ACL RUPTURE

IO/RM

Anatomy

Intra-articular ligament
Inserts just anterior to and
between tibial
intercondylar eminences
Attaches to posteromedial
aspect of lateral femoral
condyle
33 mm long, 11 mm in
diameter
Two bundles
anteromedial bundle
posterolateral bundle

ACL

PCL

Thight In
Flexion

AM

AL

Thight In
Extension

PL

PM

Function

provides 85% of the stability to

preventanterior translation of the
tibiarelative to the femur
acts as secondary restraint to tibial
rotation and varus/valgus rotation
Blood

supply

middle geniculate artery

Innervation

posterior articular nerve (branch of tibial

nerve)

Clinical features
Mechanism

of injury
low velocity,
deceleration and
pivotal injury, usually
non-contact
Valgus external rotation
or hyperextension force
in contact injury
Audible or feeling of
popping
Acute haemarthrosis in
young

Clinical features
Inability

to continue
playing sport
Females more
susceptible
20% of ACL injury
associated with MCL
injury
80% incidence of lateral
meniscal injury with
combined ACLMCL
In chronic ACL deficiency
medial meniscal injury is
more common

Inside the knee joint

The

ACL intact

The ACL torn

ACL Exam
1. LACHMAN
Check PCL sag and
medial tibial step-off
before the test
Maintain the knee in
neutral rotation during
the test
At 20-30 Flexion
(more sensitive)

ACL Exam
2. PIVOT SHIFT
Place a valgus stress,
axial load and internal
rotation on the tibia as
the knee is slowly flexed.
In full extension, gravity
pulls the femur posteriorly
resulting in anterior
subluxation of the tibia.
With further flexion,
posterior pull by the
iliotibial tract reduces the
tibia at about 2030
(shift).

ACL Exam
3. ANTERIOR DRAWER
The

patient should be supine

with knees fl exed to 90.
The feet are stabilized in a
neutral position and the
examiner sits at the forefeet
of the patient.
Grasp the knee with both
hands; the tip of your thumbs
should be just below the joint
line
The amount of anterior
translation of tibia and quality
of end point is assessed.

Radiographic Findings
Avulsion

of the
intercondylar
tubercle
Anterior
displacement of
the tibia with
respect to the
femur
Segond fracture

ACL MRI
95%

accurate
Low signal
intensity
Saggital view
Acute injury high
signal intensity on
T2 image

Management
Non Operative
Associated with high incidence of
instability in younger patients
Potentially may lead to meniscal
tear, articular injury and
subsequent degenerative
changes

Management
Operative
ACL reconstruction
indications
in younger, more active patients
(reduces incidence of mensical or
chondral injury)
older active patients (Age >40 is not
contraindication if high demand athlete)
ACL reconstuction failure
lattempted ligament "repair" has high
failure rate

Management
Operative
Treatment of associated injuries
MCL injury
nonoperative
allow MCL to heal (varus/valgus stablity) and
then perfom ACL reconstruction
varus/valgus instability can jepardize graft
Meniscal tear
operative
perform meniscal repair at same time as ACL
reconstuction
increased healing rate when repaired at the
same time as ACL

Surgical technique
Graft

placed in the footprint of

the posterolateral bundle of ACL
Notchplasty is unnecessary if the
graft is correctly placed.
Remove osteophytes
Tensioned in extension

Complications
Anterior

placement of the femoral

tunnel limits flexion
Anterior placement of the tibial
tunnel limits extension
Graft rupture from impingement
Flexion contracture and arthrofibrosis
Failure of fixation
Infection
Osteoarthritis

Thanks