Anterior cruciate ligament surgery

Causes and symptoms of anterior cruciate ligament rupture

Where is the anterior cruciate ligament located?

Four ligaments provide knee joint stability. The lateral and medial collateral ligaments on either side prevent lateral movement, while the intersecting anterior and posterior cruciate ligaments on the inside of the knee prevent forward and backward movement.

The anterior cruciate and the medial collateral are the two most often damaged knee ligaments. While there is a good chance that the medial collateral ligament will heal with conservative treatment, i.e. without surgery, this is not the case for the anterior cruciate ligament, which is the most important stabilizing ligament of the knee joint.

What can cause an anterior cruciate ligament injury?

Cruciate ligaments are very strong, so it is not surprising that the anterior cruciate ligament is most often injured during sporting activities. Most commonly, skiers, footballers, basketball players, handball players, etc. have a foot that hits the ground at the wrong angle, the knee moves laterally or the foot twists, which can cause a partial or complete tear of the anterior cruciate ligament.

In addition to a recent injury, the problem may also be the result of a previous untreated, partially healed injury.

Symptoms of anterior cruciate ligament rupture

The moment an anterior cruciate ligament tears, there is a loud popping or cracking sound, accompanied by severe pain, rapid swelling and the inability to step on the injured leg.

If the problem is long-standing, the anterior cruciate ligament (ACL) injury can cause a wide range of symptoms, most commonly a feeling of instability at the knee, but sometimes, even without any particular loss of stability, symptoms can include a feeling of unsteadiness, fluid retention, and knee pain. This mixture of symptoms is because sometimes a cruciate ligament deficiency is accompanied relatively early on by a meniscus injury or cartilage damage.

How is the injury diagnosed?

Anterior cruciate ligament tears can be diagnosed by specific tests. Examples include the Lachman test or the pivot shift test. If the tests do not give a clear result, x-rays, MRI scans or knee arthroscopy can help to diagnose a torn ligament.

How can an anterior cruciate ligament injury be treated?

In the case of anterior cruciate ligament injury or insufficiency, directional instability develops, which, according to the medical literature, leads to progressive wear of the cartilage surfaces of the knee joint in the long term. While abrasive lesions can usually be treated with compromised surgical solutions, replacement of the anterior cruciate ligament can effectively stabilize the knee joint and reduce the chance of progressive cartilage wear. For these reasons, reconstruction of the anterior cruciate ligament is recommended in young and middle-aged people with an active lifestyle. In view of the favourable follow-up results, the upper age limit of 50-55 years has now been shifted to 60-65 years, assuming adequate cartilage condition.

Replacement of the anterior cruciate ligament can be performed by arthroscopic surgery and can be accompanied by treatment of meniscal injuries and focal cartilage damage to the articular surfaces. It is important to note, however, that if the cartilage damage is severe and extensive, anterior cruciate ligament reconstruction may stabilize the knee joint, but symptoms may remain and worsen over time.

How is anterior cruciate ligament reconstruction performed?

The reconstruction of the anterior cruciate ligament is a ligament reconstruction with autografts or allografts in which the missing or damaged anterior cruciate ligament is replaced by implanting tissue that will be incorporated into the body during the healing process and become the knee joint's own. The plastic ligaments that were occasionally used in the past are not suitable for this because they do not integrate and will tear within a few years of use.

There are, however, some high tensile strength soft tissues in the human body that can be used for replacement and proper regeneration will occur at the site of graft removal. Of these own (autograft) soft tissues, in our hospital we prefer in most cases to use the semitendinosus tendon of one of the parallel internal hamstring muscles. This long and strong tendon folded four times provides an excellent stabilizing structure for replacement.

For certain specific considerations, in the case of previous unsuccessful surgical interventions or reinjury, a good quality autologous graft can be obtained from the middle of the tendon of the knee extensor apparatus below the patella (bone-patellar tendon-bone graft) or from the tendon above the patella (quadriceps graft).

There are also cadaver-derived grafts that can be ordered from tissue banks, but their incorporation is slow, and they are not used in our hospital.

Successful anterior cruciate ligament reconstruction requires accurate positioning and proper fixation of the tissue used for the reconstruction. The arthroscopic technique used in our surgeries not only has advantages due to its minimally invasive nature, but also allows for precise graft placement and treatment of any cartilage lesions found.

Preparations and procedure for anterior cruciate ligament surgery

Preoperative period

Although the directional instability of the knee joint can be reliably determined by physical examination, additional imaging studies (weight-bearing x-ray, special native x-ray, MRI) may be necessary to clarify possible axis deviations, associated cartilage lesions and other ligamentous abnormalities. These biomechanical parameters may also influence the surgical plan.

The surgical recommendation is based on the patient’s medical history, an outpatient physical examination, native weight-bearing x-rays and other imaging studies (ultrasound, MRI, bone scintigraphy) and possibly other additional tests as needed. This will also include planning the graft selection and any additional procedures that may be necessary (treatment of meniscus injuries, cartilage resurfacing, etc.). When the proposal is made, the main elements of the post-op check-ups, the rehabilitation schedule and any questions about the surgery will be answered during the consultation.

The patient will then be given a written offer of surgery, together with the main details of the hospital stay, where the necessary preoperative tests and the subsequent anesthetic consultation are organized. If the offer of surgery is accepted, the planned date of the operation will be set.

During the consultation, we will decide on the planned anesthesia method. The choice of the type of anesthesia and the determination/modification of any medication required prior to surgery (e.g. switching to blood thinning medication) is made in consultation with the anesthetist, based on the patient's medical condition and prior tests.

The operation

This orthopedic surgery is performed under general anesthesia or spinal anesthesia with the application of a tourniquet cuff. During the arthroscopic examination of the joint, any cartilage damage found is treated as necessary. The surgical plan is finalized on the basis of the findings and the autograft is removed to replace the anterior cruciate ligament.

In most cases, the semitendinosus tendon, which is attached directly under the joint on the inner side, is used, but the central part of the tendon below the patella of the extensor apparatus may be chosen for professional reasons. The former is removed through a 2-3cm incision on the inner side of the knee, the latter, the so-called bone-patellar tendon-bone graft, is removed through a 4-6cm skin incision below the patella.

The graft is implanted into the bone canals of the femur and tibia, and both the recipient canals and the graft are fixed arthroscopically. The fixation elements are titanium-based, MRI compatible and do not need to be removed later.

Occasional postoperative insertion of a suction drain may be warranted and will be removed the day after surgery. Antibiotic prophylaxis is given during the operation, and postoperative medical and mechanical thrombosis prophylaxis is used to prevent infectious or clotting complications.

What to do after surgery

The day after the operation, the patient can get up with the help of a physiotherapist and walk unencumbered with the use of an assistive device. An external knee brace (orthosis) is not routinely used after surgery, but the quality of the graft and the condition of the soft tissue around the knee may make this temporarily necessary.

In unproblematic cases, discharge is usually after one night in hospital following surgery, with suture or surgical staple removal between days 7-14.

During your hospital stay, your physiotherapist will teach you the movement restrictions applicable to the first three weeks, how to use assistive devices, and your initial exercise routines. The exercises you learn will need to be continued regularly at home. A recommendation for home physical therapy (as part of home care) will be given in the final report, a prescription for the necessary medication (blood thinners, anti-inflammatory, painkillers, gastroprotective medicine) will be provided and the necessary check-ups will be scheduled. In the event of a complaint, we will provide an out-of-hours check-up.

What to look out for after anterior cruciate ligament surgery?

Postoperative rehabilitation

It is not usually necessary to change the dressing that was applied in hospital during the home recovery period. The wound should not be exposed to water until the stitches are removed. If the dressing is damaged or bleeds through, it can be replaced with a dry top dressing. The day after the operation, the patient will get up in our hospital with the help of a physiotherapist and will be taught how to walk unencumbered using an assistive device. The physiotherapist will also teach the initial rehabilitation exercises. A knee mobilizing device may also be used.

Postoperative check-ups

First check-up

At the first check-up, between 7 and 14 days after surgery, the sutures are removed. The dressing applied at this time can be removed the next day and the limb can be weight-bearing after the third week. Anti-inflammatory therapy and thromboprophylaxis with tablets or injections should be continued for the period prescribed at discharge. In the event of a complaint, the patient should present for an unscheduled follow-up examination.

Second check-up

The second check-up takes place 6 weeks after surgery. At this time, we will assess the range of motion, gait and muscle strength of the operated joint to determine whether additional physical therapy is needed in our hospital or elsewhere. Some of our patients will already have satisfactory function and do not require specialized physiotherapy in our hospital, and the exercises they have learned or the physiotherapy they receive via home care is sufficient to achieve good daily physical activity.

At this stage, stretching is usually complete and well developed, flexion is above 90 degrees, and the thigh muscles have started to recover. The focus is now on flexion exercises and hamstring strengthening, so in addition to physiotherapy, we recommend indoor cycling and strengthening the hamstrings on gym machines.

Third check-up

The third check-up is between 2 and 3 months post-op. By this time, we expect to see that everyday activity is functioning at the desired level and that our patients can start more demanding sports proprioceptive training and running.

Further check-ups

The scheduling of sports activities involving jumping and impact will be considered at the follow-up examinations, taking into account the opinion of the physiotherapist supervising the patient's rehabilitation. The return to sport is largely influenced by the condition of the muscles, but in general, sports that are less demanding on the knee joint can be undertaken between 3 and 6 months, while contact sports can be started gradually six months after surgery, following prior sport-specific conditioning exercises.

Common questions about anterior cruciate ligament replacement

What movements are not recommended?

During the first three weeks, we limit bending over 90 degrees and straining the knee in an extended position. During this period, movement helps the limb’s circulation, but in a passive position, when sitting for long periods of time, we recommend padding the limb to avoid swelling of the knee and peripheral edema.

What medical aids are needed for physiotherapy at home?

During rehabilitation, in our hospital we provide all the necessary medical aids that our patients may need when they leave for home. These include elastic stockings to protect against blood clots and walking aids (elbow or underarm crutches).

In consultation with a physiotherapist or doctor, it may be useful to hire a passive knee exerciser to supplement home exercise in the week or two following surgery, to help regain knee function more quickly. It should be stressed that this is not a substitute for active exercise, but a complement to it. The final function of the knee joint will be determined mainly by physiotherapy, active stretching and flexion exercises and muscle strengthening.

Knee braces (orthoses) are not routinely used and are only prescribed for a few weeks after surgery in selected cases. In some cases, we recommend the involvement of a physiotherapist for rehabilitation. We can provide this in our hospital for our outpatients in addition to our home care provision. The assistance of our physiotherapists is also of particular importance when returning to sport.

Can MRI scans be performed after metal plates and staples have been implanted?

Medical metals are generally MRI-compatible, so small metal plates and staples implanted during a cruciate ligament replacement can also be MRI scanned. However, as medical metals can heat up slightly in a magnetic field, we generally do not recommend an MRI scan until after the first six weeks following surgery. The implants we use are made of titanium and do not heat up, so present no problem with an MRI scan in the early post-operative period.

How does the implant behave at the airport or other metal detector gates?

The implant can be detected by a metal detector. Neither the hospital discharge report nor any other certificate will exempt you from being screened with a handheld metal detector, as these checkpoints are essentially designed to detect metal weapons.

When can I start driving a car after ligament surgery?

If there are no problems, we recommend that you resume driving 4 weeks after surgery. It can be resumed earlier with an automatic car following left knee surgery.

What sports activities can I do after a cruciate ligament replacement?

The aim of the operation is to relieve the patient of their symptoms and to enable them to lead as full and active a life as possible with a stable knee joint, while regaining their previous mobility. The pace of the gradual return to sporting activity is decided jointly by the doctor and the physiotherapist and is determined not only by the function of the operated joint but also by the patient's other parameters and general musculoskeletal condition.

The surgeon's opinion is based on the joint's range of motion, stability and the amount of muscle regained, but their recommendation takes into account the physiotherapist's assessment of the functional capacity of the operated limb. In general, swimming and cycling are recommended after 3-6 weeks and running after 8-10 weeks. Movement involving changes of direction and jumping can be attempted after 3 months and contact sports can usually be started after six months for patients who have undergone ligament replacement.

Why choose Dr. Rose Private Hospital?

• We offer a full range of orthopedic services. At our specialist orthopedic clinic, we provide the necessary tests (MRI, CT, x-ray, ultrasound, laboratory tests) to make an accurate diagnosis. Anterior cruciate ligament surgery is performed without a waiting list. After the operation, our physiotherapist and sports rehabilitation staff will help you to regain your mobility as quickly as possible.
• A highly trained team of specialists. Our specialists use state-of-the-art, minimally invasive techniques to speed recovery, complemented by our physiotherapists, physical therapists and sports rehabilitation staff. In the case of complex problems, we decide on the appropriate course of treatment, necessary tests and therapies in a consultation.
• Exclusive environment. Our premium inpatient department has 3 operating theatres and 24 patient rooms with 33 beds to meet all your needs. The highest professional standards together with a unique healing environment mean you can recover in safety and with complete peace of mind.

For all your cruciate ligament complaints, feel free to contact the doctors at Dr. Rose Private Hospital.