a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
Over the last 15 years, knowledge of tearing and recon-struction of the anterior cruciate ligament (ACL) has evolvedconsiderably. Anatomical studies have made it possible toprecisely identify ligament insertions in bones,1,2whilebiomechanical studies have provided better understandingof the function of each of the ligament bundles.2Betteranatomical knowledge and biological interest in preservingthe remnants of the torn ACL have led to modification of theclassical reconstruction techniques: double-band, anatomicaland selective for partial tears.
Complete tearing of the ACL can be diagnosed through clin-ical examination,8while partial tearing often cannot. In suchcases, complementary examinations are needed for confirma-tion. The definitive diagnosis of a partial ACL tear is reached bycombining clinical findings, imaging examinations and, whennecessary, arthroscopic findings. In cases of partial ACL tears,it is essential to assess the competence and functionality ofthe remaining fibers with regard to knee stabilization. It alsohas to be ascertained whether the event in question was apartial tear or whether there was a complete tear that is nowhealing.
A consensus for defining, diagnosing and treating partialACL tears is sought. Motivated by the discussion that stillexists in the literature and the need for better understand-ing, the present review had the aim of discussing partial ACLtears.
Definition
Norwood and Cross apud Colombet et al.9described threebands for the ACL that have anatomical and functionalimportance: anteromedial (AM), posterolateral (PL) and inter-mediate. Others have described two bands that present knownand accepted functionality.8-11Each band would contributeseparately toward stabilizing the knee and could be injuredseparately in partial tears. According to Hong et al.,10partialtears would be those in which less than 50% of the ligament istorn. On the other hand, according to Noyes et al.,11the def-inition of partial tears would be related to the percentage ofthe ACL fibers that are torn, given that tearing of 50-75% of thediameter would be highly correlated with clinical failure.
The American Medical Association, which divides theseinjuries into three degrees of severity, defines traumatic ACLtears as grade II when these tears are partial: moderate sprainscaused by direct or indirect trauma.9The clinical presentationin these cases would be characterized by pain, partial func-tional limitation, hemarthrosis and the possibility of episodesof instability. DeFranco and Bach6put forward a multifacto-rial definition that took into consideration the combinationof clinical and arthroscopic factors, and other authors wouldagree with this.
In cases of partial ACL tears, the most important objec-tive is to determine whether any remnant fibers are presentand whether they would enable clinical stability if they werekept. Although arthroscopic evaluation makes it possible toobserve these remnants, use of the traditional portals maygive rise to confusion in assessing them. Sonnery-Cottet andChambat12suggested using a "figure of 4" (Cabot) position forbetter assessment of the remnants of the PL band. Crain et al.,7Colombet et al.9and Sonnery-Cottet et al.13described pat-terns of partial tears. Among the cases evaluated, 17% wereconsidered to present good clinical quality and 83%, poor qual-ity. Better-quality tissue with preserved mechanical propertieswas seen more frequently when the PL band was present(70%), to the detriment of intercondylar healing (27%) or heal-ing of remnants adhering to the posterior cruciate ligament(13%). Although some studies have demonstrated clinical sta-bility associated with partial tears, Maeda et al.14did not findgreat stability in these cases.
Diagnosis
Diagnosing partial ACL tears remains a challenge. It needs tobe based on a combination of clinical examination and imag-ing examinations (radiography and magnetic resonance), withthe definitive diagnosis reached through arthroscopic assess-ment, when this is indicated.
Clinical examination
In a study conducted by the French Society of Arthroscopy,15aclinically significant degree of laxity (p < 0.05) was detected ina comparison between a population with complete ACL tears(98% of the patients presented a positive Lachman test and80% had a positive pivot shift test, i.e. +2 or +3) and a group withpartial tears (30-64% presented a hard or delayed stop in theLachman test and had a negative pivot shift test, i.e. 0 or +1). Inthat study, having a "soft stop" in the Lachman test was con-sidered to be a strong predictor of complete ACL tears, while a pivot shift test with less rebound (0 or +1) would correspond in94% of the cases to partial tears or even to incomplete healing.
Studies on cadavers have proven the difficulty in cor-relating the magnitude of the injury and its types withthe alterations seen in clinical tests.16Several authors havereported that it is possible to observe a hard stop in theLachman test in cases of partial tears.9,16,17The Lachmantest is more sensitive for diagnosing complete ACL tears,while the pivot shift test and jerk test are more specific.16-18Another point to be considered is that the sensitivity ofthe pivot shift test increases from 24% to 92% when thepatient is assessed under anesthesia, which is the best sit-uation for evaluating the functional state of the remainingfibers.9,19-21When this test is positive, it indicates rotationalinstability, which is not evaluated through differential anteriortranslation tests. In negative cases, the arthroscopic eval-uation makes it possible to assess associated injuries thatmight cause difficulty in the test: meniscal lesions, displacedchondral lesions and interposing of the remnants of theACL.
Measurement of the differential anterior translation
A variety of devices are available for measuring differentialanterior translation. The ones that are best known and usedin clinical practice are the KT 1000®, KT 2000®, Rolimeter®and Telos®devices. Their use for making diagnoses is moreaccurate in cases of subacute and chronic lesions with betterpain control and absence of muscle contractions. The differ-ential anterior translation is less than 3 mm in 95% of normalknees. In comparative evaluations, when this translation isgreater than 3 mm in relation to the asymptomatic side, 90%of such cases present ACL tears. Measurements of between3 and 5 mm may represent partial tears.17,20,21Dejour et al.17described differences in translation measurements betweenpatients with complete and partial tears. The patients withcomplete tears presented a mean of 9.1 ± 3.4 mm, in compari-son with 5.2 ± 2.9 mm among those with partial tears (p < 0.05).They also observed that 67% of the patients with preservationof the PL band presented adequate remaining clinical func-tion, versus 17% of those in whom the AM band was present.It was considered that functionality remained when the pivotshift test result was 0 or +1 and when the differential ante-rior translation was less than 4 mm. It needs to be borne inmind that these devices only evaluate the differential ante-rior translation, without any rotational evaluation. Their usein association with the other tests and imaging examinationsis fundamental for making the diagnosis and defining the ther-apy.
Imaging examinations
Radiology
Radiological evaluation performed together with measure-ments of the differential anterior translation has been shownto be important for diagnosing ACL injuries. In lateral radio-graphs with anteriorization of the tibia that are produced onindividuals with complete tears, significant translation of the
medial and lateral compartments can be seen, while in thosewith partial tears, little translation is seen in relation to thenormal side.9,22
Magnetic resonance
Despite all the technological development that has takenplace, it is still difficult to diagnose partial ACL tears. Magneticresonance may suggest that such injuries are present but
without the capacity to confirm this or make a functionalassessment on the remaining portions.21-23Specific slices arenecessary in order to make a distinction between completeand partial tears. Van Dyck et al.22suggested that certain axialand perpendicular views would be more accurate in makingdiagnoses based on magnetic resonance. Along with clinicalexamination and measurement of the differential anteriortranslation, magnetic resonance imaging is important fordefining and guiding the best treatment (Fig. 1).
Arthroscopic evaluation
Arthroscopic evaluation has been proposed by some authorsfor diagnosing partial tears.9,12,13,16,17However, in the lightof the current knowledge, there is no indication for system-atic arthroscopic evaluations for diagnosing such injuries.Arthroscopy makes it possible to diagnose the type of partialtear and, together with the clinical and imaging examinations,it determines the best type of reconstruction in cases in whichsurgical treatment is indicated (Fig. 2).
Multifactorial theoryPartial tears are common and account for 10% to 27% ofACL injuries.9Preservation of the AM and PL bands is seenin 11% and 16% of the cases, respectively. The frequencyof meniscal lesions is similar and the mean differentialanterior translation is 4.49 and 4.97 mm, respectively. Thetime that elapses between injury and surgical treatment isshorter (five months).3DeFranco and Bach6proposed a bet-ter approach in which multiple factors would be defined,such that asymmetrical Lachman tests, negative pivot shifttests, differential anterior translation from 3 to 4.9 mmand complementary positive evaluations using magneticresonance imaging and arthroscopy would be taken intoconsideration.
Treatment
The treatment needs to be individualized and appropriatefor each patient's needs. Identifying patients with low andhigh risk of progression of the clinical deficiency of the ACLis fundamental for providing therapeutic guidance. Low-riskpatients are the ones with low physical demands, with-out associated injuries or complaints of instability, whoseclinical tests are negative. These patients' signs and symp-toms generally tend not to progress and can be treatedconservatively.9,21,23High-risk patients are the ones withproven clinical instability and lifestyles that present a highrisk of new torsion. In these cases, the best option would beto perform selection surgical reconstruction of the ACL.21,23The treatment strategy always needs to take into consider-ation the symptoms, clinical examination, percentage of fibersremaining, associated injuries, length of time since the injuryand daily physical work demands.
Conservative treatment
The conservative treatments used include immobilizationwhile the patient remains symptomatic and then, after theacute phase, stimulation of complete movement and progres-sive weight-bearing.9,21,23The principles of rehabilitation forpatients with partial tears are the same as those used forpatients with complete tears. This rehabilitation consists ofexercises for muscle stretching and strengthening and car-diovascular, proprioceptive and adaptive training.24-26Pujolet al.27demonstrated that partial ACL tears may have thecapacity to heal, contrary to what had been thought.
Conservative treatment produces good results when cor-rectly indicated, with minimal reduction of activity leveland without impairing stability.21,23,24Other authors havesuggested that partial tears are functionally equivalent to complete tears and that conservative treatment wouldimply worse clinical and functional results.26,27Pujol et al.27described a series in which 25% of the patients with partialACL tears evolved with functional instability over the mediumto long term. Serial assessments would be necessary in orderto monitor the rehabilitation and residual laxity, which thuswould enable evaluation of whether conservative treatmentshould be maintained or whether it should be changed to asurgical approach.
Surgical treatment
IndicationTreatment with selective ACL reconstruction in cases of par-tial tears may be justified by different factors. The first ofthese is clinical: many partial tears progress to complete tearswith increasing differential anterior translation and the con-sequent possibility of meniscal and chondral lesions.9,16,17,28The second is biological: the central fibers of the ACL provideadequate vascular and nervous supplies to the new ligaments.Mechanoreceptors present in the remaining ligament areresponsible for preserving and restoring the stability and jointbalance.3,4,7,27Histological evaluations on ACL remnants havedemonstrated that they have the capacity to accelerate cellproliferation, revascularization and, consequently, integrationof the graft in cases of selective reconstruction.27-31The thirdis epidemiological: the risk of degenerative lesions subsequentto partial tears has not yet been established, although Kannusand Jarvinen25reported that 15% of their patients with par-tial tears presented degenerative lesions after eight years offollow-up.
Treatment
Selective reconstruction has some points in common withanatomical ACL reconstruction: graft options, rehabilitationprogram and time taken to return to physical practices. Themost important difference lies in the biological concept. Otherdifferences relate to tunnel positioning and milling, along withthe graft diameter and passage. The options for surgical treat-ment of partial ACL tears include thermal measures, classicalreconstruction and selective reconstruction. Thermal meas-ures and classical reconstruction are not addressed in thisreview.
The arthroscopic evaluation is started through the clas-sical portals: anteromedial and anterolateral. Some authorshave proposed that an accessory anteromedial portal shouldbe created: this would facilitate viewing the graft and the foot-prints. Sonnery-Cottet et al.29proposed that the anterolateralportal should be constructed slightly proximally in order tohave better viewing and less need for debridement of Hoffa'sfat. After an inventory of all compartments has been made,the associated lesions are treated and then the remainingfibers of the ACL are assessed. This evaluation is visual (withconfirmation of the presence of continuous fibers connectingfootprints) and mechanical, and is done both in a semi-flexedposition and in a "figure of 4" position. Tension is assessed bymeans of palpation and via clinical tests under arthroscopicviewing.
32,33Graft selection
The choice of graft should follow the surgeon's routine. Sev-eral authors have reported making increasing use of flexortendons, which may be triple or quadruple and either freeor maintained in their tibial insertions.3,4,9,13The presenceof bone blocks may make passage through the tunnels thuscreated more difficult. From the intercondylar space that isassociated with preservation of greatest numbers of rem-nant fibers, a graft diameter of 8 mm has been found to bemost appropriate.5,9,12,13The concept that the greater the graftdiameter is the better this would be conflicts with the anatom-ical concept of preservation of the remnants and with thebiology of healing between these remnants and the graft.
Technical details
Reconstruction of the AM band
The arthroscopic procedure begins with moderate debride-ment of the remnants of the AM band with preservation ofthe PL band. Siebold and Fu34recommended that a tibial guideat an angle of 60?should be used, with an entry point around1.5 cm medially to the anterior tuberosity of the tibia. The posi-tion of the femoral tunnel should follow the presence of theremnants in the femur in the anatomical position. To con-struct this tunnel, inside-out or outside-in guides can be used.Milling should be done manually or by means of low-velocitydrilling, so as to avoid further injuring the remains of the ACL.
Reconstruction of the PL band
The position of the tibial tunnel is more medial and beginsaround 3.5 cm medially to the anterior tuberosity of the tibia.The intra-articular portion is located in the posterior part ofthe tibial insertion and 5 mm medially to the lateral inter-condylar eminence. Use of the femoral remains is the mostreliable way of finding the site for the femoral tunnel. It isconstructed by means of the anteromedial portal or using anoutside-in technique. For tunnels constructed by means of themedial portal, attention needs to be given to the risk of iatro-genic lesions in the medial femoral condyle at the time ofmilling.
Graft fixation
The fixation will depend on the technique used. If the inside-out technique is used, interference screws or Endobutton®are recommended for the femoral portion and interferencescrews for the tibial portion. If the outside-in technique isused, interference screws can be used in both tunnels. Thereis room for debate regarding whether the fixation should bedone without pre-tensioning, or whether it should be doneafter pre-tensioning, which theoretically would ensure betteradaptation of the graft.28,29,34For selective reconstruction ofthe PL band, fixation is done with flexion of between 0?and10?, while for reconstruction of the AM band, the fixation angleis more variable. Some authors have described fixation atbetween 50?and 60?, while others have recommended flexion of 20?.9,21,23,34After fixation, the entire range of motion shouldbe tested, with special attention to extension. If this is notachieved, it may be a source of pain and/or loss of movement.
Clinical evaluation
Mott was the first author to report satisfactory clinical resultsfrom selective reconstruction after acute ACL tearing.9,21,23Adachi et al.3,35and Ochi et al.4,36published data on patientseries in which they compared selective and classical ACLreconstruction. Smaller differential anterior translation wasfound in the selective group. This observation was perhapsdue to the better vascularization and reinnervation at thetime of selective reconstruction. In 2009, Ochi et al.36pub-lished data on a new series of 45 patients who underwentselective reconstruction with a follow-up of two years. Theyshowed using magnetic resonance imaging that the differen-tial anterior translation was less than 0.5 mm, proprioceptionwas better and healing was effective after the operation. Thesefindings corroborated those of a study conducted in 2002 thatdemonstrated that there was an association between the pres-ence of mechanoreceptors in the remaining fibers and betterproprioception.
Buda et al.5evaluated 47 patients who underwent selec-tive reconstruction. Good or excellent clinical results wereseen in 95.7% of the cases. Good clinical results were corre-lated with integration of the graft with the remaining fibersand with presence of a signal on magnetic resonance imaging.Attention was drawn to the fact that in selective reconstruc-tion procedures, the graft needs to be between 7 and 8 mm,which would avoid an excess of fibers between the remainderof the ACL and the graft.5,32Sonnery-Cottet et al.37evaluated36 patients who underwent reconstruction of the AM bandand observed that the differential anterior translation was lessthan 0.8 mm. In following up patients who had been treatedwith selective reconstruction of partial tears, Chouteau et al.38demonstrated that the stability and proprioception of thetreated knee were similar to those of the normal knee.
Few published papers have compared classical ACLreconstructions and selective reconstruction procedures, withfunctional and non-functional remnant ligaments. A greaternumber of studies would be useful in order to evaluate theenvironment created by the remnants and their effect on grafthealing. The results from selective reconstruction are encour-aging, although there is still a lack of evidence that wouldprove its real benefit.
Final remarks
Partial ACL tears are being diagnosed more and more fre-quently. They account for 10-27% of all such injuries. Thereis no single definition for them in the literature. They canbe diagnosed through a combination of clinical examinationand imaging examination, with confirmation through arthro-scopic examination. The pivot shift test under anesthesia,the hard-stop Lachman test, magnetic resonance findings, thelevel and type of sports activity, the arthroscopic appearanceof the remnant ligament and the mechanical properties areelements used by orthopedists for deciding between conserva-tive treatment, surgical treatment with reinforcement of thenative ACL (selective reconstruction) and classical (anatom-ical) ACL reconstruction. When there is an indication forsurgery, preservation of the remaining fibers is fundamental,in order to preserve the mechanical, vascular and propriocep-tive capacity of the knee.
Conflicts of interest
The authors declare no conflicts of interest.
s1. Purnell ML, Larson AI, Clancy W. Anterior cruciate ligamentinsertions on the tibia and femur and their relationships tocritical bony landmarks using high-resolutionvolume-rendering computed tomography. Am J Sports Med.2008;36(11):2083-90.2. Zantop T, Herbort M, Raschke MJ, Fu FH, Petersen W. The roleof the anteromedial and posterolateral bundles of theanterior cruciate ligament in anterior tibial translation andinternal rotation. Am J Sports Med. 2007;35(2):223-7.3. Adachi N, Ochi M, Uchio Y, Sumen Y. Anterior cruciateligament augmentation under arthroscopy. A minimum2-year follow-up in 40 patients. Arch Orthop Trauma Surg.2000;120(3-4):128-33.4. Ochi M, Adachi N, Deie M, Kanaya A. Anterior cruciateligament augmentation procedure with a 1-incisiontechnique: anteromedial bundle or posterolateral bundlereconstruction. Arthroscopy. 2006;22(4), 463.e1-5.5. Buda R, Ferruzzi A, Vannini F, Zambelli L, Di Caprio F.Augmentation technique with semitendinosus and gracilistendons in chronic partial lesions of the ACL: clinical andarthrometric analysis. Knee Surg Sports Traumatol Arthrosc.2006;14(11):1101-7.6. DeFranco MJ, Bach BR Jr. A comprehensive review of partialanterior cruciate ligament tears. J Bone Jt Surg Am.2009;91(1):198-208.7. Crain EH, Fithian DC, Paxton EW, Luetzow WF. Variation inanterior cruciate ligament scar pattern: does the scar patternaffect anterior laxity in anterior cruciate ligament-deficientknees? Arthroscopy. 2005;21(1):19-24.8. Amis AA, Dawkins GP. Functional anatomy of the anteriorcruciate ligament. Fibre bundle actions related to ligamentreplacements and injuries. J Bone Jt Surg Br. 1991;73(2):260-7.9. Colombet P, Dejour D, Panisset JC, Siebold R. Current conceptof partial anterior cruciate ligament ruptures. OrthopTraumatol Surg Res. 2010;96(8 Suppl):S109-18.10. Hong SH, Choi JY, Lee GK, Choi JA, Chung HW, Kang HS.Grading of anterior cruciate ligament injury. Diagnosticefficacy of oblique coronal magnetic resonance imaging ofthe knee. Comput Assist Tomogr. 2003;27(5):814-9.11. Noyes FR, Mooar LA, Moorman CT 3rd, McGinniss GH. Partialtears of the anterior cruciate ligament. Progression tocomplete ligament deficiency. J Bone Jt Surg Br.12. Sonnery-Cottet B, Chambat P. Arthroscopic identification ofthe anterior cruciate ligament posterolateral bundle: thefigure-of-four position. Arthroscopy. 2007;23(10), 1128. e1-3.13. Sonnery-Cottet B, Barth J, Graveleau N, Fournier Y, Hager JP,Chambat P. Arthroscopic identification of isolated tear of theposterolateral bundle of the anterior cruciate ligament.Arthroscopy. 2009;25(7):728-32.14. Maeda S, Ishibashi Y, Tsuda E, Yamamoto Y, Toh S.Intraoperative navigation evaluation of tibial translation afterresection of anterior cruciate ligament remnants.Arthroscopy. 2011;27(9):1203-10.15. Panisset JC, Duraffour H, Vasconcelos W, Colombet P, Javois C,Potel JF, et al. Clinical, radiological and arthroscopic analysisof the ACL tear. A prospective study of 418 cases. Rev ChirOrthop Reparatrice Appar Mot. 2008;94(8 Suppl):362-8.16. Abat F, Gelber PE, Erquicia JI, Pelfort X, Tey M, Monllau JC.Promising short-term results following selective bundlereconstruction in partial anterior cruciate ligament tears.Knee. 2013;20(5):332-8.17. Dejour D, Ntagiopoulos PG, Saggin PR, Panisset JC. Thediagnostic value of clinical tests, magnetic resonanceimaging, and instrumented laxity in the differentiation ofcomplete versus partial anterior cruciate ligament tears.Arthroscopy. 2013;29(3):491-9.18. Robert H, Nouveau S, Gageot S, Gagnière B. A new kneearthrometer, the GNRB: experience in ACL complete andpartial tears. Orthop Traumatol Surg Res. 2009;95(3):171-6.19. Araki D, Kuroda R, Matsushita T, Matsumoto T, Kubo S,Nagamune K, et al. Biomechanical analysis of the knee withpartial anterior cruciate ligament disruption: quantitativeevaluation using an electromagnetic measurement system.Arthroscopy. 2013;29(6):1053-62.20. Panisset JC, Ntagiopoulos PG, Saggin PR, Dejour D. Acomparison of TelosTMstress radiography versus RolimeterTMin the diagnosis of different patterns of anterior cruciateligament tears. Orthop Traumatol Surg Res. 2012;98(7):751-8.21. Lorenz S, Imhoff AB. Reconstruction of partial anteriorcruciate ligament tears. Oper Orthop Traumatol.2014;26(1):56-62.22. Van Dyck P, Vanhoenacker FM, Gielen JL, Dossche L, VanGestel J, Wouters K, et al. Three tesla magnetic resonanceimaging of the anterior cruciate ligament of the knee: can wedifferentiate complete from partial tears? Skelet Radiol.2011;40(6):701-7.23. Tjoumakaris FP, Donegan DJ, Sekiya JK. Partial tears of theanterior cruciate ligament: diagnosis and treatment. Am JOrthop (Belle Mead NJ). 2011;40(2):92-7.24. Sonnery-Cottet B, Panisset JC, Colombet P, Cucurulo T,Graveleau N, Hulet C, et al. Partial A.C.L. reconstruction withpreservation of the posterolateral bundle. Orthop TraumatolSurg Res. 2012;98(8 Suppl):S165-70.25. Kannus P, Järvinen M. Conservatively treated tears of theanterior cruciate ligament. Long-term results. J Bone Jt SurgAm. 1987;69(7):1007-12.26. Kocher MS, Micheli LJ, Zurakowski D, Luke A. Partial tears ofthe anterior cruciate ligament in children and adolescents.Am J Sports Med. 2002;30(5):697-703.27. Pujol N, Colombet P, Cucurulo T, Graveleau N, Hulet C,Panisset JC, et al. Natural history of partial anterior cruciateligament tears: a systematic literature review. OrthopTraumatol Surg Res. 2012;98(8 Suppl):S160-4.28. Dejour D, Potel JF, Gaudot F, Panisset JC, Condouret J. The ACLtear from the pre-operative analysis to a 2-year follow-up,influence of the graft choice on the subjective and objectiveevaluation. Rev Chir Orthop Reparatrice Appar Mot. 2008;94(8Suppl):356-61.29. Sonnery-Cottet B, Lavoie F, Ogassawara R, Scussiato RG,Kidder JF, Chambat P. Selective anteromedial bundlereconstruction in partial ACL tears: a series of 36 patientswith mean 24 months follow-up. Knee Surg Sports TraumatolArthrosc. 2010;18(1):47-51.30. Adachi N, Ochi M, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M.Mechanoreceptors in the anterior cruciate ligamentcontribute to the joint position sense. Acta Orthop Scand.2002;73(3):330-4.31. Nakamae A, Ochi M, Deie M, Adachi N, Kanaya A, NishimoriM, et al. Biomechanical function of anterior cruciate ligamentremnants: how long do they contribute to knee stability afterinjury in patients with complete tears? Arthroscopy.2010;26(12):1577-85.32. Buda R, Ruffilli A, Parma A, Pagliazzi G, Luciani D, Ramponi L,et al. Partial ACL tears: anatomic reconstruction versusnonanatomic augmentation surgery. Orthopedics.2013;36(9):e1108-13.33. Condouret J, Cohn J, Ferret JM, Lemonsu A, Vasconcelos W,Dejour D, et al. Isokinetic assessment with two yearsfollow-up of anterior cruciate ligament reconstruction withpatellar tendon or hamstring tendons. Rev Chir OrthopReparatrice Appar Mot. 2008;94(8 Suppl):375-82.34. Siebold R, Fu FH. Assessment and augmentation ofsymptomatic anteromedial or posterolateral bundle tears ofthe anterior cruciate ligament. Arthroscopy.2008;24(11):1289-98.35. Adachi N, Ochi M, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M.Mechanoreceptors in the anterior cruciate ligamentcontribute to the joint position sense. Acta Orthop Scand.2002;73(3):330-4.36. Ochi M, Adachi N, Uchio Y, Deie M, Kumahashi N, Ishikawa M,et al. A minimum 2-year follow-up after selectiveanteromedial or osterolateral bundle anterior cruciateligament reconstruction. Arthroscopy. 2009;25(2):117-22.37. Sonnery-Cottet B, Lavoie F, Ogassawara R, Scussiato RG,Kidder JF, Chambat P. Selective anteromedial bundlereconstruction in partial ACL tears: a series of 36 patientswith mean 24 months follow-up. Knee Surg Sports TraumatolArthrosc. 2010;18(1):47-51.38. Chouteau J, Testa R, Viste A, Moyen B. Knee rotational laxityand proprioceptive function 2 years after partial ACLreconstruction. Knee Surg Sports Traumatol Arthrosc.2012;20(4):762-6.39. Papalia R, Franceschi F, Zampogna B, Tecame A, Maffulli N,Denaro V. Surgical management of partial tears of theanterior cruciate ligament. Knee Surg Sports TraumatolArthrosc. 2014;22(1):154-65.
