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Ligament injury to knee: ACL
Ligament injury to knee: ACL
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  3. 3. ANATOMY  ACL is composed of multiple collagen fascicles 31 – 35 mm in length and 31.3 mm2 in cross section  synovial membrane envelope the ACL thus making it extrasynovial.  Blood supply from middle geniculate artery. ACL vascularization arises from the middle genicular artery and vessels of the infrapatellar fat pad and adjacent synovium  Nerve supply from posterior articular nerve.
  4. 4.  ORIGIN - From the posteromedial corner of medial aspect of lateral femoral condyle in the intercondylar notch  INSERTION - Fossa in front of & lateral to anterior spine of tibia.
  5. 5.  ACL is composed of two principal parts 1. Small Anteromedial band and 2. Larger bulky posterolateral portion CLINICAL IMPORTANCE - Anteromedial bundle is tight in flexion and the posterolateral bundle is tight in extension
  6. 6. Functions -Resist anterior translation of tibia -Resist medial rotation of the tibia -Resistance to hyperextension -Resist varus and valgus angulation at full extension -It has proprioceptive function which help of postural changes of knee joint.
  7. 7. Mechaniusm of injury  The classic history of an ACL injury begins with a noncontact deceleration, jumping, or hyperextension, valgus external rotation force  Other mechanisms of injury include external forces applied to the knee. O'Donoghue unhappy triad due to lateral blow to the knee.
  8. 8. Symptoms  The patient often describes the knee as having been hyperextended or popping out of joint and then reducing.  A pop is frequently heard or felt.  The patient usually has fallen to the ground and is not immediately able to get up.  Resumption of activity usually is not possible, and walking is often difficult.  Within a few hours, the knee swells (haemarthrosis).
  9. 9. There are no pain receptors in the ACL, therefore pain is not an immediate feature in isolated ACL tears, but develops with hemarthrosis. 70% of acute knee hemarthrosis are associated with ACL tears. Locking in ACL-deficient knees denotes associated meniscal tears either from the original injury, or from repeated giving way . Difficulty rising from a chair or walking up stairs
  11. 11. ANTERIOR DRAWER TEST  To perform anterior drawer test, examiner grasps pt's tibia & pulls it forward when the affected leg is flexed at 90 degree while noting degree of anterior tibial displacement
  12. 12. LACHMAN’S TEST  This is a variant of the anterior drawer test  The examination is carried out with the knee in 20 deg of flexion, and external rotation (relaxes IT band)  For a right knee, the examiner's right hand grips the inner aspect of the calf and the left hand grasps outer aspect of the distal thigh  Attempt to quantify the displacement in mm is done by
  13. 13.  End point should be graded as hard or soft - End point is said to be hard when the ACL abruptly halts the forward motion of the tibia on the femur - End point is soft when there is no ACL & restraints are more elastic secondary stabilizers;
  14. 14. PIVOT SHIFT TEST  During this test, pt is kept in supine & examiner holds pt's leg with both hands abduct the pt’s hip (to relax the ITB and allow the tibia to rotate)  Holding above ankle in one hand and applying a valgus stress in internal rotation of 20 degree the other hand on proximal leg , the knee is slowly flexed  After the anterior subluxation of the tibia is noticed, the knee is slowly flexed, and the tibia will reduce with a snap at about 20° to 30°of flexion.
  15. 15. INVESTIGATIONS  X-RAY  MRI  Arthroscopy
  16. 16. Radiographic evaluation Plain x-ray  Plain radiographs often are normal; however, a tibial eminence fracture indicates an avulsion of the tibial attachment of ACL.  Segond fracture (avulsion fracture of the lateral capsule), is pathognomonic of an ACL tear.
  18. 18. Radiographic evaluation MRI  MRI is the most helpful diagnostic radiographic technique.
  19. 19. Radiographic evaluation MRI Primary signs:  Absent ACL  Fuzzy ACL  Bony avulsion
  20. 20. Radiographic evaluation MRI Secondary signs:  Those alert attention to ACL tear  Lateral femoral condyle contusion  Anterior translation of the tibia  Sigond fracture  Lateral femoral condyle impression fracture  Contusion of the posteromedial corner of tibia  Buckled PCL
  21. 21. Lateral femoral condyle contusion
  22. 22. Anterior translation of the tibia
  23. 23. Sigond fracture
  24. 24. Lateral femoral condyle impression fracture
  25. 25. Contusion of the posteromedial corner of tibia
  26. 26. Natural history  As a result of abnormal loading and shear stresses in the ACL–deficient knee, the risk of late meniscal injury is high and appears to increase with time from the initial injury.  Most late meniscal tears occur in the medial meniscus because of its firm attachment to the capsule.  Osteochondral damage also influences prognosis and may be precursors of osteoarthritis.
  27. 27. Treatment  Treatment options available include 1. Nonoperative management 2. Repair of the ACL (± augmentation) 3. Reconstruction with either autograft or allograft tissues or synthetics.
  28. 28. Nonoperative management  Nonsurgical management is indicated in patients with - partial tears and no instability symptoms - complete tears and no symptoms of knee instability - Who do light manual work or live sedentary lifestyles - Whose growth plates are still open (children)
  29. 29. Nonoperative management  Immediately after injury  R.I.C.E ( Rest Ice Compression Elevation ()  Exercise (after swelling decreases and weight- bearing progresses)  Braces  Rehabilitation Brace  Functional Brace
  30. 30. Precautions  Modification of active lifestyle to avoid high demand activities  Muscle strengthening exercises for life  May require knee brace  Despite above precautions ,secondary damage to knee cartilage & meniscus leading to premature arthritis
  31. 31. Surgical Treatment Timing of Surgery  1) Swelling in the knee must go down to near- normal levels  2) Range-of-motion (bending and straightening) of the injured knee must be nearly equal to the uninjured knee  3) Good Quadriceps muscle strength must be present.
  32. 32. Primary repair (±Augmentation)  Primary repair of the ACL is no longer practised; reconstruction several weeks after the acute injury is the preferred choice.  Acute repair is appropriate when a bony avulsion occurs with the ACL attached.  The avulsed bone fragment often can be replaced 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.
  33. 33. ACL Reconstruction  As evidence mounted that primary repair of midsubstance ACL tears routinely failed, interest turned to reconstruction of the ligament.  The advances made in arthroscopy have led to the development of arthroscopic techniques for ACL reconstruction.
  34. 34. Proper selection of patients. Appropriate graft. Meticulous technique. Adequate rehabilitation. Pre-requisites for successful reconstruction
  35. 35. Graft selection Autograft tissues  Autograft tissue is used most commonly.  Advantages:  Low risk of adverse inflammatory reaction  No risk of disease transmission.
  36. 36. Graft selection Autograft tissues The most common current graft choices are:  Bone–patellar tendon–bone graft  Quadrupled hamstring tendon graft.
  37. 37. Graft selection Autograft tissues Bone–patellar tendon–bone (BPTB) graft  Taken from the central third of patellar tendon, with its adjacent patella and tibial bone blocks.
  38. 38. Graft selection Autograft tissues Hamstring tendon graft  Low donor site morbidity.  semitendinosus or gracilis tendon is used for reconstruction of ACL.
  39. 39. Graft selection Autograft tissues Quadriceps tendon graft • It can be harvested with a portion of patellar bone or entirely as a soft-tissue graft. • Revision ACL surgeries and for knees with multiple ligament injuries
  40. 40. Graft selection Allograft ligament replacement  Autograft sacrifice a normal musculotendinous structure in an already deficient knee, adding to the functional disturbance.  Extensive surgical exposure, long tourniquet times, and prolonged rehabilitation are other disadvantages of these techniques.
  41. 41. Graft selection Allograft ligament replacement  Bone-patellar tendon-bone  Achilles’ tendon  Hamstrings  Quadriceps tendon  Fascia lata
  42. 42. Graft selection Autograft vs. allograft  Viral disease transmission (1:1million)  Graft incorporation & remodeling is faster with autografts.  Donor site morbidity with autografts
  43. 43. Graft placement  Various tools have been developed to assist the surgeon with placement of the tunnels.  These include devices in which the key point of reference is the over-the-top position, the roof of the intercondylar notch, or the anterior surface of the PCL.
  44. 44. Tibial drill guide for ACL referencing off PCL. ACL femoral guide.
  45. 45. Graft fixation  In the early weeks after surgery, the weakest links in reconstruction are the fixation sites, not graft tissue itself.  Fixation of replacement grafts can be classified into direct and indirect methods.
  46. 46. Graft fixation  Direct fixation devices include  Interference screws  Staples  Washers  Cross pins
  47. 47. Graft fixation  Indirect fixation devices include  Polyester tape–titanium button  Suture-post.
  48. 48. Rehabilitation after ACL Reconstruction  Goal of rehabilitation after ACL surgery: to restore normal joint motion and strength while protecting the ligament graft.
  49. 49. Rehabilitation after ACL Reconstruction  Most important step is the early restoration of full extension.  Knee immobilization in a fully extended brace is started immediately after surgery to prevent development of a flexion contracture.
  50. 50. Rehabilitation after ACL Reconstruction  After surgery, the thigh muscles atrophy quickly.  Early quadriceps strengthening concentrates on quadriceps sets and straight leg raises.
  51. 51. Rehabilitation after ACL Reconstruction  After isolated ACL reconstruction, partial weight 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 3-4 weeks postoperatively
  52. 52. Rehabilitation after ACL Reconstruction  Proprioceptive training also is instituted in the first 2 weeks.  Return to sports should be delayed for at least 6 months after surgery to allow maturation of the graft
  53. 53. Results of ACL Reconstruction  The results reported with use of patellar tendon and hamstring tendons are comparable.
  54. 54. Complications of ACL Surgery Intraoperative  Patellar fracture  Inadequate graft length  Mismatch between bone plug & tunnel sizes  Graft fracture  Suture laceration  Violation of posterior femoral cortex  Incorrect femoral or tibial tunnel placement
  55. 55. Complications of ACL Surgery Postoperative Motion (primarily extension) deficit  This can result from  Preoperative factors: incl. preoperative effusion, limited ROM, & concomitant knee ligament injuries. Those make poor postoperative motion more likely.  Intraoperative factors: incl. incorrect tunnel position and inadequate notchplasty, which can result in overtightening or impingement of the graft, leading to loss of extension.  Postoperative factors: incl. prolonged immobilization and inadequate or inappropriate rehabilitation.
  56. 56. Complications of ACL Surgery Postoperative Persistent anterior knee pain  Anterior knee pain probably is the most common and most persistent complication after ACL reconstruction.  Several studies have suggested a relationship between patellofemoral pain and persistent flexion contracture or quadriceps weakness .
  57. 57. Failure of ACL Reconstruction Factors potentially involved in the failure of ACL reconstruction include  surgical technique,  selection of graft material,  problems with graft incorporation,  integrity of the secondary restraints,  condition of articular & meniscal cartilage,  postoperative rehabilitation,  motivation and expectations of the patient.
  58. 58. Failure of ACL Reconstruction  Selection of patients and timing of surgery are crucial aspects of the preoperative plan.
  59. 59. Failure of ACL Reconstruction  Early failure, usually within the first 6 months, most often is the result of  Technical errors: This is the most avoidable and most common cause. Errors in surgical technique can include improper tunnel placement, inadequate notchplasty, and errors in graft selection, size, physiometry, or tensioning.  Incorrect or overly aggressive rehabilitation  Premature return to sport  Failure of graft incorporation.
  60. 60. Failure of ACL Reconstruction  Later failure, usually after 1 year, more typically is caused by recurrent injury.
  61. 61. THANK YOU