ACL and PCL Reconstruction

*
By : Carissa R.V. Pratiwi

* An ACL tear is most often a sports-related injury. ACL tears can also
occur during rough play, mover vehicle collisions, falls, and work-
related injuries. About 80% of sports-related ACL tears are "non-
contact" injuries. This means that the injury occurs without the
contact of another athlete, such as a tackle in football. Most often
ACL tears occur when pivoting or landing from a jump. The knee
gives-out from under the athlete when the ACL is torn.
* The posterior cruciate ligament, or PCL, is one of four ligaments
important to the stability of the knee joint. The anterior cruciate
ligament, or ACL, sits just in front of the PCL. The ACL is much better
known, in part because injuries to the ACL are much more commonly
diagnosed than injuries to the PCL. Interestingly, it is thought that
PCL injuries account for about 20 of knee ligament injuries, however,
the PCL is seldom talked about because these injuries are often left
undiagnosed.
*
* The medial collateral ligament
(MCL) provides stability to the
inside of the knee.
* The lateral collateral ligament
(LCL) provides stability to the
outside of the knee.
* The anterior cruciate ligament
(ACL), in the center of the knee,
limits rotation and the forward
movement of the tibia.
* The posterior cruciate ligament
(PCL), also in the center of the
knee, limits backward movement
of the tibia.
*
* Articular cartilage :
weight-bearing
surfaces
* Meniscus : shock
absorber
* Quadriceps tendon,
patellar tendon
* Quadriceps muscle
group, hamstring
muscle group
* most frequently injured
* contributes stability to
other movements at the
joint including the
angulation and rotation
at the knee joint
* most often a sports-
related injury
* Symptoms : knee
swelling, pain,
instability, sensation of
giving out
*
* History of injury
* Lachman Test
* Pivot Shift Knee
* Anterior Drawer Test
* MRI
*
Knee instability
Activities that require normally functional ACL
High-Demand Sports Moderate-Demand Sports Low-Demand Sports

* Football * Baseball * Running/Jogging
* Soccer * Doubles Tennis * Cycling
* Basketball * Track (Field Events) * Crew
* Skiing
* Gymnastics
* Hockey (Ice and Field)
* Wrestling
* Lacrosse *
* Rugby
* Singles Tennis
* Cheerleading
Pros Cons
Allows return to high- Surgery is not 100%

level athletic activity effective -- some
May protect future people don't improve
damage to the knee Many activities can
cartilage be accomplished
Offers a near-normal without an ACL There
knee are complications
that may occur
*
(+)
Patellar
Tendon closely resembles what needs reconstruction
The length of the patellar tendon is about the same as the ACL
"bone to bone" healing
(-)
risk of patellar fracture or patellar tendon rupture
pain on the front of the knee ("anterior knee pain")
*
Hamstring (+)
Tendon no pain on the front of the knee
smaller incision
protected for a longer period of time while the graft heals into place
(-)
longer period of time is necessary for the graft to become rigid
(+)
Allograft
(donor decreased operative time
tissue) no need to remove other tissue to use for the graft

smaller incisions
less post-operative pain
(-)
disease transmission
not as strong as a patient's own tissue (autograft)
visualization of the interior
of a joint through the use
of optic instruments,
performing on larger joints
using direct visualization
and miniaturized
techniques
* The first step : insert an

arthroscope into the
knee joint to inspect the
damage done to the joint
*
"Harvest" and Prepare the Graft
ACL tear is confirmed the graft must be obtained the tissue being used to
create a new ACL is prepared to be the proper length and width
Tibial Tunnel
Drill is used to make a tunnel in the shin bone. The end of this tunnel in the
knee joint is directly where the ACL should attach to the shin bone.
Femoral Tunnel
Drill is passed directly through the middle of the knee joint. A second bone
tunnel is made from inside the knee up into the end of the femur.
Pass the Graft
the new ACL graft must be passed into position
Secure Femoral Side of Graft
use a screw to hold the graft end within the tunnel.
Secure Tibial Side of Graft

the tibial side of the new ligament is then fixed, similarly to the femoral side
Months 4-7
sports specific
Weeks 7-12 activities
Early sports most difficult
activities (jogging, phase, because
cycling outdoors, patients may have a
Weeks 3-6 knee that "feels"
and pool workouts)
Physical therapy normal, but is not
(balance and ready for the
proprioceptive stresses of some
excersice) sport activities
Weeks 1-2
Range of motion
exercises (focus :
full extension of
knee)
The First
Days
Icing
frequently
*
Elevating the
affected knee
Using crutches
Pros Cons
May protect you if May make patients

you slip or fall more likely to slip
Allows the knee to or fall
rest Can be
Helps maintain uncomfortable
extension of leg May prevent normal
motion of the knee
*
* associated with the graft
* Include : failure of the graft, loosening of the
graft, and a chance that the graft does not
provide optimal stabilization of the knee
following ACL surgery
* may require a revision reconstructive surgery
*
* Most common mechanism :
"dashboard injury."
* This occurs when the knee is
bent, and an object forcefully
strikes the shin backwards.
* It is called a 'dashboard injury'
because this can be seen in car
collisions when the shin forcefully
strikes the dashboard.
* Other common mechanism :
sports injury when an athlete
falls on the front of their knee.
* In this injury, the knee is
hyperflexed (bent all the way
back), with the foot held pointing
downwards. These types of
injuries stress the PCL, and if the
force is high enough, a PCL tear
*
will result.
* Mild knee swelling, with or without the knee
giving out when you walk or stand, and with or
without limitation of motion
* Mild pain at the back of the knee that feels
worse when you kneel
* Pain in the front of the knee when you run or
try to slow down This symptom may begin one
to two weeks after the injury or even later.
*
* History of injury
* Posterior Drawer Test
* Tibial Drop Back Test
* Quadriceps Active Test
* X-rays and MRI
*
A mild injury causes only microscopic tears in the ligament. Although these
tiny tears can stretch the PCL out of shape, they do not significantly affect
the knee's ability to support your weight.
Grade I
The PCL is partially torn, and the knee is somewhat unstable, meaning it
gives out periodically when you stand, walk or have diagnostic tests.
Grade II
The PCL is either completely torn or is separated at its end from the bone
that it normally anchors, and the knee is more unstabile. Because it
usually takes a large amount of force to cause a severe PCL injury, patients
with Grade III PCL sprains often also have sprains of the ACL or collateral
Grade III ligaments or other significant knee injuries.
*
First
RICE
Aid - Splinting
- Applying ice - Rest the joint
to the area - Ice the injured
- Elevating the area to reduce
joint (above swelling
the level of the - Compress the
heart) swelling with an
- Taking elastic bandage
nonsteroidal - Elevate the
anti- injured area
inflammatory
drugs (NSAIDs)
for pain
*
Graft of
choice :
Hamstring
Indications :
tendon
symptomatic for pain and
instability
a lesser risk of pain

at the front of the
knee after surgery
Procedure :
arthroscopic surgery
easier to
rehabilitate after a
*
hamstring graft
Stage 1 (0-6 weeks)
avoid active flexion
Stage 2 (6-12 weeks)

proprioceptive training
Stage 3 (3-6 months)

patient can continue in the gym, gradually
stepping up intensity.

return to sport specific training in a non-
contact fashion

have passed as they "learn to use the knee"
again.
*
* Stiffness of the knee
* Persistent pain over the front of the knee
* Persistent swelling of the knee
* Deep vein thrombus
* Infection of the knee
* Failure of the graft
* Damage to the popliteal artery or vein
* Swelling of the calf
*
* Overall, 50% to 80% of all athletes with PCL
injuries who are treated without surgery return
to their sport at their pre-injury activity level
after rehabilitation.
* Among people who have surgical reconstruction
of the PCL, more than 80% are able to return to
their pre-injury level of physical activity within
three years after surgery.

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*

By : Carissa R.V. Pratiwi

High-Demand Sports Moderate-Demand Sports Low-Demand Sports

Allows return to high- Surgery is not 100%

"bone to bone" healing

risk of patellar fracture or patellar tendon rupture

pain on the front of the knee ("anterior knee pain")

Tendon no pain on the front of the knee

longer period of time is necessary for the graft to become rigid

tissue) no need to remove other tissue to use for the graft

* The first step : insert an

the new ACL graft must be passed into position

Secure Femoral Side of Graft

use a screw to hold the graft end within the tunnel.

Secure Tibial Side of Graft

May protect you if May make patients

a lesser risk of pain

Stage 2 (6-12 weeks)

Stage 3 (3-6 months)

Stage 4 (6-9 months)

Stage 5 (9-24 months)

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