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Medicina
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Anterior Cruciate Ligament (ACL) Injury
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Anterior Cruciate Ligament (ACL) Injury

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: 31 January 2026 | Viewed by 5190

Special Issue Editors

Dr. Riccardo D'Ambrosi

E-Mail Website
Guest Editor
IRCCS Orthopedic Institute Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
Interests: anterior cruciate ligament; arthroscopy; sports medicine; meniscus; posterior cruciate ligament; multi-ligament knee injuries
Special Issues, Collections and Topics in MDPI journals
Dr. Alessandro Carrozzo

E-Mail Website
Guest Editor
Department of Life Sciences, Health, and Health Professions, Link Campus University, Via del Casale di San Pio V, 00165 Rome, Italy
Interests: anterolateral ligament; knee; arthroscopy; ACL; sports medicine; knee arthroplasty
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Anterior cruciate ligament (ACL) injury is one of the most commonly treated injuries in sports medicine surgery. Currently, many kinds of surgical treatment options are being developed for ACL injuries and disorders. There have been many developments in ACL surgery; surgeons are focusing on methods to make the procedure less invasive, more precise, and last longer, helping to lessen the likelihood of revision, secondary surgeries or persistent instability. In this Special Issue of Medicina, we aim to provide an overview of the recent advances in the field of ACL surgery, outcomes and rehabilitation. Therefore, researchers in the field of ACL surgery are encouraged to submit original articles or reviews to this Special Issue.

Dr. Riccardo D'Ambrosi
Dr. Alessandro Carrozzo
Guest Editors

Manuscript Submission Information

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Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2200 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • anterior cruciate ligament
  • anterolateral ligament
  • arthroscopy
  • knee
  • sports medicine

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Published Papers (5 papers)

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16 pages, 5095 KB  
Article
Nationwide Epidemiology of Hospitalized Acute ACL Ruptures in Romania: A 7-Year Analysis (2017–2023)
by Gloria Alexandra Tolan, Ionut Daniel Raducan, Bogdan Uivaraseanu, Delia Mirela Tit, Gabriela S. Bungau, Andrei-Flavius Radu and Cristian George Furau
Medicina 2025, 61(9), 1672; https://doi.org/10.3390/medicina61091672 - 15 Sep 2025
Viewed by 325
Abstract
Background and Objectives: Anterior cruciate ligament (ACL) rupture is one of the most frequent and debilitating knee injuries, especially among young, physically active individuals. While extensively studied in Western countries, large-scale epidemiological data from Eastern Europe remain scarce. This study offers the first [...] Read more.
Background and Objectives: Anterior cruciate ligament (ACL) rupture is one of the most frequent and debilitating knee injuries, especially among young, physically active individuals. While extensively studied in Western countries, large-scale epidemiological data from Eastern Europe remain scarce. This study offers the first nationwide assessment of hospitalization-based incidence of acute ACL rupture in Romania. Materials and Methods: We conducted a retrospective analysis of all hospital discharges coded as S83.53 (ACL rupture) between 2017 and 2023, using national public health datasets. Incidence rates were calculated per 100,000 inhabitants based on the 2021 national census. Data were analyzed by sex, age, year, and region. Results: A total of 4332 ACL-related discharges were recorded (3130 males and 1202 females), yielding an average incidence of 3.23 per 100,000 per year. Incidence in males was consistently higher (up to 5.63) than in females (up to 2.10). The peak incidence occurred in 2023, while the lowest was observed in 2020, likely due to COVID-19-related restrictions. Linear regression showed a significant upward trend over time (R2 = 0.966, p < 0.001). The highest age-specific incidence was found in males aged 25–29 years (116.3/100,000) and in females aged 15–19 years (35.4/100,000). Cases were rare above the age of 50. Geographically, incidence varied widely, with Bucharest, Timiș, and Bihor recorded the highest rates, while several other counties reported near-zero values. Conclusions: This study provides the first nationwide analysis of hospitalization-based ACL rupture incidence in Romania, revealing marked differences by age, sex, and region. While the findings reflect only acute cases requiring inpatient care, they underscore the need for more comprehensive injury surveillance, improved access to orthopedic services, and targeted prevention strategies tailored to high-risk populations. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injury)
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12 pages, 4469 KB  
Article
Clinical and Radiological Outcomes of Revision Anterior Cruciate Ligament Reconstruction Using a Quadriceps Tendon Autograft with a Bone Block: A Single-Center Case Series
by Dhong Won Lee, Sung Gyu Moon, Ji Hee Kang, Seung Ik Cho and Woo Jong Kim
Medicina 2025, 61(9), 1634; https://doi.org/10.3390/medicina61091634 - 10 Sep 2025
Viewed by 332
Abstract
Background and Objectives: Revision anterior cruciate ligament reconstruction (ACLR) is demanding and yields inferior outcomes compared with primary procedures. The quadriceps tendon (QT) autograft with bone block has biomechanical and biological advantages though clinical evidence in revision remains limited. This study evaluated the [...] Read more.
Background and Objectives: Revision anterior cruciate ligament reconstruction (ACLR) is demanding and yields inferior outcomes compared with primary procedures. The quadriceps tendon (QT) autograft with bone block has biomechanical and biological advantages though clinical evidence in revision remains limited. This study evaluated the clinical and radiological outcomes of revision ACLR using bone-block QT autograft in young, active patients. Materials and Methods: A case series with a level of evidence of 4. Thirty-four patients (28 men, 6 women; mean age, 27.2 ± 5.8 years) who underwent revision ACLR with a bone-block QT autograft between 2021 and 2023 were retrospectively reviewed. The mean follow-up was 37.4 ± 3.2 months. Clinical assessments included the Lysholm, International Knee Documentation Committee (IKDC) subjective, and Tegner activity scores, along with isokinetic strength testing. Objective stability was evaluated using pivot shift grading and Telos stress radiography. Radiological analyses included 3D computed tomography for tunnel positioning and magnetic resonance imaging for tunnel widening. Perioperative and postoperative complications were recorded. Results: All clinical outcomes improved significantly from baseline to 2-year follow-up: Lysholm (62.7 ± 9.6 to 87.1 ± 10.3), IKDC (59.0 ± 10.8 to 79.5 ± 11.1), and Tegner (3.5 ± 1.2 to 5.6 ± 1.3; all p < 0.001). However, the Tegner score remained lower than the pre-injury level (6.1 ± 1.4; p = 0.035). At the final follow-up, 91.2% of the patients had returned to sports, with 59% resuming sports at their pre-injury level or higher. Side-to-side anterior laxity decreased from 8.5 ± 1.7 mm to 1.4 ± 1.1 mm on Telos stress radiography (p < 0.001). Preoperatively, 82% of patients demonstrated high grade pivot shift (≥grade 2), which improved to 91% graded as negative or grade 1 at final follow-up (p < 0.001). Isokinetic evaluation showed improvements in quadriceps (28.7% ± 12.5% to 12.4% ± 8.1%) and hamstring (18.3% ± 9.7% to 8.9% ± 6.5%) deficit (both p < 0.001). MRI demonstrated minimal tunnel widening (tibia, +1.3 ± 0.9 mm, p = 0.012; femur, +0.3 ± 0.6 mm, p = 0.148). Three complications (8.8%) were observed: one cyclops lesion, one transient extension deficit, and one graft rupture. No patellar fractures, septic arthritis, or revision procedures occurred during the follow-up period. Conclusions: Bone-block QT autografts provide a reliable option for revision ACLR, yielding functional improvement, restored stability, and minimal donor-site morbidity, with low complications. These findings support their consideration as the preferred graft choice for young active patients needing revision reconstruction. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injury)
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12 pages, 578 KB  
Article
The Role of Allografts in Revision ACL Reconstruction
by Antonio Maestro, Carmen Toyos, Nicolás Rodríguez, Iván Pipa, Lucía Lanuza, Filipe Machado, César Castaño and Santiago Maestro
Medicina 2025, 61(8), 1350; https://doi.org/10.3390/medicina61081350 - 25 Jul 2025
Viewed by 559
Abstract
Background and Objectives: Although the use of allografts in revision anterior cruciate ligament reconstruction is associated with theoretical advantages, it has historically led to poorer clinical results and lower survival rates. However, the heterogeneity of the available literature makes it difficult to [...] Read more.
Background and Objectives: Although the use of allografts in revision anterior cruciate ligament reconstruction is associated with theoretical advantages, it has historically led to poorer clinical results and lower survival rates. However, the heterogeneity of the available literature makes it difficult to elucidate the effectiveness of allographs, as most of the studies published do not make any reference to some of the key aspects related to the processing of the allograft employed. The present study analyzed the clinical results and the survival of allografts in patients undergoing revision anterior cruciate ligament reconstruction with a well-characterized, single type of allograft. Materials and Methods: This was a retrospective observational study analyzing a series of patients undergoing revision anterior cruciate ligament reconstruction with an Achilles tendon allograft with a bone block (FlexiGraft, LifeNet Health), subjected to low-dose irradiation at dry ice temperatures. Preoperative and follow-up clinical variables (IKDC, pain, hop test, and YBT scores) were recorded. Survival was analyzed using the Kaplan–Meier methodology. Results: A total of 39 patients (34 male, 5 female) were included in the study. The mean patient age was 37.3 years and mean postoperative follow-up was 78.7 months. Forty-one percent of patients were competitive athletes, and all of the patients in the sample exhibited preoperative instability. The mean allograft thickness was 9.2 mm. During surgery, 51.3% of patients required meniscus repair and 20.5% had to be treated for chondral defects. At the last follow-up visit, 92.3% of the subjects presented with IKDC grade A and 7.7% with IKDC grade B. The mean subjective IKDC score was 0.79 and mean pain intensity was 1.15 according to the VAS scale. Limb symmetry, as measured by the various hop tests and the Y balance test, were within the safety range, with 74.4% of patients succeeding in returning to their previous level of sport. Ten-year survival was estimated at 97.4%. Conclusions: Allografts obtained and processed following the current regulations governing patient selection and graft harvesting, which are additionally processed without recourse to chemical procedures and sterilized at less than 2 MRad in dry ice conditions, represent an effective and safe alternative in revision anterior cruciate ligament reconstruction. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injury)
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10 pages, 1268 KB  
Article
Optimal Tunnel Positioning and Graft Diameter to Minimize Impingement in Single-Bundle ACL Reconstruction: A 3D CT Simulation Analysis
by Sang-Woo Jeon, Sung-Hwan Kim and Kang-Il Kim
Medicina 2025, 61(6), 946; https://doi.org/10.3390/medicina61060946 - 22 May 2025
Viewed by 697
Abstract
Background and Objectives: Graft impingement against the intercondylar notch has been identified as a significant contributor to graft deterioration and suboptimal outcomes following anterior cruciate ligament (ACL) reconstruction. This study aimed to (1) identify the optimal combination of tunnel positions that minimizes impingement [...] Read more.
Background and Objectives: Graft impingement against the intercondylar notch has been identified as a significant contributor to graft deterioration and suboptimal outcomes following anterior cruciate ligament (ACL) reconstruction. This study aimed to (1) identify the optimal combination of tunnel positions that minimizes impingement between the ACL graft and femoral intercondylar notch. Materials and Methods: Three-dimensional models of nine normal knees were reconstructed using computed tomography scans obtained at four knee flexion angles (0°, 45°, 90°, and 120°). Virtual ACL grafts with diameters of 7 mm and 9 mm were modeled as cylinders. Nine graft configurations were investigated by varying femoral and tibial footprint locations (anteromedial, central, and posterolateral) in all possible combinations. For each configuration, impingement volume was quantified by measuring the overlap between the intercondylar notch and the virtual graft using Boolean operators in 3D simulation software. The effects of graft diameter, footprint location, and knee flexion angle on impingement volume were analyzed. Results: Maximum impingement volumes were observed at 0° knee extension, with significant reductions at 45° flexion (p < 0.01) and negligible impingement at 90° and 120° flexion. The 9 mm diameter grafts demonstrated significantly greater impingement volumes than 7 mm grafts (p < 0.01). Impingement volumes increased progressively as footprint locations shifted from posterolateral to anteromedial positions in both femoral and tibial components. However, statistically significant differences in impingement volume across footprint locations were observed only for tibial positioning (p < 0.001), not for femoral positioning (p > 0.05). The femoral anteromedial-tibial anteromedial configuration exhibited the highest impingement volume (577.8 ± 171.3 mm3 for 9 mm grafts), while the femoral posterolateral-tibial posterolateral configuration showed the lowest (73.5 ± 85.6 mm3). Conclusions: Tunnel position, graft diameter, and knee flexion angle significantly influence impingement risk in ACL reconstruction. Tibial tunnel position appears more critical than femoral position in minimizing graft impingement. Posterolateral positioning of tunnels, particularly on the tibial side, may reduce impingement volume. Clinical Relevance: This study provides quantitative evidence to guide surgeons in optimizing tunnel placement and graft selection for anatomical single-bundle ACL reconstruction, potentially reducing the risk of graft deterioration and failure due to mechanical impingement. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injury)
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18 pages, 1575 KB  
Systematic Review
Anterior Cruciate Ligament Reconstruction Using Lateral Extra-Articular Procedures: A Systematic Review
by Filippo Migliorini, Ludovico Lucenti, Ying Ren Mok, Tommaso Bardazzi, Riccardo D’Ambrosi, Angelo De Carli, Domenico Paolicelli and Nicola Maffulli
Medicina 2025, 61(2), 294; https://doi.org/10.3390/medicina61020294 - 8 Feb 2025
Cited by 5 | Viewed by 2636
Abstract
Background and Objectives: The present systematic review investigated the efficacy of lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) as lateral extra-articular procedures (LEAPs) for anterior cruciate ligament (ACL) reconstruction. ACL reconstruction using LEAP may reduce graft rupture and rotatory laxity and [...] Read more.
Background and Objectives: The present systematic review investigated the efficacy of lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) as lateral extra-articular procedures (LEAPs) for anterior cruciate ligament (ACL) reconstruction. ACL reconstruction using LEAP may reduce graft rupture and rotatory laxity and allow a quicker return to sports. The outcomes of interest were patient-reported outcome measures (PROMs), return to sport, laxity, failure rate, and safety profile. Materials and Methods: The present systematic review followed the 2020 PRISMA guidelines. In December 2024, PubMed, EMBASE, and Web of Science were accessed without constraints. All clinical investigations evaluating LEAP for ACL reconstruction were considered. Only studies that considered LET and ALL as LEAP were considered. Only studies using a hamstring tendon autograft associated with LET or ALL were considered. Results: Data from 27 clinical studies (3423 patients) were retrieved. The mean length of follow-up was 61.8 ± 39.5 months. ACL reconstruction using LEAP led to a statistically significant improvement in the Lysholm score (p < 0.01) and IKDC (p < 0.01). The mean joint laxity, as measured by the arthrometer, was 1.5 ± 1.8 mm. Finally, 72.3% (623 of 668) of patients returned to their pre-injury level of sport at a mean of 6.3 ± 4.4 months. At the last follow-up, the LET group showed greater IKDC (p = 0.04). On the other hand, there was a statistically significant greater rate of patients positive to the Lachman test (p < 0.01), return to sport (p < 0.01), and reoperation (p = 0.01). No significant differences were found in Lysholm scores (p = 0.6), Tegner scores (p = 0.2), arthrometer measurements (p = 0.2), Pivot shift test results (p = 0.1), time to return to sport (p = 0.3), and failure rates (p = 0.7). Conclusions: LEAP for ACL reconstructions seems to be effective and safe. Most patients returned to their pre-injury level of sport after a mean of 6 months. LET-based ACL reconstruction may be associated with greater clinical outcomes and a higher reoperation rate compared to ALL-based reconstruction. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injury)
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