Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency.

In a prospective seven-year study, we treated 32 patients with partial ruptures of the anterior cruciate ligament (ACL) verified by arthroscopy. Twelve knees (38%) progressed to complete ACL deficiency with positive pivot shift tests and increased anteroposterior translation on tests with the KT-1000 arthrometer. Patients with partial ACL tears frequently had limitation for strenuous sports, while those developing ACL deficiency had additional functional limitations involving recreational activities. Three factors were statistically significant in predicting which partial tears would develop complete ACL deficiency: the amount of ligament tearing--one-fourth tears infrequently progressed, one-half tears progressed in 50% and three-fourth tears in 86%; a subtle increase in initial anterior translation; and the occurrence of a subsequent re-injury with giving-way.

Controversy about treatment of the knee with anterior cruciate laxity.

A complete tear of the anterior cruciate ligament represents the initiation of a clinical syndrome characterized by a continuum of functional disability. The authors present here a risk factor checklist, based on statistics drawn from their previous articles, to identify those patients at significant risk for future joint arthrosis. Risk factors are grouped under the categories of activity level, symptoms, clinical laxity, meniscal damage, lower limb alignment, tibiofemoral crepitus, patellofemoral factors, rehabilitation, and patient compliance. They also present their subjective and functional rating system in which six activity levels are related to pain, swelling, and giving way. The functional disability of the anterior cruciate insufficient knee is activity-level related. Thus, activity levels must be rigorously and comprehensively defined for adequate appreciation of the degree of existing disability. The authors also examined the reasons for the conflicting opinions on the functional disability of the anterior cruciate ligament syndrome that exists in the literature. Differences in subjective and objective rating systems; failure to specifically define preinjury and postinjury activity levels and associated symptoms; and different populations as to laxity, giving way episodes, and type of athletic activity (jumping, twisting activities versus light recreational pursuits) are but a few of the important differences that make comparisons between studies often invalid. Long-range treatment guidelines are necessary for management of the acute and chronic anterior cruciate ligament insufficient knee.

The variable functional disability of the anterior cruciate ligament-deficient knee.

The goal of the authors has been to define the syndrome of the anterior cruciate ligament-deficient knee. These concepts have been applied to pertinent articles in order to explain the discrepancies and contrasting opinions in the literature. The authors have suggested guidelines for treatment based on the quantification of risk factors and a method for the prediction of the functional disability level of patients. Functional disability is activity level-related and is also related to the type of sport and the intensity level of play. Functional disability is symptomatically expressed by pain, swelling, and giving way, which must be correlated with a specific activity level.

Functional disability in the anterior cruciate insufficient knee syndrome. Review of knee rating systems and projected risk factors in determining treatment.

The complete tear of the anterior cruciate ligament initiates the clinical syndrome represented by continued functional disability. The precise degree of functional disability is highly debated. Agreement is elusive due to the lack of uniform and scientific methodology. An historical review and analysis of functional and subjective rating systems is reported, and the strengths of previous systems are identified. A subjective and functional rating system is proposed in which 6 activity levels are related to pain, swelling, giving-way and overall activity. This is important because of the marked dependence of the functional disability of the anterior cruciate insufficient knee on the activity level of the patient. Thus, activity levels must be rigorously and comprehensively defined. In addition, we propose the utilisation of a risk factor checklist, based on the statistics drawn from our previous articles, to identify those patients at significant risk for future joint arthrosis. Risk factors are grouped under the categories of activity level, symptoms, clinical laxity, meniscal damage, lower limb alignment, tibiofemoral crepitus, patellofemoral factors, rehabilitation and patient compliance. Thirdly, we examine controversial aspects of the anterior cruciate ligament syndrome existing in the literature today and demonstrate why contrasting opinions are not mutually exclusive. Finally we propose our treatment guidelines for management of the acute and chronic anterior cruciate ligament insufficient knee.