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Diagnosis and Treatment of ACL Injuries Jeff Martin DO.

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Presentation on theme: "Diagnosis and Treatment of ACL Injuries Jeff Martin DO."— Presentation transcript:

1 Diagnosis and Treatment of ACL Injuries Jeff Martin DO

2 Author has no conflicts of interest to disclose

3 Improve knowledge and treatment of ACL tears from injury through treatment and rehabilitation. Goals:

4 Introduction 150, ,000 ACL tears annually Chronic ACL deficient knees associated with – chondral injuries – complex unrepairable meniscal tears – relation with arthritis is controversial 2 nd most commonly tested topic on yearly Orthopedic resident inservice test over the last ten years

5 The Female Athlete Women athletes have 4-6x rate of ACL injuries then males – Increased Q angle – Valgus Leg alignment – Effects of estrogen – Small ACL width – Narrow femoral notch – Increased Joint Laxity – Jump patterns (extended knee with greater hip adduction moments) Focus of ACL injury prevention programs which have shown decreased incidence of ACL tears

6 Prevention Level 2 evidence shows that high intensity plyometrics coupled with balance training and strengthening improves neuromuscular feedback This reduces ligamentous strain during pivoting and landing activities For the training regimen to be effective, a minimum of 1 session per week for 6 weeks needs to be implemented

7 neuromuscular training / plyometrics (jump training) land from jumping in less valgus and more knee flexion increasing hamstring strength to decrease quadriceps dominance ratio

8 Anatomy Primary function is to prevent anterior translation of the tibia Secondary role in preventing internal rotation of tibia

9 Anatomy of ACL ACL attachments: Arises from posteromedial corner of the lateral femoral condyle in the intercondylar notch Broad insertion at anterior intercondylar portion of the tibia length of 38 mm (range 25 to 41 mm) width of 10 mm (range 7 to 12 mm) ACL is intra-articular and extra-synovial Blood supply is the middle genicular artery Due to relatively poor blood supply, ACL has little intrinsic capacity to heal

10 ACL composed of Two Bundles Anteromedial Tight in Flexion Controls anterior Translation Posterolateral Tight in Extension Rotator Stability and anterior motion

11 Mechanism of Injury typically, the ACL is torn in a noncontact deceleration situation that produces a valgus twisting injury this usually occurs when the athlete lands on the leg and quickly pivots in the opposite direction Other Mechanisms - hyperextension - marked internal rotation of tibia on femur - pure deceleration

12 Presentation Classic “pop” % of acute hemarthroses are secondary to ACL injury

13 Physical Exam ACL Quadriceps avoidance gait – most patients will alter their gait in order to avoid anterior displacement of the tibia which occurs with quadriceps contraction between 0 to 45 deg of flexion, contraction of the quadriceps will cause anterior translation of the tibia (which is normally resisted by the ACL) Lachman (most sensitive) Anterior drawer pivot shift (most specific, usually done under anesthesia)

14 Classic O’Donoghue Triad (Terrible Triad) rare – ACL, MCL, medial meniscus Lateral meniscus – Acute Medial meniscus – Chronic At the time of injury approximately 1/3 of patients will have meniscal tears

15 Imaging ACL Tear Plain radiograph – Segond (capsular sign) Small fracture at periphery of proximal lateral tibia

16 Imaging MRI ACL Tear best seen on sagittal view Osteochondral middle third of the lateral femoral condyle and posterior third of the lateral tibial plateau 50% injuries

17 Treatment Nonoperative – low demand patients with decreased laxity – increased meniscal/cartilage damage linked to loss of meniscal integrity frequency of buckling episodes High level of activity (e.g. jumping, cutting, side-to-side sports, heavy manual labor)

18 Operative (ACL reconstruction) Indications in younger, more active patients (reduces incidence of mensical or chondral injury) older active patients (Age >40 is not contraindication if high demand athlete) ACL reconstruction failure Attempted ligament "repair" has high failure rate

19 Surgical Techniques 2006 study with BTB (minimum 13 year follow up) showed 79% of patients had radiographic evidence of degenerative changes 2007 meta-analysis reported only 33-41% normal knee scores after ACL reconstructions

20 Tunnel Placement Transtibial Technique has tendency to place femoral tunnel vertical=less rotational stability Anatomic ACL reconstructions- place tunnnels in native femoral and tibial attachment sites

21 Double Bundle vs Single Bundle Some biomechanical evidence suggests that double bundle reconstructions result in better restoration of knee stability No clinical evidence of difference

22 Surgery Arthroscopic Assisted ACL Reconstruction with Patellar tendon Autograft – 1) If certain ACL is nonfunctional (side to side difference of >5mm), harvest autograft before the arthroscopy. If not certain, evaluate the knee arthroscopically first.

23 Surgery 2) The middle third (~10mm) of the patellar tendon is harvested with bone plugs from the tibia and patella. Bone plugs are trimmed to facilitate passage through the osseus tunnel. Holes are drilled in the bone plugs to pass nylon sutures. Arthroscopy.

24 Surgery 3) Arthroscopic Soft tissue debridement of ACL attachment sites 4) Position and prepare osseus tunnels – Length of tibial tunnel is calculated – Cannulated core drill used to create a tibial tunnel and then a femoral tunnel for transtibial technique – Accessory medial portal can do tibial or femoral tunnel first.

25 5) Graft implantation and fixation – Pin is retrograded through tunnels and out anterolateral thigh – suture on graft is threaded through the pin and the suture and graft are pulled through tunnel into the joint – Bone plugs are fixed by interference screws and inserted flush with the bone tendon junction

26 Surgery 6) Knee flexed through full ROM, pivot and lachman tests performed – Core of bone from the tibial tunnel used to fill bony defect of the patella – Patellar tendon loosely re-approximated to prevent any palpable gaps w/out shortening the patella tendon – Peritenon, subcutaneous tissue, skin closed in separate layer

27 Graft Options in ACL Reconstruction Autograft Bone-patella tendon- bone Hamstring Quadriceps Allograft Bone-patella tendon-bone Hamstring Quadriceps Tibialis anterior Tibialis posterior Achilles tendon Fascia lata Peroneus longus

28 ACL Autografts Advantages: No issue regarding cost and availability of graft No risk of disease transmission Good potential of bone- graft interface No tissue rejection Disadvantages More wound pain More prominent scar Longer surgical time Donor site morbidity

29 ACL AutoGrafts Load to Failure Native ACL 2160N 10mm BTB 2977N Quadrupled Hamstring 4090N Quadriceps 2352 N 1 N = 1 kg ⋅ m/s2

30 Bone-patella tendon-bone For past few decades, Gold Standard for ACL Reconstruction Clinical Studies have not shown significant differences between grafts Ease of harvest Bone-to-bone healing with secure fixation

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32 Bone-patella tendon-bone Disadvantages Potential negative effect on the knee extensor mechanism Anterior knee pain / kneeling pain Risk for patella fracture Anterior knee numbness

33 Hamstring tendon Combined semitendinosus and gracilis hamstring tendons Less anterior knee pain, no disruption of knee extensor mechanism, and less risk for patella fracture Quadrupled Hamstring strongest Graft 4090N nearly double native ACL

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35 Hamstring tendon Potential Limitations: Slower soft-tissue graft-tunnel healing (when compared to bone-to-bone healing with patella tendon grafts) Potential for tunnel widening and graft laxity Functional hamstring weakness from graft harvesting Some studies show lower return to pre-injury activity levels

36 Quadriceps tendon Noted to be more difficult to harvest Potential for anterior knee pain Persistent quadriceps weakness? Thicker then patellar tendon

37 Graft Selection in Anterior Cruciate Ligament Reconstruction Walter R. Shelton, MD Bryan C. Fagan, MD JAAOS 2011;19:

38 Allografts Wide range of graft sources and availability Availability of larger grafts Quicker surgical time No donor site morbidity Lower incidence of post-operative arthrofibrosis Faster immediate post-operative recovery and less post- operative pain Easier rehabilitation Useful in revision ACL reconstruction procedures

39 ACL Allografts Disadvantages Expensive ($1500) Risk (minimal) of tissue rejection Risk (minimal) of disease transmission Relatively longer healing time of the graft Variability in mechanical properties of ACL allografts In some studies higher failure rates When irradiated and chemically processed grafts were excluded, then failure rates were no longer statistically significant

40 Gamma Irradiation of ACL Allografts One of the most widely utilized forms of secondary graft sterilization is gamma irradiation Known pathogens include HIV, hepatitis, bacteria, and fungus Susceptibilities: Non-spore-forming bacteria: 0.5 Mrad Bacterial spores: 2.1 Mrad Yeast/Mold: 0.8 Mrad HIV: 1.5 – 4 Mrad Irradiation doses > 2 Mrad have demonstrated decreases in biomechanical properties of the allograft Increased elongation and decreased stiffness, maximum force, strain, and maximum stress Disruption of collagen organization and cleaving of polypeptide bonds Studies have shown that lower irradiation levels (1.0 – 2.0 Mrad) do not compromise graft biomechanical properties These doses will not eliminate HIV, hepatitis, and spore-forming bacteria. Demonstrates the importance of adequate screening

41 ACL Tears in Children Treatment in Children (< 14 yrs with open physis) – strongly consider operative activity limitation impractical transphyseal soft tissue grafts rarely lead to growth disturbances avoid transphyseal metallic fixation Fixation outside the physis (over the top techniques)

42 Rehab ROM Immediate ROM is more beneficial to a healing graft than delayed motion Immediate ROM and CPM have not been shown to endanger ACL grafts ROM helps prevent scar tissue formation in the intercondylar notch and elsewhere Knee extension loss is one of the more common complications after ACL recon Immediate, full, passive, terminal extension is required

43 Rehab Weight Bearing At least partial weight bearing should begin initially to ensure that proper gait sequence and cadence can be performed Immediate weight bearing has been shown to decrease incidence of anterior knee pain Pain should be controlled to allow progression to full weight bearing (avoids quadriceps avoidance gait) Some protocols limit weight bearing after soft-tissue fixation methods

44 – early rehab focus rehab on exercises that do not place excess stress on graft – appropriate rehab » isometric hamstring contractions at any angle » isometric quadriceps, or simultaneous quadriceps and hamstrings contraction » active knee motion between 35 degrees and 90 degrees of flexion » emphasize closed chain (foot planted) exercises – avoid » isokinetic quadricep strengthening (15-30°) during early rehab » open chain quadriceps strengthening

45 Outcomes An evaluation of NFL wide receivers and running backs after ACL reconstruction showed only 80% of the athletes returned to play Of those returning, there was a 30% decrease in statistical performance Revision reconstructions result in 60% return to athletic activity, but with decrease level of performance Most common reason for ACL recon failure? Technical failure (tunnel placement) Single stage vs two stage revisions are dictated by tunnel quality and degree of osteolysis

46 Complications Infection – septic arthritis Staph aureus most common – treatment immediate arthroscopic I&D often can retain graft with multiple I&Ds and abx (6 weeks minimum) Loss of motion & arthrofibrosis – preoperative prevention be sure patient has regained full ROM and swelling gone before you operate – operative prevention proper tunnel placement is critical to have full range of motion – postop prevention aggressive cryotherapy (ice)

47 Infrapatellar contracture syndrome Patella Tendon Rupture RSD (complex regional pain syndrome) Patella fracture Hardware failure Tunnel osteolysis Late arthritis – Thought to be related to meniscal integrity Local nerve irritation – saphenous nerve Cyclops lesion – fibroproliferative tissue blocks extension – "click" heard at terminal extension

48 Thank You

49 References Graft Selection in Anterior Cruciate Ligament Reconstruction Walter R. Shelton, MD Bryan C. Fagan, MD J Am Acad Orthop Surg 2011;19: Copyright 2011 by the American Academy of Orthopaedic Surgeons.BiomechanicsMay 2011, Vol 19, No 5259Review Article Does ACL Reconstruction Alter Natural History? A Systematic Literature Review of Long-Term Outcomes Chalmers P et al. J Bone Joint Surg Am, 2014 Feb 19;96(4): MR Imaging of Complications of Anterior Cruciate Ligament Graft Reconstruction. Bencardino J et al. Radiographics, 2009 Nov Vol Nonsurgical or Surgical Treatment of ACL Injuries: Knee Function, Sports Participation, and Knee Reinjury The Delaware-Oslo ACL Cohort Study. Grindem H et al. Bone Joint Surg Am, 2014 Aug 06;96(15): Comparison of Functional Outcome Measures After ACL Reconstruction in Competitive Soccer Players, A Randomized Trial. Mohammadi F et al. Bone Joint Surg Am, 2013 Jul 17;95(14):

50 Adams, Kenneth. Anterior Cruciate Ligament Injury. Emedicine. July 5, 2002 Arendt, E, Dick R. Knee Injury Patterns Among Men and Women In Collegiate Basketball and Soccer. Am J Sports Med. 23(6) , 1995 Ferretti A, Papandrea P. Knee Ligament Injuries in Volleyball Players. Am J Sports Med. 20 (2) , 1992 Horn, Alan. Knee, Anterior Cruciate Ligament Injuries. Emedicine. July 20, 2004 Huston, Laura. Anterior Cruciate Ligament Injuries in the Female Athlete: Potential Risk Factors. Clin Orthop Rel Res , 2000 Jackson, Douglas. Master Techniques in Orthopedic Surgery: Reconstructive Knee Surgery. 2 nd ed Katz J, Fingeroth R. The Diagnostic Accuracy of Ruptures of the Anterior Cruciate Ligament comparing the Lachman test, the Anterior Drawer test, and the Pivot Shift Test in Acute and Chronic Knee Injuries. Am J Sports Med. 14 (1) 88-91, 1986 West R, Harner D. Graft Selection in Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg , 2005 OrthoBullets.com Wheeless.com


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