Anterior cruciate ligament rupture is one of the most common injuries of the knee. In most patients with cruciate ligament rupture, if the anterior cruciate ligament is completely ruptured, surgery is required to regain the old functions of the knee.
Aims of this article:
- How does the anterior cruciate ligament tear? Is Surgery Necessary?
- What should be done before the surgery?
- What is done during the surgery?
- Healing process? You need to find answers to your questions.
How Common Is Anterior Cruciate Ligament Rupture?
Surgery of the ruptured anterior cruciate ligament, anterior cruciate ligament reconstruction. It is called . Since there are no registered statistics in our country, it is difficult to give the average number of ACL surgeries per year. But in the USA, this number is around 150,000 annually. I can say that the number of surgeries is high in our country. The fact that patients want to regain their former functions increases the number of candidates who will decide to have this surgery.
What Does the Knee Joint Consist of? What is its anatomy?
The knee joint consists of three bones. It consists of bones called femur, which is the thigh bone, tibia, which is the shin bone, and patella, which is the kneecap. There are four main ligaments connecting these bones. These ensure that the knee joint holds together and remains stable. These ligaments are the anterior cruciate ligament, the posterior cruciate ligament, the inner lateral (medial) ligament of the knee, and the outer (lateral) ligaments of the knee. These lateral ligaments are also called collateral ligaments. In medical language, it is called ligament. For example, the anterior cruciate ligament is called anterior cruciate ligament in Latin. While the posterior cruciate ligament is called the posterior cruciate ligament, the lateral ligaments are called medial collateral and lateral collateral ligaments.
- The anterior cruciate ligament prevents the knee from slipping forward
- The posterior cruciate ligament prevents it from running backwards
- Lateral (Collateral) Ligaments; The lateral ligaments prevent the knees from bending sideways and inwards.
All these ligaments increase the knee's resistance against opposing forces and ensure that the knee works as a stable joint.
- < s Anterior and posterior cruciate ligaments are located side by side in the middle of the knee joint and are called cruciate ligaments because they cross over each other in an X shape. The one located behind the knee and the one in front of it is called the anterior cruciate ligament. These structures control the forward and backward movement of the knee and provide the stability of the knee to rotate around its own axis.
- Anterior Cruciate Ligament (ACL) = (ACL-anterior cruciate ligament)
The ACL connects the thigh and shin bones in the middle of the knee and is approximately 2-3 cm long. It is a hard, white, inelastic ligament, cm long and 8 mm in diameter, that starts from the protrusion of the tibia, called eminence, and attaches towards the outer surface and back of the notch on the femur. The picture can also be seen arthroscopically. The red mark is the ACL, while the blue mark shows the posterior cruciate ligament.
In addition, the anterior cruciate ligament consists of two main bands: anteromedial and posterolateral. While one of these bands controls the movement of the knee in the anterior-background, the other prevents the knee from rotating around its own axis. In partial ruptures of the anterior cruciate ligament, only one or a part of this band or one band may be completely ruptured and the other band may be partially ruptured. Sometimes, with a partial tear, there may be elongation in the remaining healthy part, which can disrupt the stability of the knee. In short, ACL should not be considered as a single ligament. It consists of two bands. In recent studies, there is also a third band and this is called intermediate.
- Meniscus
Thigh and shin. While there are four main ligaments connecting the bones, there are two anatomical structures called meniscus, located inside the joint, in the form of a half-moon cartilage, one on the inside and the other on the outside. These reduce the load on the knee joints and increase the slipperiness of the knee joints on each other. They work almost like shock absorbers of cars. They absorb shock and also contribute to the stability of the knee.
In unstable knees, the menisci are damaged every time the knee dislocates or the anterior cruciate ligament ruptures. They can be removed. This situation may bring other problems. Over time, the knee's shock absorber mechanisms decrease, which can lead to serious problems such as cartilage damage and arthritis in the knee. In short, an unstable knee may result in meniscus tear and knee arthritis.
How to Rip the Anterior Cruciate Ligament? What are the Reasons for Rupture?
The anterior cruciate ligament may rupture for many reasons.
- Sudden turning while running fast
- Stopping quickly - for example, while playing paint-ball, squatting down and hitting your knee during this process (I personally experienced it - but edema only occurred in the ACL)
- Without jumping wrong (jumpin ) while descending
- But it is usually seen in direct hard contact sports such as football, basketball and skiing.
- In our country, it is most frequently seen in those who play an astroturf match without warming up from time to time. It is important to know how to fall when falling in double combat during a match.
- It is generally seen frequently in men. But athletics is also common in women. This may be due to different condition, different muscle strength and flexibility, or lack of neuromuscular control. Other reasons have been shown to be different bone structure alignments, weak and elastic ligaments due to the estrogen hormone.
The Degree and Severity of Anterior Cruciate Ligament Rupture? strong>
In more than 50% of anterior cruciate ligament injuries, other structures such as cartilage, meniscus and collateral ligament accompany the injury.
Anterior cruciate ligament injuries have their own It is graded according to its severity;
- Stage 1 tears; It is in the form of a mild stretch and there is pain in the knee but there is no loss of stability.
- Stage 2 tears; There is a partial tear in the ACL and nearly half of it is torn.
- Stage 3 tears; A full thickness tear occurred in the ACL. There is a loss of stability in the knee. Loss of stability; It means loss of balance, along with a feeling of insecurity in the patient's knee while running or descending stairs.
What are the Symptoms of Anterior Cruciate Ligament Rupture or How to Understand? What are the Clinical Complaints or Symptoms?
General Especially when the ACL ruptures, a popping or snapping sound may be heard from the front of the knee and you may feel like something is tearing inside your knee. It may feel like your knee is pulling away from you and spinning out of control in one direction. Many people cannot continue their sports activities after such a situation. Additionally;
- Pain and swelling: The knee may swell and become tight within 24 hours. Even though the swelling is not much, and sometimes due to late and slow swelling, the person may feel partially well and therefore may want to continue sporting activities. However, instability of the knee may lead to insecurity and dislocation of the knee, as well as cartilage and meniscus damage. Therefore, if there is any doubt, one should be cautious and cautious.
- Loss and locking in knee movements
- Tenderness at the joint line
- There may be symptoms such as pain and restlessness while walking and bearing weight.
How is Anterior Cruciate Ligament Rupture Diagnosed?
The stability of the knee is examined with special tests. However, a meaningful stability examination can be performed approximately 3 weeks after the trauma, after the knee swelling has subsided.
Patients usually apply to us with the above complaints. In the long term, insecurity, a feeling of dislocation and locking occur in the knee.
Physical examination and history of trauma are very important. Both knees are compared. Joint range of motion is checked. We evaluate the stability of the knee, especially with tests such as anterior drawer, Lachman and Pivot-Shift. Especially the Lachman test is valuable. With this test, the looseness of the shin bone forward relative to the femur is checked. Sometimes a significant stability examination is performed 2 weeks after the trauma, that is, after the knee swelling has subsided.
Radiologically, x-ray and MRI should be taken. Although the anterior cruciate ligament rupture is not visible on the x-ray, it is necessary to diagnose accompanying bone fractures, cracks, sometimes the lateral ligaments causing fractures from the bone, or eminence avulsion fractures at the tibia attachment site of the anterior cruciate ligament. However, MRI is indispensable for the definitive diagnosis of ACL tear. It has a very important place in diagnosis.
X-rays are also used for adolescents who have not completed their growth and whose growth plates have not closed. It is also important in evaluating the As seen in Figure 11, if the growth plates are open, a different surgical technique is used.
Because the open lines shown with blue arrows have a cartilage consistency, they are growth plates and cause the bones to lengthen. If these lines are damaged during surgery, the growth plate closes and causes the femur to remain short, which will lead to inequality between the legs.
Magnetic Resonance Imaging (MRI)
The ACL is not visible on x-ray. However, in MRI, all soft tissues, including meniscus, cartilage, all anterior-posterior cruciate, medial and external lateral ligaments, can be evaluated in detail. It is the gold standard in diagnosis and planning of surgery. In picture 12, the ACL is intact on the left side and completely ruptured on the left.
Should I Have Surgery?
You and your doctor will make this decision according to your life. But if you have a young and active life, you should definitely be.
What Happens If I Don't Have Surgery?
If you don't have surgery, you can usually walk comfortably. However, since you do not have an anterior cruciate ligament, the thigh and shin bones will move more freely in the knee joint in an uncontrolled manner, which will damage your cartilage and meniscus. It will cause damage to your knee and this situation will cause calcification day by day.
How to Treat If Anterior Cruciate Ligament is Ruptured?
Treatment is of two types. Surgery or non-surgical treatment.
Non-surgical treatment
The definitive treatment of a completely ruptured ACL is surgery. However, sometimes surgery may not be required in case of partial tears and in cases where the stability of the knee is not impaired. We recommend follow-up with physical therapy and muscle strengthening in these patients.
It usually does not pose a problem in their lives, especially if their lifestyle is sedentary and inactive. If it is an acute tear;
- Ice should be applied around the knee.
- Physical therapy: As the swelling in the knee decreases, we should start the rehabilitation program. We start specific muscle strengthening and stretching exercises with our special teams. After the swelling in the knee subsides, exercises should be given to strengthen the muscles around the knee.
- There will be suggestions for changes in activity and lifestyle.
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