PORTFOLIO

Identity

Name : Piyan Anggayoni

Sex : Male

Age : 23 y.o

Insurance : JKN

No. MR : 433-31-90

Attending : Dr.dr. Andri MT Lubis, SpOT(K)

Chief Complaint

Feeling giving away of right knee since 1 year ago

History of present illness

3 months ago, patient's left wrist was in pain. The pain was continuous all day. The pain
aggravated with movement. Did not decrease by rest or analgetics. There was no History of
trauma and infection. She was consulted by rheumatologist. The rheumatologist said that she
has unspecified autoimmune. Has not have any therapy yet.

Local state of right hand

Look : Deformity (-), swelling (-), inflammation signs (-), mass (-), wound (-), sinus (-), sag
sign (-)

Feel : Joint line tenderness (-), CRT <2 sec, neurovascular distal normal, mass (-)

Move : Active extension-flexion of both knees 00 - 1350

Clinical Manifestation of the Patient

Anterior drawer test

Lachman test
Pivot test

Test Right Left

Varus Stress - -

Valgus Stress - -

Anterior Drawer + -

Posterior Drawer - -

Lachman +3 -

Pivot Shift + -

Apley Grinding - -

McMurray - -
Pre-Operative X-Ray

Preoperative of the Patients

Preoperative MRI of the knee

Diagnosis

Total rupture of right ACL

Treatment

Arthoroscopy asissted ACL Reconstruction

Intraoperative

Lachman test and anterior drawer test

Pivot test and varus valgus test

Graft preparation and peroneus longus graft exposed

Graft harvesting

Peroneus longus graft harvesting

Graft preparation
Scope portal: anterolateral, anteromedial
Literature Review

Total ACL Rupture

Introduction

Epidemiology

The ACL is the most commonly injured ligament in the body. It is estimated that 175,000 ACL
reconstructions were performed in the year 2000 in the US. The incidence of ACL tears is 3.2%
for men versus 3.5% for women. When considering sports or activities in which both sexes
participated, women had a significantly higher incidence ratio than men (incidence ratio. The
majority of ACL tears (67% in men and almost 90% in women) occurred without contact. The
increased risk of ACL tear in female athletes may be caused by several factors, including
mechanical axis (leg alignment, that is with females on average more knock-kneed) and notch
width (females may have less space for ACL), hormonal factors (increased risk during
preovulatory cycle), and neuromuscular control. ACL tear significantly increases the risk for
premature knee osteoarthritis (OA). It is estimated that 50% of patients with ACL tears develop
osteoarthritis 10 to 20 years later, while still young.

Clinical Manifestation and Diagnosis

The mechanism of injury suggesting ACL tear is a non-contact mechanism of injury,

identification of a "pop", early occurrence of swelling (hemarthrosis) from rupture of the
vascular ACL, and inability to continue to participate in the game or practice after the injury.
Collateral ligament tears usually do not result in swelling, and frequently patients with partial
posterior ligament tears (PCL) can continue to play. Meniscus tears are associated with a
delayed onset of swelling in the subsequent day. Two physical exam maneuvers, the Lachman
test and the pivot shift test, are useful in assessment for ACL tear. The sensitivity and specificity
of the Lachman test for ACL tear was 85% and 94%, respectively. For the pivot shift,
specificity was high (98%) but sensitivity was low (24%). However, when the diagnosis by
history and physical examination is clearly established an MRI is optional before proceeding
to ACL reconstruction in an athlete. Magnetic resonance imaging (MRI) is used to confirm the
diagnosis. MRI has a sensitivity of 86%, specificity of 95%, and accuracy of 93% for ACL
tear1.

Treatment

The majority of patients with ACL tear are able to walk normally and can perform straight
plane activities including stair climbing, biking, and jogging. The indication of surgical
treatment is when the patient has a sensation of instability in normal activities of daily living
or wants to resume activities that involve cutting and pivoting. The activities include football,
soccer, basketball, and tennis. Occupations such as firefighting, law enforcement, and some
construction jobs also require an intact ACL1.

The initial management of ACL tears is reducing the hemarthrosis with RIC. E principle
(rest, ice, compression, and elevation), and non-steroidal anti-inflammatory agents, regaining
normal range of motion, reinitiating quadriceps control, and restoring normal gait. all of which
usually takes on average 2 to 4 weeks from the time of the injury. The surgical approach to
ACL tears involves ACL reconstruction, using a graft through tunnels drilled into the tibia and
femur at insertion points of the ACL to approximate normal anatomy, with the goal of
eliminating ACL instability. ACL reconstruction is preferred over repair because clinical
researches showed that ACL repair is no better than nonoperative treatment, and that ACL
reconstruction will result in significantly improved knee stability and likelihood of return to
previous activity1.

ACL Reconstruction

In general, decisions in ACLR types should be guided by the following principles:

1. Double bundle reconstruction surgery is, in general, considered in patients with a large
tibial insertion site (anteroposterior length >14 mm), large intercondylar notch (length
and width >14 mm), in the absence of concomitant ligament injuries, absence of
advanced arthritic changes (Kellgren Lawrence grade <3), absence of severe bone
bruising, and closed physes
2. Single bundle reconstruction is indicated for tibial insertion sites less than 14 mm in
length, narrow notches (less than 12 mm in width), in the presence of concomitant
ligamentous injuries, severe bone bruising, severe arthritic changes (grade 3 or higher
Kellgren Lawrence changes) and in the setting of open physes.

The purpose of the double-bundle graft is to reconstruct both the AM (anteromedial) and
PL (posterolateral) bundles, with the aim to closely reproduce the native knee anatomy and
subsequently kinematics. The selection of a graft type is based on patient-specific factors (i.e.,
patient age, skeletal maturity, and activity level) and supported by evidence in the current
literature. The most commonly used graft is hamstring tendon, quadriceps tendon, and bone-
patella tendon-bone grafts2.

The timing of ACLR can influence rehabilitation outcomes as early ACLR has been
associated with delays in quadriceps recovery as well as a loss in range of motion. Several
articles demonstrate reduced quadriceps strength at multiple intervals following early ACLR
(postinjury days 0–7) compared to delayed reconstruction (postinjury days 8–21), as well as
significant loss in terminal knee extension. This highlights a growing trend in the use of
preoperative rehabilitation. Preoperative rehabilitation should focus on preservation of
quadriceps strength and knee range of motion as deficits in both of these parameters are
associated with poorer functional outcomes2.

References:

1. Spindler K, Wright R. Anterior Cruciate Ligament (ACL) Tear. N Engl J Med 2008
Nov 13; 359(20) 2135–2142. 2013;

2. Kiapour AM, Murray MM. Basic science of anterior cruciate ligament injury and
repair. Bone Jt Res. 2014;

Etiology and Epidemiology

Clinical Mnifestation and Diagnosis

Treatment