ACL Rupture and reconstruction

7/29/2019 ACL Rupture and reconstruction

1/21

{"

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


2/21

! Anatomy"" 38mm&long&and&10&mm&wide&(


3/21

! Rapid&deceleration&or&rotational&injury"" Most&likely&when&athletes&rapidly&decelerates&and&

then&makes&a&sharp&change&in&direction&(cu ing&movement)"

" Or&twisting&and&turning&when&landing."! Heavy&or&stiffUlegged&landing&(on&a&valgus&knee)"! Direct&contact&(+/U&collaterals)"! Activities:"

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

Mechanism&of&injury"


4/21

! nhappy&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,&stiffness,&swelling,&locking,&

instability&with&twisting&(sideUtoUside&movements),&reduced&ROM."

Associated&injuries"


5/21


6/21

!

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"


7/21

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

" 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"

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

Epidemiology"


8/21

! 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"


9/21

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

$ Slight&exion&(15&degrees) &stabilize&femur&and&pull&on&the&posterior&aspect&of&proximal&tibia"

" Anterior&drawer&test"$ False&negatives&(secondary&restraints&&collaterals)&

especially&if&it&is&an&isolated&ACL&rupture."" 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&felat&30&degrees&exion."

"

Valgus&and&varus&deformities"

Examination"


10/21

! MRI"" Can&clearly&visualize&the&ACL&and&other&soft&tissues."" Can&assess&damage&to&further&structures&(menisci,&

collaterals,&bone&marrow&changes/bruising)"! XUray"

" Rosenberg&(45&degree&exion,&PA&weightUbearing)"$ Signs&of&ACL&deciency&like&tibial&spines&peaking&or&

intercondylar&notch&narrowing."" Avulsion&fractures&of&lateral&tibial&plateau"

! Arthroscopy"

Investigations"


11/21

! 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"

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

Management&&Non&operative"


12/21

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

surfaces"! PreUOperatively&"

" Cannot&operate&until&inammatory&phase&nishes&to&

reduce&the&incidence&of&arthrobrosis."" Encourage&range&of&motion&exercises,&gait&and&quadriceps&function&exercises."

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

Management&&Operative"


13/21

! 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&off."! Tunnels&drilled&into&the&femur&and&tibia&at&the&original&ACL&

a achment&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."" There&are&variety&of&xation&devices&like&interference&screws,&bu ons&

and&post&xation&devices."! Test&again&to&conrm&knee&stability&and&graft&strength."



14/21



15/21

! 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)"

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



16/21

! Types&of&grafts"" Autografts:&using&bone&or&tissue&harvested&from&

the&patients&body"$ Graft&obtained&from&an&accessory&hamstring&or&part&

of&the&patellar&tendon."" Allografts:& sing&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."" Synthetic&grafts"

Graft&choices"


17/21

! Choice"" Placement&>&Type"" Type"

$ Autograft&is&preferred&"% Longer&recovery&(further&damage)"

$ Allograft&is&used&when&Autografts&are&hard&to&obtain.&"% Irradiation&&does&it&weaken&the&graft?"

" Site"$ There&isn t&an&ideal&place"$ BoneUPatellar&tendonUBone&(BTB)"

% Candidates:&Young,&high&demand&athletes"% Advantages:&Strength&(bone&to&bone),&knee&stability,&rapid&healing,&

early&rehab."% Disadvantages:&knee&pain&when&lunging,&Patellar&fractures"

$ Hamstring"% Advantages:&less&anterior&knee&pain,&less&stiffness,&smaller&

incisions."% Disadvantages:&problems&with&xation&slippage&and&stretching&out&

over&time.&As&well&as&slower&recovery."$ Quadriceps&tendon"

% 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"

Graft&choices"


18/21

! Placement&of&the&graft"" Femur"

$ Too&anterior"% 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."$ Too&posterior"

% The&graft&becomes&too&tight&in&extension"! Other&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"

Complications"


19/21

! Motion&in&the&postUoperative&phase&can&affect&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&"" range&of&motion&(ROM)&exercises&to&regain&exibility&of&the&ligaments,&

prevent&scar&tissue&forming&and&reduce&the&loss&of&muscle&tone"" se&of&Continuous&passive&motion&(CPM)&device"" Isometric&exercises&that&put&no&strain&on&the&knee"

! It&takes&6&weeks&for&graft&true&healing&(&graft&a achment&to&bone)"" During&this&phase,&patients&can&walk&with&caution.&"

! After&12&weeks,&patients&can&perform&more&aggressive&exercises&pu ing&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&"" Collagen&tissue&in&graft&works&as&scaffold&and&new&collagen&tissue&is&laid&

down,&this&procedure&usually&takes&6&months."! sing&knee&brace&can&reduce&the&chance&of&reUinjury."

Rehabilitation"


20/21

! Griffin&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,&Ferre i&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,&Se er&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:&h p://orthoinfo.aaos.org/topic.cfm?topic=a00297.&Last&accessed&7th&Feb&2013."

References"


21/21

! Rosenberg,&Thomas&D.& Method&for&ACL&reconstruction. & .S.&Patent&5,139,520,&issued&August&18,&1992."

! The&Daily&Mail,&(2011),&Vidic$ACL$injury&[ONLINE].&Available&at:&h p://i.dailymail.co.uk/i/pix/2011/12/08/articleU0U0F18683B00000578U97_468x286.jpg&[Accessed&07&February&13]."

! Physio1st,&(2011),&Vidic$ACL$injury&[ONLINE].&Available&at:&h p://www.physio1st.co.uk/wpUcontent/uploads/2012/02/C_71_article_1467511_image_list_image_list_item_0_image.jpg&[Accessed&07&February&13]."

! citifmonline,&(2011),&Vidic$ACL$injury&[ONLINE].&Available&at:&h p://kitnes.net/1_188398/300..1.1207507.jpg&[Accessed&07&February&13]."

References"

ACL Rupture and reconstruction

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