Complete overview of anterior cruciate ligament injury and its management

1. Anterior cruciate
injuries and
management
By DR.M.IMRANASHRAF
PGR ORTHOPEADIC SURGERY
UNIT-1

2. Important points about ACL anatomy
 IT IS A LIGAMENT WHICH
IS COMPOSED OF
COLLAGEN FASCICICLES
 CONSISTS OF TWO
BUNDLES
 ANTEROMEDIAL AND
POSTEROLATERAL

3.  Its is connected in the femur
 From posteromedial corner of
medial aspect of lateral femoral
condyle in the intercondylar
notch
 And inserted into tibia at
 Fossa in front of and lateral to
anterior spine of tibia

4.  The posterior articular
nerve, a branch of the
tibial nerve, innervates
the ACL
 Blood supply is middle
genicular artery
 It has Golgi tendon
receptors which are
proprioceptors

5. CAUSES OF ACL INJURIES
 Three major types of ACL
injuries are described:
 Direct Contact: 30% of the cases
 Indirect Contact.
 Non-Contact: 70% of the cases:
by doing a wrong movement

7. SYMPTOMS OF ACL INJURIES
 PAIN WITH SWELLING
 LOSS OF FULL RANGE OF MOTION
 DISCOMFORT AND INSTABILITY WHILE WALKING

8. EXAMINATION FOR ACL INJURIES
 LACHMAN TEST
 ANTERIOR DRAWER TEST
 Levers Lelli’s test
 PIVOT SHIFT TEST
 KT 2000 ARTHROMETER TEST

9. Grade of ACL rupture
 The grade of ACL rupture is classified based
on the degree of anterior tibial translation in
mm.
 Grade 1 (3-5 mm), grade 2 (5-10 mm), and
grade 3 (> 10 mm translation).
 However, the injured side should always be
compared with the good side.
 (Additionally, the physician should be aware
that a PCL tear may result in a "false"
Lachman test interpretation due to
translating the tibia from a posteriorly
subluxated position)

10. LACHMAN TEST
 Patient is supine, examiner holds knee
between full extension and 30 degrees
flexion. Femur is stabilized outside hand
while other hand stresses tibia. For max
results tibia should be laterally rotated.
False results if femur not stabilized
properly or meniscus tear is blocking
translation or tibia medially rotated

11.  A positive grade 1
 Lachman test produces 1 to 5 mm of anterior
translation compared to the uninjured knee.
 A grade 2 moves 6 to 10 mm,
 grade 3 is more than 10 mm of displacement
compared to the opposite knee.
 Further subclassification adds an “A” for a firm or
hard endpoint and a “B” for soft endpoint

12.  The position of the examiner’s hands is
important in doing the test properly.
 One hand should firmly stabilize the
femur while the other grips the proximal
tibia in such a manner that the thumb
lies on the anteromedial joint margin.
 When an anteriorly directed lifting force
is applied by the palm and the fingers,
anterior translation of the tibia in
relation to the femur can be palpated by
the thumb.
 Anterior translation of the tibia
associated with a soft or a mushy end
point indicates a positive test result.
 The hamstrings must be relaxed (any
tension in them will prevent anterior
translation of the tibia

13. PIFALLS
 The patient must be supine and relaxed
because the sitting position rotates the
pelvis and places the hamstrings on
stretch. The fingers of the examiner’s
hand on the femur should palpate the
tension in the hamstrings so that he or
she can feel when the hamstrings relax
and the fingers “sink” into the posterior
thigh.

15.  With the patient supine on the examining table, the hip is
flexed to 45 degrees and the knee to 90 degrees, with the
foot placed on the tabletop.
 The dorsum of the patient’s foot is sat on to stabilize it,
and both hands are placed behind the knee to feel for
relaxation of the hamstring muscles.
 The proximal part of the leg then is gently and repeatedly
pulled and pushed anteriorly and posteriorly, noting the
movement of the tibia on the femur.
 The test is done in three positions of rotation, initially
with the tibia in neutral rotation and then in 30 degrees of
external rotation and finally 30 degrees of internal
rotation.

16. Lateral Pivot Shift Test of Macintosh
 With the knee extended, the foot is lifted and
the leg internally rotated, and a valgus stress is
applied to the lateral side of the leg in the
region of the fibular neck with the opposite
hand.
 The knee is flexed slowly while valgus and
internal rotations are maintained. With the
knee extended and internally rotated, the tibia
is subluxed anteriorly. As the knee is flexed
past approximately 30 degrees, the iliotibial
band passes posterior to the center of rotation
of the knee and provides the force that reduces
the lateral tibial plateau on the lateral femoral
condyle.

18. Levers Lelli’s test
 Patient lies supine with fully extended both legs.
One fist of clinician is placed under the proximal
third of the calf of one leg. Then, with the other
hand, a downward force is applied over distal
third of the patient’s quadriceps of same leg
 Negative test: When the ACL is intact the
downward force applied over the quadriceps will
cause the heel to rise.
 Positive test: With damaged ACL the downward
force will cause anterior translation of tibia in
relation to the femoral condyle. So, in this case
heel will not rise

19. DIGITAL DEVICES

21. INVESTIGATIONS
 Ultrasound
 RADIOLOGY
 MRI
 ARTHROSCOPY

22. Femoral notch sign.
A, Ultrasound probe position for visualizing the
femoral notch sign.
B, Anatomic drawing showing the positive US findings
at the level of the femoral intercondylar notch.
C, Normal knee sonogram of the femoral
intercondylar notch.
D, Sonogram showing a positive intercondylar notch
sign with a hypoechoic collection (asterisk) at the
origin of the ACL and a mass effect displacing the
intercondylar fat pad medially.
E, Fat‐saturated T2‐weighted coronal MRI of the same
patient in D with the image flipped vertically to
match the orientation of the sonogram. The
hypoechoic collection (arrowheads) at the origin of
the ACL corresponds to the positive intercondylar
notch sign, a secondary sign of an ACL tear with a
bone contusion at the lateral femoral condyle.

23. The Segond fracture typically occurs when a strong varus
(inward) force is applied to the knee while the foot is
planted on the ground, and the knee is slightly flexed.
This force causes tension on the lateral structures of the
knee, including the iliotibial (IT) band and the lateral
collateral ligament (LCL). The avulsion fracture occurs at
the point where the IT band inserts into the lateral tibial
plateau, known as the anterolateral aspect of the tibia.
The ACL, being one of the primary stabilizing ligaments of
the knee, is often injured in conjunction with a Segond
fracture due to the biomechanical forces involved in the
injury mechanism. The force causing the Segond fracture
can also create a rotational component, which is known to
be a common mechanism for ACL injuries. The combined
forces of varus stress, IT band tension, and rotational
forces can lead to the tearing of the ACL

24. The deep lateral femoral notch
sign is a finding on a lateral
radiograph that is considered an
indirect sign of a torn anterior
cruciate ligament (ACL).It is an
abnormal deepening of the lateral
condylopatellar sulcus from an
osteochondral impaction fracture.
A depth greater than 1.5 mm is a
reliable sign of a torn ACL

25. Souryal and Freeman formulated
the notch width index, which is the ratio of the
width of the intercondylar notch to the width of
the distal femur at the level of the popliteal
groove measured on a tunnel view
radiograph of the knee
The normal intercondylar
notch ratio was 0.231 ± 0.044.
The intercondylar notch width
index for men was larger than that for women.
They found noncontact ACL injuries to be more
frequent in athletes who had a notch width
index that was at least 1 standard deviation
below the mean.

26. Normal ACL
Sagittal T1: Normal
course of ligament;
compact fibers of low
signal intensity. Fibers
parallel to
Blumensaat’s line( It
represents the roof of
the intercondylar fossa)

27. Normal ACL
Sagittal T2*: Normal
course of
ligament; compact
fibers of low
signal intensity

28. Grade I lesion
Sagittal;
left T1
right T2*:
Both sequences show
increased signal
intensity of ACL,more
pronounced in tibial
two thirds, slight
spreading of fibers,
bulk of fibers intact

29. Partial ACL tear, femoral
portion, grade II
Sagittal; left T1, right T2*:
Increased signal intensity of
ACL in both sequences with
spreading of fibers;
irregularity and partial
discontinuity near femoral
insertion (arrows) but main
fibers still continuous.
Reactive effusion

30. ACL tear, grade III
a Sagittal T1: Highly irregular
course of ligament; adequate
fiber
continuity not discernible,
especially
in proximal and central
portions.
Abnormal course with slight
posterior
convexity

31. Sagittal T2*:
Clear depiction of extent
of damage of proximal/
central portion (arrow)
(faint octopus sign).

32. MRI shows bone bruise after
anterior cruciate
ligament tear.

33. MANAGEMENT OF ACL INJURY
 Nonoperative management
 Repair of the ACL (either isolated or with
augmentation)
 Reconstruction with either autograft or allograft
tissues or synthetics.
 NOTCHPLASTY

34. NON OPERATIVE MANAGEMENT
 It is a viable option for a patient who is willing to
make lifestyle changes and avoid the activities
that cause recurrent instability
 Partial tear with no instability symptoms
 Lives a sedentary lifestyle
 Open physis

35. ACL reconstruction indications
 The ideal patient for ACL reconstruction is a
young patient (<40 years) with an active lifestyle
and an acute ACL injury

36. ACL reconstruction Contraindications
 ACL reconstruction is contraindicated in
patients with partial tears OF ACL, minimal
instability and no joint laxity on examination.
 It is also contraindicated in elderly, low-
demand patients with minimal instability,
patients with knee malalignment and
associated comorbidities that make surgical
intervention unsafe (e.g., active infection).

37.  Relative contraindications,
which should be evaluated case
by case, include :
 patients with open physes
(Tanner stage ≤3, males ≤16
years, or females ≤14 years),
 radiographic evidence of
degenerative joint disease
(Kellgren-Lawrence grade ≥3),
 a sedentary or inactive
lifestyle, and an unwillingness
or inability to comply with the
required postoperative
rehabilitation protocol.

38. Importance of timing in operative
treatment of ACL rupture.
INCLUDES:
 Preoperative ROM,
 swelling, and quadriceps strength
 Limited ROM and swelling linked to arthrofibrosis
development post-surgery.

39. Recommendations for Surgery Timing
 Surgical intervention delay until:
 Resolution of postinjury knee effusion.
 Full knee ROM is regained.
 Quadriceps control achieved.
 Patient physically and psychologically prepared.
 Full postoperative physical therapy program
readiness.

40. OPERATIVE ACL SURGERY
 PRIMARY REPAIR
1.REPAIR OF BONY TIBIAL AVULSIONS OF ANTERIOR
CRUCIATE LIGAMENT
2.(biologic augmentation and internal bracing
methods, bridge-enhanced ACL repair (BEAR)
procedure) for mid substance ACL
3.Dynamic intraligamentary stabilization devices
RECONSTRUCTION FOR ANTERIOR CRUCIATE
LIGAMENT INSUFFICIENCY
 Augmentation of primary ACL repair
(over-the-top orientation to preserve the femoral
attachment)
 Extra articular
 Intra articular (open, arthroscopic)

41. Repair of avulsion of tibial
attachment of anterior
cruciate ligament with
fragment of bone. Crater in
tibia should be
deepened, and bone fragment
on end of ligament is pulled
into crater
depth to restore tension in
avulsed ligament

42. EXTRA-ARTICULAR PROCEDURES
 These procedures generally create a
restraining band on the lateral side of the
knee, extending from the lateral femoral
epicondyle to Gerdy's tubercle in a line
parallel with the ACL

43. EXTRAARTICULAR PROCEDURES
(ILIOTIBIAL BAND TENODESIS)
Dissect a 1.5-cm-wide strip of
iliotibial band from its midportion
beginning approximately 16 cm
from its distal
insertion and turn it down to its
attachment at Gerdy’s
tubercle

45.  Andrew modification
 Attachment of two bundles to lateral
femoral condylar area through
transosseous drill holes to medial side of
femur.

46. RECONSTRUCTION of ACL
 OPEN APPROACH IS
THROUGHT MINI
ARTHROTOMY
 ARTHROSCOPICALLY
THROUGH STANDARD
PORTALS

47. STEPS OF ACL RECONSTRUCTION
 Graft Selection
 Graft Placement
 Graft Tension
 Graft Fixation

48. GRAFT SELECTION

49. Bone-patellar tendon-bone (BPTB)
autograft
Advantages
Using patient's own tissue
Most common source of graft
Faster incorporation
Less immune reaction
No chance of acquiring someone else's infection
Maximum load to failure is 2600 newtons (intact ACL is
1725 newtons)
Complications
Anterior knee pain
Chance of Patella fracture

50. Quadrupled hamstring autograft
 smaller incision, less perioperative pain, less anterior knee pain
 maximum load to failure is approximately 4000 Newtons
 decreased peak flexion strength at 3 years compared to BPTB
 concern about hamstring weakness in female athletes leading to
increased risk of re-rupture
 complications
 "windshield wiper" effect (suspensory fixation away from joint
line causes tunnel abrasion and expansion with flexion/extension
of knee)
 residual hamstring weakness
 parasthesias due to injury to saphenous nerve branches during
harvest

51. Quadriceps tendon autograft
 small incision in area that does not see pressure during kneeling
 does not involve physis
 maximum load to failure 2185 Newtons
 similar patient-reported and functional outcomes as other
autografts
 may include bone block or completely soft tissue
 less commonly used so is often available in revision setting
 same disadvantages as
 hamstring autograft with suspensory fixation

52. ACL Repair in Pediatric patients
 physis-sparing (all intra-
epiphyseal)
 trans-physeal
 partial trans-physeal

53. GRAFT PLACEMENT
 A femoral tunnel that is too
anterior will result in
lengthening of the
intraarticular distance
between tunnels with knee
flexion. The practical
implications of this anterior
location are “capturing” of
the knee and loss of flexion
or stretching and perhaps
clinical failure of the graft
as flexion is achieved.

54. femoral tunnel placement
 sagittal plane
 1-2 mm rim of bone between
the tunnel and posterior cortex
of the femur
 coronal plane
 tunnel should be placed on the
lateral wall at 2 o'clock for left
knee or 10 o'clock for right
knee
 drilling tunnel in over 70
degrees of flexion will prevent
posterior wall blowout

55. Tibial tunnel placement
 sagittal plane
 the center of tunnel entrance into joint should be
10-11mm in front of the anterior border of PCL
insertion, 6mm anterior to the median eminence,
9mm posterior to the inter-meniscal ligament
 coronal plane
 tunnel trajectory of < 75° from horizontal
 obtain by moving tibial starting point halfway
between tibial tubercle and a posterior medial
edge of the tibia

56.  Posterior placement of the femoral tunnel or
placement of the graft over the top of the
lateral femoral condyle produces a graft that is
taut in extension but loosens with flexion.
 This location produces an acceptable result
because the instability from an ACL deficiency
occurs near terminal extension.
 The clinical examination yields a negative
Lachman test result and a 1+ anterior drawer.
 If this location is chosen, the surgeon must
secure the graft with the knee in extension
because securing the posteriorly located graft
with the knee in flexion may result in loss of
extension

57. REFERENCE POINT FOR TUNNELING
 over-the-top
 position, the roof of the intercondylar notch,
 the anterior surface of the PC

58. NOTCHPLASTY
 widening of the intercondylar notch or
notchplasty IS SOMETIMES REQUIRED to
prevent impingement, which is more
likely with anterior placement of the
graft.
 The posterior tibial location requires a
minimal notchplasty, if at all, unless the
ACL deficiency is chronic and the
intercondylar notch has become
stenotic with osteophytes.
 On occasion, the surgeon encounters a
narrow intercondylar notch, which has
been shown to contribute to ACL injury,
and notchplasty will protect the graft.


59. In routine cases, we prefer a limited notchplasty
that improves visualization in the posterior aspect
of the intercondylar notch and assists in the proper
placement of the femoral tunnel.
The anterior aspect of the notch is deepened by 2
to 3 mm, depending on the size of the graft. The
notchplasty is tapered posteriorly so that no bone is
removed at the femoral insertion site.

61. GRAFT TENSION
 Theoretically, the desired tension in the graft
should be sufficient to obliterate the
instability (Lachman test).
 Too much tension may “capture” the joint,
resulting in difficulty in regaining motion, or
it may lead to articular degeneration from
altered joint kinematics.
 To date, an optimal protocol for applying
tension to a graft has not been defined, but
over tensioning should be avoided.
Supraphysiologic tendon tension has been
shown to lead to focal degeneration,
increased vacuolization, coarser and less
oriented collagen fibers, and a significant
decrease in tensile strength.

62.  For femoral tunnel fixation with a bone plug,
metal or bio-interference screws are the most
commonly used devices.
 Metal interference screws have been used as
the standard fixation with a bone-patellar
tendon-bone autograft.
 However, with the increasing use of hamstring
soft tissue grafts,
 bioabsorbable interference screws (poly-L-
lactic acid, PLLA, polyglyconate) and
biocompatible, non-resorbable screws
(polyetheretherketone, PEEK) are becoming
more popular

63.  Fixation is recommended at
15–20° of flexion for Single
bundle reconstruction,
 differentiated angles are
recommended for Double
Bundle reconstruction
according to each bundle:
full extension for the PL
bundle and 45° of flexion
for the AM bundle

64. COMPLICATIONS
The most serious complications
after ACL reconstruction are
neurological vascular injuries,
arthrofibrosis and
infections.
Intraoperative complications
include
patellar fracture,
inadequate graft length,
mismatch between the bone plug
and
tunnel sizes,
graft fracture,
suture laceration,
violation of the
posterior femoral cortex, and
incorrect femoral or tibial tunnel
placement

65. postoperative complications
 The most common postoperative complications
are motion (primarily extension) deficits
 persistent anterior knee pain(several studies have
suggested a relationship between patellofemoral
pain and persistent flexion contracture or
quadriceps weakness)

66. POSTOPERATIVE CARE AND REHABILITATION
 Immediately after surgery, the knee is immobilized with a brace.
 The patient can be discharged with adequate pain medication and a
cooling device the same day.
 During the first week, focus should be placed on reducing pain and
swelling, and restoring full ROM and quadriceps muscle strength.
 On the day after surgery, patients begin to perform ankle pumps,
straight leg raise, quadriceps sets, gastrocnemius stretch and heel
slides.
 At the end of the first week, continuous passive motion is initiated
with progression to full extension.
 Depending on the progress made, crutches and brace are typically
weaned after 6 weeks.
 Once quadriceps muscle strength returns, straight line walking can be
initiated at 6 weeks, with progression to jogging in a straight line and
a stationary bike around 3 months.