Updated CPG on Managing ACL Injuries Incorporates Skeletal Maturity, Activity Level

The latest version of the Clinical Practice Guideline (CPG) for Management of Anterior Cruciate Ligament (ACL) Injuries from the American Academy of Orthopaedic Surgeons (AAOS) updates 12 of 24 previous evidence-based recommendations and includes 2 new recommendations.

Some of the recommendations in the new edition have been updated to account for the specificity and nuances related to the patient’s skeletal maturity and activity level. Specifically, the committee recommends using an autograft instead of an allograft to improve patient outcomes and lower graft ruptures or revisions, particularly in young or active patients.

The guidelines also include a moderate recommendation that when performing an ACL reconstruction with an autograft for a skeletally mature patient, surgeons may favor the bone patellar bone as the tendon source to reduce the risk of graft failure or infection or the hamstring to reduce the risk of anterior or kneeling pain.

“While skeletal maturity and age are related, they are not the same,” said Robert Brophy, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value.

“Essentially, a patient reaches skeletal maturity when the vast majority, if not all, of their bony growth is complete around the joints in the body including the knee. There’s no doubt there are advantages to using autograft, particularly in younger and more active patients, factors which also play a role when selecting which autograft to use.”

New Recommendations

The updated CPG features 2 new recommendations including:

  • A strong strength recommendation favoring ACL reconstruction over repair due to a lower rate of revision surgery when compared with ACL repair
  • A moderate strength recommendation stating that in select patients, anterolateral ligament/lateral extraarticular tenodesis could be considered when performing hamstring autograft reconstruction to reduce graft failure and improve short-term function

“The committee found strong evidence that reconstruction of a midsubstance tear – one of the most common types of ACL tears – has better outcomes over repair,” said Kent Jason Lowry, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value.

“The committee also updated the recommendation that ACL reconstruction can be considered in order to lower the risk of future meniscus pathology or procedures, especially in younger and/or more active patients as a way to protect the meniscus and articular cartilage to try to minimize the degree to which that knee has early problems down the road from PTOA or other complications.”

Updated Recommendations

Additional updates to the recommendations and options from this CPG include:

  • Surgical treatment of an acute isolated ACL tear is now recommended within 3 months of the injury, reduced from 5 months in the previous edition. Early reconstruction is preferred because the risk of additional cartilage and meniscal injury starts to increase within 3 months.
  • Training programs designed to prevent injury can be used to reduce the risk of primary ACL injuries in athletes participating in high-risk sports.
  • Functional evaluation, such as the “hop” test, may be considered as 1 factor to determine return to sport after ACL reconstruction.

“There’s still a lot to learn when it comes to optimizing the timing of intervention, rehabilitation, the ideal time to return to sport, and interventions to reduce risk of injury, both in people who have never had an ACL injury [and] those who have already experienced it,” Dr. Brophy said.

“The evidence in these areas of focus is still very much evolving and we look forward to following future research to provide orthopaedic surgeons and patients with continued guidance for patient care.”

More Information

The Clinical Practice Guideline for Management of Anterior Cruciate Ligament Injuries can be found here.

Development of this CPG was a collaborative effort between representatives from the AAOS, American Orthopaedic Society for Sports Medicine, the Pediatric Orthopaedic Society of North America, the American Academy of Physical Medicine and Rehabilitation, the American College of Emergency Physicians, and the American Medical Society for Sports Medicine.


American Academy of Orthopaedic Surgeons. Management of Anterior Cruciate Ligament Injuries: Evidence-Based Clinical Practice Guideline. www.aaos.org/aclcpg Published August 22, 2022.

Leave a Reply

CME Updates