ACL

RECONSTRUCTION
Reported by:
ELAZEGUI, Christopher Algen E.
UY, Elizabeth Jane
YENOGACIO, Ellerine Joy C.
 MEDICAL
BACKGROUND

2
DEFINITION
▪ A key stabilizing ligament in the knee.
▪ It prevents the shin bone from sliding out in front of
the thigh bone.
▪ Anterior cruciate ligament is the most frequently
and completely disrupted ligament in the knee.
(Brotzman, p.211)
3
4
CLINICALLY
RELEVANT ANATOMY

5
The anterior cruciate ligament runs
diagonally in the middle of the knee.
It prevents the tibia from sliding out
in front of the femur, as well as
provides rotational stability to the
knee.

6
o Collateral Ligaments
o They control the sideways motion of your knee and brace it
against unusual movement.
o Cruciate Ligaments
o Comes from the Latin word “crucere” (cross) because they
cross each other The cruciate ligaments control the back
and forth motion of your knee.
o Meniscus
o Shock absorber, lubrication, increasing the concavity of
the tibia & they play a role in stabilizing the knee

7
o Four main ligaments connect these two bones:
o Medial collateral ligament (MCL)
o Runs along the inside of the knee.
o It prevents the knee from bending in.

o Lateral collateral ligament (LCL)

o Runs along the outside of the knee.
o It prevents the knee from bending out.

8
o Anterior cruciate ligament (ACL)
o It is in the middle of the knee.
o It prevents the shin bone from sliding out in front of the
thigh bone.

o Posterior cruciate ligament (PCL)

o Works with the ACL. It prevents the shin bone from sliding
backwards under the femur.

9
10
ETIOLOGY
o Changing direction rapidly
o Stopping suddenly
o Slowing down while running
o Landing from a jump incorrectly
o Direct contact or collision, such as a football tackle

11
EPIDEMIOLOGY
o F>M
o Women being two to eight times more likely to sustain an ACL injury
than men participating in the same sports , and is thought to be due to
the following reasons:
o Smaller size and different shape of the inter-condylar notch
o Wider pelvis and greater Q angle
o Greater ligament laxity
o Shoe surface interface
o Neuromuscular factors
o ACL size
o Muscular strength and muscular activation patterns
o Hormonal influence 12
o A wider pelvis requires the femur to have a greater angle
towards the knee, lesser muscle strength provides less knee
support, and hormonal variations may alter the laxity of
ligaments.
o The 15 to 45 years age group is at highest risk. Injuries occur
primarily among active people, especially in sports involving
cutting, pivoting, and decelerating (e.g., soccer, basketball,
skiing) or contact (e.g., football).

13
 100,000
More than 100,000 ACL reconstruction are performed
annually in the United States.

14
o About 70% of ACL tears occur during sports activities. In
children, falling off of a bike while trying to plant the ipsilateral
foot is a common mechanism of ACL avulsion from the tibial
eminence.
o About 80% of sports-related ACL tears are noncontact
injuries, occurring during pivoting maneuvers or landing from
a jump. Noncontact ACL injuries are more common in females
than in males. Only 60,000 individuals with ACL deficiency
actually undergo reconstruction annually.

15
o ACL tears result from a player decelerating and pivoting on a
partially extended knee or from a direct blow that produces a
valgus and external rotation force on a planted leg.
o ACL injury often results in long-term problems, such as
subsequent meniscal injuries, failure of secondary stabilizers,
and development of osteoarthritis.
o “Risk for OA – 60% - 90% within 10 years.” (Andersson et al. 2009)

16
RISK FACTORS
o MODIFIABLE : o NON-MODIFIABLE:
o Proprioception o Gender
o Core strength o Reduced femoral inter-
o Decreased hamstring condylar notch size
strength o Increased slope of tibial
o Conditioning plateau
o Footwear o Knee hyperextension
o Playing surface o Physiological rotatory
o Training techniques laxity
o Small ACL size
o Familial predisposition 17
CLINICAL MANIFESTATION
o Feeling or hearing a “pop” sound in the knee
o Loss of full range of motion
o Discomfort while walking
o Severe pain and inability to continue activity
o Swelling that begins within a few hours
o A feeling of instability or "giving way" with weight bearing

18
MECHANISM OF INJURY
o The typical ACL injury occurs with the knee externally rotated
and in 10–30° of flexion when the knee is placed in a valgus
position as the athlete takes off from the planted foot and
internally rotates with the aim of suddenly changing direction.
o Majority of tears occur in a noncontact manner.
o Landing from a jump, pivoting or decelerating suddenly.
o Hyperextension of the knee.

19
PROGNOSIS
o ACL reconstruction decreases the incidence of meniscal injury
that requires meniscectomy. Normal kinematics are not
restored. Osteoarthritis levels are thus reduced by the meniscal
preservation associated with the reconstruction; however,
these levels of osteoarthritis are not eliminated. Bone bruising
may also play some role in the on going incidence of
osteoarthritis following reconstruction.

20
GRADES OF INJURY

Grade 1 Sprain Grade 2 Sprain Grade 3 Sprain

21
GRADES OF INJURY
o Grade I Sprain:
o The fibers of the ligament are stretched but there is no
tear.
o There is a little tenderness and swelling.
o The knee does not feel unstable or give out during
activity.
o No increased laxity and there is a firm end feel.

22
GRADES OF INJURY
o Grade II Sprain:
o The fibres of the ligament are partially torn or incomplete
tear with haemorrhage.
o There is a little tenderness and moderate swelling with
some loss of function.
o The joint may feel unstable or give out during activity.
o Increased anterior translation yet there is still a firm end
point.
o Painful and pain increase with Lachman's and anterior
drawer stress tests.
23
GRADES OF INJURY
o Grade III Sprain:
o The fibres of the ligament are completely torn (ruptured); the
ligament itself has torn completely into two parts.
o There is tenderness but not a lot of pain, especially when compared
to the seriousness of the injury.
o There may be a little swelling or a lot of swelling.
o The ligament cannot control knee movements. The knee feels
unstable or gives out at certain times.
o There is also rotational instability as indicated by a positive pivot
shift test.
o No end point is evident.
o Haemarthrosis occurs within 1-2 hours 24
GRADES OF INJURY

25
DIFFERENTIAL
DIAGNOSIS
26
Patellofemoral Syndrome
o Age: 20-50 y/o
o Mechanism of injury: Gradual
o Area of symptoms: Anterior knee
o Aggravated by symptoms:
o Prolonged sitting
o Kneeling
o Observation: Positive soft tissue thickening/ Swelling at
anterior knee
27
Patellar Tendinitis
o Age: 15-50 y/o
o Mechanism of injury: Gradual (repeated eccentric
overloading during deceleration activities
o Area of symptoms: Anterior knee
o Aggravated by symptoms:
o Squatting
o Jumping
o Observation: Usually unremarkable
28
Quadriceps Muscle Tear
o Age: 20-40y/o
o Mechanism of injury: Sudden overload
o Area of symptoms: Anterior thigh
o Aggravated symptoms:
o Squatting
o Observation:
o Possible bruising over anterior thigh/knee
o Possible swelling over anterior thigh/knee
29
Knee Osteoarthritis
o Age: 50+
o Mechanism of injury: Gradual due to microtrauma
o Area of symptoms: Generalized knee
o Aggravated by symptoms: Weight bearing
o Observation:
o Possible soft tissue thickening
o Swelling around knee

30
Collateral Ligament Injury
▪ Age: Varies
▪ Mechanism of injury: Trauma to contralateral aspect of knee
(Valgus or Varus)
▪ Area of symptoms: Distal femur on medial or lateral aspect
depending on whether MCL or LCL is involved
▪ Aggravated by symptoms:
□ Varus Stress (LCL)
□ Valgus Stress (MCL)
▪ Observation:
▪ sSwelling may be present depending on extent of trauma 31
Prepatellar Bursitis
o Age: 15-50y/o
o Mechanism of injury: Direct trauma to anterior aspect of knee
o Area of symptoms: Anterior knee
o Aggravated by symptoms:
o Kneeling
o Observation:
o Local swelling
o Fuctuation
32
Patellar
subluxation/dislocation
o Age: Varies
o Mechanism of injury: Twisting injury with the femur internally
rotating on a fixed foot, although there may be no history of
trauma
o Area of symptoms: Varies according to tissues involved
o Aggravated by symptoms:
o Weight bearing
o Observation:
o Depending on the degree of trauma 33
Diagnostic Procedures
o X-rays
o X-rays may be needed to rule out a bone fracture. However,
X-rays can't visualize soft tissues, such as ligaments and
tendons.
o Notch width index
o Osteochondral fracture
o Segond fracture
o Bone bruise

34
Diagnostic Procedures
▪ Magnetic resonance imaging (MRI)
□ An MRI uses radio waves and a strong magnetic field to
create images of both hard and soft tissues in your body. An
MRI can show the extent of an ACL injury and signs of
damage to other tissues in the knee.
▪ Ultrasound
□ Uses sound waves to visualize internal structures,
ultrasound may be used to check for injuries in the
ligaments, tendons and muscles of the knee.
35
FUNCTIONAL ASSESSMENT
o Single hop for distance
o Triple crossover hop for distance
o One leg rise
o 6 metre timed hop
o Battery of hop tests

36
OUTCOME MEASURES
o KOOS
o SF-36
o Tegner activity level scale

37
38
39
40
41
42
MANAGEMENT
Acute Phase
A. Reduction of Joint Swelling
o Ice Compression
o Haemarthrosis Aspiration
B. ACL Reconstruction (Surgery)
o Not Advisable within the first 3 weeks
o Rationale: ↑ Incidence of graft arthrofibrosis
o Alternative Mgt: Aggressive nonsurgical rehabilitation program
C. Isometric co-contractions of quadriceps and hamstrings
D. Protected weight-bearing
E. Avoidance of knee hyperextension. 44
Post-Operative Phase (ACL
Reconstruction)
o Rehabilitation Goals (Weeks 0-4):
A. Pain Control
o Rationale: Maximization of effort in rehabilitation
B. Rapid Reduction of Effusion
o Management:
o Continuous Passive Motion (CPM)
o Done even at home ( Patient instruction on
correct use prior to hospital discharge ).
o Compression, Ice, and elevation 45
C. Prevention of Extension Block Development
o Management: Electrical stimulation of quadriceps
o Rationale: Prevention of quadriceps atrophy
D. Improvement of flexion to 90 degrees by weeks 3-4
o Management:
o Weight bearing in extension while wearing an
immobilizer.
o Passive Stretching
o Procedure: Prone position with towel beneath the knee while
wearing an ankle weight
o Indication: Swelling inhibition to full extension
o Bicycle exercise without resistance
46
E. Promotion of wound healing and mobilization of adhesions
o Management: Patellar soft tissue mobilization
F. Activation of quadriceps mechanism
o Management: Crutch Walking
o Progression: 2 crutches with partial weight bearing → 1
crutch → (-) crutch by the end of the first month

47
G. Initiation of closed kinetic chain exercises
o Effect: Promotion of lower extremity strength
o Contraindicated Movements: “Hyperextension and
Dynamic pivot shifting”
H. Maintenance of general cardiovascular conditioning and
strength
o Management:
o Arm ergometry
o Tri-limbed exercises
o Jogging
48
 1st- 2nd Month
o Rehabilitation Goals:
o Further increase in hip ROM
o Abduction
o Adduction
o Extension
o Restoration of baseline hamstring and quadriceps strength.
o Improvement of cardiovascular condition
o Management: Stationary bike
o Contraindication: Knee hyperextension
o Progression: Bike → cross-country ski machine, stair
climber, or slide board
o Progression of functional activities 49
2nd-3rd Month
o Management:
o Unidirectional jogging
o Functional Bracing with derotation brace
o Indication: Once thigh circumference approximates
the size of the uninvolved limb
o Agility Drills
o Jumping rope
o Lateral shuffling around cones

50
Return to full sporting and
occupational activities
o Requirements:
o 90% (or better) strength of quadriceps, hamstring,
and prime movers of the hip in comparison with the
uninvolved limb.
o (-) Clinical pivot shifting

51
 ANTERIOR CRUCIATE
LIGMENT RECONSRUCTION

52
ACL RECONSTRUCTION
▪ Surgical treatment
 Is a surgical tissue graft replacement of the anterior cruciate
ligament, located in the knee, to restore its function after an
injury.
 The torn ligament is removed from the knee before the graft is
inserted in an arthroscopic procedure.
 The aim of an ACL reconstruction is to replace the torn ACL
with a graft that reproduces the normal kinetic functions of
the ligament.
53
INDICATIONS FOR ACL
RECONSTRUCTION
o Disabling instability of the knee due to ACL deficiency caused
by a complete or partial acute tear or chronic laxity.
o Frequent episodes of the knee giving way (buckling) during
routine ADL as the result of significantly impaired dynamic
knee stability despite a course of non-operative management.
o A positive pivot-shift test because an ACL deficit is often
associated with a lesion of other structures of the knee, such
as the MCL, resulting in rotatory instability of the joint.
54
INDICATIONS FOR ACL
RECONSTRUCTION
o Injury of the MCL at the time of ACL injury to prevent lax
healing of the MCL
o High risk of re-injury because of participation in high demand,
high joint-load activities related to work, sports, or
recreational activities

55
CONTRAINDICATIONS FOR
ACL RECONSTRUCTION
o Relatively inactive individuals with little to no exposure to work,
sport, and recreational activities that place high demands on the
knee
o Ability to make lifestyle modifications to eliminate high-risk
activities
o Ability to cope with infrequent episodes of instability

56
CONTRAINDICATIONS FOR
ACL RECONSTRUCTION
o Advanced arthritis of the knee
o Poor likelihood of complying with postoperative restrictions and
adhering to a rehabilitation program

57
Once the diagnosis is made, the
decision on whether to opt for
initial conservative or surgical
management is dependent on a
number of factors:

58
o Age of the patient
o Degree of instability
o Associated abnormalities (e.g. MCL tear, meniscal tear)
whether or not the patient performs pivoting sports.
o Patient’s occupation (e.g. fire fighter, police)
o Social factors such as cost of treatment or time off work

59
SURGICAL PROCEDURE
o ACL reconstructions were originally performed via an arthrotomy
(opening the knee capsule with a surgical incision). With the
advance of arthroscopic techniques, ACL reconstructions are now
performed ‘arthroscopically aided’ through a small incision with
arthroscope.

60
SURGICAL PROCEDURE
o The most common graft s used are:
o Bone–patellar tendon–bone (BPTB) autograft involving the
central third of the patellar tendon (GOLD STANDARD)
o Hamstring (semitendinosus +/– gracilis tendons) graft

61
BPTB vs HAMSTRING AUTOGRAFT

62
SURGICAL PROCEDURE
o Other graft options include allografts (the transplantation of
cadaver tissue such as ligaments or tendons).
o Allografts have been used successfully for many years
and are associated with decreased morbidity and
patients’ return to their daily activities more quickly.
o It has been suggested that allograft s may also be
associated with earlier return to sport, however,
there is little evidence to support this theory.

63
THE TIMING OF ACL
RECONSTRUCTION
o ACL reconstructions were performed as soon as practical
after the injury.
o However, there is evidence that delaying the surgery may
decrease the post-operative risk of arthrofibrosis
o Initial reports suggested three weeks as the appropriate delay
in surgery

64
THE TIMING OF ACL
RECONSTRUCTION
o More important than a specific time is the condition of the
knee at the time of surgery.
o The injured knee should have little or no swelling, have near
full range of motion, and the patient should have a normal
gait.

65
REHABILITATION AFTER
ACL RECONSTRUCTION
o Traditional methods of management after ACL reconstruction
included a lengthy period of non weight-bearing and knee
immobilization.
o This program led to weakness and stiff ness around the
knee joint with impaired proprioception and poor function.

66
REHABILITATION AFTER
ACL RECONSTRUCTION
o Present rehab method: principle of complete immobilization
has been replaced with protected mobilization
o Earlier commencement of a strengthening program and
rapid progression to functional exercises
o The average time for rehabilitation after ACL
reconstruction to return to sport has been reduced from
around 12 months to six to nine months
67
PROBLEMS ENCOUNTERED
DURING ACL REHABILITATION
o A part from surgical complications (e.g. infection, deep venous
thrombosis), a number of secondary problems may occur
during the rehabilitation process.
o Patellofemoral problems
o Inferior displacement of the patella
o Patellofemoral pain
o Low back pain
68
PROBLEMS ENCOUNTERED
DURING ACL REHABILITATION
o Lower limb stiffness
o Occurs as a result of a period of non-weight-bearing and
the wearing of a brace.
o MC: Tightness of the Achilles tendon
o Soft tissue stiffness (arthrofibrosis)
o Patients with stiff soft tissues may develop a large bulky
scar with adhesions after ACL reconstruction.
69
PROBLEMS ENCOUNTERED
DURING ACL REHABILITATION
o Soft tissue laxity
o Characterized by generalized increased ligamentous
laxity.
o Range of motion exercises are discouraged,
mobilization contraindicated and full extension work
reduced to avoid stretching the graft .

70
MANAGEMENT
PROTOCOLS

71
72
73
PREVENTION PROGRAMS
o Balance training
o Landing with increased flexion at the knee and hip
o Controlling body motions, especially in deceleration and
pivoting maneuvers
o Some form of feedback to the athlete during training of these
activities.

74
END OF
REPORT

75