anterior cruciate ligament injuries

1. ACL INJURIES
PRESENTER- DR SIDHESHWAR
THOSAR
JUNIOR RESIDENT
MODERATOR- DR YADNIK JADHAV
ASSISTANT PROFESSOR
MIMER MEDICAL COLLEGE , PUNE

2.  ANATOMY
 FUNCTIONS
 MECHANISM OF INJURY
 SYMPTOMS
 TESTS
 IMAGING- PRIMARY , SECONDARY SIGNS
ON MRI
 NATURAL HISTORY
 TREATMENT-3 GRAFT ISSUES, FIXATION
DEVICES
 REHABILITATION
 COMPLICATIONS OF SX
 FAILURE- EARLY , LATE

3. ANATOMY
 ACL is composed of multiple collagen
fascicles
31 – 35 mm in length and
31.3 mm2 in cross section
 synovial membrane envelope the ACL thus
making it extrasynovial.
 Blood supply from middle geniculate artery.
ACL vascularization arises from the middle
genicular artery and vessels of the infrapatellar
fat pad and adjacent synovium
 Nerve supply from posterior articular nerve.

4.  ORIGIN
- From the posteromedial corner of medial
aspect of lateral femoral condyle in the
intercondylar notch
 INSERTION
- Fossa in front of & lateral to anterior spine
of
tibia.

5.  ACL is composed of two principal parts
1. Small Anteromedial band
and
2. Larger bulky posterolateral portion
CLINICAL IMPORTANCE
- Anteromedial bundle is tight in flexion and
the
posterolateral bundle is tight in extension

9. Functions
-Resist anterior translation of tibia
-Resist medial rotation of the tibia
-Resistance to hyperextension
-Resist varus and valgus angulation at full
extension
-It has proprioceptive function which help of
postural changes of knee joint.

10. Mechaniusm of injury
 The classic history of an ACL injury begins
with a noncontact deceleration, jumping,
or hyperextension, valgus external rotation
force
 Other mechanisms of injury include
external forces applied to the knee.
O'Donoghue unhappy triad due to
lateral blow to the knee.

11. Symptoms
 The patient often describes the knee as having
been hyperextended or popping out of joint and
then reducing.
 A pop is frequently heard or felt.
 The patient usually has fallen to the ground and
is not immediately able to get up.
 Resumption of activity usually is not possible, and
walking is often difficult.
 Within a few hours, the knee swells
(haemarthrosis).

12. There are no pain receptors in the ACL, therefore
pain is not an immediate feature in isolated
ACL tears, but develops with hemarthrosis.
70% of acute knee hemarthrosis are associated with
ACL tears.
Locking in ACL-deficient knees denotes
associated meniscal tears either from the
original injury, or from repeated giving way .
Difficulty rising from a chair or walking up stairs

13. PHYSICAL EXAMINATION
INCLUDE
 ANTERIOR DRAWER TEST
 LACHMAN’S TEST
 PIVOT SHIFT TEST

14. ANTERIOR DRAWER TEST
 To perform anterior drawer test, examiner
grasps pt's tibia & pulls it forward when the
affected leg is flexed at 90 degree while noting
degree of anterior tibial displacement

15. LACHMAN’S TEST
 This is a variant of the anterior drawer test
 The examination is carried out with the knee in 20 deg
of
flexion, and external rotation (relaxes IT band)
 For a right knee, the examiner's right hand grips the
inner
aspect of the calf and the left hand grasps outer aspect
of
the distal thigh
 Attempt to quantify the displacement in mm is done by

16.  End point should be graded as hard or soft
- End point is said to be hard when the
ACL
abruptly halts the forward motion of the tibia
on
the femur
- End point is soft when there is no ACL &
restraints are more elastic secondary
stabilizers;

17. PIVOT SHIFT TEST
 During this test,
pt is kept in supine & examiner holds pt's leg with
both hands
abduct the pt’s hip (to relax the ITB and allow the
tibia to rotate)
 Holding above ankle in one hand and applying a
valgus stress in internal rotation of 20 degree
the other hand on proximal leg , the knee is
slowly flexed
 After the anterior subluxation of the tibia is noticed,
the knee is slowly flexed, and the tibia will reduce with
a snap at about 20° to 30°of flexion.

18. INVESTIGATIONS
 X-RAY
 MRI
 Arthroscopy

19. Radiographic evaluation
Plain x-ray
 Plain radiographs often are
normal; however, a tibial
eminence fracture indicates an
avulsion of the tibial
attachment of ACL.
 Segond fracture (avulsion
fracture of the lateral capsule),
is pathognomonic of an ACL
tear.

20. ACL AVULSION FROM
TIBIA

21. Radiographic evaluation
MRI
 MRI is the most helpful diagnostic radiographic
technique.

22. Radiographic evaluation
MRI
Primary signs:
 Absent ACL
 Fuzzy ACL
 Bony avulsion

23. Radiographic evaluation
MRI
Secondary signs:
 Those alert attention to ACL tear
 Lateral femoral condyle contusion
 Anterior translation of the tibia
 Sigond fracture
 Lateral femoral condyle impression fracture
 Contusion of the posteromedial corner of tibia
 Buckled PCL

24. Lateral femoral condyle
contusion

25. Anterior translation of the tibia

26. Sigond fracture

27. Lateral femoral condyle
impression fracture

28. Contusion of the posteromedial
corner of tibia

29. Natural history
 As a result of abnormal loading and shear
stresses in the ACL–deficient knee, the risk of
late meniscal injury is high and appears to
increase with time from the initial injury.
 Most late meniscal tears occur in the medial
meniscus because of its firm attachment to the
capsule.
 Osteochondral damage also influences
prognosis and may be precursors of
osteoarthritis.

30. Treatment
 Treatment options available include
1. Nonoperative management
2. Repair of the ACL (± augmentation)
3. Reconstruction with either autograft or allograft
tissues or synthetics.

31. Nonoperative management
 Nonsurgical management is indicated in
patients with
- partial tears and no instability symptoms
- complete tears and no symptoms of knee
instability
- Who do light manual work or live sedentary
lifestyles
- Whose growth plates are still open (children)

32. Nonoperative management
 Immediately after injury
 R.I.C.E ( Rest Ice Compression Elevation ()
 Exercise (after swelling decreases and weight-
bearing progresses)
 Braces
 Rehabilitation Brace
 Functional Brace

33. Precautions
 Modification of active lifestyle to avoid high
demand activities
 Muscle strengthening exercises for life
 May require knee brace
 Despite above precautions ,secondary
damage to knee cartilage & meniscus leading
to premature arthritis

34. Surgical Treatment
Timing of Surgery
 1) Swelling in the knee must go down to near-
normal levels
 2) Range-of-motion (bending and
straightening) of the injured knee must be
nearly equal to the uninjured knee
 3) Good Quadriceps muscle strength must be
present.

35. Primary repair (±Augmentation)
 Primary repair of the ACL is no longer
practised; reconstruction several weeks after
the acute injury is the preferred choice.
 Acute repair is appropriate when a bony
avulsion occurs with the ACL attached.
 The avulsed bone fragment often can be replaced
and fixed with sutures or passed through
transosseous drill holes or screws placed through
the fragment into the bed.
 ACL avulsions usually occur from the tibial
insertion.

36. ACL Reconstruction
 As evidence mounted that primary repair of
midsubstance ACL tears routinely failed,
interest turned to reconstruction of the
ligament.
 The advances made in arthroscopy have led
to the development of arthroscopic techniques
for ACL reconstruction.

37. Proper selection of patients.
Appropriate graft.
Meticulous technique.
Adequate rehabilitation.
Pre-requisites for successful
reconstruction

38. Graft selection
Autograft tissues
 Autograft tissue is used most commonly.
 Advantages:
 Low risk of adverse inflammatory reaction
 No risk of disease transmission.

39. Graft selection
Autograft tissues
The most common current graft choices
are:
 Bone–patellar tendon–bone graft
 Quadrupled hamstring tendon graft.

40. Graft selection
Autograft tissues
Bone–patellar tendon–bone (BPTB) graft
 Taken from the central third of patellar tendon,
with its adjacent patella and tibial bone blocks.

41. Graft selection
Autograft tissues
Hamstring tendon graft
 Low donor site morbidity.
 semitendinosus or gracilis tendon is used for
reconstruction of ACL.

42. Graft selection
Autograft tissues
Quadriceps tendon graft
• It can be harvested with a portion of patellar bone
or entirely as a soft-tissue graft.
• Revision ACL surgeries and for knees with multiple
ligament injuries

43. Graft selection
Allograft ligament replacement
 Autograft sacrifice a normal
musculotendinous structure in an already
deficient knee, adding to the functional
disturbance.
 Extensive surgical exposure, long tourniquet
times, and prolonged rehabilitation are other
disadvantages of these techniques.

44. Graft selection
Allograft ligament replacement
 Bone-patellar tendon-bone
 Achilles’ tendon
 Hamstrings
 Quadriceps tendon
 Fascia lata

45. Graft selection
Autograft vs. allograft
 Viral disease transmission (1:1million)
 Graft incorporation & remodeling is faster with
autografts.
 Donor site morbidity with autografts

46. Graft placement
 Various tools have been developed to assist
the surgeon with placement of the tunnels.
 These include devices in which the key point
of reference is the over-the-top position, the
roof of the intercondylar notch, or the anterior
surface of the PCL.

47. Tibial drill guide for ACL referencing off
PCL. ACL femoral guide.

48. Graft fixation
 In the early weeks after surgery, the
weakest links in reconstruction are
the fixation sites, not graft tissue
itself.
 Fixation of replacement grafts can be
classified into direct and indirect
methods.

49. Graft fixation
 Direct fixation devices
include
 Interference screws
 Staples
 Washers
 Cross pins

50. Graft fixation
 Indirect fixation devices include
 Polyester tape–titanium button
 Suture-post.

51. Rehabilitation after ACL Reconstruction
 Goal of rehabilitation after ACL surgery: to
restore normal joint motion and strength while
protecting the ligament graft.

52. Rehabilitation after ACL Reconstruction
 Most important step is the early restoration of
full extension.
 Knee immobilization in a fully extended brace
is started immediately after surgery to prevent
development of a flexion contracture.

53. Rehabilitation after ACL Reconstruction
 After surgery, the thigh muscles atrophy
quickly.
 Early quadriceps strengthening concentrates
on quadriceps sets and straight leg raises.

54. Rehabilitation after ACL Reconstruction
 After isolated ACL reconstruction, partial
weight bearing with crutches is allowed
immediately.
 A straight-leg brace is worn to support the
weakened quadriceps.
 Certain types of concurrent meniscal repairs
or articular cartilage procedures may dictate a
different weight bearing status.
 Crutches usually are discontinued by 3-4
weeks postoperatively

55. Rehabilitation after ACL Reconstruction
 Proprioceptive training also is instituted in the
first 2 weeks.
 Return to sports should be delayed for at least
6 months after surgery to allow maturation of
the graft

56. Results of ACL Reconstruction
 The results reported with use of patellar
tendon and hamstring tendons are
comparable.

57. Complications of ACL Surgery
Intraoperative
 Patellar fracture
 Inadequate graft length
 Mismatch between bone plug & tunnel sizes
 Graft fracture
 Suture laceration
 Violation of posterior femoral cortex
 Incorrect femoral or tibial tunnel placement

58. Complications of ACL Surgery
Postoperative
Motion (primarily extension) deficit
 This can result from
 Preoperative factors: incl. preoperative effusion,
limited ROM, & concomitant knee ligament injuries.
Those make poor postoperative motion more likely.
 Intraoperative factors: incl. incorrect tunnel position
and inadequate notchplasty, which can result in
overtightening or impingement of the graft, leading to
loss of extension.
 Postoperative factors: incl. prolonged immobilization
and inadequate or inappropriate rehabilitation.

59. Complications of ACL Surgery
Postoperative
Persistent anterior knee pain
 Anterior knee pain probably is the most
common and most persistent complication after
ACL reconstruction.
 Several studies have suggested a relationship
between patellofemoral pain and persistent
flexion contracture or quadriceps weakness .

60. Failure of ACL Reconstruction
Factors potentially involved in the failure of ACL
reconstruction include
 surgical technique,
 selection of graft material,
 problems with graft incorporation,
 integrity of the secondary restraints,
 condition of articular & meniscal cartilage,
 postoperative rehabilitation,
 motivation and expectations of the patient.

61. Failure of ACL Reconstruction
 Selection of patients and timing of surgery are
crucial aspects of the preoperative plan.

62. Failure of ACL Reconstruction
 Early failure, usually within the first 6 months,
most often is the result of
 Technical errors: This is the most avoidable and
most common cause. Errors in surgical technique
can include improper tunnel placement,
inadequate notchplasty, and errors in graft
selection, size, physiometry, or tensioning.
 Incorrect or overly aggressive rehabilitation
 Premature return to sport
 Failure of graft incorporation.

63. Failure of ACL Reconstruction
 Later failure, usually after 1 year, more
typically is caused by recurrent injury.

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