General talk about Anterior Cruciate Ligament tear. it presented during my orthopedic rotation in KFUH. under supervision of Dr. Balwi "sport injuries consultant"

1. ACL TEAR
Prepared be:
Fahad Al Hulaibi
Supervised by:
Dr. Mohammed Al Balwi

2. 
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Stability of knee.
Anatomy of the ACL.
Functions of ACL.
Risk Factors to ACL tear.
Clinical picture.
Examinations.
Investigations.
Treatment.
complications

3. Stability of knee

4. 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

5. 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

6. Attachment

On the Femur, the ACL is attached to:
a fossa on the posteromedial edge of the lateral femoral condyle.

7. Attachment
On the Tibia, the ACL is inserted to:
a fossa that is anterior to the anterior tibial spine


8. 
(Intercondylar eminence )
wider and stronger

9. Function of ACL
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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.

10. Risk Factor to ACL tear
High-risk sports:
football, baseball, soccer, skiing, and basketball
 Sex:
F>M
 Femoral notch stenosis :
 < 0.2
 Footwear:


11. 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.


12. Clinical picture
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Contact and high-energy traumatic injuries:
often are associated with other ligamentous and
meniscal injuries.
- Terrible Triad !!

13. Examinations
1. Inspection:
- immediate effusion >> intra-articular trauma.
2. Assess ROM:
Lack of complete extension.
3. Palpation:
Any meniscus or collateral tears or sprain.

14. 
Lachman test: most sensitive test

15. 
Pivot shift test:

16. 
Anterior drawer test : least reliable

17. Investigations
Laboratory Studies
 Imaging Studies
 Other Tests


18. 
Laboratory Studies
Arthrocentesis (rarely performed)

19. 
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Imaging Studies:
- Plain radiographs. Usually -ve
- Arthrograms. replaced by MRI
- MRI
* Gold standard
* 90-98% sensitivity.
* identify bone bruising.

22. KT-1000
greater than 3 mm as measured by the KT-1000 is
classified as pathologic.

23. Treatment
Acute Phase
 Recovery Phase
 Maintenance Phase


24. Acute Phase
Physical Therapy
Before any treatment, encourage strengthening of the
quadriceps and hamstrings, as well as ROM
exercises


25. 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.


26. 
Grafting can be from :
- patellar tendon
- quadriceps tendon.
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-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.

27. 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

28. Recovery Phase

Knee braces:

29. 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

30. 
Lifestyle and home remedies
- Rest
- Ice. at least every two hours for 20 minutes at a time.
- Compression
- Elevation

31. 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.

32. Other complications
patella fractures
 patella-tendon ruptures.
 Reflex sympathetic dystrophy,
 postoperative infection
 neurovascular complications .
 Stiffness.


33. Summary
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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.

34. References
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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.

35. Thank you