ruptur ligamen

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RUPTUR LIGAMEN Nadia Andriani 030.10.200

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RUPTUR LIGAMEN

RUPTUR LIGAMENNadia Andriani030.10.200Insidensi400.000 rekonstruksi ACL/tahunwanita : pria = 4.5 : 1Biasanya sering berhubungan dengan ruptur meniskus (50% ruptur meniskus lateral)ACL kronisChondral injuriesComplex unrepairable meniscal tearsAnterior Cruciate Ligaments - IntroductionFungsiMemberikan 85% dari stabilitas untuk mencegah proses pergerakan anterior dari tibia ke arah femur. Acts as a secondary restraint to tibial rotation and varus/valgus rotationAnatomy33mm x 11mm in sizeGoes from LFC to anterior tibiaTwo bundlesAnteromedial bundle (more isometric, tight in flexion)Posterolateral bundle (tightest extension where it likely contributes greatest to rotational stability)Blood supply: middle geniculate arteryInnervation: posterior articular nerve (branch of tibial nerve)Composition: 90% type I collagen &10% type III collagenStrength: 2200 N (anterior)ACL - AnatomyACL PresentationPresentationfelt a "pop"Deep pain in kneeimmediate swelling (70%) / hemarthrosis Physical examLachman's test most sensitive exam testgradingA= firm endpoint, B= no endpointGrade 1: < 5 mm translationGrade 2 A/B: 5-10mm translationGrade 3 A/B: > 10mm translationPCL tear may give"false" Lachmandue to posterior subluxationPivot shift extension to flexion: reduces at 20-30 of flexionpatient must be completely relaxed (easier to elicit under anesthesia)mimics the actual giving way eventLachmans test & Anterior Drawer Test

ACL - ImagingRadiographsUsually normalSegond fracture (avulsion fracture of the proximal lateral tibia) is a pathognomonic for an ACL tearMRIACL tear best seen on sagittal viewBone bruising occurs in more than half of acute ACL tearsMiddle 1/3 of LFC (sulcus terminalis)Posterior 1/3 of lateral tibial plateauSubchondral changes on MRI can persist years after injury

NonoperativePhysical therapy & lifestyle modificationsOperativeACL reconstructionIndications: younger, more active patients, children, older active patients, Prior ACL reconstruction failureAssociated injuries:MCL injury: allow MCL to heal (varus/valgus stability) and then perform ACL reconstruction, varus/valgus instability can jeopardize graftMeniscal tear: perform meniscal repair at same time as ACL reconstruction, increased healing rate when repaired at the same time as ACLPosterolateral corner injury: reconstruct at the same time as ACL or as 1st stage of two stage reconstructionLigament repair: high failure rateRevision ACL reconstruction, indications: failure to prior ACL reconstructionACL - TreatmentFemoral tunnel placementTibial tunnel placementGraft placementHigh tibial osteotomyRevision ACL reconstructionGraft Selection:Bone patellar bone autograftQuadruple hamstring autograftAllograftQuadriceps tendon autograftACL Surgical TechniquesEarly postoperativeimmediateaggressive cryotherapy (ice)immediate weight bearing (shown to reduce patellofemoral pain)emphasizeearly full passive extension(especially if associated with MCL injury or patella dislocation)early rehabfocus rehab on exercises that do not place excess stress on graft appropriate rehab isometric hamstring contractions at any angleisometric quadriceps, or simultaneous quadriceps and hamstrings contractionactive knee motion between 35 degrees and 90 degrees of flexionemphasizeclosed chain(foot planted) exercisesavoidisokinetic quadricep strengthening (15-30) during early rehab open chainquadriceps strengthening Injury preventionfemale athleteneuromuscular training / plyometrics (jump training) land from jumping in less valgus and more knee flexionincreasing hamstring strength to decrease quadriceps dominance ratio skier trainingteach skiers how to fallACL bracingno proven efficacy exceptfor ACL-deficient skiersACL - RehabilitationFailure due to Tunnel MalpositionInfectionseptic arthritisStaph aureus most commonPresentation: pain, swelling, erythema, and increased WBC at 2-14 days postopTreatment: perform immediate joint aspiration with gram stain and cultures treatmentimmediate arthroscopic I&Doften can retain graft with multiple I&Ds and abx (6 weeks minimum)Loss of motion & arthrofibrosisInfrapatellar contracture syndromePatella Tendon Rupture Patella fractureHardware failureTunnel osteolysisLate arthritisLocal nerve irritationComplicationsInjuries may be isolated or combined and often go undiagnosed in the acutely injured kneeEpidemiologyincidence5-20% of all knee ligamentous injuriesPathophysiologymechanismdirect blow to proximal tibiawith a flexed knee (dashboard injury)noncontacthyperflexion with a plantar-flexed foot hyperextension injurypathoanatomyPCL is the primary restraint to posterior tibial translationfunctions to prevent hyperflexion/slidingisolated injuries cause the greatest instability at 90 of flexionPrognosischronic PCL deficiencyPCL deficiency leads to increased contact pressures in thepatellofemoralandmedial compartmentsof the knee due to varus alignment controversial whetherlate patellar and MFC chondrosiswill developPosterior Cruciate Ligaments - IntroductionOrigin: posterior tibial sulcus below the articular surface Insertion: anterolateral medial femoral condyle, broad, crescent-shaped footprintDimensions: 38 mmin length x13 mmin diameter, PCL is 30% larger than the ACLPCL has two bundles anterolateralbundle: tight in flexion, strongest and most important for posterior stability at 90 of flexion, mnemonic "PAL" -PCL has anAnteroLateral bundleposteromedialbundle: tight in extension, reciprocal function to the anterolateral bundleBlood supply: supplied by branches of themiddle geniculate arteryand fat padBiomechanics: strength is 2500 - 3000 N (posterior), minimizes posterior tibial displacement (95%) PCL - Anatomy

PCL - PresentationHistorydifferentiate between high- and low-energy trauma: dashboard injury, hyperflexion athletic injury with a plantar-flexed footascertain a history of dislocation or neurologic injurySymptomsposterior knee painInstability: often subtle or asymptomatic in isolated PCL injuriesPhysical examvarus/valgus stressposterior drawer test(at 90flexion) most accuratemaneuverfor diagnosingPCL injuryquadriceps active test positive if anterior reduction of the tibia occurs relative to the femurdial test > 10 ER asymmetry at30 & 90consistent withPLC and PCLinjury> 10 ER asymmetry at30 onlyconsistent with isolated PLC injurya

Classification based on posterior subluxation of tibia relative to femoral condyles (with knee in 90 of flexion)Grade I (partial)1-5 mmposterior tibial translationtibia remains anterior to the femoral condylesGrade II (complete isolated)6-10 mmposterior tibial translationcomplete injury in which the anterior tibia is flush with the femoral condylesGrade III (combined PCL and capsuloligamentous)>10 mmposterior tibial translationtibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC injury

Varus Valgus Stress Test- laxity at0indicatesMCL/LCL and PCLinjury- laxity at 30 alone indicates MCL/LCL injury

- isolated PCL injuries translate >10-12 mm in neutral rotation and 6-8 mm in internal rotation- combined ligamentous injuries translate >15 mm in neutral rotation and >10 mm in internal rotationPosterior Drawer TestQuadriceps Active TestDial Test

PCL - ImagingRadiographsrecommended viewsAP and supine lateralmay see avulsion fractures with acute injuries, assess forposterior tibiofemoral subluxation, medial and patellofemoral compartment arthrosis may be present with chronic injurieslateral stress view apply stress to anterior tibia with the knee flexed to 70, asymmetric posterior tibial displacement indicates PCL injury, contralateral knee differences >12 mm on stress views suggest a combined PCL and PLC injury, becoming thegold standardin diagnosing and quantifying PCL injuries

PCLMRI confirmatory study for the diagnosis of PCL injury

PCL - TreatmentNonoperativeprotected weight bearing & rehabIndications: isolatedGrade I (partial)andII(complete isolated)injuriesModalities: quadriceps rehabilitationwith a focus on knee extensor strengthening Outcomes: return to sports in 2-4 weeksrelative immobilization in extension for 4 weeksIndications: isolatedGrade IIIinjuries, surgery may be indicated with bony avulsions or a young athleteModalities: extension bracing with limited daily ROM exercises, immobilization is followed by quadriceps strengtheningOperativePCL repair of bony avulsion fractures or reconstructionIndications: combinedligamentous injuries, isolated Grade II or IIIinjurieswith bony avulsion, isolated chronic PCLinjuries with a functionally unstable kneeTechniques: primary repair of bony avulsion fractures with ORIFoutcomesgood results achieved with primary repair of bony avulsionsprimary repair of midsubstance ruptures are typically not successfulresults of PCL reconstruction are less successful than with ACL reconstructiohigh tibial osteotomyIndications: chronic PCL deficiencyRehabilitationPostoperative care immobilize in extension early andprotect against gravity, early motion should be inprone positionRehabilitationfocus on quadriceps rehabilitation, avoid resisted hamstring strengthening exercises (ex. hamstring curls) in early rehab because the hamstrings create a posterior pull on the tibia which increases stress on the graft.

ComplicationsPopliteal artery injury at risk when drilling the tibial tunnellies just posterior to PCL insertion on the tibia, separated only by posterior capsulePatellofemoral pain/arthritisdue to chronic PCL deficiency

PCL Rehab & ComplicationsThe medial collateral ligament is both a primary and secondary valgus stabilizer of the knee, also known as the tibial collateral ligamentEpidemiology: most commonly injured ligament of the kneeMechanism of injuryvalgus and external rotation force to the lateral kneenon-contact force results in milder sprainsdirect blow usually causes complete disruption of MCLrupture usually occurs atfemoral insertionof ligament with proximal tears having greater healing rates distal injuries tend to have excessive valgus laxityAssociated conditionsACL tears: comprise up to 95% of associated injuries: 20% are with grade I MCL injuries, 52% are with grade II MCLinjuries, 78% are with grade IIIinjuriesmeniscal tears: up to 5% of isolated MCL injuries are associated with meniscal tearsPellegrini-Stieda Syndrome calcification at the medial femoral insertion siteresults from chronic MCL deficiency

Medial Collateral Ligament - IntroductionLigaments of the knee Medial capsulo-ligamentous complex of the knee Function: resist valgus and external forces at the kneeCompositioncomposed of 3 layers which extend from the anterior midline to the posterior midlineContains:static stabilizers: superficial MCL (primary restraint to valgus stress), deep MCL and posterior oblique ligaments (secondary restraints to valgus stress)dynamic stabilizers: semimembranosus complex ;consists of 5 attachments(vastus medialis, medial retinaculum, pes anserine muscle group, sartorius, semitendinosus, gracilis)Blood supplysuperior medial and inferior medial geniculate arteriesMCL - Anatomy

MCL - AnatomyMCL - ClassificationMCL - PresentationMCL - ImagingRadiographsrecommendedAP and lateraloptional viewstress radiographs in skeletally immature patient may indicate gapping through physeal fractureFindings: usually normal, calcificationat the medial femoral insertion site(Pellegrini-Stieda Syndrome)

MRImodality of choice for MCL injuries identifies location and extent of injuryuseful for evaluating other injuries

MCL - TreatmentNonoperativeNSAIDs, rest, therapyIndications: grade Itherapyquad sets, SLRs, and hip adduction above the knee to begin immediatelycycling and progressive resistance exercises as toleratedreturn to play: grade I may return to play at 5-7 daysbracing, NSAIDs, rest, therapyIndications: grades II, grade III(if stable to valgus stress in full extension, no associated cruciate injury)techniqueimmobilizer for comforthinged knee brace for ambulationreturn to playgrade II return to play at 2-4 weeks, grade III return to play at 4-8 weeksOutcomes: distal MCL injuries have less healing potential than proximal injuriesOperativeligament repair vs. reconstructionrelative indicationsAcute repair in grade III injuriesin the setting of multi-ligament knee injurydisplaced distal avulsions with "stener-type" lesionentrapment of the torn end in the medial compartmentSub-acute repair in grade III injuriescontinued instability despite nonoperative treatment>10 mm medial sided opening in full extensionReconstructionchronic injuryloss of adequate tissue for repairtechniquediagnostic arthroscopyrecommended for all surgical candidates to rule out associated injuriesPreventionknee bracingfunctional bracing may reduce MCL injury in football players, particularly interior linemen

Loss of motionNeurological injurySaphenous nerveMCL - Complicationsalso referred to as fibular collateral ligamentEpidemiologydemographicsincidenceisolated injury extremely rare7-16% of all knee ligament injuries when combined with lateral ligamentous complex injuriesparticularlyposterolateral corner (PLC)injury Mechanismtraumaticmost frequently result from athletic injuriesdirect blow or force to weightbearing kneeexcessive varus stress, external tibial rotation, and/or hyperextension

Lateral Collateral Ligament - IntroductionLCL - AnatomyLCL characteristicstubular, cordlike structuredimensions3-4 mm diameter66 mm lengthoriginlateral femoral epicondyleposteriorandproximalto insertion ofpopliteus insertionanterolateral fibula headmost anteriorstructure on proximal fibula order of insertion from anterior to posteriorLCLpopliteofibular ligament biceps femorisBlood supplysuperolateral and inferolateralgeniculate arteries Biomechanicsfunctionprimary restraint to varus stress at 5 and 25 of knee flexionprovides 55% of restraint at5provides 69% of restraint at 25secondary restraint to posterolateral rotation with 10 mm lateral opening without an endpointsprains classified according to amount of ligamentous disruptiongrade I: minimalgrade II: partialgrade III: completeLCL - ClassificationSymptomsinstability near full knee extensiondifficulty ascending and descending stairsdifficulty with cutting or pivoting activitieslateral joint line painand swellingPhysical examinspection and palpationecchymosis and lateral joint line tendernessROM & stabilityvarus stress test varus instability (lateral opening) at 30 flexion only - isolated LCL injuryvarus instability at0 and 30 flexion - combined LCL and/or ACL/PCL injuriesdial test varus instability and increased tibial external rotation at 30 flexion - combined LCL and posterolateral corner injuries gait assessment hyperextension orvarus (lateral)thrustgaitneurovascular examcommon peroneal nerveinjuries may occur with LCL/PLC injuryLCL - PresentationLCL - ImagingRadiographsrecommended viewsAP, lateral, andvarusstress radiographs

MRIimaging modality of choiceprovides information about severity (complete vs. partial rupture) and location (avulsion vs. midsubstance tear)

Nonoperativelimited immobilization, progressive ROM, and functional rehabilitationindicationsisolated grade I or II LCL injury(no instability at0)outcomesreturn to sport expected in 6-8 weeksprogressive varus/hyperextension laxity can occur with unrecognized associated injuries to the PLCOperativeLCL repair/reconstruction +/- PLC/ACL/PCL reconstructionindicationsgrade III LCL injuryrotatory instabilityinvolving LCL/PLCposterolateral instability (LCL/PLC) at 0(ACL/PCL rupture)outcomesmore favorable outcomes with surgery when injuries are acuteComplication:Persistent varus or hyperextension laxityPeroneal nerve injuryStiffnessHardware irritationLCL - TreatmentMeniscal Tears

Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella).Two wedge-shaped pieces of cartilage act as "shock absorbers" between your thighbone and shinbone. These are called meniscus. They are tough and rubbery to help cushion the joint and keep it stable.DescriptionMenisci tear in different ways. Tears are noted by how they look, as well as where the tear occurs in the meniscus. Common tears include longitudinal, parrot-beak, flap, bucket handle, and mixed/complex.

Sports-related meniscal tears often occur along with other knee injuries, such as anterior cruciate ligament tears.

Sudden meniscal tears often happen during sports. Players may squat and twist the knee, causing a tear. Direct contact, like a tackle, is sometimes involved.Older people are more likely to have degenerative meniscal tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

CauseYou might feel a "pop" when you tear a meniscus. Most people can still walk on their injured knee. Many athletes keep playing with a tear. Over 2 to 3 days, your knee will gradually become more stiff and swollen.The most common symptoms of meniscal tear are:PainStiffness and swellingCatching or locking of your kneeThe sensation of your knee "giving way"You are not able to move your knee through its full range of motionWithout treatment, a piece of meniscus may come loose and drift into the joint. This can cause your knee to slip, pop, or lock.

SymptomsExamination

Nonsurgical TreatmentIf your tear is small and on the outer edge of the meniscus, it may not require surgical repair. As long as your symptoms do not persist and your knee is stable, nonsurgical treatment may be all you need.RICERest.Take a break from the activity that caused the injury. Your doctor may recommend that you use crutches to avoid putting weight on your leg.Ice.Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.Compression.To prevent additional swelling and blood loss, wear an elastic compression bandage.Elevation.To reduce swelling, recline when you rest, and put your leg up higher than your heart.Non-steroidal anti-inflammatory medicines.Drugs like aspirin and ibuprofen reduce pain and swelling.

TreatmentProcedure.Knee arthroscopy is one of the most commonly performed surgical procedures. In it, a miniature camera is inserted through a small incision. This provides a clear view of the inside of the knee. Orthopaedic surgeon inserts miniature surgical instruments through other small incisions to trim or repair the tear.Meniscectomy.In this procedure, the damaged meniscal tissue is trimmed away.Meniscus repair.Some meniscal tears can be repaired by suturing (stitching) the torn pieces together. Whether a tear can be successfully treated with repair depends upon the type of tear, as well as the overall condition of the injured meniscus. Because the meniscus must heal back together, recovery time for a repair is much longer than from a meniscectomy.

Surgical Treatment

Rehabilitation.After surgery, your doctor may put your knee in a cast or brace to keep it from moving. If you have had a meniscus repair procedure, you will need to use crutches for about a month to keep weight off of your knee.Once the initial healing is complete, your doctor will prescribe rehabilitation exercises. Regular exercise to restore your knee mobility and strength is necessary. You will start with exercises to improve your range of motion. Strengthening exercises will gradually be added to your rehabilitation plan.For the most part, rehabilitation can be carried out at home, although your doctor may recommend physical therapy. Rehabilitation time for a meniscus repair is about 3 months. A meniscectomy requires less time for healing approximately 3 to 4 weeks.RecoveryMeniscal tears are extremely common knee injuries. With proper diagnosis, treatment, and rehabilitation, patients often return to their pre-injury abilities

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