ruptur ligamen

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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 c