The Treatment of ACL Tears

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70% of athletes that present with a swollen knee have a torn ACL. Learn about Anterior Cruciate Ligament (ACL) injuries, treatment and prevention.

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The Treatment of ACL Tears

  1. 1. Anterior Cruciate Ligament (ACL) Injuries: Treatment & Prevention David A. Abrutyn, M.D. Sports Medicine Shoulder & Knee Surgery
  2. 2. What Are We Talking About?
  3. 3. Anatomy • Two Bundles:  Anteromedial (AM) • Proximal/Posterior • Anterior/Medial  Posterolateral (PL)
  4. 4. Significance
  5. 5. What Does the ACL Do? • Functions to resist anterior translation of the tibia on the femur – AM bundle – Provides 85% of resistance to the anterior drawer in 90o of flexion • Resists tibial rotation – PL bundle • Helps provide varusvalgus stability when the knee is in full extension
  6. 6. Why Are We Talking About It?
  7. 7. Background • Second most commonly injured ligament in the knee • Estimated to occur in 1 in 3000 people in the U.S. • Resulting in an estimated 100,000 reconstructions a year • 6th most common orthopaedic procedure performed in the U.S.
  8. 8. Gender Differences • Female:Male Ratio 9:1   Collegiate Basketball 3.5x Soccer 2.67x • Recreational Alpine Skiers
  9. 9. How Does It Happen? • The majority of ACL injuries occur from non-contact injuries (70%) – Pivot shift injury – Individual decelerates – Try to change directions abruptly or lands from a jump – Females are 6-9 times more likely to suffer an ACL tear
  10. 10. What Causes ACL tears? • Position of body during landing, cutting, pivoting Hips & Knees are straight Landing on flat feet Puts ACL at risk • Versus Hips & Knees bent Landing on toes Risk of ACL injury minimized      
  11. 11. Risk Factors • Muscle Imbalance Hamstring/Quadriceps Poor Hamstring Strength • Hamstring protect ACL • Quadriceps stretch/stress ACL • Slow activation of hamstring with pivot/landing  
  12. 12. Risk Factors • Anatomic Factors
  13. 13. Risk Factors • Environmental Factors
  14. 14. Risk Factors • Hormonal Factors   ACL estrogen receptors Estrogen • Ligament looseness • Increased in girls vs. boys • Increased @ specific times during menstrual cycle  Studies VERY inconsistent
  15. 15. Goals of ACL Reconstruction • Provide stable & painfree knee under physiologic loads • Expedient return to previous level of function • Help prevent future injury to meniscus & cartilage • Prevent future degenerative arthritis?
  16. 16. Are We Successful? • Risk of re-tearing after ACL reconstruction 6% Range 3-30% • Risk of re-tearing opposite side 12% • 50% return to competing at same level 80% return to competitive level  
  17. 17. What is the Problem? • Surgical Technique Tunnel position Fixation Graft choice • Rehab program • Patient factors Concomitant injuries Not all ACL injuries are the same     
  18. 18. Principles ACL Reconstruction • Anatomic Approach    Restore knee mechanics Improves Rotatory stability Tunnels drilled independently • Sadoghi P et al Arthroscopy 2011
  19. 19. Trans-Tibial Approach
  20. 20. Rehab Principles • Immediate Post-Op      Bracing Cold Modalities Quad isometrics SLR Heel Slides • Week 1-2    Minimal Swelling Increase ROM (0-90) Closed Kinetic Chain Activities
  21. 21. Rehab Principles • 4 weeks     ROM (0-120) Increase Strength Cardiovascular training Aquatic Therapy • Weeks 5-12     Increase flexibility Continue Strengthening Neuromuscular control Running
  22. 22. Return To Play Criteria • Increase strength, power and endurance  90% uninvolved leg • Increase running & cutting to meet demands of individual sport • Increase cardiovascular demands • Progress to partial or full sport activities  6-9 months • RTP < 7 months--15.3% retear • RTP > 7 months--5.2% – Laboute et al, Ann Phys Med Rehab 2010
  23. 23. We Can’t Rush Biology • ACL Graft   Undergoes necrosis & remodeling Revascularizes @ 8-10 weeks • Completed in 16 weeks    Cellular Proliferation 4-8 weeks Graft firmly attach to bone @ 8 weeks 1 year before graft appears histologically normal
  24. 24. Can We Prevent It? • Biomechanical factors critical • Neuromuscular/Proprioce ptive programs • Dramatic reduction in ACL tears • Plyometric/jump training  Balance drills
  25. 25. Principles • Emphasize proper jump/landing techniques    Land on balls of feet Soft landing Toe-to-heel rocking of the foot • Decrease ground reactive forces     Knee flexed Knee forward Discourage inward buckling Chest over knees
  26. 26. Studies • PEP program    80% reduction over 2 years in girls playing soccer ages 14-18 Mandelbaum aclprevent.com • Balance Drills  Carraffa • Jumping Drills  Hewett
  27. 27. Summary • • • • ACL tears continues to increase Not all ACL tears are the same Anatomic Reconstruction is important Return to play   Need to be realistic Appropriate expectations • ACL Prevention   Neuromuscular training is effective aclprevent.com
  28. 28. Questions?

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