1.  Knee is like a round ball on a flat surface  Ligaments provide most of the support to the knees  Little structure or support from the bones

2.  First-degree: mild minimal signs and symptoms, minimal functional loss and resolves in a few days.  second-degree: moderate- partial structural disruption, swollen tender, may show some signs of instability. Performance deficit for up to 6 weeks.  Third-degree: severe extensive structural disruption, extensive swelling, severe pain, joint unstable. Performance deficit. Minimum 6-8 weeks.

3.  Third-degree:  Grade I: less than a 0.5- cm opening of the joint surfaces  Grade II: a 0.5- to 1-cm opening of the joint surface  grade III: a rupture larger than a 1-cm opening

4.  Ligaments are slow to heal due to their hypovascular nature.  Pathologically ligaments are a type of dense connective tissue, 90% type I collagen, 9% type III collagen and 1% fibroblast cells

5. OPERATIVE TxNON OPERATIVE Tx

6.  FACTORS :  Degree of spain  What?  Where?  Age  Demand  Assosiated injury

7.  RICE  Bracing  Strengthening  Functional brace

8.  Repair : surgical treatment of acute injuries(Optimal surgical dissection and repair become increasingly difficult beyond 7 to 10 days after injury)  Reconstruction : usually refers to surgical treatment of ligamentous laxity several months after injury

10.  An ACL injury (either grade I, II or III) can occur during the following:  Sudden hyperextension of the knee.  Body weight twisting across the knee joint causing a shearing force while the foot is still planted on the ground.  Sudden deceleration.

11.  The ACL provides both mechanical stability and proprioceptive feedback to the knee.  Restrains anterior translation of the tibia on the femur.  Prevents hyper-extension of the knee.  Secondary stabilizer to valgus stress  Controls rotation of the tibia on femur in the last 30 degrees of knee extension. (part of the locking mechanism)

12.  Operative vs. Non-operative Demand level Age lifestyle Other lesions

13.  The decision to reconstruct an ACL tear should be based not only on the presence of symptomatic instability, but also on the lifestyle and activity level of the patient.  Age is’nt base of guide line for reconstruction because the more important factor is the overall level of activity.

14.  Consequently, age itself should not be a contraindication to ACL reconstruction.  Symptomatic patients with a more sedentary lifestyle and those who are willing to modify their level of activity can be considered for nonoperative treatment,

15.  TIMING:  No swelling  Good leg control  Full ROM (full hyperextension)

16.  Aggressive rehabilitation program  functional knee brace

17.  Healing is good:  Blood supply  Relatively wide surface area  Association with other secondary stabilizers  Extra-articular location. Shockwave

18.  Non operrative tx:  Bracing(full time for 4 to 6 weeks and daytime for another 4 to 6 weeks)  Early motion and weight bearing  Quadriceps and hamstring strengthening

19.  Operative tx :  Large bony avulsions identified on radiographs  Stener-type lesions of the distal MCL  patients with persistent functional valgus instability after nonoperative treatment

20.  Nonoperative treatment of the MCL  ACL reconstruction  For chronic ACL tears with residual valgus instability, simultaneous reconstruction of the ACL and MCL.  ACL/PCL/MCL injuries with reconstruction of all injured ligaments

21.  PCL injuries are present in up to 3% of knee injuries in the general population and as many as 37% of knee injuries in trauma patients with acute hemarthrosis.  PCL injury typically results following an excessive posteriorly directed force on the tibia

22.  Non operative Tx :  Low-grade isolated PCL injuries

23.  Operative Tx :  Multiligamentous injuries  symptomatic chronic grade II or III  PCL avulsions(Repaire)  PCL injuries in active patients who are unwilling to change their lifestyle

25.  Less commonly injured than the cruciate ligaments or the medial knee ligament complex.  Associated posterolateral corner injuries provide a potential source of residual instability following anterior cruciate ligament and posterior cruciate ligament reconstruction  Can lead to reconstruction graft failure

26.  Non operative Tx:  Grades I and II injuries  Knee bracing(3-6 wks)  Full weight bearing  In combined Injury ACL and PCL treated operativly and grade I,II injury to PLC treated non op

27.  Operatve Tx:  Grade III injuries  Combined ACL,PCL,PLC concurrent repair or reconstruction  Repair and Reconstruction

28.  Intrasubstance repairs of the fibular collateral ligament and popliteus have not fared well and therefore should not be performed.  Other structures of the PLC areamenable to intrasubstance repair. These include the coronary ligament of the lateral meniscus, meniscofemoral and meniscotibial ligaments, and fibers of the popliteomeniscal ligaments

29.  Reconstruction better and had fewer failures (9% vs. 37%) than the repair  These include nonanatomic and anatomic techniques.  Operative management provides improved outcomes compared with nonoperative  Early surgical management (within 3 weeks) is better