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Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation
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Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation

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

Deadline for manuscript submissions: 25 September 2025 | Viewed by 2685

Special Issue Editor

Dr. Young-Jin Seo

E-Mail Website
Guest Editor
Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Republic of Korea
Interests: orthopedic surgery; anterior cruciate ligament reconstruction; osteotomy; knee; bone graft

Special Issue Information

Dear Colleagues,

Anterior cruciate ligament (ACL) injuries remain a prevalent challenge, particularly in athletic populations. Advances in clinical treatment and rehabilitation have transformed outcomes, but challenges persist. ACL reconstruction has seen significant technical evolution, emphasizing precision, durability, and optimized recovery. Innovations like lateral extra-articular procedures, all-inside techniques, internal bracing, slope reducing osteotomy, and biologic augmentation promise to enhance healing, graft integration, and biomechanical stability.

Rehabilitation plays a critical role in recovery and long-term success. A growing focus on injury prevention through neuromuscular training programs has demonstrated efficacy in reducing ACL injury rates, particularly in young athletes. However, addressing psychological readiness, particularly fear of reinjury, remains a vital yet underexplored dimension of recovery.

A multidisciplinary approach, combining surgical, rehabilitative, and preventive strategies, is essential for optimizing outcomes and reducing the long-term burden of ACL injuries.

This Special Issue aims to provide a thorough exploration of the challenges and advancements in clinical treatment and rehabilitation for ACL injuries. By featuring contributions from experts, it emphasizes clinical progress and long-term recovery outcomes, offering valuable knowledge to advance both research and practice.

Dr. Young-Jin Seo
Guest Editor

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Keywords

  • anterior cruciate ligament (ACL)
  • reconstruction
  • lateral extra-articular procedures
  • all-inside technique
  • internal bracing
  • slope reducing osteotomy
  • biologic augmentation
  • rehabilitation

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Published Papers (3 papers)

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Research

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15 pages, 2398 KB  
Article
Propensity Score-Matched Comparison of Six-Strand All-Inside and Conventional Four-Strand Hamstring Autografts for ACL Reconstruction
by Young Jin Seo, Si Young Song and Dongju Kim
J. Clin. Med. 2025, 14(17), 6010; https://doi.org/10.3390/jcm14176010 - 25 Aug 2025
Viewed by 454
Abstract
Background/Objectives: All-inside ACL reconstruction has emerged as a minimally invasive alternative to conventional techniques, with potential advantages in graft configuration and reduced surgical trauma. This study aimed to compare the clinical outcomes of all-inside and full tibial tunnel ACL reconstruction, focusing on graft [...] Read more.
Background/Objectives: All-inside ACL reconstruction has emerged as a minimally invasive alternative to conventional techniques, with potential advantages in graft configuration and reduced surgical trauma. This study aimed to compare the clinical outcomes of all-inside and full tibial tunnel ACL reconstruction, focusing on graft diameter, postoperative stability, and functional recovery. We hypothesized that the all-inside technique would allow for thicker grafts and yield superior postoperative knee stability and functional outcomes, with postoperative anterior laxity as a major outcome of interest. Methods: This retrospective comparative study reviewed patients who underwent ACL reconstruction between January 2020 and February 2024. From January 2020 to September 2022, a four-strand hamstring autograft with full tibial tunnel technique (FT-4) was used, while from September 2022, a six-strand hamstring autograft with the all-inside technique (AI-6) was adopted to enable thicker grafts and optimize fixation. Among a total of 103 patients, 1:1 propensity score matching (PSM) was performed based on age, sex, BMI, laterality, ALL reconstruction, meniscal lesion, and preoperative anterior laxity (SSD). Graft diameter and clinical outcomes, including knee stability and functional scores, were compared between the matched groups. Results: After PSM, two comparable groups of 29 patients each were established. Graft diameter was significantly larger in the AI-6 group (9.5 ± 0.7 mm) compared to the FT-4 group (7.8 ± 0.8 mm, p < 0.001), while other baseline characteristics remained well balanced between the groups. At the final follow-up, both groups exhibited significant improvements in anterior laxity, functional scores, and pivot shift grades (all p < 0.001). The AI-6 group demonstrated superior outcomes with a significantly higher Lysholm score (82.2 ± 6.7 vs. 75.6 ± 8.9, p = 0.002), lower WOMAC score (8.0 ± 4.3 vs. 12.9 ± 10.5, p = 0.023), and reduced anterior laxity (1.6 ± 1.1 mm vs. 2.5 ± 1.4 mm, p = 0.005) compared to the FT-4 group, whereas no significant differences were observed in the IKDC, Tegner, Korean knee score, or pivot shift test results. A simple linear regression revealed a significant negative correlation between graft diameter and postoperative anterior laxity (B = −0.398, p = 0.048). Conclusions: The present study demonstrated that the use of a six-strand hamstring graft configuration in the AI-6 technique resulted in significantly thicker grafts and was associated with reduced postoperative anterior knee laxity compared to the FT-4 technique. While interpretation of these findings requires caution in light of MCID thresholds, the AI-6 group showed favorable outcomes in anterior laxity and selected functional scores, such as the Lysholm and WOMAC. This technique may offer practical clinical value, particularly in populations prone to smaller graft diameters, as it facilitates adequate graft thickness through multifold preparation, with the all-inside approach accommodating the inherent graft shortening. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)
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8 pages, 190 KB  
Article
The Risk of Secondary Knee Procedures After Anterior Cruciate Ligament Reconstruction—A Nationwide Retrospective Cohort Study
by Han-Kook Yoon, Chang-Min Lee, Hyun-Cheol Oh, Taemi Youk and Sang-Hoon Park
J. Clin. Med. 2025, 14(11), 3823; https://doi.org/10.3390/jcm14113823 - 29 May 2025
Viewed by 787
Abstract
Objectives: Some following up patients have poor clinical outcomes when they experience anterior cruciate ligament reconstruction. The patient will undergo progression of knee joint osteoarthritis or several secondary knee procedures such as high tibial osteotomy, total knee arthroplasty, menisectomy, meniscus repair, or meniscus [...] Read more.
Objectives: Some following up patients have poor clinical outcomes when they experience anterior cruciate ligament reconstruction. The patient will undergo progression of knee joint osteoarthritis or several secondary knee procedures such as high tibial osteotomy, total knee arthroplasty, menisectomy, meniscus repair, or meniscus transplantation on their knees after anterior cruciate ligament reconstruction. This may be related to the remaining instability of the knee joint, changes in the knee joint biomechanics, and progression of osteoarthritis. This study aims to determine which secondary knee procedures are performed over time after anterior cruciate ligament reconstruction. Methods: The National Health Insurance Service-Health Screening database analyzed 146,122 patients who underwent ACL reconstruction surgery between 1 January 2002 and 31 December 2021. Secondary knee procedures were investigated by categorizing them into revisional reconstruction, high tibial osteotomy, total knee arthroplasty, menisectomy, meniscus repair, and meniscus transplantation, respectively. Multivariable Cox Proportional Hazard model analysis was used. The significant predictors for complications (p < 0.05) were as follows. Results: Among a total of 146,122 patients with anterior cruciate ligament reconstruction, 1073 (0.7%) patients underwent HTO, 908 (0.6%) patients underwent TKA, 15,218 (10.4%) patients underwent meniscectomy, 7169 (4.9%) patients underwent meniscus repair, and 938 (0.6%) patients underwent meniscus transplantation. The hazard ratio differed according to graft type, gender, and age group. Conclusions: Patients who undergo ACL reconstruction may experience poor clinical outcomes, such as progression of osteoarthritis and undergoing secondary knee procedures several years after ACL reconstruction. It is important for decision-making, ongoing monitoring, and follow-up care for patients undergoing ACL reconstruction. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)

Other

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17 pages, 3381 KB  
Systematic Review
Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Shows Reduced Graft Failure Rates and Superior Residual Rotational Stability Regardless of Anterolateral Ligament Reconstruction Graft: A Systematic Review
by Joo Hyung Han, Sung-Hwan Kim, Min Jung, Hyun-Soo Moon and Kwangho Chung
J. Clin. Med. 2025, 14(7), 2237; https://doi.org/10.3390/jcm14072237 - 25 Mar 2025
Viewed by 995
Abstract
Objectives: The aim of this study is to evaluate the literature for comparing clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with concomitant anterolateral ligament reconstruction (ALLR) versus isolated ACLR, with a primary focus on analyzing differences in outcomes based on the [...] Read more.
Objectives: The aim of this study is to evaluate the literature for comparing clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with concomitant anterolateral ligament reconstruction (ALLR) versus isolated ACLR, with a primary focus on analyzing differences in outcomes based on the type of graft used for ALLR. Methods: We identified comparative studies involving primary ACLR performed in conjunction with ALLR. Graft failure rates, residual pivot shift, residual anterior–posterior (AP) laxity at follow-up, and patient-reported outcome measures were determined. Variables associated with isolated ACLR and ACLR combined with ALLR were compared based on the type of graft used for ALLR. Results: This systematic review included nine studies involving 2740 patients. Combined ACLR with ALLR using hamstring tendon (HT) autografts or tibialis allografts showed lower graft failure rates than isolated ACLR (HT autograft: rate, 0–5.9%, odds ratio [OR], 2.16–12.91; tibialis allograft: rate, 0%, OR, 2.00–5.27). Similarly, the combined procedure showed reduced residual pivot shift rates (HT autograft: rate, 0–9.1%, OR, 2.00–12.16; tibialis allograft: rate, 0%, OR, 7.65–15.33) compared to isolated ACLR. Residual AP laxity and patient-reported outcomes were similar or more favorable for the combined procedure; however, the results were heterogeneous. Complications related to the type of graft used for ALLR or the presence of ALLR itself were not reported. Conclusions: Regardless of the graft type used for ALLR, the combination of ACLR with ALLR showed better clinical outcomes, including reduced graft failure rates and superior residual rotational stability compared to isolated ACLR. However, the high heterogeneity observed across studies suggests that these findings should be interpreted with caution, and further research is needed to draw more definitive conclusions. Full article
(This article belongs to the Special Issue Anterior Cruciate Ligament (ACL) Injuries: Clinical Treatment and Rehabilitation)
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