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ACL&Rupture"

{"

Fadi&Hassan&&Hull&York&Medical&School"

Anatomy"
" " "

38mm&long&and&10&mm&wide&(<&PCL)" Viscoelastic#&adjust&to&forces&over&time" Supplied&by&the&middle&geniculate&artery." Mechanical"


$

Function"
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Prevents&anterior&tibial&translation&as&well&as& providing&rotational&stability" Resists&knee&abduction&(valgus/varus)&forces."

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Proprioception"

What&is&ACL?"

Rapid&deceleration&or&rotational&injury"
"

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Most&likely&when&athletes&rapidly&decelerates&and& then&makes&a&sharp&change&in&direction&(cuRing& movement)" Or&twisting&and&turning&when&landing."

! ! !

Heavy&or&stiUlegged&landing&(on&a&valgus&knee)" Direct&contact&(+/U&collaterals)" Activities:"


" " "

Jumping,&cuRing&or&pivoting&sports&like&football" Side&to&side&movements&like&tennis" Light&or&heavy&manual&work&like&jogging/running"

Mechanism&of&injury"

Unhappy&triad&or&ODonoghue&triad"
" "

"

Injury&&to&ACL,&MCL&and&the&meniscus&(M+L)" Caused&by&a&lateral&blow&to&the&knee&while&the& foot&is&xed&on&the&ground" Features:&pain,&stiness,&swelling,&locking,& instability&with&twisting&(sideUtoUside& movements),&reduced&ROM."

Associated&injuries"

Grade&1&sprains:&Microscopic&changes." ! Grade&2&sprains:&ligament&is&mildly&damaged& after&slight&stretching&but&is&still&able&to& maintain&the&knee&stability." ! Grade&3&sprains:&ligament&is&stretched&to&the& point&where&it&becomes&loose&(partial&tear)" ! Grade&4&sprains:&Complete&tear&of&the&ligament"


!

Injury&grading"

Women&in&sports&are&more&at&risk&of&ACL&injury& than&men&(due&to&anatomical&dierences&and& muscular&strength&dierences)"


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Less&incidence&in&athletes/teams&that&perform& regular&neuromuscular&training&that&enhances& proprioception,&balance,&movement&paRerns& and&muscle&strength."

Variation&in&hormonal&levels&(lax&ligaments)&vs& relatively&stronger&ligaments&in&men" Less&hip&and&knee&exion&in&women&(anatomy)" Wider&Q&angle&for&women"

Epidemiology"

Classic&pop&heard&or&felt" ! Swelling&(immediate,&resolves&in&time)" ! Severe&pain&during&knee&exion" ! Instability&of&the&knee&(wobbly&feeling)" ! Locking&during&movement" ! Giving&way&or&instability&upon&weight&bearing" ! Continuous&athletic&activity&on&an&injured&knee& #&cartilage&damage&#&osteoarthritis"


!

Clinical&features"

Examination"
" "

Haemarthrosis&within&hours&and&joint&line&tenderness." Lachman&test&"
$

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Anterior&drawer&test"
$

Slight&exion&(15&degrees)&#&stabilize&femur&and&pull&on& the&posterior&aspect&of&proximal&tibia" False&negatives&(secondary&restraints&&collaterals)& especially&if&it&is&an&isolated&ACL&rupture."

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Pivot&shift&test&"
$ $

subluxation&upon&exion&and&valgus&stress" Knee&extended&and&internally&rotated&#&apply&a&lateral& force&on&the&knee&while&exing&it&#&Positive&if&a&crash&is&felt& at&30&degrees&exion."

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Valgus&and&varus&deformities"

Examination"

MRI"
" "

Can&clearly&visualize&the&ACL&and&other&soft&tissues." Can&assess&damage&to&further&structures&(menisci,& collaterals,&bone&marrow&changes/bruising)" Rosenberg&(45&degree&exion,&PA&weightUbearing)"


$

XUray"
"

Signs&of&ACL&deciency&like&tibial&spines&peaking&or& intercondylar&notch&narrowing."

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Avulsion&fractures&of&lateral&tibial&plateau"

Arthroscopy"

Investigations"

NonUoperative&measures&aim&to&reduce& swelling,&control&pain&and&restore&full&range&of& motion." ! ICE&and&elevation&to&reduce&swelling&and&pain" ! NSAIDS" ! Physiotherapy" ! Functional&bracing" ! Minimal&operative&measures"


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Menisectomy" Treating&impingements&(ACL&stump&removal)"

Management&&Non&operative"

! !

ACL&reconstruction&is&a&graft&replacement&of&the&ACL&to& restore&its&function&after&an&injury" Reconstruction&depends&on&Age,&activity&level,&skeletal& maturity,&previous&injuries&and&cooperation/motivation." Goal&of&the&treatment"


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PreUOperatively&"
" "

Protect&knee&stability&as&well&as&meniscal&and&articular& surfaces"

Repair/reinforcement&is&possible&if&the&ligament&is&not& ruptured&completely."

Cannot&operate&until&inammatory&phase&nishes&to& reduce&the&incidence&of&arthrobrosis." Encourage&range&of&motion&exercises,&gait&and&quadriceps& function&exercises."

Management&&Operative"

! ! ! ! !

! !

Quick&examination&is&done&when&the&patient&is&anaesthetized.&" The&operation&is&done&through&arthroscopic&incisions&(incision&for& arthroscopy&is&made,&as&well&as&other&portals&for&instruments)." The&torn&ligament&is&removed&from&the&knee.&" Damaged&surfaces&are&often&trimmed&or&shaved&o." Tunnels&drilled&into&the&femur&and&tibia&at&the&original&ACL& aRachment&sites." Hamstring&autografts&are&made&with&semitendinosus&tendon&either& alone&or&accompanied&by&gracilis&tendon&(4&strand&hamstring&graft,& 25cm&long)." Tendon&segments&are&folded,&braided&together&to&form&a&quadruple& thickness&strand&" A&long&needle&is&passed&through&the&tunnel&and&out&through&the& skin.&" The&sutures&are&then&placed&through&the&eye&of&the&needle&and&the& graft&is&pulled&into&position&up&through&the&tibial&tunnel&and&then& up&into&the&femoral&tunnel" The&ends&are&then&xated&on&the&opposite&sides&of&the&two&bones."
"

Test&again&to&conrm&knee&stability&and&graft&strength."

There&are&variety&of&xation&devices&like&interference&screws,&buRons& and&post&xation&devices."

Management&&Operative"

Management&&Operative"

Patellar&tendon&could&also&be&used.&The&graft&is& taken&from&the&middle&third&of&the&injured&or& other&knee.&(including&a&piece&of&bone&from&the& patellar&and&tibial&ends)"


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The&graft&is&then&threaded&through&drilled&holes& in&the&tibia&and&femur"

Management&&Operative"

Types&of&grafts"
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Autografts:&using&bone&or&tissue&harvested&from& the&patients&body"
$

Graft&obtained&from&an&accessory&hamstring&or&part& of&the&patellar&tendon."

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Allografts:&Using&bone&or&tissue&from&a&donor/ cadaver."
$

Screening&and&sterilization&is&crucial.&(Irradiation& weakness?)" Graft&obtained&from&patellar&tendon,&anterior& tibialis&tendon&or&achilles&tendon."

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Synthetic&grafts"

Graft&choices"

Choice"
" "
$

Placement&>&Type" Type"
%

Autograft&is&preferred&"

Allograft&is&used&when&Autografts&are&hard&to&obtain.&"
%

Longer&recovery&(further&damage)"

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Site"
$ $

Irradiation&&does&it&weaken&the&graft?"

There&isnnt&an&ideal&place" BoneUPatellar&tendonUBone&(BTB)"
% %

Hamstring"
% %

Candidates:&Young,&high&demand&athletes" Advantages:&Strength&(bone&to&bone),&knee&stability,&rapid&healing,& early&rehab." Disadvantages:&knee&pain&when&lunging,&Patellar&fractures" Advantages:&less&anterior&knee&pain,&less&stiness,&smaller& incisions." Disadvantages:&problems&with&xation&slippage&and&stretching&out& over&time.&As&well&as&slower&recovery." Suitable&to&those&who&failed&ACL&reconstruction" Graft&taken&from&the&middle&third&of&the&tendon&and&a&bone&plug& from&the&upper&patellar&end." Also&suitable&for&taller&and&heavier&patients"

Quadriceps&tendon"
% %

Graft&choices"

Placement&of&the&graft"
"

Femur"
$
%

Too&anterior"

Too&posterior"
%

High&strain&on&the&graft&when&the&knee&is&exed&which&may&restrict& exion&(xed&exion&deformity)&or&it&may&simply&elongate&the& graft." Happens&when&the&tunnels&are&placed&too&far&in&the&femur&or&tibia& or&both." The&graft&becomes&too&tight&in&extension"

Other&complications"
" " " " " " " " "

Complications"

Fibrosis&if&the&operation&is&done&in&the&rst&4&weeks&after& rupture&while&the&knee&is&still&inamed&and&has&poor&ROM" Graft&failure" Fixation&failure&(widening&of&tunnel)" Loss&of&motion" ReUoperation" Patellar&fractures" Infections" Bleeding&and&numbness" Blood&clots"

Motion&in&the&postUoperative&phase&can&aect&the&stability&of&the& hamstring&tendon&graft.&Therefore,&a&brace&is&often&used&to& immobilize&the&knee&for&1U2&weeks&to&allow&for&healing." Initial&physiotherapy&consists&of&"


" " "

It&takes&6&weeks&for&graft&true&healing&(&graft&aRachment&to&bone)"
"

range&of&motion&(ROM)&exercises&to&regain&exibility&of&the&ligaments,& prevent&scar&tissue&forming&and&reduce&the&loss&of&muscle&tone" Use&of&Continuous&passive&motion&(CPM)&device" Isometric&exercises&that&put&no&strain&on&the&knee" During&this&phase,&patients&can&walk&with&caution.&"

! !

After&12&weeks,&patients&can&perform&more&aggressive&exercises& puRing&more&pressure&on&the&knee&and&increasing&resistance.& (jogging&is&allowed)" After&4&months,&more&intense&activities&like&running&can&be& performed." After&5&months:&light&ball&work&can&be&incorporated&as&the& ligament&is&nearly&regenerated." After&6&months:&full&strength&"


"

Rehabilitation"

Using&knee&brace&can&reduce&the&chance&of&reUinjury."

Collagen&tissue&in&graft&works&as&scaold&and&new&collagen&tissue&is&laid& down,&this&procedure&usually&takes&6&months."

Grin&LY,&Armstrong&A,&DeMaio&M.&The&female&athlete.&In:& DeLee&JC,&Drez&D&Jr,&Miller&MD,&eds.&DeLee$and$Drezs$ Orthopaedic$Sports$Medicine.&3rd&ed.&Philadelphia,&Pa:&Saunders& Elsevier;&2009:chap&10." Honkamp&NJ,&Shen&W,&Okeke&N,&FerreRi&M,&Fu&FH.&Anterior& cruciate&ligament&injuries:&1.&Anterior&cruciate&ligament& injuries&in&the&adult.&In:&DeLee&JC,&Drez&D&Jr,&Miller&MD,&eds.& DeLee$and$Drezs$Orthopaedic$Sports$Medicine.&3rd&ed.& Philadelphia,&Pa:&Saunders&Elsevier;&2009:chap&23,&section&D." Cimino&F,&Volk&BS,&SeRer&D.&Anterior&cruciate&ligament&injury:& diagnosis,&management,&and&prevention.&Am$Fam$Physician.& 2010;82:917U922." American&Academy&of&orthopaedic&surgeons.&(2009).&ACL$ Injury:$Does$It$Require$Surgery?.&Available:&hRp:// orthoinfo.aaos.org/topic.cfm?topic=a00297.&Last&accessed&7th& Feb&2013."

References"

Rosenberg,&Thomas&D.&vMethod&for&ACL& reconstruction.v&U.S.&Patent&5,139,520,&issued&August&18,& 1992." The&Daily&Mail,&(2011),&Vidic$ACL$injury&[ONLINE].& Available&at:&hRp://i.dailymail.co.uk/i/pix/2011/12/08/ articleU0U0F18683B00000578U97_468x286.jpg&[Accessed& 07&February&13]." Physio1st,&(2011),&Vidic$ACL$injury&[ONLINE].&Available& at:&hRp://www.physio1st.co.uk/wpUcontent/uploads/ 2012/02/ C_71_article_1467511_image_list_image_list_item_0_im age.jpg&[Accessed&07&February&13]." citifmonline,&(2011),&Vidic$ACL$injury&[ONLINE].& Available&at:&hRp://kitnes.net/ 1_188398/300..1.1207507.jpg&[Accessed&07&February&13]."

References"

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