8/25/23

Authored by:
Harris Slone, MD
Medical University of South Carola

§ Review Epidemiology of ACL tears and associated injuries

§ Discuss anatomy and biomechanics of the Anterior Cruciate Ligament

§ Describe the evaluation of suspected ACL tear

§ Review treatment options for patients with ACL deficiency

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September 2

§ Over 400,000 ACL

reconstructions are performed
annually in the US
§ Incidence of ACL injuries is
increasing especially in
younger patients

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Abram SGF, et al. Br J Sports Med 2019;0:1–7. doi:10.1136/bjsports-2018-100195 September 3

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§ Meniscal tears are common in patients with ACL injuries

§ In acute injuries, lateral meniscal tears are more common
(high% of acute ACL tears have lateral meniscal pathology)
§ In chronic ACL tears, medial meniscal tears are more common
than lateral.
§ There is an increased incidence of chondral pathology in
chronic ACL tears
§ Female athletes have a higher incidence of ACL injuries than
male athletes

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September 4

§ ACL course: medial aspect of the lateral

femoral condyle to the medial tibial eminence

§ Blood supply from the middle geniculate artery

§ Innervated by the posterior articular nerve via

posterior tibial nerve

§ 90% Type I Collagen

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Image from: The American Journal of Sports Medicine, Vol. 39, No. 4 DOI: 10.1177/0363546510387511 September 5

§ Two bundles:
§ Anteromedial (AM) and Posterolateral (PL)
§ AM bundle primary restraint to translation
§ More isometric
§ PL bundle primary restraint to rotational instability
§ Less isometric, tighter in extension

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Image from: Sonnery-Cottet B, Colombet P. Partial tears of the anterior cruciate ligament. Orthop Traumatol Surg Res (2016) September 6

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§ When talking about ACL

anatomy (especially on the
femoral side), it is helpful to
describe the anatomy
anatomically – which stays
constant as the knee is
flexed or extended
§ Example- if talking about the
femoral side while the knee is
flexed to 90 degrees-
POSTERIOR is toward the floor!

OrthoACCESS
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Image from: The American Journal of Sports Medicine, Vol. 39, No. 4 DOI: 10.1177/0363546510387511 September 7

§ Femoral footprint is on ~ 43% -51% of

the proximal-to-distal distance of the
lateral femoral condyle, centered over
the bifurcate ridge
§ No fibers are located anterior to the
lateral intercondylar ridge (A.K.A.
resident's ridge)
§ The distance between the posterior edge
of the footprint and the posterior articular
cartilage is approximately 2.5 mm

OrthoACCESS
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Image From: The American Journal of Sports Medicine, Vol. 39, No. 9 DOI: 10.1177/0363546511402660 September 8

§ The center of the tibial footprint

is parallel to the posterior edge
of the anterior horn of the lateral
meniscus in the anterior-
posterior direction, and 40% of
the medial-to-lateral
interspinous distance

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Image from: The American Journal of Sports Medicine, Vol. 39, No. 4 DOI: 10.1177/0363546510387511 September 9

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§ Primary:
§ Resist anterior tibial translation
§ Resist internal tibial rotation

§ Secondary:
§ Varus and Valgus Restraint

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September 10

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§ Noncontract vs. Contact mechanism

§ Perturbed landing injury
§ “Pop”
§ Effusion/hemarthrosis
§ Loose knee? Giving out? Locked knee?

§ **Pop + Pain + hemarthrosis = ACL >70% of the time**

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September 11

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§ Inspection/Alignment
§ Palpation
§ Range of Motion
§ Ligamentous Exam
§ Coronal Plane Stress
§ Lachman
§ Pivot Shift
§ Anterior/Posterior Drawer

** Examine the normal knee first!

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September 12

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** Most sensitive exam test

§ A= firm endpoint
§ B= no endpoint
§ Grade 1: < 5 mm
translation
§ Grade 2 A/B: 5-10mm
translation
§ Grade 3 A/B: > 10mm
translation

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https://drrobertlaprademd.com/lachmans-test/ September 13

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https://drrobertlaprademd.com/pivot-shift-test/ September 14

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§ Start with plain x-ray

§ Segond fracture
§ Deep sulcus terminais (lateral femoral notch sign)
§ Anterior tibial translation (may be present in chronic setting)
§ Tibial eminence
§ Associated injuries
§ Evaluation of physis

§ MRI
§ If concern for ACL tear and/or internal derangement
§ Bone age hand x-ray?
§ Consider for skeletally immature patient

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Image From: Cosgrave CH, Burke NG, Hollingsworth J. Emergency Medicine Journal 2012;29:846-847 September 16

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Images from: http://www.radiologyassistant.nl/en/p42764e8fe927e/knee-non-meniscal-pathology.html September 17

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Autograft Advantages Allograft Advantages

§ No risk of disease transmission § No donor site morbidity/pain
§ Lower cost § Faster surgery
§ Lower re-rupture rates overall § More cosmetic
§ Predictable graft size

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§ Bone tendon bone autograft (A.K.A. Patellar tendon autograft)

§ Harvested with patellar bone block, patellar tendon, and tibial bone block
§ “Gold standard” graft
§ Bony incorporation
§ Maintains hamstring as medial stabilizer

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Image from: https://www.orthopaedicsone.com/display/Main/Revision+Anterior+Cruciate+Ligament+% 28ACL% 29+Reconstruction Accessed June 2020 September 19

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§ Quadriceps tendon autograft

§ Less commonly utilized, becoming more popular
§ Versatile- can harvest with/without bone
§ Can harvest shorter graft and preserve normal anatomy
§ Smaller harvest incision
§ Predictable graft size
§ Lest donor site pain vs. BTB
§ Maintains hamstring as medial stabilizer

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September 20

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§ Hamstring tendon autograft

§ Most common graft worldwide
§ Lest donor site pain vs. BTB
§ No risk of patellar fracture
§ ? Higher re-tear rate
§ Less predictable graft size

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Image from: https://www.aoaortho.com/media/files/ACL-HSgraft.jpg Accessed June 2020 September 21

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§ Two major categories:

§ Suspensory
§ Cortical button
§ Tie over post screw +/-
washer
§ Interference
§ Bioabsorbable, metal,
PEEK commonly used

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Image From: THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 31, No. 2; DOI: 10.1177/03635465030310020501 September 22

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§ Transtibial ACL reconstruction

§ The tibial tunnel is drilled first, and the femoral
tunnel is drilled through the tibial tunnel
§ Therefore the position of the femoral tunnel is
dependent on the position of the tibial tunnel
§ Anatomic positioning of both femoral and tibial
tunnels can be more challenging

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Image from: Arthrex.com. Accessed June 2020 September 23

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§ Medial Portal Technique

§ The femoral tunnel is drilled via a medial
portal allowing for anatomic positioning
§ Therefore the position of the femoral
tunnel is independent on the position of
the tibial tunnel.
§ Increased risk for iatrogenic chondral
injury to the medial femoral condyle

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Image from: Arthrex.com. Accessed June 2020 September 24

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§ Outside-in, 2 incision, retro-drilling

§ The femoral tunnel is drilled from the
lateral cortex towards the notch.
§ Therefore the position of the femoral
tunnel is also independent on the
position of the tibial tunnel.

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§ Re-tear**
§ Tunnel malposition** (most common cause of graft failure)
§ Patella fracture (BTB or QT grafts)
§ Graft tunnel mismatch (BTB grafts)
§ “Blow out” of the posterior wall
§ Infection
§ Arthofibrosis
§ Cyclops lesion

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§A chondroepiphyseal avulsion of the ACL insertion on the

anteromedial tibial eminence
§ 8-14 years old; M=F
§ High association with other knee injuries
§ MRI helpful
§ May have coexistent attenuation of ACL

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§ (Modified)Meyers and
McKeever Classification

*Xrays will often

underestimate the severity
of these injuries

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Image from: https://musculoskeletalkey.com/arthroscopy-assisted-management-or-open-reduction-and-internal-fixation-of-tibial-spine-fractures-2/ Accessed June 2020 September 28

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§ Type I
§ Generally treated in long leg cast
§ Position of immobilization controversial

§ Type II
§ Operative vs. Non-operative treatment
§ Closed reduction by full extension of knee and LLC
§ Arthroscopic assisted internal fixation vs. ORIF

§ Type III & IV

§ Arthroscopic assisted internal fixation vs. ORIF

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§ Suture fixation
§ Transligamentous or transosseous
§ Transphyseal or physeal sparing
§ Absorbable vs. Non-absorbable suture
§ Small/large bony fragment, comminution

§ Screw fixation
§ Anterograde or retrograde
§ Requires large bony fragment (>15mm)

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§ A 16-year-old female
sustained a non-contact knee
injury while playing basketball
72 hours ago. She reports
feeling a pop, followed by knee
swelling and pain.
§ No pertinent PMH or PSH.
§ On exam, she has normal
alignment, a moderate
effusion, and 5 degree flexion
contracture and flexion to 45
degrees. There is medial and
lateral joint line tenderness.

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§ Diagnosis?

§ Next step?

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§ MRI

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§ Diagnosis?

§ Next step?

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§ Findings:
Medial
meniscal tear,
ACL tear
§ Treated with
medial meniscus
repair and
autograft ACL
reconstruction

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