Guideline sources The following summarized guidelines for the evaluation and management of anterior cruciate ligament injury are prepared by our editorial team based on guidelines from the European Bone and Joint Infection Society (EBJIS 2023), the American Academy of Orthopaedic Surgeons (AAOS 2022), and the American College of Radiology (ACR 2020). 1 2 3 Guidelines 1. Diagnostic investigations History and physical examination: elicit a relevant history and perform a focused musculoskeletal examination of the lower extremities in the evaluation for an ACL injury. A Knee radiography: obtain knee radiography as initial imaging for the evaluation of a fall or acute twisting trauma to the knee in 5 years old patients with focal tenderness, effusion, or inability to bear weight. B Show 3 more Knee magnetic resonance imaging: https://web.pathway.md/diseases/recV6EtuRC9W22XJi 1/4 6/23/23, 2:38 AM Anterior cruciate ligament injury Pathway Knee magnetic resonance imaging: Obtain knee MRI as the next imaging modality for the evaluation of suspected occult knee fractures or internal derangement after a fall or acute twisting trauma to the knee in adult or pediatric patients (whether skeletally mature or immature) with negative radiographs. B Obtain knee MRI or knee CT angiography as the next imaging modality for the evaluation of suspected additional bone or soft tissue injury after a fall or acute twisting trauma to the knee in 5 years old patients with a radiographic diagnosis of tibial plateau fracture. B Knee computed tomography: Obtain knee radiography or CT angiography of the lower extremity as initial imaging for the evaluation of significant trauma to the knee (such as motor vehicle accident or knee dislocation) in 5 years old patients. B Obtain knee CT angiography or knee MRI as the next imaging modality for the evaluation of suspected additional bone or soft tissue injury after a fall or acute twisting trauma to the knee in 5 years old patients with a radiographic diagnosis of tibial plateau fracture. B 2. Nonpharmacologic interventions Functional knee bracing: do not use functional knee braces routinely in patients after isolated primary ACL reconstruction, as they confer no clinical benefit. D 3. Therapeutic procedures Knee joint aspiration: consider performing knee joint aspiration of painful, tense effusions after a knee injury. E 4. Surgical interventions ACL reconstruction (indications): consider performing ACL reconstruction in order to lower the risk of future meniscus pathology or procedures, particularly in younger and/or more active patients, and to improve long-term pain and function. C ACL reconstruction (timing): prefer early reconstruction when surgical treatment is indicated for an acute isolated ACL tear because the risk of additional cartilage and meniscal injury starts to increase within 3 months. A ACL reconstruction (choice of technique): consider using either single or double bundle techniques in patients undergoing intra-articular ACL reconstruction due to similar outcomes. B ACL reconstruction (choice of graft): consider using an autograft over allograft for articular ACL reconstruction to improve patient outcomes and decrease articular ACL graft failure rate, particularly in young and/or active patients. B Show 2 more https://web.pathway.md/diseases/recV6EtuRC9W22XJi 2/4 6/23/23, 2:38 AM Anterior cruciate ligament injury Pathway MCL reconstruction: offer nonoperative treatment of the medial collateral ligament tears injury in patients with combined ACL and medial collateral ligament tears. Consider offering surgical treatment in selected cases. B Meniscal repair: consider offering a meniscal-preserving strategy to optimize joint health and function in patients with ACL tear and meniscal tear. C 5. Specific circumstances Patients with postoperative septic arthritis: suspect septic arthritis after reconstruction of the ACL in the presence of a delayed ROM recovery, increased warmth or swelling, wound drainage and arthrofibrosis, unusual pain, and systemic symptoms, such as fever and malaise. Confirm the diagnosis in the presence of purulent discharge/aspirate, sinus tract communication with the joint, and intra-articular pus. B Show 4 more 6. Preventative measures Education programs: consider offering training programs designed to prevent injury to reduce the risk of primary ACL injuries in athletes participating in high-risk sports. C Prophylactic knee bracing: avoid offering prophylactic bracing for the prevention of ACL injuries. D 7. Follow-up and surveillance Return to sport activities: consider obtaining functional evaluation, such as the hop test, as one factor to determine return to sport after ACL reconstruction. C Likelihood Ratios Pertinent positives The following findings increase the probability of anterior cruciate ligament injury in adults. 1 1 Finding LR+ Value Positive pivot shift test 20.3 Positive Lachman test 12.4 Positive anterior drawer test 3.7 Pertinent negatives The following findings decrease the probability of anterior cruciate ligament injury in adults. 1 1 Finding LR- Value https://web.pathway.md/diseases/recV6EtuRC9W22XJi 3/4 6/23/23, 2:38 AM Anterior cruciate ligament injury Pathway Negative Lachman test Negative pivot shift test 0.1 0.4 Negative anterior drawer test 0.6 References 1. The American Academy of Orthopaedic Surgeons Board of Directors. Management of Anterior Cruciate Ligament Injuries. AAOS. 2022 Aug 22. Open 2. Expert Panel on Musculoskeletal Imaging, Mihra S Taljanovic, Eric Y Chang et al. ACR Appropriateness Criteria Acute Trauma to the Knee. J Am Coll Radiol. 2020 May;17 5S S12 S25. Open 3. Christen Ravn, Jeroen Neyt, Natividad Benito et al. Guideline for management of septic arthritis in native joints SANJO . J Bone Jt Infect. 2023 Jan 12;8 1 29 37. Open https://web.pathway.md/diseases/recV6EtuRC9W22XJi 4/4