ANTERIOR CRUCIATE

LIGAMENT-INJURY &
MANAGEMENT
ANATOMY
ACL is composed of multiple collagen
fascicles
surrounded by an endotendineum which is
grouped into fibers measuring around
38mm in length (range 25 to 41 mm) and
10 mm in width (range 7 to 12 mm)

Microspocially composed of interlacing

fibrils
(150 to 250 Nanometer in diamter)
 ORIGIN
- From the posteromedial corner of medial
aspect of
lateral femoral condyle in the intercondylar
notch
INSERTION

- Fossa in front of & lateral to anterior spine

of
tibia
 ACL is composed of two principal parts
1. Small Anteromedial band
and
2. Larger bulky posterolateral portion

CLINICAL IMPORTANCE
- Anteromedial bundle is tight in flexion and
the
posterolateral bundle is tight in extension
- In extension both bundles are parallel
- In flexion both bundles are crossed
Action

These attachments allow the ACL to resist

anterior translation and medial rotation of the
tibia, in relation to the femur.
INNERVATION:
- Tibal nerve( Infiltrates the capsule
posteriorly)
- Golgi tendon receptors
BLOOD SUPPLY:
- Major blood supply is from
MIDDLE GENICULAR ARTERY

Bony attachments do not provide a

significant
 ACL vascularization arises from the middle
genicular artery and vessels of the infrapatella
fat pad and adjacent synovium
The artery gives rise to periligamentous
vessels which form a web-like network within
the synovial membrane
These periligamentous vessels give rise to
penetrating branches which transversely cross
the ACL and anastomose with a network of
longitudinally oriented endoligamentous
vessels
 Terminal branches of the inferior medial and
lateral genicular arteries supply the distal
portion of the ACL directly.

The extremities of the ACL seem to be better

vascularized than the middle part, and the
proximal portion seems to have a greater
vascular density than the distal portion
CAUSE OF ACL INJURY
The anterior cruciate
ligament can be injured
in
several ways
Changing direction
rapidly
Stopping suddenly

Slowing down while

running
Landing from a jump
incorrectly
Direct contact or
collision, such as a
football tackle
 Several studies have shown
that female athletes have a
higher incidence of ACL injury
than male athletes because of
Differences in
- Physical conditioning
- Muscular strength
- Neuromuscular control
- pelvis and lower extremity
(leg) alignment
and
- the effects of estrogen on
ligament properties.
 ACL injuries occur in combination with
damage to
-The meniscus
-Articular cartilage or
-Other ligaments

Secondary damage may occur in patients

who
have
repeated episodes of instability due to ACL
 With chronic instability, up to 90 percent of
patients will have meniscus damage when
reassessed 10 or more years after the initial
injury.

Similarly, the prevalence of articular cartilage

lesions increases up to 70 percent in patients
who have a 10-year-old ACL deficiency
GRADING
Partial tears of the anterior cruciate ligament
are
rare

Most ACL injuries are complete or near

complete tears

Injured ligaments are considered "sprains" and

are graded on a severity scale.
 Grade 1 Sprains.
The ligament is mildly damaged . It has been
slightly stretched, but is still able to keep the knee
joint stable.
Grade 2 Sprains.

The ligament is stretched to the point where it

becomes loose. This is often referred to as a
partial tear of the ligament.
Grade 3 Sprains.

This type of sprain is most commonly referred to

as a complete tear of the ligament. The ligament
has been split into two pieces, and the knee joint
is unstable.
SYMPTOMS
When ACL is injured , pt might hear a
"popping"
noise.

Other typical symptoms include:

-Pain with swelling.
-Loss of full range of motion
-Tenderness along the joint line
-Discomfort while walking
PHYSICAL EXAMINATION
INCLUDE
ANTERIOR DRAWER TEST

LACHMANS TEST

PIVOT SHIFT TEST

KT-2000 ARTHROMETER TEST

ANTERIOR DRAWER TEST
To perform anterior drawer test, examiner
grasps pt's tibia & pulls it forward when the
affected leg is flexed at 90 degree while noting
degree of anterior tibial displacement
 LACHMANS TEST
This is a variant of the anterior drawer test

The examination is carried out with the knee in 15 deg

of
flexion, and external rotation (relaxes IT band)

For a right knee, the examiner's right hand grips the

inner
aspect of the calf and the left hand grasps outer aspect
of
the distal thigh

Attempt to quantify the displacement in mm is done by

 End point should be graded as hard or soft
- End point is said to be hard when the ACL
abruptly halts the forward motion of the tibia on
the femur
- End point is soft when there is no ACL &
restraints are more elastic secondary
stabilizers;
PIVOT SHIFT TEST
During this test,
pt is kept in supine & examiner holds pt's leg with
both hands

abduct the pts hip (to relax the ITB and allow the
tibia to rotate)

Holding the heel in one hand and applying a valgus

stress in the other hand, the knee is slowly flexed
 The tibia, as well as the valgus, subluxes
easily if anterior force is applied.

After the anterior subluxation of the tibia is

noticed, the knee is slowly flexed, and the tibia
will reduce with a snap at about 20 to 30of
flexion.
INVESTIGATIONS
MRI
Arthroscopy
INVESTIGATION
TREATMENT

NON-SURGICAL METHOD
SURGICAL METHOD
 Immediately after injury
R.I.C.E ( Rest Ice Compression Elevation ()
Non surgical treatment
Exercise (after swelling decreases and weight-
bearing progresses)
Braces
Rehabilitation Brace
Functional Brace
Nonsurgical Treatment
Nonsurgical management is indicated in
patients with
-partial tears and no instability symptoms
-complete tears and no symptoms of knee
instability
-Who do light manual work or live sedentary
lifestyles
-Whose growth plates are still open (children)
Precautions
Modification of active lifestyle to avoid high
demand activities
Muscle strengthening exercises for life

May require knee brace

Despite above precautions ,secondary

damage to knee cartilage & meniscus leading
to premature arthritis
Surgical Treatment
Timing of Surgery
1) Swelling in the knee must go down to near-
normal levels
2) Range-of-motion (bending and straightening)
of the injured knee must be nearly equal to the
uninjured knee
3) Good Quadriceps muscle strength must be
present.
Usually it takes a couple of weeks after injury
before ACL reconstruction can be performed.
The presence of any associated injuries to the
knee joint involving cartilage, meniscus, or other
Surgical Treatment
ACL tears are not usually repaired using
suture to
sew it back together, because repaired ACLs
have
generally been shown to fail over time

Therefore, the torn ACL is generally replaced

by a
substitute graft made of tendon
The grafts commonly used to replace the ACL
include

autograft Allograft
patellar tendon,
Patellar tendon Achilles tendon,
Hamstring tendon semitendinosus,
Quadriceps tendon gracilis, or posterior
tibialis tendon
 Patients treated with surgical reconstruction of
the
ACL have long-term success rates of 82 %-
95%

The goal of the ACL reconstruction surgery is

to prevent instability and restore the function of
the torn ligament, creating a stable knee.

Recurrent instability and graft failure are seen

PATIENT CONSIDERATIONS

Active adult patients involved in sports or jobs

that
require pivoting, turning or hard-cutting as well
as
heavy manual work are encouraged to consider
surgical treatment.

Activity, not age, should determine if surgical

intervention should be considered.
 In young children or adolescents with ACL
tears,
early ACL reconstruction creates a possible
risk of
growth plate injury, leading to bone growth
problems. The surgeon can delay ACL surgery
until
the child is closer to skeletal maturity or the
surgeon
 A patient with a torn ACL and significant
functional
instability has a high risk of developing
secondary
knee damage and should therefore consider
ACL
reconstruction.

It is common to see ACL injuries combined

with
 Surgical Choices

1.PATELLAR TENDON AUTOGRAFT.

The middle third of the patellar tendon of the patient,
along
with a bone plug from the shin and the patella is used
in the
patellar tendon autograft. Occasionally referred to by
some
surgeons as the "gold standard" for ACL
reconstruction,
recommended for high-demand athletes and patients
whose
jobs do not require a significant amount of kneeling.
 In addition, most studies show equal or better
outcomes in terms of postoperative tests for
knee
laxity (Lachman's, anterior drawer and
instrumented
tests) when this graft is compared to others.
The Disadvantages of the patellar tendon
autograft are:
-Postoperative patello femoral pain
-Pain with kneeling
-increased risk of postoperative stiffness
-risk of patella fracture
-Quadriceps Weakness
-Persistent Tendon Defect
2.Hamstring tendon autograft.
The semitendinosus hamstring tendon on
the inner
side of the knee is used in creating the
hamstring
tendon autograft for ACL reconstruction.

Some use an additional tendon, the gracilis,

which
is attached below the knee in the same area.
 Hamstring graft proponents claim there are
fewer
problems associated with harvesting of the
graft
compared to the patellar tendon autograft
including:
- Fewer problems with anterior knee pain
after surgery
- Less postoperative stiffness problems
- Smaller incision
 The graft function may be limited by the strength
and
type of fixation in the bone tunnels, as the graft
does
not have bone plugs.

There have been conflicting results in research

studies
as to whether hamstring grafts are slightly more
susceptible to graft elongation (stretching), which
may
lead to increased laxity during objective
testing. Recently,
 There are some indications that patients who
have
intrinsic ligamentous laxity and knee
hyperextension
of 10 degrees or more may have increased risk
of
postoperative hamstring graft laxity on clinical
exam.
Therefore, some clinicians recommend the use
of
patellar tendon autografts in these hypermobile
 chronic or
residual medial collateral ligament laxity
(grade 2 or more) at the time of ACL
reconstruction may be a contra-
indication
for
use of the patient's own semitendinosus
and
gracilis tendons as an ACL graft.
3.QUADRICEPS TENDON AUTOGRAFT.
The quadriceps tendon autograft is often used

for
patients who have already failed
ACL reconstruction.

Middle third of the patient's quadriceps tendon

and
a bone plug from the upper end of the patella
are used.
 This yields a larger graft for taller and heavier
patients. Because there is a bone plug on one
side
only, the fixation is not as solid as for the
patellar
tendon graft.

There is a high association with postoperative

anterior knee pain and a low risk of patella
fracture. Patients may find the incision is not
cosmetically appealing
ALLOGRAFTS.

Allografts are grafts taken from cadavers and are

becoming increasingly popular.

These grafts are also used for patients who have

failed
ACL reconstruction before and in surgery to repair
or
reconstruct more than one knee ligament.

Advantages of using allograft tissue include

- Elimination of pain caused by obtaining the
graft
 The PATELLAR TENDON ALLOGRAFT
allows for strong bony fixation in the tibial and
femoral bone
tunnels with screws.
 However, allografts are associated with
- Risk of infection, including viral transmission
(HIV and Hepatitis C)
There have also been conflicting results in
research studies as to whether allografts are
slightly more susceptible to graft elongation
(stretching), which may lead to increased laxity
during testing.
 Recently published literature may point to a
higher failure rate with the use of allografts for
ACL reconstruction.
Failure rates ranging from 23% to 34.4% have

been reported in young, active patients

returning to high-demand sporting activities
after ACL reconstruction with allografts.
This is compared to autograft failure rates
ranging from 5% to 10%.
Meta-analysis of Patellar vs.
Hamstring tendons in ACL
reconstruction
Controlled trials with minimum 2 year follow-
upEvaluated; return to pre-injury level of
activity, KT testing, Lachmanscores, pivot shift
scores, ROM, complications, failures4 studies
fulfilled inclusion criteriaB-T-B showed a
>20% chance return to pre-injury activity level
versus hamstring, (p value = 0.01)
Yunes, M. et al Patellar Versus Hamstring

Tendons in ACL reconstruction; A Meta-

analysis Arthroscopy Vol. 17, No. 3 (March)
2001; pp248-257
Synthetic Grafts

The best scenario for the use of the synthetic

graft is when the
graft can be buried in soft tissue, such as in

extra-articular reconstruction.
This allows for collagen ingrowth and ensures

the long-term viability of the synthetic graft.

It will be sure to fail early if it is laid into a joint

bare, especially going around tunnel edges,

and is unprotected by soft tissue.
 Disadvantages
The main disadvantage is that all the long-term
studies have shown high failure rate. There is the
potential for reaction to the graft material with
synovitis, as seen with the use of the Gore-Tex graft.
With the Gore-Tex graft, there was also the increased
risk of late hematogenous joint infection.
The results that have been reported with the use of
the Gore-Tex
graft suggest that it should not be used for ACL
reconstruction.
Unacceptable failure rates have also been reported
with the use of the Stryker Dacron ligament and the
Leeds-Keio ligament.
` GRAFT FIXATION
Ultimate load to failure of femoral fixation
devices.
Mitek 600N
BioScrew 400N
Endo-button: tape 500N
BioScrew: Endo-pearl 700N
Bone mulch screw 900N
Cross pin 900N
Endo-button with closed loop tape 1300N
Interference Fit Screws

Advantages
Quick, familiar, and easy to use.

Direct bone to tendon healing, with Sharpeys fibers at the

tunnel
aperture.
Less tunnel enlargement.

Disadvantages

The disadvantages are as follows:

Longer graft preparation time.

Bone quality dependent.

Damage to the graft with the screw.

Divergent screw has poor fixation.

Removal of metal screw makes revision difficult

 Interference screw
Biodegradable

Metalic
Inteference Screw
Cross-Pin Fixation

Advantages
The advantages are as follows:

Strongest tested fixation.

May individually tension all bundles of graft.

Disadvantages
The disadvantages are as follows:

Pin may tilt in soft bone and lose fixation.

Steep learning curve of fiddle factor.

Special guides are required.

Transfix
Crosspin/transfix
Endobutton
The EB is a small oval button that anchors the graft against
the outer femoral cortex.
The Endobutton (EB) is the most widely used femoral fixation
device worldwide that is designed specifically for soft tissue
grafts.
Pioneered by Dr. Thomas Rosenberg and introduced around
1990, it was the first device specifically designed to hold soft
tissue grafts.
As originally designed, the surgeon would tie a Dacron tape
connecting the button to the tendon.
In the past 5 years, this technique has been largely
supplanted by use of the EB-CL (continuous loop), which
obviates the need to tie knots.
Due to the longevity of the device, there is a much greater
literature concerning it than any of the other newer, soft
tissuespecific devices.
ENDOBUTTON
Advantages
The Endo-button with closed loop tape is strong,

The plastic button is cheap, available and easy to

do
Disadvantages
Fixation site is distant with increase in laxity, with

the bungee cord effect.

Increased in tunnel widening.

Plastic button has low pullout strength, dependent

on the sutures
Endobuttom Loop
 Clinical Results
In the largest meta-analysis of anterior cruciate
ligament reconstruction (ACLR) autografts, the
EB-hamstring combination was found to have
the highest stability rates of any graft-fixation
construct when paired with modern tibial
fixation.Morbidity has been minimal.
 Milagro (Beta-Tricalcium Phosphate,
Polylactide Co-Glycolide Biocomposite)
The Milagro screw can be used for femoral or
tibial fixation for soft tissue or bonetendon
bone (BTB) autografts or allografts. It is
available in various diameters from 7 to
12mm and in 23-, 30-, and 35-mm lengths.
The Milagro screw is made from a polymer
composite, Biocryl Rapide.
 EZLoc Femoral Fixation of a Soft Tissue Graft
The EZLoc (Arthrotek, Warsaw, IN) is a cortical
femoral fixation device for a soft tissue anterior
cruciate ligament (ACL) reconstruction that combines
superior fixation properties (high resistance to
slippage, infinite stiffness, and 1427N strength) with a
simple surgical technique.
The EZLoc consists of a deployable lever arm
connected to an axle in a slotted body through which
the ACL graft is looped.
The EZLoc comes sterilely package with a sharp-tip
passing pin that is secured in the slotted body with a
suture tied under tension. The passing pin is passed
through the tunnels, the gold lever arm is positioned
lateral, and the soft tissue graft is looped through the
slot in the EZLoc.
Tibial Fixing Devices
Ultimate load to failure of tibial fixation devices.
Single staple 100N
Double staple 500N
Screw post 600N
Button 400N
RCI 300N
BioScrew 400N
BioScrew and button 600N
Intrafix 700N
Screw and washer 800N
Washer Loc 900N
One bundle or two bundle
ACL reconstruction
 What is an Anatomic ACL reconstruction?
Every person is different; some people are short,
others are tall. Similarly, each person has a
different size and shape of the ACL. In order to
properly reconstruct the ACL it is important to
reproduce each persons individual anatomy.

The goals of anatomic ACL reconstruction are to:

Restore 60 80% of normal ACL anatomy
Regain stability and return to pre-injury activity
level
Maintain long term knee health
 What is anatomic Double-Bundle ACL
reconstruction?
In a double-bundle ACL reconstruction, the

ACL is restored using two bundles. Just like

the normal ACL, there will be an AM and a PL
bundle.

In a single-bundle reconstruction, the ACL is

restored using one bundle. There are some
benefits of a double-bundle reconstruction,
when compared to a single-bundle
 Anatomic double-bundle reconstruction better
restores knee stability compared to single-
bundle reconstruction.

Because anatomic double-bundle

reconstruction uses two bundles to restore the
ACL, it allows for a replacement of a larger
size ACL
Pre requisite for single-
bundle/double-bundle
reconstruction
An ACL insertion site greater than 18 mm
allows for double-bundle reconstruction.
If the insertion site is less than 14 mm, there is

only space available for a single-bundle

procedure.
Between 14 18 mm, we can perform either

double- or single-bundle reconstruction.

Indications for single bundle
recon.
The patient is still growing and his or her
growth plate is not closed.
The patient has severe arthritis of the knee.

The patient has multiple knee ligament injuries

or a knee dislocation and multiple other

ligaments need to be reconstructed at the
same time.
The patient has bone that is severely bruised.

The patient has a small Intercondylarnotch.

 A prospective comparative cohort study was carried
out with 72 consecutive patients with chronic ACL
deficiency to compare three ACL reconstruction
procedures using hamstring tendon grafts.
The first 24 patients underwent a single-bundle
procedure using a six-strand hamstring tendon graft.
The next 24 patients underwent a nonanatomical
double-bundle procedure using four-strand and two-
strand hamstring tendon grafts.
The final 24 patients underwent the anatomical
double-bundle procedure using the same four-strand
and two-strand hamstring tendon grafts. All 72
patients underwent postoperative management with
the same rehabilitation protocol.There were no
significant differences among the background factors.
Conclusion
The postoperative anterior laxity measured

was significantly less after the anatomical

double-bundle reconstruction than after the
single-bundle reconstruction. Concerning the
results of the pivot-shift test
 Outcome of Arthroscopic Single-Bundle Versus
Double-Bundle Reconstruction of the Anterior
Cruciate Ligament: A Preliminary 2-Year
Prospective Study
Se-Jin Park, M.D., Young-Bok Jung, M.D., Hwa-
Jae Jung, M.D., Ho-Joong Jung, M.D., Hun Kyu
Shin, M.D., Eugene Kim, M.D., Kwang-Sup Song,
M.D., Gwang-Sin Kim, M.D., Hye-Young Cheon,
P.A., Seonwoo Kim, Ph.D.Received: December
29, 2008; Accepted: September 9, 2009;
Published Online: February 22, 2010
ArthroscopyVolume 26, Issue 5, Pages 630636,
May 2010
 113 were included in this study. They serially
obtained clinical and radiologic data
preoperatively and postoperatively. They
compared preoperative data and data at 2 years
postoperatively in patients who had undergone
single-bundle ACL reconstruction versus patients
who had undergone double-bundle ACL
reconstruction.
There were 50 single-bundle reconstructions and
63 double-bundle reconstructions. Anteroposterior
stability was assessed objectively by anterior
stress radiographs with the telos device (telos,
 Conclusions
Double-bundle reconstruction of the ACL by a

method using 2 femoral tunnel and 2 tibial

tunnels showed no differences in stability
results or any other clinical aspects or in terms
of patient satisfaction.
COMPLICATIONS
Skeletally immature patients
Anterior cruciate ligament injuries in skeletally
immature adolescents are being diagnosed
with increasing frequency.

Nonoperative management of midsubstance

ACL injuries in adolescent athletes frequently
results in a high incidence of giving-way
episodes, recurrent meniscal tears, and early
onset of osteoarthritis
 The concern about ACL reconstruction in the
athlete with open growth plates is that there
will be
premature fusion of the plate, growth arrest,
and potential for angular deformities.
Skeletally immature patients
Non surgical methods
or
surgical methods
Non surgical method
In some less active individuals with mild-to-

moderate instability, reduction of activity level

may be all that is necessary until they have
had an appropriate growth spurt and maturing
of the physes.
Muscle strengthening exercises

knee brace

Away from sports activities

TRANSEPIPHYSEAL REPLACEMENT OF
ANTERIOR CRUCIATE LIGAMENT
USING QUADRUPLE HAMSTRING
GRAFTS
The transepiphyseal replacement of anterior
cruciate ligament using quadruple hamstring
grafts
procedure described by Anderson is indicated in

patients in Tanner stage I, II, or III of development.

The procedure is contraindicated in patients in

Tanner stage IV of development, who can have

conventional anterior cruciate ligament
reconstruction
The tunnels are drilled centrally through the

epiphysis and fixed with a button on the periosteal

surface. There are no reported growth deformities
Anderson transepiphyseal replacement of
anterior cruciate ligament using quadruple
hamstring grafts
physeal-sparing, combined intraarticular
and extraarticular reconstruction of acl by Kocher,
Garg, and Micheli
Anterior Cruciate Ligament Reconstruction
in Skeletally Immature Patients With
Transphyseal Tunnels
Lauren H. Redler, M.D., Rebecca T. Brafman,
B.A., Natasha Trentacosta, M.D., Christopher S.
Ahmad, M.D.(Department of Orthopaedic Surgery,
Columbia University Medical Center, New York,
New York, U.S.A.)
Arthroscopy Volume 28, Issue 11, Pages 1710
1717, November 2012
Moises Cohen, M.D., Ph.D., Mario Ferretti, M.D.,
Ph.D., Marcelo Quarteiro, M.D., Frank B.
Marcondes, M.D., Joo P.B. de Hollanda,
M.D., Joicemar T. Amaro, M.D., Rene J. Abdalla,
M.D., Ph.D.(Orthopedic Sports Medicine Division,
Department of Orthopaedic Surgery and
Traumatology, Universidade Federal de So
PauloEscola Paulista de Medicina, So Paulo,
Brazil)
Conclusions
ACL reconstruction by use of the transphyseal

technique in an immature skeleton with a

hamstring autograft, with careful attention
being paid to the technique, resulted in good
clinical outcomes and no growth abnormalities.