Case Presentation

Anterior Cruciate Ligament (ACL) Rupture Oscar Ng 09037032D

Patients of History Mr Tsang, Male, 38years old

PMHx: Good

SHX
- Live with family - Work as a internal renovation worker - Lift landing - Play soccer 3 times /week Pre-morbid: unaided

HPI
6/11/11 - Left knee twisting injury while playing soccer - Immediate left knee swelling and pain - Attended private O & T specialist and private MRI done - DX: Left ACL deficiency

HPI
26/1/12 - Clinically admitted to QMH - Operative findings: 1. Left ACL complete rupture (both anteromedial (AM)and posterolateral (PL) bundle) 2. Full thickness tear of Left posterior horn of medial meniscus ( longitudinal, red red) 3. Left patella: outer-bridge grade 2 4. All other compartments healthy 5. No loose body

Outerbridge Classification
The Outerbridge classification is a grading system for joint cartilage breakdown Grade 0 normal Grade I - cartilage with softening and swelling Grade II - a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter Grade III - fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm Grade IV - exposed subchondral bone

HPI
26/1/12 Operation done 1.

Anterior cruciate ligament reconstruction Left side, double bundle, ipsilateral hamstring ( semitendinosus) graft Repair of left meniscus PWB x 3/52 Knee Flexion 0 90 degree x 3/52 Avoid squatting x 3/12

2.

HPI
6/2/12

Clinically admitted to MMRC for day patient Rx

Post OP D 11 PWB with a pair of crutches

ACL Rehabilitation Protocol

Day 0 3 months : Close Kinetic Chain Training
Day 0 3 week Maximal Protection Phase (PWB) Controlled Ambulation Phase (FWB) Moderate Protection Phase

4 weeks 6 weeks

6 weeks 12 weeks

ACL Rehabilitation Protocol

4months to 6 months: Open Kinetic Chain Training
13 weeks 18 weeks

Eccentric Quadriceps Training

19 weeks 24 weeks Isokinetics and Treadmill Running

7 Months to 9 Months: Light Activity Phase 10 Months to 1 Year: Return to Activity Phase

For Mr Tsang Case

1st Session: 8/2/2012 Post OP 13D, PWB, walk with a pair of crutches
S/E: Tight feeling at the end of available left knee flexion range O/E Observation: 1. Left knee mild swelling 2. Left VMO wasting 3. Delayed activation of Left VMO MMT: Hip abductor , flexor and extensor: 5 Knee extensor : L: >3 , R: 5 Knee flexor: 5 ROM: L Knee: 5 10 90 -90 R knee 5- 5 140 - 140 Palpation: good mobility of left patella

1st session
Treatments 1. 2.

3.
4. 5. 6.

Lyphmapress to L knee x 15 minutes ( 50mmHg) Active mobilisation of Left knee with a therapeutic ball in supine ( left Knee F < 90) x15minutes ES to left VMO x 15minutes ( 30 mA, 10 on 15 off ) Wobble Board exercise in sitting x 10 minutes Tubigrip to L knee Hamstring Curl exercise in standing , patellar mobilization exercise, static VMO contraction exercise in sitting , SLR exercise in 4 planes taught

2nd Session: 10/2 Post OP 2W1D

S/E: tightness around 40 degree of left Knee F O/E: 1. Improved activation of left VMO on verbal command 2. Decrease in left knee swelling Treatment - Wobble board in sitting x 10 minutes

3rd 5th sessions

Post OP 2 W 3 D 3W and 5 Days

Continue PWB
Continue Treatments

6th session: 24/2/2012 Post OP 4W 1D

Start of Controlled Ambulation Phase Allow FWB Allow Knee Flexion < 120

O/E Left Knee ROM: 5 -10 105 110 Fx Mobility: Walking unaided on level ground // WB more on right side Walking unaided up and down stair // L knee straight during walking downstairs

6th session: 24/2/2012 Post OP 4W 1D

Treatments 1. Cycling exercise with light resistance(F<120) 2. Wobble board ( AP) in standing 3. Wall slide x 15 minutes 4. Leg press with ES x 15 minutes ( 20 bls) 5. Hamstring curl exercise

Progression
28/2/12 Left knee ROM: 5-5- 100 115 2/3/12 Left knee ROM: 5-5-110 -120 Treatments Increase the poundage for leg press and hamstring curl

Discussion

Anatomy : Anterior Cruciate Ligament

2 main functional bundles

1. AM Bundle Anteroposterior stability Taut throughout the knee ROM ( highest at 60 knee F) 2.PL Bundle Rotational stability In situ force highest at 0 -30 knee F

Tibial Insertion: area intercondylais anterior Femoral Insertion: posterior area of intercondylar wall of the lateral femoral condyle

Anatomy : Anterior Cruciate Ligament

Tibial Insertion: area intercondylais anterior Femoral Insertion: posterior area of intercondylar wall of the lateral femoral condyle

Single(SB) Vs Double Bundle(DB)

Sienold et al. 2007 Prospective RCT 19 month FU Significant benefit of DB in terms of anterior and

rotational stability and objective IKDC 2000 Insignificant benefit of DB in terms of subjective IKDC2000, Cincinnati Knee Score , Lysholm Score
Meredick et al. 2008: a meta analysis No significant benefit of double bundle in terms of

anterior stability ( KT -1000) and rotational stability (pivot shift)

Aglietti et al. 2009 Prospective RCT 2 year FU DB: better VAS, anterior knee laxity , final objective

IKDC

Return to Sports
Barber westin 2011 a systemic review of 21 studies

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