1.Update on ACL injuries and management NOOR AZMI MN (2).pptx

ACL injury update

1. Updates on ACL injuries and management Presented by Dr Noor Azmi Bin Mohamad Nor Orthopaedic Department Hospital Raja Perempuan Zainab II

2. KNEE ANTERIOR VIEW

3. Anatomy of ACL 25-41mm in length (30mm) 7-12mm in diameter (10mm) ACL has 2 bundles 1. Anteromedial (AM) bundle Taut in flexion, anterior restrain 2. Posterolateral (PL) bundle Taut in extension, rotatory restrain Both are parallel in extension and crosses in flexion

4. Primary restraint of : Anterior tibia translation Tibia internal rotation 2. Secondary restraints of: Varus Valgus 3. Proprioception Function of ACL

5. Incidence of ACL Injury Most common among knee injuries Reported 1 in 3500 people and about 400,000 ACL reconstructions done every year in US Female to male ratio 4.5: 1 W eaker hamstrings (more quadriceps dominant) in preventing anterior tibial translation Landing biomechanics- increased valgus angulation and extension of the knee Hormone- Estrogen effects on the strength and flexibility of tissues

6. ACL injuries can associated with other structure damage: Meniscus (50-75%) Articular cartilage (84-98%) Other ligaments(PCL, PLC and MCL) Secondary damage may occur in patients who have repeated episodes of instability due to ACL injury ACL INJURIES

7. Mechanism of ACL injury

8. Non contact pivoting injury - 70%

9. Hyperextension & awkward landing

10. Direct contact / collision

11. Evaluation of ACL injuries History/chief complaints H earing and feeling a sudden “ pop” sound De ep knee pain Immediate swelling due to haemarthrosis (70%) K nee giving way Recurrent swelling R educed knee range of movement, sometimes associated with locking because of meniscal injury or ACL stump

12. Physical examination Inspection:   Q uadriceps avoidance gait (no active knee extension) Varus k nee malalignment - increases the risk of ACL re-rupture and may warrant a concomitant procedure (knee realignment osteotomy) when performing ACL reconstruction 2. Palpation:   S w elling / effusion J oint line tenderness with an associated meniscal injury Any bony tenderness indicating associated cartilage injury 3. Movement:   Range of motion of both knees Knee locking due to associated meniscal injury/ ACL stump Other ligamentous structures should be assessed

13. Pr ovocative maneuvers for ACL Injury A nterior drawer test Lachman test- most sensitive, 95% sensitivity and 94% specificity P ivot shift test The KT-1000 arthrometer

14. Anterior Drawer Test (ADT)

15. Lachman Test

16. Pivot Shift Test

17. KT 1000 arthrometer P erformed with the knee in slight flexion and 10-30 degrees of external rotation. It helps assess and quantify anterior laxity

18. IMAGING

19. Radiograph Knee AP, lateral, skyline or merchant - To look for associated injuries Arcuate fracture Segond fracture Tibia spine fracture Sulcus terminalis sign

20. M RI

21. Diagnostic Arthroscopic

22. Arthroscopy image of torn ACL

23. Acute Rest Elevation Ice compression Protected weight bearing Brace Management of ACL injury

24. ACL repair Very limited indication (proximal femoral avulsion tear) Not routinely done in our practice because of outcome is not good compared to ACL reconstruction (high risk of re-tear and may not provide same stability as ACL reconstruction ACL reconstruction (Gold standard) - To prevent instability and restore the function of the torn ligament and creating ‘Stable knee’ Long term success rate 82%- 95 % Surgical option of ACL injury

25. Most of the patient Patient who perform activities requiring an intact ACL – active patients Who need an ACL reconstruction

26. ACL dependent/non dependent activities

27. Perioperative swelling, edema, hyperthermia Near normal range of motion Good quadriceps strength suggest that surgery be performed only when involved quadriceps muscle strength is 80% of the uninvolved lower extremity Normal alignment of the lower limb Proper assessment of other ligament Pre- operative requirement for ACL reconstruction

28. Early vs D elayed ACL reconstruction Early: Less than 3 weeks Delayed: More than 3 weeks Should be performed at least 3 weeks after injury in order to avoid arthrofibrosis However, if surgery perform after 12 months after injury may lead to further knee damage including meniscal tears, osteochondral defects, and ligament tears (secondary damage) Why?? - chronic rotational and translation instability due to torn ACL Ideal time for ACL reconstruction

29. Autograft (patient’s own tissue) Hamstring Bone patella tendon bone (BPTB) Quadriceps tendon Allograft (Donor) Achilles tendon (commonly used) BPTB & quadriceps tendon Synthetic graft - Artificial material replace the tendon Polyethylene, polyester For augmentation Option of graft for ACL reconstruction

30. A utograft - Hamstring Hamstring ( gracilis and semitendinosus tendon)

31. Autograft - BPTB Bone patella tendon-bone (BPTB)

32. ACLR using Hamstring graft ACLR using BPTB

33. After fixation of Hamstring graft ACL Reconstruction

34. X-Ray Post ACL Reconstruction

35. Trans-tibial vs trans-porta l ACL reconstruction Trans-portal produce an anatomically positioned femoral tunnel because positioning femoral tunnel is independent of the tibia tunnel Evolution of ACL reconstruction

36. - D ouble-bundle reconstruction is more technically demanding and invasive than single-bundle reconstruction techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL (anatomic) Long term outcome: No significant difference in: Clinical function Knee stability Failure rate Single bundle vs double bundle ACL reconstruction

37. Different from double bundle technique by u sing a single femoral tunnel and 2 tibial tunnels Developed to reduce the complication that occur in double bundle ACL reconstruction – posterior wall blow out, arthrofibrosis post surgery Also no significant difference compared to standard ACL reconstruction (single bundle) Hybrid ACL reconstruction

38. - 'all-inside' technique uses the semitendinosus alone and spares the gracilis , shorter graft bone preserving nature, reduced postoperative pain,  and smaller skin incision Similar overall result compared to standard ACL reconstruction Standard vs ‘ all inside’ ACL reconstruction

39. Complication of ACL surgeries

40. Take Home Message KEEP CALM