Computer assisted surgery for knee ligament reconstruction

One-incision versus two-incision techniques for arthroscopically assisted anterior cruciate ligament reconstruction in adults

BACKGROUND

Anterior cruciate ligament (ACL) tears are serious knee injuries that are frequently treated surgically in the form of arthroscopically assisted reconstruction with grafts from the patella or hamstrings tendons. We reviewed the evidence for the choice of arthroscopically assisted ACL reconstruction technique in terms of whether it should involve one incision (femoral tunnel drilled from inside the knee joint under arthroscopic visualisation) or two incisions (femoral tunnel drilled from outside to inside the knee joint).

OBJECTIVES

To assess the effects (benefits and harms) of one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Latin American and Caribbean Health Sciences (LILACS), the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, reference lists, and conference abstracts. The date of the search was 16 August 2017.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials evaluating one-incision versus two-incision techniques for arthroscopically assisted ACL reconstruction in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched and selected studies, and extracted data and assessed the risk of bias of the eligible studies. We undertook limited pooling of data using the fixed-effect model.

MAIN RESULTS

We included five trials (four randomised and one quasi-randomised) evaluating a total of 320 participants who were mainly in their 20s. All participants underwent ACL reconstruction with patella tendon grafts. All five included trials were at a high risk of bias, particularly performance bias. Based on these limitations and the insufficiency of the available data resulting in imprecision of effect estimates, we judged the quality of the evidence as very low for all outcomes. This means that we are uncertain of the findings of the review.We found very low-quality evidence of no clinically important differences between the two techniques in self reported knee function, measured using the Lysholm knee score (scale 0 to 100: best outcome), at short-term (3 months) (mean difference (MD) 2.73 favours one-incision technique, 95% confidence interval (CI) -2.70 to 8.15; 79 participants, 2 studies), intermediate-term (12 months) (MD -3.68 favours two-incision technique, 95% CI -6.61 to -0.75; 79 participants, 2 studies), and long-term follow-up. The data available for long-term follow-up (2 to 5 years) was expressed in terms of the numbers of participants with excellent Lysholm scores (90 points or more); we found no difference between the two groups (42/45 versus 36/40; risk ratio (RR) 1.04, 95% CI 0.91 to 1.18; 1 study). There were no data for quality of life measures or for overall numbers of participants incurring an adverse event. We found very low-quality evidence of little between-group differences in individual adverse events such as infection, knee stiffness, reoperation, and graft failure.We found very low-quality evidence from one study (59 participants) of little difference between the two groups in activity levels measured using Tegner scores (scale 0 to 10: highest sport activity) at two years (MD -0.80 favours two-incision technique, 95% CI -1.90 to 0.30). There was very low-quality evidence from four studies of minimal between-group difference in the number of participants with normal or nearly normal objectively measured knee function (International Knee Documentation Committee objective assessment grading) at intermediate follow-up (means 12 to 28 months): 56/78 versus 63/89; RR 1.01, 95% CI 0.85 to 1.21; 167 participants).

AUTHORS' CONCLUSIONS

The very low-quality and often absent evidence means that we are uncertain whether one-incision arthroscopically assisted ACL reconstruction techniques yield better, worse, or equivalent results compared with two-incision techniques in terms of short-, intermediate-, or long-term subjective function, quality of life, adverse outcomes, activity levels, and objectively rated knee function. The evidence was available only for single-bundle ACL reconstruction using patella tendon grafts.When considering priorities for high-quality randomised trials on techniques for ACL reconstruction, it is important to note the insufficiency of the evidence available to inform this key comparison.

Contacting of authors by systematic reviewers: protocol for a cross-sectional study and a survey

BACKGROUND

Synthesizing outcomes of underreported primary studies can pose a serious threat to the validity of outcomes and conclusions of systematic reviews. To address this problem, the Cochrane Collaboration recommends reviewers to contact authors of eligible primary studies to obtain additional information on poorly reported items. In this protocol, we present a cross-sectional study and a survey to assess (1) how reviewers of new Cochrane intervention reviews report on procedures and outcomes of contacting of authors of primary studies to obtain additional data, (2) how authors reply, and (3) the consequences of these additional data on the outcomes and quality scores in the review. All research questions and methods were pilot tested on 2 months of Cochrane reviews and were subsequently fine-tuned.

METHODS FOR THE CROSS-SECTIONAL STUDY

Eligibility criteria are (1) all new (not-updates) Cochrane intervention reviews published in 2016, (2) reviews that included one or more primary studies, and (3) eligible interventions refer to contacting of authors of the eligible primary studies included in the review to obtain additional research data (e.g., information on unreported or missing data, individual patient data, research methods, and bias issues). Searching for eligible reviews and data extraction will be conducted by two authors independently. The cross-sectional study will primarily focus on how contacting of authors is conducted and reported, how contacted authors reply, and how reviewers report on obtained additional data and their consequences for the review.

METHODS FOR THE SURVEY

The same eligible reviews for the cross-sectional study will also be eligible for the survey. Surveys will be sent to the contact addresses of these reviews according to a pre-defined protocol. We will use Google Forms as our survey platform. Surveyees are asked to answer eight questions. The survey will primarily focus on the consequences of contacting authors of eligible primary studies for the risk of bias and Grading of Recommendations, Assessment, Development and Evaluation scores and the primary and secondary outcomes of the review.

DISCUSSION

The findings of this study could help improve methods of contacting authors and reporting of these procedures and their outcomes. Patients, clinicians, researchers, guideline developers, research sponsors, and the general public will all be beneficiaries.

Current use of navigation system in ACL surgery: a historical review

PURPOSE

The present review aims to analyse the available literature regarding the use of navigation systems in ACL reconstructive surgery underling the evolution during the years.

METHODS

A research of indexed scientific papers was performed on PubMed and Cochrane Library database. The research was performed in December 2015 with no publication year restriction. Only English-written papers and related to the terms ACL, NAVIGATION, CAOS and CAS were considered. Two reviewers independently selected only those manuscripts that presented at least the application of navigation system for ACL reconstructive surgery.

RESULTS

One hundred and forty-six of 394 articles were finally selected. In this analysis, it was possible to review the main uses of navigation system in ACL surgery including tunnel positioning for primary and revision surgery and kinematic assessment of knee laxity before and after different surgical procedures. In the early years, until 2006, navigation system was mainly used to improve tunnel positioning, but since the last decade, this tool has been principally used for kinematics evaluation. Increased accuracy of tunnel placement was observed using navigation surgery, especially, regarding femoral, 42 of 146 articles used navigation to guide tunnel positioning. During the following years, 82 of 146 articles have used navigation system to evaluate intraoperative knee kinematic. In particular, the importance of controlling rotatory laxity to achieve better surgical outcomes has been underlined.

CONLUSIONS

Several applications have been described and despite the contribution of navigation systems, its potential uses and theoretical advantages, there are still controversies about its clinical benefit. The present papers summarize the most relevant studies that have used navigation system in ACL reconstruction. In particular, the analysis identified four main applications of the navigation systems during ACL reconstructive surgery have been identified: (1) technical assistance for tunnel placement; (2) improvement in knowledge of the kinematic behaviour of ACL and other structures; (3) comparison of effectiveness of different surgical techniques in controlling laxities; (4) navigation system performance to improve the outcomes of ACL reconstruction and cost-effectiveness.

LEVEL OF EVIDENCE

IV.

MRI signal intensity of anterior cruciate ligament graft after transtibial versus anteromedial portal technique (TRANSIG): design of a randomized controlled clinical trial

Background

There are two primary surgical techniques to reconstruct the anterior cruciate ligament (ACL), transtibial (TT) technique and anteromedial portal (AMP) technique. Currently, there is no consensus which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study is to compare the MRI derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare the outcomes of both the AMP and TT ACL reconstruction technique.

Methods/design

Thirty-six patients will be included in a randomized controlled trial. Patients who are admitted for primary unilateral ACL reconstruction will be included in the study. Exclusion criteria are a history of previous surgery on the ipsilateral knee, re-rupture of the ipsilateral ACL graft, associated ligamentous injuries or meniscal tear of the ipsilateral knee, unhealthy contralateral knee, contra-indications for MRI and a preference for one of the two surgical techniques and/or orthopaedic surgeon. Primary outcome is MRI Signal intensity ratio (SIR) of the ACL graft. Secondary outcome measures are the International Knee Documentation Committee (IKDC) Knee Examination Form,the Knee injury and Osteoarthritis Outcome Scores (KOOS) and the Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS). Differences between MRI SIR assessment with the current MRI protocol (proton density weighted imaging protocol) and the additional T2*-weighted gradient-echo protocol will be assessed.

Discussion

There is no consensus regarding the TT or AMP ACL reconstruction technique. SI measurements with MRI have been used in other clinical studies for evaluation of the ACL graft and maturation after ACL reconstruction compared to clinical and functional outcomes. This randomized controlled trial has been designed to compare the TT technique with the AMP technique with the use of MRI SI of the graft after ACL reconstruction.

Trial registration

Netherlands Trial Registry NTR5410 (registered on August 24, 2015).

Constrained Statistical Modelling of Knee Flexion From Multi-Pose Magnetic Resonance Imaging

Reconstruction of the anterior cruciate ligament (ACL) through arthroscopy is one of the most common procedures in orthopaedics. It requires accurate alignment and drilling of the tibial and femoral tunnels through which the ligament graft is attached. Although commercial computer-assisted navigation systems exist to guide the placement of these tunnels, most of them are limited to a fixed pose without due consideration of dynamic factors involved in different knee flexion angles. This paper presents a new model for intraoperative guidance of arthroscopic ACL reconstruction with reduced error particularly in the ligament attachment area. The method uses 3D preoperative data at different flexion angles to build a subject-specific statistical model of knee pose. To circumvent the problem of limited training samples and ensure physically meaningful pose instantiation, homogeneous transformations between different poses and local-deformation finite element modelling are used to enlarge the training set. Subsequently, an anatomical geodesic flexion analysis is performed to extract the subject-specific flexion characteristics. The advantages of the method were also tested by detailed comparison to standard Principal Component Analysis (PCA), nonlinear PCA without training set enlargement, and other state-of-the-art articulated joint modelling methods. The method yielded sub-millimetre accuracy, demonstrating its potential clinical value.

A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament

BACKGROUND

There has been a substantial increase in the amount of systematic reviews and meta-analyses published on the anterior cruciate ligament (ACL).

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the ACL in the past decade and to provide an overall summary of this literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all ACL-related systematic reviews and meta-analyses published between January 2004 and September 2014 was performed using PubMed, MEDLINE, and the Cochrane Database. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 1031 articles were found, of which 240 met the inclusion criteria. Included articles were summarized and divided into 17 topics: anatomy, epidemiology, prevention, associated injuries, diagnosis, operative versus nonoperative management, graft choice, surgical technique, fixation methods, computer-assisted surgery, platelet-rich plasma, rehabilitation, return to play, outcomes assessment, arthritis, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on the ACL can supply the surgeon with a single source for the most up-to-date synthesis of the literature.

Three-dimensional computed tomography evaluation of anterior cruciate ligament footprint for anatomic single-bundle reconstruction

PURPOSE

Femoral and tibial footprint coordinates have been well studied in double-bundle anterior cruciate ligament (ACL) reconstruction. However, in a single-bundle reconstruction approach, the central coordinate of femoral and tibial footprints have not been determined. The purpose of this study was to describe the central point locations of the ACL footprints visualized by three-dimensional computed tomography (3D CT) images and analysed by the quadrant method.

METHODS

Eight cadaveric knees were dissected, and the central points of ACL femoral and tibial footprints were marked and analysed using 3D CT images.

RESULTS

In the present study, the means (and standard deviation) of ACL femoral footprint dimensions were in the ventral-dorsal plane and in the cranial-caudal plane 9.4 ± 0.8 and 15.6 ± 0.9 mm, respectively. In the tibial side, the means of ACL footprint dimensions were in the anterior-posterior and in the medial-lateral 18.5 ± 1.9 and 15.5 ± 1.0 mm, respectively. In the tomographic analyses, the means of femoral central location coordinates in the ventral-dorsal (y) and in the cranial-caudal (x) axes were 35.3 ± 4.5 and 30.0 ± 1.6 %, respectively. The means of tibial central location coordinates were in the anterior-posterior (y) and in the medial-lateral (x) axes, respectively: 40.5 ± 5.3 and 50.2 ± 1.3 %, respectively.

CONCLUSIONS

These computed tomographic coordinates might help future studies as a reference on ACL single-bundle anatomic reconstruction, with respect to the management of ACL revision surgery or in symptomatic patients after ACL reconstruction. Improvements in three-dimensional image acquisition could facilitate its intraoperative applicability in the coming years.

Computer-assisted surgery for knee ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults.

SEARCH METHODS

For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI).

MAIN RESULTS

The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes.

AUTHORS' CONCLUSIONS

From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.

Computer-assisted surgery for knee ligament reconstruction

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction is one of the most frequently performed orthopaedic procedures. The most common technical cause of reconstruction failure is graft malpositioning. Computer-assisted surgery (CAS) aims to improve the accuracy of graft placement. Although posterior cruciate ligament (PCL) injury and reconstruction are far less common, PCL reconstruction has comparable difficulties relating to graft placement. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To assess the effects of computer-assisted reconstruction surgery versus conventional operating techniques for ACL or PCL injuries in adults.

SEARCH METHODS

For this update, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (from 2010 to July 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2013), MEDLINE (from 2010 to July 2013), EMBASE (from 2010 to July 2013), CINAHL (from 2010 to July 2013), article references and prospective trial registers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials that compared CAS for ACL or PCL reconstruction versus conventional operating techniques not involving CAS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results, assessed the risk of bias in the studies and extracted data. Where appropriate, we pooled data using risk ratios (RR) or mean differences (MD), both with 95% confidence intervals (CI).

MAIN RESULTS

The updated search resulted in the inclusion of one new study. This review now includes five RCTs with 366 participants. There were more female than male participants (70% were female); their ages ranged from 14 to 53 years. All trials involved ACL reconstructions performed by experienced surgeons.Assessing the studies' risk of bias was hampered by poor reporting of trial methods, and consequently several studies were judged to be 'unclear' for several types of bias. One trial presenting primary outcome data was at high risk of detection bias from lack of clinician blinding and attrition bias from an unaccounted loss to follow-up at two years.We found moderate quality evidence (three trials, 193 participants) of no clinically relevant difference between CAS and conventional surgery in International Knee Documentation Committee (IKDC) subjective scores (self-reported measure of knee function; scale of 0 to 100 where 100 was best function). Pooled data from two of these trials (120 participants) showed a small, but clinically irrelevant difference favouring CAS (MD 2.05, 95% CI -2.16 to 6.25). A third trial (73 participants) also found minimal difference in IKDC subjective scores (reported MD 0.2).We found low quality evidence (two trials, 120 participants) showing no difference between the two groups in Lysholm scores, also measured on a scale 0 to 100 where 100 is best function (MD 0.25, 95% CI -3.75 to 4.25). We found very low quality evidence (one trial, 40 participants) showing no difference between the two groups in Tegner scores. We found low quality evidence (three trials, 173 participants) showing the majority of participants in both groups were assessed as having normal or nearly normal knee function (86/87 with CAS versus 84/86 with no CAS; RR 1.01, 95% CI 0.96 to 1.06).Similarly, no differences were found for our secondary outcome measures of knee stability, loss in range of motion and tunnel placement. None of the trials reported on re-operation.No adverse post-surgical events were reported in two trials (133 participants); this outcome was not reported by the other three trials.CAS use was associated with longer operating times compared with conventional operating techniques: the mean difference in operating times reported in the studies ranged between 9 and 27 minutes.

AUTHORS' CONCLUSIONS

From the available evidence, we are unable to demonstrate or refute a favourable effect of CAS for cruciate ligament reconstructions of the knee compared with conventional reconstructions. However, the currently available evidence does not indicate that CAS in knee ligament reconstruction improves outcome. There is a need for improved reporting of future studies of this technology.

Anterior cruciate ligament reconstruction best practice: A review of graft choice

There is much literature about differing grafts used in anterior cruciate ligament (ACL) reconstruction. Much of this is of poor quality and of a low evidence base. We review and summarise the literature looking at the four main classes of grafts used in ACL reconstruction; bone-patella tendon-bone, hamstrings, allograft and synthetic grafts. Each graft has the evidence for its use reviewed and then compared, where possible, to the others. We conclude that although there is no clear “best” graft, there are clear differences between the differing graft choices. Surgeon’s need to be aware of the evidence behind these differences, in order to have appropriate discussions with their patients, so as to come to an informed choice of graft type to best suit each individual patient and their requirements.

Accuracy of a computer-assisted planning and placement system for anatomical femoral tunnel positioning in anterior cruciate ligament reconstruction

BACKGROUND

Femoral tunnel positioning is a difficult, but important factor in successful anterior cruciate ligament (ACL) reconstruction. Computer navigation can improve the anatomical planning procedure besides the tunnel placement procedure.

METHODS

The accuracy of the computer-assisted femoral tunnel positioning method for anatomical double bundle ACL-reconstruction with a three-dimensional template was determined with respect to both aspects for AM and PL bundles in 12 cadaveric knees.

RESULTS

The accuracy of the total tunnel positioning procedure was 2.7 mm (AM) and 3.2 mm (PL). These values consisted of the accuracies for planning (AM:2.9 mm; PL:3.2 mm) and for placement (about 0.4 mm). The template showed a systematic bias for the PL-position.

CONCLUSIONS

The computer-assisted templating method showed high accuracy for tunnel placement and has promising capacity for application in anatomical tunnel planning. Improvement of the template will result in an accurate and robust navigation system for femoral tunnel positioning in ACL-reconstruction.

Applications of computer navigation in sports medicine knee surgery: an evidence-based review

Computer-assisted surgery (CAS) has been investigated in a number of sports medicine procedures in the knee. Current barriers to its widespread introduction include increased costs, duration, and invasiveness of surgery. Randomized trials on the use of CAS in anterior cruciate ligament reconstruction have failed to demonstrate a clinical benefit. Data on CAS use in high tibial osteotomy are more promising; however, long-term studies are lacking. CAS has a number of research applications in knee ligament surgery, and studies continue to explore its use in the treatment of osteochondral lesions. This article reviews the applications of CAS in sports medicine knee surgery and summarizes current literature on clinical outcomes.

Research status and application prospects of digital technology in orthopaedics

In the last 10 years, basic and clinical research in orthopaedics has developed rapidly. Understanding of orthopaedic disorders involves not only routine diagnosis, but also the pursuit of highly efficient and accurate three-dimensional imaging of the intra- and extra-medullary distribution, form and structure of orthopaedic disorders, thus allowing scientific evaluation of the indications for surgery, drawing up of the best surgical plan, minimization of operative trauma and the earliest possible restoration of limb function. Meanwhile, the most important type of basic research, which was previously biomechanical research, has gradually become computational biomechanics based on in vitro cadaver experiments. This review aims to summarize the research status and application prospects of digital technology in orthopaedics, including virtual reality technology, reverse engineering and rapid prototyping techniques, computational biomechanics, computer navigation technology and management of digitization of medical records.

Guideline on anterior cruciate ligament injury

The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the "Appraisal of Guidelines for Research and Evaluation" instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.