ANTERIOR CRUCIATE LIGAMENT

 
 
ANATOMY
 
The knee is considered a “hinged” joint since it is designed to allow the lower leg to flex
and extend.  The knee is formed by the femur (thigh bone), the tibia (shin bone), and
the patella (knee cap).  Each bone is covered with a layer of smooth cartilage, called
articular cartilage.
 
                 
There are four main ligaments that stabilize the knee joint.  These act like rubberbands
to allow motion while maintaining proper orientation of the bones.  A ligament is a
tissue located anywhere within the body that connects one bone to another.  Within the
knee, there are four ligaments present to stabilize the joint:  the posterior cruciate
ligament, the lateral and medial collateral ligaments, and the anterior cruciate
ligament.  The anterior cruciate ligament, located in the center of the knee, is the most
important ligament of the knee.  This is because of its’
main function, which is to stabilize the joint during deceleration. It prevents backward
dislocation of the femur on the tibia ( or forward slipping of the tibia on the femur and
the hyperextension of the knee joint.
The ACL runs from the back of the femur, or thighbone, to the front of the tibia.  The
most common mechanism of injury to the ACL is a twisting or cutting motion, which
stretches or tears the ligament.
 
LIGAMENT TEARS
The ACL and the PCL cross one another in the center of the knee.  The ACL is tightest
when the knee is straight, and the PCL is tightest when the knee is flexed.  If these
ligaments are stretched too far, they can tear or separate.  The injury can happen in one
of three “grades”:
l      Grade 1, in which the ligament is stretched, but not torn
l      Grade 2, where the ACL is partially torn
l      Grade 3, where the ACL is completely torn and instable
Depending upon the level of activity of the individual and what level of activity he or
she is attempting to return to may help decide on a conservative methods to manage
the deficient ACL or often a surgical procedure to replace the torn ligament with similar
tissue.
 
SYMPTOMS OF THE TEAR
When the ACL is torn, the patient may feel a “pop” in the knee, followed by swelling and
difficulty continuing the sport.  The patient may have a hard time walking and may also
feel a sense of instability.  A torn ACL makes the knee vulnerable to re-injury because it
is not stable with certain activities.  This can lead to the knee repeatedly giving way,
which damages other supporting structures of the knee.
 
DIAGNOSIS
An ACL tear is best diagnosed by an orthopedist during a physical exam to determine
the laxity (looseness), strength, and pain points within the joint.  A MRI (magnetic
resonance imaging) may be obtained to confirm an ACL tear as well as to rule out any
other problems within the knee joint.
 
SURGERY
The orthopedist will then schedule to reconstruct the ACL, replacing it with a graft from
the central 1/3 of the patella tendon or grafting from two of the hamstring tendons (the
semitendonosis and the gracilis). Another graft option may be that of one harvested
from a cadaver which is equivalent to that of the patients. The patient may choose to
have an epidural or general anesthesia during the procedure which commonly lasts
between one and one and a half hours.  Initially, the torn ends of the ACL must be
removed.  Then the femoral notch is widened to accept the new graft. Then through a
separate incision, a tunnel is drilled through the tibia and through the femur in the
same alignment as the original ligament. The graft is pulled into position using sutures
placed through the drill holes.  Once the graft is in the correct path, screws are used to
hold it in place. Following the attention given to any other problems, the surgery is
completed and the patient is placed in a post-op brace to protect the reconstruction.  
  
RECOVERY
Hospitalization overnight is possible although this procedure can be provided as
outpatient.  While resting in bed, the swelling may be reduced by elevating the leg and
pumping the ankles.  Crutches are required immediately post-op but can be discharged
per doctor order.  The post-op brace is worn at all times until otherwise directed by the
physician.  The knee must be kept dry until the incisions are healed (about 7 to 10 days)
or until the physician directs otherwise.  Ice may be applied as needed for 15 to 20
minutes and activities must be modified  to avoid unnecessary stress on the new graft. 
Restrictions on activity may last 6 to 12 months after surgery or until the physician
directs.
 
EXERCISES
Immediately post-op, it is imperative to begin some basic exercises to accentuate the
healing process.
1.      Quad set--  (Figure 1) do as many as possible to help increase the function of
the quad and to work on decreasing the swelling.
2.      Ankle pumps—(Figure 2) flex the ankle up and down, pumping the calf to
increase the circulation and initiate movement, this also helps to relieve
some of the bruising in the lower extremity.
3.      Straight leg raise—(Figure 3) lift the leg, attempting to maintain the knee as
straight as possible, approximately 6 inches holding in place for 5 seconds. 
This exercise can be performed as many times as possible while maintaining
proper form.
4.      Extension— it is extremely important to achieve and to maintain full
extension immediately following surgery.  Propping the ankle on a chair, foot
stool, or coffee table or, if possible, prone lying to achieve full extension. 
These exercises should be attempted for up to 30 minutes at a time.  For no
reason should a pillow or towel roll be placed under the knee, only at the
ankle.
 
Sources:
1.      Anterior Cruciate Ligament: http://www.knee1.com/care/condition20.cfm
2.      Anterior Cruciate Ligament Injuries: Surgery and Rehabilitation
 http://homepage.together.net/
3.      Center for Orthopaedics, M. Alan Hinton, MD
www.lac.laci.net/pweb/hintonmd/acl.htm
4.      Orthogate Medical Media Group
5.      Orthopaedic Institute of Central Jersey, “About ACL Reconstruction Surgery”
6.      Rothman Institute at Jefferson, Michael G. Ciccotti, MD, “ACL Injury and
Reconstruction

Anterior Cruciate Ligament (ACL) FAQ

 Does this Weaken the Hamstrings?
Why is the ACL Important?

Will I have to Stay in the Hospital?

How is the ACL Injured?

When Can I Walk on my Leg after Surgery?

What are the Signs of an ACL Tear?

Will I need Rehab or Physical Therapy?

How is a ACL Tear Diagnosed?

What are the Risks of Surgery?

Will I need Surgery?

What would Happen if I did Nothing about an Injured

How is the ACL Treated Surgically?
ACL?

Why is the ACL Important?

Without the ACL the knee is less stable. Without its stabilizing influence, the knee can buckle
suddenly as it is used and this leads to cartilage damage and eventually to arthritis. This is
usually not a problem for "straight-ahead" activities such as walking or jogging. However, it
can be a big problem for activities involving twisting, pivoting, jumping, or suddenly changing
directions. Examples of these activities include most sports (especially basketball, football,
volleyball, soccer, skiing, etc.) and many jobs (such as carpentry, warehouse, refinery, etc.)

Back to Top

How is the ACL Injured?

One of the most common ways for the ACL to be injured is by a direct blow to the knee, which
commonly happens in football or a fall when skiing. In this case, the knee is forced into an
abnormal position that results in the tearing of one of more knee ligaments.

However, most ACL tears usually happen without contact between the knee and another
object. Such non-contact injuries happen when the athlete is planting the foot and cutting,
landing on a straight leg, or making an abrupt stop. These movements are common in
basketball, football, volleyball and soccer.

Back to Top

What are the Signs of an ACL Tear?

In many cases, when the ACL is torn, you will feel the knee give way with an audible pop. The
injury is usually associated with a moderate amount of pain and continued activity is usually
not possible. Over the next several hours, the knee becomes very swollen and walking
becomes difficult. The swelling and pain are usually the worst for the first two days and then
begin to subside.

Back to Top

How is a ACL Tear Diagnosed?

ACL tears usually cause enough discomfort to seek medical attention. The physician will
examine the knee, and , in most cases, be able to identify which ligaments are injured.
However, there may also be injuries to the joint surface that are more difficult to diagnose. In
 addition, swelling may sometimes make it difficult to diagnose a tear. Further evaluation with
an MRI or arthroscope may be necessary to completely evaluate the injury.

Back to Top

Will I need Surgery?

The answer varies from person to person. Many factors must be considered by the patient and
the physician when determining the appropriate treatment. These factors include the activity
level and expectations of the patient, whether there are associated injuries, and the amount of
abnormal knee laxity, or looseness.

A young patient, who wants to return to competitive sports and has a knee that is very
unstable on examination is more likely to need surgery for a satisfactory outcome than an
older patient, who wants to return to recreational jogging and has only mild laxity.

If surgery is not indicated, rehabilitation of the knee begins with exercises to help restore the
full range of motion. This is followed by strengthening exercises for the muscles around the
knee. A return to sports with or without a knee brace is allowed only after leg strength,
balance, and coordination have returned to near normal.

Back to Top

How is the ACL Treated Surgically?

Many different surgical approaches have been tried for the ACL injured knee. Years of
experience have shown that simply stitching the ligament together is rarely successful, as the
ligament almost always tears again. Therefore, current techniques involve reconstructing the
ACL using a tendon from your own body. There are two choices for this substitute tendon: the
central third of the patellar tendon (the tendon which runs from the knee cap to the shin bone),
or the hamstring tendons from behind the knee. This tissue is passed through drill holes in the
thigh bone and shin bone, and then anchored in place to create a new ACL. Shortly after the
surgery, your knee will be in a continuous passive emotion machine (CPM). This is essentially
a hammock for your leg which gently bends and straightens the knee. Over time, the new ACL
regains its blood supply and cells and becomes a living ligament anchored to the bone on each
end.

Back to Top

Does this Weaken the Hamstrings?

Will I have to Stay in the Hospital?

Most patients stay overnight and go home early the next morning. Everything is done
arthroscopically (through small poke holes) except for harvesting the patella tendon or
hamstring graft which requires a shirt incision on the front of the knee.

Back to Top

When Can I Walk on my Leg after Surgery?

Will I need Rehab or Physical Therapy?

 Yes, this is very important. Your chance of achieving a normal knee function after the surgery
is greatly increased by the proper rehab. In fact, it takes a great commitment from the patient to
get to the therapist and do the exercises with the appropriate diligence. It is also important to
do only the correct exercises, as doing the wrong exercises can be more damaging than doing
none at all. Unless otherwise instructed, you should start supervised physical therapy one to
two days after your surgery. At first, physical therapy emphasizes obtaining your full range of
motion and some strengthening exercises. As your motion improves, more emphasis is placed
on strengthening. Usually within a week you are on a stationary bike and gradually progressed
to a stair climber. You will also be doing some weight lifting exercises such as mini-squats and
leg press. There is a gradual return to sports with shooting baskets at 2-3 months, golf at 2-3
months, and so on. Full-speed sports are usually allowed at 5 months assuming your strength
and agility have returned to near normal.

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What are the Risks of Surgery?

The risks of surgery are possible, but uncommon. The most frequent problem is stiffness. That
is why your knee should be flexible beforehand, and why you need to use the CPM machine
and attend physical therapy. 

Blood clots are also possible, but rare (less than one percent). You will have a stocking on
your leg to minimize swelling and lower your chances of getting a blood clot in your leg.
Keeping your leg mobile also decreases this risk. 

Infection is also rare, but possible. We sterilize your leg and use antibiotics to prevent this. 

It is also possible to stretch or tear the graft. For the first five months the graft is weak, so you
will need to avoid twisting and cutting activities. Even after the graft is mature, you can still
tear it. 

While any surgery should be taken seriously, please rest assured that complications are
relatively rare.

Back to Top

What would Happen if I did Nothing about an Injured ACL?

Usually within weeks of tearing a ligament, the pain and swelling go away and the knee starts
to move well. The problem comes when you try to cut, pivot, or twist the knee. Without the
stabilizing influence of the ACL, it is likely to buckle and give way. Patients usually end up with
a "trick knee" that gives way unexpectedly. The problem with this is that with each episode of
buckling, the joint gets scuffed and cartilage often tears leading to arthritis. People who elect
to live less active lives (no jumping, cutting, pivoting, running sports" can get by without this
ligament. Currently, the conservative way to treat the injury is with reconstructive surgery, if
you plan to remain active agility in sports.

Back to Top

MRI

MRI (magnetic resonance imaging) uses radio waves and a strong magnetic field rather than x-
rays to provide remarkably clear and detailed pictures of internal organs and tissues. The
procedure is valuable in diagnosing a broad range of conditions in all parts of the body,
including heart and vascular disease, stroke, cancer, and joint and musculoskeletal disorders.
MRI is unique in that it can also create detailed images of blood vessels without the use of
contrast media (although there is a trend toward the use of special MRI-contrast medium, for
example, Gadolinium), when imaging the vessels, as well as soft tissue like the brain. MRI
 requires specialized equipment and expertise and allows evaluation of some body structures
that may not be as visible with other imaging methods.

ARTHROSCOPE

The arthroscope is a tube-like viewing instrument with special optic fibers and lenses that
produce high resolution images on a television screen, allowing the surgeon to examine a
patient’s joint without majorly damaging surrounding tissue. The incisions required for
arthroscopy are only ¼ inches long on either side of the joint, resulting in very little blood.

Arthroscopy is a surgical procedure used by orthopedic surgeons to visualize, diagnose, and

treat problems inside joints. A small incision is made in the patient’s skin and then a pencil-
sized instrument is inserted. A small lens magnifies and illuminates the structures within the
joint. An arthroscope acts much like a miniature television camera, allowing the surgeon to see
the interior of the joint. The image is displayed on a television screen, and the surgeon can
determine the amount and type of injury, and then repair or correct the problem. On many
occasions, diagnosis through an arthroscope is more accurate than through an open surgery
or from X-rays.

Arthroscopy is a surgical procedure used by orthopedic surgeons to visualize, diagnose, and

treat problems inside joints. A small incision is made in the patient’s skin and then a pencil-
sized instrument is inserted. A small lens magnifies and illuminates the structures within the
joint. An arthroscope acts much like a miniature television camera, allowing the surgeon to see
the interior of the joint. The image isi displayed on a television screen, and the surgeon can
determine the amount and type of injury, and then repair or correct the problem. On many
occasions, diagnosis through an arthroscope is more accurate than through an open surgery
or from X-rays.

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 Meniscus Repair/Menisectomy
 

                       

  General            Q & A             Pictures             Footage

THE MENISCUS: SHOCK ABSORBER FOR THE KNEE

ANATOMY

The meniscus is a half moon shaped piece of cartilage that lies between the weight
bearing joint surfaces of the femur and the tibia.  The menisci of the knee are rubbery,
fibrocartilaginous cushions which provide improved stability and gliding of the knee
joint by virtue of their unique shape.  In a normal knee, there are two menisci, one on
either side of the knee, the medial and the lateral meniscus.

The menisci play an important role in absorbing about one third of the impact load that
the joint cartilage surface is exposed to. Research shows that the menisci and their
presence in the knee can be directly related to the progression of arthritis in the knee
joint if the entire meniscus must be removed.  This, of course, is directly related to the
age, activity, and preexisting “wear-and-tear” of the individual. The menisci also cup the
joint surfaces of the femur and therefore provide some degree of stabilization for the
knee.

The menisci itself is for the most part avascular, that is, it does not bleed if cut and does
not have blood vessels inside.  The exception to this is at the periphery where it joins to
the vascular knee lining that provides the outermost 20% of the menisci with their blood
supply.  As a result, a torn meniscus does not have the ability to heal itself unless the
tear is in the outside vascular zone. For purpose of description of the menisci,
orthopedic surgeons refer to the front third as the anterior horn, the back third as the
posterior horn, and the middle third the body.
 MENISCUS TEARS

There are two different mechanisms for tearing a meniscus:

1.                  Traumatic tears which are a result of a sudden load being applied to the
tissue occurring with a twisting injury or blow to the side of the knee.

2.                  Degenerative meniscal tear which is best thought of as a failure of the

meniscus over time. Sometimes there are no memorable injuries or violent
events which is the cause for the tear.

A tear can happen in almost any pattern but the tear isolated to the anterior horn is not
likely.  The tear typically begins in the posterior horn and then can extend forward into
the middle body as well as the anterior horn. Figure 1 shows examples of different
tears.

                                                            Figure 1

 
 
 
 
 
 
 
 
SYMPTOMS OF A TEAR

A torn meniscus will usually cause pain on the side of the knee that is injured along with
swelling in the joint itself may occur.  Typically low-level swelling will set in the day
after the injury causing stiffness and limping.  Occasionally, the knee will “lock” and is
quite painful.  This can be cause by the mechanical blockage from a displaced tear. Any
twisting, squatting, or impacting activities will tend to pinch the meniscus tear or flap
and cause pain.  Meniscal tissue does not heal due to the lack of blood supply, so
symptoms are persistent until the tear is treated.

 
 DIAGNOSIS

The diagnosis of a tear is made based on the history and joint line findings.  An
orthopedist can often manipulate the joint in a way that may provoke the tear to snap
or cause pain.  This reproduction of the pain, notes a probable diagnosis of a tear.  At
times, an MRI will be obtained to visualize the integrity of the meniscus.

TREATMENT

Once the diagnosis has been made, there is one of two options for the treatment. 
Arthroscopic surgery may be performed if the size and location of the tear require this
method, or physical therapy treatments have been successful if a more conservative
method is opted. 

SURGERY

The surgery is performed as an arthroscopy on an outpatient basis.  This is done by

placing two to three incisions in the anterior of the knee.  The surgeon inspects the
entire knee to rule out any other problems within the knee and then evaluates the
meniscal tear by inspecting it with a blunt probe.  Based on the location and the size of
the tear, the decision is then made to either repair or remove the tear(s).  A
menisectomy (removal) removes the torn portion leaving as much normal tissue as
possible to remain as the shock absorber.

If the tear is confined to the zone of blood supply, it is preferable to repair the meniscus
by suturing the ends. 

POST OPERATIVE EXERCISE

Depending on whether there was a removal or a repair will make a difference in the
immediate care following surgery.  If the meniscus was removed, the patient can be full
weight bearing within a week following surgery as per doctor order.  If the meniscus
was repaired, weight bearing is not allowed for the first 3 to 4 weeks depending on size
and location of the tear and range of motion is limited to

0-60 degrees initially. Physical therapy is began within 1 week post-op.

EXERCISES

Immediately post-op, it is imperative to begin some basic exercises to accentuate the

healing process.

1.      Quad set--  (Figure 1) do as many as possible to help increase the function of
the quad and to work on decreasing the swelling.

2.      Ankle pumps—(Figure 2) flex the ankle up and down, pumping the calf to
increase the circulation and initiate movement, this also helps to relieve
some of the bruising in the lower extremity.

Straight leg raise—(Figure 3) lift the leg, attempting to maintain the knee as straight as
possible, approximately 6 inches holding in place for 5 seconds.  This exercise can be
performed as many times as possible while maintaining proper form.
  

            Figure 1                                  Figure 2                                  Figure 3

Sources:

1.      Orthopaedic Associates of Portland—Sports Medicine Center

http://orthoassociates.com/meniscus.htm
2.      MEDFACTS Sports Doc- Medical Library
3.      Meniscal Tears  http://www.sechrest.com/mmg/knee/meniscus.html
 

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