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Abstract

Profile of The Anterior Cruciate Ligament Injury from December 2014 – August 2015

in Sanglah General Hospital

Putu Feryawan Meregawa *, IGN Wien Aryana **

*Orthopaedic and Traumatology Resident, Udayana University, Sanglah General Hospital, Denpasar

**Orthopaedic and Traumatology Staff, Udayana University, Sanglah General Hospital, Denpasar

***

Objectives :

Anterior Cruciate Ligament is one of the most important ligament in our body. This ligament

is used for walking, running, and jumping. Nowadays, Anterior Cruciate ligament injury is

increased in Indonesia especially in Bali and give the disadvantage of the economic and

psychological problems.

Material and Method :

About seventeen patients who had Anterior Cruciate ligament injury from December 2014

until August 2015 in Sanglah General Hospital had collected from the operating central room

reports. This mini research is the descriptive retrospective study, which had researched the

variables about sex, age, risk factors, onset, and grafts harvested. For analyzed this study, we

used the spss 16.0 program.

Results :

From the sex variables, we identified that male had Anterior Cruciate ligament injury more

than female (70.6% : 29.4%). Age variables, we had : 29.4% (early adolescent), 17.6% (late

adolescent), 5.9% (early adult), late adult (29.4%), and early elderly (17.6%). Risk factors

variables, we had : 41.2% (traffic accident) and 58.8% (sport). Onset variables, we had 47.1%

(acute phase) and 52.9% (chronic phase). And in grafts harvested variables, we had : 94.10%

(semitendinosus), and 5.9% (combined gracilis and semitendinosus).

Conclusions :

The accident of Anterior Cruciate ligament injury in Sanglah General Hospital from

December 2014 – August 2015, is most common in male (early adolescent and late adult)

which is occurred in sport accident with chronic phase. And the most graft harvested for

reconstruction is semitendinosus.

Keywords : Anterior Cruciate Ligament, Sex, Age, Risk Factors, Onset, Grafts Harvested.

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Free Paper

Profile of The Anterior Cruciate Ligament Injury from December 2014 – August 2015

in Sanglah General Hospital

I. Background

Human being has a lot of ligaments of their body and has an important function in life. One

of the most important ligament of human body is the Anterior Cruciate Ligament (ACL).

Nowadays, this ligament become the most important thing to discussion because the etiology

and treatment management are still have many controversion. Research study for Anterior

Cruciate Ligament (ACL) is became increased in the world and made many doctors used

their knowledge for done the best treatment. 1

Anterior Cruciate Ligament (ACL) is important for a knee, especially for athletes

which they can done for walking, running, jumping, and kicking. Normally, Anterior

Cruciate Ligament (ACL) can protect for knee joint while a human do the daily activity.

After that, it has a good viscoelasticity degree for doing tension and resting without damage

the knee joint and give the good configuration, and it can give the knee can do rotation and

translation movement.2

The progression of management of the diagnosis and treatment of the Anterior

Cruciate Ligament (ACL) was begun at the 1970 and 1980. On 1990, the research has

focused to identificate the mechanism of injury, risk factors of injury, treatment of injury, and

physical rehabilitation. For the severe Anterior Cruciate Ligament (ACL), doctors usually

done the reconstruction surgery and it need high cost for the treatment. So we can said,

patient who had Anterior Cruciate Ligament (ACL) injury will spent many money and give

the emotional, phychological, and economic problems.3

The newest result of the research about Anterior Cruciate Ligament (ACL) injury are

increased everey recent years, it can be occured in women more than in man (2-8:1), more

occured in foot ball and basket ball player, and more frequently occured after adolescent

phase.4

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II. Anatomy of Anterior Cruciate Ligament

Picture 1. Anatomy of Anterior Cruciate Ligament (ACL) 7

Anterior Cruciate Ligament (ACL) has 38 mm length and 11 mm width. It has two bundle,

they are anteromedial and posterolateral bundle. This classification is based on the its

insertion to the tibia and its function for doing tension when the knee is working. Anterior

Cruciate Ligament (ACL) is attached from lateral intercondylar notch of the posterior lateral

condyle, then pass through the anteromedial aspect of the plateau tibia and attached to the

eminentia tibia (knee can do extention and flexion motion). The function of the two bundle

are anteromedial bundle is shortening when the knee flexed and the posterolateral bundle is

shortening when the knee extended. Two bundle of Anterior Cruciate Ligament (ACL) is in

pararel position when the knee extended and crossed each other when the knee flexed.1,2

Anterior Cruciate Ligament (ACL) consist of type I collagen matrix about 90%, type

III collagen matrix about 10%, elastin (<5%), proteoglican (<1%) and water (60%). This

ligament has many nerve fibers which had proprioceptif function or mechanoreseptor (pain

respon). The nerve supply from Anterior Cruciate Ligament (ACL) is from tibial nerve which

can penetrated the posterior capsule joint and the synovial membrane. This ligament has the

blood supply from medial genicular artery (branch of poplitea artery) which can penetrated

the posterior capsule. The other side, it has the blood supply from medial inferior arteri and

lateral genicularartery from the fat tissues.1,2

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Insertion of Anterior Cruciate Ligament (ACL) to the bone is through the

fibrocartilagenous enthesis. This is can divided into four zone, such as 1:

First zone is the edge of the Anterior Cruciate Ligament (ACL),

Second zone is collagen fibers ligament with fibrocartilage region,

Third zone is mineralization of the fibrocartilage

Fourth zone is joined with the bone

Picture 2. Intraoperative Anterior Cruciate Ligament (ACL). (A) picture of two bundle

Anterior Cruciate Ligament (ACL) : anteromedial (AM) dan posterolateral (PL). PL

bundle is located in posterolateral of the AM bundle and we pushed the AM bundle to

the medial, give the bundle PL is seen more clearly. B and C, picture show the anatomy

of LCA foot prints. LM = lateral meniscus, MM = medial malleolus.2

III. Definitive Treatment of Anterior Cruciate Ligament (ACL) Injury

A. Management Non Operative

Indication of management non operative of this ligament injury, are 5,6

:

Active and young people who is confused the reconstruction ligament

Elderly (age more than 60 years)

Patient with Knee Osteoarthritis ( especially afflicted the medial compartment).

Management non operative of Anterior Cruciate Ligament (ACL) Injury include

range of motion exercise of the knee joint, weight bearing exercise, strengthening hamstring

and quadriceps muscle, proprioceptive exercise, and functional knee brace (still

controversion). 5,6

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B. Management Operative

The management operative of Anterior Cruciate Ligament (ACL) Injury, such us 5,6

:

1. Repair

Stitched the Anterior Cruciate Ligament (figure of eight technique) with cat gut or

mersilene to the lateral condyle of femur.

2. Augmentation Autogenous.

Stitched the anterior cruciate ligament remnant and augmentation with illiotibial band (1.5

cm width) pass through the hole of the lateral condyle of femur.

3. Extra-Articular Tenodesis.

Repair the Anterior Cruciate ligament by strengthening the Medial Collateral ligament

stitched with the fascia.

4. Reconstruction

The graft is used for reconstruction of the Anterior Cruciate ligament injury, are

- Bone Patellar Bone Bone

- Semitendinosus tendon (hamstring graft)

- Gracillis tendon and Distal Iliotibial Tract

- Quadriceps Patellar Retinaculum-Patellar Tendon Complex

Picture 3. Autograft Hamstring and Bone Patellar Tendon Bone 5

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Picture 4. Quadrisep Tendon with Bone Plug Graft 6

Table 1. Comparison Type of Graft in Reconstruction Anterior Cruciate Ligament

Injury

IV. Aim

To know the profile of sex, age, risk factors, onset, and grafts harvested of the Anterior

Cruciate ligament injury from December 2014 until August 2015 in Sanglah General Hospital

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V. Benefit

To give the information about the most sex distribution which had Anterior Cruciate ligament

injury from December 2014 until August 2015 in Sanglah General Hospital.

To give the information about the age distribution which had Anterior Cruciate

ligament injury from December 2014 until August 2015 in Sanglah General Hospital.

To give the information about the most risk factors which affected Anterior Cruciate

ligament injury from December 2014 until August 2015 in Sanglah General Hospital.

To give the information about the most onset of Anterior Cruciate ligament injury

from December 2014 until August 2015 in Sanglah General Hospital.

To give the information about the most graft harvested for reconstruction in Anterior

Cruciate ligament injury from December 2014 until August 2015 in Sanglah General

Hospital.

VI. Research Design

This research is Descriptive Retrospective Analysis.

VII. Location and Time of Research

Sanglah General Hospital, in December 2014 until August 2015.

VIII. Data Source

Operating central room reports.

IX. Instrument of Research

Tabulation table including patient identity, medical record number, sex, age, risk factors,

onset, and grafts harvested.

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X. Procedure of Research

Schema 1. Research Procedure

XI. Methods

We had collected the data from the operating central room reports in Sanglah General

Hospital, based on identity of the patient, sex, age, risk factors, onset, and grafts harvested.

And we had about seventeen patients who had Anterior Cruciate ligament injury from

December 2014 until August 2015 in Sanglah General Hospital had collected from the

operating central room reports. This mini research is the descriptive retrospective study,

which had researched the variables about sex, age, risk factors, onset, and grafts harvested.

For analyzed this study, we used the spss 16.0 program.. For the sex variables is categorized

Data Collection from operating

central room reports

Data Tabulation

Data Entry to SPSS 16.0

Descriptive Retrospective

Analysis

Writing of Research

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into male and female, age variables is categorized into 3 groups (based on World Health

Organization), they are early adolescent (12-16 years old), late adolescent (17-25 years old),

early adult (26-35 years old), late adult (36-45 years old), early elderly (46-55 years old), risk

factors variables categorized into traffic accident and sport, onset variables is ccategorized

into acute and chronic condistion of the patient who came to the hospital for had a further

treatment, and for the graft harvested in reconstruction is categorized into semitendinosus and

combined gracilis and semitendinosus. Finally, This mini researched is analyzed with the

spss 16.0 program.

Table 1.1

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Table 1.2

Table 1.3

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Table 1.4

Table 1.5

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XII. Result

From the sex variables, we identified that male had Anterior Cruciate ligament injury more

than female (70.6% : 29.4%). Age variables, we had : 29.4% (early adolescent), 17.6% (late

adolescent), 5.9% (early adult), late adult (29.4%), and early elderly (17.6%). Risk factors

variables, we had : 41.2% (traffic accident) and 58.8% (sport). Onset variables, we had 47.1%

(acute phase) and 52.9% (chronic phase). And in grafts harvested variables, we had : 94.10%

(semitendinosus), and 5.9% (combined gracilis and semitendinosus).

XIII. Discussion

From this mini research, we got male more afflicted had Anterior Cruciate ligament than

female. Because male are more active than female for do some activity, such us sport, riding

motor cycle, or racing. This activities give the highest distribution of anterior cruciate

ligament injury in male (including the risk factors about sports and traffic accident).

This injury is more afflicted in early adolescent and late adult, because a research who

did by Hamlet et al, that he found an androgen receptor content in Anterior Cruciate ligament

specimen when the male is in 18 – 24 years old of age and it give the protection to the

ligament. And there is research who did by Hunt Valley II, that injury of Anterior Cruciate

ligament can be occured in early of menstruation phase and the end of menstruation phase

(low content of estrogen and progesteron hormon).3

Injury of the Anterior Cruciate ligament is caused by non contact (70%) and contact

(30%). This injury can be occured with several problem, such us 4,5,6

:

1. Extrinsic factors (shoes, dusting, climate, and floor of the yard gymnasium)

2. Intrinsic factors

a. Quadricep Angle

If the quadrisep angle is wider than normal (supine position is about 2.7°-5.8° and

standing position is about 3.4°-4.9°), that will made the high risk of injured.

b. Intercondylar Notched

Human has three types of intercondylar notched, they are : A-shaped , B. U-shaped ,

C. W-shaped. The A-shaped is the high risk to have an injury of Anterior Cruciate

ligament.

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Picture 5. Type of Intercondylar Notched. A. A-shaped , B. U-shaped ,

C. W-shaped. 5

c. Posterior Tibial Slope

High grading angle of Posterior Tibial Slope (PTS) caused position of the tibia is

more anterior than femur. Its give effect more easier to get the injury of Anterior

Cruciate ligament.

d. Biomechanic factor

Picture 5. Illustration that show the biomechanic of landing position. 2

e. Genetic Factor

there is a study found that if in one family, the parent of that family had the injury of

Anterior Cruciate ligament, so it will make their child will increased the risk twice to

get the injury of Anterior Cruciate ligament. But this study is recall bias, because the

information is not enough and still controversial.

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f. Hormonal factor

Hamlet et al, that he found an androgen receptor content in Anterior Cruciate ligament

specimen when the male is in 18 – 24 years old of age and it give the protection to the

ligament. And there is research who did by Hunt Valley II, that injury of Anterior

Cruciate ligament can be occured in early of menstruation phase and the end of

menstruation phase (low content of estrogen and progesteron hormone)

We found of this mini research that patient with Anterior Cruciate ligament usually

came in chronic phase than acute phase. Because the Indonesian especially balinese life style,

if they had a problem of the bone or the ligament, first time, they usually go to the bone setter

for treatment. If the disease became worse after go to the bone setter, they will choose the

second opinion for treat by a doctor.

For the graft is used for reconstruction, its depend on the knowledge, experience, and

skill of the Orthopedyc surgeon. As we explained before, for graft reconstruction in Anterior

Cruciate ligament, the Orthopedyc surgeon can use :

- Bone Patellar Bone Bone

- Semitendinosus tendon (hamstring graft)

- Gracillis tendon and Distal Iliotibial Tract

- Quadriceps Patellar Retinaculum-Patellar Tendon Complex

XIV. Conclusion

The accident of Anterior Cruciate ligament injury in Sanglah General Hospital from

December 2014 – August 2015, is most common in male (early adolescent and late adult)

which is occurred in sport accident with chronic phase. And the most graft harvested for

reconstruction is semitendinosus.

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