The knee joint is one of the most traumatic (along with the shoulder joint). Injuries to menisci, ligaments, fractures are only part of the problems that a person can face. The most prone to knee injuries are athletes of contact sports – football players, rugby players, hockey players.
Most often, hockey players, football players and other players of contact sports are prone to knee joint injuries.
The most important thing when receiving an injury or diagnosing a pathology is to perform the operation on time and correctly recover after it.
Knee diseases are divided, first of all, into inflammatory, traumatic and infectious. The most common cause of pathologies is injuries, the most difficult of which are fractures. As a rule, they require a long recovery, and even after that, it is not always possible for a person to restore his athletic performance one hundred percent.
As for infectious diseases, they can be rheumatic (lead to inflammation and loss of function) and septic (sometimes lead to melting of bone tissue).
The main types of operations on the knee joint.
In total, there are many different types of operations on the knee joint, the most common of them are presented below:
- Arthroscopy — by means of small incisions, a tube with a camera and tools are inserted inside;
- Arthrotomy – the capsule is dissected and all pathological bodies are removed;
- Knee ligament and meniscus surgery;
- Excision of Baker’s cyst;
- Endoprosthetics — installation of a prosthesis;
- Arthrodesis is a procedure for immobilizing the joint;
- Osteosynthesis is a process during which parts of the joints are fixed if there is a fracture passing through the articular line.
Indications for surgery.
The main reasons why a doctor may prescribe an operation are:
- Arthrosis (is a degenerative chronic deviation in the work of the joint, violation of integrity, loss of functional properties);At the 3rd stage of arthrosis of the knee joint, if the disease progresses, arthroscopic surgery is prescribed.
- Rupture of the meniscus, cartilage, ACL, PCL;
- Dislocation of the patella;Dislocation of the patella with ligament rupture is also an indication for surgery.
- Arthritis and other inflammatory processes;
- Rheumatoid abnormalities;
- Infections received as a complication after injuries;
- Excessive wear of the joint due to high physical exertion (in professional athletes);
- Congenital anomalies of the development of the motor apparatus, rapid bone growth and deviations of the axes of the lower extremities.
An innovative method is arthroscopy!
Arthroscopic examination is rightfully very popular in the world — in all the leading clinics of the world it is preferred by doctors of the highest level.
There may be several indications for its conduct:
- Ruptures and injuries of ligaments, tendons;
- Arthritis and arthrosis;
- Deforming osteoarthritis;
- Problems with the meniscus;
- Intra-articular fractures;
- The presence of foreign bodies in the tissues;
- Clarification of the existing diagnosis.
The main advantages of this type of manipulation.
Arthroscopy is an excellent alternative to classical operations. This is due to the following factors:
- It does not involve a complete dissection of the articular cavity — the doctor gets access to the intra-articular space by making just a couple of small holes and a special tube with a camera at the end, data from which is displayed on the monitor. Due to this, the traumatism of the periarticular tissues is significantly reduced.
- The camera, which the device is equipped with, has a very high resolution and is able to magnify the image displayed on the medical screen several times – thanks to this, a specialist can make an absolutely accurate diagnosis and assess the level of damage with maximum care.
- Subsequently, almost no scars will remain on the patient’s body – due to the low level of traumatism, the cosmetic defect will be represented only by small scars, barely noticeable to a person.
- Being in the hospital will take much less time — already on the first day after arthroscopy, the client can go home (except in difficult cases).
- There are practically no complications after surgery.
- Rehabilitation will not take much time — it does not take much time to recover.
The process of surgical intervention.
Arthroscopic surgery is performed according to the following algorithm:
- The first stage is preparation: consultation with a doctor, X-ray examination or MRI.
- Preoperative examination. As with any other operation, the appointment of arthroscopy is possible only after a thorough history collection and urine and blood tests, etc.
- 12 hours before the operation, you need to give up smoking, alcohol, drinking and eating. In addition, it is forbidden to use aspirin and other drugs that affect blood clotting.
- Then comes the day of the operation. The patient lies down on the surgical table, and his leg is fixed in a position that allows the doctor to have maximum access to the damaged area. Local anesthesia is used during the intervention.
- After that, two or three holes are made through which surgical instruments are inserted. To improve visibility, a sodium chloride solution is pre-injected into the joint.
- Next, the composition of the synovial fluid is studied, the cavity is analyzed for the presence of chondromic bodies, as well as viruses and pathogens. If necessary, therapeutic manipulations are carried out, for example, if a ligament rupture is detected during the diagnosis, they are immediately stitched and fixed.
After arthroscopic surgery on the knee joint, rehabilitation does not take as much time as with classical interventions. As a rule, a special recovery course is prescribed, which is aimed at a speedy recovery and includes wearing bandages, kinesiotaping, magnetic therapy, myostimulation, massages and, of course, physical therapy – physical therapy.
In order to get back in shape as quickly as possible, the following rules should be followed:
- In the first few days, keep the limb raised up, apply ice to reduce inflammation, swelling, pain syndrome;
- Follow hygiene and keep the bandage dry and clean (do not take a shower without a doctor’s permission and come to dressings on time);
- Follow all recommendations — a few days after discharge, a rehabilitation course is prescribed;
- Use crutches or other devices for walking — in any case, do not rely on the injured leg for the first time — this can lead to serious problems until the intervention is repeated;
- To drive a car only after two or three weeks, if a specialist has allowed it (sometimes they are allowed to drive earlier — it all depends on the type of gearbox, the severity of limb injuries, the presence of pain, and so on);
- Follow the instructions regarding therapeutic gymnastics – only if the prescribed exercises are performed accurately, the muscles will come into tone, it will be possible to move as before and feel good;
- If a specialist has prescribed medications, take them according to the schedule (most often, medications are prescribed that reduce the likelihood of postoperative blood clots);
- After surgery, it is recommended to wear knee orthoses.
Types of ACL reconstruction
– Immediate ACL reconstruction in case of fresh damage (up to 14 days!)with the use of artificial implants as a base for the regeneration of one’s own ligament (internal bracing technique — internal — intra-articular bandage, “orthosis”). This technique is characterized by a significantly faster return to full functionality compared to the classical method (approximately 12 weeks). In addition, this technique allows you to save your own anterior cruciate ligament, which can regain all the corresponding parameters and functions. The risk of arthrofibrosis (excessive postoperative fibrosis) is comparable to delayed procedures performed today 3 months after the injury. This is the latest and least invasive surgical technique, characterized by a speedy return to physical activity.
– Hybrid ACL reconstruction using an artificial implant and an auto- or allogeneic tendon of the latest generation – Neoligaments JewelACL Thanks to innovative artificial ligaments, you can return to sports even 3 months after surgery! The classical operations that still exist, performed with their own ligament, patella or hamstrings (ST and GT), allowed them to return to the sport only a year later, and an early return caused relaxation of the ligament and its failure (the transplanted ligament is weakest only 6 weeks after surgery, but even after many months it can stretch and lose strength). An innovative artificial ligament over time sprouts its own tissue of the body, becoming a new ligament of its own, but it does not stretch, because it has an artificial frame inside. A special surgical technique allows a hybrid combination of living tissue with an artificial implant, combining the advantages of traditional methods with an artificial ligament. The hybrid method of ACL reconstruction makes it possible to quickly return to the sport, this is especially important in cases with professional athletes.
– Reconstruction of the ACL together with other ligaments (reconstruction of two or more ligaments) together with damaged meniscus and cartilage (such injuries coexist in more than 50% of ACL injuries according to ICRS (International Cartage Regeneration & Joint Preservation Society). Stem cells are often used during the operation.
– Classical reconstruction of the anterior cruciate ligament using the patient’s own tissues (patellar ligament or ligaments of the semi-tendon ST and thin GT muscles) with surgical treatment of concomitant injuries.
One of the most common and most serious knee injuries is a rupture of the anterior Cruciate Ligament (Anterior Cruciate Ligament).
Athletes of disciplines such as football, handball or basketball are the most vulnerable group for damage to the anterior cruciate ligament. ACL injury often happens in skiers – both professionals and those engaged in this sport as an amateur.
In the case of damage to the anterior cruciate ligament (ACL), the injury usually requires surgery to restore full functionality of the knee and provide protection from progressive, irreversible degenerative disease. In an unstable knee, it often comes to severe wear of the cartilage and cracks of the menisci. The latest recommendations indicate the need for ACL reconstruction not only in athletes and young people, but also in elderly people who are less physically active. This big change in views on this injury has occurred in recent years.
The choice of the type of surgery depends on several factors, including the degree of damage to the ligament itself, accompanying injuries (meniscus, cartilage …), the level of athletic activity and the patient’s expectations. Depending on the parameters of the chosen operation, the period of rehabilitation and return to full athletic loads will also be different.
Anatomy of the ACL
Four bones are joined in the knee joint: the femur, tibia, fibula and patella (patella). The kneecap is located directly opposite the knee joint, protecting it and increasing the strength of the quadriceps femoral muscle. Ligaments provide connections between bones and joint stability. There are four main ligaments in the knee. They act as strong, slightly elastic bands.
They are located on the outer sides of the knee. The medial collateral ligament (MCL – l Collateral Ligament) is located on the inside of the knee joint, while the lateral collateral ligament (LCL (Lateral Collateral Ligament) is located on the outside. They control the movements of the knee joint to the sides and prepare the knee for atypical movements.
They are located inside the knee joint. Each of them crosses with the other, creating an “X— – hence the name. The cruciate ligaments control the movements of the knee joint forward and backward (excessive protrusion of the tibia forward and backward).
The anterior cruciate ligament runs obliquely to the central part of the knee. This prevents the tibia from protruding in relation to the femur, and also provides rotational stability of the knee.
Description of the injury
About half of all anterior cruciate ligament injuries occur simultaneously with damage to other structures in the knee, such as articular cartilage, menisci and other ligaments.
There are three degrees of ACL damage, depending on the severity:
- Grade 1 injury: The ligament is slightly damaged. It was stretched, but it is so healthy that it can provide stability of the knee joint.
- Grade 2 injury: The ligament is stretched to such an extent that it becomes loose and partially ineffective. This condition is often referred to as a partial ligament rupture. The stability of the knee joint is impaired.
- Trauma of the 3rd degree: This is a complete inefficiency of the anterior cruciate ligament – a rupture (violation of integrity) or a complete failure to perform functions due to excessive stretching (elongation) of the ligament. This means that the knee joint is unstable. There is a significant risk of further damage to intra-articular structures and the development of degenerative disease (osteoarthritis) of the knee joint.
Unfortunately, a significant part of ACL injuries is a complete rupture or damage close to complete rupture. Moreover, the main injury coexists with concomitant injuries, which becomes an indication for arthroscopy of the knee joint.
The anterior cruciate ligament can be damaged as a result of several situations:
- sudden change in direction of movement
- sudden delay/stop while running
- unsuccessful landing after a jump
- direct contact or collision with something solid (collision on the football field, etc.).
Numerous studies have shown that among female athletes, anterior cruciate ligament injuries occur more often than in men. According to the researchers, this is due to differences in physical fitness, muscle strength and neuromuscular control. Other reasons have been suggested: differences in the structure of the pelvis and lower extremities, a tendency to weaken the ligament or the effect of estrogen on its properties.
In case of ACL damage, pain, swelling, crackling or clicks in the knee may appear.
Many patients feel instability, as if the knee was “running away”, “flying out” of its axis, (Eng. “giving way”).
Pain with a tumor. Within 24 hours, the knee may swell and the pain may increase. These symptoms may disappear completely after about 2 weeks, by themselves. However, returning to sports without a full diagnosis and treatment can lead to knee instability, which increases the risk of further damage and serious intra-articular wear of structures, including cartilage and meniscus.
Loss of the ability to perform a full range of knee joint movements. Full straightening and strong bending of the knee can be painful.
Soreness along the line of the knee joint.
Feeling of discomfort when walking.
During the first visit, we examine specific symptoms and conduct a medical conversation in order to record the history of the injury. During the physical examination, we check all the structures of the damaged knee and compare them with the healthy structures of the other knee. In fact, most ligament injuries can be diagnosed already with a thorough first medical examination.
Imaging studies, however, can help confirm the diagnosis after a physical examination, or show concomitant damage to other structures:
X-ray examination (RTG):
Despite the fact that this study does not visualize ACL damage, it can show whether the injury is associated with a fracture (for example, Segond fracture – separation of the anterior cruciate ligament from the place of attachment to the tibia with a bone block – often accompanying ACL damage) or, for example, with posterior instability, as with damage to the posterior cruciate ligament PCL (Posterior Cruciate Ligament).
Magnetic resonance imaging (MRI):
the study most accurately shows soft tissues, which also include the anterior cruciate ligament. Magnetic resonance imaging, however, is not a mandatory study for the diagnosis of rupture or failure of ACL functioning.
– Ultrasound – ultrasound examination of the knee joint demonstrates well the majority of intra- and periarticular structures. It also allows you to conduct a study in motion (dynamic ultrasound), and this is much better than magnetic resonance imaging (MRI).
Ligament reconstruction and treatment
Treatment of the anterior cruciate ligament (ACL) after injury depends on the individual expectations of the patient, his activity and the degree of damage to the ligament. For example, a young athlete engaged in a sport that requires a lot of physical activity and a variety of movements (for example, rotational movements in the knee, changing the direction of running – such as tennis, football), will need arthroscopic surgery. Only she will allow you to safely return to your sport. Below and in the initial part of the text, modern methods of treating ACL rupture using arthroscopic technique (minimally invasive) are presented.
Less active, usually elderly people, can sometimes return to daily functionality without surgery. However, according to the latest guidelines, surgery is indicated even for this less active group of older patients. Instability of the knee leads to irreversible changes in the cartilage and meniscus, which leads to the development of irreversible degenerative changes around the joint. In the future, this condition can cause severe pain and lead to the need for endoprosthetics.
Conservative treatment of a damaged anterior cruciate ligament (ACL) will not restore full functionality of the knee joint. However, it can be used in cases of very old age, very low activity level and in patients with internal diseases (there is no possibility to perform surgery). If, as a result of the injury, the ACL has not reached complete failure, simple non-surgical methods of treatment can be recommended, including:
– Using an external stabilizer (orthosis) – the stabilizer will never restore full stability of the joint, but it can help in part. It is recommended to walk with the help of orthopedic crutches in the first days after the injury, so as not to overload the knee (especially if additional damage or partial failure of the ligament in intracranial injuries is suspected – as the only means that makes it possible to form scar tissue and restore the continuity of the ACL).
– Physiotherapy: Appropriate physiotherapy procedures are recommended from the first moment after injury. On the other hand, special exercises are aimed at restoring mobility in the knee and strengthening the muscles that increase the stability of the knee joint.
Operative (surgical) treatment is the most recommended form of treatment
– until recently, it was believed that it was not possible to sew most of the torn anterior cruciate ligaments. Recent data, however, show that the stitching of the ACL and the implantation of an artificial tape as an internal “framework” (internal barcing) allows reconstructing the cruciate ligament. The artificial tape provides immediate restoration of stability, and over time sprouts the patient’s own tissue and becomes a new, reconstructed ligament. The operation is usually performed up to 14 days after the injury, that is, very quickly — the patient does not have to wait, as before, about 3 months after the injury. The method is characterized by minimal damage and a quick return to sports activity. The appearance of this method was due to significant achievements in the field of engineering science of materials, with the help of which it became possible to produce modern implants — braid for internal stabilization. The procedure is performed arthroscopically (minimally invasive).
Reconstruction of the anterior cruciate ligament ACL using artificial ligaments Neoligaments JewelACL
– this is the second modern form of reconstruction. It can be used, especially when the internal bracing technique cannot be applied or a very quick return to the big sport is required. The procedure is performed arthroscopically (minimally invasive).
Classical arthroscopic reconstruction of the anterior cruciate ligament
— during the operation, the torn ACL ligament will be replaced with the transplanted tissue. The transplant will serve as a kind of “framework” for the reconstruction of a new ligament. We use for this purpose the patient’s own tendon of the semi-tendon (and thin) muscles or the patellar ligament. The disadvantage of removing one’s own tissue for transplantation is a slight muscle weakness and a slight limitation of the medial stability of the knee (tendon) or in about 10% of cases of pain in the anterior part of the knee joint with the removal of 1/3 of the medial ligament of the patella. The time of the return of the full biomechanical functionality of such a ligament will also be longer – about 6 months after transplantation, the ligament is very weak (weaker than during surgery – as a result of reconstruction).
ACL reconstructions using allograft (ligament transplantation from a deceased donor)
– a method often used in repeated operations due to repeated rupture of an already transplanted ligament.
Time to return to sports
After ACL reconstruction, the time to return to sports activity depends on the chosen method of reconstruction and the progress of rehabilitation. When choosing the classical method, this period will be up to 9-12 months (often they write 6 months, but this is associated with a high risk of stretching the transplanted ligament and loss of its functionality). Methods using artificial implants (internal bracing or Neoligaments JewelACL) allow you to return to the sport after 3 months.
Knee rehabilitation after a procedure or surgery
Depending on whether the treatment includes surgery or not, rehabilitation occurs in completely different ways. But in both cases, it plays an important role. The introduced physiotherapy program will help restore muscle strength and mobility of the knee joint without the risk of further damage to intra-articular structures.
After the operation, physiotherapy primarily focuses on restoring the proper range of motion in the knee joint. This is followed by programs to strengthen the muscles surrounding the knee to protect the reconstructed ligament (especially the quadriceps and biceps femoris). The final stage of rehabilitation should be devoted to a practical return to activity adapted to a particular sport.