Cruciate ligament rupture: surgery, rehabilitation, costs

• Causes and course of the disease
• When is surgery necessary for a torn cruciate ligament?
• What happens before surgery?
• How is the operation performed at the Gelenk Clinic?
• What type of doctor performs surgical treatment of a cruciate ligament rupture?
• Probability of success after cruciate ligament rupture surgery
• What type of anesthesia is used during surgery?
• Postoperative observation, rehabilitation and aids after surgery for cruciate ligament rupture
• Will I feel pain after surgery?
• Conditions of stay at the Gelenk Clinic
• What should you pay attention to after surgical treatment of a torn cruciate ligament?
• Cost of knee surgery
• How can a foreign patient make an appointment and the operation itself?

Clear, centered view of the anterior and posterior cruciate ligaments in the knee joint. The cartilaginous surfaces and menisci on the tibial side are indicated in purple. A sprain or injury to the cruciate ligament can occur as a result of a dislocation or blow. The complete destruction of this component of the knee is called a torn cruciate ligament. © Istockphoto.com/MedicalArtInc In the center of the knee joint, two ligaments intersect, which connect the femur (Femur) and tibia (Tibia) bones and maintain their position. Due to a rupture of one or two cruciate ligaments, the knee joint becomes unstable. A rupture of the anterior cruciate ligament
is observed in patients most often. The causes of injury are injuries sustained after sports training, such as a dislocated knee joint during skiing or a collision during ball sports.

When the cruciate ligament ruptures, the knee swells greatly and the victim experiences severe pain. In most cases, the disease is accompanied by a clicking or crackling sound, during which you feel a jerk in the knee joint. After this, the patient's knee mobility is limited. To re-stabilize the knee and prevent knee osteoarthritis, the orthopedist may repair the cruciate ligament or replace it with a tendon graft.

medical request

Causes and course of the disease

A torn anterior cruciate ligament usually occurs after playing sports. Often, the outward deviation of the tibia puts stress on the anterior cruciate ligament, causing it to tear more easily. The following situations are typical for this injury:

• violent side collision with an opponent during a game of football
• hyperextension of the knee joint
• sudden braking at full speed
• sudden change of direction at full speed
• unsuccessful landing after a jump or spin

A typical accident circumstance involves hitting an opponent's knee while playing soccer. In addition, rupture of the cruciate ligament occurs when skiing, after a fall, followed by dislocation and hyperextension of the lower leg.

As a rule, the patient feels the rupture already during the fall. The injury is often accompanied by the characteristic clicking sound of a stretched and damaged cruciate ligament. Rupture occurs only under significant force. The cruciate ligament typically supports 2400 kg. loads. However, its strength may vary: in women, the diameter of the cruciate ligament is much smaller. Therefore, they suffer from this disease much more often. In children, a more common Segond fracture is an avulsion fracture of the tibial condyle.

A posterior cruciate ligament rupture requires more force than an anterior cruciate ligament rupture. Injuries of this magnitude are usually observed during road traffic accidents, for example, when the knee joint hits the passenger compartment of a car. Therefore, injuries to the posterior cruciate ligament are much less common, namely in only 7-10% of all cases.

When is surgery necessary for a torn cruciate ligament?

The course of the healthy posterior cruciate ligament from the facial aspect of the femur to the posterior articular surface of the tibia.
© Radiopedia.org Same patient: The anterior cruciate ligament is not visible due to its rupture.© Radiopedia.org If conservative treatment is unsuccessful or does not produce the desired result, and if the patient is young and leads an active lifestyle, surgical reconstruction is the optimal solution for in order to maintain the patient’s quality of life and sports activity. In addition, surgery must be performed if more than 75% of the cruciate ligament is torn or if the ligament is torn off with a bone fragment.

A torn cruciate ligament must be treated promptly. Otherwise, you will develop other injuries in your knee joint within a few years. Excessive stress will be placed on the articular surfaces and menisci, which can lead to premature wear, damage to the articular cartilage, and after 10-15 years to arthrosis of the knee joint. Often, due to existing instability of the cruciate ligament, the meniscus also tears.

In 80% of cases, cruciate ligament rupture causes damage to other structures of the knee joint:

• Internal meniscus tear (69% chance)
• External meniscus tear (49% chance)
• Articular cartilage injuries (20-50% chance)
• Secondary arthrosis of the knee joint due to limited functionality of the meniscus
• Internal ligament injuries (common)
• Damage to external ligaments (less common)
• Rupture of the joint capsule of the knee joint

Clinical manifestations of ACL damage during diagnosis.

From the observation of 587 cases of isolated ACL injuries carried out at the Sports Clinic from 2015 to 2021, the following distribution of knee joint instability was determined:

• In 146 cases or 24.8% when the injury lasted no more than 2 months, instability of the knee joint did not manifest itself during diagnostic tests.
• In 426 cases or 72.6% with an injury period of more than 1 year, instability was mildly expressed in one plane.
• And only in 15 cases (2.5%) significant multiplanar instability was observed, including anteroposterior displacement of the tibia, an increase in pathological adduction/abduction + rotational component.

Thus, in only 2.5% of cases, additional surgical procedures were required in addition to ACL reconstruction.

What happens before surgery?

Before the operation, the doctor conducts a comprehensive clinical examination. First, all the circumstances of the injury and the degree of instability of the knee are clarified. Thus, the specialist receives information about the extent of the gap. Unfortunately, the diagnosis is often made several years after the injury, since patients do not attach much importance to it and consider the injury to be a simple sprain.

In the presence of strong thigh muscles, the diagnosis is usually not made as part of a clinical examination and surgery is not considered. However, over time, the patient feels discomfort in the knee joint. Arthrosis can be caused by trauma that damages the cartilage. Very often, problems of the knee joint appear only after several years, and only then does the patient notice some instability while climbing stairs or during rotational movements, after which he feels severe pain in the knee.

In addition to diagnosing the degree of instability of the knee joint, a cruciate ligament tear is determined using special techniques such as the anterior drawer test (ADT), the Lachman test, or the lateral slip test (McIntosh test).

The Lachman test helps determine the stability of the cruciate ligaments. The test is performed using the anterior drawer principle (ADD), but also involves bending the knee to 30°. © joint-surgeon

In addition, the condition of the cruciate ligaments is determined by MRI. X-rays are required to rule out osseous associated injuries to the knee joint. Also, joint puncture—aspiration of synovial fluid from the joint capsule—helps make the diagnosis. Cruciate ligaments have a good blood supply. Therefore, their rupture causes hemorrhage into the joint. The presence of blood in the joint fluid indicates a cruciate ligament rupture.

AAfter diagnosing and checking the patient’s health status, the attending physician conducts an explanatory conversation with the patient, during which he talks in detail about the progress of the surgical intervention, as well as possible complications. After this, you will be referred to an appointment with an anesthesiologist, who will once again check whether your health condition allows the administration of anesthetic drugs. As a rule, surgery for cruciate ligament rupture is performed the next day after a conversation with the surgeon and anesthesiologist.

Ankle ligament sprain

When ankle ligaments sprain, symptoms appear immediately after the traumatic impact. As soon as the traumatic swelling of the soft tissues subsides, the instability of the position of the head of the tibia and fibula in the joint capsule becomes visible to the naked eye. Constant displacement occurs even with careful walking. Repeated ankle sprains occur constantly.

After a few months, the patient begins to feel a constant dull pain in the joint area. After significant physical activity, swelling and redness of the skin appears.

Unfortunately, all these are signs of deforming osteoarthritis of the ankle joint, which began to develop against the backdrop of dislocation of the ankle ligaments.

Fiber separation often occurs in the projection of the interosseous, deltoid or tibial ligaments. It is they who together provide stability to the joint and a strong connection between the heads of the tibia and femur.

Risk factors that can provoke the development of ankle ligament sprains:

• curvature of the legs and thighs due to rickets and osteomalacia;
• incorrect placement of the foot in the form of clubfoot and flat feet;
• practicing outdoor sports (football, volleyball, basketball, tennis, etc.);
• wearing high-heeled shoes;
• stretching of the Achilles tendon and its subsequent scar deformation;
• incorrect choice of shoes for everyday wear and sports;
• plantar fasciitis and heel spurs;
• excess body weight;
• diabetic foot and other types of angiopathy.

If the ankle ligaments are torn, you should seek medical help from an orthopedist or traumatologist. If the ankle ligaments are torn, you should seek medical help from an orthopedist or traumatologist. At the initial stage, treatment is carried out using conservative methods without surgery.

How is the operation performed at the Gelenk Clinic?

The lateral or medial ligaments of the knee may suddenly fuse.
This self-healing process does not apply to the anterior and posterior cruciate ligaments. © ttsz, iStock As a result of acute injuries, surgery can only be performed after the concomitant diseases have been cured and the wound has completely healed. For this reason, cruciate ligament reconstruction is performed approximately 2-3 months after the injury itself. During this period, the mobility of the knee joint is severely limited. Physical therapy helps prepare the knee for surgery.

Cruciate ligaments differ in structure from other ligaments of the knee joint: with ruptures of the external and internal collateral ligaments, immobilization of the joint using a special orthosis can promote sudden healing of the injury. Cruciate ligaments do not have this self-healing effect. As a rule, operations on the cruciate ligaments are performed to restore their functionality.

Surgical intervention usually lasts 1.5 - 2 hours. During the operation, surgeons perform a tendon transplant or perform a suture. Which method is right for you should be discussed with your doctor.

Cruciate ligament replacement and tendon transfer

The most common surgical technique is cruciate ligament replacement surgery. During this procedure, the surgeon first completely removes the damaged ligament in order to prepare the patient for transplantation. To obtain a graft, the doctor takes parts of autogenous tendons from other areas of the knee joint. As a rule, the operating doctor uses the patellar ligament, located between the kneecap and the tibia, for this purpose.

The advantage of autologous tendon transplantation is certainly the absence of body rejection, since the graft is obtained from the patient’s own body, namely from the patellar tendon and Achilles tendon. After completing the transplantation process in the femur and tibia using special bone screws, after some time the tendon graft is well absorbed by the body and begins to be supplied with blood vessels.

The only drawback of this intervention is the feeling of pain in the leg, namely at the site of graft collection. The patient may feel discomfort for several months. Tendon removal also slows down the development of physical strength. However, this fact only matters for athletes. After surgery, the patient will undergo long periods of physical therapy and specialized training.

In addition, the operation does not help restore the innervation process, which is of great importance for coordination of movements. In elite sports this is considered a disadvantage, but for most patients this fact is not of great importance.

Stitching of the cruciate ligaments by refixation of damaged structures

Modern procedures make it possible to preserve endogenous cruciate ligaments even after their rupture. The purpose of plastic surgery using the Ligamis method, offered by our clinic since the beginning of 2014, is to restore the stability of the knee joint in accordance with its natural functions. Using this system, the surgeon replaces the torn ligament with an artificial implant, which, during the recovery period, is responsible for mechanical stabilization of the damaged cruciate ligament in the very center of the knee joint. In this case, the torn parts grow together again and heal under the influence of the implant. If this technique is successful, the patient will not require cruciate ligament reconstruction using endogenous tendons.

The result after surgery using the Ligamis technique is much better than after autologous tendon transplantation, since after refixation all nerves are preserved and, thus, the process of controlling the movements of the knee joint remains normal. Athletes should pay attention to the choice of surgical method.

Since refixation of a tendon graft does not require donor material, there is no need for material collection, which is accompanied by pain and muscle weakness in the area of ​​graft extraction. Already a few days after re-fixation, the patient can fully load the knee.

Before referring a patient for surgical refixation of the cruciate ligament, it is necessary to undergo a comprehensive MRI examination. After this, the decision should be made as quickly as possible, since more than 3 weeks after the injury, the self-healing ability of the cruciate ligament decreases. Thus, this surgical intervention is recommended during an exacerbation of the rupture, namely within three weeks after the injury. Otherwise, only transplantation can help the patient.

Our highly qualified specialists usually remove the Ligamis implant 6-9 months after successful healing of the cruciate ligament. During the removal of the implant, the process of its healing is also checked.

ACL plastic surgery

The cruciate ligaments are under constant tension, so applying sutures to restore their integrity is ineffective. Only in case of a Segond fracture is the integrity of the bone restored by fixing the torn fragment. For reconstruction, plastic surgery is performed using an autograft, that is, using the patient’s own tissues. This is usually the semitendinosus tendon. The efficiency of such operations is high. After completing rehabilitation measures, functionality is restored. However, plastic surgery is not required in all cases.

The need for it is based on:

• results of analysis of the intra-articular cavity, the absence of pronounced consequences of inflammation in the joint with extensive fibrosis and adhesions;
• presence of knee instability and other functional disorders;
• sports activity (the desire to return to sports with certain expected intense loads).

Plastic surgery is not performed immediately, but some time after the injury. However, it is not worth postponing the operation for a long time, since instability causes microdamage to the articular cartilage, which can result in the development of arthrosis. The key condition for surgery is the absence of internal inflammation. Preparation for surgery includes conservative treatment methods. Then plastic surgery is performed using the autotransplantation method. The rehabilitation period after such an operation is very important, and compliance with the recommendations of a rehabilitation physician plays a significant impact on the recovery process.

What type of doctor performs surgical treatment of a cruciate ligament rupture?

At the orthopedic medical center Gelenk-Klinik in Germany, a trusting relationship between the patient and the medical staff is highly valued. Your attending orthopedic surgeon will accompany you from your first meeting with him until the postoperative period. He also provides follow-up care for the patient. This way, you will have a responsible person whom you can contact at any time. The specialists in the treatment of knee diseases and cruciate ligament ruptures at the Gelenk Clinic are Dr. Baum, Prof. Dr. Ostemaer Privatdozent Dr. med. Dr. Markwas.

Risk factors

1. Genetic (hyperelasticity, hypermobility of joints and connective tissue).
2. Anatomical factors (width of the intercondylar space, tibial plateau inclination, valgus).
3. Hormonal factors (in women, the risk of ACL rupture increases 2-5 times depending on the cycle).
4. Internal factors (diabetes).
5. External factors (nutrition, quality of coating, shoes, humidity, etc.).
6. Muscle biomechanics (muscle imbalance - predominance of quadriceps strength over flexor muscles).

What type of anesthesia is used during surgery?

As a rule, cruciate ligament surgeries are performed under general anesthesia. However, doctors sometimes consider administering a spinal anesthetic to avoid the risk of general anesthesia. To do this, the anesthesiologist injects an anesthetic into the spinal canal of the lumbar spine. In this case, the patient is fully conscious. Anesthesiologists at the Gelenk Clinic have many years of experience in performing such operations. Which of the above methods corresponds to your indicators is decided during an explanatory conversation.

Will I feel pain after surgery?

Every surgical procedure may involve pain. Surgery to treat a ruptured cruciate ligament of the knee joint is no exception. Thanks to the high professionalism and long-term experience of our surgeons, we are able to reduce the patient’s pain to a minimum. Before the operation, the anesthesiologist gives a special injection that numbs the knee joint for approx. for 30 hours. After this, the pain decreases and the patient’s treatment continues with conventional medications. The goal of the medical staff of the Gelenk Clinic is to ensure a painless postoperative period for the patient

How to repair a torn knee ligament?

In most cases, the separation of the knee ligament is a reason for performing endoscopic plastic surgery. For reconstruction, synthetic materials or parts of ligaments taken from the ankle joint are used. They are installed using bone screws. After surgery, active rehabilitation is required.

There are techniques for restoring ligament dislocation using manual therapy methods. This can only be done in the early stages, when the risk of ligament rupture is not high. By increasing microcirculation of blood and lymphatic fluid, the scarring process can be accelerated. Reflexology allows you to start the process of natural tissue regeneration. And physical therapy in combination with kinesiotherapy allows you to enhance diffuse nutrition and strengthen the ligamentous apparatus of the knee.

Conditions of stay at the Gelenk Clinic

Single ward at the Gelenk Clinic in Gundelfingen, Germany.
© joint-surgeon During your inpatient stay at the clinic, you are in a single room, which has a shower and toilet. Towels, bathrobe and slippers are provided in each room. In addition, you can use the safe, minibar and watch TV. You must bring your own medications, comfortable clothes and nightwear. After surgery, your condition is monitored around the clock by medical staff and professional physiotherapists. As a rule, you stay in the clinic for no more than three days. Your relatives can stay at a hotel located near the medical center. We will gladly take care of your hotel room reservation.

What should you pay attention to after surgical treatment of a torn cruciate ligament?

Immediately after surgery for a torn cruciate ligament, the knee should be elevated. In addition, a cooling compress should be applied to the knee. Approximately 10 days after surgery, the stitches will be removed and you will be able to shower.

To avoid possible complications, the knee should be at rest for approximately 6 weeks. During this time, you will be issued sick leave and given elbow crutches. Prevention of thrombosis when it is impossible to carry out full loads on the knee is a necessary procedure. To prevent loss of muscle mass and preserve the natural functions of the knee joint, a course of physical therapy is carried out.

You can plan your return flight home no sooner than 10 days later. However, we recommend leaving the clinic after at least two weeks.

• Inpatient treatment: 3–4 days
• Recommended length of stay in the clinic: 10–14 days
• When to book a return ticket: 10 days after surgery
• When is it recommended to leave the clinic: after 2 weeks
• When can you shower: after 10 days
• How long sick leave is issued: 6–8 weeks (depending on professional activity)
• When the stitches are removed: after 10 days
• Outpatient physical therapy: 2 weeks
• When can you drive again: after 6 weeks
• Light sports activity: 3-6 months after surgery
• Habitual sports activities: after 9 months

Indications for surgery

Arthroscopic plasty of the ACL of the knee joint is not performed immediately after the incident to avoid complications. As a rule, a surgical session is not scheduled until the inflammatory focus and swelling are eliminated. Throughout this period, competent conservative medical care and limb immobilization are provided.

For what identified problems will it be necessary to undergo ACL reconstruction of the knee joint after some time? There are certain factors that are a clear reason for performing plastic surgery using arthroscopy, these are:

• transverse rupture of the ligament along the entire line of width;
• absolute separation of fibers from the place of attachment to the bone;
• partial injury with a pronounced degree of knee instability;
• unsuccessfully performed plastic surgery of the injured ACL of the knee joint, which did not contribute to stabilization due to incorrect transplantation;
• chronically recurring sprains and tears;
• unsuccessful conservative treatment.

Important! Let us remind you once again that a reconstructive procedure is not performed immediately after an injury, but this does not mean that the victim does not need the help of a traumatologist. In order not to aggravate the problem, you need to immediately get examined, get qualified recommendations from a specialist and immediately begin to implement them! As an exception, immediate surgery can be performed either for extensive combined trauma (ACL rupture in combination with injuries to bones, menisci, or other ligaments), or for athletes to quickly return to professional sports.

Cost of knee surgery

In addition to the cost of surgery for cruciate ligament rupture, it is necessary to take into account the additional costs of diagnostics, doctor's appointments and aids (eg elbow crutches), which range from approximately 1,500 to 2,000 euros. If you plan to undergo physical therapy after surgery, we will provide you with a cost estimate and email it to you.

You can obtain information about the cost of staying at the hotel, as well as possible additional treatment, on the service provider’s website.

How can a foreign patient make an appointment and the operation itself?

You will first be asked to provide current MRI scans as well as X-ray results. This way the doctor can assess the condition of the knee joint. After we receive all the necessary documents through our website, within 1-2 days we will send you a preliminary treatment plan and cost estimate.

The Orthopedic Medical Center Gelenk-Klink provides foreign patients with the opportunity to make an appointment within a short time. We will be happy to help you with obtaining a visa after the advance payment specified in the preliminary cost estimate has been received into our account. In case of refusal to issue a visa, the advance payment is refunded in full.

For patients from abroad, we try to reduce the time between the preliminary examination and the operation itself. This way you will not need to come to the clinic several times. During both outpatient and inpatient treatment, you will be accompanied by qualified medical personnel who speak several foreign languages ​​(English, Russian, Spanish, Portuguese). We also provide assistance in finding a translator (for example, into Arabic), which is paid for by the patient separately. We will be happy to help you organize a transfer, find a hotel and tell you how to spend your free time in Germany interestingly for you and your family members.

medical request