. 32 Rationale . 32 Benefits of Implementation. .. 32 Possible Harms of Implementation 32 Future Research .. 32 Summary of Findings .. . 33 Results .. 37 ACL Radiographs 43 Rationale . 43 Benefits of Implementation. .. 43 Possible Harms of Implementation 43 Future Research .. 43 ACL Magnetic Resonance Imaging (MRI) . 44 Rationale . 44 Possible Harms of Implementation 44 Future Research .. 44 Summary of Findings .. . 45 Results .. 47 ACL Pediatric 59 Rationale . 59 Benefits of Implementation. .. 59 Possible Harms of Implementation 59 Future Research .. 59 Summary of Findings .. . 60 Results .. 63 ACL Young Active Adult .. . 68 Rationale . 68 Possible Harms of Implementation 68 Future Research .. 68 Summary of Findings .. . 69 Results .. 72 ACL Meniscal Repair .. . 84 Rationale . 84 Possible Harms of Implementation 84

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3 Future Research .. 84 Summary of Findings .. . 85 Results .. 88 ACL Recurrent Instability.. . 97 Rationale . 97 Possible Harms of Implementation 97 Future Research .. 97 Results .. 99 ACL Conservative Treatment . 109 Rationale .. 109 Benefits of Implementation. 109 Possible Harms of Implementation . 109 Future Research 109 Summary of Findings .. .. 110 Results 113 ACL Surgery Timing .. 123 Rationale .. 123 Possible Harms of Implementation . 123 Future research .. 123 Summary of Findings .. .. 124 Results 131 ACL Combined MCL .. .. 154 Rationale .. 154 Potential Benefits of Implementation 154 Potential Harms of Implementation 154 Future Research 154 Summary of Findings .. .. 155 Results 156 ACL Locked Kne e 160 Rationale .. 160 Potential Harms of Implementation 16 0 Future Research 160 ACL Single or Double Bundle Reconstruction . 161 Rationale .. 161 Potential Harms of Implementation 161 Future Research 161 Summary of Findings .. .. 162 Results 167 ACL Autograft Source .. . 190 Rationale .. 190 Potential Harms of Implementation 190 Future Research 190 Summary of Findings .. .. 191 Results 205 ACL Autograft vs Allograft .. .. 305 Rationale .. 305

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4 Potential Harms of Implementation 305 Future Research 306 Summary of Findings .. .. 307 Results 320 ACL Femoral Tunnel Technique . . 350 Rationale .. 350 Potential Harms of Implementation 350 Future Research 350 Summary of Findings .. .. 351 Results 357 ACL Post-Op Functional Bracing . 402 Rationale .. 402 Potential Benefits of Implementation 402 Potential Harms of Implementation 402 Future Research 402 Summary of Findings .. .. 403 Results 412 ACL Prophylactic Braces .. .. 427 Rationale .. 427 Future Research 427 Summary of Findings .. .. 428 Results 429 ACL Neuromuscular Training Programs .. 433 Rationale .. 433 Potential Benefits of Implementation 433 Potential Harms of Implementation 433 Future Research 434 Results 438 ACL Post-Op Physical Therapy. 452 Rationale .. 452 Potential Benefits of Implementation 452 Potential Harms of Implementation 452 Future Research 452 Summary of Findings .. .. 454 Results 459 ACL Return to Sports .. .. 476 Rationale .. 476 Potential Harms of Implementation 476 Future Research 476 Summary of Findings .. .. 477 Results 478 V.Appendices .. 484 Appendix I 484 Work Group Roster .. .. 484 Guidelines Oversight Chair . 486 AAOS Clinical Practice Guidelines Section Leader .. 486

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