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Anterior cruciate ligament reconstruction treatment review
What exactly is involved in anterior cruciate ligament reconstruction? The anterior cruciate ligament has limited ability to form scar tissue and heal. The untreated knee is at risk of instability, meniscal tears and osteoarthritis.
By: A+ Orthopaedic & Sports Medicine Clinic
When conservative management fails
Patients with anterior cruciate ligament tears who place high demands on their knees, generally require anterior cruciate ligament reconstruction. Such demands include the ability to jump, cut, accelerate and decelerate. Patients with symptomatic instability and associated meniscal lesions may also require anterior cruciate ligament reconstruction. Non-operative management is reserved for the physiologically older patient with a low activity level and minimal or very mild symptoms. Failure of conservative management is an indication that surgical reconstruction may be needed.
The absolute indication for operative treatment is symptomatic instability that has failed to improve with an adequate rehabilitation programme. In the chronic anterior-cruciate deficient knee the other ligament supports (the secondary restraints) may begin to give way. Many anterior cruciate ligament injuries in this country present late and therefore have laxity of the secondary restraints by the time of surgery. This is most commonly seen in athletes who return to sports without reconstruction and is associated with a high incidence of medial and lateral meniscus injuries. These athletes often say that they can run in a straight line, but any attempt to twist or alter direction causes a feeling of the joint being unstable and giving way.
The two groups
Reconstruction of the anterior cruciate ligament is the surgical treatment of choice once direct primary repair of the ligament has been shown to result in persistent laxity and instability of the knee(2). The aim of reconstruction is to restore stability of the knee without restricting its other functions, especially motion.
Reconstruction techniques can be broadly split into two groups:
(i) Extraarticular reconstruction
(ii) Intraarticular reconstruction
Extraarticular reconstruction uses the structures on the lateral side of the knee to mimic the actions of the anterior cruciate ligament. For example, by surgically tightening the iliotibial tract, excessive lateral excursion of the tibia is prevented. The overall aim is to prevent anterior subluxation of the lateral tibial plateau in relation to the lateral femoral condyle and to correct anterolateral rotatory instability. The success of extraarticular reconstruction has been limited and as a result the trend has been towards intraarticular reconstruc-tions, and arthroscopically assisted reconstructions in particular. In some centres, extraarticular reconstruction is still favoured in the skeletally immature patient where the physes are still open and fixation across a physis may lead to premature closure of that growth plate - this too is an area of great debate, however some orthopaedic surgeons have advocated the use of combined intra and extraarticular reconstructions(
Intraarticular reconstruction tries to reproduce the anatomic anterior cruciate ligament. The donor tendon graft spans the intercondylar notch from the origin to insertion of the anterior cruciate ligament. Significant advances in arthroscopic techniques, and very good clinical results, have led to the increased availability and popularity of arthroscopically assisted anterior cruciate ligament reconstruction. The most commonly used grafts are bone patellar tendon bone (BPTB) and four stranded hamstring tendons. The results of these are equally satisfactory at five years(8).
Important steps in intraarticular anterior cruciate ligament reconstruction
Once the graft is harvested (graft types will be discussed in a further review), it is passed through a tibial tunnel, through the knee joint, and through a femoral tunnel. It is usually secured at either end with compression interference screws or an alternative fixation device. Surgery is now facilitated by the use of jigs, which allow arthroscopic reconstruction.
» Thorough examination of the knee under anaesthetic - particularly to pick up associated instabilities that may lead to premature failure of the reconstruction.
» Diagnostic arthroscopy - to examine the menisci and joint surfaces.
» Meniscal repair or excision
» anterior cruciate ligament stump excision
» Lateral superior expansion notch-plasty - expanding the femoral notch to allow accurate graft placement and free motion.
» Placement of an appropriately sized tibial tunnel (based on the size of the graft). It should be in the posterior third of the anterior cruciate ligament tibial footprint. If the tibial tunnel is positioned anteriorly, extension is restricted and graft impingement may cause early rupture or loss of knee extension.
» Placement of appropriately sized femoral tunnel. It should be at 11 o'clock in the right knee and 1 o'clock in the left knee at the back of the intercondylar notch when viewed arthroscopically. If the femoral tunnel is positioned anteriorly, flexion is restricted which may cause a loss of motion or graft failure due to stretching.
» Secure fixation of the graft in both tunnels, usually using interference screws, although there are more and more fixation devices available. These are usually left in permanently.
» Evaluation of the graft fixation, stability, and impingement-
» Standard wound closure.
Some units will perform this procedure as daycase surgery. This, however, also necessitates extensive pre- and post-operative visits to learn about the procedure and about the post-operative rehabilitation. Most units will admit the patient the day prior to surgery and will allow discharge within 24-48 hours of surgery once pain control is achieved and knee swelling has started to settle down.
Reconstruction of the anterior cruciate ligament tendon-bone has been demonstrated in numerous series to be a valuable procedure which abolishes instability and improves performance in 90% or more of patients over a five -year period. Great motivation is required for satisfactory rehabilitation.
A+ Orthopaedic and Sports Medicine Clinic is a very specialized establishment looking after Orthopaedic problems and taking care of need of all in the field of sports and physical activity. It was established in 2002 with view to address all the needs of people of all age group. In Sports from assisting in assessment of injury to full sports and activity related issues weather be injury, growth & development, nutrition, body statistics, deficiency in specific group of muscles, psychology behind winning instinct. While in Orthopaedics dealing with all bone and joint related problems to all kind of arthritis and Joint replacement surgeries are performed by experienced doctor with long experience abroad and in India in the field.
Dr. Prateek Gupta (Senior Surgeon)
C2/5 Safdarjung Development Area (SDA),
Aurobindo Marg, New Delhi - 110016
Telephones: +91 9810852876, +91 11 26517776
24 x 7 Helpline & Appointment:
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Arthroscopy Surgery Clinic is a purpose built facility for diagnosis & management of all arthroscopic disorders, including knee, shoulder, hip & elbow arthroscopy. Arthroscopy Surgery Clinic is located at New Delhi, India. www.arthroscopysurgeryindia.com