TREATMENTS
Tear cruciate ligaments
Advanced techniques for cruciate ligament reconstruction and early return to sports activity.
CRUCIATE LIGAMENTS IN FIGURES
of every 100,000 people a year suffer from it.
Most frequent age of rupture.
times higher risk of ligament rupture in women.
%
risk sports: soccer, volleyball, sky, basketball.
%
of patients who undergo surgery return to their previous sporting level.
Cruciate ligaments
Cruciate ligament injuries are the most common, especially in sports involving rapid changes of direction, such as football, skiing or basketball. They usually require surgery intervention to restore knee stability, especially in active or athletic people.
DESCRIPTION
What are cruciate ligaments
The anterior cruciate ligament tear (ACL tear) is one of the four main ligaments of the knee. Its name comes from its cross-arrangement with the posterior cruciate ligament tear (PCL tear), both of which are intra-articular.
Main LCA functions
- Prevention of anterior displacement of the tibia with respect to the femur.
- Rotational stability of the tibia.
- Range of motion control
DIAGNOSIS
Anterior cruciate ligament tear
Diagnosis begins with an interview in which the physician asks about how the injury occurred (e.g., a sharp turn or a jump) and the symptoms experienced, such as pain, effusion, swelling or a feeling of instability. A history of previous injuries is also reviewed.
It is usually performed by physical examination and imaging tests, such as radiography and magnetic resonance imaging (MRI). It is important to diagnose the lesion early because excellent clinical results are obtained with a preferential surgical indication.
Maneuvers
specific
Lachman’s test
Evaluates the stability of the tibia by moving it forward at 30º.
Test of the previous drawer
It measures the forward displacement of the tibia at 90º.
Pivot Shift Test
It examines rotational instability of the knee through combined movements.
Imaging tests
Magnetic Resonance Imaging (MRI)
It is the most common test to evaluate the ACL, showing detailed ligament injuries and possible meniscal or cartilage damage.
Radiography
It is used to rule out bone fractures and to verify alterations in the bones of the knee.
Arthroscopy
In cases where the diagnosis is unclear or treatment does not improve, arthroscopy may be performed to directly examine the inside of the knee.
LCA INJURY TREATMENTS
Arthroscopic surgery
For anterior cruciate ligament reconstruction, a ligament or tendon is needed to be used as a new ACL tear.
Autografts (taken from the patient himself) are usually preferred because of their lower risk of rejection and better integration.
The allografts (during cadaveric), are a good option in special cases where the use of an autologous graft is not feasible and undesirable or in revision surgeries.
The choice of graft type depends on several factors:
The patient's age, type of sport and activity level.
The condition of the patient's tendons or tissues.
The risk of complications or tendon failure.
Surgeon's preference and experience.
Longitudinal breakage
It extends along the meniscus, parallel to its curvature.
HTH patellar tendon plasty
Advantages:
- Mild pain at the donor site without loss of function.
- Recovery time is usually shorter.
- Short oblique incision (percutaneous extraction).
Disadvantages:
- Lower initial resistance with slow healing.
- Possible hematoma in the donor region.
Longitudinal breakage
It extends along the meniscus, parallel to its curvature.
Hamstring tendon plasty
Advantages:
- Mild pain at the donor site without loss of function.
- Recovery time is usually shorter.
- Short oblique incision (percutaneous extraction).
Disadvantages:
- Lower initial resistance with slow healing.
- Possible hematoma in the donor region.
HTH patellar tendon plasty
It is one of the most common grafts and consists of taking a segment of the patient’s own patellar tendon (central portion of the tendon, including bone at both ends).
Advantages:
- Good integration and healing
- High success rate and knee stabilization.
Disadvantages:
- Pain in the donor site
- Long longitudinal incision
Quadricipital tendon plasty
It is the newest and its trend is increasing, it is obtained from the central portion of the quadricipital tendon at its insertion in the patella.
Advantages:
- Mild postoperative pain with good functional recovery of the quadriceps.
- Short longitudinal incision (percutaneous extraction).
Disadvantages:
- Risk of quadriceps weakness.
- The healing process may take longer.
Surgical technique
Anterior cruciate ligament tear (ACL tear) reconstruction is performed by arthroscopy. This procedure allows visualizing the joint using a small camera and working with specialized tools that are introduced through small incisions. The approximate time is 90 minutes. It consists of:
- Diagnostic arthroscopy: inspect the joint in detail to identify possible additional lesions, such as meniscal or chondral lesions, which may require treatment in the same procedure.
- Removal of the damaged cruciate ligament: is done to clean the central area and prepare the space where the new graft will be placed. Sometimes there are some remaining fibers that, if so, are kept to improve the integration of the graft to be implanted.
- Creation of bone tunnels: An anatomical technique is used where we reproduce the orientation and position of the native ligament with the help of specific guides. Small holes are drilled tunnels in the femur and tibia to allow its placement in the anatomical site, being incomplete to favor the integration of the graft within the bone.
- Graft implantation: The graft is passed through the tunnels created and fixed by means of percutaneous cortical suspensions or screws. These fixations ensure that the graft remains stable while the body integrates it.
- Closing and completion: Once the graft is in position and properly tensioned, the joint is checked for proper function. Finally, the incisions are closed and a protective dressing is applied.
Video rights Dr. Cory Calendine MD
Are there any added surgical gestures to stabilize knee rotation?
Extra-articular bracing is a complementary technique that reinforces the stability of the knee outside the joint, especially useful in patients with high rotational instability, high-risk athletes or in cases of surgical revisions.
It is performed using structures such as the iliotibial band or an additional graft, and is fixed to the outer aspect of the femur and tibia. This limits excessive rotational movements, improves stability and reduces the risk of re-injury.
OTHER LIGAMENT INJURIES
Posterior, medial and lateral ligament
Posterior cruciate ligament (PCL tear) injury
Posterior cruciate ligament (PCL) tears are less common than ACL tears and usually occur from direct trauma to the tibia that is transposed posteriorly, such as in traffic accidents or contact sports.
Causes posterior knee instability of the knee, although it is often better tolerated than an ACL tear injury. Treatment may be conservative in mild cases or surgical in severe injuries, especially if other structures are affected. Surgical reconstruction uses grafts similar to those of the ACL tear, seeking to restore the functional stability of the knee.
Medial Collateral Ligament (MCL) Injury
The MCL injury is commonly caused by a blow to the outer side of the knee. outer side of the knee which stretches or tears the ligament on the inner side of the knee. Often, this injury occurs in conjunction with a tear of the anterior cruciate ligament tear (ACL tear). Anterior cruciate ligament tear (ACL tear), as both structures are often affected by the same mechanism of injury, especially in contact sports.
Mild to moderate injuries are treated conservatively with physiotherapy and conservatively with physical therapy while severe or complete rupture may require surgery, especially if there is significant instability or if the injury is associated with other structures.
Lateral Collateral Ligament Injury (LCL)
The LCL injury less common and occurs when there is an impact to the inner aspect of the knee. inner side of the knee, which stretches or tears the ligament on the which stretches or tears the ligament on the outer side of the knee. Although it is often associated with an injury to the ACL tear it can also occur in isolation.
It is more common for LCL injury to require surgical intervention, especially if there is lateral instability or if the injury is associated with other structures.
It is important to discuss all options with a knee specialist to determine the best approach.
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