Downloaded 21 times
More Related Content
More from PratikDhabalia
Acl tears
- 1.
- 2. Anatomy of anteriorcruciate ligament • It is an intra Articular but extra synovial ligament. • 2 bundles-Anteromedial bundle and posterolateral bundle. • Anteromedial bundle-Proximal part of the femur to the anteromedial aspect of tibial insertion. • Posterolateral bundle-Distal part of femur to posterolateral aspect of tibial insertion. • Main blood supply-Middle genicular artery. • Function of ACL-Static stabilizer preventing anterior translation of tibia over the femur. • Attatchment:Posterior aspect of inner surface of lateral condyle of femur to Anterior intercondyloid of tibia.
- 3.
- 4. Biomechanics of ACL •Average length of ACL is 4cm and average width is 11mm. • Ligament is taut in full extension of knee and relaxed at 40-50 degree flexion. • It is an elastic ligament (Under tension the ligament lengthens)
- 5. • -Biomechanics andfailure of ACL must be correlated with associated injuries • 1) External rotation and abduction with knee in 90 degree flexion-External rotation will stretch MCL,Abduction will tear MCL and finally when both forces are increased ACL disrupted. • 2)Internal rotation of tibia with knee hyperextended-Isolated ACL tear As we know posterolateral part is taut in full extension and both posterolateral and anteromedial band tighten when extended knee is internally rotated. • 3)Complete dislocation of knee joint-Due to hyperextension first posterior capsule ruptures at approximately 30 degrees of hyperextension followed by PCL and ACL Tears.
- 6. • The twobundles of ACL have different functions during various degrees of knee motion. • When the knee is extended they lie parallel to each other. • When the knee is flexed the femoral origin of posterolateral bundle moves Anteriorly causing two bundles to cross each other. • Anteromedial bundle tightens and posterolateral bundle loosens in knee flexion whereas in extension posterolateral bundle tightens.
- 7. Etiology • ACL injuriesare common in sports which involve sudden stops,or changes in directions like • 1)Skiers • 2)Soccer players • 3) Basketball players • • Mucoid degeneration of ACL-Age related degeneration in which secondary signs of an ACL injury like bone bruise, meniscus tears and anterior translation of tibia is absent.
- 8. Pathology • Disruption usuallyoccurs through the midportion of the ligament and is commonly associated with meniscal tears and medial collateral ligament tears.
- 9. Clinical features • Poppingsensation at the time of injury with pain,swelling, instability. • A rapid accumulation of fluid into the joint is due to haemarthrosis.
- 10. Tests • 1) AnteriorDrawer test • Prerequisite-Always exclude PCL tear as tibia sags Posteriorly. • Patient in supine position and hamstrings relaxed • While doing the rest compare the normal side • Hip flexed at 45 degree and knee flexed at 90 degree with leg in 10 degrees external rotation and foot fixed • Hands of examiner encircling the limb we see for Anterior translation of tibia over femur with soft/Mushy end point. • The drawer sign is minimal in isolated rupture.
- 12. • Grades ofanterior drawer test • Grade 1-0-5 mm translation • Grade 2 -5-10 mm translation • Grade 3->10 mm translation
- 13. • False negativeanterior drawer test seen in • 1)Hamstring spasm and haemarthrosis • 2)Door Stopper effect of Posterior horn of medial meniscus-In 90 degree knee flexion medial meniscus abuts against medial femoral condyle Hindering Anterior translation of tibia.
- 14. • Slocum’s AnteriorDrawer test is for rotatory instability • Perform anterior drawer test in 30 degrees of external rotation for • Anterolateral rotatory instability and 15 degrees of internal rotation for anteromedial rotatory instability
- 15. • Lachman test •Most sensitive • Done in 20 degree knee flexion left hand over distal femur and right hand holding tibia and we watch for end point(Soft/Mushy)and anterior translation of tibia over femur
- 17. • Grading • Grade1-Feel of positive test • Grade 2-Visible anterior translation • Grade 3-Passive subluxation of tibia with patient lying supine • Grade 4-Active subluxation of tibia
- 18. • Pivot shifttest/Mac intosh test • Prerequisite-Intact MCL • Supine position • Hip flexed and abducted to 30 degree • One hand over Calcaneum and one over knee internal rotate tibia and give valgus force and go from extension to flexion. • Test is positive if at about 30 degree patient experiences subluxation of lateral tibial plateau experienced as a clunk.
- 20. Investigations • 1)X-ray ofthe knee-Anteroposterior and lateral view • See for seconds fracture-Avulsion fracture if lateral capsular ligament of knee which is ACL insertion site • • Deep Lateral sulcus sign-Depression of lateral femoral condyle.
- 21.
- 22.
- 23. • 2)MRI ofthe knee joint • Normal ACL is seen as smooth,well defined structure with low signal intensity in sagittal image through intercondylar notch. A disrupted ACL will show discontinuity in the saggital plane. Also see for bone bruises seen as areas of increased signal intensity. See for meniscal injuries,MCL ligament injuries.
- 24. A T2 saggitalsection of MRI of knee showing discontinuity in fibres of ACL
- 25. T2 weighted saggitalsection of knee showing celery stalk appearance suggestive of mucoid degeneration of ACL
- 26. Injuries associated withACL tears • 1) Meniscal injuries • 2) Collateral ligament injuries • 3)Bone bruises-Occult osteochondral lesions due to impaction between posterior part of lateral tibial plateau and lateral femoral condyle. • 4)Chondral damage.
- 27. Management • Treatment ofACL can be divided into • Conservative management • Operative management
- 28. Goals of treatment •1) Minimise pain and swelling • 2)Have relatively normal walking pattern • 3)Full extension of knee. • 4)120 degrees of knee flexion. • 5) Quadriceps and hamstrings control. • 6)Working towards having single leg control.
- 29. • RICE-Rest,Ice, compressionand elevation • Pain Medications-NSAIDS • • Immobilise knee in extension brace for 3 weeks followed by hinged knee brace for 3 weeks • Avoidance of sports • Neuromuscular electrical stimulation To enhance and strengthen quadriceps muscles • Physiotherapy-Quadriceps and hamstrings strengthening
- 30. -Long sitting calfstretch-Towel wrapped around forefoot and pulled for 20 seconds
- 31.
- 32.
- 33.
- 34.
- 35.
- 36. • Double legsquat,single leg squats
- 37. Operative management • Indications •1)) Occupational requirements-High contact sports. • 2) Instability in day to day living • 3)Young patient
- 38. Arthroscopic ACL reconstructionwith meniscal root repair/Menisectomy
- 40. Grafts • Autografts -Transplanted fromone part of the body to another in the same individual. • Allografts:Transplanted from one individual to another of the same species Which are not genetically Identical. • Synthetic grafts
- 41. • Autografts arepreferred over allografts as they are biologically better and have lesser infection.
- 42. • Autografts • Bonepatellar tendon bone graft • • Quadruple strand hamstring graft(Semi T) • Quadriceps tendo autograft
- 43. Bone patellar tendonbone autograft • Most commonly used and gold standard for ACL reconstruction • Generally taken from middle third of patellar tendon • Advantage-Bone to bone healing • Disadvantages • Increases incidence of anterior knee pain • Donor site morbidity • Quadriceps weakness • Patellar fractures
- 45. Quadruple strand hamstringgraft(Semi T- Gracillis autograft) • Provides biomechanical properties similar to BPTB autograft. • Disadvantages-Weakness of hamstrings,tunnel widening
- 46. Quadriceps tendon autograft •AdVantage-preserves hamstring function,decreased risk of patellar fracture. • Disadvantage-Difficukty in harvesting the graft
- 47. Allografts • Avoid donorsite complications • Patellar fracture • Anterior knee pain • Extensor weakness • • Examples-Tibialis anterior and posterior • Quadriceps tendon • Hamstring tendon
- 48.
- 49. Types of reconstruction •Single bundle reconstruction • Double bundle reconstruction
- 50. Single bundle reconstruction •Done using transitional technique • 1. One incision arthroscopically assisted ACL reconstruction introduced drilling of femoral tunnel through tibial tunnel. Advantages-Simple,quick,does not require knee to be flexed beyond 90 degrees, interference screws can be placed parallel Disadvantages-Difficulty in placing grafts,damage to posterolateral structures.
- 51. Double bundle reconstruction •To replicate both anteromedial and posterolateral bundles endobutton is used. • Disadvantage-Increased surgical time,improper placement of tunnels.
- 52. Complications of ACLreconstruction • Intraoperative • Post operative
- 53. Intraoperative • 1)Improper placementof tunnels-Ideally tunnels should be posterior to blumensaats line • If too anterior they lead to raft failure,if too Posterior graft becomes too vertical • • 2)Graft tension • 3) Inadequate placement of graft
- 54. Post operative • 1)Infection •2)Joint stiffness
- 55. Post operative protot •4 phases • Phase 1-1st 4 weeks • Phase 2-4-12 weeks • Phase 3-Starting impact loading activities • Phase 4-Normal routine activities
- 56. Phase 1 • Bracein extension • Static quadriceps excercises,ankle pumps,toe touch walking. • Patient mobilization with bilateral axillary crutches • Knee is kept in hinged brace for 4 weeks to prevent undue stress on the graft.
- 57. Phase 2 • After4 weeks • Aim to achieve full rom progressing at 10-15 degree flexion per week. • Weight bearing is gradually increased at 4 weeks and patient is gradually weaned from crutches at the end of 6 weeks. • Isometric close chain excercises are started after 6 weeks
- 59. Phase 3 • After12 weeks impact loading activities such as jogging and double legged hopping are initiated. • If patient has good eccentric quad and hip abductor and external rotator control progressive jogging to running and jumping is started.
- 60. Phase 4 • Patientto return back to preinjury level • • When can patient return to sport • If he/she has completed all goals of post operative phases 1,2 and 3 and he/she is able to complete a single leg hop atleast 90 percent while comparing to uninjured limb at 6 months post operatively.
- 61. Summary of rehabilitationprotocol
- 62.