ACL Injuries

Current Concepts WORLD CUP 2006

for Medical students &
ENGLAND Vs SWEDEN
Physiotherapy Students
Dr. Patrick Shu-Hang, YUNG
Email: patrick@ort.cuhk.edu.hk

President Sports Medicine Chapter, Hong Kong Orthopaedic Association (HKOA-SMC)

President Hong Kong Association of Sports Medicine & Sports Science (HKASMSS)
(HKASMSS)

Honorary Consultant in Sports Medicine, Hong Kong Sport Institute

Chairman, Liaison Commission, International Federation of Sports Medicine (FIMS)

Torn ACL ends Owen's

World Cup with England Extent of the problem
Updated: June 21, 2006
BADEN-
BADEN-BADEN, Germany (AP) -- Michael Owen will miss the rest of
the World Cup after tearing the anterior cruciate ligament in his right knee.
1,6-
1,6-1,9 miljon in the US consulted a physician for
a knee sprain each year
The England striker was injured Tuesday in the second minute of his team's 2-
Sweden in Cologne. Owen had a scan on his knee Wednesday near England's
2-2 draw with
England's team base in
Incidence for ACL tear is 1 /3000 individuals/year
southern Germany and was to return home later in the day. 150.000 ACL and 45000 ACL/MCL injuries in the
"Obviously it's a massive blow to suffer the injury -- and be out of the World Cup," Owen
US annually
said in a statement. "As soon as it happened I knew I was in trouble.
disappointment to pick up the injury so early in the game."
trouble. It was a major Total cost for treatment alone is estimated to one
billion US dollars a year
Owen's right knee buckled after he played a pass. He rolled off the field and lay on the
sideline clutching his leg while play continued. He was treated by doctors and then
strapped to a stretcher and taken away. Conclusion:
The English Football Association said Owen's recovery would be handled
handled by his English ACL injury is the most common cause for long
Premier League club Newcastle. Freddy Shepherd, the club's chairman,
chairman, said Owen had
ruptured the ligament, but it was "too early to say how long he will be out for, although it is
term problems for an athlete
a serious injury."

Michael Owen took 9 months to recover from ACL injury

Major problem in contact sports

One problem is the fact that there

are more ACL injuries in women

Epidemic ? than men in team sports

Team handball 5 -fold increase

Incidents Soccer 3-
Basketball
Increasing
3-

Pivoting Sports ? Notch-Size Mycklebust 1998, Arndt 1999

? Landing Postion ? Hormnal Factor

 263 ACL Injury
1996
1996

198
19875.29%
75.29%
is very
88
88
62
62
common !!!
18
18

8
8
207.6%
20
7.6%
3513.3%
35
13.3%

Active Patient Macroscopic anatomy

- Two bundles :
High Expectation Antero-
Antero-medial bundle (AMB):
Postero-
Postero-lateral bundle (PLB):

Michael Owen Cheng Ka Ho Strain and length increase during passive flexion

PL P
L

AM
AM

AM bundle initially shortens

until 30 of flexion, and then
gradually elongates until
maximum at 120. INJURY MECHANISM
Internal/external rotation
lengthens the ACL only a little
more, most noticeably at 30.

(Aims and Dawkins, 1991,

JBJS73-B:260-7)
 Injury Mechanism analysis Basketball ACL injury-landing

Krosshaug et al., 2006 (in press)

The 3D motion reconstruction Knee kinematics visualized

Injury mechanism - Plant and cut Pivoting injury:

Valgus, Semi-
Semi-flexion, Rotation
Semi-flexion,
Foot planted and
firmly fixed to the floor
Push-
Push-off knee injured
Knee position:
Knee nearly straight
(5- 20)
(5-20
All in valgus (5-20)
(5-20
Some rotation: in or
out
Similar results for
landing Olsen, Myklebust, Engebretsen & Bahr. Am J
Sports Med 32: 1002-
1002-1012, 2004
Sports that require : Injury mechanism and
Pivoting biomechanical risk factors
Jumping In 100% of male basketball players and 50% of female
Abrupt change ACL injuries occur during landing after a jump
in direction The other 50% were injured during sudden stops along
Body contact the sideline
Center of gravity was behind the knee in 2/3 of the
injuries (Griffin et al J Am Acam Orthop Surg 2000)

Warning Features

Intensive pain
Progressive increase swelling
Significant Decreased ROM
Feel a Pop
Cannot continue to play

Acute Acute Signs

Symptoms

ACL tear in
75% of
haemarthrosis
 Diagnosis
History taking
Physical Examination
Imaging
Radiographs
Radiographs MRI

MRI

ACL Clinical Examination

Anterior Drawer Test Lachman Test

MRI features of torn ACL

What the next step
after suspecting
ACL injury?

A wavy ACL
 Arthroscopy of Knee
Non-surgical Treatment

Physical therapy
Full range of motion
Muscle strength
Proprioception
Change the Activity
?? Knee Brace
Normal & Torn ACL

ACL-Conservative therapy Repeated ACL Injury

May give satisfactory results if the injured is willing to
modify lifestyle and
accept some instability and
increased risk for meniscus & cartilage injury

Problems:
Many non-
non-operated patients developed osteoarthritis
Patients cannot perform in sports
with cutting and twisting activities

Reasons for not having surgery

ACL Background
information
Ho Ka Lai, female
Fencing Player,
Former representative
Meniscus Articular of Hong Kong

Cartilage Medal Holder of Asian

Games
Left knee ACL and
MCL injury
 BRACE
BRACE forfor
Outcomes of non-surgical treatment
ACL
ACL deficient
deficient
Knee
Knee

ACL Primary repair

When using the brace the subjects in the brace group experienced
less sense of instability (P = 0.047) than the control group.

However, bracing had no effect on any of the variables in Knee

Osteoarthritis Outcome Score or Cincinnati knee score and no effect
on quadriceps or hamstring muscle peak torque.

POOR HEALING POTENTIAL

Operative treatment for torn ACL

Pre-op Assessment
- GOLDEN STANDARD
 Surgical Treatment
i) ii) iii)
Types of grafts used
Autograft
Bone-
Bone-Patellar tendon-
tendon-Bone
Hamstring tendon
Quadricep tendon
http://www.juestkd.com/juehome/
Allograft
i) Drilling tunnels through bones
Synthetic graft Bone-Patellar
tendon-Bone
ii) Threading the graft Graft
iii) Securing with screws

Graft material Artificial Ligaments

Original ACL
strength LARS: Ligament
2160N (-
(-4000N?) Augmentation and
Reconstruction System

I. Artificial Ligaments
ACL reconstruction with artificial ligament
Not recommended,
- poor results

Allografts
No Donar site morbidity
Patellar Hamstring Quadriceps
Quite readily a/v in some regions. Tendon Tendon
Tendon
Transmission of infection
Quality not guaranteed
used less today. Seen as a reserve
 BPB graft

www.medicalmultimediagroup.com/

Harvest of BPBG

B-PT-B Graft IF screw

Advantages
Rigid fixation
Bone to bone healing

Disadvantages (donar site morbidity)

Extensor mechanism disrupted
- Anterior Knee pain
- Numbness of anterior-
anterior-medial aspect of knee

Hamstring Tendon Harvest

Tibial
Tuberosity
 ACL recon using Hamstring graft
Description of surgery

Gracilis tendon

Semitendinosus
tendon

Harvesting Hamstring tendon

Hamstring Grafts
Increasingly popular as
Low donor site morbidity
Quadrupled tendon strand
Strength 4108 N
Extensor mechanism not
affected

Concerns:
?? Healing of tendon in osseous
tunnel
Tunnel widening

- Works well

Ultimate tensile load of the intact

Hamstring Graft human ACL and common ACL
Grafts
Adv:
Graft type Ultimate tensile
Cosmetically appealing load (N)
Extensor mechanism not affected
Intact ACL 2160157
2160
B-PT-
PT-B(10MM) 2376 151
Dis-
Dis-Adv: Single-
Single-strand semitendinosus 1216 50
Problematic graft integration Quadruple hamstring graft 4108 200
Strength? Quadriceps tendon (10mm) 2352 495
 Complications Complications
Donor side morbidities:
Arthrofibrosis or loss of motion Anterior knee pain
Donor side morbidities
Recurrent Laxity Donor side of B-PT-B graft
Technical errors:
Tunnel location
Tunnel Widening
Graft impingement
Graft tension
Graft fixation
Graft Integration
New Injuries

Rehabilitation of the ACL

ACL Rehabilitation Problem:
Is there enough focus on rehabilitation that may
occupy the patient over 100 hours compared to the
1-2 hours for an ACL reconstruction surgery takes?
takes?
No Cook
Cook Book Approac
Book Factors affecting rehabilitation
Muscle Inhibition
Early Motion
Closed vs. Open Chain
Patient -oriented
Strength Training
Patient-oriented Endurance Training
Individualized Bracing
Motor Sensory Control
Accelerated programme Graft Healing

ACL rehabilitation after

Operation
Proprioceptive Training
1. Early Motion to regain Full
ROM
2. Close chain muscle ex.
3. Proprioception training
4. Functional Training
5. Return to sports
 When to return to sport after ACL surgery?
Various forms of fitness
training seem to be highly
promising in preventing
Litterature
knee & ACL injuries
Competitive athletes return with 90% predictability 6-9
Focus on: months after surgery
knee control
Recreational athletes return in 80% in 8-12 months
technique
strength
Problem:
balance
Large- Varies after sport
Large-scale intervention
studies needed in different Very little science support to guide safe return
athlete populations

Best Time to Reconstruct ACL ?

Updated: July 17, 2006

Six - week wait for Owen

ahead of second knee op
Key Slides to
Newcastle striker Michael Owen must wait for the swelling in his knee
to go down before he undergoes a second bout of surgery.

Owen awoke from the first operation on his knee to find

had only repaired the cartilage rather than the damage to the cruciate
ligament damage itself, which he ruptured in England's World Cup
that surgeons
Remember
clash with Sweden.

He is pencilled in for further surgery under the supervision of knee

specialist Dr R ichard Steadman in September.

'I'm just hoping the next (operation) can be successful. I have to make
sure the knee is in a fit state and the swelling is down,' he told The
Sun.

'That way I can give myself the best possible chance of having the
cruciat e operation.

'The plan is to go back out there in six or seven weeks - hopefully, that
will be the last I see of America.

'Maybe then there will be light at the end of the tunnel and I can head
for a comeback.'

It is feared Owen could miss virtually the whole of the coming

campaign.

Pivoting injury:
Valgus, Semi-
Semi-flexion, Rotation
Semi-flexion,
Warning Features
May give satisfactory results if the injured is willing to
Intensive pain
Progressive increase swelling
Significant Decreased ROM
Feel a Pop
Cannot continue to play
ACL-Conservative therapy
modify lifestyle and
accept some instability and
increased risk for meniscus & cartilage injury
Problems:
Many non-
non-operated patients developed osteoarthritis
Patients cannot perform in sports with cutting and twisting
activities

ACL rehabilitation after

ACL Operation
1. Early Motion to regain Full
ROM
2. Close chain muscle ex.
3. Proprioception training
Articular 4. Functional Training
Meniscus 5. Return to sports
Cartilage

Dr Patrick Shu-
Shu-Hang, YUNG
z Associate Consultant

z Deputy Team Head, Orthopaedics Sports Medicine Team, Prince of Wales Hospital

z Team Head, Orthopaedics Sports Medicine Team, Alice Ho Miu Ling Nethersole Hospital

z Honorary Clinical Assistant Professor, Department of Orthopaedics

Orthopaedics and Traumatology, CUHK.

zHonorary Adjunct Professor, Hong Kong Polytechnic University

z Honorary Consultant in Sports Medicine, Hong Kong Sport Institute

Institute

z President, Hong Kong Orthopaedic Association, Sports Medicine Chapter

Chapter (HKOA-
(HKOA-SMC)

z Chairman, Liaison Commission, International Federation of Sports

Sports Medicine (FIMS)

z Honorary Secretary, Asia-

Asia-Pacific Orthopaedic Society of Sports Medicine (APOSSM)

E-mail: patrick@ort.cuhk.edu.hk
Tel: 26322722 / 73821457 / 92707003
BREAK