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Overview
Ligament Anatomy
Type 1 collagen (70%) Elastin Extracellular matrix Hierarchical structure Fibrils > fibres >subfascicular unit >fasciculus Longitudinal fasciculi (MCL, LCL) Helical fasciculi (ACL, PCL)
Anatomic Features
Bonding Crimping Random collagen alignment Complex blood supply Diffusion from synovium Proprioception and nociception
Biomechanics
Laxity Stiffness Strength Viscoelastic behavior (creep, stress relaxation, hysteresis) Dynamic properties
Ligament healing
Immobilization
Loading dramatically affects recovery of normal mechanical properties Decrease strength Insertion site vs. midsubstance
Exercise
Favourable effect
Epidemiology
Increasing incidence Combined injuries common Females > males Conditioned vs. unconditioned
Conditioned
Unconditioned
ACL Anatomy
ACL Function
Mechanism / Hx
Usually noncontact Change direction Stop / jump Audible pop Instability Swelling
Difficult acutely Early exam beneficial Pt. relaxed Displacement Endpoint quality Compare
ACL Exam
Lachman best Pivot Shift diagnostic Anterior drawer chronic tear Associated injuries
ACL Imaging
XRAY
R/O # ACL avulsion Segond #
ACL MRI
95% accurate Low signal intensity Saggital view Acute injury high signal intensity on T2 image Bone bruising
ACL Tx
Non-operative
Acutely splint & crutches Early active ROM Closed chain WB to strengthen Avoid high risk Functional bracing controversial
Operative
Pt selection
High demand Young Good ROM
Graft
Auto vs. allo Collagen lattice Resorption revascularization restructuring Bone-patellar tendon-bone Semitendinosus/gracilis tensioning
Rehab
Closed kinetic chain strengthening Acutely fixation weak Graft weakest 6-12 wks Outcome
MCL Anatomy
Origin femoral condyle Insertion 4cm below joint line + posterior obl. Lig. + middle capsular ligament Parallel collagen
MCL
Most common isolated ligament injury Valgus force Post. Obl. Lig. damage with rotn. injury Associated ACL common
MCL exam
Assoc. POL,ACL,PCL
MCL Tx
MCL Classification / Tx
Grade 1 : 1-5 mm
Symptomatic Tx
Grade 2 : 610 mm
Grade 3 : 11-15 mm
Physio
PCL Injury
1.5 x ACL strength 5% all knee lig. inj. 10 restraint post. translation tibia Forced flexion Dashboard Associated injuries
PCL
PCL exam
Grade I - III
Non-operative
Aggressive rehab Focus quadriceps No support for bracing closed kinetic chain Open kinetic chain extension avoided 90% quads strength prior to normal athletics
PCL Tx
Repair :
Associated posterolateral corner Associated ACL / MCL Grade 3 Drawer test Bony avulsion 20% athletes with isolated injury require repair
Operative Repair
Require good ROM pre-op Graft > 40mm No good rehab protocol
Posterolateral Complex
Combination of Structures
ITB biceps femoris fibular collateral Popliteus complex Capsule etc
Posterolateral corner
Biomechanical
Increased:
External tibial rotation Varus rotation Posterior tibial translation
Exam
Swelling / bruising Gait : Varus thrust AP translation > 300 than 900 Best tests:
Varus stress opening > 300 than 00 Prone external rotation test
Other tests
Operative
10 Repair
Acute injury Bony avulsion
Reconstruction
Biceps tenodesis / arcuate lig advancement : mixed results Graft - results pending
Conclusion