ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION in HEALTH

Edited by Dr. FABRIZIO MATASSI

The anterior cruciate ligament injury is one of the most common knee injuries in sports. It occurs most frequently in young sportspeople between the age of 15 and 25, with a clear prevalence in the female sex (M<F 1:3-5), particularly in those who play sports where rapid changes of direction and speed, jumps and landings are more common.

The function of the anterior cruciate ligament (ACL) is to stabilize the knee joint and in particular to prevent anterior (forward) movement of the tibia off of the femur, as well as hyperextension of the knee (a movement that goes beyond the normal range of motion of the joint). (Image 1)

The presence and integrity of this ligament is essential both to ensure the stability of the knee and to maintain the physiological movement of the joint. In fact, an anterior cruciate ligament injury causes an abnormal shift of the femur on the tibia leading to repetitive strain and a rapid degeneration of the joint cartilage that develops in about 50% of cases within 10-15 years from the first injury. (Image 2)

A reconstruction of the anterior cruciate ligament is therefore essential both to ensure stability in the knee and to promote the resumption of sports activity but also to restore normal movement of the joint and therefore reduce the incidence of early osteoarthritis.

Nowadays the development of arthroscopic surgery (also called keyhole surgery), which involves using an arthroscope, an endoscope that is inserted into the joint through a small incision. This technique allowed us to carry out a reconstruction of the anterior cruciate ligament in an extremely accurate and precise manner, to the point of respecting the anatomy of the knee and thus restoring the normal functionality of this ligament.

How does the injury occur?

The injury of the anterior cruciate ligament is always the result of a major twisting trauma due to forced rotation of the tibia off of the femur or to hyperextension of the knee. It is generally an injury that can occur in isolation or associated with meniscus injuries and/or other ligaments of the same knee depending on the direction and extent of the trauma.

The rupture of a cruciate ligament comes with pain and inability to move the knee that vary depending on the degree of injury. Generally there is the formation of joint effusion which may leeks blood.

Once the acute symptoms are resolved (usually within 2 to 3 weeks) and if there are no associated lesions, the patient can recover most joint functionality, however a feeling of instability and “weakness” of the joint remains.

How do we diagnose?

The diagnosis is both clinical and instrumental. The knee initially appears swollen and sore and can be difficult to examine. We can perform a suction of the joint fluid (arthrocentesis) to reduce tension and relieve the pain, the liquid that is found is generally blood. It is important to perform X-rays immediately after the trauma in anterior-posterior and lateral-lateral projection allowing for the diagnosis of associated fractures.

After a few days and with the improvement of the symptoms and the resumption of movement it is possible to make an accurate visit which will highlight an increase in the anterior laxity of the tibia compared to the femur (Image 3). Let’s not forget the importance of a full examination of the knee also aimed at looking for other lesions such as medial and lateral ligaments and meniscus. Clinical examination must always be confirmed by an MRI that allows to highlight the injury, to take a look at the cartilage status and any additional meniscus or ligament lesions.

How do we treat it?

Immediately after the trauma it is advisable to immobilize the knee to reduce pain, avoid weight bearing by walking with two crutches and ice it repeatedly. However, the immobilization of the knee should be maintained as little as possible by encouraging the patient to resume movement as soon as possible and begin an immediate physiotherapy treatment for functional recovery. It is important to achieve a complete recovery of movement and muscle tone before undergoing surgery to reconstruct the anterior cruciate ligament.

Surgical treatment was once reserved only for young and sporty patients, however nowadays the improvement of surgical techniques has broader its application. It should be considered that any slight joint failure that can arise even from simple activities such as climbing stairs is to be considered a small knee sprain that can create damage to the healthy joint structures (meniscus, cartilage), causing an early onset of degenerative phenomena, leading to osteoarthritis. For this reason, surgery is now suitable for all patients under the age of 45 even if they do not play sports at a competitive level.

The surgery is performed in arthroscopy, performing two small incisions and with the help of a camera and precision instruments. The most frequently used transplant to reconstruct the anterior cruciate ligament consists of the tendons of the semitendinous and gracilis or alternatively from the patellar tendon. We can also use cadaver or synthetic tendons but they are not to be preferred as the first choice for their limited biological properties and host integration. (Image 4-5) Two bone tunnels, a tibial and a femoral tunnel are carried out with dedicated instruments. (Image 6-7) Within these holes drilled in the bone the transplant of the tendons that will constitute the new ligament and stabilize the tibia to the femur is then inserted. (Image 8)

Recovery After Surgery

The average stay for this type of surgery is one day, given the minimal invasiveness of modern techniques. The patient is given a rehabilitation protocol where the exercises that need to be performed are indicated week by week, this will have to be followed scrupulously.

From day 2, the patient must begin isometric and knee-mobilising exercises aimed at recovering joint movement. You can immediately walk on crutches by resting your foot on the ground. You will have to wear a protective brace with sidebars for about a month.

15 days from the surgery the patient is checked again by the orthopaedist to remove the stitches. 30 days after surgery you can leave your crutches and start muscle tone reinforcement exercises.

The resumption of work may take place from the second month after surgery in the case of sedentary work, from the third month for heavier work. Competitive sports activity, on the other hand, can be resumed after 5-6 months.

[/vc_column_text]