1	Current Trends in ACL Management Lesley Hall MSc. MCSP Droitwich Knee Clinic & The Knee Foundation
2	Injury Prevention ACL injuries in female Athletes (Hewett et al 2006) (meta-analysis) ‘all 3 studies that incorporated high-intensity plyometrics reduced ACL risk, whereas the studies that did not incorporate high-intensity plyometrics did not reduce ACL risk’
3	Injury Prevention Female athletes have 4-6 fold ↑ risk of ACL injury compared with male counterparts. Plyometric training (high intensity) Biomechanics analysis and feedback (eg. Leg alignment) Technique training (eg.jump landing) Strength training Balance & core stability training Hewett,t. et al (2006) ACL injuries in female athletes – part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention
4	PEP programme Santa Monica Orthopaedic & Sports Medicine Group www.aclprevent.com
5
6
7
8	Incidence of Re-injury <18 - 25% 18 - 25 - 10% >25 - 5% Arthrofibrosis early 1980’s - 19% >1996 - 1% Shelbourne
9	Mechanism of ACL injury Non-contact injury at contact sports (72%) Sudden deceleration followed by change of direction or landing motion (often valgus) Majority with foot-strike near full extension Quads implicated (with lax hams) in straining ACL with max eccentric contraction Boden et al, 2000.
10	Clinical Examination:
11	Lachman’s test Very sensitive and specific for ACL Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med & Rehab 2003; 84(4):592-603. Low correlation with subjective instability
12	Feagin’s test Feagin JA, Cooke TD. Prone examination for ACL insufficiency. JBJS 1989; 71-B:863
13	Lateral Pivot Shift Principle: Easy anterior subluxation of lateral femoral condyle Components: Full (hyper) extension Patient relaxed Lift foot and suspend knee Simultaneous valgus and internal rotation LTC now subluxed (you can’t see this yet) Flexion, keeping valg/IR stress: LTC reduces with a palpable / visible clunk / shift/ glide
14	The lateral pivot shift sign Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med & Rehab 2003; 84(4):592-603.
15	Closed Kinetic Chain Exercises Strain on the ACL: CKC exercises do NOT shield the ACL totally from strain – peak strain on the ACL during OKC active extension and bilateral squatting are equal (Beynnon et al 1997) However á resistance in OKC ex’s increases ACL strain á load in CKC ex’s does NOT increase ACL strain. (Fleming et al 2003)
16	Closed Kinetic Chain Exercises Step ups Step downs Lunge Unilateral sit to stand (Heijne et al 2004)
17	"Open Kinetic Chain Exercises" Open Kinetic Chain Exercises It is only OKC quadriceps exercises which compromise the ACL & then only in 0-50° range
18
19	"Peak ACL strain occurs when..." Peak ACL strain occurs when the knee is flexed at smaller angles - ie. 20-30° á knee flexion angle â ACL strain - ? Due to increased hamstring activity with greater hip flexion “At this time it is not possible to identify which exercises are safe or harmful to a healing graft because strain thresholds that are beneficial and/or detrimental to graft healing remain unknown” (Heijne et al 2004)
20	Treatment ROM = to other side (ext & flexion). Facilitate hamstring function. (Positive pivot shift - add resisted ext tibial rotation with knee flexion - esp eccentric.) Progressive strengthening: PNF/NWB ex’s Bilat WB ex’s Unilat WB ex’s Unidirectional Multidirectional
21
22	Include: Balance Proprioception Endurance Agility Sport/occupation specific activities
23	Potential problems in the ACL deficient knee Recurrent meniscal tears Advanced joint surface erosion Progressively increasing laxity Chronic synovitis Improper rehabilitation can elicit or accelerate these symptoms
24	Indications for Surgery Instability Activity level Age ?????????
25	Timing of surgery: What is urgent? Ligament repair – urgent (within a few days) Ligament reconstruction - not urgent Optimum time 4 weeks Meniscus: Partial menisectomy: non-urgent Meniscal repair: better early Bucket handle tear with locked knee: urgent Knee dislocation: urgent hospitalisation - Check for vascular damage
26	Patellar tendon graft Advantages Disadvantages Indications
27	Quads tendon graft Advantages Disadvantages Indications
28	Hamstring tendon graft Advantages Disadvantages Indications
29	Double BundleTechnique Postero-lateral bundle - controls rotational stability Antero-medial bundle - controls A/P stability
30	Allograft
31	Healing / Ligamentisation Graft necrosis Revascularisation Cellular population Collagen deposition Maturation
32	Vascular Response Autografts: 6 wks – graft shows avascular necrosis surrounded by a vascular synovial sheath 8-10 wks – graft invaded by budding capillaries 16 wks – near complete revascularisation 20wks - revascularised
33	"Graft plays innocent role in..." Graft plays innocent role in the race between avascular necrosis & revascularisation Revascularisation takes place from the ends of the graft towards the middle Nutrition to the graft is by diffusion from synovial fluid The tibial remnant of the ACL & the fat pad are important structures for synovialisation & vascularisation & ? feedback mechanism.
34	ACL graft at 3 months post-op
35	Tensile Strength Autografts are strongest at the time of transplantation Tensile strength ↓ during first 12 weeks Strength then ↑ over next 9 – 12 months
36	Fixation PTG: bone on bone healing – secure by 6-8 weeks Hamstring graft: soft tissue/bone healing – 8-12 weeks Rodeo, Scott et al (1991) Scranton, Pierce et al (1998)
37	"Four Phases" Four Phases Of Rehabilitation Shelbourne et al.(1992)
38	"Phase 1 – Pre-operative Phase" Phase 1 – Pre-operative Phase Focuses on: Resolving swelling Regaining maximum range of movement Initiating a strengthening programme Mental preparation by the patient
39	"Goal of Phase 1" Goal of Phase 1 To prepare the patient for surgery with a full understanding of the operative and post-operative procedures.
40	"Phase 2 – Initial Post-operative..." Phase 2 – Initial Post-operative Phase Focuses on regaining active and passive knee movement full extension (hyperextension) flexion to 90 degrees wound healing maintenance of active quadriceps control early functional weight bearing closed kinetic chain activity
41	"Mobilisation" Mobilisation Early range of motion exercises will prevent adhesion formation and tightening of soft tissues around the joint, thereby restricting the development of contractures or excessive scar tissue
42
43	"Loss of full extension increases..." Loss of full extension increases patello-femoral contact forces and contributes to quadriceps weakness (Sachs et al) Aims: Flexion = to opposite side Extension = to opposite side
44	"Phase 3 – Progressive Rehabilitation" Phase 3 – Progressive Rehabilitation Focuses on restoration of improved motor function restoring a normal gait pattern increasing flexion to 135 degrees improve muscle timing, coordination and strength training progress functional activity
45	"Phase 4 – Fully Integrated..." Phase 4 – Fully Integrated Function Focuses on restoration of full function sport/ work specific training return to sport/work on reaching 70% of the strength of the unaffected leg Monitor all stages, progression is dependent on swelling and range of motion
46	Integrated rehabilitation (functional testing algorithm) Davies’ sequential testing series: Basic measurements – VAS for pain AROM; PROM (<10% diff) KT2000 (<3mm diff – normal, if >3mm – guarded progression) Proprioception / balance tests (<10%→progress) Closed chain testing – linea bilat isokinetic (<30% diff →progress)
47	"Open chain testing - isokinetic" Open chain testing - isokinetic Why test? ‘ If a muscle cannot function in an isolated muscle test then it cannot function in an integrated kinematic movement’ When safe to test? BPTB - >6wks FSHG – 8-12wks (if slightly lax consider ROM) Progress if <25% diff.
48	"Functional tests:" Functional tests: Bilat squat – even weight (b’room scales) Functional jump tests-bilat - single jump for distance. (males100% height; females 90% height) Functional hop tests – uninv leg then inv leg Lower extremity function test Sports specific tests NB look at quality of movement in each test, not just distance – good control is imperative
49	Donald Shelbourne Current Ideas (2003) Primary aim is to regain limb symmetry Avoid haemarthrosis & gross effusion – bed rest X 1 week, CPM & cryocuff Use of contra-lateral graft to avoid clash of treatment principles in the early stages Mechanism of injury
50	"Mastrokalos et al," Mastrokalos et al, May 2005 “ The contra-lateral bone-patellar tendon graft appears to present no advantage over the ipsilateral graft, as all symptoms concerning donor site morbidity are shifted from the injured into the healthy knee, and return to activity is not more rapid”
51	Comparison of PTG & Hamstring Grafts These authors all found results comparable: Maeda et al 1996 Siegal & Barber-Westin 1998 Corry et al 1999 Eriksson et al 2000 Aune et al 2001 Beard et al 2001 Goradia & Grana 2001
52	Increased Laxity in FSHG subjects Aglietti et al 1994 Barrett et al 2002 Beynnon et al 2002 NO increase in laxity: Cooley et al 2001 Corry et al 1999
53	More restricted rehabilitation for FSHG Siegal & Barber-Westin 1998 Fu et al 2000 Barrett et al 2002 Restriction not required: Howell &Taylor 1996 Corry et al 1999
54	Females & the FSHG Barrett et al 2002: PTG – 8% failure rate FSHG - 23% failure rate Corry et al 1999 Noojin et al 2000
55	Tibial Tunnel Widening Occurs in FSHG > PTG subjects á with accelerated rehabilitation 75% widening occurs in first 3 months (Hantes et al 2004) 50% occurs in first 6 weeks, before biological graft incorporation (Fink et al 2001) Expansion occurs over time – 1-12 weeks, not immediately after surgery (Buck et al 2004)
56	Reading the Literature Outcome measures: Stability – KT2000; Lachman Function Patient Satisfaction
57	"Laxity tests:" Laxity tests: Commonly used to measure success of reconstructive surgery NO correlation between laxity test results and any function test or patient satisfaction results (Harter et al, 1988; Lavoie et al, 2001; Kocher et al, 2002)
58
59	"Functional Performance Tests:" Functional Performance Tests: Lephart et al (1991) Co-contraction test – timed side-stepping using rubber cord Carioca test – timed Shuttle runs – timed ? What is target / normal for each subject ? Useful for monitoring progress
60	"Single leg hop tests:" Single leg hop tests: >15% limb difference is classed as abnormal (Barber et al 1992) Timed 6 metre hop (Barber et al 1990) Single hop for distance Triple hop for distance Cross-over hop for distance (Noyes et al 1991) Stair hop Vertical hop (Hopper et al 2002) Adapted cross-over hop test (Clarke et al 2002)
61	"Hop test asymmetry correlates with..." Hop test asymmetry correlates with low velocity isokinetic results (Noyes 1991; Jarvela 2001) Test – retest reliability in ACL reconstruction subjects at 1yr post-op (Hopper et al 2002) Eastlack et al (1998) compared copers and non-copers following ACL injury & found the cross-over hop test to be the most discriminatory (lateral movements)
62	Adapted cross-over hop test (Clark et al, 2002)
63	"Scoring systems:" Scoring systems: Lysholm knee scoring scale: specific to activities of daily living & symptoms. Scores out of 100 Tegner activity scale: work / sport related activities. Scores 1-10 IKDC subjective evaluation form: Complicated scoring system (David Johnson & Roger Smith, 2001)