MUHAMMAD AZFAR BIN MAZLAN

C014172027

SUPERVISOR : Dr.dr. Muhammad Sakti, Sp. OT (K)

RESIDENT : dr. Kerwin
dr. Maxmillian

Orthopaedic and Traumatology Department, Faculty of Medicine Hasanuddin University

INTRODUCTION

 Clinical definition : injury in the form of tear or rupture affecting the anterior cruciate
ligamentum ( ACL) and posterior cruciate ligament (PCL) in the knee.

 Epidemiology
Incidence : Non-contact ACL and PCL injuries are more common
Demographics : more common in female athletes
Risk factors : sports ( football,soccer,skiers and basketball ) , motorcycle accidents

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 ANATOMY

ATTACHMENT Cruciate ligaments:

POSTEROMEDIAL ANTERIOR TIBIAL • Anterior cruciate ligament (ACL) : Primary
ASPECT OF restraint to anterior tibial translation
ACL LATERAL FEMUR
CONDYLE • Posterior cruciate ligament (PCL) : Primary
LATERAL ASPECT POSTERIOR
restraint to posterior tibial translation
OF MEDIAL PROXIMAL TIBIA
PCL FEMUR CONDYLE
Thompson JC. Netter’s Concise Orthopaedic Anatomy 2nd ed. 2010
 FUNCTION OF ACL AND PCL

 provides 85% of the stability to prevent anterior

and posterior translation of the tibia relative to
the femur

 acts as secondary restraint to tibial rotation and

varus/valgus rotation

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POSTERIOR CRUCIATE LIGAMENT (PCL)
INJURIES
 PATHOLOGY
- Direct blow to the knee while it is flexed (dashboard injury)
- Falling hard on the knee
- Hyperextension injury
- (any mechanism that involve the knee to be forced posteriorly can leads to pcl
injury)
 CLASSCIFICATION
• Based on poesterior subluxation of tibia relative to femoral condyles (with knee in
90degree of flexion)
- Grade 1 ( partial )
1-5mm posterior tibial translation
Tibia remain anterior to the femoral condyles
- Grade II (complete isolated)
6-10mm posterior tibial translation
Complete injury in which the anterior tibial is flush with the femoral condyles
- Grade III (combined PCL and capsuloligamentous)
>10mm posterior tibial translation
Tibia is posterior to the femoral condyles and often indicates an associated ACL and/or
PLC injury
 DIAGNOSIS
• History
• Special Test
• MRI / CT Scan

MRI of the knee shows a torn posterior

cruciate ligament
 SPECIAL TESTS
• Posterior Drawer Test
• Reverse Lachmans Test
• Posterior Sag Sign
Reverse Lachmans Test
The posterior tibial sag sign. The photo on the left demonstrates the
clinical finding of the posterior tibial sag sign. The photo on the right
show the quadriceps active drawer test. With the knee in 70-90’ of
flexion, the extensor mechanism is contracted, pulling the tibia
anteriorly into a reduced position

A close-up view of a posterior tibial sag with

an incompetent posterior cruciate ligament
 TREATMENT
• Complete rest
• Surgical Intervention
• Physiotherapy Rehabilition
REST
• Complete rest is advised within a supportive brace for grade 1 and grade 2 tear of
PCL, which generally heals on its own

SURGERY
• Performed for grade 3 and grade 4 tearing
• Graft is taken from either hamstrings or achilles tendon
• Ligament reconstruction arthroscopy is performed
Anterior Cruciate Ligament (ACL)
INJURIES
 PATHOLOGY :

•Injury that causes hyperextension or valgus deformation of the knee ( e.g football injury )
Contact
mechanisms •High speed motor vehicle accident

•Changing direction ,pivoting,or landing that leads to rotation or valgus stress of the knee after
Non contact sudden deceleration
mechanisms

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 MECHANISM OF
INJURY

Non contact
Contact injury
injury

The Quadriceps Hyperflexion or

Noncontact Muscular Body
Active Limb Alignment Hyperextension
Pivot Strength Movement
Mechanism Mechanisms

Don Johnson.ACL Made Simple, 2003

 MECHANISM OF INJURY : NON CONTACT

Noncontact Pivot, Internal

Rotation/External Rotation
 The most common injury
mechanism involves no contact
with others.
 The athlete is simply running
and abruptly changes direction
 The athlete lands in the flexed
position, the quadriceps
contract, and the tibia is
subluxed anteriorly.
 Then with further flexion, the
tibia reduces with a snap.

Don Johnson.ACL Made Simple, 2003

 MECHANISM OF INJURY : NON CONTACT

The Quadriceps Active Mechanism

 The quadriceps contraction may be of
importance in injuring the ACL.
 Barrett and coworkers have reproduced this
mechanism of active quadriceps contraction in
the laboratory.
 In the video, the cadaver knee is clamped, the
quadriceps mechanism is held with the dry ice
clamp, and the force of pulling on the
quadriceps subluxes the tibia forward and
ruptures the ACL.
 The next sequence shows the ruptured ACL.
The last sequence demonstrates a positive
Lachman test on the specimen.

Don Johnson.ACL Made Simple, 2003

 MECHANISM OF INJURY : CONTACT

 A common mechanism in football or hockey

is the blow to the outside of the knee when
the knee is flexed and rotated.
 The elements of a potential ACL tear by the
contact mechanism are:
• Uphill arm back.
• Skier off balance to the rear.
• Hips below the knees.
• Uphill ski unweighted.
• Weight on the inside edge of downhill ski.
• Upper body generally facing downhill ski.

Don Johnson.ACL Made Simple, 2003

 MECHANISM OF INJURY : CONTACT

 Hyperflexion or Hyperextension Mechanisms

 These less-common mechanisms of injury are often
associated with other injuries to ligaments, such as
the posterior cruciate ligament.
 Gender Issues
 During the past decade, the incidence of ACL injury
in female athletes has increased more than the rate
in male athletes.
 In an article by Traina and Bromberg, the authors
listed the following as possible causative factors:
• Extrinsic • Muscular strength. • Body movement. •
Shoe surface interface. • Level of skill.
• Intrinsic • Joint laxity. • Limb alignment. • Notch
width and ligament size.

Don Johnson.ACL Made Simple, 2003

 MECHANISM OF INJURY : CONTACT
 Limb Alignment
 Ireland has emphasized limb alignment (the
wider pelvis, increased femoral anteversion,
and the genu valgum) with decreased
muscular support, specifically the hamstrings,
as possible causes for the increased ACL
injury rates in women
 Notch Width
 Shelbourne and Klootwyk have documented that
women have a smaller notch than men.
 It has also been reported that athletes who sustain
ACL injuries have a narrow notch.
 It may well be that the narrow notch is only one
indication of a small incompetent ligament that is
easily torn.
Don Johnson.ACL Made Simple, 2003
 MECHANISM OF INJURY : CONTACT
 Muscular Strength
 Woitys (in Griffin et al.) has shown that gender
differences exist in muscle strength, muscle
recruitment order, and hamstring peak torque
times.
 The implication is that women should emphasize
hamstring strengthening to protect the ACL.
 Extrinsic Conditioning
 Many authors believe that the novice female athlete
is introduced to activities that are beyond her physical
conditioning.
 Tim Hewett has demonstrated that unconditioned
females land from a jump with the knee more
extended, and, because of the wide pelvis, in a
valgus position.
 This extended valgus position puts them at risk for an
ACL injury.
Don Johnson.ACL Made Simple, 2003
 MECHANISM OF INJURY : CONTACT
 Body movement
 Arendt and others have documented that most ACL injuries are the
result of noncontact mechanisms.
 The common mechanisms are: • planting and cutting: 29%. • straight
knee landing: 28%. • landing with knee hyperextended: 26%.

 Intrinsic joint laxity

 There are contradictory studies on the role of ligamentous laxities.
 Yu et al. have shown that the ACL has both estrogen and
progesterone receptors.
 The cyclic variation of estrogen may affect the ligament metabolism
and make females more prone to injury during the estrogen phase of
their cycle.
 Karangeanes and vangelos studied the incidence of ACL injury during
the cycle of increased estrogen and found no significant difference.

Don Johnson.ACL Made Simple, 2003

PRESENTATION
Symptoms :
 Feeling a ‘pop’ in the knee acute swelling and pain
 Instability or ‘giving out’ knee

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 PHYSICAL EXAMINATION

 Patients may walk with a “quadriceps avoidance” gait.

 swelling usually occurs within first 2 hours after an acute injury
(hemarthrosis).
 effusion may be apparent visually, especially in acute cases.
 muscle atrophy could be present in chronic cases

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 SPECIAL TEST

• Lachman Test

• Anterior drawer test

• Pivot shift test

 LACHMAN'S TEST
 is the most definitive and easily performed test for
ACL tears
 The knee should be positioned
at 20° to 30° of flexion
 The upper hand controls the distal thigh, while the lower
hand, with the thumb on the tibial tubercle and the fingers
feeling to ensure that the hamstrings are relaxed, pulls the
tibia forward

Value Interpretation
0 Negative
1+ 0-5 mm of anterior displacement,sometimes with
an end point
2+ 5-10 mm of anterior displacement,with no end
point
3+ 10 mm af anterior displacement ,with no end
point

ACL Made simple,Don Johnson, Diagnosis of ACL Injury, p14. SPRINGER,New York 2003
 ANTERIOR DRAWER TEST

 The proximal tibia is anteriorly pulled while

the patient is supine and the knee is flexed at
90 degrees
 If there is anterior translation then the test is
positive

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 PIVOT-SHIFT TEST
 Knee placed in internal rotation, valgus, and an axial-
directed load with the knee in full extension (anterior
translated)
 When the knee is carefully flexed to 200 to 300 the tibia,
which is anteriorly translated, suddenly reduces
posteriorly (secondary to the pull of the iliotibial band),
giving the sensation of a pivot or shift.
 Positive : if there is anterior translation

Operative technique : sports knee surgery, 2008,saunders, an imprint of elsevier inc Mark D.Miller,P8 ,Ligament examination
 KT 1000
• The KT-1000 arthrometer
will normally show side to
side difference of less than
5 mm.
• The examination is
expensive and need a
professional medicine.
IMAGING OF ACL RUPTURE
MRI : To confirm diagnosis
• ACL tear best seen on sagittal view
• Discontinuity of fibers on T2
• Abnormal orientation NORMAL
• Non visualization of ACL ACL
ACL TEAR
• Bone bruising occurs in more than half
of acute ACL tears
–middle 1/3 of LFC (sulcus terminalis)
–posterior 1/3 of lateral tibial plateau

BONE BRUISING

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TREATMENT
Before any treatment , encourage strengthening of the quadriceps and hamstring , ROM
exercise
TREATMENT
Treatment option depend on patient preoperative level of activity based on the International
Knee Documentation Committee:
Level 1 include jumping, pivoting, and hard cutting
Level 2 is heavy manual work or side-to-side sports
Level 3 encompasses light manual work and noncutting sports (running, cycling)
Level 4 is sedentary activity without sports
TREATMENT

Non operative :
 rest ,ice,compression, and elevation ( RICE) therapy, goal to obtain a full ROM and
strength compared with uninjured knee
Indication : 1) to reduce pain,edema and hemarthrosis in the acute stage of the injury
2) elderly patient or in less active athletes
Operative :
 Surgical reconstruction
indication : 1) Young and active patients with demand sports or jobs
2) Significant knee instability ( injuries affecting multiple knee structures)

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 CHOICES OF RECONSTRUCTION
 The gold standard is BPTB ( Bone Patella Tendon
Bone) surgery.
 Hamstring tendon
 Single bundle surgery
 Double bundle surgery

Don Johnson.ACL Made Simple, 2003

 REHABILITATION
 Physical therapy – closed chain exercise used to emphasize early and long-term
maintenance of full extension
 4 Categories per Shelbourne and Nitz
- Phase 1: Operative period when the goal is to maintain full ROM
- Phase 2 (0-2 wk): To achieve full extension, maintain quadriceps control, minimize
swelling and achieve flexion to 90degree
- Phase 3 (3-5 wk): Maintain full extension and increase flexion up to full ROM
- Phase 4 (6 wk): Increase strength and agility, progressive return to sports. Return to
all sports without activity may take 6-9mth and should be closely monitored by the
surgeon and physical therapist

Don Johnson.ACL Made Simple, 2003

CRITERIA FOR RETURN TO SPORTS
Frandak and Berasi
• Minimum of 9 months after surgery
• Full ROM
• Isokinetic test indicates quadriceps strenght at least 90 % of uninvolved led
• No pain or swelling

Don Johnson.ACL Made Simple, 2003

THANK YOU !