Knee Ligament Injuries & Operative Management.pdf

Knee alignment injuries procedures and how to counter them

1. Knee Ligament Injuries &
Operative management

2. Ligament Injuries: Surgical and
Postoperative Management
General considerations and indications
for ligament surgery.
The ligament injured
The location and size of the lesion
The degree of instability experienced by the
patient
The presence of concomitant pathology such
as a meniscal or articular cartilage damage
The potential for achieving the desired level
of function to which the patient wishes to
return

3. The risk of reinjury and prevention of
future impairment are also considerations
because acute ligament injury, if not
managed adequately, can lead to chronic
instability.
In turn, chronic instability is thought to
contribute to degeneration of articular
cartilage over time and early-onset OA

4. Many authors recommend surgical
intervention for acute, isolated ACL and
LCL injuries after a brief period of acute
symptom management in recreationally
active individuals.

5. Types of ligament surgery
Intra articular
Extra articular
Combined procedures

6. Initially, intra-articular procedures were
performed through an open approach and
involved a direct repair of the ligament.
The repair was accomplished by reopposing
and suturing the torn ligament.
Postoperatively, a long period (usually 6
weeks) of immobilization and restricted
weight bearing were required.

7. Extra-articular reconstruction procedures,
which involve the transposition of dynamic
musculotendinous stabilizers or inert
restraints around the knee, such as the IT
band, were designed to provide external
stability to the knee joint.
Extra articular procedures, in common use
in the past, particularly for MCL and LCL
injuries, are used rarely today as primary
procedures because they do not restore
normal kinematics to the knee as
effectively as intra-articular procedures

8. Grafts: Types, healing
characteristics, and fixation.
Most often an autograft (the patient’s own
tissue)
Occasionally an allograft (donor tissue) or
a synthetic graft
a bone-patellar tendon-bone autograft
has been used reliably and has been
considered the gold standard for ACL
reconstruction

9. General considerations for
rehabilitation
The expected outcomes following surgery
and postoperative rehabilitation after
ligament reconstruction are:
(1)Restoration of joint stability and motion
(2)Pain free and stable weight bearing
(3)Sufficient postoperative strength and
endurance to meet functional demands
(4)The ability to return to pre-injury activities

10. Anterior Cruciate Ligament
Reconstruction

The healing capacity of a torn ACL is poor,
giving rise to the frequent recommendation
for surgical reconstruction to restore knee
stability, particularly in the young, active
individual

11. Indications for Surgery
Disabling instability of the knee due to ACL
deficiency caused by a complete or partial
acute tear or chronic laxity
Frequent episodes of the knee giving way
(buckling) during routine ADL as the result
of significantly impaired dynamic knee
stability despite a course of non operative
management.

12. Procedure(Surgical approach, graft
selection, and harvesting)
The most common ACL reconstruction
procedure today is an arthroscopically
assisted or endoscopic procedure using an
autograft.
If a bone-patellar tendon-bone graft is
selected, it is harvested through a small,
longitudinal incision over the patellar
tendon from the patient’s involved knee or
occasionally from the contralateral knee

13. The central one-third portion of the tendon
is dissected along with small bone plugs
attached to the tendon.

If a semitendinosus-gracilis tendon
autograft (hamstringtendon graft) is
selected, it is harvested through an
incision centered over the tibial insertion
of the semitendinosus and gracilis tendons

14. Graft placement and fixation
After the graft is harvested and prepared
for implantation, the arthroscopic
instrumentation is reinserted to drill femoral
and tibial bone tunnels.
Graft placement is achieved by passing the
graft through the tunnels to its final
position in the tibia and femur.
Precise, anatomical graft placement is
crucial for restoration of joint stability and
mobility

15. Improper graft placement can lead to loss of
ROM postoperatively.
A graft placed too far posteriorly may result
in failure to regain full flexion, and a graft
placed too far anteriorly may limit extension.
Graft fixation is vital to the success of ACL
reconstruction.

16. After the incision is closed, a small
compression dressing is immediately
placed on the knee, and the leg may be
placed in a knee immobilizer for protection.

18. Postoperative Management
Accelerated rehabilitation is based on the
premise that a precisely placed and
appropriately tensioned graft not only is
strong enough to withstand the stresses of
early motion and weight bearing but also
responds favorably to these stresses
during the healing process

21. Immobilization and Bracing
Protecting the graft from excessive strain
and preventing the loss of full knee
extension

Types of postoperative bracing
1.Rehabilitative bracing
2.Functional bracing.

22. Rehabilitative bracing, if prescribed,
usually is a hinged, range-limiting orthosis
with a locking mechanism.
It is typically is worn for just the first 6
weeks after surgery.
In contrast, a functional brace is worn
when returning to high-demand sports or
workrelated activities to potentially reduce
the risk of reinjury.

23. Brace use and initiation and
progression of knee ROM.
Initially, the brace is locked in full
extension during ambulation with crutches
in the event of a fall.
When ROM is initiated, the rehabilitative
brace can be set to limit the range of knee
flexion during exercise and functional
activities so that flexion is progressed
gradually.

24. Full, active knee extension and 90° to
110° of flexion is expected by 4 to 6
weeks postoperatively.
The patient is weaned from brace use at
about 6 weeks postoperatively if full
extension has been achieved
Depending on the stability of the knee,
sometimes the protective brace may need
to be worn longer

25. These timelines are progressed more slowly
when ACL reconstruction is combined with
another procedure, such as a collateral
ligament, meniscus, or articular cartilage
repair.
Some patients are advised to wear a
functional brace to reduce the risk of reinjury
during the advanced phases of rehabilitation
and when participating in high-demand
sports or heavy manual labor after
completing their rehabilitation program.

26. Weight-Bearing Considerations
Recommendations for a period of
protected weight bearing immediately
after surgery vary, ranging from some
degree of restricted weight bearing the
first 2 weeks to weight bearing as
tolerated with use of two crutches
immediately after surgery

27. Full weight bearing and ambulation
without crutches and with or without an
unlocked protective brace usually is
permitted by 4 weeks if weight bearing is
pain-free and the patient has achieved
full, active knee extension and sufficient
strength of the quadriceps to control the
knee

28. Exercise Progression
Preoperative exercise
1.Restore full knee ROM, particularly
extension
2.Prevent atrophy
3.Improve the strength
4.Flexibility of hip and ankle musculature

29. Postoperative exercise progression.
Exercise begins immediately on the first
postoperative day.
Already discussed

30. The following exercises are advocated for the maximum
protection phase.
Ankle pumping exercises.
1.To reduce the risk of a DVT.
Voluntary isometric and dynamic
activation of knee musculature.
1.Begin muscle setting of quadriceps,
hamstrings, and hip abductors, adductors,
and extensors within the patient’s comfort
Use electrical stimulation or biofeedback
to augment quadriceps activation.

31. Consider low-intensity, eccentric
quadriceps training between 20° and 60°
on a motorized, eccentric ergometer, if
available.
To activate the hamstrings dynamically,
include supine heel-slides to a comfortable
level of hip and knee flexion, knee flexion
in a standing position (hamstring curls
without resistance added), and scooting
forward while seated on a rolling stool

32. ACL Reconstruction
Shockwave

33. Graft Harvest

34. Drill

35. Attach

36. Rehab

37. PCL Injuries

38. PCL Injuries

The posterior cruciate ligament, or PCL, is not
injured as frequently as the ACL.
PCL sprains usually occur because the
ligament was pulled or stretched too far,
anterior force to the knee, or a simple
misstep.
PCL injuries disrupt knee joint stability
because the tibia can sag posteriorly.
The ends of the femur and tibia rub directly
against each other, causing wear and tear to
the thin, smooth articular cartilage.
This abrasion may lead to arthritis in the knee.

39. Posterior Cruciate Ligament
Reconstruction
Indications for Surgery
Complete tear or avulsion of the PCL with
posterolateral, posteromedial, or rotary
instability of the knee combined with
damage to another ligament and often the
menisci or articular cartilage
Isolated, symptomatic, grade 3 PCL tear
with greater than 8 to 10 mm posterior
displacement compared with the
contralateral, noninjured knee, resulting in
instability during functional activities

40. Persistent pain and instability after an
unsuccessful course of nonoperative
treatment following an isolated PCL injury
Chronic PCL insufficiency associated with
posterolateral instability, pain, limitations
in functional activities, and deterioration of
articular surfaces of the knee

41. Graft options using single-bundle or
double-bundle reconstruction include a
bone-patellar tendon-bone autograft, a
hamstring (semitendinosus-gracilis) or
quadriceps tendon autograft, an Achilles
tendon or anterior tibialis tendon allograft,
or, occasionally, a synthetic graft.

42. Complications
Because PCL reconstruction involves the
posterior aspect of the knee, there is risk
of damage to the popliteal neurovascular
bundle.
Risk is highest during drilling of the tibial
bone tunnel.
Postoperatively, bleeding can lead to
compartment syndrome.

43. If a patellar tendon autograft was
harvested, the patient may experience
anterior knee pain and pain during
kneeling.
If motion is lost postoperatively, usually
knee flexion becomes limited.

44. Postoperative Management
Immobilization, Protective Bracing,
and Weight Bearing
The immobilizer is worn during the day
and even during sleep for the first 4 to 8
weeks to prevent posterior displacement
of the tibia as the result of gravity or
sudden contraction of the knee flexors
It may be removed after the first
postoperative week for bathing and
exercise.

45. It is unlocked or removed for exercise 1
day to a week after surgery
Recommendations range from partial
weight bearing (about 30%) immediately
after surgery using two crutches and
wearing the protective brace locked in
extension to non weight-bearing for a
week to 5 weeks postoperatively

46. Crutches are discontinued and full weight
bearing with the brace unlocked is
permitted when the patient has met
specified criteria (Box 21.13).
These criteria typically are met at
approximately 8 to 10 weeks
postoperatively.
Brace use is then discontinued gradually

48. Thank you