Prepared be:

Fahad Al Hulaibi

Supervised by:

Dr. Mohammed Al Balwi

ACL TEAR

Stability of knee.

Anatomy of the ACL.

Functions of ACL.

Risk Factors to ACL tear.

Clinical picture.

Examinations.

Investigations.

Treatment.

complications

Stability of knee

Introduction

50% of patients with ACL

injuries also have meniscal

tears.

- Acute >> Lateral

- Chronic >> Medial

Incidence is higher in soccer

players, basketball or any

high risk sports.

95,000 ACL Tear in USA annually

Anatomy

The ACL is composed of densely organized, fibrous

collagenous connective tissue that attaches the

femur to the tibia.

2 groups:

- Antromedia band

- Postrolateral band

Attachment

On the Femur, the ACL is attached to:

a fossa on the posteromedial edge of the lateral femoral condyle.

Attachment

On the Tibia, the ACL is inserted to:

a fossa that is anterior to the anterior tibial spine

(Intercondylar eminence )

wider and stronger

Function of ACL

primary (85%) restraint to limit anterior

translation of the tibia.

secondary restraint to tibial rotation and

varus/valgus angulation at full extension.

The average tensile strength for the ACL is

2160 N.

Risk Factor to ACL tear

High-risk sports:

football, baseball, soccer, skiing, and basketball

Sex:

F > M

Femoral notch stenosis :

< 0.2

Footwear:

Clinical picture

Non-contact injury:

- often occurs while changing direction or landing

from a jump.

- "popping" noise.

- Within a few hours, a large hemarthrosis develops.

- pain, swelling, and instability or giving way of the

knee.

- - unable to return to play.

Clinical picture

Contact and high-energy traumatic injuries:

- often are associated with other ligamentous and

meniscal injuries.

- - Terrible Triad !!

Examinations

1. Inspection:

- immediate effusion >> intra-articular trauma.

2. Assess ROM:

Lack of complete extension.

3. Palpation:

Any meniscus or collateral tears or sprain.

Lachman test: most sensitive test

Pivot shift test:

Anterior drawer test : least reliable

Investigations

Laboratory Studies

Imaging Studies

Other Tests

Laboratory Studies

Arthrocentesis (rarely performed)

Imaging Studies:

- Plain radiographs. Usually -ve

- Arthrograms. replaced by MRI

- MRI

* Gold standard

* 90-98% sensitivity.

* identify bone bruising.

KT-1000

greater than 3 mm as measured by the KT-1000 is

classified as pathologic.

Treatment

Acute Phase

Recovery Phase

Maintenance Phase

Acute Phase

Physical Therapy

Before any treatment, encourage strengthening of the

quadriceps and hamstrings, as well as ROM

exercises

Acute Phase

Non-Surgical intervention:

who are elderly or have a very low activity level.

Surgical intervention:

- surgical intervention be delayed at least 3 weeks following injury to prevent the complication of arthrofibrosis.

- Method of surgeries:

1- Primary repair .

2- Extra-articular repair.

3- Intra-articular reconstruction.

Grafting can be from :

- patellar tendon -Hamstring tendons

- quadriceps tendon. - Allograft

the expected long-term success rate of ACL reconstruction

is between 75-95%.

Failure Rate is 8%, which may be attributed to: recurrent

instability, graft failure, or arthrofibrosis.

Recovery Phase

Physical Therapy:

Therapy protocols divided into the following 4 categories:

Phase I: preoperative period when the goal is to maintain full ROM.

Phase II (0-2 wk): The goal is to achieve full extension, maintain

quadriceps control, minimize swelling, and achieve flexion to 90o.

Phase III (3-5 wk): Maintain full extension and increase flexion up to

full ROM.

Phase IV (6 wk): Increase strength and agility, progressive return to

sports.

Return to all sports without activity may take 6-9 months

Recovery Phase

Knee braces:

Maintenance Phase

Physical Therapy

Once quadriceps strength reaches 65% of the

opposite leg, sports-specific activities may be

performed; >>>>>>>>>>>>>>>>>>>

The athlete may return to activity when the

quadriceps strength has reached 80% >>>

Re-growth to takes time, it may be need >>>>

5-8 weeks

3-4 month

6 months

Lifestyle and home remedies

- Rest

- Ice. at least every two hours for 20 minutes at a time.

- Compression

- Elevation

Complications

The 3 major categories of failure in an ACL reconstruction

(1) arthrofibrosis (due to inflammation of the synovium and

fat pad),

(2) pain that limits motion,

(3) recurrent instability, secondary to significant laxity in the

reconstructed ligament.

Other complications

patella fractures

patella-tendon ruptures.

Reflex sympathetic dystrophy,

postoperative infection

neurovascular complications .

Stiffness.

Summary

ACL is one of the ligament that stabilize the knee.

ACL tear is a popular injury in high risk sports.

History & clinical examination is the most important

tools in diagnosis.

MRI is the gold standard in diagnosis.

The goal of surgery is to stabilize the knee.

Success rate of ACL reconstruction is up to 95 %.

Physiotherapy is an important factor in treatment.

References

Matthew Gammons MD, Anterior Cruciate Ligament Injury ,

Medscape Updated: May 4, 2012

AAOS, American Orthopaedic Society for Sports Medicine ,

Anterior Cruciate Ligament Injuries , March 2009.

ACL injury , Myoclinin Family Health Book, Fourth Edition.

Thank you