Sunteți pe pagina 1din 37

JOURNAL READING

Christoph Domnick
Michael J Raschke
Mirco Herbort

Biomechanics Of The Anterior Cruciate Ligament:


Physiology, Rupture And Reconstruction
Techniques
Roshynta Linggar Andatu
20130310198
The Anatomy Of The Knee
The Anatomy Of The Knee
LIGAMENTS
LIGAMENTS
LIGAMENTS INJURY
ANTERIOR CRUCIATE LIGAMENT POSTERIOR CRUCIATE LIGAMENT
LIGAMENTS INJURY

MEDIAL COLLATERAL LIGAMENT LATERAL COLLATERAL LIGAMENT


ACL PCL
Most commonly injured during 5-20% of all knee ligamentous
sports-related activity injuries

EPIDEMIOLOGY

LCL
MCL 7-16% of all knee ligament
most commonly injured injuries when combined with
ligament of the knee lateral ligamentous complex
injuries
ANTERIOR CRUCIATE LIGAMENT

ANATOMY
• 32mm length x 7-12mm width in size
• goes from LFC to the anterior tibia (tibial insertion is broad
and irregular and inserts just anterior and between the
intercondylar eminences of the tibia)
• two bundles : anteromedial bundle and posterolateral
bundle

FUNCTION
• provides 85% of the stability to prevent anterior translation
of the tibia relative to the femur
• acts as a secondary restraint to tibial rotation and
varus/valgus rotation
ANTERIOR CRUCIATE LIGAMENT
ANTERIOR CRUCIATE LIGAMENT

PRESENTATION
• 70% hear or feel a "pop"
• pain deep in the knee
• immediate swelling (70%) / hemarthrosis

PHYSICAL EXAM
PHYSICAL EXAM
IMAGING
• Segond fracture (avulsion fracture of the proximal
lateral tibia) is pathognomonic for an ACL tear :
represents bony avulsion by the anterolateral
ligament (ALL)associated with ACL tear 75-100% of the

RADIOGRAPHS time
• deep sulcus (terminalis) sign : depression on the lateral
femoral condyle at the terminal sulcus, a junction
between the weight bearing tibial articular surface and
the patellar articular surface of the femoral condyle.

• Sagittal view : ACL fibers and bone bruising in >half of acute


ACL tears
MRI • Coronal view : discontinuity of fibers (do not reach the femur)
and fluid against the lateral wall ("empty notch sign")
MRI
Sagittal view Anterior Cruciate Ligament Visualized
Between Femoral Condyles
TREATMENT

Non • Partial injuries


• Rehabilitation to strengthen hamstrings and quadriceps
• Activity modification

Operative • ACL sports braces

• Indications : Failure in non surgical treatment, For athletes


and who occupy in physical combat, Difficult to perform
Activity Daily Living (ADL)

Operative • Contraindications : Lack of quadriceps function, Regained


full of ROM, Good quadriceps function, Control of effusion,
Normal gait, Advanced osteoarthritis
• Reconstruction
POSTERIOR CRUCIATE LIGAMENT

ANATOMY
• Origin : posterior tibial sulcus below the articular surface
• Insertion : anterolateral medial femoral condyle, broad, crescent-shaped
footprint
• Dimensions : 38 mm in length x 13 mm in diameter, PCL is 30% larger
than the ACL
• PCL has two bundles : anterolateral bundle and posteromedial bundle

PATHOPHYSIOLOGY
• Mechanism : direct blow to proximal tibia with a flexed knee (dashboard
injury), noncontact hyperflexion with a plantar-flexed foot,
hyperextension injury
• Pathoanatomy : PCL is the primary restraint to posterior tibial
translation, functions to prevent hyperflexion/sliding, isolated injuries
cause the greatest instability at 90° of flexion
CLASSIFICATION

GRADE II (COMPLETE GRADE III (COMBINED PCL


GRADE I (PARTIAL)
ISOLATED) AND CAPSULOLIGAMENTOUS)

• Translation <10mm on • The PCL only is injured • The PCL is injured in


posterior drawer test • Physical examination is conjunction with other
with the knee in neutral normal structures, such as the ACL,
rotation • Posterior drawer test is posterolateral corner, and
• Some sort of end point is positive with the knee in medial side
present neutral rotation and is
diminished with the
knee in internal rotation
PRESENTATION
• History
1. differentiate between high- and low-energy
trauma
2. ascertain a history of dislocation or
neurologic injury
• Symptoms
1. posterior knee pain
2. instability
PHYSICAL EXAM
• Varus/valgus stress
• Posterior sag sign
• Posterior drawer test (at 90° flexion)
• Dial test
PHYSICAL EXAM
IMAGING
Posterior Cruciate Ligament Seen
Beyond Medial Meniscus
TREATMENT

Nonoperative
• protected weight bearing & rehab
• relative immobilization in extension for 4 weeks
Operative
• PCL repair of bony avulsion fractures or
reconstruction
• high tibial osteotomy
MEDIAL COLLATERAL LIGAMENT
• Primary and secondary valgus stabilizer of the knee also
known as the tibial collateral ligament
• Valgus and external rotation force to the lateral knee
• Concomitant ligamentous injuries (95% are ACL) occur in 20%
of grade I, 52% of grade II, and 78% of grade III injuries
PRESENTATION
History
• "pop" reported at time of injury

Symptoms
• medial joint line pain
• difficulty ambulating due to pain or instability

Physical exam
• inspection and palpation : tenderness along medial aspect of knee,
ecchymosis, knee effusion
• ROM & stability : valgus stress testing at 30 degrees knee flexion,
valgus stressing at 0 degrees knee extension
IMAGING
RADIOGRAPH MRI
• Recommended : AP • Coronal T2- weighted image
and lateral showing a medial collateral
• Optional view : stress ligament tear with
radiographs in skeletally surrounding oedema and
immature patient, may
indicate gapping through joint effusion.
physeal fracture
• Findings : usually normal
calcification at the medial
femoral insertion
site (Pellegrini-Stieda
Syndrome)
TREATMENT

Nonoperative • NSAIDs, rest,


therapy, bracing

Operative • ligament repair vs.


reconstruction
LATERAL COLLATERAL LIGAMENT
REFERRED TO AS FIBULAR COLLATERAL LIGAMENT
MECHANISM

• direct blow or force to weight bearing knee


• excessive varus stress, external tibial rotation, and/or hyperextension

CHARACTERISTICS
• tubular, cordlike structure
• Dimensions : 3-4 mm diameter, 66 mm length
• Origin : lateral femoral epicondyle, posterior and proximal to insertion
of popliteus

FUNCTION

• primary restraint to varus stress at 5° and 25° of knee flexion (provides 55% of
restraint at 5°, provides 69% of restraint at 25°)
• secondary restraint to posterolateral rotation with <50° flexion
• resists varus in full extension along with ACL and PCL
PRESENTATION
• instability near full knee extension
• difficulty ascending and descending stairs
• difficulty with cutting or pivoting activities
Symptoms • lateral joint line pain and swelling

• inspection and palpation (ecchymosis and lateral joint line tenderness)


• ROM & stability (varus stress test and dial test)
• gait assessment (hyperextension or varus (lateral) thrust gait)
Physical • neurovascular exam (common peroneal nerve injuries may occur with
LCL/PLC injury)
exam
IMAGING
RADIOGRAPH MRI
• AP, lateral, and varus stress
radiographs
TREATMENT
Nonoperative Operative
• limited immobilization, • LCL repair/reconstruction
progressive ROM, +/- PLC/ACL/PCL
quadriceps strengthening, reconstruction
and functional
rehabilitation
• Complication : progressive
varus
ACL
PCL
Deep infection
Patellofemoral pain
Knee stiffness
Arthritis (Chronic PCL defc.)
Loss of full extension

COMPLICATION

MCL LCL
Pellegrini-Stieda Syndrome Progressive varus
Loss of motion Peroneal nerve injury
Saphenous nerve injury
WHAT IS SPRAIN?
Acute ligament injury
Grade I sprains
partial tears with mild rupture or stretching of the collagen fibers and no
apparent instability of the joint when the ligament is stressed

Grade II sprains
partial but more severe, and there is some laxity on stressing of the joint

Grade III sprains


are complete ligament ruptures with complete instability of the ligament
on stress maneuvers