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Anterior Cruciate Ligament (ACL): Innovations in Clinical Management

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (25 December 2025) | Viewed by 12728

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Special Issue Editors

Dr. Xaver Feichtinger

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Guest Editor

Herz-Jesu Krankenhaus · Department of Orthopaedic Surgery
Interests: individualized ACL surgery; hamstrings; QuadTend; BTB; ACL refixation

Dr. Thomas Hoffelner

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Guest Editor

1. Department of Orthopedics and Traumatology, Paracelsus Medical University Hospital, Strubergasse 21, 5020 Salzburg, Austria
2. Department of Orthopedic Surgery, St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
Interests: orthopaedics; traumatology; accident surgery

Dr. Georg Brandl

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Guest Editor

Department of Orthopedic Surgery, St. Vincent Shoulder & Sports Clinic, Baumgasse 20A, 1030 Vienna, Austria
Interests: knee surgery; knee endoprosthetics; joint-maintaining knee surgery; customized; state-of-the-art cruciate ligament surgery; meniscal surgery; cartilage surgery; minimal invasive knee endoprosthetics and partial replacement; mechanical axis correction of the upper/lower leg; sports medicine

Special Issue Information

Dear Colleagues,

Lesions of the Anterior Cruciate Ligament (ACL) are common among physically active patients.

Despite the improvements regarding surgical techniques and various graft choices in the last decade, the number of re-ruptures and persisting instability remains high.

This Special Issue aims to focus on innovations in clinical management of ACL injuries. Alternative graft choices (e.g., QuadTend autograft) must confirm their promising short-term results in longer observation periods in comparison to modern HT and BTB techniques. ACL repair techniques are of increasing scientific interest. However, there is still a lack of data regarding perfect patient choice and applicability in high-demanding patients.

Recently, many studies are focusing on anterolateral and anteromedial instabilities. The results are controversial. The need for an ALL reconstruction in primary ACL reconstruction or if the graft choice is depending on co-injuries (e.g., HT in medial insufficiency) remains unanswered.

Furthermore, bony surgical interventions in revision ACL surgery are still part of discussion. There is still need for an algorithm in ACL revision management.

This Special Issue combines original and review articles to demonstrate innovations and trends in ACL injury management.

Dr. Xaver Feichtinger
Dr. Thomas Hoffelner
Dr. Georg Brandl
Guest Editors

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Keywords

ACL
graft choice
ACL repair
ALL
tibial slope

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Published Papers (6 papers)

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Research

20 pages, 785 KB

Open AccessArticle

Effectiveness of Transcutaneous and Percutaneous Electrical Nerve Stimulation as Adjunct Therapies in Patients After Anterior Cruciate Ligament Reconstruction: Study Protocol for a Randomized Controlled Trial

by Luis Blanco-López, Iván Nácher-Moltò, Juan Luis Sánchez-González, Daniel Casado-Gómez, Adrián Cases-Sebastià and Javier Reina-Abellán

J. Clin. Med. 2026, 15(3), 989; https://doi.org/10.3390/jcm15030989 - 26 Jan 2026

Viewed by 544

Abstract

Background/Objectives: Quadriceps arthrogenic muscle inhibition (AMI) represents a key impairment following anterior cruciate ligament reconstruction (ACLR), contributing to quadriceps weakness. Although transcutaneous electrical nerve stimulation (TENS) and percutaneous electrical nerve stimulation (PENS) have been primarily investigated for analgesia, their effects on quadriceps strength in the early postoperative period remain underexplored. Methods: This study describes a single-blinded, parallel-group randomized controlled trial investigating the short-term effects of a single high-frequency TENS session and a novel long-term potentiation (LTP) PENS protocol on quadriceps strength and related clinical outcomes after ACLR. Fifty-four participants will be randomly allocated using block randomization in a 1:1:1 ratio to one of three groups: a control group (conventional post-ACLR rehabilitation only), a TENS group (conventional rehabilitation plus a single high-frequency TENS session), or a PENS group (conventional rehabilitation plus a single LTP PENS session). Participants will receive neuromodulatory intervention during the sixth postoperative week. The LTP PENS protocol consists of five 5 s stimulation bursts at 100 Hz and 250 μs pulse width and has only been investigated once in patients with upper limb pathology, underscoring its novelty in a postoperative setting. Results: The primary outcome is quadriceps maximal voluntary isometric contraction, selected as a clinically relevant surrogate of quadriceps activation deficits associated with AMI. Secondary outcomes include pain intensity, pressure pain threshold, knee range of motion, thigh muscle perimeter, knee effusion and swelling, and self-reported function and knee-related quality of life. Outcomes will be assessed at baseline, immediately post-treatment, and 1 and 7 days post-intervention by a blinded assessor. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL): Innovations in Clinical Management)

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14 pages, 420 KB

Open AccessArticle

Effects of Visual Perturbation on Single-Leg Drop Jump Biomechanics in Patients Post-Anterior Cruciate Ligament Reconstruction

by Xavier Laurent, Damien Dodelin, Nicolas Graveleau and Nicolas Bouguennec

J. Clin. Med. 2026, 15(1), 118; https://doi.org/10.3390/jcm15010118 - 24 Dec 2025

Viewed by 668

Abstract

Background: Patients after anterior cruciate ligament reconstruction (ACLR) often exhibit persistent biomechanical deficits, particularly during high-demand tasks like the single-leg drop jump (SLDJ). At approximately six months post-ACLR, patients frequently rely on visual input to compensate for persistent sensorimotor deficits during dynamic tasks, which may lead to altered movement patterns. While visual perturbations have been studied in bilateral jump tasks, their impact on SLDJ biomechanics in ACLR patients remains unexplored. Methods: Patients who were still engaged in rehabilitation and not yet cleared for unrestricted return to sport performed SLDJ under three visual conditions: normal vision, low visual perturbation, and high visual perturbation using stroboscopic glasses. Kinematic and kinetic variables were measured using a 3-dimensional motion analysis system and force platform. Comparisons were made between the ACLR and non-operated limbs, as well as across visual conditions. Results: 24 patients (17 males, 7 females; mean age 25.6 ± 6.3 years, mean height 174 ± 9.0 cm, mean weight 74.7 ± 17.2 kg) were included in the analysis. Knee adduction excursion during landing was significantly affected by visual perturbation (F(2, 46) = 6.55, p = 0.004, η² = 0.019). Post hoc analysis showed that high visual perturbation significantly decreased knee adduction excursion compared to normal vision on the ACLR limb (mean difference 1.499°, SE = 0.388, pBonf = 0.003, Cohen’s d = 0.542). A significant difference was also found between low and high visual perturbation on the ACLR limb (mean difference 1.543°, SE = 0.388, pBonf = 0.002, Cohen’s d = 0.558). No significant changes were observed in the non-operated limb across visual conditions. Conclusions: High visual perturbation significantly altered knee adduction excursion on the ACLR limb, resulting in a shift toward greater knee abduction during landing. No changes were observed in the non-operated limb. These findings support the use of visual perturbation in functional assessment protocols after ACLR to better identify persistent biomechanical deficits that may contribute to reinjury risk. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL): Innovations in Clinical Management)

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12 pages, 660 KB

Open AccessArticle

Retrospective Study on the Efficacy of Platelet-Rich Plasma Treatment in the Recovery of Quadriceps Muscle Strength After Anterior Cruciate Ligament Reconstruction in Non-Professional Athletes

by Roxana Mihaela Munteanu, Bogdan Voicu, Diana Șandru, Arpad Solyom, Pia Simona Făgăraș and Tudor Sorin Pop

J. Clin. Med. 2025, 14(10), 3593; https://doi.org/10.3390/jcm14103593 - 21 May 2025

Cited by 1 | Viewed by 2530

Abstract

Background/Objectives: This retrospective study aimed to evaluate whether PRP infiltrations improve quadriceps muscle strength recovery following anterior cruciate ligament reconstruction (ACLR), while minimizing the recovery time required to resume daily activities and sports. Numerous studies have explored the use of platelet-rich plasma (PRP) in treating ACL injuries. PRP therapy has demonstrated high efficacy in accelerating ligament healing in animal models. However, clinical trials involving human participants have reported inconsistent results regarding the effects of PRP on ACL reconstruction outcomes. Methods: Between 2020 and 2024, a total of 68 subjects who underwent ACLR were included in the study. Participants were divided into two groups, namely a treatment group that followed a standard rehabilitation protocol and received PRP infiltrations, and a control group that followed the same protocol without PRP treatment. Muscle strength was assessed using the isometric max strength balance (IMSB) test and the concentric max strength balance (CMSB) test, both performed using the Kineo Intelligent Load device (Globus Kineo 7000, Italian Excellence, Rome, Italy). Results: The results of IMSB test showed a significant difference between treatment groups according to a two-way ANOVA test (F(1, 198) = 7.345; p = 0.0073). The PRP-treated group showed significantly higher quadriceps muscle strength at 6 months (34.9 ± 9.6 vs. 30.0 ± 8.2 kg). The CMSB test also showed a significant difference at 6 months (F(1, 198) = 5.976; p = 0.00154), with the PRP-treated group having significantly higher concentric muscle strength (35.5 ± 9.5 vs. 30.7 ± 8.5 kg). Conclusions: These findings suggest that post-ligamentoplasty PRP infiltrations may have beneficial effects on muscle strength recovery. However, further prospective studies with larger sample sizes are necessary to confirm these results. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL): Innovations in Clinical Management)

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10 pages, 2507 KB

Open AccessArticle

Use of Anthropometric Data for the Prediction of Four-Strand Hamstring Graft Size in White Caucasian Population

by Theodoros Bouras, Ioanna Lianou, Andreas Filippopoulos, John Lakoumentas and Dimitrios Ntourantonis

J. Clin. Med. 2025, 14(3), 825; https://doi.org/10.3390/jcm14030825 - 27 Jan 2025

Cited by 1 | Viewed by 1219

Abstract

Background/Objectives: The purpose of this study was to preoperatively estimate the four-strand hamstring graft size in a White Caucasian population, using anthropometric data. Methods: This was a prospective study of a consecutive series of fifty patients with anterior cruciate ligament (ACL) rupture, who were scheduled for reconstruction using hamstring autografts; however, one of them was ultimately not enrolled according to the exclusion criteria (49 patients in total). Preoperatively, age, sex, weight, body mass index (BMI), length, and diameter of the contralateral thigh, length of the harvested gracilis/semitendinosus tendons, and length and thickness of the four-stranded graft were recorded. Graft diameter and length were dependent variables, measured via a graft sizer and a ruler, respectively. Quantitative variables were described with mean ± SD (correlated in a pairwise manner with Pearson’s r correlation). Qualitative variables were described with an absolute count (relative % percent) per categorical level, and their dependency on any quantitative (dependent) variable was assessed via Student’s t-test. Results: The mean lengths of the gracilis and semitendinosus were 25.6 ± 3.2 cm and 28.4 ± 3.3 cm, respectively, and they were positively correlated with the length of the four-strand hamstring graft along with the patients’ height and thigh length. Conclusions: The use of anthropometric data can assist in the prediction of the hamstring autograft size, aiding the selection of an appropriate graft type. The four-strand hamstring graft length was related to the gracilis, semitendinosus, and thigh length. The patients’ height was related to the graft length and diameter. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL): Innovations in Clinical Management)

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10 pages, 241 KB

Open AccessArticle

The “11 to Perf Score”, a Test for Professional Players Returning to Soccer After Anterior Cruciate Ligament Reconstruction

by Elio Disegni, Geoffrey Memain, Jean Bouvet, Maxime Gaspar, Romain Maille, Bertrand Tamalet, Emmanuel Orhant, Pascal Maille, Yoann Bohu and Alexandre Hardy

J. Clin. Med. 2025, 14(1), 11; https://doi.org/10.3390/jcm14010011 - 24 Dec 2024

Cited by 5 | Viewed by 3543

Abstract

Rupture of the anterior cruciate ligament (ACL) is common among soccer players. Although there are no strict recommendations for the return to sport, more and more practitioners are having their patients perform isokinetic and even composite tests. However, these tests have not yet been shown to be predictive of re-injury, and are not specific to professional footballers. Objectives: The “11 to Perf” is a test designed to help professional footballers return to sport after ACL reconstruction. Its originality lies in its integration of soccer practice with specific tests. The aim of this article is to present the “11 to Perf” evaluation method. Methods: A prospective cohort study was conducted at the Centre National du Football (FIFA center) in Clairefontaine, including professional footballers who have undergone anterior cruciate ligament surgery and rehabilitation. Tests include clinical assessments, jumping, agility, psychological and isokinetic tests and match simulation. Conclusions: The “11 to Perf” is a composite test designed to assess the return to sport of professional footballers after ACL reconstruction. Its predictive capacity for recurrence should be assessed in the future. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL): Innovations in Clinical Management)

9 pages, 561 KB

Open AccessArticle

Lateral Extraarticular Tenodesis in Revision Anterior Cruciate Ligament Reconstruction: An Analysis of Clinical Outcomes and Failure Rates

by Lorenz Fritsch, Luca Bausch, Armin Runer, Philipp W. Winkler, Romed P. Vieider, Sebastian Siebenlist, Julian Mehl and Lukas Willinger

J. Clin. Med. 2024, 13(23), 7201; https://doi.org/10.3390/jcm13237201 - 27 Nov 2024

Cited by 3 | Viewed by 2976

Abstract

Background/Objectives: Lateral extraarticular tenodesis (LET) has been advocated in revision anterior cruciate ligament reconstruction (ACLR) to improve knee stability and furthermore, decrease failure rates. The aim of this study was to compare clinical outcomes, knee laxity, and failure rates after revision ACLR with LET (ACLR + LET) versus without LET. It was hypothesized that ACLR + LET improves clinical outcomes and reduces the failure rate. Methods: A retrospective analysis of prospectively collected data was conducted to examine patients who underwent revision ACLR with and without LET between 2017 and 2021 with a minimum follow-up of 24 months. Patients with coronal malalignment (>5°), posterior tibial slope >12°, and concomitant injuries to collateral ligaments were excluded. Patient reported outcome measures (PROMs) included the International Knee Documentation Committee (IKDC) subjective knee score, the Lysholm score, and the Tegner activity scale (TAS). Anterior knee laxity was measured with a Rolimeter and side-to-side difference (SSD) was determined. Revision ACLR failure was defined as ACL revision surgery and SSD > 5 mm. Group comparisons were performed using chi-square-, independent-samples students t-test or Mann–Whitney–U tests. Results: Of 56 eligible patients, 45 (80%, follow up, 23 isolated rACLR vs. 22 rACLR + LET) were included with a mean follow-up of 45.6 ± 15.8 months. Postoperative PROMs were not statistically different between rACLR and rACLR + LET groups (IKDC: 73.0 ± 18.9 vs. 68.7 ± 16.6, n.s.; Lysholm: 84.8 ± 12.3 vs. 77.7 ± 16.2, n.s.). Both groups showed similar TAS (rACLR vs. rACLR +LET (5; range 4–6 vs. 4; range 3–5; n.s.). Anterior knee laxity SSD was 2.4 ± 1.3 mm in the rACLR group and 1.8 ± 1.8 mm in the rACLR + LET group (n.s.). The failure rate was 13% in the rACLR group compared to 4.5% in the rACLR + LET group (n.s.). Conclusions: Isolated revision ACLR showed comparable postoperative patient-reported outcome measures and anterior knee laxity compared to ACLR + LET at mid-term follow up. The addition of a LET demonstrated a lower, though non-significant, failure rate after revision surgery. However, future studies with a prospective, randomized design and an increased number of patients are needed to clearly identify the exact indication for the use of additional LET. Full article

(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL): Innovations in Clinical Management)

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