The anterior cruciate ligament is one of the structures that connects the femur and tibia bones in the knee joint. This ligament, which is very important for the normal functioning of the knee, is the most important structure that prevents the tibia bone from shifting forward abnormally. Anterior cruciate ligament injuries take the first place among the injuries that cause the patient to stay away. Anterior cruciate ligament injuries are followed by medial meniscus and medial collateral ligament injuries. It has been determined that approximately 200 thousand anterior cruciate ligament injuries occur annually in the United States. This frequency is expected to increase with the increasing interest of society in sports. Although there is no reliable data in our country, it is estimated that around 3 thousand anterior cruciate ligament injuries occur annually.
HOW DO ANTERIOR CROSS LIGAMENT INJURIES OCCUR?
Anterior cruciate ligament injuries. It usually occurs during a sudden turning movement on a fixed foot. It often occurs during a movement performed by the athlete himself. Less commonly, anterior cruciate ligament injuries may occur after direct blows to the knee, traffic accidents, falls from height, and industrial accidents. In this case, injuries to the posterior cruciate ligament, lateral ligaments and menisci may be added to the anterior cruciate ligament injuries. Due to the structural characteristics of female athletes, anterior cruciate ligament injuries are more common than male athletes. While injuries in adults occur in the form of the ligament breaking off from its body, in children the injury can occur in the form of the ligament tearing off a piece from where it attaches to the bone.
WHAT ARE THE SYMPTOMS OF ANTERIOR CROSS LIGAMENT INJURIES?
Anterior Cruciate Ligament. During the injury, severe pain occurs along with a sudden feeling of breaking in the knee. Some athletes can hear the sound of the ligament breaking and often fall to the ground. Swelling occurs due to rapidly developing bleeding inside the knee joint. The athlete usually cannot continue playing sports and has to quit the competition. Due to pain and swelling, movement restriction occurs in the knee and limping occurs. Some athletes may feel their knees coming out of place.
Within a few days or weeks. Swelling and pain in the knee joint decrease. Knee movements are gained and limping disappears. However, this time, a feeling of emptiness and unsafety occurs in the knee, especially during sudden turns, sudden deceleration, and when descending stairs. Sports such as swimming and cycling can be done on knees with anterior cruciate ligament rupture; However, it is not possible to perform sports that involve sudden jumps, turns and accelerations, such as football, basketball, handball, volleyball and skiing, at a high level. If the athlete wants to continue these sports without the anterior cruciate ligament, the risk of new injuries and increased damage to the knee is very high.
FIELD SIDE FIRST AID FOR ANTERIOR CROSS LIGAMENT INJURIES
In the knee. Anterior cruciate tear should be considered in every athlete who has severe pain and swelling after sudden turning movements. Immediate application of ice and elastic bandage to the knee will reduce swelling and pain. The athlete should not be allowed to return to competition. The athlete should leave the field without putting any weight on the relevant leg and use crutches until a definitive diagnosis is made.
HOW ARE ANTERIOR CROSS LIGAMENT INJURIES DIAGNOSED?
MRI anterior cruciate ligament rupture
Anterior cruciate ligament rupture on MRI
Diagnosis of anterior cruciate ligament rupture begins with a detailed explanation of the way the injury occurred. This is followed by a careful examination. Only with this history and examination, the diagnosis of anterior cruciate ligament tear can be made with a rate of over 90%. Sometimes, an adequate examination cannot be performed because the knee is very painful at first. In this case, a second examination within 10 days is diagnostic. If early diagnosis is required in high-level professional athletes, MRI is helpful in diagnosis.
X-rays should be obtained in all patients with serious knee injuries and it should be investigated whether there are any fractures in the bones. Radiographs are usually normal in anterior cruciate ligament injuries. Magnetic resonance imaging has an accuracy rate of over 90% in the diagnosis of anterior cruciate ligament tears. Additionally, accompanying meniscus, collateral ligament and cartilage injuries and bone edema can be diagnosed. However, in rare cases, MRI can be misleading; even though the ligament is injured to a point where it cannot function, the continuity of the ligament may appear to be preserved on MRI. This Therefore, MRI is not the only determinant when deciding on treatment, examination and history findings should also be taken into consideration.
ARE THERE ANY INNOVATIONS ON ANTERIOR CROSS LIGAMENT INJURIES IN RECENT YEARS?
Many important developments have occurred in recent years regarding anterior cruciate ligament injuries. First, it has been shown that the risk of ligament injury can be reduced when certain exercise programs are implemented, especially in female athletes. Your physician who is interested in this subject will give you information about how you can apply these programs with the help of trainers and physiotherapists. The second development is the understanding that the ligament is structurally in the form of two bundles and that these bundles have different functions. As a result of this development, two-bundle anterior cruciate ligament repair techniques that better mimic the original structure of the ligament were developed and it was possible to achieve successful results. Another development has occurred in better recognition of partial anterior cruciate ligament injuries. When necessary, techniques have been developed to surgically repair the ruptured part of the ligament while preserving the intact fibers. Anterior cruciate ligament surgery can be performed using special techniques in children whose growth has not yet been completed. In this way, the risk of growth defects was minimized and secondary meniscus and cartilage injuries were prevented by ligament repairs.
TREATMENT OPTIONS IN ANTERIOR CROSS LIGAMENT INJURIES
An example of one of the knee braces that can be used in the absence of the anterior cruciate ligament
An example of one of the knee braces that can be used in the absence of the anterior cruciate ligament
The treatment of anterior cruciate ligament injuries in individuals who are young, do sports or have an active lifestyle is surgery. Surgical treatment may not be performed in individuals who are older and do not have a high activity level, do not do sports, and do not have complaints such as gap and insecurity in their knees in daily life.
In children who have not completed their growth, first wait until the growth is completed and then undergo surgery. treatment was recommended. However, today, after it was observed that irreversible meniscus and cartilage injuries occur in the knee in children who do not receive surgical treatment, the trend has shifted towards performing surgery at an earlier age.
If non-surgical treatment is chosen, muscle strengthening programs are recommended to reduce the feeling of insecurity and emptiness that may occur in the knee, and protective knee pads can be used in sports that strain the knee. However, in case of severe strain, neither of them can prevent the knee from dislocating and additional injuries may occur in the knee.
WHAT ARE THE GOALS OF ANTERIOR CROSS LIGAMENT SURGERY?
Anterior Cruciate Ligament The aim of individuals with injuries is to eliminate the feeling of emptiness and insecurity in the knee and to obtain a knee that the person can safely step on during sports or challenging activities. Another purpose is to protect the meniscus if it is not damaged during the initial injury and to prevent wear and tear that may occur on the knee in the following years by repairing meniscus tears that can be repaired. Another purpose of surgery is to return athletes to the sports level they were at before the injury and to prevent new injuries in the knee.
HOW IS ANTERIOR CROSS LIGAMENT REPAIRED?
If the anterior If the cruciate ligament has been separated by tearing off a piece of bone from where it was attached, the broken bone piece is attached to its place. In this case, which is mostly seen in children, fixation can be done with screws or stitches. This procedure is usually performed arthroscopically; in rare cases, open surgery may be necessary.
Arthroscopic screw fixation of the anterior cruciate ligament, which is separated from its attachment point by a piece of bone.
Arthroscopic suture fixation of the anterior cruciate ligament, which is separated from its attachment point by a piece of bone.
In adults, the anterior cruciate ligament is usually torn by the fibers in its body being separated and fragmented. It is not possible to repair the ligament in the form of a fringed tissue, and the ligament must be repaired with new tissue during surgery. The tendons of the muscles around the knee are often used for ligament repair. The most commonly used tissue for this is the patellar tendon, which is located in the front of the knee and is removed with a bone block at both ends.
Patellar tendon removal
Patellar tendon removal
The second most frequently used tissue is the tissues located at the back of the knee and known as hamstring tendons. There is no bone block at the ends of the hamstring tendons.
Removal of hamstring tendons
Removal of hamstring tendons
In some cases, it is taken from the cadaver and sterilized and ready for use. Rendered textures can be used. These tissues, called allografts, are generally used in cases where more than one ligament is injured and the person's own tissues are not sufficient; It may be preferred in cases where surgery has been performed before and their own tissues have been used, and in very young children. Synthetic ligaments, which were popular in the eighties, were abandoned due to their unsuccessful results.
WHAT ARE THE STEPS OF THE SURGERY?
First, the tissue to be used in ligament repair is taken, this tissue is called graft. is given. Then, knee arthroscopy is performed and other structures within the joint are evaluated. If there is an injury to the meniscus and joint cartilage, the necessary intervention is performed. Then, tunnels are opened in the bones in the knee joint and the path for the new ligament is prepared. The graft is passed through these tunnels and the bone is fixed in the tunnels with appropriate tension. For this purpose, metal or fusible screws, cross nails and u-shaped nails are used. These screws and nails that hold the ligament in place can remain in the body for life as long as they do not cause discomfort and do not need to be removed.
Arthroscopic single-bundle anatomical anterior cruciate ligament repair.
Surgery 40 It may take from minutes to 1 hour. A thin plastic tube called a drain is placed to remove the blood accumulated in the knee joint. This drain is usually removed during the dressing 24 hours after the surgery.
WHAT DOES DOUBLE BUNCH ANTERIOR CROSS LIGAMENT REPAIR MEAN? ?
Single or two-bundle anterior cruciate ligament repair can be performed depending on the characteristics of the patient's knee and the surgeon's experience and preference. Especially in larger patients, double bundle ligament repair can be performed to better create the original fan structure of the ligament. In these patients, instead of 2, 4 separate tunnels are opened and 2 graft tissues are fixed by adjusting the tension at different angles. Although it was found to be superior to single bundle in experimental studies, no significant difference was found in patient applications.
Double bundle anatomical anterior cruciate ligament repair.
POST-SURGERY PERIOD
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