The anterior cruciate ligament (lat. lig. cruciatum anterius) starts from the postero-superior part of the inner surface of the lateral condyle (bone protrusion) of the femur, crosses the cavity of the knee joint and is attached to the anterior part of the anterior intercondylar fossa of the tibia, also in the joint cavity. The cruciate ligament stabilizes the knee joint and prevents the tibia from moving excessively forward, and also supports the lateral condyle of the tibia. The posterior cruciate ligament of the knee joint (lat. lig. cruciatum posterius) starts from the anterosuperior part of the lateral surface of the internal femoral condyle, crosses the knee joint and attaches to the posterior intercondylar fossa of the tibia. It stabilizes the knee joint and keeps the lower leg from moving backward.
The articular surfaces of the bones are covered with cartilage. Between the articulating surfaces of the femur and tibia there are internal and external menisci, which are crescent-shaped cartilages. The knee joint is enclosed in a joint capsule. In humans, the knee joint allows movements of flexion and extension, and when bent, rotation around an axis.
The knee is the most common site of sports injuries (such as a torn meniscus or ligament).
Knee-joint
Knee joint
The knee joint is a complex part of the musculoskeletal system. The anterior and posterior cruciate ligaments are strong bands of connective tissue. They are necessary to strengthen the joint and stabilize it.
Their damage occurs due to rotation (rotation) of the thigh with the lower leg fixed in one position, as well as due to direct mechanical impact in the form of an impact. This often occurs in people actively involved in sports (people involved in basketball, gymnastics). ACL rupture is also possible in everyday life, in particular when twisting your leg or falling on your knee.
What complications can there be?
After the intervention, there is a risk of developing undesirable consequences. Among them:
- Joint contracture (may occur due to improper intervention).
- Arthrosis, degenerative changes in the knee.
- Pain, limited mobility.
- Displacement or tearing of the transplanted tissue.
- Material rejection is extremely rare.
- Allergic reaction to anesthesia.
Full recovery takes about four months. In 95 cases out of 100, the operation is successful.
Classification
Depending on the degree of damage, there are several degrees of injury severity:
- Incomplete (partial) rupture, in which partial damage to the connective tissue fibers of the ligament occurs without disturbing the overall anatomical structure.
- Moderate injury, in which the number of damaged fibers is greater. This results in a slight increase in the length of the cruciate ligament with partial loss of knee stability.
- A complete break with a violation of integrity. At the same time, the functions of the knee deteriorate significantly, in particular the stability of the joint decreases.
Determining the severity of the rupture during an objective diagnosis of such an injury as a rupture of the cruciate ligament of the knee, treatment allows you to select the most effective one.
Indications
Indications
Determining indications for surgery is a complex diagnostic process, which in modern medical institutions is carried out using high-quality equipment.
Trauma with ACL damage
Trauma with ACL damage
- Pain sensations developing inside the joint and in the area of its anterior surface. They are usually high intensity and appear immediately after injury.
- Increased severity of pain during loading of the knee.
- Impaired functioning of the knee joint, which is manifested by a limitation in the range of passive and active movements in it.
- The appearance of pathological mobility of the knee joint with a complete rupture.
The severity of the symptoms depends on the severity of the damage, as well as the individual characteristics of the human body.
Causes
ACL damage is a polyetiological condition that can develop under the influence of various causes. For ease of diagnosis and determination of treatment tactics, including surgery, they are divided into 2 groups:
- Injuries - the implementation of the main pathogenetic mechanisms of injury often occurs in active young people, as well as athletes.
- Pathological conditions are changes leading to a decrease in the strength of connective tissue fibers. They often develop in older people against the background of degenerative-dystrophic processes, as well as in young patients with the development of autoimmune processes (rheumatism, rheumatoid arthritis) or congenital weakening of connective tissue components caused by changes in the functional state of certain genes.
Determining the main causative factor using complex diagnostics determines the tactics of subsequent treatment.
Diagnostics
Determining the location and severity of anterior cruciate ligament injury in modern medical clinics is carried out using various diagnostic techniques. These include:
- Radiography and fluoroscopy.
- Arthroscopy.
- Ultrasound.
- CT or MRI.
In clinics where there are technical capabilities for this, arthroscopy is used. It is a diagnostic method. Its principle is to introduce an optical device equipped with a camera and a light source into the joint cavity. Using a manipulator, a medical specialist can perform plastic surgery of joint structures.
Damage to the cruciate ligament of the knee
At this stage of medical development, surgery to restore the cruciate ligament is performed using arthroscopy, through the smallest possible incisions.
Most surgeons prefer to reconstruct the anterior cruciate ligament using a graft from the patient's own tendons and ligaments.
A transplant that is formed using the patient's own tissue is called an autograft in medicine.
Most ligament reconstruction surgeries are performed on an outpatient basis, meaning many patients can go home the same day after surgery. Some patients may need to stay in the hospital for two or three nights.
There are many different ways to reconstruct the anterior cruciate ligament. One of the most commonly used is to take the semitendinosus and gracilis tendons from the patient, form them into a graft, and place it in place of the torn anterior cruciate ligament.
In some cases, to restore the anterior cruciate ligament, for example, in professional athletes or in elderly people with severe artosis, a special synthetic endoprosthesis can be used. The use of synthetic endoprostheses has a number of advantages and disadvantages.
The advantages include the high strength and inertness of the synthetic endoprosthesis to the tissues of the body, which allows for aggressive rehabilitation immediately after surgery, there is no pain at the site of taking the tendons of the semitendinosus and tender muscles, the anatomy of the muscles of the posterior surface of the thigh and the function of the flexor apparatus of the knee joint are not disturbed.
Disadvantages include the low elasticity of the synthetic endoprosthesis, which requires precise positioning of the bone canals, as well as the low bioavailability of this method of reconstruction of the anterior cruciate ligament.
Surgery technique using a graft from the tendons of the pes anserine (semitendinosus and tender muscle)
The muscles of the back of the thigh in humans are well developed. They originate from the pelvis and femur, cross the knee joint on both sides and attach to the lower leg.
The tendons for the graft are taken from the semitendinosus and gracilis muscles, which are attached by their tendons along the inner surface of the leg.
During surgery, the surgeon uses a special optical device (arthroscope) to control manipulations inside the joint. This surgical technique does not require the surgeon to make large incisions in the joint area, which significantly speeds up healing and recovery after surgery.
Anterior cruciate ligament (ACL) reconstruction surgery is usually performed under spinal anesthesia.
The surgeon begins the operation by making two mini punctures in the joint area of no more than 4 mm, through which an arthroscope and special mini-instruments are inserted into the joint. After the joint cavity is examined and the diagnosis is confirmed, the surgeon makes a small incision in the soft tissue in the projection of the attachment of the tendons of the semitendinosus and tender muscles and removes them with a special tool.
The tendons are specially processed and folded 3 or 4 times, which significantly increases the strength of the entire graft.
Next, the surgeon prepares the knee joint for implantation of a new ligament. The remains of the damaged ligament are removed, and if necessary, the intercondylar space is expanded so that the graft is not damaged. This manipulation is called notch plastic.
Once this is done, special instruments are used to drill holes in the femur and tibia through which the autograft will be inserted.
Very important at this stage is the correct location of the canals in the femur and tibia, only under this condition will the ligament work correctly and the patient will not feel pain and instability.
Subsequently, the autograft, under arthroscope control, is pulled through the canals and joint cavity, stretched with a certain force and fixed intraosseously with special screws or buttons.
Then the range of motion in the joint is checked, drainage is installed, sutures are applied, and the leg is placed in a postoperative orthosis.
Surgery technique using a graft from the patellar ligament
Another long-established method of reconstruction of the anterior cruciate ligament is arthroscopic plasty using an autograft from the tendon of the patellar ligament. For the operation, a strip of tendon with bone blocks at each end is removed.
The advantage of this type of autograft is its inherently greater strength and the possibility of rapid rehabilitation.
The tendon of the patellar ligament is very thick and strong, located on the front surface of the knee joint. It starts from the lower pole of the patella and is attached just below the knee joint to the tibia. The main function of the patellar ligament is to extend and elevate the leg.
When using the tendon of the patellar ligament as an autograft, the surgeon removes a strip of tendon, usually in its middle part, and also cuts out bone blocks from the patella and tibial tuberosity fixed to it.
The anatomy of the graft helps speed healing and create a strong attachment of the new ligament to the tibia and femur. When a graft is implanted, bone blocks are placed into bone canals. The surfaces of the bone walls of the canal and the bone blocks of the graft are in contact with each other and heal over time, like a normal fracture.
The surgeon performs the operation using an arthroscope connected to a monitor; this method allows you to control manipulations inside the joint without performing extensive soft tissue incisions, which were practiced in the pre-arthroscopic era. This surgical technique significantly speeds up recovery and is characterized by significantly lower pain and swelling after surgery.
Surgical procedures for reconstruction of the anterior cruciate ligament (ACL) are usually performed under spinal anesthesia. The orthopedic surgeon begins the operation by making two skin punctures, through which an arthroscope and special mini-instruments are inserted into the joint cavity. After inspection of the joint cavity and confirmation of the diagnosis, two small incisions are made in the projection of the patellar ligament. Precautions are taken to avoid damaging nearby nerves and blood vessels.
Working through small incisions, the surgeon removes the middle portion of the patellar tendon with two bone blocks from the patella and tibia.
The bone blocks are rounded and smoothed, and holes are drilled in the blocks through which strong threads are passed, through which the autograft will be pulled through the tunnels in the femur and tibia and stretched.
Next, the surgeon prepares the knee joint, removes degenerative tissue,, if necessary, sutures the meniscus, and resects the remains of the damaged anterior cruciate ligament.
Once this is done, bone canals are drilled into the femur and tibia.
The holes in the bones are located in such a way that the autograft, passed through them and fixed, functions as the original anterior cruciate ligament.
The graft is then pulled through the tunnels in the bones, stretched and secured with screws or special buttons.
After arthroscopic control of the position of the ligament, drainage is installed in the joint cavity, and sutures are applied to the soft tissue.
treatment without surgery
treatment without surgery
If the cruciate ligament is slightly damaged, treatment without surgery is possible. It includes conservative measures, the duration of which depends on the severity of the injury.
Typically, medications (non-steroidal analgesics, vitamins) and physiotherapy (electrophoresis with medications, mud therapy) are used.
For the entire period of treatment, it is imperative to ensure functional rest for the knee joint.
Postoperative period
Any surgical intervention leads to a certain amount of tissue damage, so immediately after it, time is required for their regeneration (healing), which is called the rehabilitation period. It includes several activities, which include:
- Providing functional rest for the limb, in particular the knee, which is performed with tight bandages using an elastic bandage or plaster splint.
- Treatment of postoperative sutures with antiseptic agents to prevent infection, as well as their subsequent removal after tissue healing.
- Prescription of medications, which is carried out if necessary to prevent bleeding and the development of an infectious process.
The duration of the postoperative period varies from 3-5 (after arthroscopy) to 10-14 (after open surgery) days.
Surgery
If there is a pronounced rupture of the cruciate ligament, treatment must be carried out using surgical methods. Based on the severity of the knee injury and the location of the damage, several techniques can be used:
- An open access operation involves a wide layer-by-layer dissection of all tissues surrounding the knee joint, and then plastic surgery of the damaged ligaments.
- Arthroscopy is a low-traumatic technique in which manipulators and an arthroscope are inserted into the joint cavity through small incisions.
The choice of surgical treatment method is determined by the severity of the injury, as well as the capabilities of the clinic. In modern medical institutions, arthroscopy is predominantly used.
Benefits of Arthroscopy
Benefits of Arthroscopy
In general, thanks to the use of arthroscopic operations on the anterior cruciate ligament, it was possible to achieve a significant reduction in the cost of the entire course of treatment for the patient, which is associated with a shorter duration of his hospital stay, as well as the amount of medications for the postoperative period.