TIS

Chapter 11
ACL, PCL and Combination Injuries


  1. ACL anatomy
    1. attachments:
        femoral = posterior part of medial surface of lateral femoral condyle
        tibial = wide area in front of and lateral to anterior tibial spine; some fibers attach to lower anterior surface of spine and anterior horn of lateral meniscus
      • tibial attachment is wider and stronger than femoral attachment; femoral attachment is behind axis of flexion while tibial attachment is in front of axis
    2. bundles: based upon relative attachments on tibia
      • anteromedial: femoral attachment from posterior and superior convexity, tibial attachment forms medial corner of tibial attachment
      • posterolateral: femoral attachment anterior and inferior, tibial attachment represents posterior apex of triangle
    3. blood supply: major supply from the branches of the middle geniculate artery; vessels predominantly in the soft tissues (fat pad, synovial membrane) and not bone

  2. Mechanism of injury/acute eval

  3. Natural history of ACL deficient knee
    1. Noyes (1983)
      • 35% reinjury within 6 mos, 51% within 1 yr
      • at 5 year R/U: significant subjective disability, pain, giving way and 44% of those with the longest R/U has significant x-ray DJD changes

    2. Kannus (1986)
      • 80% decreased activities
      • 40% reinjuries
      • 70% x-ray DJD

    3. Hawkins (1986)
      • 87.5% fair or poor result
      • 10% returned to unlimited activities

    4. Barrach (1989)
      • 59% poor
      • 5% returned to sports at a 33% lower level

  4. ACL repair

  5. Extra-articular reconstruction

  6. Intra-articular reconstruction

    Autogenous:
    Synthetics:

    * these materials currently performing poorly; ie. instability, sterile effusions, material breakdown, etc.

    Allografts:

    * OUTCOME STILL VERY DEPENDENT UPON SURGEON SKILL AND TECHNIQUE!
    Graft placement is critical to assure isometric placement and adequate fixation, and avoiding graft impingement. Additionally, they are still the gatekeeper for rehab; therapist's skills are challenged when the patient doesn't show up for the first 6 weeks

  7. Post-op rehabilitation considerations


PCL ANATOMY, SURGERY, REHAB


  1. PCL anatomy

  2. Biomechanics

    Contact pressures:

  3. Mechanism of injury

  4. Natural history of PCL deficient knees
    1. pain
      • with activity 70%
      • patellofemoral 50%
    2. DJD
      • Clancy: 48% med>lat, 71% @ 2-4 yrs; 90% @ >4 yrs
      • Kennedy: 44% @ 61 mos
    3. instability
      • 8-59% instability with activity
      • up to 40% instability with ADL

  5. Treatment


POSTEROLATERAL KNEE INSTABILITY

  1. Pertinent anatomy

    Arcuate Ligament Complex

    Three Layer Organization

  2. Biomechanics

  3. Mechanism of injury

  4. Evaluation

  5. Treatment

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