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AMRO ALHIBSHI
The exact incidence of ACL injuries is unknown; however, it has been estimated that 200,000 are torn each year, and 100,000 ACL reconstructions are done each year in the United States. The controversy for managing this injury now centers more on the choice of graft selection for reconstruction instead of whether surgery is necessary.
The ACL inserts on the tibial plateau, medial to the insertion of the anterior horn of the lateral meniscus. The tibial attachment site is larger and more secure than the femoral site. The ligament is 31 to 35 mm in length and 31.3 mm2 in cross section.
the middle geniculate artery, which pierces the posterior capsule and enters the intercondylar notch near the femoral attachment.
Additional supply comes from the retropatellar fat
surface of the ligament, mostly at the insertions of the ligament (especially femoral), well beneath the external synovial sheath.
ACL
From anterior and central tibia to posterior and medial aspect of LFC
Femoral insertion
Tibial Insertion
17 mm long ( 2 mm)
9 mm wide ( 2 mm)
PL
AM
AM PL
Femoral insertion AM: anterior and proximal PL: posterior and distal
displacement, accounting for approximately 85% of the resistance to the anterior drawer test when the knee is at 90 degrees of flexion and neutral rotation.
The anteromedial band is tight in flexion, while the
flexion.
presence of mechanoreceptors in the ligament. These nerve endings may provide the afferent arc for postural changes of the knee through deformations within the ligament.
The exact contributions of the receptors have not
determined the ultimate load to be 1725 269 N; the stiffness, 182 33 N/mm; and the energy absorbed to failure, 12.8 2.2 N-m.
been hyperextended or popping out of joint and then reducing. A pop is frequently heard or felt.
walking is often difficult. Within a few hours, the knee swells, and aspiration of the joint reveals hemarthrosis 70% .
assist in the diagnosis but are more effective in evaluating patients with chronic ACL disruption when pain and associated muscle guarding are absent.
These devices also are useful for documentation of surgical
left difference is less than 3 mm in 95% of normal knees. The right-left difference is 3 mm or more in 90% of knees with an ACL ligament injury.
Plain radiographs often are normal; however, a tibial eminence fracture indicates an
Avulsion fracture of the tibia (Segond fracture) with anterior cruciate ligament tear.
technique.
The reported accuracy for detecting tears of the
accuracy for MRI in evaluating injuries to the anterior cruciate ligament approaches 95% to 100%.
influenced by the natural history of the injury, patients' ages and activity levels, extent of injury, resultant instability, follow-up duration and evaluation.
an ACLdeficient knee who resumes athletic activities and has repeated episodes of instability will sustain meniscal tears and osteochondral injuries that eventually lead to arthrosis.,
meniscal tears with acute ACL injuries to range from 50% to 70%.
The lateral meniscus is more commonly injured with
patients examined after the initial injury. most resolve between 6 and 12 months.
Osteochondral abnormalities identified on MRI may
be precursors of osteoarthritis.
the levels of proinflammatory cytokines such as interleukin-1 and tumor necrosis factor-a are markedly elevated,
whereas protective, antiinflammatory proteins such as
management, repair of the anterior cruciate ligament (either isolated or with augmentation), and reconstruction with either autograft or allograft tissues or synthetics.
who is willing to make lifestyle changes and avoid the activities that cause recurrent instability
and fixed with sutures or passed through transosseous drill holes or screws placed through the fragment into the bed.
ACL avulsions usually occur from the tibial
insertion.
Repair of avulsion of tibial attachment of anterior cruciate ligament with fragment of bone.
Extraarticular
Intraarticular
technique that attempts to reconstruct the anatomy as well as the function of the ligament.
Extraarticular reconstruction does not reconstruct
the anatomy, but focuses on the two main aspects of ACL function: resisting anterior drawer, and internal rotation of the tibia.
extraarticular reconstruction alone leaves a significant deficit from the normal tibial rotation and anterior drawer. extraarticular has been shown to provide no additional stability over that achieved by intraarticular reconstruction alone with an isolated ACL rupture.
over constraint of the joint, and increase lateral compartment contact pressures.
band.
technical issues of graft selection, placement, tensioning, and fixation as well as of postoperative rehabilitation led to dramatically improved results compared with previous intraarticular reconstructions.
adverse inflammatory A, but initially a 50% loss of graft strength occurs after implantation.
Therefore, it is desirable to begin with a graft
8- to 11-mm-wide graft taken from the central third of the patellar tendon, with its adjacent patella and tibial bone blocks.
ultimate tensile load (approximately 2300 N), its stiffness (approximately 620 N/mm), and the possibility for rigid fixation with its attached bony ends.
tendon is inadequate because the semitendinosus tendon has only 75% and the gracilis tendon only 49% the strength of the anterior cruciate ligament.
Now, surgeons are using either a triple- or quadruple-
stranded semitendinosus graft or a quadruple-stranded semitendinosus-gracilis tendon graft with both ends folded in half and combined. This latter graft has an ultimate tensile load reported to be as high as 4108 N.
multiple-bundle replacement graft that may better approximate the function of the two-bundle anterior cruciate ligament.
Disadvantages of this soft-tissue graft include the
concern over tendon healing within the osseous tunnels and the lack of rigid bony fixation.
interest recently. It can be harvested with a portion of patellar bone or entirely as a soft-tissue graft.
Biomechanical studies have shown the ultimate
graft, especially for revision ACL surgeries and for knees with multiple ligament injuries.
Extensive research has been devoted to identification of the ideal position for graft placement to reproduce the anatomy and function of an intactACL.
the proximity to the center of axis of knee motion. A femoral tunnel that is too anterior will result in lengthening of the intraarticular distance between tunnels with knee flexion.
The practical implications of this anterior location are
placement of the graft over the top of the lateral femoral condyle produces a graft that is taut in extension but loosens with flexion.
This location produces an acceptable result, since the
graft at the posterior portion of the ACL tibial insertion site near the posterolateral bundle position for best reproduction of the function of the intactACL.
This location also decreases graft impingement against
the roof of the intercondylar notch with knee extension that can occur with anterior placement.
notchplasty, if at all, unless the ACL deficiency is chronic and the intercondylar notch has become stenotic with osteophytes.
A bony ridge (resident's ridge) anterior to the
femoral attachment of the ACL should be removed, if present, since it impairs the proper identification of the femoral attachment site and also hinders the proper placement of the over-thetop guides used to drill the femoral tunnel.
A, Tibial drill guide for anterior cruciate ligament referencing off posterior cruciate ligament. B, Anterior cruciate ligament femoral guide.
notch near the 12-o'clock position has been shown to provide stability in the anteroposterior plane but does not restore stability in the rotational direction. With this tunnel placement, the Lachman test result is normal but the pivot shift test result is positive.
femoral tunnel lower on the lateral wall toward the 10:30- or 1:30-o'clock position, which more accurately reproduces the femoral attachment site of the ACL and provides rotational stability.
femoral tunnel in a more vertical position. With effort, the surgeon can get the guidewire to approximate the 10:30- or 1:30-o'clock position.
Alternatively, the femoral guide can be placed through a
low medial portal hugging the patellar tendon to reach the lower spot on the lateral femoral condylar wall.
The single-bundle technique traditionally used recreates
of initial fixation can significantly alter joint kinematics and in situ forces in the graft during knee motion. Theoretically, the desired tension in the graft should be sufficient to obliterate the instability (Lachman test).
Too much tension may capture the joint,
resulting in difficulty in regaining motion, or it may lead to articular degeneration from altered joint kinematics.
after fixation of the graft unless the graft has been cyclically preconditioned.
To date, an optimal protocol for applying tension to a
reconstruction are the fixation sites, not graft tissue itself. Fixation of replacement grafts can be classified into direct and indirect methods. Direct fixation devices include interference screws, staples, washers, and cross pins. Indirect fixation devices include polyester tape titanium button and suture-post.
fixation method for bonepatellar tendonbone grafts. and the tunnel wall. This is ensured by the use of a cannulated screw system over a guidewire inserted down the tunnel over which the screw is inserted. the screw to the bone plug can significantly affect the ultimate failure load. the ultimate tensile load up to 50%.
placement of the tunnel and attachment sites, less postoperative pain, fewer adhesions, earlier motion, and easier rehabilitation
semitendinosus and gracilis tendons on themselves, creating four strands and theoretically doubling the strength of the graft construct.
ligament 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.
passively.
After surgery, the thigh muscles atrophy quickly. Studies
revealed that maximal thigh atrophy was recorded 6 weeks after surgery.
reconstructions with autogenous bonepatellar tendon bone grafts decreased the quadriceps strength recovery at 12 weeks after surgery.
However, at 52 weeks, there was no significant difference in
thigh girth and quadriceps strength recovery compared with a control group done without a tourniquet.
hamstrings, which function in concert with the anterior cruciate ligament to prevent anterior translation of the tibia. Also, their strengthening does not stress the graft.
worrisome because they put some strain on the anterior cruciate ligament, especially in the last few degrees of extension of the knee if the limb is not bearing weight, so-called open chain exercises.
and perhaps the contours of the joint help stabilize the knee and protect the graft, so-called closed chain exercises.
bearing with crutches is allowed immediately. A straight-leg brace is worn to support the weakened quadriceps.
Certain types of concurrent meniscal repairs or
articular cartilage procedures may dictate a different weight bearing status. Crutches usually are discontinued by 3 to 4 weeks postoperatively.
weeks. Return to full activity requires 80% return of thigh strength and the ability to perform sport-specific agility duties.
usually delay return to sports for at least 6 months
0-2 weeks
1. 2. 3. 4. 5.
partial weight bearing 50-75%. full extension, active and passive. quadriceps exercises (isometric). straight leg raising (SLR). active flexion till 90.
2-4 weeks
1. Full weight bearing. 2. Full extension. 3. SLR with low resistance. 4. Active flexion till 120. 5. Active extension 90-60.
4-8 weeks
1. Active full range of motion. 2. Active extension 90-40 with
resistance. 3. SLR with resistance. 4. Double leg quarter squats. 5. Double leg press (light weight high repetition).
8-10 weeks
1. Progress the above exercises.
surgery, adequate preoperative conditioning and strengthening, and graft and fixation choices.
Although each of these has been debated, current
opinion generally holds that early reconstruction is preferable for early return to sporting activities, better clinical and laxity testing results, and decreased risk of late osteoarthritic changes.
include minimal or no swelling, leg control, and full range of motion, including full hyperextension.
inadequate graft length, mismatch between the bone plug and tunnel sizes, graft fracture, suture laceration, violation of the posterior femoral cortex, and incorrect femoral or tibial tunnel placement
tunnel position and inadequate notchplasty, which can result in overtightening or impingement of the graft, leading to loss of extension.
Postoperative factors prolonged immobilization
most persistent complication after ACL reconstruction. The exact cause has not been determined
limited or no immobilization and more aggressive rehabilitation have greatly decreased the frequency of both motion loss and anterior knee pain.