 So today I will be talking on one of the most common injuries of the knee joint which is the ACL injury or also called as anterior cruciate ligament injury. So first coming to the anatomy of the knee joint. So the knee joint includes the thigh bone as well as the leg bone but the main stability is provided by four major ligaments of the knee joint. They are called the anterior cruciate ligament, the posterior cruciate ligament, the medial collateral ligament and the lateral collateral injury. So there are four ligaments, two inside the knee joint which help in providing stability and two ligaments on either side of the knee joint which provide in sideways stability. So these ligaments are the most important structures which gives stability to the knee joint. So the anatomy or what is this ACL ligament? So this ACL ligament is a band which attaches from the thigh bone going down to the leg bone and it is situated in front of the knee. There is another ligament called the PCL which again attaches from the but it is from the back of the knee. But the most common injury that occurs in the knee joint that is about 80% of the knee injuries is anterior cruciate ligament injury. So coming to the function of the anterior cruciate ligament, what is the main function? The main function of this ligament or this band is to limit the anterior movement of the knee joint. So whenever the knee bends and straightens this ligament provides stability does not allow the thigh bone to move forward or backward. The second important function of this ligament is it provides rotational stability to the knee joint. That means whenever we twist and turn it does not allow the knee to excessively rotate. So it provides rotational stability. So one is it provides front and back stability. The second is it provides rotational stability. So these two are the most important functions of the anterior cruciate ligament. What is the mechanism of injury? When does it get injured? One is whenever there is high contact or high velocity injuries there is injury to the knee joint thereby causing the tear in this ligament. Usually in high contact injuries associated with ACL injury will be a meniscal injury that is the injury to the cushion or there can be associated other ligament injuries. The second most common mechanism of injury is by non-contact injury when there is a rapid deceleration that is when a patient is running or walking very fast and then there is a sudden stop and twisting of the knee occurs and thereby causing air to this ligament. And whenever the patient lands in a very awkward position from a certain height that can also cause awkward twisting of the knee joint and thereby causing injury to the anterior cruciate ligament. So what are the symptoms? So whenever there is an injury to the knee joint there is always a popping sound which is heard in the knee joint. So this is the most common symptom and the knee swells up there is a collection of blood inside the knee joint called eumarthosis and the patient will have difficulty in walking and also bending the knee joint. And as this injury becomes chronic that is after about three weeks the patient gives history of instability or history of giving way that means and the patient is trying to walk there is a giving way of the knee joint or instability the patient suddenly feels like he is going to fall down and there is no stability in the knee joint. So these are the common symptoms that occur with anterior cruciate ligament injuries. So what are the signs? So when the patient usually comes with these symptoms to our OPD we check one is there is usually swelling in the knee joint there is a wasting of the muscles when the patient comes and presents late. The most common presentation is whenever we try to pull the leg forward so there is excessively abnormal movement of the knee joint. So the knee joint is very unstable and there is what we call as anterior droid test positive. There is a lot of laxity in the knee joint. So these tests help us to clinically determine whether there is a anterior cruciate ligament injury. There are also certain other tests called lack of test and pivot shift test which will which aids us in diagnosing this clinically. What so once we clinically suspect that there is a anterior cruciate ligament injury we ask for a certain investigation one is x-ray to see if there is any bony injury involved. But on the x-ray we cannot visualize this ligament. So always we ask for a MRI scan to determine whether there is a tear in the anterior cruciate ligament injury. So the MRI is a gold standard investigation in diagnosing the anterior cruciate ligament injury and it is a very sensitive test 90 to 98 percent of sensitivity and it also helps in identifying if there is any edema around the bone to suggest whether the injury is acute or chronic. So the MRI is the gold standard investigation where it can clearly give us the diagnosis coming to the treatment of ACL injuries. So one is conservative the other is surgical. So when do we conservatively or non-operatively treat or in patients who are willing to make lifestyle changes and avoid the activities that cause recurrent instability. So aggressive rehabilitation program and also functional knee brace can be provided in conservative treatment. But what is the disadvantage with not treating or conservatively treating anterior cruciate ligament injuries. So whenever there is ACL tear what it does is it causes instability to the knee joint. That means there is frequent friction between the thigh bone and the leg bone. So whenever the patient is trying to walk fast whenever the patient is going down the stairs or patient wants to play any sporting activity. So this causes instability in the knee joint. So there is frequent wear and tear thereby it causes cartilage damage and it causes arthritis in the knee joint. So any untreated ACL tears leads to very ugly arthritis of the knee joint. So therefore we suggest that the ideal treatment for complete ACL tears would be arthroscopic ACL reconstruction surgery. So what do we do in this arthroscopic ACL reconstruction. So the indications for surgery like I said is recurrent episodes of giving way or recurrent swelling and recurrent instability in the knee joint. So patients who complain that they are feeling the knee joint is unstable and whenever they walk it gives way and there is a lot of wobbling that happens in the knee joint. These are the patients who require definitive surgery. So when do we plan the surgery? So we always wait for at least 3 weeks from the time of injury before taking the patient up for surgery. So in this 3 weeks we allow all these swelling the hematrhosis or the blood that is collected in the knee joint to subside. The second thing is during the 3 weeks we advise the patient certain exercises so that before the surgery the patient would have achieved almost full range of motion. So this helps in faster rehabilitation post surgery. So usually we do not operate immediately after the injury we usually give about 3 to 4 weeks of time before we take up the patient for surgery from the time of injury. So what do we do in this surgery? So we reconstruct the anterior cruciate ligament that means that we provide a new graft to the patient. So where is this graft taken from? The most common is called as the autograft that means the graft is taken from the patient himself. There are also grafts that can be taken from cadaveric labs and the third one is the synthetic that is synthetically prepared implants that are available which can be used as graft. But the most common that we use is autograft that means we take a ligament other ligament from the patient's own body. So which are the commonly used autografts? So we take grafts from around the knee itself. So they are called either the hamstring graft or it is the bone patala tendon bone graft or it is also called as the other one that we use is called as the cordyceps graft. So these are the three main grafts that we take depending on the requirement of the intubizert patient but the most commonly used among graft is the hamstring graft. So what is the technique in arthroscopy? So arthroscopy is nothing but a keyhole surgery where we do not open the joint completely. There are only about two small incisions of about one centimeter made on either side of this patala tendon. So there is a telescope which is called as the arthroscop which we insert into the knee joint. So this is the viewing instrument. So once we place this into the knee joint we can visualize this on the monitor. So first is we do a diagnostic arthroscopy that means we put the arthroscope we examine for all the ligaments ACL, PCL, the menisci or the cushions and also the cartilage. So all this can be visualized. So before actually performing the surgery we first visualize and reconfirm our diagnosis and see to the anti-crochet ligament as to what extent the tear has occurred. So once this is done we take the graft from the patient. The graft is prepared as closely in resemblance to the anti-crochet ligament. After the graft is prepared we make small tunnels in the tibia as well as in the femur and so that we can pass the graft. So once the tunnels are made we pass the graft into the knee joint along the direction of the anti-crochet ligament. So it is called as anatomic fixation of the ACL graft that means in the same direction as which the native ACL was that we pass the graft in the same direction and there are various fixation methods. So once the graft is passed we have to fix it on the thigh bone as well as the leg bone. On the thigh bone most commonly we use something called as the endobutton which is held onto the thigh bone. We pull the graft, we attain the adequate length of the graft that is needed and we also achieve the adequate tension as the native ACL and on the tibial side we use something called as the bioscrew. So the bioscrew is a biodegradable screw which degrades into the bone itself. So later on there is no need to go ahead and remove the implant so it gets degraded within the bone itself. So once the surgery is done the most important part after the surgery is rehabilitation to achieve normal function. So usually what happens once the surgery is done we put the patient on something called as the knee brace or the bed. The patient is allowed to walk from the very next day itself. If it is only an ACL reconstruction surgery then we allow full weight bearing as well. So the patient is independently walking from the very next day putting full weight bearing only that he will be on a knee brace. So in phase one we also start allowing gradual knee range of motion exercises from 0 to 2 weeks it is about 90 degrees from the third to fifth week we allow full range of motion and after six weeks we ask the patient to gradually start walking without the knee brace. He is allowed to even start slight jogging or running at the sixth week. The only thing that we don't allow from six weeks to six months is any sudden twisting or turning sports. Sports activity is not allowed up to six months because the graft that we put in has to integrate into the bone. So till then they are not allowed to do sudden twisting or turning sports but they are allowed to start jogging and running from the sixth week itself. There are certain complications that occur with this surgery like stiffness there can be loosening of the graft, there can be infection, deep vein thrombosis and recurrent instability but correctly performed surgery and very strict and supervised rehabilitation will allow the patient to achieve full function and also get back to sporting activity. So arthroscopic ACL reconstruction is a very successful surgery and it allows the patient to get back to their normal activity as well as to their sporting activity. Joining this live Facebook session if you have any doubts or queries you can always comment in the comments section below and we will further meet you in the next sessions on FB Life. Thank you.