Updated ACL and MCL Injuries for Postgraduate Orthopaedic Course in Newcastle March 2015

POSTGRAD ORTH Deiary Kader
ACL Injuries
FRCS(Tr&Orth) Revision Course
Professor Deiary Fraidoon Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield

Postgraduate Orthopaedics
Newcastle Upon Tyne 16-21 March 2015
•
Professor Deiary Kader
Knee Surgeon
Nuffield Hospital Newcastle
NGMV Charity

Classification of Knee Stabilisers
Lateral Complex
ITB
LCL
Popliteus
Biceps Femoris
Central Complex
ACL
PCL
Med Menx
Lat Menx
Medial Complex
MCL
Postromedial Capsule
Semi-Memb
Pes anserinus

Anatomy
 33 mm long, 11 mm in diameter
 Two bundles
 AM bundle – tighten in flexion
 PL bundle – tighten in extension
 Supplied by middle geniculate artery
 90% type I and 10% type III collagen

Anatomy
 (Weber brothers 1836)
 (PL) bundle fibres tighten
rapidly during the early
extension <30º.

ACL is a primary resister to internal rotation of the tibia at <35º of flexion while the
anterolateral ligament is a stabiliser of internal rotation
in >35º of flexion .
Erin M. Parsons, Albert O. Gee, Charles Spiekerman, and Peter R. Cavanagh
The Biomechanical Function of the Anterolateral Ligament of the Knee
Am. J. Sports Med. Jan 2015

POSTGRAD ORTH Deiary KaderPOSTGRAD ORTH Deiary Kader

Immunohistochemical analysis revealed some free nerve endings ( ) and ovoid
Ruffini corpuscles ( * ) are present.
Curtesy of French Arthroscopic Society
Dr Sonnery Cottet
Free nerve endings
Ruffini corpuscles
Proprioception:
“Call for help” from ACL under stress to the
surrounding muscles. The Hamstrings
Type II receptors (Ruffini and Pacini bodies
Anatomy: ACL Mechanoreceptors

Anatomy
Proprioception:
knee proprioception
returned to normal within
6 months of ACL reconstruction,
Angoules AG, Mavrogenis AF, Dimitriou R, Karzis K, Drakoulakis E, Michos J, et al. Knee proprioception following ACL
reconstruction; a prospective trial comparing hamstrings with bone-patellar tendon-bone autograft. Knee. 2011;18:76–82.
Curtesy of Mr Panos Thomas

Mechanism of injury
 Low velocity, deceleration and pivotal injury, usually non-contact
 High-energy RTA
 Audible or feeling of “popping”
 Acute haemarthrosis in young 1–2 h, less dramatic in older patient
 20% of ACL injury associated with MCL injury
 80% incidence of lateral meniscal injury with combined ACL–MCL

Valgus + ER
POP

Causes of Injury
Mechanisms of Injury:
1) “plant-and-cut” manoeuvre
2) Knee Hyperextension (Fall
backwards)
3) Landing on one leg
following a jump
(Olsen et al 2004)

Clinical presentation
Chronic ACL Deficiency:
1) “Subjective Instability”
2) ‘Pain’
3) Recurrent joint
effusion
4) Locking
5) Quadriceps Atrophy

McDaniel – Rule of Thirds
 One-third is able to compensate, and can pursue
normal recreational sports
 One-third is able to compensate but will have to
reduce their sporting activities
 One-third does poorly and develop instability with
simple activities daily living

Clinical Examination
Stability Testing:
The Lachman test is the most
Sensitive test in Dx ACL tear
History:
- Noulis test (Georges Noulis Thesis in Paris,
1875)
- Ritchley test (1960)
- Ritchley-Lachman test (Torg et al 1976)

Positive Lachman test with a FIRM ENDPOINT
1. Partial ACL tear
2. Displaced bucket-handle meniscus tear
3. Intra-articular loose bodies
4. OA changes

LFC
PCL
ACL
“Lambda healing” AM bundle heals over PCL
(no subjective instability) (Zantop et al 2007)
An Empty wall sign

Pivot Shift Sign:
Intact Iliotibial tract is
required
Lachman tests anterior
translation,
Pivot shift tests rotational
stability

Paul F. Segond
a Paris surgeon
1879

ACL Injury
Diagnosis
 Physical Exam
 Lachman
 Pivot shift (confirmatory)
 Plain Radiographs
 Segond Fracture (<5%)
 Standing films for middle-aged
athlete (Arthritis)
 MRI

MRI
Acute tear:
1. Discontinuity ACL fibres (T1
weight)
2. Signal irregularities in the
ACL course (T2 weight)
3. Empty notch sign (coronal T1
weight)
4. Changes of the ACL angle
5. Partial ACL tear (T2 weight)
Indirect signs:
1. Buckling of PCL
2. Bone bruise (Lat femoral
condyle, lat tibial plateau)

MRI
Chronic tear:
1) Direct and indirect signs
of ACL tear
2) Subchondral lesions
3) Notch changes
4) Evaluation of articular
cartilage lesions
5) Loose bodies
6) Evaluation of menisci
7) Subchondral oedema
8) Other soft tissue (PCL,
PLC)

ACL Evidence-Based Review
Factors affecting results:
Patient Selection
Tunnel placement
Strong graft choices
Solid fixation
Rational rehabilitation

Non-Operative Treatment
 Activity modification
(swimming, bicycling,
jogging on flat ground)
 Muscle Training
(Hamstrings strength)
 Proprioceptive Training
 Bracing (reduce anterior
drawer)

Surgical Treatment
Indications:
1) Subjective instability (non-coper)
2) ACL tear in children and
adolescents
3) Multiligament injury
4) Displaced meniscal tears
5) Instability in OA (positive brace
test)?

Surgical
 Extra-articular reconstruction (Lemaire 1967 & MacIntosh 1972)
Involves tenodesis of the iliotibial tract. Eliminates pivot shift but there is concern
regarding its effectiveness in addressing anterior translation
 Intra-articular reconstruction. Current best practice
 Intra + Extra articular reconstruction

Intra-articular ACL Reconstruction

Techniques of femoral tunnel placement
A. Transtibial technique
B. Medial portal
technique

Transtibial technique
Advantages:
1) Simple technique
2) No graft angulation
Disadvantages:
1) Little ability to adjust
femoral tunnel position
2) Posterior placement of the
tibia tunnel
3) Risk of tibia tunnel
enlargement
4) Need for a notch plasty
5) Irrigating fluid leak from the
tibia tunnel

Medial portal technique
Advantages:
1) Independent placement of the
femoral and tibia tunnels
2) No fluid leakage from the tibia
tunnel
3) Anatomic placement of the tibia
tunnel
4) Ability to customise the tunnel
diameters
5) Excellent for revision procedures
Disadvantages:
1) Restricted vision in max flexion
2) Learning curve

Hamstring BTB
Grafts / Fixations
Quads
Curtesy of Dr Sonnery Cottet

Hamstring tendons
Advantages Disadvantages
1. Small incisions
2. Easy graft passage
3. High initial ultimate
load (>4000 N, Woo et al,
1991)
4. Less risk of cyclops
syndrome
5. Variable graft length
1. Exacerbation of medial
instability
2. Prolonged
osseointegration of the
graft 8-12 weeks
3. Weakening of knee deep
flexion (3-4 months)
4. Saphenous nerve injury

 Bone-to-bone healing
 Direct rigid fixation
 Faster biological
integration in 6 weeks
 PFJ Morbidity (Pinczewski)
 Anterior knee pain 30%–50%
 Patellar tendinosis 3%–5%
 Fracture patella, rare
 Patella baja
 Development of late OA
Patellar tendon
Advantages Disadvantages

Allograft
 Biologically inactive
 Slower incorporation
 Less stability in 6 months
 Risk of disease transmission
 Role in revision surgery
 Weaker after having been irradiated

In 1972, D. L. MacIntosh
In 1967,1975, M. Lemaire
Extra-articular reconstruction

ANTEROLATERAL LIGAMENT

Am J Sports Med. 2015 Jan 2.
The Biomechanical Function of the
Anterolateral Ligament of the Knee.
Damage to the ALL of the knee could result in knee instability
at high angles of flexion.
It is possible that a positive pivot-shift sign may be observed in
some patients with an intact ACL but with damage to the
ALL.
This work may have implications for extra-articular
reconstruction in patients with chronic anterolateral
instability.

The effect of femoral tunnel placement on ACL graft orientation and
length during in vivo knee flexion. J Biomech 2011
Abebe ES, Kim JP, Utturkar GM, Taylor DC, Spritzer CE, Moorman CT, Garrett WE, DeFrate LE.

Anatomic Single bundle recon

Comparison of 2 femoral tunnel locations in anatomic single-bundle
anterior cruciate ligament reconstruction: a biomechanical
study. Arthroscopy 2012;
Driscoll MD, Isabell GP, Conditt MA, Ismaily SK, Jupiter DC, Noble PC, Lowe WR
Centre AM Bundle vs centre of femoral foot print

Single or Double bundle technique?
Anatomical Single-Bundle
Technique Double-Bundle Technique
Advantages:
1) Simplicity
2) Broad spectrum of grafts
3) Simpler graft passage
4) Lower cost
Disadvantages:
1) Inadequate rotational
stability
Advantages:
1) ?Better rotational stability
2) Allowance for individual
variables
Disadvantages:
1) Anatomic or not? (Numerous
double bundle techniques)
2) Technically demanding
3) Longer operating time
4) Limited graft selection

Cochrane Database Rev. 2012
Double-bundle versus single-bundle reconstruction for anterior
cruciate ligament rupture in adults
There is insufficient evidence to determine the relative effectiveness of double-
bundle and single-bundle reconstruction for anterior cruciate ligament rupture in
adults, although there is limited evidence that double-bundle ACL reconstruction
has some superior results in objective measurements of knee stability and
protection against repeat ACL rupture or a new meniscal injury.

45°, Curve, QuickPass Lassos

HIDDEN LESION and Ramp tear

ACLR Clinical Questions?? Evidence
What is the risk of infection after ACLR 0.8% (LOE1)
Menx Repair Not on tech 94% success
What are the risk of ACLR graft failure at
2 years
3% (LOE1)
What are the risk of ACL tear in the
normal contra lateral knee at 2 years
3-6%
What is the risk of future OA
(radiographic) after ACL tear/ACLR?
Isolated ACL tear:0-13%
ACL+Menx tear: 21-48%
(LOE2)

ACLR Clinical Questions Evidence
What is the best graft autograft or
allograft
No difference from meta-analysis but does
not address the young active or elite
athlete (LOE3)
Bioabsorbable or metal Screws No difference
Only knee effusion is higher in Bio!
(LOE1)
What is the best Autograft choice HG or
PTB
No difference (LOE1)
Should I use a brace after ACLR? No Evidence in isolated ACLR (LOE1)

What are the
complications after ACL
reconstruction?

Complications
 Infection
 DVT and PE
 Osteoarthritis
 Cyclops lesion residual tissue anterior to the ACL
blocks extension

Complications
 Failure of Fixation
 Anterior placement of the femoral tunnel limits
flexion
 Anterior placement of the tibial tunnel limits
extension
 Flexion contracture and arthrofibrosis
 Graft rupture from impingement

Tibial Eminence Fracture
Meyers and McKeever classification (1959)
 Type I: non displaced
 Type II: partially displaced or hinged
 Type III: completely displaced (Type III)
 Type IIIA (Zifko) involves the ACL insertion only
 Type IIIB (Zifko) includes the entire intercondylar eminence.
 Type IV (Zaricznyj 1977): comminution of the fracture fragment.

Treatment
 Casting in extension for type I
 Open reduction and internal fixation.
 Arthroscopic reduction and fixation
 Rarely ACL reconstruction is necessary

Postgraduate Orthopaedics
Professor Deiary Kader
Knee Surgeon
Newcastle Nuffield
MCL

Medial Collateral Ligament Injury
 Incidence >> LCL Injury
 Mechanism of injury
Direct blow laterally, valgus stress,
forced external rotation

Medial Collateral Ligament Exam
 Opening @ 30o only
 Isolated MCL Injury
 Opening @ 0o
 Injury to Posteromedial
Capsule
 Usually with ACL +/or PCL
injury

25-30° of flexion, the MCL
provides 80% of the support
to valgus stress

Classification
I Localised tenderness, no instability, or laxity on testing
II localised swelling, possibly mild laxity, no instability
III definite clinical laxity ..Instability symptom . (80% MLI)
< 5 mm, 5-10 mm, > 10 mm
MCL

MCL
4 mm proximal
4 mm posterior to the medial epicondyle

MCL tear arising from the tibial insertion May lead to
STENER type lesion

Treatment
Acute isolated MCL tear
I Simple rest, ice, compression bandage, early physiotherapy. 2 Wks
II Hinged brace for symptom improves, WBAA, 1-2weeks
III Hinged brace 30-90/ Surgical 3-4 wks
Operative treatment depend on site and patient
Chronic isolated MCL tear – simple reapproximation – tend to elongate and stretch
therefore needs Augmentation with semitendinosis
Combined injury ACL and MCL→Reconstruction ACL and non-operative
treatment MCL I-II but surgical for III
MCL

MCL Reconstruction
with AT
+
Revision ACLR
Chronic MCL Injury

Updated ACL and MCL Injuries for Postgraduate Orthopaedic Course in Newcastle March 2015

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