The lower extremities are exposed to massive physical activity every day. When walking, running, jumping, a huge number of large and small joints are involved. But the main load falls on the ankle and knee. Together with the arches of the feet, they absorb up to 70% of the shock-absorbing load and provide protection for the hip joint and spinal column from extreme overloads. But, unfortunately, it is precisely high loads that lead to the fact that the ligamentous and tendon apparatus of the ankle and knee quickly comes to a destroyed and deformed state.
Sprained ankle ligaments often lead to instability and periodic twisting of the leg. And when the ligaments of the knee joint become separated, functional instability occurs, in which independent movement of a person becomes either difficult or impossible.
Differential diagnosis of fiber separation is necessary to exclude ruptures, bone fractures, destruction of menisci, etc. The diagnosis begins with a visit to an orthopedist. Already during the initial examination and a series of functional diagnostic tests, an experienced doctor will be able to make an accurate diagnosis. An x-ray is then ordered. It eliminates damage to bone tissue, fractures, cracks, and dislocations. When conducting an MRI examination, a verdict may be made - fiber separation of one or another ligament. In this case, diagnostic arthroscopy of the knee or ankle is prescribed. During an endoscopic abdominal examination, if ruptures are detected, an operation is performed to restore the integrity of the ligamentous and tendon apparatus. Then follows a period of rehabilitation and the patient completely restores the health of his joint.
To undergo complete rehabilitation treatment, you can contact our manual therapy clinic in Moscow. Call the administrator and make an appointment for a free appointment with an orthopedist. The doctor will review the results of the examinations completed, conduct an examination and talk about the prospects for using manual therapy methods in your individual case.
Ligament dislocation - what is it?
Let's look at the question of what it is - ligament separation and how it is dangerous for the health and mobility of the patient. First, let's take a look at the anatomy and physiology of the knee and ankle joints.
So, the knee joint is formed by connecting the condyles of the tibia and femur. They are separated from each other by dense cartilaginous menisci, which absorb shock absorbing loads when walking, running and jumping. A dense articular capsule is formed around the joint; inside it is synovial fluid, which is absorbed and secreted by the cartilage layer covering the heads of the bones. This is another shock-absorbing protective mechanism. The front of the joint is bordered by a triangular bone - the patella. It is attached to the epiphyses of the tibia and femur with the help of tendons and its own ligamentous apparatus.
The stability of the knee itself is provided by four large ligaments:
- the anterior cruciate prevents the femoral condyle from moving forward;
- the posterior cruciate restricts the posterior movement of the tibial condyle;
- 2 lateral (lateral and medial) limit mobility in the right and left lateral planes).
Most often in the practice of a traumatologist and orthopedist, swelling and disintegration of the anterior cruciate ligament occurs, since it bears the maximum physical, mechanical and shock-absorbing load. Young active people who are fond of sports and experience regular overload of the lower extremities suffer more often.
The posterior cruciate and collateral ligaments are less affected. But even with significant injuries, they are subject to destruction of the collagen fibers that form the ligament tissue.
Normally, the ligament of the ankle or knee joint consists of tightly intertwined collagen fibers. It is a strong connective tissue. Its disadvantage is a low degree of extensibility and a complete lack of its own blood supply. She can receive fluid in limited quantities only with the active work of the muscles surrounding her.
When an injury occurs, mobility is limited for natural reasons. Therefore, the damaged ligament does not receive enough diffuse nutrition. It begins to undergo ischemia and gradual degenerative dystrophic destruction. The fibers become sparser, the density of the ligamentous tissue decreases.
In this condition, there is a high probability of a complete or partial rupture, which will not heal on its own. Surgery will be required to restore its integrity. This is the biggest threat to patient mobility. In addition, when the ligaments become loose, he risks that the process of deformation of the cartilage and bone tissue of the joint will begin in the near future. Deforming osteoarthritis may require joint replacement surgery or make it impossible for a person to move independently. Therefore, if a process of ligament disintegration is detected, you should immediately contact an experienced orthopedist for restorative treatment using conservative methods of manual therapy.
Since the knee joint (KJ) is one of the most active and functionally loaded, it plays a leading role in the statistics of injuries to the capsular ligamentous apparatus. The largest number of patients with such injuries are people of working age (mostly young), somatically healthy, leading an active lifestyle. As the main intra-articular stabilizers, the cruciate ligaments play an important role in maintaining multiplanar stability of the joint and the biomechanics of the entire lower limb. When the knee joint is damaged, the anterior cruciate ligament (ACL) is most often affected and accounts for 25 to 60% of all injuries to the capsular ligament apparatus of the knee joint [1–3].
However, reconstructive interventions on the cruciate ligaments do not always achieve their functional goal, resulting in persistent chronic instability due to failure, which is painful for the patient and detrimental to the joint. It causes sudden and difficult to control subluxations of the leg, accompanied by acute dysfunction and causing secondary meniscus tears, destruction of articular cartilage and the development of osteoarthritis [4, 5].
With the beginning of the widespread use of arthroscopic techniques, synthetic materials were initially actively used for ACL reconstruction. Meanwhile, the number of surgeons using autografts from the middle third of the patellar ligament, as well as from the semitendinosus and gracilis tendons, to reconstruct the anterior cruciate ligament has been constantly increasing. Currently, more than 400 different techniques for ACL reconstruction are described in the literature [6].
Material and methods
We carried out a study aimed at studying the influence of the features and techniques of performing primary reconstructive operations on the ACL in the context of revision and repeated reconstructive arthroscopic operations in case of failure and re-rupture of the autograft.
The following causes of failure and repeated rupture of the autograft were identified in our sample of patients: repeated injury - in 17, graft rupture due to unsatisfactory quality of the material (synthetic ligament) - in 3, mechanical damage (usually from a protruding interference screw) - in 5, constant compression of the graft due to an anteriorly displaced tibial canal - in 11, insufficient strength of the graft due to inadequate fixation - in 4, weakening of the graft tension (stretching) - in 7.
In most cases, patients did not report re-injury, but indicated increased instability in the knee joint. In case of repeated injury, its force was usually sufficient to rupture the graft. When performing the Lachman test, we paid special attention to concomitant joint instability, with posterolateral instability most often detected.
X-rays in lateral projections were performed in a standard manner - at maximum extension or under load, with slight flexion of the knee joint - to identify anterior displacement of the tibia. In this case, special attention was paid to metal fixators (location, type of product), location of bone canals, assessment of the severity of degenerative changes and destruction of bone canals (femoral, tibial).
The purpose of the revision surgery in these cases was to perform all manipulations in a single stage, including ACL reconstruction. In some cases, revision had to be performed in several stages, for example, when filling the bone canals with cancellous bone and then installing an ACL graft. We highlight the following factors that need to be analyzed to develop treatment tactics:
1. Material used for transplantation in the first operation. It is very important to determine the type of grafts that were used during the first operation.
2. Autogenous tissues. If an autograft from the patellar ligament was initially used, then for revision surgery in 14 cases we successfully used the tendon of the semitendinosus muscle of the same lower limb. If the semitendinosus tendon had already been used, then for revision surgery in 4 patients, the semitendinosus tendon of the other lower limb or the middle third of the patellar tendon of the same lower limb was used.
3. Synthetic material. In 3 cases, synthetic material was used for primary plastic surgery. In all cases, we aimed to remove all synthetic material, including the intraarticular and intracanal compartments, especially if the canals were malpositioned. If possible, the maximum amount of synthetic material should be removed, since remaining material can lead to the development of chronic synovitis. As a result, the inflammatory response may adversely affect the condition of the ACL autograft after revision reconstruction.
4. Allografts. First of all, we determined whether old bone canals would interfere with the formation of new ones. Obviously, if a new tibial canal is to be placed posterior to the primary, the anterior wall of the new canal may fracture, displacing the graft anteriorly. In these cases, we recommend a thorough revision, during which the remaining allograft is removed, and the old canals are processed with a shaver and filled with cancellous bone tissue. If possible, metal anchors should be removed and ACL reconstruction performed as a second step.
5. Condition of soft tissues. After restoration of the ACL with an autograft from the patellar ligament, in 3 out of 4 cases a low position of the patella and scars in the area of the fat pad were revealed, so in the following we paid special attention to the condition of the postoperative scar after the primary operation. In such situations, it is preferable to take material for transplantation from the opposite side, which minimizes difficulties with the donor zone on the reconstruction side.
6. Location of channels. Controlling the location of channels is the most important aspect of planning and auditing. With the correct location of the canals and their diameter less than 8 mm, in all cases we can easily perform a one-stage reconstructive operation.
When the new tibial tunnel is positioned posterior to the original by 1-2 mm, the risk of breaking its anterior wall increases during reaming between the old and new canal or when placing a graft, which will lead to anterior displacement of the new graft. In our opinion, if there is the slightest possibility of a fracture of the anterior wall of the canal during revision surgery, it is better to limit ourselves to filling the primary canal with cancellous bone, and perform ACL restoration after 3-4 months.
Similar problems can arise with the location of the femoral canal - a fracture of the wall between the canals is possible, which will lead to displacement of the graft. As a result, instability and lack of isometry of the canals will be the reason for refusing one-stage revision reconstruction of the ligament. In such cases, at the first stage, it is more advisable to only inspect and clean the canal walls, as well as fill them with spongy bone tissue.
7. Bone canal enlargement is a known problem after ACL reconstruction. We have encountered it most often in the tibial tunnel after reconstruction using a VTV graft. The femoral canal is most often widened by the placement of a semitendinosus tendon graft secured to the femur with button-type fixators or fixation rods, resulting in a “wiper effect” or “spring effect” caused by rocking of the graft. Expansion of bone canals is of greatest clinical importance in cases where it leads to graft weakness, instability, and rupture. Absorbable (biodegradable) screws are known to cause changes in bone tissue (formation of cysts, foci of lysis).
8. Determination of changes in canals (expansion, formation of cysts). In all cases, we determined changes in the canals with maximum accuracy before revision of the joint. X-ray computed tomography should be considered the diagnostic method of choice, since magnetic resonance imaging is less suitable due to artifacts from metal clamps.
If the tibial or femoral canals are correctly located, the diameter of the tibial canal is greater than 12 mm, then we recommend filling the enlarged canal with cancellous bone tissue in the first stage, and performing ACL reconstruction later. When the diameter of the tibial canal was more than 12 mm, we completely filled the enlarged canal with cancellous bone. A slight discrepancy between the diameters of the graft and the canal is easily corrected with interference screws using a hybrid type of fixation.
When the bone canals were slightly widened (from 8 to 12 mm), we collected cancellous bone from the upper third of the tibia. In 3 cases with defects larger than 12 mm, the autograft was obtained from the iliac wing on the opposite side. Despite the expansion of the scope of surgical intervention, large bone defects can be filled with autograft from the iliac crest.
Moreover, after bone grafting, ACL restoration was delayed for 3-4 months, and before the second operation, X-ray data necessarily excluded such changes in bone tissue as persistent enlargement of the canals, osteolysis, or cysts.
A significant factor determining the possibility of performing one-stage reconstructive surgery on the ACL is the type of fixation that was used during the first operation. Many fixation techniques do not pose revision problems. To obtain a longer canal, we typically reamed the femoral canal at a different angle (usually with the knee joint flexed at 60-70°).
After femoral fixation using interference screws (inserted from the joint), the first decision was whether to leave the screw in place or remove it. If the screw is in place of the new femoral tunnel, it must be removed. At the same time, we can highlight the following circumstances that make it difficult to remove screws.
1. Titanium screws that have a high degree of ingrowth into bone tissue are difficult to remove, especially if the screw was installed several years ago.
2. Difficulties in detection when the screw is inserted deeply into the canal (in such cases it is necessary to use fluoroscopy).
3. Increased risk of instrument breakage when removing scars surrounding the screw with a shaver (synovial resector). Therefore, we recommend the use of electrocautery to detect the interference screw.
4. Variety of screw slots. A set of screwdrivers is required to match the different screw slot diameters.
5. Difficulty installing the screwdriver. If the femoral interference screw was placed through a patellar ligament donor site defect or (in rare cases) through the tibial bone tunnel, inserting a screwdriver into the screw slot may be difficult. In one of these cases, we needed to install an additional instrument port. An incorrectly selected screwdriver can damage the screw slot. This complication necessitates the use of a special distraction device and lengthens the operation time. In 3 cases we had to drill out the screw using a cannulated drill.
6. Limitation of working space in the anterior part of the joint. If the screw was placed anteriorly and was too long, there may not be enough working space to manipulate the joint.
Some problems arise when removing interference screws from the tibial tunnel. So, in 4 cases we encountered a very deep screw location. Due to the relatively short length of the tibial tunnel, the screw can usually be detected and removed without much difficulty. However, after removal of the interference screw, a hole remains anterior to the new tibial tunnel. Obviously, “headless” interference screws should not be used to fix the graft, and primary fixation should be performed in such a way as not to complicate revision surgery.
conclusions
Typical technical errors made during primary reconstructive surgery on the knee joint are the following:
- the location of the femoral canal is excessively anterior or medial;
- the location of the tibial canal is too medial;
— excessive tension of the graft during its fixation.
The main factor determining the possibility of one-stage revision plasty is the location of the tibial canal. The use of a thin graft (less than 12 mm) and a canal far anterior for primary plastic surgery allows the formation of a revision canal posterior to the primary one, at a sufficient distance from it.
Sprain of the anterior cruciate ligament of the knee joint
Sprain of the cruciate ligament of the knee joint is an occupational disease of athletes, loaders, builders, painters, plasterers and representatives of other professions associated with increased physical stress exerted on the lower extremities.
In approximately 60% of cases, anterior cruciate ligament rupture of the knee joint is associated with trauma. It can develop after the first dislocation, or it can begin to form against the background of scar deformation after several sprains or bruises.
Disintegration of the cruciate ligament manifests itself as a feeling of instability in the knee when walking. Any awkward movement causes an attack of acute pain, which limits the mobility of the leg for several days. Then everything returns to relative normality again. Sooner or later, the separation of the anterior cruciate ligament leads to its complete rupture. This makes it impossible to walk independently. Surgery is required to restore integrity.
Sprain of the posterior cruciate ligament is compensated in most cases. The shock-absorbing load is absorbed due to the increased work of the surrounding muscles. Therefore, this pathology worries patients little. Even with a complete rupture of the posterior cruciate ligament, a person can walk and do squats at first. However, after 2–3 months, this will negatively affect the condition of the anterior cruciate ligament, which will also begin to become loose against the background of increased physical stress on it.
Causes of damage
The anterior cruciate ligament is subject to injury much more often due to the peculiarities of its structure; it consists of 3 bundles: medial, lateral and median, which creates conditions for fiber disintegration during injuries.
The anterior or posterior cruciate ligament can be torn for the following reasons:
- Sharp rotation (turn) of the lower leg,
- Strong direct blow to the knee,
- A strong blow to the back of the shin.
- Excessive sharp flexion of the knee joint,
- Deviation (twisting) of the shin inward, outward, posteriorly.
This mechanism of injury mainly occurs in athletes - football players, handball players, basketball players, therefore people involved in team sports are at risk for cruciate ligament injuries. It is they who are more likely to experience cross fiber disintegration due to regularly repeated excessive loads on the ligaments.
Female athletes are at greatest risk for this injury. This is due to the structural features of the knee joint in women, when the ligament is close to the thigh muscles and can rub against the bone. Hormonal levels also play a role - estrogens, progesterone, they reduce the density of the ligamentous apparatus, making it less durable.
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 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.
Physical examination
The most important diagnostic tests include the posterior drawer test and the shin drop sign. They not only help identify PCL injury, but also determine a treatment plan.
The choice of conservative or surgical treatment depends on the degree of damage to the PCL, as well as associated soft tissue structures.
Degree of damage:
- I degree: posterior displacement of the tibia by 0-5 mm.
- II degree: posterior displacement of the tibia by 5-10 mm.
- III degree: displacement by more than 10 mm.
Surgical treatment is indicated for
- III degree of damage to the PCL in combination with damage to the ACL and posterolateral angle of the joint. The combination of posterior sprain and rotational instability can lead to adverse consequences, since in this case the joint remains unstable, which poses a danger when returning to sports or active work.
- Lack of results with conservative treatment for grades II and III and ACL injury, as evidenced by joint instability and/or displacement of the tibia during active activity.
- Damage to several ligaments at once.
Very soon there will be a seminar by Maxim Nikitin dedicated to the diagnosis and treatment of the knee joint. Find out more...
In case of isolated ACL injury, regardless of the degree of damage, conservative treatment can be recommended.
Conservative treatment
Goal setting plays a large role in conservative treatment, and we recommend that short-term and long-term goals for non-surgical therapy be discussed with the patient carefully.
One of the studies followed the condition of 46 patients who were diagnosed with II and III degrees of PCL rupture for five years. All of them received only conservative treatment from the moment of injury until their return to sports. The results of the study showed that on average it took participants 16 weeks to return to professional sports. 91% of them played at the same level as before the injury or even better within two years of their injury. 69% of participants played at their usual level within five years. The results of the study suggest that conservative treatment has good results in terms of return to high performance and functional abilities.
However, among the advantages of non-surgical treatment there are also disadvantages. Thus, it can be clearly stated that conservative therapy is followed by the development of osteoarthritis.
Thus, a study in which 14 patients with PCL injuries took part revealed an increase in the load on the anteromedial portion of the cartilage in all participants. This indicates increased loads on the medial compartment of the knee joint. Another 2003 study looked at 181 patients who received conservative treatment for 5 years after an ACL injury. In 77% of them, degenerative changes were found in the medial condyle of the femur and in 47% of them - in the articular surface of the femoral head.
Treatment of anterior cruciate ligament rupture of the knee joint
It is necessary to begin treatment of anterior cruciate ligament rupture of the knee joint with differential diagnosis and selection of appropriate tactics. An experienced orthopedist must evaluate the condition of the knee joint, eliminate the risk of complete rupture of the ligament, and decide whether the ligament will be treated with surgery or the patient will be placed in a cast for several months. After a period of immobilization of the lower limb, restoration of mobility begins. After surgery, rehabilitation begins 10 days later. An individual program is being developed, which includes manual therapy, therapeutic exercises, physiotherapy, etc.
Complex treatment of anterior cruciate ligament dislocation is carried out over 3 to 4 months. During this time, the patient completely restores the health of the damaged joint. The usual range of mobility of the lower leg returns, serious physical activity and sports are allowed.
If you need treatment for a sprained ligament, you can make a free appointment with a podiatrist at our chiropractic clinic. The doctor will conduct an examination, make a diagnosis and develop an individual rehabilitation program depending on the type of traumatic injury to the ligamentous apparatus.
Diagnosis of pathology
Additional diagnostic methods include:
- Computed tomography,
- Arthroscopy,
- Ultrasound scanning,
- Magnetic resonance imaging (MRI),
- X-ray of the knee joint in 2 projections.
As a rule, an X-ray examination is initially performed to rule out damage to bone tissue. It also allows you to study the nature and height of the joint space, the presence of a “joint mouse” in it, a torn fragment of bone or cartilage.
Patients for whom radiation examination is contraindicated (small children, pregnant women, patients with an artificial pacemaker) undergo ultrasonography - ultrasound of the joint. It can reveal both bone damage and changes in articular cartilage and ligaments.
MRI is the most reliable modern tomography method; it can be used to determine any changes in the tissues of the joint, their size and location with a high degree of accuracy.
Arthroscopy is a modern visual diagnostic method that allows you to completely examine the entire joint from the inside and study all its elements. Through a small incision in the skin, an optical apparatus with a video camera, a lighting and magnification system is inserted into the joint, and the image is projected onto the screen. This procedure is not only diagnostic, it also allows you to perform a number of therapeutic measures.