Acl injury

Anterior cruciate ligament injury/tear

1. ACL INJURY Sivendu P MBBS Final Year KMCT MEDICAL COLLEGE

2. INTRODUCTION Anterior cruciate ligament is the most commonly ruptured ligament of knee joint, often in association with the tears of medial or lateral collateral ligaments. Commonly, it occurs as a result of twisting force on a semi-flexed knee. Often the injury to medial collateral ligament, medial meniscus and anterior cruciate ligament occur together. This is called O'Donoghue triad

3. ANATOMY OF ACL Th e A C L is a fan shaped ligament c ompo s ed o f de n se l y o r g ani z ed, c olla g enous fibers th a t a t t ach e s the f emur t o the tibia. ATTACHMENTS On the Femur - a f oss a o n the po s t e r omedia l ed g e o f t he l a t e r al f emo r al c ond y le. On the Tibia - a f oss a a n t erior and lateral t o the tibial spine BLOOD SUPPLY: Major blood supply is from MIDDLE GENICULAR ARTERY

4. Dual band structure of ACL The fibers of the ligament are divided into 2 bands Anteromedial (AM) - tight in flexion Posterolateral (PL) - tight in extension

5. FUNCTIONS OF ACL Primar y functions R e s t r ai n t t o li m it a n t erior disp lacement o f the tibia Prevent hyperextension of knee Se c onda r y functions R e s t r ai n t t o t i bia l r o t a t i o n and v aru s / v algus angul a t i o n a t f ul l e x t ension.

6. MECHANISM OF INJURY Co n t act and hig h - e n e r g y t r aum a tic inj u r ies: Tackles , Collisions Are of t en associ a t ed with othe r l i g ame n t ous and men i s c al injur i e s . Non c o n t act: Cu t ti n g (Changing direction rapidly) Stopping suddenly while running Landing from a jump incorrectly

7. RISK FACTORS Athletes involved in games involving rapid side change movements ( Eg Footballers) Female affected more easily than males .

8. CLINICAL FEATURES ACUTE INJURY “Popping sound” heard by the patient Pain with swelling. Knee effusion ( Haemarthrosis ) Loss of full range of motion Tenderness CHRONIC INJURY (INSTABILITY/GIVING WAY) Discomfort while walking

9. Differential Diagnosis Collateral ligament injuries Posterior cruciate ligament injury Patellar Dislocation Meniscal Injuries

10. PHYSICAL EXAMINATION Anterior drawer test - POSITIVE Lachman Test – POSITIVE Pivot Shift Test - POSITIVE

11. Anterior Drawer test Patient is made to lie in supine position with Hip flexed at 45⁰ and knee is flexed to 90⁰ The foot is prevented from sliding and the tibia is drawn forwards using both hands. The test is said to be Positive if the tibia moves forward more than that of the uninjured leg or if the end point feels soft or absent .

12. Lachman Test Better sensitivity than Anterior drawer test Patient is made to lie in supine position with the knee flexed 20 - 30 ⁰ Hold the calf with one hand and the thigh with the other, and try to displace the joint backwards and forwards. The test is said to be Positive if the tibia moves forward more than that of the uninjured leg or if the end point feels soft or absent .

13. Pivot shift test The examiner supports the knee in extension with the tibia internally rotated . Valgus stress is applied The knee is then gradually flexed. In a positive test, as the knee reaches 20 or 30 degrees flexion, there is a sudden jerk as the tibial condyle slips backwards. Usually performed after the swelling subsides and in chronic cases.

14. INVESTIGATIONS Imag i ng Stu d i e s: MRI 90 -98% sensiti vi t y . Can ide n t i f y bon e bru i sing. Gold s t and a rd Pl a in X ray - Usually normal ,but may show tibial spine avulsion if present A r th r o g r am s – (X ray of a joint after contrast medium is injected ) R eplace d b y MRI Arthroscopy

15. MRI

16. Grading

17. TREATMENT Conservative (Non Surgical) Surgical Immediate treatment in an acute injury - R.I.C.E ( R est I ce C ompression E levation)

18. INDICATIONS Partial tears Isolated tears of ACL No instability symptoms Patients who do li g ht m a n u al wo r k or live se d e n t a ry lifestyl e s Children and Young adolescents - risk of growth plate injury during surgery , leading to bone growth problems. CONSERVATIVE TREATMENT

19. Methods A g g r essi v e r ehabili t a tion p r o g r am and c ounselin g about act i vity l e v el. After swelling decreases Physiotherapy Muscle strengthening exercises Braces – Worn until symptoms subside Functional Brace Rehabilitation Brace – To allow controlled movement during rehabilitation

20. SURGICAL TREATMENT INDICATIONS Professional Athletes Associated Meniscal or collateral ligament injuries Recurrent episodes of giving way, recurrent effusions. Persistant anterior knee pain. Tibial spine avulsion

21. Timing of Surgery Swelling in the knee must go down to near normal levels Range-of-motion (bending and straightening) of the injured knee must be nearly equal to the uninjured knee Good Quadriceps muscle strength must be present. Usually it takes a 2-3 weeks after injury The presence of any associated injuries to the knee joint involving cartilage, meniscus, or other ligaments may change the time-frame for surgery

22. Surgical Reconstruction Graft fixation Grafts used are – Au t og r a fts – Patellar tendon , Tendons of Hamstrings , Quadriceps. Al l o g r a fts S y n th e tic grafts Fixations can be of 2 types – Aperture Fixation – With I n t er f e r ence Screws Suspensory Fixation - Endobuttons , Tightrope

23. I n t er f e r ence Screws Tightrope Endobutton

24. Technique Diagnostic arthroscopy Adressing meniscal pathologies Clearing remnants of ACL Graft harvesting and preparation Preparing femoral and tibial tunnels Passing the graft Fixation of the graft Post operative rest and physiotherapy Return to active sports activities after 6-9 months

25. Double Bundl e T echnique In a “ d o u bl e- b u ndle” ACL rec o ns t ruc t ion, the ACL is r e stored usi n g two b u n d les. Just like the n o r m al ACL, the r e wi l l be an AM and a PL b u n d le.

26. Tibial spine avulsions Severe valgus or varus stress, or twisting injuries, may damage the knee ligaments and fracture the tibial spine Treatment Under anaesthesia the joint is aspirated and gently manipulated into full extension. If there is a block to full extension or if the bone fragment remains displaced, operative reduction is essential. The fragment is restored to its bed and anchored by small screws. After reduction plaster cast is advised for 6 weeks.

27. Complications In Untreated Cases Adhesions – When a ligament with partial tear is not regularly exercised Ossification in the ligament (Pellegrini– Stieda’s disease) Instability (‘giving way’) Osteoarthritis After Surgery Loss of fixation Postoperative joint fibrosis Infections

28. Referernces Apley's System of Orthopaedics and Fractures 9th ed Essential Orthopaedics Maheshwari & Mhasker

29. Thank You