1 – INTRODUCTION

The rupture, or stretching, of the anterior cruciate ligament is one of the most common knee injuries, It is very common in sportsmen of various modalities, like soccer, but it can appear in any person.

When the anterior cruciate ligament is injured, the possibility of going through surgery to recover the functions of the knee is great. It will depend on several factors, including: the severity of the injury and the level of activity of the patient.

2 – BRIEF ANATOMICAL CONSIDERATIONS

Three bones meet to form the knee joint: the thighbone (femur), shinbone (tibia), and kneecap (patella).

The kneecap sits in front of the joint to provide some protection. Bones are connected to other bones by ligaments. There are four primary ligaments in the knee. They act like strong ropes to hold the bones together and keep the knee stable.

The Anterior Cruciate Ligament (ACL) is one of the four main ligaments in the knee joint that connect it to the shinbone (tibia) and thighbone (femur). These are found inside your knee joint. They cross each other to form an “X” with the anterior cruciate ligament in front and the posterior cruciate ligament in back. The cruciate ligaments control the back and forth motion of your knee. The anterior cruciate ligament runs diagonally in the middle of the knee. It prevents the tibia from sliding out in front of the femur, as well as provides rotational stability to the knee.

3 – CHARACTERISTICS OF ANTERIOR CRUCIATE LIGAMENT TEARS

There are several mechanisms that can cause injury to the ACL. The ACL is most commonly injured by indirect, noncontact mechanisms such as vigorous cutting, landing, or twisting motions. At the time of ACL injury, individuals will experience a sudden severe knee pain and possibly hear or feel a “popping” sensation in their knee.

ACL injuries can be classified by the amount of damage to the ligament (partial or complete disruption).

Grade I Sprain
There is some stretching and micro-tearing of the ligament. The joint remains stable. These injuries rarely require surgery.

Grade II Sprain – (Partial Disruption)
There is some tearing and separation of the ligament fibers. The ligament is partially disrupted. The joint is moderately unstable. Depending on the activity level of the patient and the degree of instability, these tears may or may not require surgery.

Grade III Sprain – (Complete Disruption)
fibers. The ligament is completely disrupted. The joint is unstable. Surgery is usually recommended in young or athletic persons who engage in cutting or pivoting sports.

In 50% of cases, the lesion of this ligament presents other associated lesions (meniscus, lateral ligaments or PCL).

4 – SYMPTOMS

At the time of ACL injury, around 50% of the individuals will experience a sudden severe knee pain and possibly hear or feel a “popping” sensation in their knee.
The most common symptoms in patients presenting with knee problems are:

  • Joint effusion
    The knee will become significantly swollen and the range of motion will typically decrease due to the limiting effects of pain and swelling. But by making slight torsion movements and / or straining the knee, as it will be unstable, the complaints will come back and may cause further damage to the knee structures;
  • Giving Way
    Giving way is where the knee suddenly ‘gives out’, causing you to stumble or fall;
  • Locking Loss of range of motion
    ‘Locking’ is where a knee gets stuck in one position. The most classic type of locking is where one develops a sudden inability to fully straighten the knee, with a feeling that there is something inside the knee blocking it. The locking may be painful

5 – DIAGNOSIS

How is the diagnosis made?

  1. Anamnesis – A narrative or record of past events and circumstances that are or may be relevant to a patient’s current state of health.
  2. Clinical Examination – The diagnosis of ACL injuries can usually be accurately diagnosed by clinical examination of the knee. A skilled examiner can usually evaluate the knee joint in a painless manner and discern if the ACL has been injured. The 3 diagnostic tests validated in this review were:

The Lachman Test

The Drawer Test

The Pivot Shift Test

  1. Complementary Diagnostic Tests (ECD) – Imaging tests, such as X-rays, may also be ordered to rule out a bone fracture. A Magnetic Resonance imaging (MRI) may be done if your doctor suspects a fracture, a serious injury to the ligaments, or damage to the surface of the ankle joint. The MRI test uses a strong magnetic field and radio waves to create detailed images of the body. This allows your doctor to make a proper diagnosis.

MRI for Anterior Cruciate Ligament Injury

6 – TREATMENT

Debate continues regarding clinical intervention for the patient with Anterior Cruciate Ligament Injury. Issues exist which the clinician must consider, including which structures require repair, timing of surgical procedure, and rehabilitation approaches. We should keep in mind that each patient is a Unique Human Being, so it is very important to be person-centred, to make sure it is the best solution for that particular patient.

There are 2 major types of treatment, the rehabilitative/nonsurgical and the surgery,
As stated before, each case should be analyzed on its own.

However, active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgery. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical procedure should be considered. Nevertheless, a patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.

IMPORTANT – EVALUATE THE PATIENT AND BE PERSON-CENTRED.

  • Home care treatment
  • Apply to ice at least every two hours for 15 to 20 minutes at a time
  • Elevating your foot with pillows as necessary to reduce swelling
  • Non-steroidal anti-inflammatory drugs
  • Wrap an elastic bandage or compression wrap around your knee to protect the knee from instability and avoid body weight
  • When a joint causes pain, swells, is red, or has limited range of motion, the doctor may recommend using a needle and syringe to remove fluid from the joint (Arthrocentesis).
  • Physiotherapy. A well-targeted rehabilitation program is essential to gradually restore your knee’s full range of motion, and strengthen muscles.
  1. Surgery

Surgery is performed when the damage to the ligaments is severe and there is evidence of instability, or when the injury doesn’t improve with nonsurgical treatment. During ACL reconstruction, the surgeon removes the damaged ligament and replaces it with a segment of tendon — tissue similar to a ligament that connects muscle to bone. This replacement tissue is called a graft.

Your surgeon will use a piece of tendon from another part of your knee (autograft)) or a tendon from a deceased donor (allograft)). The graft will serve as scaffolding on which new ligament tissue can grow. Several studies attempt to use some species of synthetic grafts, but so far the results obtained are not satisfactory.

The ‘bone-patellar tendon-bone’ autograft, or “BPTB” is a widely used source for ACL reconstruction. In general, the surgeon takes the middle 1/3 of the patellar ligament that runs from the bottom of the kneecap (patella) to the front of the tibia. This graft is ‘harvested’ with bone blocks from the patella and tibia respectively.

These bone blocks can then be secured into bone tunnel ‘sockets’ that are placed at the anatomic location where the ACL originates on the femur (the ‘origin’) and the anatomic location where the ACL ends at the tibia (the ‘insertion’).

Advantages of this graft include its stiffness, strength, and low re-tear rate. It is also rapidly incorporated into the patient. Potential disadvantages include temporary or permanent pain at the front of the knee, slight motion losses, and a more difficult/painful early postoperative course.

It is also possible to use one or two hamstring tendons, from the inner part of the knee to reconstruct the ACL. While the hamstring tendons used are technically stronger than the BPTB construct, the methods to fix the soft tissue graft into the sockets is generally less stiff. Advantages to hamstring grafts are that they are strong, easy and relatively painless to remove, and do not result in long-term knee pain. Disadvantages include the fact that the reconstructed ligament may not be quite as stiff, they are slower to incorporate, and there is controversy about whether there may be a slight loss in total hamstring strength after they are harvested. These options should be discussed with the orthopedic surgeon to determine which is best for each case.

If the ends of the ligament cannot be joined together with a suture – something that can only be achieved with very recent tendon injuries – a tendon replacement procedure is carried out using the patient’s own tissue in an operation known as a ligamentoplasty. Ligamentoplasties of the knee joint can usually be carried out arthroscopically via small incisions in the skin.

This method of treatment offers the following benefits: postoperative pain is greatly reduced due to the minimal invasive character of the surgical intervention (arthroscopy) and faster rehabilitation.
GIGA well trained Orthopedic Surgeons, Specialists in knee pathology have extensive experience in anterior cruciate ligament reconstruction surgery using the latest and most innovative techniques associated with specially designed equipment for this type of surgery ( BPTB; Hamstring tendons).

7 – REHABILITATION

Following surgery, a progressive program of rehabilitation will initially focus on preventing muscle atrophy (shrinking), maintaining and increasing range of motion and improving muscle control.

After that, physical therapy is implemented to help the patient regain his strength, flexibility, and endurance without compromising the tendon graft or predisposing the patient to complications. At the end of the rehabilitation the patient will be progressing to reach the best possible functional level, depending on the type of activity, whether they are a cutting athlete, runner, or heavy laborer.

Every patient is slightly different in his or her progression through the rehabilitation, but it can be expected that the patient will be participating in rehabilitation for up to six months. There are many innovative techniques associated with specially designed equipment supervised by an orthopedic surgeon or physical therapist. To ensure your safe recovery, be sure to check with your therapist or surgeon.

By choosing GIGA, you will have access to a wide range of Medical Rehabilitation Professionals. GIGA has at its disposal a lot of excellent and dedicated professionals with extensive experience, as well as the most suitable and suitable equipment for their recovery.