Question

A 22 year old female patient arrives in the emergency department after a skiing accident. She was going downhill quickly when she twisted, fell, and reports hearing and feeling a loud "pop" in the right knee. The ED physician has diagnosed her with an ACL tear and refers her to the orthopedic surgeon for arthroscopic repair.

1. What equipment is required for all arthroscopic procedures?

2. What is the ACL, what purpose does it serve, and how is it positioned in relation to the other knee ligaments?

3. Can ligaments be repaired, and if so, how? Provide examples.

4. What is long-term postoperative prognosis? How long until she can ski again?

5. Place the following in their order of use during a knee arthroscopy: blunt trocar, irrigation/inflow cannula, sharp trocar, #11 blade.

Answer 1

1. The equipment required for all arthroscopic procedures is an arthroscope, which consist of a lens and lighting system that helps surgeon to view inside a joint.

2.ACL

The term ACL means anterior cruciate ligament. In the human knee there are a pair of cruciate ligaments present, ie, anterior and the posterior. They are arranged in a crossed manner. ACL crosses the posterior cruciate ligament and it form an “X”. This is made up of strong fibrous material and assists in controlling excessive motion by limiting mobility of the joint.It is the most injured ligament of the four located in the knee.

ACL originates deeply within the notch of the distal femur and its proximal fibers fan out along the medial wall of the lateral femoral condyle. The two bundles of the ACL are the anteromedial and the posterolateral, named according to where the bundles insert into the tibial plateau. Tibial plateau is the critical weight-bearing region on the upper extremity of the tibia. The ACL jointed in front of the intercondyloid eminence of the tibia. Here it blends with the anterior horn of the medial meniscus.

Purpose

To resist the motions of anterior tibial translation and internal tibial rotation ACL is important in order to have rotational stability.It prevents anterior tibial subluxation of the lateral and medial tibiofemoral joints is important for the pivot shift phenomena. The ACL has mechanoreceptors that detect changes in direction of movement, position of the knee joint, changes in acceleration, speed, and tension. Athletes who involved in sports that has cutting, jumping, and rapid deceleration it is important for the knee to be stable in terminal extension, in which it is the screw-home mechanism.

3. Athletes who have ACL injury will require reconstructive surgery in which the torn or ruptured ACL is completely removed and replaced with a piece of tendon or ligament tissue from the patient ie,Autograft or from a donor ie, Allograft. The common sources for tissue are the patellar ligament and the hamstrings tendon. The patellar is used, if bone plugs on each end of the graft are extracted which helps integrate the graft into the bone tunnels, during reconstruction. In arthroscopic surgery a tiny camera is inserted through a small surgical cut sends video to a large monitor so that the surgeon can see any damage to the ligaments. During an autograft, the surgeon will make a larger cut to get the needed tissue. During  an allograft, this is not necessary since no tissue is taken directly from the patient's own body.The surgeon will drill a hole to form the tibial bone tunnel and femoral bone tunnel to allow for the patient's new ACL graft to be guided through. When the graft is pulled through the bone tunnels, two screws are placed into the tibial and femoral bone tunnel. Normally the recovery time ranges between one and two years or longer, depending if the patient chose an autograft or allograft.

4. For the recovery from the reconstruction post-surgical rehabilitation is very essential. It will typically take 6 to 12 months to return to life as it was prior to the injury. It is divided into 5 phases which include; protection of the graft, improving range of motion, decrease swelling, and regaining muscle control. Each phase is having different exercises based on the patients needs. An example for this is while the ligament is healing the patient should be not be fully weight bearing but should strengthen the quad and hamstrings by doing quad sets and weight shifting drills. In phase 2 it require fully weight-bearing and correcting gait patterns, so exercises like core strengthening and balance exercises would be appropriate. In phase 3, the patient can begin running but can do aquatic workouts to help with reducing joint stresses and cardiorespiratory endurance. In phase 4 includes multiplanar movements, so enhancing running program and beginning agility and plyometric drills. In phase 5 it focuses on sport specific, or life specific things depending on the patient.