anterior cruciate ligament-injury & management
DESCRIPTION
TRANSCRIPT
ANTERIOR CRUCIATE LIGAMENT-INJURY & MANAGEMENT
ANATOMY ACL is composed of multiple collagen
fascicles surrounded by an endotendineum which is grouped into fibers measuring around 38mm in length (range 25 to 41 mm) and 10 mm in width (range 7 to 12 mm)
Microspocially composed of interlacing fibrils (150 to 250 Nanometer in diamter)
synovial membrane envelope the ACL
ORIGIN - From the posteromedial corner of
medial aspect of lateral femoral condyle in the
intercondylar notch INSERTION - Fossa in front of & lateral to anterior
spine of tibia
ACL is composed of two principal parts 1. Small Anteromedial band and 2. Larger bulky posterolateral portion
CLINICAL IMPORTANCE - Anteromedial bundle is tight in flexion
and the posterolateral bundle is tight in extension - In extension both bundles are parallel - In flexion both bundles are crossed
Action
These attachments allow the ACL to resist anterior translation and medial rotation of the tibia, in relation to the femur.
INNERVATION: - Tibal nerve( Infiltrates the capsule
posteriorly) - Golgi tendon receptorsBLOOD SUPPLY: - Major blood supply is from MIDDLE GENICULAR ARTERY
Bony attachments do not provide a significant source of blood to distal or proximal ligaments
ACL vascularization arises from the middle genicular artery and vessels of the infrapatella fat pad and adjacent synovium
The artery gives rise to periligamentous vessels which form a web-like network within the synovial membrane
These periligamentous vessels give rise to penetrating branches which transversely cross the ACL and anastomose with a network of longitudinally oriented endoligamentous vessels
Terminal branches of the inferior medial and lateral genicular arteries supply the distal portion of the ACL directly.
The extremities of the ACL seem to be better vascularized than the middle part, and the proximal portion seems to have a greater vascular density than the distal portion
CAUSE OF ACL INJURY
The anterior cruciate ligament can be injured in
several ways Changing direction
rapidly Stopping suddenly Slowing down while
running Landing from a jump
incorrectly Direct contact or collision,
such as a football tackle
Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes because of Differences in
- Physical conditioning - Muscular strength - Neuromuscular control - pelvis and lower extremity
(leg) alignment and - the effects of estrogen on
ligament properties.
ACL injuries occur in combination with damage to
-The meniscus -Articular cartilage or -Other ligaments
Secondary damage may occur in patients who have
repeated episodes of instability due to ACL injury.
With chronic instability, up to 90 percent of patients will have meniscus damage when reassessed 10 or more years after the initial injury.
Similarly, the prevalence of articular cartilage lesions increases up to 70 percent in patients who have a 10-year-old ACL deficiency
GRADING
Partial tears of the anterior cruciate ligament are
rare
Most ACL injuries are complete or near complete tears
Injured ligaments are considered "sprains" and are graded on a severity scale.
Grade 1 Sprains. The ligament is mildly damaged . It has been
slightly stretched, but is still able to keep the knee joint stable.
Grade 2 Sprains. The ligament is stretched to the point where it
becomes loose. This is often referred to as a partial tear of the ligament.
Grade 3 Sprains. This type of sprain is most commonly referred to
as a complete tear of the ligament. The ligament has been split into two pieces, and the knee joint is unstable.
SYMPTOMS
When ACL is injured , pt might hear a "popping"
noise.
Other typical symptoms include: -Pain with swelling. -Loss of full range of motion -Tenderness along the joint line -Discomfort while walking
PHYSICAL EXAMINATION
INCLUDE ANTERIOR DRAWER TEST LACHMAN’S TEST PIVOT SHIFT TEST KT-2000 ARTHROMETER TEST
ANTERIOR DRAWER TEST
To perform anterior drawer test, examiner grasps pt's tibia & pulls it forward when the affected leg is flexed at 90 degree while noting degree of anterior tibial displacement
LACHMAN’S TEST
This is a variant of the anterior drawer test
The examination is carried out with the knee in 15 deg of flexion, and external rotation (relaxes IT band)
For a right knee, the examiner's right hand grips the inner aspect of the calf and the left hand grasps outer aspect of the distal thigh
Attempt to quantify the displacement in mm is done by comparing this displacement to the normal side
End point should be graded as hard or soft - End point is said to be hard when the ACL
abruptly halts the forward motion of the tibia on
the femur - End point is soft when there is no ACL &
restraints are more elastic secondary stabilizers;
PIVOT SHIFT TEST
During this test, pt is kept in supine & examiner holds pt's leg with both hands
abduct the pt’s hip (to relax the ITB and allow the tibia to rotate) Holding the heel in one hand and applying a valgus
stress in the other hand, the knee is slowly flexed
The tibia, as well as the valgus, subluxes easily if anterior force is applied.
After the anterior subluxation of the tibia is noticed, the knee is slowly flexed, and the tibia will reduce with a snap at about 20° to 30°of flexion.
INVESTIGATIONS
MRI Arthroscopy
INVESTIGATION
TREATMENT
NON-SURGICAL METHOD SURGICAL METHOD
Immediately after injury R.I.C.E ( Rest Ice Compression Elevation ()
Non surgical treatment Exercise (after swelling decreases and
weight-bearing progresses) Braces
Rehabilitation Brace Functional Brace
Nonsurgical Treatment
Nonsurgical management is indicated in patients with
- partial tears and no instability symptoms - complete tears and no symptoms of
knee instability - Who do light manual work or live
sedentary lifestyles - Whose growth plates are still open
(children)
Precautions
Modification of active lifestyle to avoid high demand activities
Muscle strengthening exercises for life May require knee brace Despite above precautions ,secondary
damage to knee cartilage & meniscus leading to premature arthritis
Surgical Treatment
Timing of Surgery 1) Swelling in the knee must go down to near-
normal levels 2) Range-of-motion (bending and straightening) of
the injured knee must be nearly equal to the uninjured knee
3) Good Quadriceps muscle strength must be present.
Usually it takes a couple of weeks after injury before ACL reconstruction can be performed.
The presence of any associated injuries to the knee joint involving cartilage, meniscus, or other ligaments may change the time-frame for surgery.
Surgical Treatment
ACL tears are not usually repaired using suture to
sew it back together, because repaired ACLs have
generally been shown to fail over time
Therefore, the torn ACL is generally replaced by a
substitute graft made of tendon
The grafts commonly used to replace the ACL include
Patellar tendon Hamstring
tendon Quadriceps
tendon
patellar tendon, Achilles tendon, semitendinosus, gracilis, or
posterior tibialis tendon
autograft Allograft
Patients treated with surgical reconstruction of the
ACL have long-term success rates of 82 %- 95%
The goal of the ACL reconstruction surgery is to prevent instability and restore the function of the torn ligament, creating a stable knee.
Recurrent instability and graft failure are seen in approximately 8% of patients.
PATIENT CONSIDERATIONS
Active adult patients involved in sports or jobs that
require pivoting, turning or hard-cutting as well as
heavy manual work are encouraged to consider
surgical treatment. Activity, not age, should determine if surgical intervention should be considered.
In young children or adolescents with ACL tears,
early ACL reconstruction creates a possible risk of
growth plate injury, leading to bone growth
problems. The surgeon can delay ACL surgery until
the child is closer to skeletal maturity or the surgeon
may modify the ACL surgery technique to decrease
the risk of growth plate injury.
A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.
It is common to see ACL injuries combined with damage to the menisci (50 %), articular cartilage (30 %), collateral ligaments (30 %), joint capsule,
or a combination of the above.
Surgical Choices
1.PATELLAR TENDON AUTOGRAFT. The middle third of the patellar tendon of the patient, along with a bone plug from the shin and the patella is used in the patellar tendon autograft. Occasionally referred to by some surgeons as the "gold standard" for ACL reconstruction, recommended for high-demand athletes and patients whose jobs do not require a significant amount of kneeling.
In studies comparing outcomes of ACL reconstruction, the rate of graft failure was lower in the patellar tendon group
In addition, most studies show equal or better
outcomes in terms of postoperative tests for knee
laxity (Lachman's, anterior drawer and instrumented
tests) when this graft is compared to others.
The Disadvantages of the patellar tendon autograft are:
-Postoperative patello femoral pain -Pain with kneeling -increased risk of postoperative
stiffness -risk of patella fracture
-Quadriceps Weakness -Persistent Tendon Defect
2.Hamstring tendon autograft. The semitendinosus hamstring tendon on the
inner side of the knee is used in creating the hamstring tendon autograft for ACL reconstruction. Some use an additional tendon, the gracilis,
which is attached below the knee in the same area. This creates a two- or four-strand tendon graft.
Hamstring graft proponents claim there are fewer
problems associated with harvesting of the graft
compared to the patellar tendon autograft including: - Fewer problems with anterior knee pain
after surgery - Less postoperative stiffness problems - Smaller incision - Faster recovery
The graft function may be limited by the strength and type of fixation in the bone tunnels, as the graft does not have bone plugs.
There have been conflicting results in research studies as to whether hamstring grafts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during objective
testing. Recently, some studies have demonstrated decreased hamstring strength in patients after surgery.
There are some indications that patients who have
intrinsic ligamentous laxity and knee hyperextension
of 10 degrees or more may have increased risk of
postoperative hamstring graft laxity on clinical exam.
Therefore, some clinicians recommend the use of
patellar tendon autografts in these hypermobile patients.
chronic or residual medial collateral ligament
laxity (grade 2 or more) at the time of ACL reconstruction may be a contra-
indication for use of the patient's own
semitendinosus and gracilis tendons as an ACL graft.
3.QUADRICEPS TENDON AUTOGRAFT. The quadriceps tendon autograft is often
used for patients who have already failed ACL reconstruction.
Middle third of the patient's quadriceps tendon and
a bone plug from the upper end of the patella
are used.
This yields a larger graft for taller and heavier patients. Because there is a bone plug on one
side only, the fixation is not as solid as for the patellar tendon graft.
There is a high association with postoperative anterior knee pain and a low risk of patella fracture. Patients may find the incision is not cosmetically appealing
ALLOGRAFTS.
Allografts are grafts taken from cadavers and are becoming increasingly popular.
These grafts are also used for patients who have failed
ACL reconstruction before and in surgery to repair or
reconstruct more than one knee ligament.
Advantages of using allograft tissue include - Elimination of pain caused by obtaining the graft from the patient - Decreased surgery time and smaller incisions.
The PATELLAR TENDON ALLOGRAFT allows for strong bony fixation in the tibial and femoral bone
tunnels with screws.
However, allografts are associated with - Risk of infection, including viral
transmission (HIV and Hepatitis C) There have also been conflicting results
in research studies as to whether allografts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during testing.
Recently published literature may point to a higher failure rate with the use of allografts for ACL reconstruction.
Failure rates ranging from 23% to 34.4% have been reported in young, active patients returning to high-demand sporting activities after ACL reconstruction with allografts.
This is compared to autograft failure rates ranging from 5% to 10%.
Meta-analysis of Patellar vs. Hamstring tendons in ACL reconstruction
•Controlled trials with minimum 2 year follow-up•Evaluated; return to pre-injury level of activity, KT testing, Lachmanscores, pivot shift scores, ROM, complications, failures•4 studies fulfilled inclusion criteria•B-T-B showed a >20% chance return to pre-injury activity level versus hamstring, (p value = 0.01)
Yunes, M. et al “Patellar Versus Hamstring Tendons in ACL reconstruction; A Meta-analysis” Arthroscopy Vol. 17, No. 3 (March) 2001; pp248-257
Synthetic Grafts
The best scenario for the use of the synthetic graft is when the
graft can be buried in soft tissue, such as in extra-articular reconstruction.
This allows for collagen ingrowth and ensures the long-term viability of the synthetic graft.
It will be sure to fail early if it is laid into a joint bare, especially going around tunnel edges, and is unprotected by soft tissue.
Disadvantages The main disadvantage is that all the long-term
studies have shown high failure rate. There is the potential for reaction to the graft material with synovitis, as seen with the use of the Gore-Tex graft.
With the Gore-Tex graft, there was also the increased risk of late hematogenous joint infection.
The results that have been reported with the use of the Gore-Tex
graft suggest that it should not be used for ACL reconstruction.
Unacceptable failure rates have also been reported with the use of the Stryker Dacron ligament and the Leeds-Keio ligament.
` GRAFT FIXATION
Ultimate load to failure of femoral fixation devices.
Mitek 600N BioScrew 400N Endo-button: tape 500N BioScrew: Endo-pearl 700N Bone mulch screw 900N Cross pin 900N Endo-button with closed loop tape 1300N
Interference Fit Screws
Advantages Quick, familiar, and easy to use. Direct bone to tendon healing, with Sharpey’s fibers at the
tunnelaperture. Less tunnel enlargement. Disadvantages The disadvantages are as follows: Longer graft preparation time. Bone quality dependent. Damage to the graft with the screw. Divergent screw has poor fixation. Removal of metal screw makes revision difficult
Interference screw
Biodegradable
Metalic
Inteference Screw
Cross-Pin Fixation
Advantages The advantages are as follows: Strongest tested fixation. May individually tension all bundles of graft.Disadvantages The disadvantages are as follows: Pin may tilt in soft bone and lose fixation. Steep learning curve of fiddle factor. Special guides are required.
Transfix
Crosspin/transfix
Endobutton
The EB is a small oval button that anchors the graft against the outer femoral cortex.
The Endobutton (EB) is the most widely used femoral fixation device worldwide that is designed specifically for soft tissue grafts.
Pioneered by Dr. Thomas Rosenberg and introduced around 1990, it was the first device specifically designed to hold soft tissue grafts.
As originally designed, the surgeon would tie a Dacron tape connecting the button to the tendon.
In the past 5 years, this technique has been largely supplanted by use of the EB-CL (continuous loop), which obviates the need to tie knots.
Due to the longevity of the device, there is a much greater literature concerning it than any of the other newer, soft tissue–specific devices.
ENDOBUTTON
Advantages The Endo-button with closed loop tape is strong, The plastic button is cheap, available and easy
to doDisadvantages Fixation site is distant with increase in laxity,
with the bungee cord effect. Increased in tunnel widening. Plastic button has low pullout strength,
dependent on the sutures
Endobuttom Loop
Clinical Results In the largest meta-analysis of anterior
cruciate ligament reconstruction (ACLR) autografts, the EB-hamstring combination was found to have the highest stability rates of any graft-fixation construct when paired with modern tibial fixation.Morbidity has been minimal.
Milagro (Beta-Tricalcium Phosphate, Polylactide Co-Glycolide Biocomposite)
The Milagro screw can be used for femoral or tibial fixation for soft tissue or bone–tendon–bone (BTB) autografts or allografts. It is available in various diameters from 7 to 12mm and in 23-, 30-, and 35-mm lengths. The Milagro screw is made from a polymer composite, Biocryl Rapide.
EZLoc Femoral Fixation of a Soft Tissue Graft The EZLoc (Arthrotek, Warsaw, IN) is a cortical femoral
fixation device for a soft tissue anterior cruciate ligament (ACL) reconstruction that combines superior fixation properties (high resistance to slippage, infinite stiffness, and 1427N strength) with a simple surgical technique.
The EZLoc consists of a deployable lever arm connected to an axle in a slotted body through which the ACL graft is looped.
The EZLoc comes sterilely package with a sharp-tip passing pin that is secured in the slotted body with a suture tied under tension. The passing pin is passed through the tunnels, the gold lever arm is positioned lateral, and the soft tissue graft is looped through the slot in the EZLoc.
Tibial Fixing Devices
Ultimate load to failure of tibial fixation devices. Single staple 100N Double staple 500N Screw post 600N Button 400N RCI 300N BioScrew 400N BioScrew and button 600N Intrafix 700N Screw and washer 800N Washer Loc 900N
One bundle or two bundle ACL
reconstruction
What is an “Anatomic” ACL reconstruction? Every person is different; some people are short,
others are tall. Similarly, each person has a different size and shape of the ACL. In order to properly reconstruct the ACL it is important to reproduce each persons individual anatomy.
The goals of anatomic ACL reconstruction are to: Restore 60 – 80% of normal ACL anatomy Regain stability and return to pre-injury activity level Maintain long term knee health
What is anatomic Double-Bundle ACL reconstruction?
In a “double-bundle” ACL reconstruction, the ACL is restored using two bundles. Just like the normal ACL, there will be an AM and a PL bundle.
In a “single-bundle” reconstruction, the ACL is restored using one bundle. There are some benefits of a “double-bundle” reconstruction, when compared to a “single-bundle” reconstruction.
Anatomic double-bundle reconstruction better restores knee stability compared to single-bundle reconstruction.
Because anatomic double-bundle reconstruction uses two bundles to restore the ACL, it allows for a replacement of a larger size ACL
Pre requisite for single-bundle/double-bundle reconstruction
An ACL insertion site greater than 18 mm allows for double-bundle reconstruction.
If the insertion site is less than 14 mm, there is only space available for a single-bundle procedure.
Between 14 – 18 mm, we can perform either double- or single-bundle reconstruction.
Indications for single bundle recon. The patient is still growing and his or her
growth plate is not closed. The patient has severe arthritis of the knee. The patient has multiple knee ligament
injuries or a knee dislocation and multiple other ligaments need to be reconstructed at the same time.
The patient has bone that is severely bruised. The patient has a small Intercondylar“notch”.
A prospective comparative cohort study was carried out with 72 consecutive patients with chronic ACL deficiency to compare three ACL reconstruction procedures using hamstring tendon grafts.
The first 24 patients underwent a single-bundle procedure using a six-strand hamstring tendon graft.
The next 24 patients underwent a nonanatomical double-bundle procedure using four-strand and two-strand hamstring tendon grafts.
The final 24 patients underwent the anatomical double-bundle procedure using the same four-strand and two-strand hamstring tendon grafts. All 72 patients underwent postoperative management with the same rehabilitation protocol.There were no significant differences among the background factors.
Conclusion The postoperative anterior laxity
measured was significantly less after the anatomical double-bundle reconstruction than after the single-bundle reconstruction. Concerning the results of the pivot-shift test
Outcome of Arthroscopic Single-Bundle Versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament: A Preliminary 2-Year Prospective Study
Se-Jin Park, M.D., Young-Bok Jung, M.D., Hwa-Jae Jung, M.D., Ho-Joong Jung, M.D., Hun Kyu Shin, M.D., Eugene Kim, M.D., Kwang-Sup Song, M.D., Gwang-Sin Kim, M.D., Hye-Young Cheon, P.A., Seonwoo Kim, Ph.D.Received: December 29, 2008; Accepted: September 9, 2009; Published Online: February 22, 2010
ArthroscopyVolume 26, Issue 5, Pages 630–636, May 2010
113 were included in this study. They serially obtained clinical and radiologic data preoperatively and postoperatively. They compared preoperative data and data at 2 years postoperatively in patients who had undergone single-bundle ACL reconstruction versus patients who had undergone double-bundle ACL reconstruction.
There were 50 single-bundle reconstructions and 63 double-bundle reconstructions. Anteroposterior stability was assessed objectively by anterior stress radiographs with the telos device (telos, Marburg, Germany) and the maximal manual test with the KT-2000 arthrometer
Conclusions Double-bundle reconstruction of the ACL
by a method using 2 femoral tunnel and 2 tibial tunnels showed no differences in stability results or any other clinical aspects or in terms of patient satisfaction.
COMPLICATIONS
Skeletally immature patients Anterior cruciate ligament injuries in
skeletally immature adolescents are being diagnosed with increasing frequency.
Nonoperative management of midsubstance ACL injuries in adolescent athletes frequently
results in a high incidence of giving-way episodes, recurrent meniscal tears, and early onset of osteoarthritis
The concern about ACL reconstruction in the athlete with open growth plates is that there will be
premature fusion of the plate, growth arrest, and potential for angular deformities.
Skeletally immature patients Non surgical methods
or surgical methods
Non surgical method In some less active individuals with mild-
to-moderate instability, reduction of activity level may be all that is necessary until they have had an appropriate growth spurt and maturing of the physes.
Muscle strengthening exercises knee brace Away from sports activities
TRANSEPIPHYSEAL REPLACEMENT OF ANTERIOR CRUCIATE LIGAMENT USING QUADRUPLE HAMSTRING GRAFTS
The transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts
procedure described by Anderson is indicated in patients in Tanner stage I, II, or III of development.
The procedure is contraindicated in patients in Tanner stage IV of development, who can have conventional anterior cruciate ligament reconstruction
The tunnels are drilled centrally through the epiphysis and fixed with a button on the periosteal surface. There are no reported growth deformities with this technique.
Anderson transepiphyseal replacement of anterior cruciate ligament using quadruple hamstring grafts
physeal-sparing, combined intraarticularand extraarticular reconstruction of acl by Kocher, Garg, and Micheli
Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels Lauren H. Redler, M.D., Rebecca T. Brafman,
B.A., Natasha Trentacosta, M.D., Christopher S. Ahmad, M.D.(Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, U.S.A.)
Arthroscopy Volume 28, Issue 11, Pages 1710–1717, November 2012
Moises Cohen, M.D., Ph.D., Mario Ferretti, M.D., Ph.D., Marcelo Quarteiro, M.D., Frank B. Marcondes, M.D., João P.B. de Hollanda, M.D., Joicemar T. Amaro, M.D., Rene J. Abdalla, M.D., Ph.D.(Orthopedic Sports Medicine Division, Department of Orthopaedic Surgery and Traumatology, Universidade Federal de São Paulo–Escola Paulista de Medicina, São Paulo, Brazil)
Arthroscopy Volume 25, Issue 8, Pages 831–838, August 2009
Conclusions ACL reconstruction by use of the
transphyseal technique in an immature skeleton with a hamstring autograft, with careful attention being paid to the technique, resulted in good clinical outcomes and no growth abnormalities.