ANTERIOR CRUCIATE

LIGAMENT RECONSTRUCTION
INTRODUCTION-HISTORY
In 1970s ACL reconstruction was carried
out using extra articular reconstructions
through large ARTHROTOMIES.
In 1980s intra articular reconstructions
were carried out through ARTHROSCOPIC
TECHNIQUES which helped in use of
ACCELERATED rehabilitation protocols that
focused on early motion.

INTRODUCTION-HISTORY
In 1990s the concept of
ACCELERATED rehabilitation
developed to return athletes to
playing field quicker.
ANATOMY
ACL is placed behind the centre line
of knee.
It has 3 parts:
1. Anterior part Smaller & thin in
structure.
2. Intermediate part
3. Posterior part Larger & thicker in
structure.
ANATOMY
The anterior part of ACL is tight in
extension of knee.
The posterior part of ACL is tight in flexion
of knee.
Length of ACL ranges from 1.85 3.35cm.
Medial geniculate artery supplies blood.
ACL injuries are mainly due to Sports.
ORDER OF ACL TEAR
I Light femoral attachment (most
common area)
II Intra substance
III Firm & tight tibial attachment
(In sever tear)
SIGNS/SYMPTOMS OF ACL
TEAR
Pain is moderate to severe & placed
deeply.
Complete disruption leads to a snap
or pop frequently followed by
instability to ambulate.
Knee becomes swollen & tender after
3-4 hrs.
History of giving way.
Heamarthrosis may be present.
DIAGNOSTIC TESTS
Anterior drawer test
Lachmanns test - 30 flexion of
knee with femur stabilized, tibia is
drawn forward. Increase in ant-post
diameter leads to positive result.
Grade I Instability - <10mm
Grade II Instability 10 -15mm
Grade III Instability >15mm
FACTORS RESPONSIBLE FOR A BETTER
REHABILITATION PROTOCOL
Graft materials & fixation methods
Knowledge about graft healing
Improved understanding of graft
biomechanics
Effects of various exercises &
activities on graft strain
BIOMECHANICAL INFORMATION
ACL is a primary restraint to anterior
translation of tibia & secondary
restraint to tibial rotation & to varus
& valgus stress.
ACL can resist forces upto 2500N &
strain upto 20% before failing.
Examples of forces placed on intact
ACL ranges from;
100N on active knee extension

BIOMECHANICAL INFORMATION
400N on walking
1700N on cutting & acceleration &
deceleration activities.
Medial rotation of the extended knee
is prevented by stretches of ACL.

VARIOUS TISSUES USED FOR
AUTO-GRAFTS
(Auto graft - Tissues from the body of
the patient)
The gracilis tendon 49% of ACL
strength
Semitendinosus tendon 70% of
ACL strength
Fascia lata
The Bone Patellar Tendon Bone

VARIOUS TISSUES USED FOR
ALLO-GRAFTS
(Allo grafts Biological tissue taken
from another human body)

The major risk of using allograft
involve disease transmission &
problems with effective sterilization
procedures.

ARTIFICIAL-GRAFTS
Synthetic devices Gore tex, Leeds
Kiev a tube of fine carbon mesh.
Tissue scaffold devices
Ligament augmentation devices
The major risk is, it will deteriorate
over time & cant repair itself.
GRAFT MATERIAL PROPERTIES
BPTB has the failure strength upto
2977N
The strength of quadrupled
Semitendinosus gracilis graft has
4000N.
These strength are greatly reduced after
surgical implantation.
Current thought is that the initial
strength must exceed that of the normal
ACL to maintain sufficient strength, why
because strength is lost during the
healing phase.
GRAFT FIXATION
In BPTB with interference screw
fixation has shown to exceed 500N
for both metallic & bioabsorbable
screws. Graft slippage has not been
a problem with this construct.
In hamstring grafts, soft tissue
fixation & graft slippage vary greatly
depending on the fixation.
GRAFT FIXATION
The strongest fixation, with the least
amount of graft slippage, is with soft
tissue washer, which can provide a
construct strength above 768N.
Interference screw fixation has not
been as successful, with yield
strengths less than 350N & graft
slippage or complete failure with low
level loading.
GRAFT FIXTATION PROCEDUR
(BPTB)
It involves harvesting the graft from
the involved knee & surgically
routing this structure through
tunnels placed in the femur & tibia in
a way that duplicates normal ACL
anatomy, then securing (fixing with
interferential screws) the graft to
the bone to allow for stable healing.
GRAFT FIXTATION PROCEDUR
(BPTB)
A small stab wound is made in the knee & a
small diameter drainage tube is inserted to help
evacuate the joint of residual bleeding which if
allowed to accumulate increases arthrofibrosis.

This small drain is usually removed after a few
days when the bleeding is controlled. Even with
the placement of the drain, POP arthrofibrosis
is a clinically significant problem that occurs
frequently.
GRAFT HEALING
ACL grafts undergo sequential
phases of AVASCULAR NECROSIS,
REVASCULARIZATION &
REMODILING.
Load failure in a BPTB auto graft can
drop as low as 11% of normal ACL &
the graft stiffness can fall as low as
13% of normal ACL during graft
maturation.
GRAFT HEALING
At approximately 3months the
tensile strength of the graft is less
than 50% of its original strength.
The implanted graft begin to
resemble a native ACL structure as
early as 6 months after implantation.
The final maturation dose occur after
1 year but will never reach
preoperative levels.
REHABILITATION CONSIDERATIONS
AFTER ACL RECONSTRUCTION
1. PAIN & EFFUSION:
These two are common after any
surgical procedures.-WHY?
They cause reflex inhibition of muscle
activity and thus postoperative muscle
atrophy.
It is important to control these problems
quickly why?
To facilitate early ROM & strengthening
activities.
STANDARD THERAPEUTIC
MODALITIES TO PAIN & SWELLING
CRYOTHERAPY
COMPRESSION &
ELEVATION
Why cryotherapy is commonly used after ACL
reconstruction?
It acts through local effects, causing
VASOCONSTRICTION which reduces fluid
extravasation; inhibiting afferent nerve
conduction which pain & muscle spasm &
preventing cell death, which limits the release
of chemical mediators of pain, inflammation &
edema.
REHABILITATION CONSIDERATIONS
AFTER ACL RECONSTRUCTION
2.Motion Loss
It is perhaps the most common
complication after ACL reconstruction.
Loss of extension is more common than
loss of flexion & is poorly tolerated.



FACTORS WHICH MAY LEAD TO LOSS OF
MOTION AFTER ACL RECONSTRUCTION
1. Arthrofibrosis, infrapatellar contracture
syndrome, patella infera.
2. Inappropriate ACL graft placement or
tensioning.
3. Cyclops syndrome.
4. Concomitant MCL repair
5. Poorly supervised or poorly designed
rehabilitation program.
6. Prolonged immobilization
7. RSD
PREVENTION OF MOTION LOSS
HOW?
Anterior placement of the tibial tunnel &
inadequate notchplasty both can lead to
impingement of the graft on the roof of
the intercondylar notch with a
subsequent loss of extension.
Anterior femoral tunnel placement may
lead to increased graft tension in flexion
with subsequent limitation of flexion.
Inappropriate tensioning of the graft may
overconstrain the knee & also lead to
difficulty regaining terminal motion.
PREVENTION OF MOTION LOSS
HOW?
Inadequate notch preparation & ACL
stump debridement may predispose the
patient to formation of a fibroproliferative
scar nodule, called a Cyclops lesion
which may impinge anteriorly in the knee
causing pain & limiting extension.
Symptoms suggestive of a Cyclops lesion
include loss of extension & a large painful
clunk on attempted terminal extension of
the knee.

PREVENTION OF MOTION LOSS
HOW?
ACL reconstruction should be delayed
until the acute post traumatic
inflammation & swelling have
subsided, full ROM has returned &
the patient has regained strong
quadriceps activation. To meet these
goals, PREOPERATIVE
REHABILITATION should be started
shortly after injury.
PREOPERATIVE REHABILITATION
Modalities to control pain & swelling such
as Cryotherapy, Elevation, Compression
& anti inflammatory medication are
helpful in eliminating reflex muscular
inhibition of the quadriceps.
Quadriceps setting, SLR & CKC exercises
accompanied by ES & Biofeedback are
useful to reactivate the lower extremity
musculature, prevent atrophy & promote
strength gain.
PREOPERATIVE REHABILITATION
Proprioception activities can also be
started to improve neuromuscular
retraining.
Activities to increase motion, aided by
exs such as PRONE HANGS, WALL
SLIDES & the use of extension boards.
Less motion loss & faster return of
quadriceps strength have been reported
when surgery was delayed until motion
was restored.
NOTE :
Early ACL reconstruction, before
return of motion & cooling of the
knee increases the risk of POST
OPERATIVE ARTHROFIBROSIS.
Control of pain & swelling, early
reactivation of the quadriceps muscle
& an early return to weight bearing
all improve the return of motion.
NOTE :
Patellar mobilization technique should be
started to prevent patellar tendon
shortening or retinacular contracture both
of which can lead to motion loss.
The most important immediate goal is to
obtain & maintain full knee extension
almost immediately after surgery.
Knee flexion to 90 should be achieved
by 7 to 10 days after surgery. Failure to
do so should prompt the early initiation of
countermeasures to prevent a chronic
problem from occurring.
REHABILITATION CONSIDERATIONS
AFTER ACL RECONSTRUCTION
3.Continuous passive motion (CPM)
Is controversial Historically, its
use was advocated to improve
cartilage nutrition & limit motion
loss during a time when
immobilization was common after
surgery.