URAC
The Arizona HOPCo Specialty Care Network is the only
URAC-accredited MSK clinically integrated network in the country.

Management of ACL Injuries Clinical Practice

Clinical Region

Arizona

PRACTICE APPROACH

Expected practice

PRACTICE STATEMENT

Providers are responsible for gathering all the necessary documentation for diagnosis (x-ray, MRI, clinical exam, etc.) and determining need for surgical intervention. Evaluate for meniscal and/or concomitant ligamentous injury.

Clinical Approach

The clinical approach is based on consensus guidelines and includes expected practices which will be designed and implemented for the patients with ACL injuries.   

Providers are responsible for gathering all the necessary documentation for diagnosis (x-ray, MRI, clinical exam, etc.) and  determining need for surgical intervention. Evaluate for meniscal and/or concomitant ligamentous injury.   

Options for conservative treatment:   

  • Non-steroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen   
  • Bracing (Playmaker Brace, Custom ACL Brace)  
  • Activity modification   
    • No pivoting activities
  • Physical therapy for ROM and strengthening   
  • Consideration of therapeutic knee aspiration if large effusion/hemarthrosis  

Indication for surgical intervention:

  • Clinical instability (Lachman’s, anterior drawer, pivot shift)   
  • Activity level (Involvement in sports with running, jumping, pivot/direction change, heavy manual labor)
  • Age
  • Concomitant pathology – Potential of further meniscal/cartilage damage linked recurrent instability episodes, loss of meniscal integrity, concomitant ligamentous injury  

Expected Clinical Care - Arthroscopically Assisted ACL Reconstruction

PRE-OPERATIVE CARE

  1. Patients will participate in shared decision making so they may understand procedure, restrictions, recovery, and return to sport timeline.   
  2. Should have full knee ROM restored following injury (unless bucket-handle meniscus tear causing mechanical    
    block). Lack of pre-operative motion may be a risk factor for post-operative arthrofibrosis*.  Preoperative physical therapy may be indicated to establish necessary acceptable preop range of motion.
  3. Decision for autograft versus allograft discussed with the patient based on surgeon preference.   
    • Autograft options (generally, if patient less than 30 years old)
      • Quadriceps tendon   
      • Hamstring tendon   
      • Bone-Patellar Tendon-Bone   
      • Soft-tissue for skeletally immature   
    • Allograft options (consider, if patient greater than 30 years old): consider low level irradiated grafts if available   
  4. All soft tissue or bone block per surgeon preference (no difference in clinical outcomes) surgery scheduler contacts patient, schedules surgery, and ensures vendors are aware.   
    • Pre-op appointment   
    • DME for X-ROM brace and crutches   
    • Consider cryotherapy   
    • Postoperative pain medications prescribed   
    • Consideration of DVT prophylaxis depending on known risk factors including oral contraception   
  5. Pre-op holding orders (must be completed prior to surgery)
    • Consent   
    • Pre-op antibiotics
      • Cefazolin (Ancef) 2 gm (less than 120 kg) or 3gm (120 kg or greater) IV within 1 hour of cut time;
      • Or, Options for penicillin/cephalosporin allergic/intolerant patients:   
        • Vancomycin 1 gm (less than 90 kg) or 1.5 gm (90 kg or greater) IV within 2 hours of cut time   
    • Any additional testing that was not performed or needs to be re-done morning of surgery (INR/Urine HCG)
    • H&P must be current within 30 days of the procedure.   

INTRA-OPERATIVE CARE

  1. Patient positioning per surgeon preference (tourniquet, lateral post, foot holder, etc.)
  2. Arthroscopy tower set up on opposite side of surgical leg
  3. Consider Tranexamic acid 1000 mg IV x 1 at induction if available, repeat at end of case for all patients with no known contraindications * (reduces postoperative hemarthrosis)
  4. Dressing with foot to thigh Ace wrap placed after skin closure
  5. X-ROM brace placed and adjusted while patient is sedated, locked in full extension.
  6. Consider adductor canal blocks

POST-OPERATIVE CARE

  1. Consider additional 1 gm Ancef (if not allergic) given at end of case for patient’s that receive allograft.   
  2. Immediate initiation of exercises including ankle pumps, quad sets, and straight leg raises   
  3. Routine pain medications:   
    • Chemical DVT prophylaxis per physician preference depending on known risk factors
    • Docusate sodium (Colace) 100 mg PO BID and Zofran 4mg po prn N/V   
    • Ibuprofen 800 mg TID with food   
    • Opioid pain medication:   
      • Typically hydrocodone/acetaminophen 5/325mg PO Q4hr prn pain   
      • Consider oxycodone/acetaminophen 5/325mg PO q4hr prn pain based on previous narcotic    
        • history and pain control   
  4. Postoperative appointment at 2 week, and 6 weeks postoperatively   
    • 2-week postoperative appointment   
      • Consider 2 view knee radiographs obtained (AP and lateral)   
      • Address pain control needs and swelling   
      • Re-educate on home exercises (ankle pumps, quad sets, and straight leg raises)   
      • Assess quad function   
      • Re-adjust brace and counsel on proper crutch use   
        • Crutches typically for 2 weeks, weightbearing status per surgeon preference and    
          concomitant meniscal pathology (6 weeks NWB)   
      • Assess wound healing   
      • Check ROM and progress with PT   
      • Discontinue crutches if indicated (adequate quad control, no meniscal repair)   
        • 6-week postoperative appointment   
          1. Assess progress with PT   
          2. Discontinue brace   
          3. Review restrictions and ACL rehab protocol (no sports until 6 months)

References

  1. Diermeier TA, Rothrauff BB, Engebretsen L the Panther Symposium ACL Treatment Consensus Group, et alTreatment after ACL injury: Panther Symposium ACL Treatment Consensus Group British Journal of Sports Medicine 2021;55:14-22.