Anterior Cruciate Ligament (ACL) Reconstruction

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Original Editors - Dorien Scheirs

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Search Strategy

Databases: PubMed, web of Knowledge, Physio-pedia

Keywords: Anterior Cruciate Ligament Injury, ACL reconstruction, ACL reconstruction complications, ACL reconstruction procedures.

Definition/Description

The Anterior Cruciate ligament injury ( ) means that there is a joint instability of the knee that leads to decrease of activity. It is caused by a twist of the knee.

The reconstruction of the anterior cruciate ligament is one of the most common orthopedic surgery, at commonly there is a articular cartilage degeneration.

Clinically Relevant Anatomy

The anatomy of the femoral and the tibial tunnel:

Femoral tunnel:

The tunnel at the sagittal side of the knee goes to the cortex of the femur and the roof of the intercondylar notch.
Tibial Tunnel:

First the tibial tunnel has to be created at the correct way, to prevent impingement of the grafts against the roof of the intercondylar notch. The tibial tunnel should be oriented at the Blumensaat line. This line goes from the tibial tuberosity and the posterior side should be oriented to the line of Blumensaat

Epidemiology /Etiology

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Characteristics/Clinical Presentation

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Differential Diagnosis

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Diagnostic Procedures

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Outcome Measures

The surgery of the ACL has a good to excellent outcome. Only 15 % remains elusive. Although some patient have artistic changes. Even if the ligament is reconstructed

Examination

The reconstruction of the anterior cruciate ligament is one of the most common orthopedic surgery, at commonly there is a articular cartilage degeneration.

A total collateral ligament rupture and a full-thickness cartilage lesion would be visualized by an MRI.
                 - There is a patella tendon procedure: involves the central third of the ipsilateral patellar tendon. There is a                          fixation of the bone blocks within the tibia and femur
                - There is a hamstring-tendon procedure: four-layer, fold-up M. gracilis en M. semitendinosus tendons.

                  This means that the take a part of the patella tendon or M. gracilis or M. semitendinosus for the                                       reconstruction of the anterior cruciate ligament. The surgery takes places at 10 weeks after the injury.

The reconstruction of the Anterior Cruciate ligament is compared with other treatments. A central aspect of the treatment is a physical therapist. But it’s not always offered.

Double-bundle reconstruction:
The semitendinosus is used with the autograft trough 2 tunnels in both tibia and femur. The autograft method: bone-to-bone ( BTB) and hamstrings/ semitendinosus grafts. They also can use 3 tunnels: 2 tunnels through the tibia and 1 tunnel through the femur.

There are 2 important procedures for the reconstruction.

The first procedure is the autologous bone-patella tendon-bone graft and the autologous four-strand hamstrings graft. These are the 2 most popular procedures.

By the bone-patella tendon-bone graft, they take a couple of bone blocks from the patella and the tibial tubercle. This procedure causes more anterior knee pain than the semitendinosus graft. By the second procedure, they take the distal end of the semitendinosus and the gracilis tendon.

Other procedures are: the LARS artificial ligament,( Ligament Advanced Reinforcement System )iliotibial tract allografts, cadaveric allografts, synthetic materials and grafts from living related donor people. But all materials have their drawbacks: cross-infections, breakage, immunological responses, chronic effusions, recurrent instability, …¹

Autograft vs allograft reconstruction of the anterior cruciate ligament

Autograft: patellar tendon grafts and Achilles tendon grafts. Standard anterolateral and anteromedial portals were created. A 3-4 cm incision was made into the tibial tunnel over the proximal part of the tibia. Then the ACL beath pin was drilled into the cortex of the femur and proximally out of the skin. At last the ACL reamer is placed over the pin trough the tibial tunnel.
The allograft method: When they used this method, they’ve taken materials from cadavers. But this method isn’t that reliable as the autograft method. And it needs a longer time to revascularize.

Postoperative treatment and rehabilitation : ²

Anti-inflammatory medication, a treatment for the swelling for 5 days after the surgery. After 3 days the patient can do straight leg raising exercises for about 200 times a day. This is necessary for strengthen the Quadriceps and to prevent other muscles to shorten.
              - After 2 – 3 weeks: active flexion and extension and plantair flexion
              - After 4 weeks: exercises for proprioception
              - After 2 -3 months: exercises for proprioception and anti-resistance training.

KINEMATICS ³

The kinematics of the single- bundle ACL reconstruction: the kinematics showed that the standard single-bundle ACL reconstruction doesn’t create the same kinematics as the intact ACL in normal activities. Only the anteroposterior stability seems to be reconstructed . When the knee turns, there is an abnormal tibial rotation in the knee. So the single-bundle ACl reconstruction does not recreate a normal rotation in the knee.

The kinematics of the double-bundle ACL recontstruction: the kinematics of the double-bundle ACL reconstruction are better than the kinematics of the single-bundle ACL reconstruction. The anterior translation is comparable with the intact ACL at 0° flexion. But the most stable position of the knee is 15° and 75°.

Medical Management

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Physical Therapy Management

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Key Research

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Resources

1) R. B. FROBELL, Ph. D. E.V. ROOS, … “A randomized trial of treatment for acute anterior cruciate ligament tears” , The new England journal of medicine, july 2010 [[1) R. B. FROBELL, Ph. D. E.V. ROOS, … “A randomized trial of treatment for acute anterior cruciate ligament tears” , The new England journal of medicine, july 2010 http://www.nejm.org/doi/full/10.1056/NEJMoa0907797#t=article 2) D.L SHI, “Effect of anterior cruciate ligament reconstruction on biomechanical features of knee in level walking: a meta-analysis” , Chinese medical journal,2010 http://www.cmj.org/Periodical/paperlist.asp?id=LW2010113338438408321&linkintype=pubmed 3) A.B. MEYERS, A.H. HAIMS, ‘Imaging of anterior cruciate ligament repair and its complications’, American Journal of roentgen logy. Febuary 2010 http://www.ajronline.org/cgi/reprint/194/2/476 (kinematics) 4) C. LEGNANI, A. VENTURA, ‘Anterior cruciate ligament reconstruction with synthetic grats. A review of literature’, January 2010, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903133/?tool=pubmed 5) J.M. HUAN, ‘Cruciate ligament reconstruction using LARS artificial ligament under arthroscopy: 81 cases report’, Chinese medical journal, 2010 http://www.cmj.org/Periodical/paperlist.asp?id=LW2010120595905909751&linkintype=pubmed 6) E. TSUDA , I. YASUYUKI, “Comparable results between lateralized single- and double- bundle ACL reconstructions”, Hirosaki university graduate school of medicine, october 2008 http://www.cmj.org/Periodical/paperlist.asp?id=LW2010120595905909751&linkintype=pubmed 7) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2650066/?tool=pubmed  level of evidence is II, therapeutic study |http://www.nejm.org/doi/full/10.1056/NEJMoa0907797#t=article]]

2) D.L SHI, “Effect of anterior cruciate ligament reconstruction on biomechanical features of knee in level walking: a meta-analysis” , Chinese medical journal,2010
http://www.cmj.org/Periodical/paperlist.asp?id=LW2010113338438408321&linkintype=pubmed

3) A.B. MEYERS, A.H. HAIMS, ‘Imaging of anterior cruciate ligament repair and its complications’, American Journal of roentgen logy. Febuary 2010 http://www.ajronline.org/cgi/reprint/194/2/476 

4) C. LEGNANI, A. VENTURA, ‘Anterior cruciate ligament reconstruction with synthetic grats. A review of literature’, January 2010, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903133/?tool=pubmed

5) J.M. HUAN, ‘Cruciate ligament reconstruction using LARS artificial ligament under arthroscopy: 81 cases report’, Chinese medical journal, 2010 http://www.cmj.org/Periodical/paperlist.asp?id=LW2010120595905909751&linkintype=pubmed

6) E. TSUDA , I. YASUYUKI, “Comparable results between lateralized single- and double- bundle ACL reconstructions”, Hirosaki university graduate school of medicine, october 2008[[ http://www.cmj.org/Periodical/paperlist.asp?id=LW2010120595905909751&linkintype=pubmed%7Chttp://www.cmj.org/Periodical/paperlist.asp?id=LW2010120595905909751&linkintype=pubmed]]

7) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2650066/?tool=pubmed  level of evidence is II, therapeutic study

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

^{1 C. LEGNANI, A. VENTURA, ‘Anterior cruciate ligament reconstruction with synthetic grats. A review of literature’, Januari 2010}

^{2 J.M. HUAN, ‘Cruciate ligament reconstruction using LARS artificial ligament under arthroscopy: 81 cases report’, Chinese medical journal, 2010}

^{3 A.B. MEYERS, A.H. HAIMS, ‘Imaging of anterior cruciate ligament repair and its complications’, American Jrounal of roentgenology. Febuari 2010}