ACL Repair

7/31/2019 ACL Repair

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Anterior Cruciate

Ligament Repair..


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Ligaments

The cruciate ligaments are two strongintracapsular ligaments that crosseach other within the joint cavity.They are named anterior and

posterior, according to their tibialattachments. These importantligaments are the main bond betweenthe femur and the tibia throughout the

joint's range of movement.


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LigamentThe anterior cruciate ligament isattached to the anterior intercondylararea of the tibia and passes upward,backward, and laterally, to be attached

to the posterior part of the medialsurface of the lateral femoral condyle.The anterior cruciate ligament prevents

posterior displacement of the femur on

the tibia. With the knee joint flexed, theanterior cruciate ligament prevents thetibia from being pulled anteriorly.


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LigamentThe posterior cruciate ligament is

attached to the posterior intercondylararea of the tibia and passes upward,

forward, and medially to be attached tothe anterior part of the lateral surfaceof the medial femoral condyle. The

posterior cruciate ligament preventsanterior displacement of the femur on

the tibia. With the knee joint flexed,the posterior cruciate ligamentprevents the tibia from being pulledposteriorly.


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Epidemiology

An estimated 200,000 ACL-related injuriesoccur annually in the United States, withapproximately 95,000 ACL ruptures.

Approximately 100,000 ACLreconstructions are performed each year.The incidence of ACL injury is higher in

people who participate in high-risk sportssuch as basketball, football, skiing, andsoccer. When the frequency of participation

is considered, a higher prevalence of injuryis observed in females over males, at a rate2.4-9.7 times greater for females.


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CausesACL injuries occur when anindividual rapidly decelerates,followed by a sharp or suddenchange in direction. ACL failure

has been linked to heavy or stiff-legged landing; as well astwisting or turning the knee

while landing, especially whenthe knee is in the valgus (knock-knee) position.


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Women in sports suchas football (soccer), basketball, tennis and volleyball are significantly more prone to ACL

injuries than men. The discrepancy hasbeen attributed to differences between thesexes in anatomy, general muscularstrength, reaction time of musclecontraction and coordination, and training

techniques. A recent studysuggests hormone-induced changes inmuscle tension associated with menstrualcycles may also be an important

factor. Women have a relativelywider pelvis, requiring the femur to angletoward the knees. Recent research alsosuggests that there may be a gene variantthat increases the risk of injury


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SymptomsSymptoms of an ACL injury includehearing a sudden popping sound,swelling, and instability of the knee(i.e., a "wobbly" feeling). Pain is alsoa major symptom in an ACL injury

and can range from moderate tosevere. Continued athletic activityon a knee with an ACL injury canhave devastating consequences,

resulting inmassive cartilage damage, leading toan increased risk ofdeveloping osteoarthritis later in life.


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agnos sThe pivot-shift test, anteriordrawer test and the Lachmantest are used during the clinicalexamination of suspected ACLinjury. The ACL can also bevisualized using a magneticresonance imaging scan (MRI

scan).


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Sample MRI


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TestThe test is performed asfollows:The patient ispositioned lying supine with thehip flexed to 45 and the knee to

90. The examiner positionsthemselves by sitting on theexamination table in front of theinvolved knee and grasping

the tibia just below the joint lineof the knee. The thumbs areplaced along the joint line oneither side of the patellar tendon.


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Test

The index fingers are used to palpatethe hamstring tendons to ensure thatthey are relaxed; the hamstring musclegroup must be relaxed to ensure aproper test. The tibia is then drawnforward anteriorly. An increasedamount of anterior tibial translation

compared with the opposite limb orlack of a firm end-point indicates eithera sprain of the anteromedial bundle ofthe ACL or a complete tear of the ACL.

A D


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Anterior Drawer

Test


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ac man test

The knee is flexed at 30 degrees

Examiner pulls on the tibia toassess the amount of anteriormotion of the tibia in comparison tothe femur

An ACL-deficient knee willdemonstrate increased forward

translation of the tibia at theconclusion of the movement

h


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Lachman test


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test Person lies on one side of the

body

Knee is extended and internallyrotated

Doctor applies stress to lateralside of the knee, while the kneeis being flexed

A positive test indicates a crashfelt at 30 degrees flexion.


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Pivot shift test


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ManagementA torn ACL is less likely to restrict the movement

of the knee. When tears to the ACL are not repairedit can sometimes cause damage to the cartilageinside the knee because with the torn ACL the tibiaand femur bone are more likely to rub against eachother. Immediately after the tear of the ACL, the

person should rest it, ice it every fifteen to twentyminutes, produce compression on the knee, andthen elevate above the heart; this process helpsdecrease the swelling and reduce the pain. The formof treatment is determined based on the severity of

the tear on the ligament. Small tears in the ACLmay just require several months of rehab in order tostrengthen the surrounding muscles, the hamstringand the quadriceps, so that these muscles cancompensate for the torn ligament.


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Ligament

ReconstructionUnlike the MCL, which heals readily with non-operative management, the healing capacity of a

torn ACL is poor, giving rise to the frequentneed for surgical reconstruction to restore kneestability, particularly in the young, activeindividual. The incidence of re-injury of the

knee is lower after ACL reconstruction thanwith non-operative management, particularlyin patients younger than 25 years of age.


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a e ar en ongraft

The patellar tendon connects thepatella (kneecap) to the tibia (shin).The graft is taken from the injuredknee, but in some circumstances, suchas a second operation, the other kneemay be used. The middle third of thetendon is used, with bone fragmentsremoved on each end. The graft is thenthreaded through holes drilled in the

tibia and femur, and finally screwedinto place


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graft

Hamstring autografts are made with the

semitendinosus tendon either alone, or accompaniedby the gracilis tendon for a stronger graft. Thesemitendinosus 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 twotendons 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 toform a quadruple thickness strand for the replacementgraft. The braided segment is threaded through theheads of tibia and femur and its ends fixated with

screws on the opposite sides of the two bones.


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Indications for SurgeryAlthough there are no rigid criteria for patientselection, the most frequently cited indications forreconstruction 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 chroniclaxity

Frequent episodes of the knee giving way (buckling)

during routine ADLs despite a course of non-operativemanagement A positive pivot-shift test because an ACL deficit is

often associated with a lesion of other structures of theknee, such as the MCL, resulting in rotatory instabilityof the joint

Injury of the MCL at the time of ACL injury to preventlax healing of the MCL

High risk of re-injury because of participation in highdemand, high-joint-load activities related to work,sports, or recreational activities


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Contraindications to

ACL Reconstruction Relatively inactive individual with little to noexposure to work, sport, and recreationalactivities that place high demands on theknee

Ability to make lifestyle modifications toeliminate high risk activities

Ability to cope with infrequent episodes ofinstability

Advanced arthritis of the knee Poor likelihood of complying with

postoperative restrictions and adhering to arehabilitation program


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Rehabilitation..


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Phase

During the early postoperative period, a

delicate balance exists between adequateprotection of the healing graft and donor siteand prevention of adhesions, contractures,articular degeneration, and muscle weakness

and atrophy associated with immobilization.Early motion places beneficial stresses thatstrengthen the graft but must be carefully

controlled to avoid stretching the graft whilein a weakened state, particularly during thefirst 6 to 8 weeks after implantation.

xerc se: o era e ro ec on


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xerc se: o era e ro ec onPhase

The moderate protection phase, which begins

about 4 to 5 weeks postoperatively or at apoint when identified criteria have been met,extends to about 10 to 12 weeks

postoperatively. The emphasis of this phase isto achieve full knee ROM and increasestrength, endurance, and balance in

preparation for a transition to functional

activities without compromising the stabilityof the knee. The hinged, protective brace isworn for gait and most exercises.


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and

Return-to-Activity Phases

The advanced phases of rehabilitation andpreparation for a return to a pre-injury level ofactivity begin at about 10 to 12 weeks

postoperatively or at a point when the patienthas met specified criteria. Most post-ACLreconstruction rehabilitation programsdescribed in the literature continue until about6 months postoperatively. The intensity andduration of training typically are based on the

patients goals and the level of activity to whichthe patient wishes to return. Individualsinvolved in high-joint-loading, work-relatedactivities or competitive sports are advised to

participate in a maintenance exercise program.


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ACL Repair

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