Anterior Cruciate Ligament
Surgical Treatment of Anterior Cruciate Ligament Rupture
The treatment of anterior cruciate ligament (ACL) injuries is determined by the person’s expectations from their daily and sports life, accompanying secondary injuries, the performance of the knee, and the person’s age. Recent scientific studies have reported that complete healing is rare in cases of ACL tears near the bone.
In individuals with ACL tears, if there are no other problems accompanying the injury, swelling and pain in the knee generally subside after the first 3 weeks. The biggest complaint in these patients is the feeling of instability and rotation in the knee, which may cause swelling after intense activity. Generally, there is no pain except for these rotations and swelling. Pain is usually due to cartilage wear, arthritis, or meniscus tears that develop years later.
In the treatment of ACL ruptures, we must apply the rule that there is no disease, only patients. Surgery is recommended if there are additional injuries that require surgery or if the patient cannot compensate for their daily activities. Surgery is necessary if the knee cannot regain full range of motion, and there is pain or if the patient cannot jump on the affected leg. Surgery is necessary if instability bothers the patient. The patient’s age, sports activities, and daily expectations affect the surgical decision. For example, we have a 70-year-old patient who is actively involved in dangerous sports such as skiing, and feels instability during sports. In this case, we have to perform surgery. A patient who is 50 years old, has a very sedentary daily life and does not engage in any sports does not need surgery. However, the patient should not be discharged without rehabilitation and must be followed up closely. Another important issue is making surgical decisions based on MRI results without examining the patient, which is very wrong. Surgical decisions should not be made without examining the patient.
Risks Awaited by the Patient
The knee joint, which is formed by three bones coming together, allows us to stand, walk, and sit down, while also providing the opportunity for the toughest sports movements. In our daily life, if we only stand and do not engage in any activity, half of our body weight is put on the knee joint. Additionally, the load on the knee joint increases further during walking and running, putting more pressure on the joint. In order for the knee joint to be able to respond to the toughest conditions and meet the needs, the bones that make up the joint are connected to each other by four strong ligaments, two of which are on the inner and outer sides, and one each in the front and back.
The anterior cruciate ligament, which runs from the center of the knee to the front and from the back to the front, is the most important ligament that restricts the rotation of the knee. This ligament connects the femur and the tibia. The main function of this ligament is to prevent the tibia from moving forward and inward. Anterior cruciate ligament injuries can occur not only due to direct contact, but also without any contact in some cases.
As a result of an anterior cruciate ligament tear, swelling and pain occur in the patient’s knee. If there is no additional injury, these symptoms disappear within 2-3 weeks. If the body cannot compensate for the anterior cruciate ligament tear after this process, instability problems will arise. There will be instability in the knee, and swelling will occur after a small trauma. Pain occurs as a result of knee rotation and swelling, and there is no pain if there is no additional trauma.
Untreated tears can result in limitations in the patient’s daily activities and quality of life. People who are very active are forced to slow down because of the risk of knee dislocation. If they are involved in sports, they cannot continue or if they insist on continuing sports activities, they are exposed to additional traumas. Internal meniscus tears and cartilage injuries are particularly common. Early development of osteoarthritis occurs in all unstable knees compared to the other side. The rate of development of osteoarthritis symptoms reaches up to 80% in 10 years.
Common Mistakes in Diagnosing Anterior Cruciate Ligament Injuries
In cases of knee injuries, early physical examination may not be possible due to pain. In such cases, imaging methods such as X-ray and MRI are preferred for initial diagnosis, in addition to history and observation. MRI, which uses radio waves in a strong magnetic field created by large magnets, distinguishes specific anatomical structures from other structures clearly. It is a medical technique used to detect and identify differences between healthy and diseased tissues, and it does not involve radiation. It provides detailed information about the anterior cruciate ligament tear as well as additional injuries.
However, its accuracy is not 100%. X-ray is requested to determine whether there is a bone pathology. Sometimes, patients want to get information about diagnosis and treatment by sending their MRI scans. However, a diagnosis and treatment decision based solely on the MRI scan is not correct. It is essential to examine the patient and use the MRI as an auxiliary test. A decision made solely based on an MRI scan without examining the patient may not be correct. Physical examination is the most crucial diagnostic tool. The treatment decision is made based on the injury as well as the patient’s daily life, activities, and expectations.
Grafts Used in Anterior Cruciate Ligament Reconstruction
Due to the increasingly sedentary lifestyle brought about by urban living, the number of people of all ages who participate in sports has rapidly increased, leading to a corresponding increase in the frequency of knee ligament injuries. There are four important ligaments (anterior cruciate, posterior cruciate, medial collateral, and lateral collateral ligaments) that stabilize the knee joint. These ligaments connect the femur and tibia bones and provide stability to the knee in the anterior-posterior and lateral directions. In anterior cruciate ligament (ACL) ruptures, a graft from another location is used to replace the torn ligament. The following are some of the tendons used in this surgery:
Bone-Patellar Tendon-Bone: The middle third of the patellar tendon, which extends between the patella and the tibia, is harvested along with bone segments from both the tibia and patella.
Hamstring Tendons: Tendons located on the inner back of the knee are harvested and folded to an appropriate length and thickness. Quadriceps Tendon: The tendon above the kneecap is harvested with a bone segment from the kneecap.
Allograft: Tissue from a cadaver is used.
The ACL is a static ligament, meaning it is a ligament between two bones. Therefore, the patellar tendon, which is most similar to the ACL, was commonly used in the past. However, due to knee pain and arthritis, this tendon is no longer used except for revision and difficult cases. Hamstring tendons, which are dynamic tendons between muscles and bones, are now used instead. In recent years, the four-stranded version of these tendons has been used. The quadriceps tendon is also a dynamic ligament between muscles and bones.,
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