residency days

1. Ligament Injuries of
knee: ACL injury
Dr Sijan Bhattachan
2nd year resident
Orthopedic & Trauma Surgery
National Academy of Medical Science

4. Anatomy
• ACL originates on posteromedial corner of lateral femoral
condyle in the intercondylar notch and inserts on the tibial plateau,
medial to the insertion of anterior horn of the lateral meniscus in a
depressed area anterolateral to the anterior tibial spine.
• 33mm *11mm in size
• Functions
-Provides 85% stability to prevent anterior translation of tibia relative
to femur (when knee is at 90 degrees of flexion)
-Acts as a secondary restraint to tibial rotation and varus/valgus
angulation at full extension

5. • ACL has anteromedial and posterolateral bundles.
• Anteromedial bundle;
-Tight throughout knee ROM but tightest in flexion.
-Primarily responsible for restraining anterior tibial
translation.
• Posterolateral bundle
-Tightest in extension, slack in mid flexion
-Primarily responsible for rotational stability

6. • Blood supply by middle geniculate artery which
pierces the posterior capsule and enters the
intercondylar notch near the femoral attachment.
• Additional supply comes from the retropatellar fat
pad via the inferior medial and lateral geniculate
arteries.
• Innervated by posterior articular branches of tibial
nerve; Proprioception and modulation of quadricep
function

7. • PCL originates in medial femoral condyle and
insert in tibial sulcus.
• 38*13 mm in size
• PCL has anterolateral and posteromedial bundles.
• Posterior displacement is prevented by PCL
specifically the anterolateral bundle when the knee
is in near 90 degree flexion and by the
posteromedial bundle when the knee is straight.

8. • Blood supply by middle geniculate artery.
• Variable meniscofemoral ligaments originate from
the posterior horn of lateral meniscus and insert into
the substance of PCL;
-Ligament of Humphrey
-Ligament of Wrisberg.

9. ACL PCL
Tight in flexion AM AL
Tight in extension PL PM

10. Restraints to valgus stress
• Deep & superficial parts of MCL
• Semimembranosus
• Posterior oblique ligament
Restraints to varus stresses
• LCL
• Popliteus tendon
• Popliteofibular ligament
• Capsule

11. PLC includes
• Lateral collateral ligament
• Popliteofibular ligament
• Popliteus
• Lateral capsule
• Lateral head of gastrocnemius
• Act as stabilizers to varus and ER forces.
• Secondary stabilzers to posterior translation.

12. Acute Ligament injuries
• Injuries of knee ligaments are common, particularly in
sporting pursuits but also in road accidents, where
they may be associated with fractures or dislocations.
• Vary in severity from simple sprain to complete
rupture.
• Often involve more than one structure and it is
therefore useful to refer to them in functional terms
(eg anteromedial instability) as well as anatomical
terms (eg. torn MCL and ACL).

13. Mechanism of injury
• Most ligament injuries occur while the knee is bent i.e
when the capsule and ligaments are relaxed and the
femur is allowed to rotate on tibia.
• The damaging force may be a straight thrust (i.e
dashboard injury forcing tibia backwards ) or more
commonly a combined rotation and thrust as in a football
tackle.
• Medial structures are most often affected but if the injury
involves a twist in addition to a valgus force, ACL is also
damaged.

14. • Twisting force in a weight bearing knee often tears
the medial meniscus, causing the well recognized
triad of MCL,ACL and medial meniscal injury
described by O’Donoghue.

15. Clinical features
• H/o twisting or wrenching injury ; may even claim to have
heard a ‘pop’ as the tissues snapped.
• Knee is painful and swollen; Swelling appears almost
immediately in contrast to meniscal injury.
• Doughy feel of haemarthrosis distinguishes ligament
injuries from the fluctuant feel of synovial effusion of
meniscal injury.
• Partial tears permit no abnormal movement, but the
attempt causes pain whereas complete tear permits
abnormal movement which sometimes is painless

16. • Sideways tilting (varus/valgus) is examined first with
knee at 30 degree of flexion and then with the knee
straight.
• Isolated tear of collateral ligaments if knee
angulates only in slight flexion
• If angulates in full extension, there is almost
certainly rupture of capsule and cruciate ligaments
as well.

17. • Posterior sag of proximal tibia is a reliable sign of
PCL injury
• Drawer test
• Lachman test (with knee flexed 15-20 degrees);
more reliable.
• Rotational stability arising from acute injuries can
usually be tested only under anaesthesia.

18. Imaging
• Plain xray; may show that the ligament has avulsed
a small piece of bone
• Stress films (if necessary under anaesthesia) show
whether the joint hinges open on one side
• MRI is helpful in distinguishing partial from complete
ligament tears; May also reveal bone bruising.

19. • With severe tears of collateral ligaments and
capsule, arthroscopy should not be attempted; fluid
extravasation will hamper diagnosis and may
complicate further procedures.
• Main indication for arthroscopy which is usually
conducted after capsular healing has occurred and
knee motion recovered, is for reconstruction of
cruciate ligament tears in those individuals who
would benefit and to deal with other internal injuries
such as meniscal tears.

20. Treatment
Sprains & Partial tears
• Intact fibres splint the torn ones and spontaneous healing will occur
• Ice pack/aspiration for tense effusion
• Hazard is adhesions, so active exercise is prescribed from the start.
• Weightbearing is permitted but the knee is protected form rotational
or angulatory strain by a heavily padded bandage or a functional
brace
• With a dedicated exercise programme, the patient can usually return
to sports training by 6-8 weeks

21. Complete tears
• Isolated tears of MCL; Long cast brace for 6 weeks
followed by graded exercises
• Isolated tear of LCL;Conservative
-Fibular head fracture indicates avulsion of LCL as a solitary
injury
-If fibular styloid is avulsed, the injury is probably more severe
and involves part of the posterolateral capsule and arcuate
complex; benefit from repair.

22. Isolated tears of ACL
• Conservative
• Operative
-Professional sportsmen
-Avulsion of tibial spine; fixation required.
• Isolated tear of PCL; Conservative

23. • Combined injuries may result in significant loss of
function.
• With concurrent ACL and collateral ligament injury,
reconstruction of ACL often obviates the need for
collateral ligament treatment.
• Early operation carries the risk of postoperative joint
fibrosis, so it is wiser to start treatment with joint support
and physiotherapy in order to restore a good range of
movement before following on with ACL reconstruction

24. Complications
• Adhesions
-If the knee with partial ligament tear is not actively
exercised, torn fibres stick to intact fibres and to bone
-Knee ‘gives way’ with catches of pain
-Physiotherapy is the treatment

25. • Ossification in the ligament (Pellegrini-Stieda’s
disease); near upper attachment of medial ligament;
no prognostic significance
• Instability
-Knee may continue to give way

26. Chronic ligamentous
instability
• Instability (‘giving way’) of the knee may be obvious
soon after the acute injury has healed or it may only
become apparent much later.
• Unstable tibiofemoral relationships may result in
abnormal sideways tilt (varus or valgus), excessive
glide (forward, backward or oblique), unnatural
rotation or combination of these.

27. • Common is Anterolateral rotatory instability where
in addition to a torn ACL, lateral capsule and LCL
are torn or stretched.
• Posterolateral rotatory instability is due to chronic
deficiency of arcuate ligament complex.

28. Clinical features
• Feeling of insecurity and of giving way.
• With anterolateral rotatory instability, knee suddenly gives way as
the patient pivots on the affected side; some patients describe
this jerking sensation by grinding the knuckles of clenched fists
upon each other.
• The explanation is that, with the knee just short of full extension,
the lateral tibial condyle slips forwards then as the knee is flexed,
the iliotibial band pulls the condyle back into the reduced position
with a clunk.
• Locking is not the feature of instability and always suggest an
associated meniscal tear

29. • Joint looks normal apart from slight wasting.
• Rarely tenderness but excessive movement in one or more directions can
usually be demonstrated
• Useful routine is to observe
-Gait and knee posture in standing
-Examine for hyperextension
-Increased tilting into varus or valgus (0 and 30 degrees)
-Drawer tests/Lachman test
-Special tests for rotational instability

30. Varus/Valgus stress test
• To test stability in coronal plane, patient’s ankle is
tucked under the examiner’s armpit whilst both
hands support the knee by straddling it on either
side.
• Perform varus and valgus stress test with knee
straight and flexed at 30 degrees.

31. Posterior sag
• Place the knees at 90 degrees with soles of feet flat on the
couch and the heels lined up
• Look from side; note if there is any posterior sag of upper tibia
by checking the levels of tibial tuberosities.
• Posterior sag is a sure sign of PCL laxity

32. Quadriceps active test
• Then support patient’s thigh to
ensure hamstring muscles are
relaxed and use other hand to
grasp the patient’s ankle.
• Ask the patient to slide the foot
slowly down the couch while
resisting this movement by holding
on to ankle as the quadriceps
contracts, the posterior sag is
pulled up and the proximal tibia
shifts forward.

33. Drawer tests
• With the knees flexed at 90 degrees and both feet
resting on the couch, grasp the upper tibia with both
hands and making sure the hamstrings are relaxed,
test for anterior and posterior laxity. (Drawer sign)

34. Lachman test
• More reliable test for ACL laxity; examine for anterior posterior displacement
with the knee flexed at 20 degrees; Hold the calf with one hand and the thigh
with the other and try to displace the joint backwards and forwards
• Most sensitive exam test (95% sensitivity)
• Increased excursion relative to opposite knee and absence of firm endpoint
suggestive
• Grading;
Grade I; 3-5 mm translation
Grade II; 5-10 mm translation
Grade III; >10 mm translation

35. Tests for rotatory stability
• Modified drawer test
• Dial test (PLC vs PCL injury)
• Pivot shift test
• Macintosh test
• Reverse pivot shift test

36. Modified drawer tests
• Anterior drawer test is performed with the tibia in 30
degrees of internal rotation; If positive, it suggests
anterolateral rotatory instability.
• Positive drawer sign with the knee in external
rotation (about 15 degree) suggests anteromedial
rotatory instability)

37. Dial test
• Leg dangled over the edge of the couch.
• Examiner steadies the distal femur with one hand and holds the heel firmly in the other.
• Knee is flexed at 30 degrees and external rotation is applied through the heel and the position of
tibial tuberosity is noted; If external rotation is greater by 15 degrees as compared to the other
side, Posterolateral corner injury is suspected
• If the test is repeated with the knee flexed further to 90 degrees and the external rotation is
noted to increase, PCL injury is likely too.

39. Pivot shift test
• Examiner supports the knee in extension with the tibia internally rotated
( the subluxed position- the lateral tibial condyle is drawn in front of the
femoral condyle).
• Knee is then gradually flexed while a valgus stress is applied.
• In a positive test, as the knee reaches 20 or 30 degrees, there is a
sudden jerk as the tibial condyle slips backwards and reduces
• Positive pivot shift test indicates anterolateral rotatory instability

40. MacIntosh test
Alternative to pivot shift test
• Leg is lifted with the knee straight.
• Fibula is pushed forwards- if the
ACL is torn, the lateral tibial
condyle is now subluxed, forwards
• Held forwards while the knee is
flexed at 30-40 degrees, the
condyle reduces with a jerk

41. Reverse Pivot shift test
• Modification of pivot shift test can be used to
diagnose posterolateral rotatory instability
• Tibia is held in external rotation while the knee is
extended and similarly a valgus stress is applied as
the knee is gradually flexed- a characteristic clunk
signals the change from a subluxed to a reduced
position.

42. Imaging
• MRI is a reliable method of diagnosing cruciate
ligament and meniscal injuries.
• Almost 100% sensitivity and over 90% accuracy.

43. Arthroscopy is indicated if
• Diagnosis or the extent of ligament injury remains in
doubt
• Other lesions such as meniscal tears or cartilage
damage, are suspected
• Surgical treatment is anticipated

44. Treatment
• Most patients have reasonably good function and
will not require an operation
• So first approach should always be a supervised,
disciplined and progressively vigorous exercise
programme to strengthen the quadriceps and
hamstrings.

45. Indications for operation
• Recurrent locking, with MRI or arthroscopic
confirmation of meniscal tear
• Intolerable symptoms of giving way
• suboptimal function in sportsperson or other with
similarly demanding occupations
• ligament injuries in adolescents

46. • Combined injuries such as anterolateral or
anteromedial rotatory instability are the commonest
reasons for reconstructive surgery
• Torn ACL is replaced by autograft (usually from the
patellar tendon or from hamstring tendons) or by an
allograft.

47. ACL injury

48. • Mechanism; Non contact pivoting injury.
• Often associated with meniscal tear (50-70%)
-Lateral meniscal tears in 54% of acute ACL tears
• More common in female athletes

49. Grading of ACL injury
• Grade I; Ligament is mildly damaged; slightly
stretched but is still able to keep the knee joint
stable.
• Grade II; Ligament stretched to the point where it
becomes loose; Partial tear
• Grade III; Complete tear of ligament; knee joint is
unstable

50. Presentation;
• Felt a “pop”
• Pain deep in the knee
• Immediate swelling (70%)/hemarthrosis
O/E;
• Effusion
• Inability to actively extend knee

51. • Anterior drawer test
• Lachman test
• Pivot shift test ; mimics the actual giving way event

52. Imaging; Xray
• Tibial eminence fracture
indicates an avulsion of
tibial attachment of ACL

53. • Segond fracture (avulsion
fracture of proximal lateral tibia)
is pathognomonic for an ACL
tear.
- Represents bony avulsion of
anterolateral ligament (ALL)
-Associated with ACL tear 75-
100% of time.

54. • Lateral femoral notch sign
(Deep notch sign)
;Osteochondral impaction
fracture in condylopatellar
sulcus of lateral femoral
condyle
• Deepening of sulcus >1.5mm

55. MRI
• Most helpful diagnostic radiographic technique.
• Reported accuracy for detecting tears in ACL has
ranged form 70-100%

56. Primary signs; those that pertain to the ligament itself
• Edema
• Increased signal on T2
• Fiber discontinuity
• Change in expected course of ACL; Less steep
than blumenstat line

57. Normal ACL Torn ACL with intact PCL

58. Normal ACL Torn ACL

59. • Discontinuity of fibres (donot reach the femur)

61. Secondary signs; Closely related to ACL injuries
• Bony contusion
• >7 mm of anterior tibial translation (anterior tibial translocation sign)
• Uncovered posterior horn of lateral meniscus
• Fluid against the lateral wall (empty notch sign)
• Segond fracture
• Reduced PCL angle due to buckling of PCL
• Positive PCL line

62. Bony contusion
• Bony bruising in approx 70% of
acute ACL tears
• Anterior aspect of lateral
femoral condyle and posterior
aspect of lateral tibial plateau
• Has been suggested to predict
pain and other symptoms after
ACL reconstruction

63. Anterior tibial translocation sign
• 5-7mm ; suggestive
• >7mm; diagnostic

64. Empty notch sign
• Fluid against lateral wall

65. Buckling of PCL Positive PCL line

66. Kai-Jow Tsai,1 Hongsen Chiang,2 and Ching-Chuan Jiang2
Magnetic resonance imaging of anterior cruciate ligament rupture
BMC Musculoskelet Disord. 2004; 5: 21.
Abstract
Background
Magnetic resonance (MR) imaging is a useful diagnostic tool for the assessment of knee joint injury. Anterior
cruciate ligament repair is a commonly performed orthopaedic procedure. This paper examines the
concordance between MR imaging and arthroscopic findings.
Methods
Between February, 1996 and February, 1998, 48 patients who underwent magnetic resonance (MR) imaging
of the knee were reported to have complete tears of the anterior cruciate ligament (ACL). Of the 48 patients,
36 were male, and 12 female. The average age was 27 years (range: 15 to 45). Operative reconstruction using
a patellar bone-tendon-bone autograft was arranged for each patient, and an arthroscopic examination was
performed to confirm the diagnosis immediately prior to reconstructive surgery.
Results
In 16 of the 48 patients, reconstructive surgery was cancelled when incomplete
lesions were noted during arthroscopy, making reconstructive surgery
unnecessary. The remaining 32 patients were found to have complete tears of the ACL, and therefore
underwent reconstructive surgery. Using arthroscopy as an independent, reliable reference standard for ACL
tear diagnosis, the reliability of MR imaging was evaluated. The true positive rate for complete
ACL tear diagnosis with MR imaging was 67%, making the possibility of a false-positive
report of "complete ACL tear" inevitable with MR imaging.
Conclusions
Since conservative treatment is sufficient for incomplete ACL tears, the decision to undertake ACL
reconstruction should not be based on MR findings alone.

67. Natural history
• It has been well documented that an individual with an ACL
deficient knee who resumes athletic activities and has
repeated episodes of instability will sustain meniscal tears
and osteochondral injuries that eventually lead to arthritis.
• Discouraging results of nonoperative treatment can be
partially attributed to associated injuries that occur at the
time of ACL rupture.
-Several investigators have reported the incidence of
meniscal tears with acute ACL injury to range from 50-70%.
-Incidence of osteochondral damage ranges from 21-31%

68. • Gender and femoral intercondylar notch width have
been implicated as factors contributing to injury of
ACL ligament.
• Souryal and Freeman formulated the notch width
index, which is the ratio of the intercondylar notch to
the width of the distal femur at the level of popliteal
groove measured on a tunnel view radiograph of
the knee. Normal value was 0.231 +-0.044 (Larger
in male)

70. Treatment
Non operative
• Physical therapy and lifestyle modification
• Indicated in
-Partial or Complete tears and no symptoms of knee instability
-Low demand patients.
-Children (open growth plates)
• High risk of secondary damage to knee cartilage and meniscus
leading to premature arthritis.

71. Operative Mgt
• Operative management is indicated in younger
more active patients (reduces the incidence of
meniscal or chondral injury)
• ACL tears are not usually repaired because
repaired ACLs have generally been shown to fail
over time
• Torn ACL is generally replaced by a substitute graft
made of tendon.

72. Associated injuries
• MCL injury;
-Allow MCL to heal (varus/valgus stability) and then perform ACL reconstruction
-Varus/valgus instability can jeopardise graft
• Meniscal tear;
-Perform meniscal repair at the same time as ACL reconstruction
• Posterolateral corner injury
-Reconstruct at the same time as ACL or as 1st stage of 2 stage reconstruction

73. ACL RECONSTRUCTION

74. • The advances made in arthroscopy have led to the
development of arthroscopic techniques of ACL
reconstruction.
• Pre requisites for successful reconstruction
-Proper selection of patients
-Appropriate graft
-Meticulous technique
-Adequate rehabilitation

75. Timing of ACL
reconstruction???
• “ACL reconstruction beyond 3 weeks post injury
were at significantly lower risk of developing
arthrofibrosis” -Shelbourne et al AJSM 1991
• “ACL reconstruction should preferably be performed
within 6 months from injury to avoid the risk of
additional damage (LM in acute setting and MM as
time elapses)” -Kennedy J et al JBJS,2010

76. Graft selection
• Autograft tissue is used most commonly.
• Advantages;
-Low risk of adverse inflammatory reaction
-No risk of disease transmission
• As a biological graft, an autograft undergoes revascularization
and recollagenization, but initially a 50% loss of graft strength
occurs after implantation. Therefore, it is desirable to begin with
a graft stronger than the tissue to be replaced

77. Most common current graft choices are;
• Bone-patellar-bone autograft
• Quadruple hamstring autograft
(Semitendinosus/Gracilis)
• Quadriceps tendon autograft.

78. Bone patellar tendon graft
• Middle third of patellar tendon with bone plug from shin and patella
• 8-11 mm wide graft taken from the central third of patellar tendon
with its adjacent patella and tibial bone blocks
• High tensile loads, stiffness and possibility for rigid fixation with its
attached ends

79. Hamstring tendon graft;
• Use increased in recent years
• Relatively low donor site morbidity.
• Use of single strand of semitendinosus and gracilis tendon inadequate;the
semitendinosus tendon has only 75% and gracilis tendon has only 49% of strength
of ACL; so triple or quadruple stranded (both ends folded in half and
combined)tendon graft used

80. • Quadricep tendon graft has attracted interest recently
• Middle third of quadriceps tendon and a bone plug from
upper end of patella
• Has become an alternative replacement graft especially for
revision anterior cruciate ligament surgeries and for knees
with multiple ligament injuries.

81. • Because allografts appear capable of fulfilling many of the requirements
for an ideal ligament substitute, free allografts for ligament reconstruction
have received growing attention during past 15 years
• Allograft can be
-Bone patellar tendon bone
-Achilles tendon
-Hamstring
-Quadriceps tendon
-Fascia lata

82. Autograft Vs Allograft
• Viral disease transmission (1:1million)
• Graft incorporation and remodelling is faster with
autografts
• Donor site morbidity with autograft.

83. Graft placement
• Although both the tibial and femoral attachment sites are
important, errors in the femoral site are more critical because
of the proximity to the center of axis of knee motion.
• Femoral tunnel that is too anterior will result in lengthening of
intraarticular distance between tunnels with knee
flexion.Anterior location cause capturing of knee and loss of
flexion
• Posterior placement of 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 in flexion; this
location produces an acceptable result.

84. • Most surgeons advocate placement of graft at the
posterior portion of ACL tibial insertion site near the
posterolateral bundle position for best reproduction
of function of intact ACL.
• This location also decreases graft impingement
against the roof of the intercondylar notch with knee
extension that can occur with anterior placement.

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

86. • Earlier techniques often included widening of the
intercondylar notch or notchplasty to prevent
impingement, which is more likely with anterior
placement of the graft
• Place the femoral tunnel lower on the lateral wall
toward the 10 or 2 o clock position or even lower;
More accurately reproduces the femoral attachment
site of ACL and provides rotational stability.

87. Graft tension
• Application of tension to the graft at the time of
initial fixation can significantly alter joint kinematics
and insitu forces in the graft during knee motion
• Desired tension in the graft should be sufficient to
obliterate the instability.
• The force in the graft may decrease by as much as
30 % after fixation of the graft unless the graft has
been cyclically preconditioned

88. • To date, an optimal protocol for applying tension to
a graft has not been defined, but over tensioning
should be avoided.
• Too much tension may;
-Capture the joint, resulting in difficulty in regaining
motion or
-Lead to articular degeneration from altered joint
kinematics.

89. Graft Fixation
• In early weeks after surgery, the weakest links in
reconstruction are the fixation sites, not graft tissue itself
• Can be direct and indirect methods
• Direct fixation devices include interference
screws(Bioabsorbable screws) , staples, washers and
cross pins
• Indirect fixation devices include polyester tape, titanium
butto and suture post

90. Rehabilitation
• Goal of rehabilitation after ACL surgery is to restore
normal joint motion and strength while protecting
the ligament graft.
• Current evidence indicates that intensive
rehabilitation can help prevent early arthrofibrosis
and restore strength and function earlier.

91. Phases
• Acute phase (0-3 weeks); Restore ROM, Maintain
Q strength, Reduce inflammation.
• Recovery phase (3-6 weeks); Improve lower limb
muscle strength and functional stability.
• Functional phase (6+ weeks); Return to previous
level of activity and reduce risk of re-injury.

92. • The 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
• After surgery, the thigh muscles atrophy quickly; so
early quadriceps strengthening exercises
recommended.

93. • After isolated ACL reconstruction, partial weight bearing
with crutches is allowed immediately
• Certain types of concurrent meniscal repairs of articular
cartilage procedures may dictate a different weight
bearing status.
• Crutches usually are discontinued by 3-4 weeks
postoperatively
• Return to sports should be delayed for at least 6 months
after surgery to allow maturation of the graft

94. ACL rehabilitation
Protocol
Stage I; 0-2 weeks
• Patellar mobilisations
• Quadriceps sets /SLR all planes
• Passive extension (emphasize full extension)
• Passive, active and assisted ROM knee flexion.
• Edema control
• PWB 50-75% with crutches
• Goals;
-Full knee extension ROM
-90 degree knee flexion ROM

95. Stage II;
2-4 weeks
Goals; - 0-120 degrees ROM
-FWB without crutches
4-6 weeks
• Progress to full ROM by 6 weeks
• Progress closed chain exercises

96. At 6 months
• Return to sport if
-Motion >130 degrees
-Hamstring>90%
-Quadriceps >85%
-Sport specific agility training completed
• Maintenance exercises two to three times per week

97. Open & Closed chain
exercises
• Early quadriceps stregthening concentrates on quadriceps sets
and straight leg raises
• Certain resisted quadricep exercises are worrisome because
they put some strain on the ACL, especially in the last few
degrees of extension of the knee if the limb is not bearing
weight, so called OPEN CHAIN EXERCISES.
• In an effort to protect the ACL graft during quadriceps
exercises, it has been suggested that the patient stand instead;
the knee joint is thus loaded axially during motion and perhaps
the contours of the joint help stabilise the knee and protect the
graft, so called the CLOSED CHAIN EXERCISES.

98. Complications of ACL
surgery
Intraoperative
• Patellar fracture
• Inadequate graft length
• Mismatch between bone plug and tunnel sizes
• Graft fracture
• Suture laceration
• Violation of posterior femoral cortex
• Incorrect femoral or tibial tunnel placement

99. Post operative
Motion deficit (primarily extension)
• Preop factors; preop effusion, limited ROM, concomitant
knee ligament injuries
• Intraop factors; incorrect tunnel position and inadequate
notchplasty which can result in over tightening or
impingement of graft
• Post op facts include prolonged immobilisation and
inadequate or inappropriate rehabilitation

100. Persistent anterior knee pain
• Most common and persistent complication
• Several studies have suggested a relationship
between patellofemoral pain and persistent flexion
contracture or quadriceps weakness.

101. • Early failure, usually within the first 6 months
• Late failure, usually after 1 year, more typically is
caused by recurrent injury.

103. Factors potentially involved in failure of ACL reconstruction include;
• Surgical technique
• Selection of graft material
• Problems with graft incorporation
• Integrity of secondary restraints
• Condition of articular and meniscal cartilage
• Postop rehabilitiaion
• Motivation and expectations of patient

104. References
• Apley’s system of orthopaedics and fractures, 9th
edition.
• Campbell operative orthopaedics,12th edition.
• orthobullets.com
• Wing et al, Imaging of the anterior cruciate ligament,
World J Orthop. 2011 Aug 18; 2(8): 75–84.
• Internet sources