Cruciate ligament tear
A cruciate ligament tear , also called cruciate ligament rupture , is an incomplete (partial) or complete (complete) tear (rupture) of one or both cruciate ligaments . In most cases, the anterior cruciate ligament (ligamentum cruciatum anterius) is affected. The cause of a cruciate ligament tear is that the tear strength of the ligament is exceeded .
Cruciate ligament tears usually occur without any external influence through sudden changes of direction when running or jumping. They are the most common clinically relevant injuries in the knee joint area . Cruciate ligament tears can be diagnosed with relative certainty on the basis of their symptoms , the description of the injury process and with the help of simple palpatory examinations . Magnetic resonance tomography and arthroscopy can further confirm the diagnosis. Untreated cruciate ligament ruptures can lead to severe degenerative damage to the knee. The therapy can be conservative as well as surgically ( minimally invasive by means of arthroscopy). Which therapy is carried out when and in which variant is the subject of controversial discussions. What is undisputed, however, is that currently no form of therapy can qualitatively restore the original condition of an uninjured cruciate ligament. A long-term consequence of a cruciate ligament tear is the significantly increased likelihood of developing knee osteoarthritis - regardless of the type of treatment. A large number of studies have come to the conclusion that special preventive exercises can significantly reduce the risk of a cruciate ligament tear.
In the Anglo-American specialist literature, the term anterior cruciate ligament injury is used for injuries to the anterior cruciate ligament . Cruciate ligament rupture is correctly translated as cruciate ligament rupture . Injuries to the posterior cruciate ligament (ligamentum cruciatum posterius) are referred to as posterior cruciate ligament injury .
Types of cruciate ligament ruptures
- Anterior or posterior cruciate ligament tear with sagittal instability, that is, from anterior to posterior, and positive drawer phenomenon
- Combination injury with drawer phenomenon when the foot is turned inwards or outwards:
- Anteromedial rotational instability ( AMRI , anterior- centered rotational instability ): anterior cruciate ligament tear, tear of the medial meniscus and the mediodorsal capsule, often an additional tear of the inner ligament ( usually pointing towards the middle) (so-called unhappy triad ).
- Anterolateral rotational instability ( ALRI , anterior-lateral rotational instability ): tear of the posterior cruciate ligament, the outer ligament and the dorsolateral capsule.
- Posterolateral rotational instability ( PLRI , posterior-lateral rotational instability ): tear of the outer ligament and the posterior cruciate ligament with posterior-central or posterior-lateral rotational instability.
Anterior cruciate ligament
The anterior cruciate ligament injury typically results from a change in direction. Often there is an outward rotational position of the lower leg with valgus flexion stress or an inward rotational position with varus flexion stress . Excessive stretching or bending movements ( hyperextension or hyperflexion) can also be a trigger. The majority of the cases are sports injuries. Such injuries ( trauma ) occur particularly frequently in so-called “stop-and-go” sports (e.g. tennis or squash ) and in team sports (e.g. soccer , football , handball , hockey or basketball ) - often also less External influence - on. Even when skiing - especially when the valley ski turns outwards, but the body remains fixed above the mountain ski - ruptures of the anterior cruciate ligament are a common type of injury. The injury mechanism that involves the valgus and internal rotation position when skiing is also known as the “phantom foot mechanism”. A tear can also be caused by a dislocation of the kneecap ( patellar luxation ) with a sudden loss of stability of the knee joint.
The failure ( insufficiency ) of the anterior cruciate ligament disrupts the function of one of the two central passive guide elements (primary stabilizers) of the knee joint. This results in a pathological freedom of movement of the tibial head forwards ( ventrally ), the so-called " tibia advance". The joint capsule, collateral ligaments, posterior cruciate ligament and menisci are increasingly used to slow down the tibia advancement. The ligament structures are overstretched. Cartilage damage occurs as the tibial advance increases. These are due, among other things, to the fact that the cartilage is exposed to significantly higher loads. In such a case, higher stress means premature wear with the development of osteoarthritis . Injuries to the menisci and cartilage accompanying the anterior cruciate ligament tear increase the risk of osteoarthritis.
Posterior cruciate ligament
Tears of the posterior cruciate ligament are less common. They arise because the posterior cruciate ligament has exceeded the maximum possible stretch; usually by external force. In most cases, not only the posterior cruciate ligament is affected by a posterior cruciate ligament tear. The injuries are therefore usually much more complex and usually affect the entire knee joint. The main cause of a rupture of the posterior cruciate ligament are traffic accidents or, more generally, so-called rapid trauma . This is due to the fact that the knee is bent when sitting in the car. The rear cruciate ligament tears when the lower leg hits the dashboard . This mechanism is therefore also called dashboard injury (literally translated from the English: dashboard injury ). However, this type of injury is relatively rare and its incidence has decreased more and more over the years. In a study carried out in Germany with over 20,000 accident victims in car accidents, only 5 cases of dashboard injury were found.
In sports that involve physical contact, such as American football , force acting from the front and center can lead to an injury of the posterior cruciate ligament due to excessive extension. Often the anterior cruciate ligament and the posterior joint capsule are injured as well.
The proportion of injuries to the knee ligaments in all clinically relevant knee injuries is around 40%. Of these 40%, about two thirds of the injuries are caused by cruciate ligament tears - 46% only the anterior cruciate ligament and 4% only the rear. Mixed injuries or more complex injuries involving the cruciate ligaments account for 19%. Statistically speaking, the anterior cruciate ligament ruptures about ten times as often as the posterior one. The main cause of the significantly lower incidence of ruptures of the posterior cruciate ligament is on the one hand its larger diameter and the resulting comparatively higher load capacity and on the other hand its different function. In the United States the ratio of ruptures of the anterior cruciate ligament to the posterior one is about 9 to 10: 1, in Germany it is about 14: 1.
Around one million cruciate ligament tears occur worldwide each year. Recreational athletes are mostly affected. The tear of the anterior cruciate ligament is not only the most common knee ligament injury, but also the most common clinically relevant knee injury. The incidence is around 0.5 to 1 anterior cruciate ligament rupture per thousand population ( USA , Central Europe ) and year. In the United States, there are approximately 80,000 to 100,000 ruptures of the anterior cruciate ligament each year. The incidence is highest between the ages of 15 and 25 years. The annual cost is around $ 1 billion.
In Germany in 2002 the medical costs in hospitals for the treatment of "internal damage to the knee joint" - the main part of which is caused by cruciate ligament tears - amounted to 359.3 million euros. Statistically speaking, a cruciate ligament ruptures every 6.5 minutes in Germany. In about every third person, a meniscus is also damaged. In Switzerland, the estimates for the annual costs of cruciate ligament ruptures are between 200 and 250 million francs. Of this total, 40% are medical costs, 47% daily allowances , 2% capital benefits, such as integrity compensation ( social security compensation for pain and suffering ) and 12% disability pensions (capital values). For each cruciate ligament tear, this is almost 21,000 francs, with an average medical cost share of 8350 francs.
The Swiss accident statistics (UVG), which cover around half of all Swiss citizens, report 6350 injuries of the anterior cruciate ligament per year (period 1997 to 2001). The extrapolation for Switzerland assumes 10,000 to 12,000 cases. Of the 6350 injuries recorded, 73% are caused by “sport and play”, 10% are occupational accidents and 17% are attributable to other activities such as commuting accidents, staying in houses or other leisure activities.
Women and girls have a two to eight times higher injury rate than men who do the same sport. Various studies show that these injuries are mainly caused without contact. Here, a functional valgus position of the knee joint when landing after a jump plays a key role. According to a study, female basketball players are four times more likely to have a knee injury, knee surgery or anterior cruciate ligament surgery than male basketball players. For female soccer players, this factor is 3.41. The cause of the increased incidence in women is still largely unclear. Anatomical differences, such as greater play in the knee joint, hormones and training techniques are discussed.
The proportion of individual sports in the frequency of cruciate ligament ruptures depends very much on local preferences for the respective sport. In the USA, for example, basketball players (20%), followed by soccer (17%) and American football players (14%), have the highest proportion of cruciate ligament ruptures, while in Norway the order of soccer players (42%), handball players (26th %) and alpine skiers (10%). In Germany, the most common cruciate ligament tears occur in soccer, handball and skiing (alpine). This is followed by road traffic and work accidents . More than 70% of the tears in the anterior cruciate ligament occur without any external influence when landing after a jump, when braking or when suddenly changing direction.
The number of cruciate ligament ruptures diagnosed annually has been increasing for years. In addition to the improved diagnostic possibilities - with which cruciate ligament ruptures are more often recognized as such - the increase in sporting activities in the leisure society is also to blame for this tendency. Without some specific sports, cruciate ligament ruptures would be a relatively rare trauma.
In addition to the factors sport and gender already described under the heading Frequency, other risk factors also play a role in cruciate ligament rupture. Due to the frequency of the injury, extensive statistical data and a large number of studies derived from it are available. The etiology of an anterior cruciate ligament tear without external influence is very complex, and a number of factors, some of which are very different, influence the risk of a rupture. To date, it cannot be fully explained why individuals are at higher risk for this injury than others. For example, it is unclear why, if the anterior cruciate ligament of one knee is injured, there is an increased likelihood of the same injury to the other knee within the next few years. German soccer players who have already had a cruciate ligament rupture are more than five times more likely to have a new cruciate ligament rupture than players who have previously been spared this type of injury. In terms of risk factors, a distinction is made between intrinsic (personal) and extrinsic (external) factors. The intrinsic factors include, for example, genetic predisposition or anatomy, fitness level , neuromuscular effects or hormonal factors. On the other hand, the nature of the ground, the weather or the sports shoes are extrinsic risk factors.
Knowledge of the risk factors for cruciate ligament ruptures is an important starting point for preventive measures .
Intrinsic Risk Factors
Anatomical factors are among the risk factors that have long been suspected. The tear resistance of a cruciate ligament is directly related to its width, which in turn can vary from person to person. In an anthropometric study, the anterior cruciate ligaments of the uninjured contralateral knee of patients with a cruciate ligament rupture were compared with those of a control group with the same mean body mass. The volumes of the cruciate ligaments were determined by means of magnetic resonance imaging. In the group with cruciate ligament tears, the volume of the contralateral cruciate ligament averaged 1921 mm³, while it was 2151 mm³ in the control group. The authors of the study conclude from this that anthropometric differences in the volume - and, derived from this, the width - of the cruciate ligament have a direct influence on the probability of a cruciate ligament tear without external influence. A correlation between a narrow cruciate ligament cavity (intercondylar notch), which is in turn related to a narrow cruciate ligament, with an increased risk of a cruciate ligament rupture was found in previous studies . However, there is no scientific consensus on this as other studies come to different results. Women have a narrower cruciate ligament cavity than men, which is why this anatomical difference is an explanatory model for the higher incidence of cruciate ligament ruptures in women.
Deficits in proprioception , i.e. the perception of one's own body movement and position in space, as well as neuromuscular fatigue symptoms in the lower extremities and central fatigue symptoms when landing after a jump, are seen as risk factors for an anterior cruciate ligament rupture. One study found that patients with a cruciate ligament tear had significant deficits in neurocognitive abilities. Other risk factors include dynamic valgus stress on the knee joints, a lack of hip and trunk control, and poor knee flexion when landing after a jump. It also increases a so-called quadriceps dominance, i.e. H. a predominance of the strength of the quadriceps muscle over the hamstring muscles, the risk of an anterior cruciate ligament injury.
Extrinsic Risk Factors
The coefficient of friction between the sole of the sports shoe and the ground is a factor in causing a cruciate ligament tear. A high coefficient of friction correlates with an increased risk of injury. In a study over two seasons in the top three Norwegian handball leagues, the friction coefficient between the sports shoe and the flooring played a role in 55% of cruciate ligament tears. In American football, fewer players are injured by cruciate ligament ruptures in colder months than in warmer months. One of the reasons discussed here is the reduced grip in the cooler months.
A study of cruciate ligament ruptures in Australian football also described an association with weather conditions and the injury rate. The injury rate on dry playing fields was significantly higher than on wet ones. The cause is suspected to be a softer surface after rainfall, which reduces the power transmission between the shoe and the surface.
A relationship with soil quality was also found in Australia. In the Australian Football League, for example, fewer cruciate ligaments tore on ryegrass than on dog-tooth grass . The cause here is assumed to be a reduced adhesion of the sports shoes in interaction with the ryegrass, as a result of which the force transmission that is destructive for the cruciate ligament is lower than on the dog-tooth grass with higher adhesion.
If a cruciate ligament is torn, this usually leads to significant swelling of the knee joint and, as a result, to pain due to the capsular expansion of the joint. A bloody joint effusion ( hemarthrosis ) is the normal case in a cruciate ligament tear. It occurs in 95% of cases and very quickly restricts the mobility of the knee joint. Together with the instability of the knee joint, hemarthrosis is a leading symptom of a cruciate ligament rupture. Conversely, a cruciate ligament tear is responsible for about 50 to over 75% of all hemarthrosis. These symptoms were already described in 1879 by the French Paul Ferdinand Segond (1851–1912): Violent pain inside the knee and rapid bleeding with corresponding swelling of the joint. The cause of these symptoms are the nerve fibers and blood vessels that run in the cruciate ligament. The former cause the pain when torn, and the latter cause bleeding into the joint.
Often the tearing is associated with an audible bang ("plop"). The tearing is followed by a brief pain. The affected person notices the instability in the knee immediately after the first pain has subsided. The joint effusion usually only sets in during the day. As a rule, the practiced sport has to be stopped. An exception are skiers, who can often still manage the descent - but with considerable pain. If all of these symptoms are true, then there is a 90 percent certainty that the anterior cruciate ligament tears (or both). The knee can usually no longer be fully extended and is held in a slightly bent position ( relieving posture ). In this flexed position, you can pull the lower leg bone forward by about 5–10 mm against the thigh bone without feeling a stop, while with a healthy knee only a few millimeters (2–3 mm) are possible and then you feel a stop (positive Lachman test ).
After about a week, the symptoms of an anterior cruciate ligament tear will subside. Some patients start exercising again after two weeks. The degree of instability of the knee joint is strongly dependent on the secondary knee joint stabilizers and their training status. Secondary knee joint stabilizers are other peripheral ligaments and muscle tendons. They can partially take over the function of the anterior cruciate ligament to stabilize the knee joint. Many patients are largely symptom-free for three to six months. After that, the secondary stabilizers can usually no longer absorb the forces acting on the knee joint. Damage to the menisci and collateral ligaments as well as an increased incidence of giving way are the result.
Isolated anterior cruciate ligament tears are rather the exception. Up to 80% of all cruciate ligament tears are accompanied by other injuries. Injuries to the menisci are extremely common. In an extensive study of acute cruciate ligament tears, a tear of the medial meniscus was diagnosed in 42% of the cases and a tear of the outer meniscus in 62%. Another study found a tear of the medial meniscus in 60% of patients and a tear in the outer meniscus in 49% of cruciate ligament tears in the chronic interval (when a ligament was performed). If the injured meniscus is removed, the instability of the affected knee increases. The severely limited shock absorption also leads to an increased frequency of secondary arthrosis. Undamaged menisci have a positive effect on the outcome of a cruciate ligament surgery. For this reason it is recommended - if the tear of the meniscus permits - a refixation of the same. Ideally, this should be done together with the reconstruction of the cruciate ligament.
Another common accompanying injury is a tear in the inner and / or outer ligament of the knee joint. If the inner ligament, inner meniscus and anterior cruciate ligament are affected, one speaks of an unhappy triad . The anterolateral (front and side) bony capsule tear on the tibia plateau, the so-called Segond fracture, is rather rare . According to recent findings, this represents the bony avulsion of the anterolateral ligament (ALL). This is an important stabilizer against forced internal rotation of the knee. Only a tear in this tape allows a positive pivot shift test . In a retrospective study by the Belgian working group, which first described the ligament anatomically in 2013, it was found in 206 of 351 MRI scans of knees with a subsequently operated anterior cruciate ligament tear, which is made more difficult by the fact that the ligament runs at an angle to the standard layers of magnetic resonance imaging. An ALL tear was found in 162 (79%) of the knees, a bony tear ( Segond fracture ) in three cases (2%).
Injuries to the joint cartilage (traumatic chondropathies ) are involved in 16 to 46% of all ruptures of the anterior cruciate ligament.
Rarely, and mostly undetected, is the tear in the posterior, outer capsule shell, especially the tendon of the popliteal muscle (deep calf muscle). If left untreated, this injury leads to considerable knee joint instability with a visibly impaired gait.
In many cases, the diagnosis is made with a considerable delay, even if the patient consulted a doctor immediately after the injury. Some studies indicate a median period of 2 to 21 months that elapses between the time of injury and the correct diagnosis. In many cases, it is also necessary to visit several doctors before the correct diagnosis is made. Typical misdiagnoses are especially meniscus tear and " sprain ". It is therefore assumed that cruciate ligament ruptures are underdiagnosed. This means that they actually happen more often than they are correctly diagnosed.
If the anterior cruciate ligament tears, the so-called anterior drawer phenomenon occurs : when the knee is bent, the lower leg can be pushed forward from the back. If, on the other hand, the posterior cruciate ligament is torn, the posterior drawer phenomenon occurs : with the knee bent, the lower leg can be pushed from the front to the back.
The initial diagnosis is carried out using a drawer and Lachman test (rarely the pivot-shift test ). Due to the anatomy of the anterior cruciate ligament (two ligament parts = fascicle bundle), a clinical diagnosis is often difficult if only one bundle is torn. Here, for example, there is a negative drawer phenomenon in 90 ° flexion of the knee joint, but a positive Lachman test in 15 ° flexion.
Failure (insufficiency) of the posterior cruciate ligament can in some cases be assessed by observing ( inspecting ) the knee joint, which is bent at 90 °, from the side with the patient lying down. If the tibia head has sunk back, an injury to the ligament should be considered. This phenomenon can be intensified by additionally tensing the so-called hamstring muscles (rear thigh muscles). The posterior drawer is opened by subsequent quadriceps muscle contraction ( contraction ).
The loss of stability occurs with increasing flexion in the knee joint and is not present when the knee is extended. This explains the surprisingly low level of discomfort with isolated cracks. Complaints are mainly reported when climbing stairs or when lifting weights behind the kneecap (retropatellar) (increased pressure of the thigh bone on the kneecap).
The instability that results from a cruciate ligament tear causes overloading of the cartilage and the inner and outer meniscus. If the instability is not compensated by the musculature or removed by an operation, a meniscus tear and / or cartilage damage with osteoarthritis often occurs.
The diagnosis can be confirmed with imaging methods - namely magnetic resonance imaging (MRI, "nuclear spin"). It should be noted, however, that the interpretation of the MRI in the diagnosis of a cruciate ligament rupture provides 20 percent incorrect diagnoses . This depends on the so-called sectional images and the appropriate positioning of the knee joint during the MRI examination. The radiologist should know the exact history of the injury and also have experience examining an injured joint to avoid misjudgments. Compared to MRI, the error rate in the Lachman test, which is much easier to perform, is only 10 percent. MRI is therefore usually less sensitive and less specific for diagnosing an anterior cruciate ligament tear than clinical findings by a qualified orthopedic surgeon . The result of an MRI only rarely has an influence on clinical decision-making and should not be a substitute for a careful history and palpation. Several studies have come to the conclusion that an MRI is only useful for more complicated, unclear knee injuries - and more likely to make a diagnosis of exclusion.
X-rays do not make a direct contribution to the diagnosis of a cruciate ligament rupture. Both cruciate ligaments - whether torn or not - are not visible in the X-ray. If X-rays are taken, however, this can be used to diagnose possible concomitant bony injuries.
Diagnostic arthroscopy ( arthroscopy ) offers the highest diagnostic reliability. This procedure is the gold standard for diagnosing a cruciate ligament tear . Although the procedure is minimally invasive , it always represents a surgical intervention in the patient's knee that involves certain risks. However, since the surgical treatment of a cruciate ligament tear is usually arthroscopic ( therapeutic Arthroscopy ), there is the possibility of carrying out the therapy, for example in the form of a partial cruciate ligament resection (in the event of a tear) or a reattachment of the torn ligament, immediately after the diagnostic arthroscopy. With the increasing spread of magnetic resonance tomographs, the number of purely diagnostic arthroscopies has decreased significantly in recent years. However, diagnostic arthroscopy is still the method of choice for the reliable clarification of the diagnosis of a cruciate ligament rupture - in the case of unclear clinical findings and an unclear MRI.
Late signs of undiagnosed anterior cruciate ligament tear
If a cruciate ligament rupture is not diagnosed and consequently not treated, the so-called giving way can result. This means that the knee joint is unstable. The patient has the impression that z. B. when walking downstairs the lower leg is not under control. Athletic loads with rotational movements of the knee joint are not possible or are avoided. Recurrent swelling tendencies due to joint effusions can occur. The consequence of such an unstable knee, which is decisive for the fate of the injured knee, is the almost inevitable meniscus lesions . These occur due to the instability-related sagittal movement (giving way) beyond the rear edge of the tibial joint surface, with overrolling of the meniscus.
Clinical studies show that acutely injured cruciate ligaments have a natural self-healing potential, that is, a spontaneous tendency to grow back on by itself biologically. The decisive factor for the later, adequate knee stability, however, is that this scarring occurs at the anatomically correct attachment point. If a freshly torn anterior cruciate ligament grows together with the posterior cruciate ligament, it is a phenomenon known as lambda or Wittek healing.
A cruciate ligament rupture should always be treated according to the diagnosis. An untreated rupture can lead to degeneration of the hyaline articular cartilage and thus to meniscus damage. A large number of studies have shown that failure to take therapeutic interventions leads to progressive destruction of the joint structures and that there is a high risk of re-injury.
The treatment options can be divided into two groups: surgical therapy (operation) and conservative therapy . Which form of treatment is used is usually coordinated individually with the patient according to his needs. There are different approaches and treatment concepts for both forms, some of which are controversial. In principle, the course of chronic cruciate ligament damage varies greatly from person to person. It is generally accepted that not every patient needs surgical treatment. However, studies show that younger and, above all, physically active patients benefit from surgical restoration of the kinematics and stability of the knee joint by maintaining or replacing the torn cruciate ligament. Conservative therapy is based on physiotherapeutic muscle building, which should serve to stabilize the knee joint externally. The aim of surgical therapies is the anatomical and biomechanical restoration of the torn cruciate ligament in its original function.
Neither conservative nor surgical treatment of a torn cruciate ligament can completely restore the knee to its original condition.
Not every torn cruciate ligament needs surgery. In each case, the decision is made individually, depending on the patient's age, activity, sports ability, willingness and everyday ability. Therefore, the therapy decision requires a detailed discussion with the patient. Conservative treatment is an alternative to surgery, especially for patients with an anterior cruciate ligament rupture without accompanying injuries, limited sporting activity, and older people. An increased frequency of osteoarthritis was found in active, conservative patients compared to operated patients. Several studies have shown a significant advantage of the surgical intervention, especially for athletes who practice sports such as soccer, handball or basketball - that is, sports with high rotational and hyperextension stress on the knee joint. There are some older studies that conclude that conservative treatment of a torn cruciate ligament - even in athletes - has no negative effects. A new study also shows that in young patients with uncomplicated cruciate ligament rupture, prompt surgery within 10 weeks, in contrast to wait-and-see conservative treatment with the option of later surgery in the event of instability or the patient's request, has no advantages.
In conservative therapy, early functional movement treatment tries to compensate for knee joint instability through consistent muscle building training and thus to restore the lack of stability. Another goal is to improve the proprioceptive abilities of the (periarticular) elements around the knee joint. Sufficient stability is often achieved by splinting the knee joint in an orthosis (knee brace) for six weeks and accompanying physiotherapy.
With targeted and appropriate orthopedic treatment, the majority of patients with a rupture of the anterior cruciate ligament can in principle resume their sporting and professional activity without restriction. The patients treated in this way are able to work again after an average of seven weeks and can lead a normal life after about eleven weeks. These times are usually shorter than with a surgical procedure. About 80% of the patients can be active again after four months. However, this is essentially limited to sports without direct body contact and without pivoting movements that stress the knee. Many patients with conservative treatment of the cruciate ligament tear develop a feeling of fear while exercising in the situations that led to the original injury. One of the main reasons for this is the noticeable loss of knee stability for the affected person. This uncertainty is felt by around 30% of patients 18 months after the injury and almost 80% after four years. In contrast, it only interferes with about 10% in daily life. Most patients are pain-free in everyday life. In certain situations, for example after long periods without movement or changes in humidity, around half complain of pain after four years. Joint effusion , often together with a meniscus lesion, can be diagnosed in up to 30% of patients after four years . The latter is usually a consequence of accidents resulting from the instability of the joint. Regular monitoring of the affected knee joint is necessary for the early detection of possible complications in conservative therapy. Surgical treatment is then possible at any time.
For complex knee ligament injuries (e.g. unhappy triad ), bony tears of the anterior cruciate ligament, additional lesions in the meniscus, lack of muscular compensation after intensive physiotherapy, as well as for younger performance-oriented athletes, surgical treatment is usually carried out.
Surgical treatment of the anterior cruciate ligament tear
In the 1970s to 1980s, the age limit for anterior cruciate ligament reconstruction surgery was around 35 years. This was due to the still limited surgical options using arthroscopy and minimally invasive instruments as well as the implants available at the time. Today there is no longer an age limit. The condition of the affected knee, the demands of the patient and his or her motivation are the main factors influencing the decision for or against surgical treatment. In most cases, from a medical point of view, a cruciate ligament rupture does not have an immediate need for immediate surgical intervention. A fresh rupture is operated on for cruciate ligament replacement after a physiotherapy cycle - this is usually around six to eight weeks after the injury. The knee is then usually completely swollen again. If a cruciate ligament retention method is considered, the operation must be performed within three weeks of the accident. In some cases, surgical treatment is not performed until several months after the cruciate ligament rupture. For example, when initially only a slight instability of the affected knee leads to symptoms in the patient. In the Scandinavian countries of Norway, Denmark and Sweden, the mean time between rupture and operation is seven, nine and ten months, while in the United States it is 2.4 months. The interquartile range is from 1.2 to 7.2 months in the USA and from 4.2 to 17.8 months in Norway.
Some recent studies have come to the conclusion that degenerative symptoms can be observed on the menisci of the affected knee as early as six months after a cruciate ligament rupture without surgical intervention, so that the authors recommend reconstruction within one year to reduce the risks.
The absolute indication for an operation is instability of the knee joint. Without a stabilization operation, this leads to meniscus damage and ultimately to secondary arthrosis of the joint. It is mainly people who are active in sport at a younger age who are affected, although in recent years the generation over 50 has seen an increase in cruciate ligament sports injuries in Germany. Furthermore, if the person concerned has an occupational restriction (e.g. craft trades), the operation is also necessary here.
The clinical results of the surgical treatment of smokers are significantly worse than those of patients who refrain from tobacco consumption.
The following techniques all relate to the preservation or reconstruction of the anterior cruciate ligament. Operations on the posterior cruciate ligament are comparatively rare. They are listed at the end of this paragraph.
The standard procedure is still cruciate ligament surgery with the use of a tendon or allograft implant, which replaces the cruciate ligament as anatomically precise as possible.
Cruciate ligament surgery
The most common surgical techniques used are reconstruction of the torn cruciate ligament. The remnants of the severed tape are largely removed and replaced with a new tape. The new ligament can be made from the body's own tissue ( autologous ) or from the tissue of the deceased ( allogeneic ) or from another species ( xenogenic ) .
While in the 1980s an operation was usually performed immediately or at least shortly after the injury, the “ two-stage ” procedure has been preferred since the 1990s . After a clinical examination, often supported by the findings of a magnetic resonance tomography (MRT), the arthroscopy is performed with resection of the torn cruciate ligament and treatment of any meniscus injuries in preparation for the second operation (cruciate ligament plasty). The arthroscopy is followed by a physiotherapeutic treatment to reduce the swelling of the knee and strengthen the muscles. After the symptoms have subsided, the actual cruciate ligament operation is performed around six weeks after the first arthroscopy.
This two-stage method is still preferred by many surgeons to this day, since a higher rate of arthrofibrosis and thus massive restrictions on movement was observed after the operation in the "immediate operations" .
In recent years, however - thanks to more standardized methods, but also for the purpose of possible shortening the treatment process - more and more "one-time" operations have been performed again. The stumps of the torn cruciate ligament are usually only partially removed; often just enough to prevent the stump from becoming trapped in the joint. Clinically proven cruciate ligament injuries can be treated immediately after the injury , especially in high-performance and professional athletes , as long as the knee is still largely free of inflammation.
All reconstruction techniques try to restore the properties of the original cruciate ligament as well as possible. The anterior cruciate ligament has a multiaxial fiber structure. None of the currently used grafts achieve this structure. All reconstructions also lack proprioception . A healthy cruciate ligament has mechanoreceptors that the grafts lack. On the mechanoreceptors can afferent signals to the spinal cord led and motor neurons via the γ-loop spindle unloaded. This control loop influences the sense of movement, force and position of the knee joint and is an important factor for its stability. The entire proprioception of the affected knee is significantly worsened by the loss of the sensory system. For this reason, no currently known surgical technique achieves the quality of the uninjured ligament after reconstruction of the cruciate ligament. There is a controversial debate about which technology or which transplant comes closest to the properties of an uninjured cruciate ligament.
In the case of the graft materials used to replace the torn anterior cruciate ligament, essentially the body's own (autologous) grafts have become popular since the 1980s. At the moment, the kneecap ligament , the quadriceps tendon and the semitendinosus tendon are mainly used. The choice of graft has been the most discussed topic in knee surgery for years in specialist circles.
Strips from the iliotibial tract or the fascia of the gastrocnemius muscle are rarely used . Due to the morbidity and invasiveness of the body's own tendon grafts, synthetic ligament replacement materials or cadaverous grafts could be an obvious alternative. The guidelines of the German Society for Trauma Surgery recommend free multi-strand tendon grafts from the pes anserinus group (semitendinosus tendons or semitendinosus and gracilis tendons ) as well as from the patellar tendon and its bone attachments.
According to a study in the United States in 2006, around 46% of all anterior cruciate ligament surgery was performed using BTB, 32% using a hamstring and 22% using allograft. In Europe, however, reconstructions were performed in 84–90% of operations with hamstring tendons and in only 10–14% of operations with the patellar tendon; the use of allografts or artificial ligaments plays no role with approx. 1.4%.
The kneecap tendon (technically: patella (r) tendon , ligamentum patellae ) is a very large and strong tendon, so in many cases it is the method of choice. However, it is only half as elastic as the natural one Cruciate ligament. In the reconstruction of the cruciate ligament by autologous transplantation of the patella tendon this is with attached bone parts ( engl. : Bone tendon bone = bone-tendon-bone ; BTB-technology) removed and pulled through widened channels (8-10 mm diameter) in the tibia or femur . The length of the upper and lower bone blocks are each about 20 mm. The most stable anchoring of the bone ends of autologous graft (ger .: graft = transplants without blood supply, which is why both here and in the further explained in the following section Semitendinosustechnik of autograft is spoken, with Greek αὐτός = itself ) is the fixation with the so-called interference screws achieved . This is particularly important with regard to an early functional mobilization.
The support after the operation with an orthopedic splint ( orthosis ) is often not necessary, so that the risk of muscle atrophy is lower than with other procedures. This advantage is particularly interesting for athletes who want an early return to old performance.
Since the kneecap tendon is only half as flexible as the actual cruciate ligament, it can take up to 18 months before you can participate in so-called "stop-and-go" sports again.
The half-tendon muscle ( semitendinosus muscle ) pulls from the knee joint to the thigh bone on the side facing the middle and is part of the so-called "goose foot" Pes anserinus superficialis , which is also formed from the tendons of the gracilis muscle and sartorius muscle .
The tendon (transplant) is removed through a middle cut on the shin, just below the knee, using a so-called tendon stripper or ring stripper (tendon cutter , also harvester from to harvest = 'to harvest'). Depending on the length, the tendon is folded three or four times with a certain thread technique, twisted, fixed and guided through a hole through the lower leg to the thigh and also fastened there. Since the beginning of the 21st century, a minimally invasive technique for easier and faster removal of the tendon from the hollow of the knee with better cosmetic results has been available.
The semitendinosus tendon is four times stronger than the kneecap tendon. This technique was equivalent to the patella tendon technique until around 2003. Since then, this technique has established itself as the so-called "gold standard", since the removal site in particular heals less painfully. If the semitendinosus tendon is too short or too thin, the gracilis tendon is also removed (STG technique; semitendinosus and gracilis tendons). However, this does not make the transplant more resilient. Some surgeons always remove both tendons. Both the semitendinosus and Gracillis tendons are required in particular for the plastic of the posterior cruciate ligament, which makes removal from the opposite side necessary, especially in the case of an additional external ligament instability that needs to be treated.
The most modern surgical technique is the double bundle technique . Two bundles (anteromedial and posterolateral) are inserted into the knee using four bone canals. Better mimicking of the anatomy gives more stable results. However, this procedure is technically demanding and is currently (2010) only carried out in specialized centers. The fixation of the two grafts takes place exclusively extra-articularly using endobuttons .
Following the principle mentioned above, a part of the tendon of the four-bellied thigh muscle including a kneecap bone cylinder is removed from above the kneecap and implanted as a cruciate ligament as shown above. As a so-called press-fit method, it is used without additional screwing. The advantage is that the tendons are stronger than the gracilis tendon. Compared to the patellar tendon, there is significantly less pain when kneeling, since the pressure does not put on the scar. The disadvantage is that muscle wasting of the quadriceps femoris muscle often occurs after the operation . The quadriceps tendon has so far only been used by relatively few surgeons to reconstruct the cruciate ligament.
A so-called allograft is a corpse transplant. In addition to the three previously mentioned tendons, prepared Achilles tendons and the tibialis anterior tendon can also be used for this. A positive effect of using an allograft is that there is no morbidity with regard to removal . Further advantages are the shorter operation time, smaller operation scars and reduction of postoperative pain. Originally, allografts were only used for revision surgery and for the reconstruction of the posterior cruciate ligament. In the meantime, allografts are also increasingly used for the primary reconstruction of the anterior cruciate ligament.
Untreated frozen grafts are used. The originally used methods of sterilization ( radiation or ethylene oxide ) damaged the biomechanical properties of the transplant or led to rejection reactions . With the untreated transplants, however, the HIV problem arises . The allografts transplanted in Germany come mainly from the clinic's own stocks or from Eurotransplant , as the trade and distribution of organ parts is prohibited by law in Germany. The brain-dead living donors are examined for the HI virus, among other things. The risk of infection of the recipient is thus limited to the period of the " diagnostic gap " and is classified as very low.
The frozen allografts do not trigger a rejection reaction. A number of studies confirm that the allografts have similar values to the autologous transplants, both in the short and long term. In terms of quality, allografts are in no way inferior to autologous transplants. Whether an autologous or an allogeneic transplant is used to reconstruct a cruciate ligament is ultimately a decision made by the doctor and the patient. A major problem is that there are far too few dispensers for allografts to even come close to meeting the demand.
Synthetic reconstruction materials
Synthetic cruciate ligament prostheses, i.e. implants made from carbon fibers , polyester , polypropylene , Gore-Tex or bovine collagen , for example , were used primarily in the 1980s. They are no longer used because of their inadequate biomechanical properties and an increased number of intra-articular complications. These complications were mostly joint effusions and reactive synovitis (inflammation of the inner layer of the joint capsule). The complications were mainly caused by abrasion particles that lead to foreign body reactions in the joint . The failure rate for these synthetic cruciate ligament prostheses was between 40 and 78 percent.
Attachment of the graft
In the early 1990s, the kneecap tendon transplants were fixed with so-called titanium interference screws as fixation at both ends of the transplant, sometimes only screwed on one side, and attached to the thighbone with a so-called endobutton that is “threaded” through the transplant. The Endobutton consists of a loop made of a non-resorbable thread material with a titanium tilt button (four-hole plate), which is tilted after being passed through the bone canal. Later, the titanium screws were replaced by the so-called bio- screws ("bio-screws", which are auto-resorbable interference screws) that are used today , which make a renewed intervention to remove material unnecessary. These screws are made of degradable polymers, such as poly- L -lactide (PLLA) or poly- ( L -co- D / L -lactide) (PLDLLA). A hybrid technique of bio-screw (as intra-articular fixation) and femoral / tibial endobuttons (as extra-articular fixation) can also be used. With the so-called " Press-Fit-Technique-Fixation ", which appeared around 1995, the screw fixation with the BTB technique (bone-tendon-bone technique) can be completely dispensed with. Here, the bone ends are trimmed conically so that a firm tilting in the drill channels is guaranteed. From 1996 surgical robots appeared that automatically generated the drilling channel with a diamond milling head. They could not assert themselves because they did not produce any clearly better operational results and caused high costs (intensive in terms of personnel and equipment).
In the case of semitendinosus and gracilis transplants (STG), bio- screws are usually used for fastening. Implant-free fixation has also been possible here since the late 1990s. With this technique, the end of the semitendinosus and gracilis tendon graft is tied and the femoral canal is drilled about 4 mm narrower in the direction of the joint than at the point remote from the joint. The graft is inserted into the joint through the femoral hole. The knot of the transplant sits in front of the narrower part of the canal. Measurements have shown that joint stiffness and maximum load are similar to other techniques. By knotting the tendon ends, interference screws (implants) are unnecessary. The protagonists of implant-free fixation see this as a cost advantage. Since no implants are used, no problems can arise with these materials. The disadvantage, however, is the considerably larger canal in the thigh bone.
Graft harvest morbidity and invasiveness
The quality and technology of the reconstructed cruciate ligaments has been steadily improved since the first cruciate ligament surgery in 1917 and today has very high success rates. The high success rates of around 90% change the patient's expectations. A secondary aspect of autologous transplants is therefore becoming increasingly important: the morbidity and invasiveness of the transplant removal. It now has a significant influence on patient satisfaction, which is primarily determined by pain and mobility.
The removal of the patellar tendon is often more painful than that of the other autologous tendons. Up to 60% of patients complain of pain when kneeling. Patellar tendon transplants are therefore usually not recommended for patients with frequent kneeling activities. The pain in the knee causing the patellar tendinitis , patellar tendinitis , patellofemoral crepitus and infrapatelläre contractures. The frequency of these symptoms varies and ranges from 4 to 40% of patients depending on the study. A major cause of the complications are apparently injuries to the Hoffa fat pad , which can lead to a scarred contracture (shortening of the patellar tendon) and fibrosis . This in turn leads to limited mobility of the patellar tendon and its sticking to the leading edge of the shin bone. A number of studies have shown that the patellar tendon shortens after the transplant has been removed. The shortening can be in the range between 2 and 7 mm. Too much shortening of the patellar tendon can lead to patellofemoral osteoarthritis. Fissures of the kneecap have been observed in individual cases , which can lead to a fracture of the bone under high stress . The risk of a patellar fracture is in the range of 0.1 to 3%. It can be further minimized by carefully removing the graft. If, for example, a hollow milling cutter is used to remove the patellar bone block, the risk of the formation of predetermined breaking points is also avoided. Removal of the patellar tendon increases the likelihood of a patellar tendon rupture.
Removing a semitendinosus tendon (hamstring) to reconstruct the anterior cruciate ligament can also lead to complications. For example, the flexion strength of the hamstring muscles is reduced in the first few months after the tendon is removed. Some patients also complain about the occurrence of patellofemoral pain with this transplant method . The causes of the pain are obviously a disturbed patellofemoral movement in the affected knee, as well as the shortening of the quadriceps muscles due to the removal of the hamstring. Pain caused by harvesting the semitendinosus tendon is rather rare and then only of short duration. The simultaneous removal of the semitendinosus and gracilis tendons can disrupt the internal rotation of the knee joint in the long term. According to individual examiners, the hamstring tendons can largely regenerate completely after the transplant has been removed. However, they usually change their position and are then a little closer to the body (proximal).
The proportion of operations in which the quadriceps tendon is used to reconstruct the cruciate ligament is still quite low. The data on the morbidity of harvesting this tendon are correspondingly poor. In the existing studies, the results are sometimes very contradicting. Some authors report a significantly lower removal morbidity compared to the removal of the patellar tendon , while others write of a functional impairment and significant pain.
Typical sequence of an anterior cruciate ligament reconstruction
This example describes the process of reconstructing the anterior cruciate ligament by transplanting an autologous semitendinosus and gracilis tendon. In the 1980s, the classic open cruciate ligament operation via the Payr access was initially replaced by the mini-arthrotomy . Almost all cruciate ligament reconstructions are now carried out using minimally invasive arthroscopy. Open surgery is only performed in exceptional cases, for example in the case of very complex knee injuries.
The procedure can be performed under general anesthesia ( general anesthesia ) or under regional anesthesia . Both procedures have advantages and disadvantages for the patient. Spinal anesthesia , epidural anesthesia (PDA, spinal cord anesthesia ) and combined spinal and epidural anesthesia (CSE) are possible regional procedures . Another form of regional anesthesia that is often used in addition to the aforementioned forms of anesthesia is the femoral catheter. In this way, the pain in the affected knee after the operation (postoperatively) can be suppressed ( femoral nerve block ). For this purpose, a local anesthetic is brought into the vicinity of the pain-conducting nerve, the femoral nerve, with the help of a catheter . A complete blockage of the knee is not possible with this alone. The fibers of the femoral nerve run from the lumbar spine to the knee joint. A tube as thin as a hair transports the pain medication in the groin area to the femoral nerve via a small dosing unit . Blocking the femoral nerve not only numbs the pain, but also limits the feeling, strength and mobility of the leg. The catheter is removed three to five days after the operation. The combination of femoral catheter and thigh tourniquet during cruciate ligament reconstruction has described disorders of the thigh muscle function.
The actual procedure begins with the introduction of the arthroscope into the patient's knee. The diagnosis of a "cruciate ligament tear" can thus be confirmed again. Other injuries, particularly the meniscus, can be treated prior to the reconstruction of the cruciate ligament.
Removal and preparation of the tendon
The first surgical procedure is to remove the transplant tendon . An approximately 4 cm long skin incision on the inner tibial head, above the pes anserinus , enables the removal of the body's own (autologous) semitendinosus or gracilis tendon or both tendons. The tendons are removed with a so-called "tendon stripper" and are about 28 cm long. The tendons are pre-tensioned on a special device and sewn together as a multiple strand, for example a “quadruple”, four times. The length of the graft is then about 7 cm and has a diameter of at least 7 mm. The transplant is fixed to the fixation devices provided (e.g. Endobutton) using a special thread. The special thread is not bioabsorbable.
Removal of the cruciate ligament
remnants and drilling of the bone canals Arthroscopically, the remnants of the torn anterior cruciate ligament are removed. A motor-driven suction cutting tool ( shaver ) and / or a high-frequency (HF) ablation device is used for this purpose. It is advisable to leave a remnant of the stump on the tibial head in order to preserve some proprioception and to minimize the penetration of synovial fluid into the tibial canal. With the help of a targeting device, the position for drilling a canal through the head of the tibia is sighted and then drilled. The diameter of the drill channel is adapted to the diameter of the graft. A targeting device for the drilling is attached to the femur through the canal of the tibia, or more precisely today through an additional anteromedial arthroscopic access. With the help of this aiming device, a canal is drilled into the femur. This channel can taper upwards (blind hole) and has a length of about 35 mm. The wider part of the channel is for receiving the graft, the narrower part for pulling through the graft suspension.
Pulling in the graft
The graft is pulled into the drill channels from bottom to top using two pull cords. The transplant is attached to the femur with the help of a hollow screw (transfix screw). The end protruding from the end of the tibial canal is pretensioned and fixed with an interference screw (delta screw) by clamping. Finally the wounds are sutured. The duration of the operation is typically in the range of 45 to 90 minutes.
After the operation,
positioning in the extended position immediately after the operation is decisive for the definitive function. This should be observed for 24 hours. This positioning prevents a postoperative stretching deficit, which otherwise often develops and which can require weeks of physiotherapy to eliminate it. The day after surgery, drains are usually removed from the knee wounds. The operated leg may only be partially loaded up to the fifth week after the operation, as the transplant must grow into the bones in the drill channels. A knee brace is used to protect the sensitive graft during this period . Rehabilitation can usually begin after the fifth week.
Possible complications after reconstruction of the anterior cruciate ligament
As with any surgical intervention, reconstruction of the cruciate ligaments with the two transplants commonly used today (patellar tendon and hamstring) can lead to complications. In addition to the general risks associated with operations, such as bleeding , wound infections , impaired wound healing , thromboses , injuries to blood vessels or nerves, there are specific complications. Depending on the author, different complication rates of up to 26 percent are given. The most common complications are the failure of the transplant, for example due to tearing, re-rupture or loosening, and above all restricted movement of the knee joint.
The previously shown morbidity of the transplant removal can also be added to the complications.
- Loss of movement
Loss of movement is a serious complication after anterior cruciate ligament reconstruction. By definition, it is present when the leg does not fall below an angle of 10 ° when the leg is extended and an angle of 125 ° cannot be exceeded when the leg is bent. The loss of the ability to stretch the joint is more common than that of the ability to bend and is also more serious for the patient. The cause of loss of movement is usually an inflammation-related increase in connective tissue - a fibrosis , more precisely arthrofibrosis .
The incidence of graft failure is around 4.3%. The causes of failure of a transplant can be divided into three groups:
- surgical errors,
- biological failure, due to insufficient healing of the transplant and
- Renewed cruciate ligament rupture.
In one study, 52 percent of transplant failures were iatrogenic , or surgical errors caused by the doctor. In 25 percent of the cases the cruciate ligament ruptured again, in 8 percent inadequate incorporation of the transplant, in 3 percent restricted mobility and in 3 percent the synthetic implants used also failed. In 9 percent of the cases of transplant failure, the cause could not be precisely assigned. In general, the surgeon's surgical ability is of great importance for the success of a reconstruction of the anterior cruciate ligament. Typical surgical errors are, for example, incorrect placement of the drill channel, inadequate fixation of the transplant, insufficient tension on the transplant and insufficient notch plastic with subsequent impingement .
The renewed rupture of the cruciate ligament can be caused, among other things, by overly aggressive rehabilitation, a lack of patient compliance or too early resumption of sporting activity with excessive stress on the implant.
- Septic arthrithis
A septic arthritis (bacterial arthritis) is a relatively rare, but very serious complication of a cruciate ligament reconstruction. The incidence rates are in the 0.3 to 1.7 percent range. Septic arthritis is associated with high morbidity, mostly lengthy hospital stays and often with poor clinical results.
In a study in the United States, the rate of serious infections after cruciate ligament reconstruction was 0.75 percent. The rate for autografts was 1.2 percent and for allografts 0.6 percent. The administration of antibiotics is mandatory after postoperative infections.
In Germany, patients are prescribed prophylactic antibiotics in 62 percent of all arthroscopies in order to avoid infections such as septic arthritis.
Postoperative thrombosis has an incidence of 1.2 percent. Malignant neoplasms (malignant tumors) that develop after cruciate ligament surgery are extremely rare . So far (as of June 2010) only three cases have been described in the literature.
Cruciate ligament suture
- → see also the section on medical history
Until the 1980s, the primary suture method was preferred, for example for intraligamentous tears. In the case of the primary suture, the severed ends of the cruciate ligament were sewn back together for repair . This therapeutic approach was first carried out in 1895. The study results at that time on the primary suturing of cruciate ligament tears were not satisfactory. The failure rates in the first five years after the operation were over 20 percent, depending on the study. In the following years, the primary suturing of the cruciate ligament without augmentation was more and more abandoned as a therapy in favor of the reconstruction of the anterior cruciate ligament. Other subsequent long-term studies have shown a deterioration in the results over longer periods of time, which is why the sole primary suture in the surgical technique used at that time is no longer a therapeutic option today. The cause of the poor results was insufficient biomechanical stability of the knee joint during the healing process. As a result, in many cases no functionally adequate scar tissue could develop to ensure the required knee stability.
A further variant of the cruciate ligament suture was the reinforcement of the healing cruciate ligament through so-called augmentation. Various synthetic tape materials or the body's own tissue were used for the augmentation. The reinforcement can take place intra-articularly (inside the joint) or also extra-articularly (outside the joint). These procedures at the time are also generally viewed as outdated.
Special case of a bony avulsion
The bony tear or avulsion of the anterior cruciate ligament from the bone (tibia or femur) is much rarer than its intraligamentary rupture and is by definition not a cruciate ligament tear. This special case occurs more often in children, especially in the area of the cruciate ligament attachment on the shin eminentia intercondylica and has a generally good chance of completely healing again by re-fixing the tear - for example with screws or wire sutures. During the arthroscopic refixation of the cartilage-bone scales that support the cruciate ligament, a good overview is of decisive importance in order to avoid the trapping of the transverse ligament (between the menisci ) under the fragment. Otherwise the mini-open technology is preferable. In general, care should be taken not to block the growth plate with the implants ( screws or wire sutures) .
Cruciate ligament-preserving operations
- → see also article cruciate ligament retention
Surgical methods that preserve the cruciate ligament are still young procedures that do not require a replacing tendon graft . They can only be used within the first three weeks after a cruciate ligament tear. This time limit is due to the fact that the existing healing capacity of a cruciate ligament is to be used, which wears off fairly quickly. The desired natural scarring process of the cruciate ligament is achieved through biomechanical stabilization of the knee joint, an anatomical reduction of the injured ligament structure and a microfracture ( healing response ).
Two methods are currently used: a first treatment approach is dynamic (spring mechanism) based, the second is based on rigid, inflexible stabilization of the knee joint. In the dynamic method , the cruciate ligament is repositioned with bioresorbable sutures and the knee is stabilized with a thin, very tear-resistant implant thread. The flexible dynamics of the spring element in the shin ensure that the healing ligament is relieved during all flexion and extension movements. In the inelastic method, a rigidly fixed polyethylene tape is used to stabilize the knee, as well as non-resorbable sutures and small anchors to return the torn cruciate ligament to the original tear point until it has grown back on.
Data published so far show that good results can be achieved with a very selected indication.
In contrast to the inner and outer ligaments, the two cruciate ligaments are not able to grow together again on their own after a tear by immobilization. In the case of an inner ligament tear, for example, a support device (splint) is sufficient, which must be worn for about six weeks so that the two ends can heal and the tear heals. This is not the case with the two cruciate ligaments located inside the knee. The reason for this is not exactly known. Several factors are discussed. The synovial fluid that surrounds the cruciate ligaments may be a medium that prevents such a healing process. Changes in cell metabolism after the injury and intrinsic deficits, such as the gene expression of the cells that form the cruciate ligaments, are also held responsible for this effect.
In research, therapy concepts are aimed at activating the same abilities in the cells of the torn cruciate ligaments as, for example, in the cells of the outer and inner ligament. In principle, the cells of the cruciate ligament, such as the cells of the inner ligament, are able to proliferate and revascularize after a rupture . This was demonstrated histologically and immunohistochemically . Even one year after the rupture, the cells are still able to produce collagen within the ligament fragments. The ability to migrate cells into the wound area has also been demonstrated. Nevertheless, no support structure (scaffold) is formed in the knee for the tissue structure that connects the torn collagen fiber bundles of the cruciate ligament with one another. The ends of the torn cruciate ligament swayed aimlessly back and forth in the synovial fluid. One hypothesis assumes that the lack of extracellular matrix proteins and cytokines in the area of the wound, which are essential for building up the support structure, prevents self-healing. An indication of this is that considerable amounts of fibrinogen , fibronectin , platelet-derived growth factor A (PDGF-A), TGF-β1 , fibroblast growth factor (FGF) and von Willebrand factor (vWF) are detectable during the healing process of the inner ligament that are missing in cruciate ligament ruptures. Despite the bleeding in a cruciate ligament tear, no fibrin platelets are detectable near the injury. One possible cause is the presence of higher concentrations of the enzyme plasmin . Plasmin is able to catalyze the breakdown of fibrin ( fibrinolysis ) . It arises from the increased expression of the enzyme urokinase , which in turn catalyzes the conversion of plasminogen into plasmin.
The biological stimulation of the construction of a support structure, which enables the healing process of the torn cruciate ligament in the knee, is a potential future therapy concept. The administration of growth factors such as PDGF, TGF-β and FGF could upregulate the proliferation and migration as well as the production of collagen in vitro . In the model organism rabbits , injections of hyaluronic acid resulted in increased vascularization and increased production of type III collagen. In the domestic pig animal model , the injection of a collagen-rich hydrogel results in an improved healing process in a sutured cruciate ligament, with significantly increased ligament strength.
All related concepts of tissue engineering are still in the early stages. Initial and short-term results show that improved ligament healing can be achieved with biologically stimulating factors.
The American surgeon Richard Steadman developed the healing response technique in the early 1990s. This therapy method is only possible with fresh anterior cruciate ligament tears, with a tear in the thigh bone or with a tear in the synovial covering . In 80% of all ruptures of the anterior cruciate ligament, the tear occurs on the femur. The process is controversial as the results published so far are inconsistent. A comparative study showed that the results did not differ significantly from those of conservative therapy, while other studies documented the advantages of this treatment method.
The healing-response technique is based on the assumption that undifferentiated stem cells can differentiate into tendinocytes (wing cells) when subjected to mechanical stress - according to Wolff's law . Any accompanying injuries are first treated using arthroscopy. Then the bone marrow in the area of the cruciate ligament is opened with an awl in up to ten places (microfracture) so that stem cells can emerge from the marrow. It is important that there is sufficient blood leakage from the bone marrow. Then the cruciate ligament is repositioned at its attachment point in the coagulum and the knee joint is stretched. Treatment is inpatient, typically for two days. Without drainage, the knee joint is fixed with a splint for around four to six weeks in a 10 ° flexion. This is followed by intensive training. After an average of three months, the patient treated in this way is able to practice competitive sports again. The procedure must be performed within a few days of the injury. The success rate is over 80%. Failures can be treated with cruciate ligament surgery. The procedure may also be useful for treating tears of the posterior cruciate ligament.
Surgical treatment of the posterior cruciate ligament tear
The operation of the posterior cruciate ligament is considerably more difficult than that of the anterior and is rather the exception. The tendency towards healing is also quite high with conservative therapy. Surgical intervention is usually only indicated for complex knee ligament injuries . There are currently three competing surgical procedures established for posterior cruciate ligament rupture. These are:
- The anatomical reconstruction of the anterolateral main bundle in the single incision technique using hamstring tendons such as the semitendinosus muscle
- The anatomical reconstruction of both bundles
- The tibial inlay technique
Physiotherapy for rehabilitation after cruciate ligament surgery
The aim of therapy should not be the sole restoration of stability, but rather the maintenance of the entire joint function. That means stability, including the feeling of a stable knee joint, free joint movement and freedom from symptoms.
After the operation, functional exercises are carried out at an early stage (sometimes passively using a motorized movement splint) and the patient's mobility is established with forearm crutches and, under certain circumstances, with a knee orthosis. This is followed by physiotherapeutic treatment, which, depending on the type of operation and the school, should lead to full stress on the operated knee after about two weeks. It is recommended to do tension exercises. This is supposed to activate the muscle groups. From about the third week you can start cycling lightly. After about six weeks, exercises on the sports top or mini trampoline can be performed under supervision. Sports ability for light running training exists from around the third month after the operation. After about six months, loads such as jumping can be added. Overall, the rehabilitation phase lasts an average of six to nine months before full sports ability is achieved. Complete healing (remodeling phase) of the anterior cruciate ligament is only complete after one year.
The follow-up treatment after the operation essentially differs only marginally. There are fixed standards in physiotherapeutic treatment that differ only insignificantly. Clear follow-up treatment schemes should also be reflected in the treatment here, depending on the surgical method. The experience and work of the physiotherapist is therefore of decisive importance for the healing process.
Functional instability can remain in the affected knee joint even after optimal therapy. This instability can lead to incorrect loading of the joint body and thus cause consequential damage. Typical consequential damages are secondary cartilage damage, degeneration of the posterior horn of the medial meniscus and a significantly increased risk of knee osteoarthritis (gonarthrosis).
Several studies show that if the anterior cruciate ligament tears, the likelihood of developing knee osteoarthritis is significantly increased. About 50 to 70% of patients with a cruciate ligament tear show radiographic changes in the knee after 15 to 20 years . If the cruciate ligament tear is accompanied by injuries in the knee - such as a meniscus tear, for example - the likelihood of gonarthrosis increases further. During this period the osteoarthritis of the knee has reached Ahlbäck grade I to II and is usually without clinical symptoms. The progression is usually relatively slow. Older studies assume that in most cases gonarthrosis will probably only become clinically relevant 30 or more years after the rupture of the anterior cruciate ligament. Other studies report that as early as 10 to 20 years after the cruciate ligament rupture, functional limitations of the knee joint, combined with pain, caused by arthritic processes in the knee. The prognosis is generally very dependent on age, gender, genetics , body weight, muscle strength, physical activity and possible renewed knee injuries. American athletes have tears of the anterior cruciate ligament five times as often as athletes, although American athletes include American football, a sport that is not entirely harmless for the knees. Ford KR, Myer GD & Hewett TE (2003) therefore examined the landing behavior of volleyball players after jumping on both legs. They found that the differences in strength between strong and weak legs were significantly greater for women than for men, that valgus positions are significantly more common in women’s knee joints , and that there is a connection between valgus positions and the difference in strength of the legs. Since surgically treated cruciate ligament ruptures lead to a considerable risk of re-injury if the sport is continued, the Americans MV Paterno, LC Schmitt, KR Ford u. a. (2010) 56 athletes (35 women, 21 men) from sports with sudden changes of direction (including soccer and American football ) who had successfully operated on the anterior cruciate ligament were systematically tracked for a year to determine whether there are any peculiarities which can be used to predict a new cruciate ligament tear. During this period, 13 suffered new cruciate ligament injuries. For this purpose, a 3-dimensional movement analysis was carried out on all 56 of the deep jumps and the stability of the posture was measured with 4 video cameras and a Kissler force plate. The kinematics, kinetics and postural stability were determined to find out whether matching movement / posture anomalies were found to be statistically significant in the re-injured. With this method the probability of re-injury could be predicted very well. The specific parameters included an increase in the movement of the valgus, greater asymmetry in the movement of the internal knee extensors at the beginning of contact with the ground, and a deficit in postural stability when standing on one leg on the affected leg. Independent of these measurements, a contralateral hip rotation during the first 10% of the landing phase also allowed a (albeit less) good prediction of the re-injury of the anterior cruciate ligament. The Catalans Ferrer-Roca V., Balius Matas X., Domínguez-Castrillo O., u. a. (2014) examined 35 football players (professionals and semi-professionals) from Barcelona in the 1st Spanish League on 2 days at the beginning of the preparation time after the summer break with video analysis and 2 force plates in their movements with regard to possible intrinsic risk factors. The authors used the tests by Paterno et al. a. (2010), since they assumed that the athletes for whom the Americans predicted a risk of re- injury could also have a risk of first-time injury. They identified the same problems and tried to establish guidelines as to when countermeasures should be taken in training: 14.3% of the players had a valgus deviation of ≥ 20 degrees in the knee when landing in the low jump. In the literature, even ≥ 16 degrees is considered problematic. 31.4% of the players had functional (strength) deviations in the legs of more than 15%. Since this 15% is the maximum when a player can be reintegrated into team training after injuries, this is also a useful guide value, especially since there was no statistical correlation between the shooting leg and the stronger leg. Countermeasures were taken for the players who showed both discrepancies.
In the case of cruciate ligament ruptures that are not treated surgically, the risk of knee osteoarthritis after 20 years is 60 to 100% over several studies. In comparison, patients with an anterior cruciate ligament reconstruction have a 14 to 16 percent risk and with an additional meniscectomy a 37% risk of gonarthrosis.
According to the VBG accident insurance , the average downtime in the top German leagues of basketball, ice hockey, football and handball in Germany was around eight and a half months. Tears in the anterior cruciate ligament accounted for 0.5 percent of all injuries, but account for up to 20 percent of downtime.
Depending on the sport, around 60 to 80 percent of athletes return to their previous level after a cruciate ligament rupture.
A cruciate ligament tear has significant consequences for the person concerned. This type of injury is therefore one of the most feared by athletes. For professional and competitive athletes, a cruciate ligament rupture means a lengthy break from training and competitions - despite continuously improving treatment options. Until the 1990s, a cruciate ligament tore usually led to the end of a career. For professional athletes, as well as their clubs and sponsors, the result is still considerable loss of income. As a rule, after the ligaments have been restored and competitions restarted, it takes a further months for the athlete to regain their original level of performance. In the amateur and hobby area of sport, society incurs considerable costs due to lost work times, treatment and rehabilitation measures, to which the long-term costs due to premature knee osteoarthritis are added. In sport, with appropriate physiotherapy, regeneration times of nine months are expected on average.
The prevention , ie the prevention of a cruciate ligament injury, therefore plays an increasingly important role. Basically, it seems possible that certain training methods can reduce the likelihood of a cruciate ligament tear. Since a number of pathomechanisms that promote a cruciate ligament rupture have not been adequately understood for a long time, it is still largely unclear which exercises have a preventive character or even why they reduce the risk of injury. In the meantime, large research efforts are therefore being undertaken in many countries, on the one hand to elucidate the risk factors and pathomechanisms of a cruciate ligament tear and, on the other hand, to be able to counter this type of injury with appropriate measures derived from them. The most successful so far have been Paterno MV, Schmitt LC, Ford KR u. a. (2010), who were able to predict the probability of cruciate ligament tears with a 94% probability from the movement behavior during deep jumps. They showed that large differences between the strength of the two legs and a valgus position in the knee joint on landing were the greatest risk factors, but that instability of the back can also contribute to the danger. Since a valgus deviation of more than 16% and strength differences of more than 15% are viewed as problematic (and in this case rehab is not yet completed), appropriate leg strength training seems appropriate in addition to CORE training for the back.
So far, there are no standardized exercises to prevent cruciate ligament tears without external interference. Some studies have shown that more varied exercise programs have a greater positive effect than individual exercises. Plyometric exercises for the lower limbs, stretching exercises (stretching) , for targeted control of the hull, for gestärken perception of body movement (proprioception) and improved decision making, positive effects in the prevention seem to have. This reduces the forces when the athlete lands after a jump as well as the moments that act in varus / valgus. In addition, muscles are activated that can partially absorb moments of force that act on the knee.
In a study of more than 1,400 football players, a positive effect was due to a special warm-up (warm-up) can be achieved. Compared to the control group, the number of anterior cruciate ligament tears decreased overall by a factor of 1.7. If one only looks at the cruciate ligament tears without external influence, the frequency in the group with the special warm-up program was even lower by a factor of 3.3. The focus of the warm-up exercise is on neuromuscular control of the knee joint. In other studies, electromyography has shown that neuromuscular exercises have positive effects on the semitendinosus muscle before an athlete takes off and lands.
A study from Italy came to similarly positive results. In the mid-1990s, a total of 600 football players from 40 semi-professional and amateur teams took part. Half of the teams trained for an additional 20 minutes each day using a special sensorimotor training program that contained proprioceptive elements. The exercises were carried out , for example, with a balance board . The incidence of anterior cruciate ligament injuries was observed over three game seasons. In the participants in the special training program, the incidence of cruciate ligament injury was significantly lower than in the control group. Some authors see this study as proof of a prophylactic effect of coordinative training. Common proprioreceptive training aids are, for example, "wobble boards" and "sports tops". These give the exerciser an unstable surface, which means that he is constantly forced to keep his body in balance.
Another evidence-based study from Norway with more than 1,800 handball players aged 15 to 17 also shows that a structured warm-up program with neuromuscular exercise elements can reduce the incidence of cruciate ligament ruptures by over 50%. Among other things, balance mats were used here . A study published in 2005 by the University of Münster with over 250 German handball players also came to the conclusion that proprioceptive and neuromuscular exercises can significantly reduce the frequency of cruciate ligament ruptures.
A number of sports scientists advocate that such preventive exercise elements become an integral part of training sessions in sports with an increased incidence of cruciate ligament ruptures.
Other preventive measures
A rule change at the beginning of the 2005 season in the Australian Football League meant that the frequency of a posterior cruciate ligament tear could be reduced by more than a factor of two. The rule change was to limit the approach of the Ruckman to the nudge square.
Of the domestic animals in particular is home dog frequently affected by ruptures of the anterior cruciate ligament. However, other, non-traumatic, pathological mechanisms play a major role here. Cruciate ligament ruptures are less common in domestic cats .
Hippocrates of Kos described a subluxation of the knee, which he attributed to a ligament injury in the knee. Galenos described in detail the importance of the ligaments for stabilizing the knee and for normal movement when walking. Previously, it was thought that the cruciate ligaments are "nerve structures". The name genu cruciata , which is still valid today and used to describe the structures that stabilize the knee , also goes back to Galenos .
Although the knee dislocations and their treatment were described in detail well into the 19th century, the function of the ligaments in the knee was completely underestimated internally in the collective term dérangement . The Wittenberg brothers Wilhelm Eduard and Eduard Friedrich Weber described in detail in their work Mechanics of Human Walking Tools in 1835 the biomechanical relationships between the components within the knee and its periphery. In their research, they looked at the abnormal movement of the tibia in a knee without cruciate ligaments. They were the first to describe the abnormal walking sequence caused by a cruciate ligament tear.
In 1845, the French Amédée Bonnet described in his 1,300-page monograph Traité des maladies des articulations (German title from 1851: For the treatment of joint diseases ) the studies he carried out on cadavers. He found, among other things, that in most cases the anterior cruciate ligament tears at its femoral (on the thigh) insertion and the rupture is accompanied by a cracking noise. Valgus flexion stress would also tear the medial collateral ligament at its femoral attachment. Bonnet also recognized that bloody joint effusion (hemarthrosis) and pain are important symptoms of the anterior cruciate ligament tear. He saw the cause of the pain in the stretching of the ligament nerves. Regarding the incidence, he wrote that "ruptures of the ligaments are much more common than is generally assumed." Bonnet was also the first to mention the phenomenon of subluxation ("... des déplacements qui font croire à une luxation incomplète"), which was only taken up again at the beginning of the 1970s by RD Galway and DL MacIntosh as a pivot shift . In his book Traité de thérapeutique des maladies articulaires , published in 1853, Bonnet wrote that immobilizing the affected knee for too long had a negative effect on the healing process. He developed the first devices for active movement against the cartilage-damaging effects of immobilization . In his remarks on the treatment of acute injuries, he was way ahead of the times. For example, Bonnet suggested cold packs for initial treatment of the injury and early, gentle exercise. In the same book, Bonnet describes a two- hinge orthosis for patients with an anterior cruciate ligament tear.
The injury of the anterior cruciate ligament was treated for the first time in 1850 by the British J. Stark in a conservative way using a plaster cast.
The bony avulsion of the anterior cruciate ligament, in which the ligamentous structures are intact, was described by French surgeon Poncet in 1875. Poncet autopsied the body of someone who had been killed in a lintel from the third floor.
The Englishman Arthur Mayo Robson (1853–1933) performed a cruciate ligament suture for the first time in 1895 on a 41-year-old miner from Featherstone - Mayo Robson called him "JB" in his publication eight years later. The patient had injured his knee in an accident in a coal mine 36 weeks earlier. On November 21, 1895, Mayo Robson opened JB's knee. He found that both ligaments had completely torn off and fixed them with catgut . He sutured the anterior cruciate ligament to the synovium and tissue on the inner side of the outer condyle . He found the posterior cruciate ligament to be too short, so he split it up to get a sufficient length. Then he attached it to the synovial membrane and the cartilage tissue on the outer side of the inner condyle. He then closed the wound with catgut and the surface with silk gut. Almost six years later, on October 24th, 1901, a colleague of Mayo Robson visited the patient, who described his operated leg as perfectly strong and was able to fully practice his old job again. He only felt pain when he put too much strain on his knee while working. The circumference of both knees was identical. Other publications also recommended primary cruciate ligament sutures in the event of an acute rupture. The Berlin doctor H. Goetjes published the first collective statistics on 30 cases with primary cruciate ligament sutures in 1913, which came to a positive result. The first criticism of sewing the tapes came in 1916 from Robert Jones , a British military orthopedist. Jones thought the stitching of the ligaments was useless and saw the natural scarring as the only reliable repair. Regardless of this criticism, the primary cruciate ligament suture should last for another 60 years, as it has been confirmed and recommended by numerous authors.
In 1976, John A. Feagin and Walton W. Curl published the results of a five-year long-term study they conducted on soldiers at West Point Military Academy . Sixty-four cadets had an anterior cruciate ligament suture during college. The long-term results were extremely negative, so that in the following period the primary suturing of the cruciate ligament without augmentation as a therapy was more and more abandoned in favor of the reconstruction of the anterior cruciate ligament. Later studies confirmed the results of this study.
The Australian surgeon James Hogarth Pringle first described a reduction on a living person at the Glasgow Royal Infirmary in 1907 , which he had carried out in 1903: “The joint was then opened into, the blood and fluid in it washed out, and it was at once seen that the anterior crucial ligament still attached to its bone insertion had been torn off the tibia and taken the spine with it; with a little trouble this was sutured, and the wound closed. "
Also in 1903, Fritz Lange from Munich used silk threads to reinforce or replace the anterior cruciate ligament. The Swiss Eugen Bircher performed the first arthroscopy in the Aarau Cantonal Hospital in 1921 .
The first reconstruction of an anterior cruciate ligament in humans was probably carried out in 1914 by the Russian surgeon Grekow. According to Erich Hesse's description , Grekow used free strips of fascia lata , a connective tissue covering the thigh. Three years later, the British surgeon Ernest William Hey Groves (1872–1944) used a stalked strip of the iliotibial tract for cruciate ligament reconstruction. He led the strip through two drill channels that extended from the epicondyle to the intercondylic fossa and from the shin to the intercondylic eminence . In doing so, he laid the foundation for modern ligament surgery.
The first replacement of a cruciate ligament with a patellar tendon transplant took place in 1935 by the German A. Wittek, after the marine surgeon zur Verth had proposed this at the congress of the German Orthopedic Society in Mannheim three years earlier .
In 1926 Edwards described that reconstruction with the tendons of the semitendinosus and gracilis muscles was possible. In 1950, Lindemann carried out a cruciate ligament reconstruction with these tendons for the first time.
In 1963, Kenneth Jones was the first to use a distal pedicled graft of the middle third of the patellar tendon. He prepared this along with the bone block along its entire length from the patella. He pulled the graft distally without a drill channel under the Hoffa fat pad. On the proximal side, he pulled it through a drill channel in the area of the cruciate ligament cavity. The first description of a BTB transplant probably comes from the German doctor Helmut Brückner in 1966. The work of Jones and Brückner forms the basis of today's cruciate ligament surgery. In the German-speaking world, one often speaks of a Brückner or Brückner-Jones sculpture.
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