PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB BACHELOR MEDICINE AND SURGERY (MBBS) UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN

1. 1
TREATMENT OF INJURED
ANTERIOR CRUCIATE LIGAMENT
PROBLEM BASED LEARNING (PBL)
PREPARED BY: MUHAMMAD ARIFF B. MAHDZUB
BACHELOR MEDICINE AND SURGERY (MBBS)
UNIVERSITY COLLEGE SHAHPUTRA, KUANTAN

3. • The ACL primarily serves to stabilize the knee
in an extended position and when
surrounding muscles are relaxed; so if the
muscles are strong, many people can function
without it.
• Fluids will also build the muscle.

4. NON-SURGICAL TREATMENT
• When tears to the ACL are not repaired it can
sometimes cause damage to the cartilage inside
the knee because with the torn ACL the tibia and
femur bone are more likely to rub against each
other.
• Immediately after the tear of the ACL, the person
should rest the knee, ice it every 15 to 20
minutes, provide compression on the knee, and
then elevate above the heart; this process helps
decrease the swelling and reduce the pain

5. • The form of treatment is determined based
on the severity of the tear on the ligament
• Small tears in the ACL may just require several
months of rehab in order to strengthen the
surrounding muscles, the hamstring and the
quadriceps, so that these muscles can
compensate for the torn ligament
• Falls associated with knee instability may
require the use of a specific brace to stabilize
the knee

6. SURGICAL TREATMENT
• If the tear is severe, surgery may be necessary
because the ACL cannot heal independently, as
there is no blood supply to this ligament
• Surgery is usually required among athletes
because the ACL is needed in order to perform
sharp movements safely and with stability
• The reconstructive surgery is usually done
several weeks after the injury in order to allow
the swelling and inflammation to go down.
• During surgery the ACL is not repaired, instead, it
is reconstructed using other tendons in the body

7. Patella
tendon-
bone auto
graft
Hamstring
auto graft
TYPES OF ACL SURGERY

8. Patella tendon-bone auto graft
• The central 1/3 of the patella tendon is removed along
with a piece of bone at the attachment sites on the
kneecap and tibia
• The advantages of using this method is that the patella
tendon and ACL are relatively the same length and it
uses a bone to bone attachment which most surgeons
agree is much stronger than other healing methods.
• Disadvantages of this method is common anterior knee
pain due to the removal of bone from the kneecap.
• This method makes the side of harvest is extremely
painful for weeks after surgery and some patients
develop chronic patellar tendinitis.

9. Hamstring auto graft
• two tendons are taken from the hamstring muscles and
wrapped together to form the new ACL.
• Advantages of this method are less pain associated
with post surgery healing than that of the patella
tendon-bone graft due to the fact no bone is removed,
and the small incision.
• The disadvantage of this method is that the new
ligament takes longer to heal since there is no bone to
bone healing and the tendon to bone connection takes
relatively long to become rigid.
• After the surgery, rehabilitation is required in order to
strengthen the surrounding muscles and stabilize the
joint.

10. Two main options for ACL graft selection:
• AUTOGRAFT-the persons own tissues, and options include
the hamstring tendons or middle third of the patella tendon but
it is not known which is best
• ALLOGRAFT- cadaveric tissue sourced from a tissue bank.

11. Method of Surgery
• Using arthroscopic surgery, a minimally
invasive surgical procedure in which an
examination and sometimes treatment of
damage of the interior of a joint is performed
using an arthroscope, a type of endoscope that is
inserted into the joint through a small incision.
• two small incisions are made — one for the
arthroscope and one for the surgical instruments
to be used in the knee cavity

12. • Firstly, tunnels are drilled into the femur and tibia at
approximately the original ACL attachments
• The graft is then placed into position and held in place.
• There are a variety of fixation devices available,
particularly for hamstring tendon fixation and these
include screws, buttons and post fixation devices
• The graft typically attaches to the bone within six to
eight weeks[
• The original collagen tissue in the graft acts as a
scaffold and new collagen tissue is laid down in the
graft with time
• Hence the graft takes over six months to reach
maximal strength
• After surgery, the knee joint loses flexibility, and
the muscles around the knee and in the thigh tend
to atrophy.
• After surgery, no sports are allowed for 6 to 7 months.

13. Rehabilitation of Surgery
• very important to reconstruction
• The process to regain full use of the joint is long and
rigorous.
• Phase 1: Early rehabilitation consists of short-term
management, i.e. management of pain and swelling
while regaining movement.
• Phase 2: In weeks 3 and 4, the pain should be subsiding
and the patient will be ready to try more things on an
unsteady knee. Joint protection during this step is
emphasized. The patient will be able to start doing
exercises such as mini wall sits and riding stationary
bikes. The aim is to be able to bend the knee 100
degrees.

14. • Phase 3: Weeks 4 and 6 are the controlled ambulation
phase. At this point the patient will be doing the
exercises from phase 2 plus some more challenging
ones. The patient will try to get their knee to bend 130
degrees during this stage. The aim during this period is
to focus heavily on improving balance.
• Phase 4: This is the moderate protection phase,
covering weeks 6 to 8. In this period the patient will try
to obtain full range of motion as well as increase
resistance for the workouts.
• Phase 5: This is the light activity phase, covering weeks
8 to 10. Rehabilitation during period places particular
emphasis on strengthening exercises, with increased
concentration on balance and mobility.

15. • Phase 6: This is the return to activity phase,
lasting from week 10 until the target activity
level is reached. At this point the patient will
be able to start jogging and performing
moderately intense agility drills. Somewhere
between month 3 and month 6 the surgeon
will probably request that the patient perform
physical tests to monitor the activity level.
When the doctor feels comfortable with the
progress of the patient, s/he will clear that
person to resume a fully active lifestyle