Arthroscopic plastic surgery (reconstruction) of the anterior cruciate ligament

The complex structure of the knee joint includes the anterior cruciate ligament (ACL), which stabilizes it, prevents excessive forward movement of the tibia, and anchors the lateral tibial condyle. If the movement is too intense, it can rupture, which will lead to destabilization of the knee and, as a result, the inability to move normally. Arthroscopy of the anterior cruciate ligament is performed to diagnose and treat the injury. This minimally invasive surgery is highly complex, but is an effective way to restore limb mobility and prevent premature wear of the joint.

Structure and functions of the cruciate ligaments

The cruciate ligaments (anterior and posterior) are central in the structure of the knee joint; they connect the femur and tibia and are located perpendicular to each other, that is, they form a cross (hence the name). Their main function is to stabilize the joint, that is, to limit the mobility of the lower leg relative to the thigh. The anterior cruciate ligament prevents the shin from shifting anteriorly and inwardly relative to the thigh. The posterior cruciate ligament prevents posterior displacement of the tibia. If their integrity is violated, the patient is faced with instability of the knee, a change in its biomechanics, which leads to injury to the articular surfaces and menisci, and subsequently to the progression of degenerative diseases of the joint. At the same time, traumatic injuries to the anterior cruciate ligament occur many times more often than to the posterior cruciate ligament. The main mechanism of injury when these ligaments are torn is twisting on the supporting leg, but the cause can also be a sharp landing on the leg or a lateral blow to the shin or thigh.

Ligaments do not heal even with partial rupture due to the nature of their blood supply. In order to recreate them, it is necessary to use autografts - tendons of the patient's own muscles, or allografts - donor tissue. The main goal of the operation is to return the patient to lost functions, stability of the knee joint, as well as speedy rehabilitation and return to sports while minimizing subsequent complications. Today, such operations are performed in most cases using arthroscopy, a minimally invasive operation that is highly effective.

You can read more about anterior cruciate ligament rupture on the page: “Damage and rupture of the ACL.”

Relevance of ACL rupture

The relevance of ACL injuries is confirmed by statistical data from different countries:

• The number of new cases in Europe is 250-300,000 per year (M. Yabroudi, H. Bjornsson 2016). At the same time, about 100,000 reconstructions are carried out annually. According to insurance companies, most injuries occur among skiers. For example, in Germany there are 32 people per 100,000 of the total population, in France - 47 per 100,000.
• In the USA, the number of primary ACL reconstructions per year is 100,000 operations, including up to 50 per 100,000 people among skiers.
• According to national registries since 2004 in Scandinavia: In Sweden, 17,000 primary anterior cruciate ligament reconstructions and 1,000 revisions are performed annually. Of these, skiers account for 32 per 100,000 people.
• In Denmark 38 per 100,000 people.
• In Norway 34 per 100,000 people.

Physiotherapy

In order to accelerate the repair processes, effective physiotherapeutic treatment tactics are used, performed on an outpatient basis, such as:

• electromyostimulation;
• laser therapy;
• magnetic therapy;
• electrophoresis;
• UHF treatment;
• light lymphatic drainage massage.

Electrical stimulation

Physiotherapy can also include other procedures, and each of them is selected on a purely individual basis. It is important to note that physical techniques are used throughout all stages of knee rehabilitation after arthroscopy. They comprehensively stimulate self-regeneration mechanisms, improve metabolism, improve tissue trophism, prevent postoperative consequences, activate blood circulation and lymph outflow, and reduce pain and inflammatory reactions.

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).

Postoperative rehabilitation (6 months)

This is the earliest time you can return to full sports activities.

To resume sports activities, you need:

• Restore quadriceps muscle strength to at least 80% of the healthy leg
• Restore hamstring muscle strength to at least 80% of the healthy leg
• Restore full range of motion in the joint
• No swelling
• Satisfactory stability in the joint
• Complete the rehabilitation program

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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.

Hemarthrosis - accumulation of blood in the knee

Usually develops due to damage to the ascending lateral femoral circumflex artery. Hemarthrosis is treated by arthroscopic lavage of the synovial cavity and intra-articular injection of a local anesthetic (Lidocaine, Novocaine) with adrenaline. After this, a pressure bandage must be applied to the patient’s knee.

Accumulation of blood in the capsule.

Conservative or surgical treatment?

Arthroscopic repair is the only way to restore the cruciate ligaments.

A fairly common question that arises among patients is whether it is possible to get by with conservative treatment for an ACL rupture? Anterior cruciate ligament injury is a fairly general concept. If it is significant for the stability of the joint, then plastic surgery of the cruciate ligament is clearly indicated. If the injury did not cause instability and affected only one bundle, then you can try to treat the pathology conservatively. But you need to clearly know that this is a partial, insignificant damage to individual ligaments, which does not imply further formation of instability of the knee joint. This can be established quite confidently only with arthroscopic diagnosis.

At the same time, the concept of “conservative treatment” does not entirely correspond to the measures being taken, since the torn ligament is not restored, and the survivors will take on the entire burden. Therapy will be aimed at eliminating acute concomitant pathologies and inflammation, restoring muscles and joint performance in new conditions.

The operation is clearly indicated:

• if there is instability of the knee joint,
• if the patient leads an active lifestyle and, especially, plays sports,
• In young age,
• when engaged in heavy physical labor.

For patients belonging to the age group with severe arthrosis deformities, who do not expose their joints to serious stress, in the absence of signs of instability and other pathologies, it is permissible to prescribe conservative restorative measures. Moreover, if instability occurs during rehabilitation measures after stopping acute processes, then surgery should be scheduled as quickly as possible, since there is a risk of damage to other elements of the knee joint (menisci, patellas, etc.).

Compartment syndrome

Occurs due to leakage of irrigation fluid in the presence of a defect in the joint capsule. The development of pathology is facilitated by an increase in irrigation pressure and blockage of drainage. Compartment syndrome is accompanied by soft tissue swelling and a sharp increase in intrafascial pressure. As a rule, it leads to necrosis of muscle tissue and the appearance of contractures in the postoperative period.

Compartment syndrome is treated conservatively. Patients are prescribed analgesics (Tramadol, Ketorolac), decongestants (Furosemide) and anti-ischemic drugs. They are also administered drugs that improve the rheological properties of the blood and relieve vascular spasm. If conservative therapy is ineffective, patients undergo surgery - decompressive fasciotomy.

Arthroscopic anterior cruciate ligament repair

Reconstruction of the ACL through conservative treatment is impossible - tears cannot be “fused” without direct access. That is why, for any type of damage to the cruciate ligaments, surgical treatment is prescribed in order to restore them.

Preparation

Arthroscopic reconstruction is carried out strictly as prescribed by a specialist. This is preceded by:

1. Examination, history taking.
2. A consultation at which tests are carried out and where it is necessary to talk about all existing diseases.
3. Taking blood and urine tests.
4. Additional examination methods (CT, MRI, X-ray, ECG).

Carrying out the operation

First of all, the doctor makes small incisions in the skin. Through them, it becomes possible to introduce a fiber optic device with a built-in camera (arthroscope) into the joint cavity, as well as other surgical instruments, with the help of which the damaged part of the ligaments will be recreated. Visual review is provided by a high-resolution image, which is displayed on the screen in real time. If a decision is made to perform an autotransplantation, the doctor performs a tendon transplant, which is taken from the popliteal region (tendon of the semitendinosus muscle). After the operation, the patient can go home the same day. After the sutures are removed, the doctor will refer you to a course of postoperative rehabilitation to promote a speedy restoration of joint function.

Tool failure

In recent years, it has become less common due to the improvement of arthroscopic equipment. If an instrument breaks down, doctors immediately stop irrigation and aspiration. They then carefully remove the broken fragment using special equipment. If the piece is small and difficult to access, it may be left in the synovial cavity.

Tools.

The effectiveness of surgical treatment of ACL rupture

When a patient is faced with the task of returning to sports, the only effective treatment option is anterior cruciate ligament surgery. A satisfactory result is achieved in 85-93% of surgical interventions (Hofbauer V., Valentine P., 2010; Mihelic R., Jurdana H. 2011). At the same time, a return to sports to the previous level occurs in 50-70% of cases.

Reasons why maximum results and the return of physical activity to the previous level are not achieved:

1. Incorrect assessment of the instability option means underestimation of rotational stability. Often, an ACL tear occurs along with other injuries to the knee joint. Without their restoration, its full functioning is impossible.
2. Incorrect reconstruction technique - technical errors of the surgeon or technology: the main one - individual anatomy is not taken into account (technological errors, “guides”, incorrect interpretation of the anatomical structure or ignorance), etc.
3. Violation of the biological conditions for the restored graft: bone tunnels, features of graft formation for subsequent accretion and ligamentization, features of its fixation (design features of fixators).
4. Lack of individual adequate rehabilitation or its inconsistency with the capabilities of the joint and graft.
5. Lack of medical monitoring of the condition of the knee and graft until the completion of rehabilitation (until its growth and full blood supply).

Priorities for successful ACL reconstruction surgery.

First of all, this is taking into account biological processes, namely:

1. Anatomy, i.e. individual features of the anatomical structure of the joint - i.e. correct placement of the graft. Although the knee joint is roughly similar, each person is different and the correct location for each is how the ligament was positioned before the injury.
2. Selection of the shape and characteristics of grafts. The graft must be anatomically correct in shape with a high degree of strength and engraftment.
3. Creation of biological conditions for graft growth to the bone base.
4. During the rehabilitation process, it is important to provide it with an active blood supply so that the ligament gains strength and ligamentizes.
5. With the beginning of active movements, it is necessary to create such conditions so that the graft does not have any negative preconditions for mechanical damage and maintains the tension created during the operation.

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