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Anterior Cruciate Ligament Repair..

The cruciate ligaments are two strong intracapsular ligaments that cross each other within the joint cavity. They are named anterior and posterior, according to their tibial attachments. These important ligaments are the main bond between the femur and the tibia throughout the joint's range of movement.

Intracapsular Ligaments

The anterior cruciate ligament is attached to the anterior intercondylar area of the tibia and passes upward, backward, and laterally, to be attached to the posterior part of the medial surface of the lateral femoral condyle. The anterior cruciate ligament prevents posterior displacement of the femur on the tibia. With the knee joint flexed, the anterior cruciate ligament prevents the tibia from being pulled anteriorly.

Ligament

The posterior cruciate ligament is attached to the posterior intercondylar area of the tibia and passes upward, forward, and medially to be attached to the anterior part of the lateral surface of the medial femoral condyle. The posterior cruciate ligament prevents anterior displacement of the femur on the tibia. With the knee joint flexed, the posterior cruciate ligament prevents the tibia from being pulled posteriorly.

Ligament

Epidemiology
An estimated 200,000 ACL-related injuries occur annually in the United States, with approximately 95,000 ACL ruptures. Approximately 100,000 ACL reconstructions are performed each year. The incidence of ACL injury is higher in people who participate in high-risk sports such as basketball, football, skiing, and soccer. When the frequency of participation is considered, a higher prevalence of injury is observed in females over males, at a rate 2.4-9.7 times greater for females.

ACL injuries occur when an individual rapidly decelerates, followed by a sharp or sudden change in direction. ACL failure has been linked to heavy or stifflegged landing; as well as twisting or turning the knee while landing, especially when the knee is in the valgus (knockknee) position.

Causes

Women in sports such as football (soccer), basketball, tennis and vo lleyball are significantly more prone to ACL injuries than men. The discrepancy has been attributed to differences between the sexes in anatomy, general muscular strength, reaction time of muscle contraction and coordination, and training techniques. A recent study suggests hormone-induced changes in muscle tension associated with menstrual cycles may also be an important factor. Women have a relatively wider pelvis, requiring the femur to angle toward the knees. Recent research also suggests that there may be a gene variant that increases the risk of injury

Symptoms of an ACL injury include hearing a sudden popping sound, swelling, and instability of the knee (i.e., a "wobbly" feeling). Pain is also a major symptom in an ACL injury and can range from moderate to severe. Continued athletic activity on a knee with an ACL injury can have devastating consequences, resulting in massive cartilage damage, leading to an increased risk of developing osteoarthritis later in life.

Symptoms

Diagnosis
The pivot-shift test, anterior drawer test and the Lachman test are used during the clinical examination of suspected ACL injury. The ACL can also be visualized using a magnetic resonance imaging scan (MRI scan).

Sample MRI

Test as The test is performed

follows: The patient is positioned lying supine with the hip flexed to 45 and the knee to 90. The examiner positions themselves by sitting on the examination table in front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon.

The index fingers are used to palpate the hamstring tendons to ensure that they are relaxed; the hamstring muscle group must be relaxed to ensure a proper test. The tibia is then drawn forward anteriorly. An increased amount of anterior tibial translation compared with the opposite limb or lack of a firm end-point indicates either a sprain of the anteromedial bundle of the ACL or a complete tear of the ACL.

Anterior Drawer Test

Anterior Drawer Test

Lachman test
The knee is flexed at 30 degrees Examiner pulls on the tibia to assess the amount of anterior motion of the tibia in comparison to the femur An ACL-deficient knee will demonstrate increased forward translation of the tibia at the conclusion of the movement

Lachman test

testone side of the Person lies on

body Knee is extended and internally rotated Doctor applies stress to lateral side of the knee, while the knee is being flexed A positive test indicates a crash felt at 30 degrees flexion.

Pivot shift test

A torn ACL is less likely to restrict the movement of the knee. When tears to the ACL are not repaired it can sometimes cause damage to the cartilage inside the knee because with the torn ACL the tibia and femur bone are more likely to rub against each other. Immediately after the tear of the ACL, the person should rest it, ice it every fifteen to twenty minutes, produce compression on the knee, and then elevate above the heart; this process helps decrease the swelling and reduce the pain. The form of treatment is determined based on the severity of the tear on the ligament. Small tears in the ACL may just require several months of rehab in order to strengthen the surrounding muscles, the hamstring and the quadriceps, so that these muscles can compensate for the torn ligament.

Management

Ligament Reconstruction with nonUnlike the MCL, which heals readily


operative management, the healing capacity of a torn ACL is poor, giving rise to the frequent need for surgical reconstruction to restore knee stability, particularly in the young, active individual. The incidence of re-injury of the knee is lower after ACL reconstruction than with non-operative management, particularly in patients younger than 25 years of age.

Patellar tendon graftconnects the The patellar tendon

patella (kneecap) to the tibia (shin). The graft is taken from the injured knee, but in some circumstances, such as a second operation, the other knee may be used. The middle third of the tendon is used, with bone fragments removed on each end. The graft is then threaded through holes drilled in the tibia and femur, and finally screwed into place

Hamstring tendon graftare made with the Hamstring autografts

semitendinosus tendon either alone, or accompanied by the gracilis tendon for a stronger graft. The semitendinosus is an accessory hamstring (the primary hamstrings are left intact), and the gracilis is actually not a hamstring, but an accessory adductor (the primary adductors are left intact as well). The two tendons are commonly combined and referred to as a four strand hamstring graft, made by a long piece (about 25 cm) which is removed from each tendon. The tendon segments are folded and braided together to form a quadruple thickness strand for the replacement graft. The braided segment is threaded through the heads of tibia and femur and its ends fixated with screws on the opposite sides of the two bones.

Indications for Surgery Although there are no rigid criteria for patient selection, the most frequently cited indications for reconstruction of the anterior cruciate ligament include the following:
Disabling instability of the knee due to ACL deficiency caused by a complete or partial acute tear or chronic laxity Frequent episodes of the knee giving way (buckling) during routine ADLs despite a course of non-operative management A positive pivot-shift test because an ACL deficit is often associated with a lesion of other structures of the knee, such as the MCL, resulting in rotatory instability of the joint Injury of the MCL at the time of ACL injury to prevent lax healing of the MCL High risk of re-injury because of participation in high demand, high-joint-load activities related to work, sports, or recreational activities

Contraindications to ACL Reconstruction little to no Relatively inactive individual with


exposure to work, sport, and recreational activities that place high demands on the knee Ability to make lifestyle modifications to eliminate high risk activities Ability to cope with infrequent episodes of instability Advanced arthritis of the knee Poor likelihood of complying with postoperative restrictions and adhering to a rehabilitation program

Rehabilitation..

During the early postoperative period, a delicate balance exists between adequate protection of the healing graft and donor site and prevention of adhesions, contractures, articular degeneration, and muscle weakness and atrophy associated with immobilization. Early motion places beneficial stresses that strengthen the graft but must be carefully controlled to avoid stretching the graft while in a weakened state, particularly during the first 6 to 8 weeks after implantation.

Exercise: Maximum Protection Phase

The moderate protection phase, which begins about 4 to 5 weeks postoperatively or at a point when identified criteria have been met, extends to about 10 to 12 weeks postoperatively. The emphasis of this phase is to achieve full knee ROM and increase strength, endurance, and balance in preparation for a transition to functional activities without compromising the stability of the knee. The hinged, protective brace is worn for gait and most exercises.

Exercise: Moderate Protection Phase

The advanced phases of rehabilitation and preparation for a return to a pre-injury level of activity begin at about 10 to 12 weeks postoperatively or at a point when the patient has met specified criteria. Most post-ACL reconstruction rehabilitation programs described in the literature continue until about 6 months postoperatively. The intensity and duration of training typically are based on the patients goals and the level of activity to which the patient wishes to return. Individuals involved in high-joint-loading, work-related activities or competitive sports are advised to participate in a maintenance exercise program.

and Return-to-Activity Phases

ACL injury prevention should be taken sincerely. The best way to prevent an ACL injury is to implement and add warm up drills like jumping and balancing. These drills will induce increase neuromuscular control and conditioning. In turn, muscular reactions will improve thus decreasing the risk of an ACL injury. A warm up program of at least 15 minutes 2-3 times per week is essential in order to prevent an ACL injury. Identifying the causes of the ACL and how painful they are the best way to avoid or escaped a painful experience it is to stretch the ligament before a physical activity. The leg muscles like the quadriceps and hamstrings have to be made stronger.

Prevention

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