ACL Rupture

Definition
• ACL rupture is a tear in one of the knee
ligaments that connects the upper leg bone
with the lower leg bone.
• ACL maintains knee stability
 Epidemiology
• 1 case was found in 3500 people, estimated
95,000 ACL ruptures per year.
• Approximately 50% of patients with ACL injuries
also have a ruptured meniscus. In injury:
– Acute ACL, lateral meniscus is more often torn;
– Chronic ACL, the medial meniscus is more often torn.
• The incidence of ACL injuries is higher in people
who participate in high-risk sports such as
basketball, soccer, skiing.
 Etiology
• Sports that involve zigzag movements, changes in direction
of motion, and sudden changes in speed (accelerations) like
– soccer
– basketball
– volleyball
– futsal
• Non-contact injury (70% of cases) with knee valgus and
twisting (twisting) mechanism.
– occurs when the athlete dribbles or misses the knee when
landing.
• Contact injury (30% of cases)
– especially direct trauma to the knee in the direction of force
from the side.
 Classification
• Degree 1: Microrupture of the ligament.
Generally does not cause symptoms of
instability and can return to play after the
healing process.
• Degree 2: Partial tear with bleeding.
Decreased function and can cause symptoms
of instability.
• Degree 3: Total tear with very significant
symptoms of instability.
 Pathophysiology
• ACL injury can occur in the opposite direction of
rotation of the femur and tibia due to a rotating
motion or landing from a jump. (The most
common mechanism for ACL injury is circular
motion accompanied by slowing)
• Tearing of this ligament results in instability in the
knee joint. The tears that occur will cause
bleeding and edema.
• ACL receives a blood supply from the middle
genuelate artery, so if ACL rupture occurs
haemoarthrosis will occur.
 Clinical Manifestation
• A "pop" sounds when an injury occurs and is
followed by sudden (unsteady) knee
instability.
• Knee swelling in the first few hours can be a
sign of bleeding in the joint.
• Joint movements will be limited due to
swelling and pain.
 Diagnosis
• History (anamnesis)
– Since when was the pain experienced?
– Is there activity that precedes the pain?
– Does the patient feel shaky when standing?
– Is there a "pop" sound when an injury occurs?
 Physical Exam Maneuvers
• Lachman’s test
• Pivot shift test
Physical Exam Maneuvers
 Supporting investigation
• X-rays in 4 positions for further review of
injuries
• MRI to see soft tissue damage
 DD
• Rupture of the medial colateral ligament
– occurs when there is trauma to contact with objects
from the lateral direction. Strong lateral direction can
also result in ACL tears accompanied by MCL tears and
a medial meniscus known as the O'Donaughue
"terrible triad".
• Rupture of the posterior cruciate ligament (PCL)
– occurs when there is a strong push from the front of
the tibia posteriorly. Examination that can be done to
make a diagnosis of PCL rupture is the posterior
drawer test which is the opposite of the anterior
drawer test.
 Treatment
• After an injury, RICE is done:
• Rest
– The knee is rested and not used until the swelling disappears
• Ice
– The knee is compressed with ice or cold water which aims to
reduce swelling and pain
• Compression
– Knee wrapped with compression bandage to reduce swelling
• Elevation
– The patient lies down with the limb position higher than the
heart which aims to reduce swelling
 ACL Reconstruction
• Purpose: restore knee stability with a graft or transplant.
• The transplants used are usually autograft (taken from the body's own
organs). The most commonly used is the graft of the patellar ligament or
from the hamstring tendon.
 Rehabilitation
• Aim to restore the Range of Motion (ROM) of the joints that are
carried out by ACL reconstruction.
• The first action taken after surgery is to move the knee joint in the
operating room. Local anesthesia is usually performed on the knee
so the patient does not feel pain when flexing the knee. This
process aims to see whether the graft planted is in good condition,
not too tight or not too loose.
• The next process is to trigger the growth of the transplant by giving
the load resistance by flexing the contralateral limb. It is intended
that the transplants can grow quickly so that the knee can be used
as in normal conditions.
• This rehabilitation process is a mandatory action so that the results
of the surgery performed can be optimized without reducing the
function and movement of the joint.
 Education
• To avoid injury to the ACL include:
– Warm up before doing sports.
– Avoid making sudden movements.
– Train muscles and joints with regular exercise
– Muscles and joints that are trained will increase
the strength of its components which will reduce
the risk of injury.
 Complication
• Growth disruption
• Valgus deformity
• Difference in leg length
 Prognosis
• Generally good. Appropriate handling in cases
of ligament injury can restore damaged
ligaments back to optimal conditions by
surgery so that the goal of knee stabilization
and normal function return are achieved.