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RUPTUR LIGAMEN

(ACL)
Insidensi
400.000 rekonstruksi ACL/tahun
wanita : pria = 4.5 : 1
Biasanya sering berhubungan dengan ruptur meniskus (50% ruptur
meniskus lateral)
ACL kronis
Cedera sendi
Robek meniskus yang kompleks
ANATOMI
Fungsi
Memberikan 85% dari stabilitas untuk mencegah proses pergerakan
anterior dari tibia ke arah femur.
Berperan sekunder sebagai kontrol rotasi tibia dan rotasi varus
maupun valgus
Anatomi
Ukuran 33mm x 11mm
Goes from LFC to anterior tibia
Two bundles
Anteromedial bundle (more isometric, tight in flexion)
Posterolateral bundle (tightest extension where it likely
contributes greatest to rotational stability)
Blood supply: middle geniculate artery
Innervation: posterior articular nerve (branch of tibial nerve)
Composition: 90% type I collagen &10% type III collagen
Strength: 2200 N (anterior)
MANIFESTASI KLINIS
Presentation
felt a "pop"
Deep pain in knee
immediate swelling (70%) / hemarthrosis
Physical exam
Lachman's test most sensitive exam test
grading
A= firm endpoint, B= no endpoint
Grade 1: < 5 mm translation
Grade 2 A/B: 5-10mm translation
Grade 3 A/B: > 10mm translation
PCL tear may give "false" Lachman due to posterior subluxation
Pivot shift
extension to flexion: reduces at 20-30 of flexion
patient must be completely relaxed (easier to elicit under
anesthesia)

mimics the actual giving way event

Lachmans test & Anterior


Drawer Test

RADIOGRAFI
Radiographs
Usually normal
Segond fracture (avulsion fracture of the proximal lateral tibia) is a
pathognomonic for an ACL tear
MRI
ACL tear best seen on sagittal view
Bone bruising occurs in more than half of acute ACL tears
Middle 1/3 of LFC (sulcus terminalis)
Posterior 1/3 of lateral tibial plateau
Subchondral changes on MRI can persist years after injury

TATALAKSANA
Nonoperative
Physical therapy & lifestyle modifications
Operative
ACL reconstruction
Indications: younger, more active patients, children, older active
patients, Prior ACL reconstruction failure
Associated injuries:
MCL injury: allow MCL to heal (varus/valgus stability) and
then perform ACL reconstruction, varus/valgus instability
can jeopardize graft
Meniscal tear: perform meniscal repair at same time as
ACL reconstruction, increased healing rate when repaired
at the same time as ACL
Posterolateral corner injury: reconstruct at the same time
as ACL or as 1st stage of two stage reconstruction
Ligament repair: high failure rate
Revision ACL reconstruction, indications: failure to prior ACL
reconstruction
Femoral tunnel placement
Tibial tunnel placement
Graft placement
High tibial osteotomy
Revision ACL reconstruction
Graft Selection:
Bone patellar bone autograft
Quadruple hamstring autograft
Allograft
Quadriceps tendon autograft
REHABILITASI
Early postoperative
immediate
aggressive cryotherapy (ice)
immediate weight bearing (shown to reduce patellofemoral pain)
emphasize early full passive extension (especially if associated
with MCL injury or patella dislocation)
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

Injury prevention
female athlete
neuromuscular training / plyometrics (jump training)
land from jumping in less valgus and more knee flexion
increasing hamstring strength to decrease quadriceps
dominance ratio
skier training
teach skiers how to fall
ACL bracing
no proven efficacy except for ACL-deficient skiers
KOMPLIKASI
Failure due to Tunnel Malposition
Infection
septic arthritis
Staph aureus most common
Presentation: pain, swelling, erythema, and increased WBC at 214 days postop
Treatment: perform immediate joint aspiration with gram stain
and cultures
treatment
immediate arthroscopic I&D
often can retain graft with multiple I&Ds and abx (6 weeks
minimum)
Loss of motion & arthrofibrosis
Infrapatellar contracture syndrome
Patella Tendon Rupture
Patella fracture
Hardware failure
Tunnel osteolysis
Late arthritis
Local nerve irritation