cyclops lesion without acl repair

Featuredin theTop 50 Physical Therapy Blog. A cyclops lesion with loss of knee extension with or without an audible or palpable cluck at terminal knee extension constitutes the cyclops syndrome. It is not an actual Cyclops lesion as it is a torn ACL instead of fibrotic tissue. Rehabilitation of soleus muscle injuries in distance runners, Uncommon injuries: sural nerve neuropathy, Dr. Alexandra Fandetti-Robin, Back & Body Chiropractic, Hamstring or not? The only case reported previously was by Rubin et al following bone-patellar tendon-bone ACL reconstruction.2. (2A) The T2-weighted sagittal image demonstrates a nodular heterogeneously low signal mass (arrow) at the anterior margin of the ACL graft. Cyclops lesions detected by MRI are frequent findings after ACL surgical reconstruction but do not impact clinical outcome over 2 years . i didn't have a cyclops lesion specifically, but i did have scar tissue buildup and needed an MUA & scoping 9 weeks post-op from the initial recon (hammy ACL graft + meniscal stitch). FOIA And I've stopped running for now. An 18 year-old female 5 months after ACL reconstruction with pain and diminished range of motion. While rare, surgical complications do happen. described two histologic subtypes.6 The true cyclops is hard and composed of fibrocartilaginous tissue with active central bone formation and no granulation tissue or inflammatory cell infiltration.6 The true cyclops lesions are more likely to be symptomatic.7 The second type, termed a cyclopoid lesion, is soft and composed largely of fibrous and granulation tissue with occasional cartilaginous islands.6,4. Sanders TL, Kremers HM, Bryan AJ, Kremers WK, Stuart MJ, Krych AJ. In severe cases of infrapatellar fat pad arthrofibrosis, fibrosis between the patella, patellar tendon, and tibia can result in severe retraction and tethering of the patella leading to patella baja which may become progressive (patella infera). Menu Possible problems that can lead to the re-tear of the ACL include suboptimal positioning of the graft, improper tension on the graft, or failure of the fixation of the graft. ACL in tact." Hamstring contracture after surgery. Sagittal T2-weighted (5A) and axial fat-suppressed proton density-weighted (5B) images demonstrate a 5 mm intra-articular chondral body (arrows) surrounded by joint fluid anterior to the ACL graft. But the sharp pain still persists with some things, especially going down steps in a slow & controlled manner. MR Imaging of Knee Arthroplasty Implants. Cyclops lesions detected by MRI are frequent findings after ACL surgical reconstruction but do not impact clinical outcome over 2 years. The case studies are great and it just gives me that edge when treating my own clients, giving them a better treatment. A cyclops lesion can occur as a result of trauma without surgery and can be the result of a partial ACL tear or complete ACL rupture. This is not medical advice. Recommend medically-directed interventions such as non-steroidal anti-inflammatory medication (NSAIDs) or direct needle aspiration if indicated. Lucas TS, DeLuca PF, Nazarian DG, Bartolozzi AR, Booth RE. eCollection 2009. In simple terms, it is a lump of scar tissue at the front of the knee and it blocks it from completely straightening. When I mention the word cyclops it might conjure visions of a giant one-eyed beast from your nightmares but this type of cyclops is more of a physiotherapists nightmare. The appearance and clinical history are suggestive of patellar clunk syndrome. Predicting Recurrent Patellar Instability in Paediatric/Adolescent Patients, Kienbocks Disease: Evidence Based Assessment and Management, TSP008: LARS/ACL Reconstruction with Jonathan Mulford, Thoracic Outlet Syndrome: Assessment and Management, The Benefit Of Electro-stimulation following ACL Reconstruction, Joint Line Fullness for Diagnosing Meniscal Pathology, Radial Tunnel Syndrome: Assessment and Management, Snapping Scapula Syndrome (Scapulothoracic Bursitis): Assessment and Management, Commonly symptomatic anterior knee pain with extension, Patients report issues with lying supine, walking and running, Sometimes patients report an audible clunk with extension, Loss of extension ROM (generally about 10 degrees): typically 2 3 months following reconstruction, Extension ROM sometime reproduces audible clunk, Quadriceps dysfunction, associated with extension deficit, Cyclops Lesion occur in about 4% of ACL reconstructions, Loss of extension ROM at 2 3 months following reconstruction is a hallmark sign, Symptoms also include extension related pain, swelling and quads dysfunction, Surgical management is indicated, as conservative physiotherapy management often fails, Outcomes of surgical debridement of cyclops lesions are good, Earlier: Eccentric Training for Flexibility, Earlier: Elite Tennis Physiotherapy with ATP Physiotherapist Paul Ness. TECHNIQUE STEPS. Our Physiotherapy practice in Mermaid Waters works with clients all over the Gold Coast including the following suburbs: Your email is safe with us, and you can opt out at any time. The cyclops lesions had a mean size of 16 x 12 x 11 mm, with 90% of them located just anterior to the distal ACL. Journal of the American Academy of Orthopaedic Surgeon, 7(2), 119-127. 1990. Cyclops syndrome is caused by a scar tissue nodule adjacent to the tibial tunnel of the anterior cruciate ligament graft after surgery. Sagittal T2-weighted (1A) and T1-weighted (1B) images through the ACL graft and a coronal oblique proton density-weighted (1C) image anterior to the ACL graft are provided. Remove the effusion if present. The MRI showed my meniscus repair was not holding up at all, had new plans of tears. Retrieved from http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1681-150X2012000200011. Epidemiology This was not the same as the snap as the first year but I felt like something was off. Physiotherapy was organised for regaining range of movement. Arthrofibrosis associated with total knee arthroplasty (TKA) can result in significant pain and impairment. Bencardino JT, Beltran J, Feldman MI, Rose DJ. Went back to surgery in July (delayed 4 months because of covid) and got the meniscus clipped and ACL cleaned up and now Im doing great. At a further follow-up visit at 14 weeks, it was decided to perform an arthroscopy of the knee due to persistent flexion deformity. The https:// ensures that you are connecting to the doi:10.1177/03635465010290052401, Bradley, D. M., Bergman, A. G., & Dillingham, M. F. (2000). Activation and strengthening of your quadriceps muscles will provide you will more power to extend your knee and keep it straight with functional tasks like standing and walking. 2010. This has since been debated however the two surgeons were actually able to reduce their incidence of cyclops lesions by leaving less debris in the joint post-surgery (7). Although much less recognised, it is possible for patients who have suffered ACL trauma to develop a cyclops lesion even without having had surgery. My surgeon still thinks it's scar tissue causing my issues. I also expla. 48 year-old male with sagittal T1-weighted images at the time of the ACL tear (11A) and 2 years later after a fall (11B) demonstrates the development of severe scarring within the infrapatellar fat pad and posterior to the patellar tendon with interval inferior displacement of the patella. Steroid Profiles. Flexion contracture due to cyclops lesion after bicruciate-retaining total knee arthroplasty. MR imaging showed a well-defined, somewhat heterogeneous soft-tissue nodule with a signal intensity typically similar to that of skeletal muscle. That was back in December. SARMS. First described in 1990 by Jackson and Schaefer (1), a cyclops lesion is a reasonably common complication following anterior cruciate ligament reconstruction (ACLR), with the majority being benign and asymptomatic (2). Apr 11, 2013. Identifying the difference between focal or referred posterior thigh pain is critical in developing the appropriate management strategy. Walk forward to increase the force pulling your knee into extension. We present 2 cases (3 knees) in which cyclops lesions appeared atypically following bicruciate-retaining total . Well trained, friendly and professional. This did not resolve following intensive physiotherapy. Palmer W, Bancroft L, Bonar F, Choi JA, Cotten A, Griffith JF, Robinson P, Pfirrmann CWA. Layered Approach to the Anterior Knee: Normal Anatomy and Disorders Associated with Anterior Knee Pain. The cyclops lesion is a consequence of a localised form of anterior arthrofibrosis. Cyclops lesions occur in the minority of cases of ACLR surgery, between 1-10%. History or limited range of motion knee. #2. In cases involving an old ACL injury or loss of extension after ACL reconstruction, the footprint of the ACL should be inspected for a remnant of the ACL (Cyclops lesion). This was excised arthroscopically (Fig 2). Typically a cyclops lesion will occur in the months or years after ACLR surgery, with a greater risk of incidence with greater time since surgery. In general, arthroscopic debridement is preferred to open debridement when the pathology is largely intra-articular. 0. Pain at the front of the knee usually coincides with this reduced movement and there may even be an audible clunk. Often, due to the period of restricted mobility, the quadriceps muscles will not fire effectively and exercises are needed to regain normal function. Delinc P, Krallis P, Descamps PY, Fabeck L, Hardy D. Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: a multifactorial etiopathogenesis. Bethesda, MD 20894, Web Policies ACL Rehab Exercises It seems like it's been getting better because some of them have been getting easier, and before that I couldn't do a single leg squat, period (although if I go down too far, there's still pain). Advanced exercises used in phase one and two of nonoperative treatment of youth ACL injuries. For 17 years, we've helped hard-working physiotherapists and sports professionals like you, overwhelmed by the vast amount of new research, bring science to their treatment. The pogo practice also has absolutely everything a runner could want for their rehab process. Muellner T, Kdolsky R, Groschmidt K, Schabus R, Kwasny O, Plenk H. Cyclops and cyclopoid formation after anterior cruciate ligament reconstruction: Clinical and histomorphological differences. Srinivasan R, Wan J, Allen CR, Steinbach LS. Please enable it to take advantage of the complete set of features! Stump Entrapment of the Torn Anterior Cruciate Ligament. sharing sensitive information, make sure youre on a federal In general, a manipulation alone after acl reconstruction is not as successful. He's worked with elite level State and National rugby and football teams in Australia, the UK and France. At the end of the procedure the patient had a range of movement of -5 to 140 and negative Lachman, anterior drawer and pivot shift tests. That was back in December. Thepodcast features interviews with the worlds leading physical performers,and some of the worlds leading health and fitness experts. The scarred synovium is hypointense to muscle on proton density-weighted and T2-weighted MR images (Figure 12).17. In 13 patients without cyclops lesions, the femoral tunnel entered the notch within 2 mm of the intersection of the intercondylar roof and the posterior femoral cortex. I would highly recommend pogo physio. The cyclops lesion is a fibrous nodule in the intercondylar notch near the tibial insertion of ACL. I was going to go back to see him anyway, but wanted some opinions first if I should continue the exercises, or if it sounds like a cyclops lesion and I should go sooner than later. Etiology of total knee revision in 2010 and 2011. Cyclops Lesions That Occur in the Absence of Prior Anterior Ligament Reconstruction1. Cyclops lesions are areas of granulation tissue with neovascularization and fibrous tissue formation peripherally, most commonly at the anterolateral aspect of the tibial graft site after ACL reconstruction. Jackson and Shaefer first defined cyclops syndrome in 1990.1 The location of this lesion is frequently anterolateral to the tibial tunnel. On the sagittal inversion recovery image (13A) an abnormal low signal focus is noted posterior to the patella (arrowhead). On MRI, cyclops lesions are adherent to the ACL graft and are hypointense or isointense to muscle on T1-weighted images and variable in signal intensity on proton density- and T2-weighted images.4 Rarely, areas of ossification within the cyclops lesion are well formed and large enough to be detected on MRI as circumscribed foci with internal signal that mirrors marrow fat signal on T1-weighted and fluid-sensitive sequences (Figure 4). Simpfendorfer C, Miniaci A, Subhas N, Winalski CS, Ilaslan H. Pseudocyclops: two cases of ACL graft partial tears mimicking cyclops lesions on MRI. Federal government websites often end in .gov or .mil. Complications following primary ACLR using quadriceps tendon autograft were recorded in 10.5% of knees, with persistent knee pain being most common. . A cyclops lesion is a piece of scar tissue which develops on the anterior portion of an ACL. A follow-up appointment at 2 months showed a limitation of extension of the knee with a fixed flexion deformity progressing to 10 over the next 4 weeks. From 2001 to 2006, the authors identified 10 patients (five women and five men, ages 27-76 years) with cyclops nodules seen at magnetic resonance (MR) imaging. Mild low-signal thickening (arrowhead) is present posterior to the ACL graft, overlying the reattached posterior root of the lateral meniscus. Going. The moniker of "cyclops lesion" was given based on the arthroscopic appearance of the fibrous nodule and vessels that resemble an eye. 45(1): p. 87-97. Collateral ligaments, the posterior cruciate ligament and the posterolateral corner were intact. We recommend a consultation with a medical professional such as James McCormack. An arthroscopy four months after the original surgery showed a cyclops lesion at the roof of the femoral intercondylar notch the inverted cyclops lesion (Fig 1). Our case differs from that of Rubin et al2 by the fact that it followed a four-strand hamstring reconstruction of the ACL. Why are total knees failing today? MRI has an accuracy of 85% in detecting cyclops lesions increasing to over 90% for lesions measuring greater than 1 cm.8 Cyclops lesions are typically small and measure 10-15mm in diameter.8 However, significantly larger lesions may be encountered (Figure 3). It could be that the old ACL stump has a protective effect on the graft. The functionality is limited to basic scrolling. Press question mark to learn the rest of the keyboard shortcuts. Loss of full extension after anterior cruciate ligament (ACL) reconstruction, with development of an audible and palpable "clunk" with terminal extension was first described by Jackson and Schaefer as "cyclops syndrome." 2012 Mar; 94(2): e99e100. Epub 2016 Aug 3. Introduction. The American Journal of Sports Medicine, 29(5), 664675. 36-40, Knee Surg Sports Traumatol Arthrosc, 2014. Schroer WC, Berend KR, Lombardi A V., et al. Evaluation and treatment of disorders of the infrapatellar fat pad. government site. 2: 76-79, Arthroscopy: The Journal of Arthroscopic and Related Surgery. He offers Online Physiotherapy Appointments for 45. (i.e. During the past 3 decades, graft reconstruction of the anterior cruciate ligament (ACL) has become an accepted treatment for symptomatic ACL deficiency. 2016 Sep;15(3):214-8. doi: 10.1016/j.jcm.2016.06.003. We strip away the scientific jargon and deliver you easy-to-follow training exercises, nutrition tips, psychological strategies and recovery programmes and exercises in plain English. Arthroscopy . Houston Methodist Orthopedics & Sports Medicine. Diffuse arthrofibrosis surrounding the ACL graft is rare. 52: 829-834, The Journal of Bone and Joint Surgery, 1988. An increased incidence of anterior cruciate ligament (ACL) injuries in children over the last few decades has led to a corresponding increase in ACL reconstruction procedures in children. The reconstruction was performed using a four-strand hamstring graft and fixed on the femoral side using the TransFix technique and Bio-Interference screw (Arthrex, Naples, FL, US) fixation for the tibial side. A lump of scar tissue forms in the knee after ACLR surgery. The scar tissue can be made up of fibrous tissues, but can also include cartilage and sometimes bone. Best answers. Physio is working on strength to compensate as much as possible, but suggested meeting with Ortho to discuss surgical options, regardless of whether surgery is an immediate next move, something in 5 years or avoidable all together. A focus of soft tissue thickening is compatible with a small cyclops lesion anterior to the graft (arrowhead). I've had an excellent outcome from my sessions with you. If a cyclops lesion is suspected, you will need to return to your orthopaedic surgeon and likely have an MRI to confirm the presence of the scar tissue. A 56 year-old female 1 year after TKA with pain and stiffness. Richmond JC, Al Assal M. Arthroscopic Management of Arthrofibrosis of the Knee, Including Infrapatellar Contraction Syndrome. Simultaneously apply pressure down on the knee. 5-7,9 However, a cyclops lesion can be found in asymptomatic patients . In: Doral M, Karlsson J, eds. Our international team of qualified experts (see above) spend hours poring over scores of technical journals and medical papers that even the most interested professionals don't have time to read. Adhesions can form between the capsule and articular cartilage. Sports Injury Bulletin is the ideal resource for practitioners too busy to cull through all the monthly journals to find meaningful and applicable studies. HHS Vulnerability Disclosure, Help Great bang for your buck in terms of quality and content. Keep up to date with the science and best practice in managing sports injuries. This month, get insight and expertise on: Practical injury prevention advice, diagnostic tips, the latest treatment approaches, rehabilitation exercises, and recovery programmes to help your clients and your practice. I have seen Brad twice now and he is absolutely fantastic. Patients may present with decreased range of motion in flexion and extension. The risk of cyclops lesions is between 1-10% of ACLR surgeries. Well, I just found out today that I completely tore the ACL in my right knee. We are experimenting with display styles that make it easier to read articles in PMC. The mechanisms are thought to be similar to the post-surgery presentation (7). Cyclops syndrome due to a lesion of the anterior cruciate ligament, Fixed flexion deformity of the knee following femoral physeal fracture: the inverted cyclops lesion. Flores D V., Meja Gmez C, Pathria MN. Log in. Quadriceps grafts were found to have a higher risk than hamstring, which may have been related to the bundle size (. Early return of full extension will reduce your risk of developing a cyclops lesion. These exercises allow muscle recruitment without increasing the intra-articular pressure associated with full knee extension. Once these structures are inspected, the probe should be placed along the lateral side of the ACL, and the knee should be brought into a varus position or a figure-four . The site is secure. MAY 1951 No. The knee appeared stable. Pogo physio has not only helped me get out of pain but has helped me become a better, happier runner. Fixation of the graft at high knee flexion angles. Yep. Cyclops, inverted; Anterior cruciate ligament reconstruction; Complication, Annals of The Royal College of Surgeons of England, Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction, Extension loss secondary to femoral-sided inverted cyclops lesion after anterior cruciate ligament reconstruction, Arthroscopic findings associated with roof impingement of an anterior cruciate ligament graft, Progressive loss of knee extension after injury. Early pool work also provides hydrostatic pressure to aid with effusion drainage. I was reading about them on Google and some of the symptoms line up like the quad not fully coming back, audible clunking or occasional catching like I said when I try to fully extend it sometimes, but I have no loss of extension and can straighten both legs the same. Jackson & Schaefer suggested that problem was caused by either the debris left in the knee joint from drilling the tibial tunnel or from loose ACL graft fibres. Cyclops lesions, a form of anterior arthrofibrosis where a localized scar nodule develops, are rare but can occur after a reconstruction following ACL surgery. Dragoo JL, Johnson C, McConnell J. 2007. 2019 Oct 16;5(4):442-445. doi: 10.1016/j.artd.2019.09.003. From the moment you walk through the door, the team make you feel very welcome and comfortable. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 8(1), 10-18. doi:10.1016/0749-8063(92)90129-y, Minne, C., Velleman, & Sulleman, F. E. (2012). Patellofemoral compartment and medial tibiofemoral compartment cartilage loss. Before reconstruction of her ACL 10 weeks after injury, she had full range of movement and findings for instability included positive Lachman and anterior drawer tests (both showing 05mm of anterior displacement of the tibia) and a negative pivot shift test. As soon as you walk through the door you feel welcome and after my first session with Brad I had no doubts he would get me back to my best . Loss of extension is one of the most common complications following ACL surgery and can be of detriment to functional ability, especially in the athletic population (6). By continuing to browse this site you are agreeing to our use of cookies. Tightness in the hamstrings restricting the extension of the knee. Select appropriate exercises, like quadriceps exercises performed in positions of partial (20) knee flexion or isometric squats in 20-30 flexion. Hoser C. Minimally Invasive Harvest of a Quadriceps Tendon Graft With or Without a Bone Block. Assess the knee for effusions regularly, especially before loading. The repaired ACL was intact. A 66 year-old female 10 years post ACL reconstruction with intermittent locking. Needless to say my injuries are now easily manageable with a great plan set up to suit my specific needs. Many of these lesions may go undiagnosed as they do not all present symptomatically. This bundle of scar needs to be removed with an arthroscopy. Why is my knee so tight after ACL surgery? We failed to demonstrate any connection between the lesion and the femoral tunnel on arthroscopy but it was extending deeper into the notch towards the ACL graft. Brad and the whole team make every visit there so pleasant. At least that's one theory. Increased preoperative and postoperative inflammation reflected by swelling, effusion, and hyperthermia also plays an important role in the development of this complication.7,11 On MRI, fibrotic tissue encases the ACL graft and can extend anteriorly into the infrapatellar fat pad and suprapatellar bursa or posteriorly to the posterior joint capsule (Figure 8).7. Arthrofibrosis of the knee with a cyclops lesion anterior to the ACL graft, fibrosis of the anterior interval, and posterior pericapsular fibrosis. 327-332, Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2009. KOOS was also correlated with lesion volume. The triggering insult stimulating the formation of a cyclops lesion is unclear with theories including an inflammatory response to drilling debris from the tibial tunnel, remnants of the native ACL, and from scar tissue and piling up of graft fibers arising from repeated graft impingement.3,1,4No clear difference in the incidence of cyclops lesions is found between bone-patellar tendon-bone and hamstring allografts.5 Muellner et al. 3, Quarterly Journal of Experimental Physiology, 1988. ( a) Supine leg press with elastic band is initiated utilizing elastic band for closed-chain exercises. At least that's one theory. Thanks Pogo Physio! If you have decided that surgery is the best option, we take a look at the options for reconstruction and assess the pros and cons. This means that it should be suspected in any patient who has a loss of extension following any form of ACL injury. Cyclops lesions can be found in up to 25% of ACL reconstructions at 6 months after surgery. Sagittal T2-weighted image demonstrates Blumensaats line (red line) posterior to the tibial tunnel opening at the tibia (oval) compatible with roof impingement. An often overlooked code is 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure), which may be assigned for excision of fibrosis/adhesions/scar due to previous procedures or injuries. Key points: Cyclops lesions had a prevalence of 25% in patients after ACL reconstruction. What's new. Stiffness After TKR: How to Avoid Repeat Surgery. Usually the patient will also have some quadriceps dysfunction. Knee Imaging Following Anterior Cruciate Ligament Reconstruction: The Surgeons and Radiologists Perspectives. Generating an ePub file may take a long time, please be patient. To compare anterior cruciate ligament (ACL) soft-tissue allograft reconstruction using suspensory versus aperture fixation. Often, this occurs due to the body's natural defenses put in place, as we described in the published research article on AMI. I'm trying to work thru it with more PT first. Couldnt recommend him highly enough. 2017 Jul 10;3(4):242-246. doi: 10.1016/j.artd.2017.06.002. The axial proton density-weighted image (13B) reveals this structure to be a band-like region of arthrofibrosis (arrowheads) passing posterior to the patella and blending with the synovium medial and lateral to the patella, likely contributing to the patients mechanical symptoms. The size of cyclops lesions did not significantly change over a period of 2 years. MRI has been shown to be 84% accurate in detecting cyclops lesions (2) and surgical intervention is generally successful in restoring knee function (8). eCollection 2017 Dec. Radiol Case Rep. 2016 Oct 4;4(1):268. doi: 10.2484/rcr.v4i1.268. SA Orthopaedic Journal, 11(2). This lesion did not appear to have any communication with the femoral tunnel but it was impinging with the tibial side and limiting full extension of the knee. Its also been suggested that the cyclops lesion was caused from graft impingement when the knee was in full extension which leads to scar tissue formation (4). All patients had a history of trauma but no history of ACL reconstruction. Anatomical location of the ACL and what a torn ACL looks like (right). This syndrome, which is the result of a fibrous nodule (termed a cyclops nodule), has recently been described in patients who have sustained ACL injury but have not undergone reconstructive surgery. Complication of ACL repair. 2007; 15:144--146, Knee Surgery, Sports Traumatology, Arthroscopy. The cyclops lesion is a localized anterior arthrofibrosis most commonly seen following anterior cruciate ligament reconstruction. My x-ray and Ortho appointment are tomorrow. MeSH The repaired ACL was intact. A 35-year-old woman sustained an ACL injury to her left knee when she slipped and fell on the deck of a boat and twisted her knee 1 week prior to presentation. Despite such prevalence, cyclops lesions generally have minimal or no clinical symptoms, and their presence does not portend an inferior clinical outcome, with only 2% of cyclops lesions prompting surgical intervention.9 Symptomatic lesions present with loss of extension, snapping, catching, and painful extension with walking and/or running resulting in the cyclops syndrome. 7,8, MRI can assist in distinguishing cyclops lesions from other pathology that may limit knee extension, including roof impingement of the ACL graft (Figure 5), intra-articular bodies (Figure 6), and displaced torn ACL graft fibers. We use cookies so we can provide you with the best online experience. We report the case of an inverted cyclops lesion limiting extension of the knee joint after a four-strand hamstring anterior cruciate ligament (ACL) reconstruction.

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