Published on November 10, 2013
ACL TEAR Prepared be: Fahad Al Hulaibi Supervised by: Dr. Mohammed Al Balwi
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 - quadriceps tendon. -Hamstring tendons - 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; >>>>>>>>>>>>>>>>>>> 5-8 weeks The athlete may return to activity when the quadriceps strength has reached 80% >>> 3-4 month Re-growth to takes time, it may be need >>>> 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.
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