Anterior cruciate ligament injury/tear

1. Sivendu P
MBBS Final Year
KMCT MEDICAL COLLEGE

2.  Anterior cruciate ligament is the most commonly ruptured ligament of knee
joint, often in association with the tears of medial or lateral collateral
ligaments.
 Commonly, it occurs as a result of twisting force on a semi-flexed knee.
 Often the injury to medial collateral ligament, medial meniscus and anterior
cruciate ligament occur together.
 This is called O'Donoghue triad

4. • The ACL is a fan shaped ligament composed of densely organized, collagenous
fibers that attaches the femur to the tibia.
ATTACHMENTS
 On the Femur - a fossa on the posteromedial edge of the lateral femoral condyle.
 On the Tibia - a fossa anterior and lateral to the tibial spine
BLOOD SUPPLY:
• Major blood supply is from MIDDLE GENICULAR ARTERY

6. The fibers of the ligament are divided into 2 bands
• Anteromedial (AM) - tight in flexion
• Posterolateral (PL) - tight in extension

7. Primary functions
 Restraint to limit anterior displacement of the tibia
 Prevent hyperextension of knee
Secondary functions
 Restraint to tibial rotation and varus /valgus angulation at full
extension.

8. Contact and high-energy traumatic injuries:
 Tackles , Collisions
 Are often associated with other ligamentous and
meniscal injuries.
Non contact:
 Cutting (Changing direction rapidly)
 Stopping suddenly while running
 Landing from a jump incorrectly

10. Athletes involved in games
involving rapid side change
movements (Eg Footballers)
Female affected more easily than
males .

11. ACUTE INJURY
“Popping sound” heard by the patient
Pain with swelling.
Knee effusion (Haemarthrosis)
Loss of full range of motion
Tenderness
CHRONIC INJURY (INSTABILITY/GIVING WAY)
Discomfort while walking

12. Collateral ligament injuries
Posterior cruciate ligament injury
Patellar Dislocation
Meniscal Injuries

13. Anterior drawer test - POSITIVE
Lachman Test – POSITIVE
Pivot Shift Test - POSITIVE

14. • Patient is made to lie in supine position with Hip flexed at 45⁰ and knee is flexed to 90⁰
• The foot is prevented from sliding and the tibia is drawn forwards using both hands.
• The test is said to be Positive if the tibia moves forward more than that of the uninjured
leg or if the end point feels soft or absent .

15. • Better sensitivity than Anterior drawer test
• Patient is made to lie in supine position with the knee flexed 20 - 30 ⁰
• Hold the calf with one hand and the thigh with the other, and try to displace the joint backwards
and forwards.
• The test is said to be Positive if the tibia moves forward more than that of the uninjured leg or if
the end point feels soft or absent .

16.  The examiner supports the knee in
extension with the tibia internally rotated .
 Valgus stress is applied
 The knee is then gradually flexed.
 In a positive test, as the knee reaches 20 or
30 degrees flexion, there is a sudden jerk as
the tibial condyle slips backwards.
 Usually performed after the swelling
subsides and in chronic cases.

17. Imaging Studies:
• MRI
 90-98% sensitivity.
 Can identify bone bruising.
 Gold standard
• Plain X ray - Usually normal ,but may show tibial spine avulsion if present
• Arthrograms – (X ray of a joint after contrast medium is injected )
• Replaced by MRI
Arthroscopy

20. Conservative (Non
Surgical)
Surgical
Immediate treatment in an acute
injury -
R.I.C.E ( Rest Ice Compression
Elevation)

21. INDICATIONS
• Partial tears
• Isolated tears of ACL
• No instability symptoms
• Patients who do light manual work or live sedentary lifestyles
• Children and Young adolescents - risk of growth plate injury during surgery , leading to bone
growth problems.

22.  Aggressive rehabilitation program and counseling about activity
level.
 After swelling decreases
 Physiotherapy
 Muscle strengthening exercises
 Braces – Worn until symptoms subside
 Functional Brace
 Rehabilitation Brace – To allow controlled movement during rehabilitation

23. INDICATIONS
 Professional Athletes
 Associated Meniscal or collateral ligament injuries
 Recurrent episodes of giving way, recurrent effusions.
 Persistant anterior knee pain.
 Tibial spine avulsion

24.  Swelling in the knee must go down to near normal levels
 Range-of-motion (bending and straightening) of the injured knee must be
nearly equal to the uninjured knee
 Good Quadriceps muscle strength must be present.
 Usually it takes a 2-3 weeks after injury
 The presence of any associated injuries to the knee joint involving cartilage,
meniscus, or other ligaments may change the time-frame for surgery

25.  Graft fixation
 Grafts used are –
• Autografts – Patellar tendon , Tendons of Hamstrings , Quadriceps.
• Allografts
• Synthetic grafts
 Fixations can be of 2 types –
• Aperture Fixation – With Interference Screws
• Suspensory Fixation - Endobuttons, Tightrope

26. Interference Screws
TightropeEndobutton

27. 1. Diagnostic arthroscopy
2. Adressing meniscal pathologies
3. Clearing remnants of ACL
4. Graft harvesting and preparation
5. Preparing femoral and tibial tunnels
6. Passing the graft
7. Fixation of the graft
Post operative rest and physiotherapy
Return to active sports activities after 6-9 months

28.  In a “double-bundle”ACL reconstruction, the
ACL is restored using two bundles.
 Just like the normalACL, there will be an AM
and a PL bundle.

29. Severe valgus or varus stress, or twisting
injuries, may damage the knee ligaments and
fracture the tibial spine
Treatment
• Under anaesthesia the joint is aspirated and gently
manipulated into full extension.
• If there is a block to full extension or if the bone
fragment remains displaced, operative reduction is
essential.
• The fragment is restored to its bed and anchored
by small screws.
• After reduction plaster cast is advised for 6 weeks.

30. In Untreated Cases
 Adhesions – When a ligament with partial tear is not regularly exercised
 Ossification in the ligament (Pellegrini–Stieda’s disease)
 Instability (‘giving way’)
 Osteoarthritis
After Surgery
 Loss of fixation
 Postoperative joint fibrosis
 Infections

31.  Apley's System of Orthopaedics and Fractures 9th ed
 Essential Orthopaedics Maheshwari & Mhasker