ACL Injury and it’s

MANAGEMENT
Chair person:DR.A.K.Mannur
Speaker:Dr.Dorai
03-11-2007
Anatomy
 Marshall, and Al
Monajem described
the anterior cruciate
ligament as a two-
bundle ligament,
consisting of a small
anteromedial and a
larger posterolateral
bundle.
•ACL originates from the posterior part of
the medial surface of the lateral femoral
condyle within the condylar notch well
posterior to the longitudinal axis of the
femoral shaft.

•It inserts on the tibial plateau, medial to

the insertion of the anterior horn of the
lateral meniscus in a depressed area
anterolateral to the anterior tibial spine.

•The tibial attachment site is larger and

more secure than the femoral site.

•The ligament is 31 to 35 mm in length and

31.3 mm2 in cross section.
•The primary blood supply to the ligament is from
the middle geniculate artery.

•Additional supply comes from the retropatellar

fat pad via the inferior medial and lateral
geniculate arteries.
• This source plays a more important role when
the ligament is injured.

•The posterior articular nerve, a branch of the

tibial nerve innervates the acl
The ACL functions
to prevent
anterior
displacement of
the tibia on the
femur.
Biomechanics
 The ACL is the primary restraint to
anterior tibial displacement.
 According to biomechanical tests
by Noyes et al., it accounts for
approximately 85% of the
resistance to the anterior drawer
test when the knee is at 90
degrees flexion and neutral
rotation.
 Selective sectioning of the
ACL has shown that the
anteromedial band is tight in
flexion, providing the primary
restraint, whereas the
posterolateral bulky portion of
this ligament is tight in
extension. The posterolateral
bundle provides the principal
resistance for hyperextension.
 The normal ACL has been
shown to carry loads
throughout the entire range of
flexion and extension of the
knee.
KNEE BIOMECHANICS OF
ACL&PCL
KNEE BIOMECHANICS
 In addition to the function as a mechanical
restraint to translation, the ACL has
proprioceptive function as evidenced by
the presence of mechanoreceptors in the
ligament.
 HISTORY AND PHYSICAL
EXAMINATION
 The classic history of an anterior cruciate
ligament injury begins with a non contact
deceleration, jumping, or cutting action.
Obviously, other mechanisms of injury include
external forces applied to the knee.
 The patient often describes the knee as having
been hyper extended or popping out of joint and
then reducing.
 A pop is frequently heard or felt.
 The patient usually has fallen to the
ground and is not immediately able to get
up.
 Within a few hours, the knee swells, and
aspiration of the joint reveals
haemarthrosis. In this scenario, the
likelihood of an anterior cruciate ligament
injury is greater than 70%.
 ETIOLOGY
 Knee ligaments often are injured in athletic
activities, such as American football. Skiing,
ice hockey, gymnastics, tennis and other sports
 Motor vehicle accidents,
 Ligament disruption can occur without a fall
or direct contact when sudden, severe loading
or tension is placed on the ligaments, such as
when a running athlete plants a foot to
suddenly decelerate or change directions.
MECHANISM
 Palmer described four mechanisms capable
of disrupting the ligamentous structures about
the knee:
 (1) abduction, flexion, and internal rotation of the
femur on the tibia,
 (2) adduction, flexion, and external rotation of
the femur on the tibia,
 (3) hyperextension, and
 (4) anteroposterior displacement.
The unhappy triad of O'Donoghue
 When abduction, flexion, and internal rotation
of the femur on the tibia occur, the medial
supporting structures— the tibial collateral
ligament and the medial capsular ligament —
are the initial structures injured. If the force
is of sufficient magnitude, the anterior
cruciate ligament also can be torn. The
medial meniscus may be trapped between the
condyles of the femur and the tibia, and it
may be torn at its periphery as the medial
structures tear, thus producing “the unhappy
triad” of O'Donoghue.
PHYSICAL EXAMINATION

 Before the development of a hemarthrosis,

the physical examination is easier and
more revealing; conversely, the
examination is more difficult once pain and
muscle guarding appear.
 The Lachman test is the most sensitive
test for anterior tibial displacement.
 The Lachman test has a sensitivity of 95%.
 The pivot shift test requires a relaxed patient and
an intact medial collateral ligament.
 When positive, this test reproduces the
pathological motion in an anterior cruciate
ligament-deficient knee and is easier to elicit in a
chronic anterior cruciate ligament disruption or in
an anesthetized patient with an acute anterior
cruciate ligament injury.
 PHYSICAL EXAMINATION

Lachman Test
The Lachman test can be useful if the knee is
swollen and painful. The patient is placed
supine on the examining table with the
involved extremity to the examiner's side .
The involved extremity is positioned in slight
external rotation and the knee between full
extension and 15 degrees of flexion; the
femur is stabilized with one hand, and firm
pressure is applied to the posterior aspect of
the proximal tibia, which is lifted forward in
an attempt to translate it anteriorly.
The position of the examiner's hands is
important in doing the test properly.
 One hand should firmly stabilize the
femur
 while the other grips the proximal tibia
in such a manner that the thumb lies on
the anteromedial joint margin.
 When an anteriorly directed lifting force
is applied by the palm and the fingers,
anterior translation of the tibia in
relation to the femur can be palpated by
the thumb.
 Anterior translation of the tibia
associated with a soft or a mushy end
point indicates a positive test.
 PHYSICAL EXAMINATION

Anterior drawer test

 PHYSICAL EXAMINATION
Anterior drawer test

 With the patient supine on the examining table, the

hip is flexed to 45 degrees and the knee to 90
degrees, with the foot placed on the table top. The
dorsum of the patient's foot is sat on to stabilize it,
and both hands are placed behind the knee to feel
for relaxation of the hamstring muscles .
 The proximal part of the leg then is gently and
repeatedly pulled and pushed anteriorly and
posteriorly, noting the movement of the tibia on the
femur.
The test is done in three positions
of rotation, initially with the tibia
in neutral rotation and then in 30
degrees of external rotation.
 Internal rotation to 30 degrees
may tighten the posterior
cruciate enough to obliterate an
otherwise positive anterior
drawer test .
 The degree of displacement in each
position of rotation is recorded and
compared with the normal knee. An
anterior drawer sign 6 to 8 mm greater
than that of the opposite knee indicates a
torn anterior cruciate ligament.
 However, before applying anterior drawer
stress, the examiner must make sure that
the tibia is not sagging posteriorly as a
result of laxity of the posterior cruciate
ligament.
 Any tendency of one tibial plateau to rotate
abnormally should be noted as the test is
carried out.
 In an acutely painful knee it may not be
possible to carry out the anterior drawer test
in the conventional 90-degree flexed position.
 Small degrees of anterior translation of the
tibia on the femur may be detected better in
the relatively extended position, in which the
“doorstop” effect of the posterior horn of the
menisci is negated .
Anterior drawer sign
 PHYSICAL EXAMINATION

Lachman Test
 When viewed from the lateral
aspect, a silhouette of the inferior
pole of the patella, patellar tendon,
and proximal tibia shows slight
concavity. With disruption of the
anterior cruciate ligament, anterior
translation of the tibia obliterates
the patellar tendon slope.
Roentgenographic studies

 Plain roentgenograms often are

normal; however, a tibial
eminence fracture indicates an
avulsion of the tibial attachment of
the anterior cruciate ligament.
 The Segond fracture, or avulsion
fracture of the lateral capsule, is
pathognomonic of an anterior
cruciate ligament tear
 Notch width index

Recent studies have
implicated gender and
femoral intercondylar
notch width as factors
contributing to injury of
the anterior cruciate
ligament. Numerous
investigators have
reported that athletes
sustaining non contact
anterior cruciate ligament
tears have statistically
significant intercondylar
notch stenosis.
 Souryal and Freeman
formulated the notch
width index, which is
the ratio of the width of
the intercondylar notch
to the width of the
distal femur at the level
of the popliteal groove
measured on a tunnel
view roentgenogram of
the knee
. The normal intercondylar notch ratio was
0.231 ± 0.044. The intercondylar notch
width index for men was larger than that
for women
 MRI is the most helpful
diagnostic
roentgenographic
technique.
 The reported accuracy
for detecting tears of the
anterior cruciate
ligament has ranged
from 70% to 100%.
Magnetic resonance imaging
showing bone bruise after anterior
cruciate ligament tear.
 TREATMENT

 The treatment options available include

 nonoperative management,
 repair of the anterior cruciate ligament,
either isolated or with augmentation,
 and reconstruction with either autograft or
allograft tissues or synthetics.
 Nonoperative treatment is a viable option
for sedentary occupations, low athletic
demands, or who were older than 30 years
and a patient who is willing to make
lifestyle changes and avoid the activities
that cause recurrent instability.
 If a nonoperative approach is chosen, it should
include an aggressive rehabilitation program and
counseling about activity level.
 The use of a functional knee brace is
controversial and has not been shown to reduce
the incidence of reinjury significantly if a patient
returns to high-level sports.
 Conservative treatment involves the re-
education of the quadriceps and hamstring
muscles. Emphasis should be placed on
the hamstrings as they can restrict the
amount of anterior tibial translation on the
femur.
Operative treatment
 ACL reconstruction is done traditionally using
either an intra-articular reconstruction, an extra-
articular reconstruction, or a combination of
both.
 Isolated extra-articular reconstruction may be
useful in the skeletally immature, when there is
concern about damage to the growing physis. In
isolation, extra-articular reconstruction is prone
to failure within3 to 5 years.
Operative treatment
 Primary intra-articular repair often fails unless there is
clear evidence of bony avulsion from either the femoral
or tibial attachments, where this can be reapposed.
 In the majority of cases a reconstructive technique is
required and a bone-patellar-tendon-bone or hamstring
graft is the most frequently used method of
reconstruction. These grafts may be used in conjunction
with an extra-articular tenodesis (MacIntosh typetwo)
augment stability.
Continued…………..
 Those patients requiring reconstruction were
younger and had a higher preinjury activity level
and a stronger desire to stay at that level
 Three factors known at the time of the initial
examination that correlated with the need for
surgery:
 younger age,
 preinjury hours of sports participation,and
 amount of anterior instability as measured by
the KT-1000 arthrometer.
 Primary repair of the anterior cruciate ligament is
no longer preferred but reconstruction several
weeks after the acute injury is preferred .
 Acute repair is appropriate when a bony avulsion
occurs with the anterior cruciate ligament
attached. The avulsed bone fragment often can
be replaced and fixed with sutures or passed
through transosseous drill holes or screws
placed through the fragment into the bed.
 Anterior cruciate ligament avulsions usually
occur from the tibial insertion.
 Repair of avulsion of tibial
attachment of anterior
cruciate ligament with
fragment of bone through
Bunnel suture. Crater in tibia
should be deepened, and
bone fragment on end of
ligament is pulled into crater
depth to restore tension in
avulsed ligament.
Intraarticular Reconstruction.
 The advances made in arthroscopy have
led to the development of arthroscopic
techniques for anterior cruciate ligament
reconstruction.
 Increased understanding of technical
issues of graft selection, placement,
tensioning, and fixation, as well as
postoperative rehabilitation, led to
dramatically improved results compared
with previous intraarticular reconstructions.
 These same principles can be applied to
open intraarticular reconstruction of the
anterior cruciate ligament through a small
arthrotomy incision, which preserves
attachment of the vastus medialis obliquus
muscle to the patella, or through the
patellar tendon defect when the central
third is used as a graft source.
Graft Selection.

 Autograft tissue is used most commonly,

 but allografts and synthetics also are
available .
 Autografts have the advantages of low risk
of adverse inflammatory reaction and
virtually no risk of disease transmission.
Continued…………..

 As a biological graft, it undergoes

revascularization and recollagenization,
but initially a 50% loss of graft strength
occurs after implantation.
 Therefore it is desirable to begin with a
graft stronger than the tissue to be
replaced.
The most common current
graft choices are
 bone-patellar tendon-bone
graft
 quadrupled hamstring
tendon graft
 and
Quadriceps tendon graft
 The bone-patellar tendon-bone graft
usually is an 8- to 11-mm wide graft taken
from the central third of the patellar
tendon, with its adjacent patella and tibial
bone blocks.
 This graft's attractive features include its
high ultimate tensile load (approximately
2300 N), its stiffness (approximately
620N/mm), and the possibility for rigid
fixation with its attached bony ends
 The use of the hamstring tendon graft and
quadriceps tendon graft has increased in
recent years because of their relatively
low donor site morbidity.
 This quadriceps graft has become an
alternative replacement graft, especially
for revision anterior cruciate ligament
surgeries and for knees with multiple
ligament injuries.
Graft Placement.
 The preferred location has been isometric
placement of the graft that limits changes in
graft length and tension during knee flexion
and extension, which possibly may lead to
overstretching or failure of the graft.
 Although both the tibial and femoral
attachment sites are important, errors in the
femoral site are more critical because of the
closer proximity to the center of axis of knee
motion.
 A femoral tunnel that is too anterior will
result in lengthening of the intraarticular
distance between tunnels with knee
flexion.
 Posterior placement of the femoral tunnel
produces a graft that is taut in extension
but loosens with flexion. This location
produces an acceptable result.
 Currently, most surgeons advocate placing the
graft at the posterior portion of the anterior cruciate
ligament tibial insertion site near the posterolateral
bundle position for best reproduction of the
function of the intact anterior cruciate ligament.
 This location also decreases graft impingement
against the roof of the intercondylar notch with
knee extension that can occur with anterior
placement.
 A bony ridge (“resident's ridge”) anterior to
the femoral attachment of the anterior
cruciate ligament should be removed, if
present, since it impairs the proper
identification of the femoral attachment
site and also hinders the proper placement
of the over-the-top guides used for drilling
the femoral tunnel.
Graft Tension.

 The application of tension to the graft at the

time of initial fixation can significantly alter
joint kinematics and in situ forces in the graft
during knee motion.
 Theoretically, the desired tension in the graft
should be sufficient to obliterate the instability
(Lachman test). Too much tension may
“capture” the joint, resulting in difficulty in
regaining motion, or it may lead to articular
degeneration from altered joint kinematics.
 Less tension was required for a bone-
patellar tendon-bone graft than a
semitendinosus graft because the tendon
portion of the former was shorter and
stiffer.
 Initial graft tension remains controversial,
as the in situ forces in the anterior cruciate
ligament during daily activities are
unknown.
 In addition, the significance of the
viscoelastic behavior of the anterior
cruciate ligament replacement grafts has
not been entirely characterized.
Graft Fixation.
 Fixation of
replacement
grafts can be
classified into
 direct and
 indirect method .
 Direct fixation devices include interference
screws, staples, washers, and crosspins.
 Indirect fixation devices include polyester
tape-titanium button and suture-post.
 Interference screw fixation is the most
popular fixation method for bone-patellar
tendon-bone grafts
ACL Reconstruction Using Bone-Patellar
Tendon-Bone Graft

Modified Clancy technique . A, Single skin

incision. B, Anteromedial and lateral incisions.
A, Release of graft with Graft freed from tibial
patellar and tibial tuberosity
bony attachments. B,
tuberosity.
Removal of segment of
tibial tuberosity.
A, Free, nonvascularized, bone-tendon-bone graft:
patellar bone is 5 mm thick, 10 mm wide, and 2 to 3 cm
long and is connected to 10-mm wide full-thickness
patellar tendon attached to
piece of tibial tuberosity 8 mm thick, 10 mm wide, and 2
to 3 cm long. B, Sutures are placed through holes in
bony portions of graft.
Intercondylar notch can be explored
through defect in patellar tendon created
by harvesting of graft.
Small curet marks femoral anatomical attachment
site.
Correct positioning of pilot holes for right knee
(A) and left knee (B).
Exit site for femoral tunnel 3 to 4 cm
proximal to lateral femoral epicondyle.
Incorrect (top) and correct (bottom) positioning of graft.
Bone plug should not be too far into tunnel to avoid wear
on tendinous part of graft.
Reconstruction Using Hamstring
Tendons.

 The use of Hamstring tendon graft for

ACL reconstructions has increased in
popularity.
 Initially, the semitendinosus tendon
and gracilis tendon were used together
as two single strands. Their initial
combined strength according to Noyes'
research exceeded that of the anterior
cruciate ligament.
 The tendons could be released proximally
and left attached to the tibia, allowing a firm
site of anchorage distally. Otherwise, they
could be released both proximally and
distally and used as a free graft.
 The tendons can be released proximally by
using a commercially available tendon
stripper or by making a second, more
proximal incision. Lipscomb et al. reported
84% good results in 342 anterior cruciate
ligament-deficient knees using both the
semitendinosus and gracilis tendons for
anterior cruciate ligament reconstruction.
 More recently surgeons have chosen
to fold the semitendinosus and gracilis
tendons upon themselves, creating
four strands and theoretically doubling
the strength of the graft construct.
 Others have chosen to use only the
semitendinosus tendon and folding it
on itself to create either three or four
strands.
Anterior Cruciate Ligament Reconstruction
Using Hamstrings (with Proximal Release of
Hamstrings)

Anterior cruciate ligament reconstruction with hamstrings.

Two-screw fixation of hamstring graft in tibial tunnel
 Extra articular procedures
 Currently, extraarticular procedures are used
primarily in conjunction with an intraarticular
reconstruction when severe anterior instability is
due to injury or late stretching of the secondary
stabilizing capsular structures or the lateral side
of the knee.
 Extraarticular techniques described are those of
MacIntosh, Losee, and Andrews (iliotibial band
tenodesis and bicepsplasty).
 MacIntosh technique of lateral
reconstruction using strip of
iliotibial band
Dissect a 1.5-cm wide strip of
iliotibial band from its midportion
beginning approximately
16 cm from its distal insertion
and turn it down to its
attachment at the Gerdy
tubercle.
Pass this strip of iliotibial band
to the posterolateral corner of
the knee through a tunnel deep
to the lateral collateral ligament
 Losee modification of MacIntosh technique of lateral
reconstruction using iliotibial band. A, Fascial strip (18cm long
× 1.5 cm wide) of iliotibial tract attached to Gerdy tubercle. B,
Imbrication through lateral head of gastrocnemius plus
posterolateral corner. C, Rerouting of fascial strip deep to
fibular collateral ligament, reattaching it to Gerdy tubercle.
 Andrews “minireconstruction” technique

Hold the iliotibial tract

against the distal femur by
sutures passed through the
track and through two parallel
holes in the distal femur and
tied to each other on the
medial side of the femur,
beneath the vastus medialis .
 By fixing the tract to the distal femur, a
ligament is created that closely approximates
the biomechanical function of the anterior
cruciate ligament, extending from the distal
femur to the Gerdy tubercle and preventing
anterolateral subluxation of the lateral tibial
plateau on the lateral femoral condyle.
A, Two points on lateral femoral condyle
corresponding to major femoral intraarticular
attachments of anterior cruciate ligament.
B, Posterior band tight in extension.
C, Anterior band tight in flexion.
AFTERTREATMENT.

 At 5 days after surgery the wound is inspected

and the cast changed. The cast is removed at 6
weeks.
 Not to rigidly immobilize the knee in flexion for
several weeks because of the deterioration of
the articular cartilage surfaces associated with
the absence of motion, especially in the
patellofemoral joint.
 If extension beyond 30 degrees is
detrimental to the reconstruction early,
 to use a controlled motion brace locked at
30 degrees of extension but allowing
flexion.
Complications of Anterior Cruciate
Ligament Surgery

 Complications of anterior cruciate ligament

surgery can be caused by preoperative,
intraoperative, and postoperative factors.
 Preoperative factors include appropriate
timing of surgery, adequate preoperative
conditioning and strengthening, and graft
and fixation choices.
 Intraoperative complications include
patellar fracture, inadequate graft length,
mismatch between the bone plug and
tunnel sizes, graft fracture, suture
laceration, violation of the posterior
femoral cortex, and incorrect femoral or
tibial tunnel placement.
 The most common postoperative
complications are motion (primarily
extension) deficits and persistent anterior
knee pain.
 Anterior knee pain probably is the most
common and most persistent complication
after anterior cruciate ligament
reconstruction.
 Motion loss after anterior cruciate
ligament reconstruction can result from
preoperative, intraoperative, or
postoperative factors. Preoperative
effusion, limited range of motion, and
concomitant knee ligament injuries make
poor postoperative motion more likely.
 Intraoperative factors associated with
motion deficits most often are incorrect
tunnel position and inadequate
notchplasty, which can result in over
tightening or impingement of the graft,
leading to loss of extension.
 Postoperative factors include prolonged
immobilization and inadequate or
inappropriate rehabilitation.
Synthetic Materials for Ligament
Reconstruction.
 Artificial ligaments (Gore-Tex ligament, the
Stryker Dacron ligament, and Leeds-Keio
prostheses) offer a number of theoretical
advantages compared with reconstruction using
autogenous tissues: no autogenous tissues are
sacrificed, and the increased morbidity
associated with the harvest of autogenous
tissues is avoided.
 If autogenous tissues have been used in a
failed reconstruction or if they are unacceptable,
 the use of a readily available synthetic device is
appealing.
 Artificial ligaments generally permit a simpler
and easier reconstructive technique, frequently
arthroscopic, and they allow a more rapid
rehabilitation because they do not become weak
during tissue revascularization and
reorganization.
 Artificial ligaments function in one of three
ways:
 (1) as a prosthetic ligament; that is, the
prosthesis is implanted as a permanent
replacement for the normal ligament;
 (2) as a stent temporarily protecting or
augmenting an autogenous graft; or
 (3) as a scaffold providing support for and
stimulating the in growth of collagen
tissue.
Synthetic Augmentation for Anterior Cruciate
Ligament Repair or Reconstruction. (Kennedy)

 The Ligament Augmentation Device

(LAD), developed with the 3M Co., is a
braided, polypropylene, synthetic ribbon
that is inserted along with the biological
graft tissue in the form of a composite
biological-synthetic graft.
 The purpose of the synthetic augmentation
device was to enhance the initial graft strength,
to allow for immediate proper intraoperative
tensioning of the graft, and to provide for more
secure fixation of the graft.
 The LAD has been used in conjunction with the
Marshall-Macintosh technique, the iliotibial band,
and the hamstring tendons, as well as with
patellar bone-tendon-bone grafts and allografts.
Allograft Ligament Replacement
 The ideal ligament replacement should be
readily available; it should be of sufficient length
and diameter; it should have biomechanical
properties similar to the ligament it replaces; it
should not disturb normal structures; and it
should retain or develop a vascular supply.
 Although autogenous tissues currently are the
most commonly used grafts for reconstruction of
the cruciate ligament,
 these transfers sacrifice a normal
musculotendinous structure in an already
deficient knee, adding to the functional
disturbance. Extensive surgical exposure, long
tourniquet times, and prolonged rehabilitation
are other disadvantages of these techniques.
 collagen allografts appear capable of fulfilling
many of the requirements for an ideal ligament
substitute,
 Autografts and allografts bothgo through
four stages after transplantation: necrosis,
revascularization, cellular proliferation, and
remodeling.
 After incorporation, however, neither
autograft norallograft tendons have been
demonstrated to return to their original
strength.
 Most reports show 30% to 40% ultimate
load strengths. Because of this consistent
reductionin strength, use of grafts or
combination of grafts that begin with more
than 100% of anterior cruciate ligament
strength, which should result insufficient
strength after incorporation.
 Allografts can be sterilized either by sterile
procurement with careful donor screening or by
secondary sterilization with gaseous ethylene
oxide or gamma irradiation.
 The major concern in using allograft
transplantation for ligament reconstruction
remains the possibility of disease
transmission,especially of hepatitis or acquired
immune deficiency syndrome (AIDS).
Rehabilitation after Anterior Cruciate Ligament
Reconstruction

 The goal of rehabilitation after anterior cruciate

ligament surgery is to restore normal joint motion
and strength while protecting the ligament graft.
Appropriate rehabilitation is crucial to the
success of anterior cruciate ligament
reconstruction. Some stress to the graft is
desirable for healing and remodeling but should
not be excessive and disruptive.
 Intensive rehabilitation can help prevent early
arthrofibrosis and restore strength and function
earlier. Perhaps the most important step is the
early restoration of full extension.
 Knee immobilization in a fully extended brace is
started immediately after surgery to prevent
development of a flexion contracture.
 After isolated anterior cruciate ligament
reconstruction, partial weight-bearing with
crutches is allowed immediately. A straight leg
brace is worn to support the weakened
quadriceps. Certain types of concurrent
meniscal repairs or articular cartilage procedures
may dictate a different weight-bearing status.
Usually crutches are discontinued by 3 to 4
weeks postoperatively.
Arthroscopy
Though arthroscopic Reconstruction of
ACL is the present trend,
if the surgeon is not well versed with the
arthroscope, open ACL reconstruction
surgery results are much better than
arthroscopic ACL reconstruction
Advantages
-The arthroscopically aided approach has the advantages
of
 smaller skin and capsular incisions,
 less extensor mechanism trauma,
 Improved viewing of the intercondylar notch for
placement of the tunnel and attachment sites,
 less postoperative pain,
 fewer adhesions,
 earlier motion, and
 easier rehabilitation.
 The selection of grafts depends on the
surgeon's preference and the tissues
available.
 Among the autogenous tissues currently
available, the most commonly used are
central one third patellar tendon,
quadrupled hamstrings, and less
commonly quadriceps tendon grafts.
Techniques
 Graft harvesting – vertical skin incision
from inferior pole of patella to 1 cm medial
to tibial tubercle. Skin flap raised and
patellar tendon (central) of 1 cm width is
raised with two vertical incision from
patella to tibial tubercle. The bone plugs of
27mm length is removed with oscillating
saw.
Preparation of graft
 Excess of soft tissue is removed from graft
and diameter of bone plug is trimmed to
10mm and checked with templets. The
plug from the tibial tubercle is prepared for
placement in the femoral tunnel. Holes are
drilled in graft to permit passage of no5
non-absorbable sutures to use later to
pass and tension the graft.
Notch plasty-

 A second suprapatellar inflow is used to

improve visualization. The remnant of ACL
are removed using intra-articular punch
and then saver.
 Notch plasty is begun by removing about
6mm of antero-lateral wall of notch using
burr. It is important to identify and remove
the resident ridge.
Drilling the tibial tunnel
 A drill guide is set at 55* as more posterior
tunnel preferred to prevent the
impingement.
 The tip is inserted through the medial
portal and correct position is confermed.
The guide pin is inserted and tunnel is
drilled.
Femoral Tunnel Preparation
 With the knee flexed approximately 90 degrees, confirm
the previously chosen femoral pilot hole with an Arthrex
7-mm offset femoral guide passed through the tibial
tunnel. The starting point is at the 11-o'clock position on
the right knee (1 o'clock on the left knee) approximately
8 mm lateral to the posteriorcruciate ligament.
 Advance a long guide wire through the guide to the
chosen physiometric point on the posterolateral portion
of the femoral condyle.
 Pass a 10-mm endoscopic reamer over the previously
placed wire and ream.
Graft Passage
 Use the eyelet guide wire to pass the patellar
bone plug guide suture up through
 the femoral tunnel and then out through the
lateral thigh. When the graft is about halfway into
the femoral tunnel, pass a flexible guide wire
through either the medial portal place the wire
anterior to the graft and, with the wire parallel to
the graft, advance both up into the tibial tunnel.
Graft Fixation
 Place an 8-mm cannula with a cannulated screw with
noncutting threads through the medial portal or central
patellar portal.
 Tension the graft with about 8 to 10 pounds of pull. Over
tensioning of the graft can cause failure because of joint
capture or graft necrosis. Secure the graft with an 8-mm
screw if the bone plug-to-tunnel gap is less than 2 mm;
use a 9-mm screw if the gap is 3 mm or more. If the gap
is more than 5 mm, add a cancellous screw and washer
post 1.5 cm distal to the tibial tunnel.
Rehabilitation
Posterior drawer test
 The posterior drawer test is done with the patient
supine and the knee flexed to 90 degrees;
 the foot is secured to the table by sitting on it.
 A posterior force is applied on the proximal tibia,
which is opposite but similar to the force applied
in the anterior drawer test.
 Posterior movement of the tibia on the femur
demonstrates posterior instability when
compared with the normal tibia.
 It is sometimes difficult to interpret whether
the tibia is abnormally moving too far
anteriorly or too far posteriorly.
 Careful attention to the neutral position or
unstressed reduction point prevents
misinterpretation.
 Both knees are placed in the position to
perform a posterior drawer test, and a thumb
is placed on each anteromedial joint line.
 Loss of the normal 1-cm anterior step-off of
the medial tibial plateau with respect to the
medial femoral condyle indicates a torn
posterior cruciate ligament .
 As with the anterior drawer test, any
abnormal rotation of the tibial condyles
is noted as the posterior drawer is
tested.
 To further evaluate stability, the
Posterior force applied to tibia and
normal patellar tendon slope.
 Obliteration of patellar tendon slope
with disruption of anterior cruciate
ligament as forceful anterior translation
of tibia takes place.
Posterior drawer test
Posterior Cruciate
Ligament
Impact on
anterior tibia.
PCL Tear
The arteries supplying the joint
are the highest genicular
(anastomotica magna), a branch
of the femoral,
the genicular branches of the
popliteal, the recurrent branches
of the anterior tibial, and the
descending
branch from the lateral femoral
circumflex of the profunda
femoris.
20
The nerves are derived from
the obturator, femoral, tibial, and
common peroneal.
 ACL AND PCL
 Two important intra-articular ligaments
that provide static support to the knee
are the anterior (ACL) and posterior
(PCL) cruciate ligaments.
 Although the ligaments are intra-
articular they are not contained within
the joint capsule of the knee.
 The ACL extends from the anterior area
between the condyles of the tibia in a
posterior and lateral direction to a
posterior area on the medial surface of
the lateral condyle of the femur.
 PCL
 The PCL runs from a posterior depression
between the condyles of the tibia in an
anterior and medial direction to the lateral
side of the medial femoral condyle.
 The PCL functions to prevent
posterior translation of the tibia
on the femur.
 Additionally both the ACL and PCL serve to
reduce rotation of the femur on the tibia. The
ligaments are tense in all positions, but
increase their tension in the extremes of
flexion and extension
 Intraarticular reconstruction procedures was
discouraging because of the frequent
postoperative stiffness and persistent avulsion
laxity.
 Extra-articular procedures were developed to
obviate these problems. These procedures
generally create a restraining band on the lateral
side of the knee, extending from the lateral
femoral epicondyle to the Gerdy tubercle in a
line parallel with the anterior cruciate ligament.
They avoid the problem of a lack of blood supply
to the intraarticular reconstructions. Most lateral
extraarticular procedures use the iliotibial band
or tract connecting the lateral femoral epicondyle
to the Gerdy tubercle.
Reconstruction for Anterior
Cruciate Ligament Insufficiency
 ACL reconstruction is done traditionally using
either an intra-articular reconstruction, an extra-
articular reconstruction, or a combination of
both.
 Isolated extra-articular reconstruction may be
useful in the skeletally immature, when there is
concern about damage to the growing physis.
 In isolation, extra-articular reconstruction is
prone to failure within3 to 5 years.