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The causes effects and management of anterior crucial ligament acl injuries

Edited By Albert O. January 24, 2013 Overview Tears or 'ruptures' of the anterior cruciate ligament ACL are common injuries in athletes of different ages and activty levels. ACL tears are treatable using arthroscopy and minimally-invasive surgical techniques. The anterior cruciate ligament is one of the major supportive ligaments in the knee. It extends from the lower leg bone tibia to the thigh bone femur at the knee.

This ligament provides knee stability by preventing excessive forward movement of the tibia in relation to the femur and is also important in controlling rotation of the two bones. ACL tears most commonly result during athletics from vigorous cutting, landing, deceleration or twisting injuries. It is less common for ACL tears to occur as a result of physical contact or collisions during athletics.

The joint will typically swell within several hours which results in restricted motion of the knee. It will become uncomfortable to bear weight on the injured leg, and the patient will prefer to walk with assistive devices for added support, such as crutches or a cane. Currently, advanced surgical techniques reliably allow the return to athletic activities and physically demanding labor within 6 to 9 months.

The goals of surgically reconstructing the ACL are to decrease the time lost to the injury, avoid additional injury to the knee, and to return to unlimited participation in functional and athletic activities. There are many different ways that the ACL can be reconstructed, and depending on the age, activity level, gender, and expectations of the patient.

Click to Enlarge Figure 1a - Drawing of a right knee as viewed from the front. The ACL helps to prohibit abnormal forward motion of the tibia under the femur. Click to Enlarge Figure 1b - Arthroscopic view into the right knee. The metal probe sits across a normal-appearing ACL. Click to Enlarge Figure 2 - Clockwise from upper left: Diagram of the right knee.

Arthroscopic view of a chronically ACL-deficient knee. Arthroscopic view of the ACL reconstructed with a hamstring autograft. Direct contact forces, such as those experienced in a motor vehicle accident, can cause ACL disruption.

However, the ACL is most commonly injured by indirect, noncontact mechanisms such as vigorous cutting, landing, or twisting motions. An example of this would be an athlete who suddenly decelerates from running and makes a sharp cutting motion or when a skier catches their ski edge in the snow causing a rotational force at the knee.

Usually within the first few hours after the injury, the knee will become significantly swollen and the range of motion will typically decrease due to the limiting effects of pain and swelling. The ACL is contained within the joint and covered with a thin layer of tissue synovium. This synovial tissue is in contact with synovial joint fluid in the knee.

  • Essentials of Musculoskeletal Care;
  • January 24, 2013 Overview Tears or 'ruptures' of the anterior cruciate ligament ACL are common injuries in athletes of different ages and activty levels;
  • This success is seen in patients who can participate in not only daily life activities but also in demanding physical activities such as competitive sports;
  • However, there are theoretical risks of disease transmission from the donated tissue;
  • The joint is unstable;
  • Effectiveness In the hands of an experienced surgeon, arthroscopic ACL reconstruction no matter what graft is used or what technique is usually very effective at eliminating instability and restoring comfort and function to the knee of a well-motivated patient.

In order for healing to occur, a collection of blood must form and clot around the ligament, but once the ligament and synovial tissue are torn, the ligament will be bathed in synvoial joint fluid. In addition, even with a partially torn ligament, the mechanical function of the knee may be altered after an ACL tear such that the normal path of motion of the knee is altered like a swing with one of the chains broken.

It is very difficult for the ligament to resume a normal length and function in this setting. Types ACL injuries can be classified by the amount of damage to the ligament partial or complete disruption. Grade I Sprain - There is some stretching and micro-tearing of the ligament. The ligament is intact. The joint remains stable. These injuries rarely require surgery.

The ligament is partially disrupted. The joint is moderately unstable. Depending on the activity level of the patient and the degree of instability, these tears may or may not require surgery. The ligament is completely disrupted. The joint is unstable. Surgery is usually recommended in young or athletic persons who engage in cutting or pivoting sports. Additionally, injury can be classified by the presence or absence of associated damage to other structures in the knee isolated or combined.

Combined injuries may involve damage to the menisci, stabilizing collateral ligaments, or other knee structures. Additionally, this structure helps stabilize the knee. A meniscus tear typically occurs with twisting motions such as pivoting.

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Traumatically, this ligament is commonly injured by striking the upper tibia, causing the tibia to move backwards, thereby stretching or tearing the PCL. An example of this would be striking the upper tibia on the dashboard during an automobile accident. In athletics, a PCL will tear during a hyperextension or extreme hyperflexion injury like falling onto the shin with the knee bent and foot pointed. MCL - The medial collateral ligament provides stability to the inside aspect of the knee.

This ligament is commonly injured when a medially inward directed force is applied to the outside of the knee, forcing the knee to twist in and the foot to twist out. Injury to this structure is common, but if it is an isolated partial disruption injury then it can typically be treated with physical therapy and bracing. LCL - The lateral collateral ligament imparts stability to the outside aspect of the knee.

  • Injury to this structure is common, but if it is an isolated partial disruption injury then it can typically be treated with physical therapy and bracing;
  • Allografts have a slightly higher re-rupture rate than BPTB, hamstring, and quad tendon graft.

Isolated LCL injuries are infrequent, but when injured it is commonly due a lateral outside force applied to the inside of the knee.

Similar conditions ACL injuries are usually not subtle and most individuals will know exactly when the injury occurred.

There are conditions in the knee that can mimic a sense of instability, some operative and others non-operative: This problem can frequently be treated non-operatively after the kneecap is re-located. In cases where the problem recurs, surgery may be warranted. This problem is almost always treated non-operatively. This injury is particularly common in athletic individuals who participate in sports that involve twisting, cutting, jumping, and sudden decelerations.

These activities overload the strength and stability of the ligament, leading to an ACL tear. This injury is predominant in female athletes. It is believed that women are at greater risk than men because anatomical differences put the female knee at a mechanical disadvantage.

Additionally, hormones may play a role in ACL injuries in women. The change in hormone levels may influence the amount of laxity looseness in the ACL which predisposes it to disruption. Diagnosis The diagnosis of ACL injuries can usually be accurately diagnosed by clinical examination of the knee. A skilled examiner can usually evaluate the knee joint in a painless manner and discern if the ACL has been injuried. Magnetic resonance imaging MRI is a painless study that will give an extraordinary amount of information in regards to the degree of injury to the ACL partial versus completethe location of the tear within the ligament, and if there are any associated injuries in the joint isolated versus complex.

However, some medications such as non-steroidal anti-inflammatory drugs NSAIDs will help ease the pain or symptoms related to the meniscus deficient knee. For any medications taken, patients should be aware of: The risks associated with the medication The possible interactions with other drugs The recommended dosage The cost Exercises After visiting the orthopedic physician, it might be advised that the patient meet with a physical therapist to increase the knee range of motion, decrease the amount of swelling, and maintain muscle control.

Physical therapy and at home exercises will become part of the patients daily routine, whether the patient has the ACL reconstructed or not.

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In rare cases or in sedentary individuals, there may be a role for non-operative treatment and rehabilitation. Non-operative treatment should be considered in: The overwhelming majority of patients who undergo arthroscopic ACL reconstruction to address knee instability will have a successful result. This success is seen in patients who can participate in not only daily life activities but also in demanding physical activities such as competitive sports.

Who should consider arthroscopic anterior cruciate ligament acl reconstruction? Arthroscopic ACL reconstruction is considered when: This will essentially lead to osteoarthritis by roughening the joint surfaces, adding additional forces to the menisci and thereby damaging this tissue. Other stabilizing ligaments in the knee will be stressed as they compensate for additional forces that the intact ACL would typically act against. Click to Enlarge Figure 3 - Arthroscopic view of a right knee.

Several years after a tear, the ACL has almost completely resorbed from the knee. Click to Enlarge Figure 4 - Bone-patellar tendon-bone graft. Left, the graft is harvested from the patellar tendon. Middle, the graft has bone 'plugs' at each end. Right, the bone plugs are docked into the femur and tibia. The patellar tendon becomes the ACL arrow.

Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention

Click to Enlarge Figure 5a - Schematic drawing top and intra-operative photograph bottom of a prepared quadrupled hamstring autograft.

What happens without surgery?

Arthroscopic ACL

For individuals who choose to not have surgery, rehabilitation of the injured knee is frequently recommended. Rehabilitation will focus on strengthening the muscles around the knee in order to provide better support, control, and stability. There is nothing inherently dangerous about a mildly unstable knee so long as the patient is able to be adequately braced and willing to use appropriate assistive devices cane, crutch, or walker that will prevent falls or further injuries.

This may require significant changes in lifestyle and activities to reduce the risk of instability events. For instance, an individual may have to avoid activities such as basketball or soccer and participate in non-impact activities such as biking or swimming for fitness. The goal is for patients to find activities where the knee feels stable and is pain free.

A minority of patients will continue to have instability to the degree that they are unable to walk or put weight on the extremity without it buckling on them. These persons are best served by surgery to stabilize the knee and restore function. With or without surgery, a knee that has an ACL injury is at risk to develop osteoarthritis in the knee over time.

Even a perfectly performed surgery cannot restore absolutely ideal knee kinematics. However, the arthritis usually takes years to develop if the mechanics of the knee are optimized.