Functional pathology

Unstable tibiofemoral relationships may result in : abnormal sideways

tilt (varus or valgus), excessive glide (forwards, backwards or even in
an oblique direction), unnatural rotation (internal or external), or
combinations of these.
When testing for medial and lateral stability, valgus and varus stresses
should be applied with the knee first in 30 degrees of flexion and then
in full extension.
 More commonly there is anterolateral rotatory instability where, in
addition to a torn ACL, the lateral capsule and LCL are torn or
stretched. In this instance, not only will the anterior drawer test be
positive, but the lateral tibial condyle can be made to sublux forwards
as the tibia rotates abnormally around an axis through the medial
condyles; this is the basis of the pivot shift phenomenon
Chronic deficiency of the arcuate ligament complex causes a type of
postero-lateral rotatory instability that is a counterpart of the pivot
shift phenomenon. Complete tears of all the posterior structures also
allow the knee to hyperextend.
Imaging
MRI

Torn knee ligaments MRI (a) Coronal T2- weighted image showing a
medial collateral ligament tear with surrounding oedema and joint
effusion. (b) Sagittal T2-weighted image showing an intrasubstance tear
of the anterior cruciate ligament with a large joint effusion.
Therapy
Approach for conservative should always be a supervised, disciplined and
progressively vigorous exercise programme to strengthen the quadriceps and the
hamstrings. At the end of 6 months the patient should be reexamined.

Indications for operation :

Recurrent locking
Intolerable symptoms of giving way;
suboptimal function
ligament injuries in adolescents
Operation treatment for :
Medial collateral ligament
insufficiency
Isolated lateral instability
Isolated PCL insufficiency
Isolated ACL insufficiency
Combined injuries
- anterolateral or anteromedial
rotatory instability
- Indication for PCL
reconstruction in patients
who have more than 1015
mm of posterior tibial
translation in the drawer test.
 Partial tears of the anterior cruciate ligament are more
problematic and there is still much controversy about the need for
surgery in these cases. The decision should be based on an
assessment of the patients symptoms and functional capacity
rather than the appearance of the ligament.