Cruciate ligament rupture Vienna
Treatment & cruciate ligament surgery
Acute care & follow-up treatment
Anterior cruciate ligament rupture (= cruciate ligament rupture) is one of the most common sports injuries. Around 80% of the normal population can return to sport after a cruciate ligament injury, but only around 55% of athletes return to their previous sporting level. Constant ligament instability, particularly during sporting activity, leads to premature wear of the cartilage and meniscus and thus to joint degeneration over time. joint wear and tear . Cruciate ligament surgery is usually the only way for many athletes to be able to fully pursue their passion again. Find out more below!
OVERVIEW
Does a torn cruciate ligament require surgery?
Are you young and athletic, have high sporting ambitions and are not prepared to cut back on your sporting activities? Then you will clearly benefit from cruciate ligament surgery.
In sports with a lot of rotational movements, such as soccer, skiing or martial arts, a stable knee is essential in order to avoid consequential damage to the meniscus and cartilage. Studies show that without a functioning cruciate ligament, damage can occur at an early stage even in the absence of subjective instability. In such cases, surgery is the safest way to prevent long-term destruction of the joint.
The decision as to whether the cruciate ligament needs to be sutured (refixed) or reconstructed (tendon replacement surgery) depends on several factors – in particular the type of tear, the age of the patient and their sporting goals.
If you have a sedentary job and are less active in sports, surgery can be avoided under certain circumstances. In such cases, targeted physiotherapy and muscle building can provide very good results. However, if the feeling of instability or “giving-way attacks” occur, where the knee suddenly buckles, surgery must be considered again to avoid long-term damage.
Your cruciate ligament specialist
Find out more about cruciate ligament surgery & treatment for a torn cruciate ligament in this video!
What is a cruciate ligament?
The cruciate ligament is a complex interplay of bones, ligament complexes, muscle attachments and tendons. The knee joint can thus be stabilized even under maximum load, e.g. during sport. A simplified distinction is made between 4 main ligaments which protect the knee against rotation and axial tilt.
The most important ligaments in the knee are the anterior and posterior cruciate ligaments, which cross inside the joint and are responsible for stabilizing and controlling forward and backward movements.
The anterior cruciate ligament runs diagonally through the knee joint, originates from the inside of the lateral (= outer) femoral condyle and attaches centrally to the tibial plateau (eminentia intercondylaris). It consists of 2 main bundles: the anterolateral and the postermedial bundle. Depending on the degree of flexion of the knee joint, the bundles are tensioned to different degrees.
The cruciate ligament lies in the middle of the knee joint and is surrounded by synovial fluid (= joint fluid). For this reason, no blood clot can form, which would be so important for healing.Spontaneous healing of the ligament is therefore almost impossible.
Cause of a torn cruciate ligament in the knee
A torn cruciate ligament often occurs in sports with many changes of direction, i.e. typical stop and go sports with sudden turning movements, such as soccer, handball or basketball. The body’s centre of gravity is usually further back, the knee joint is slightly bent, the foot is fixed to the ground and the knee is forced valgus (=X-leg) and outwards.
- Landing on one leg after a jump
- Sudden stop
- Sudden rotational movements
In skiing, the knee is usually bent more, the center of gravity is further back, while the knee is rotated inwards. This is known as the phantom foot mechanism or dynamic snowplow. However, classic “threading” through a valgus (=X-leg) and external rotation can also lead to a rupture of the anterior cruciate ligament.
Accident mechanisms Ball sports
Landing on one leg after a jump
Sudden stop
Sudden turning movements
Skiing accident mechanisms
Classic "threading"
Dynamic snow plow
Hyperextension of the knee joint
Diagnosis of a cruciate ligament rupture
A suspected cruciate ligament rupture can already be diagnosed based on the medical history and the mechanism of the accident. Clinical examination by a specialist remains essential. Various clinical tests(Lachman test, pivot shift test, anterior drawer) can be used to evaluate the stability of the cruciate ligament and the entire knee joint.
Radiologically, a magnetic resonance imaging (MRI ) scan is required to confirm the clinical diagnosis and to visualize the tear and any accompanying injury.
Cruciate ligament rupture patients can be divided into 3 groups can be distinguished:
- The COPER: Conservative therapy alone can restore previous sporting activity.
- The NON COPER: Complain of knee joint instability and cannot return to their usual sport. Sometimes the feeling of instability (giving way attacks) is a problem even in everyday life. Surgery should be recommended for this group to prevent chronic wear and tear of the cartilage and meniscus.
- The ADAPTORs: Adapt their sporting activities so that no instability occurs. This group can also be treated primarily conservatively.
The difference between COPER and NON-COPER cannot currently be determined by testing. If giving way attacks occur during conservative treatment, the patient should be switched to surgical therapy.
How do I recognize a cruciate ligament rupture?
Many athletes feel a snap in the event of an accident, which is accompanied by an immediate effusion of the knee joint. A hemarthrosis (= bloodyeffusion of the joint) indicates a torn anterior cruciate ligament until proven otherwise. The loss of the stabilizing function of the ligament can result in “giving way attacks”. These are rotational movements between the thigh and lower leg which, if left untreated, lead to the destruction of the meniscus and cartilage tissue.
Symptoms of a cruciate ligament rupture
Various symptoms can occur in the event of a cruciate ligament rupture, including
- Sudden and severe pain in the knee
- Swelling
- Instability of the joint
- a feeling of joint dislocation or “buckling”
- Limited mobility
- and a cracking sound during the injury
Bruising may also occur in the knee area. It is important that a torn cruciate ligament is diagnosed and treated by a medical professional, as appropriate rehabilitation and possibly surgery may be required to restore stability and function to the knee joint.
Treatment of a cruciate ligament rupture
Depending on the patient’s age, sporting ambitions, profession and additional concomitant injuries, the decision on therapy is discussed individually with the patient.
There are 3 therapeutic options:
- Conservative therapy
- Surgical cruciate ligament refixation (cruciate ligament suture)
- Surgical cruciate ligament replacement
Conservative treatment of cruciate ligament rupture
Just because no surgery is performed does not mean that no treatment is necessary. Immediately after the injury, swelling and pain should be treated with cooling and compression. Physiotherapy should then be started quickly to restore the range of motion. The knee flexor muscles in particular, which pull the lower leg backwards and have a cruciate ligament-protective effect, must be strengthened. Proprioceptive training, which promotes depth perception through balance and concentration exercises, is also part of conservative therapy.
The stability of the joint should be continuously checked during the course of the treatment in order to evaluate the indication for conservative therapy.
Can a torn cruciate ligament also be stitched?
Good long-term results can be observed with cruciate ligaments that have been torn directly from the bone. Tears in the middle of the ligament should rather be treated with a replacement plastic.
The timing is crucial! Only injuries that are reattached to the bone in the first 3 weeks are likely to be successful. It is also known that the probability of a cruciate ligament suture failing again is higher than that of a cruciate ligament plastic tearing again. It is therefore better to refrain from cruciate ligament sutures in young athletes.
WHEN IS A SUTURE POSSIBLE?
Patient age (>25)
Surgery Within 3 weeks
Torn off directly at the bone
What is cruciate ligament replacement surgery?
In an arthoroscopic cruciate ligament plastic surgery, a tendon from the patient’s own body is removed and then inserted as a new cruciate ligament in place of the tornone (cruciate ligament replacement surgery). The sports orthopaedist has several options when choosing a graft. They all have different advantages and disadvantages, which is why the choice of tendon should be an individual decision.
Which tendon for cruciate ligament replacement surgery?
Hamstring tendons (semitendinosus and gracilis tendons STG): This is the standard tendon used by many sports orthopaedic surgeons to reconstruct a torn cruciate ligament. The tendon is removed through a 2-3 cm incision on the inside of the tibial plateau or just above the popliteal fossa (post-medial removal), folded several times and reinforced with a special suture construct.
Patellar tendon (=patellar tendon) BTB ( =bone tendon bone): In a patellar tendon graft, the middle third of the tendon is harvested with a bone block from the kneecap and another bone block from the tibial plateau.
One advantage is the faster return to sport compared to other grafts, as the bone blocks grow into the bone canals faster than other cruciate ligament grafts.
Quadriceps tendon: The middle superficial third of the quadriceps tendon is harvested through an approx. 3-4 cm long incision just above the kneecap.
One advantage is that the graft can be harvested either with or without a bone block from the kneecap.
Allograft (donor tendon from a cadaveric donation): Thanks to newer methods of processing cadaveric tendons, there are hardly any disadvantages today compared to the body’s own tendons.
How is a cruciate ligament rupture operated on?
Nowadays, an individualized treatment approach is in keeping with the times. For me, it is no longer enough to use the same cruciate ligament transplant for every patient. Different bone sizes, leg axes, concomitant injuries or favored sports (jumping or sprinting) all play a role in the individual treatment algorithm.
In many cases, the anterior cruciate ligament does not tear singularly. Concomitant injuries such as meniscus tears, capsules or ligament injuries are common. Therefore, the timing of the operation should be considered, as well as any additional interventions to increase the stability of the joint.
During a diagnostic arthroscopy (= keyhole technique), the entire joint is inspected from the inside with a camera through skin incisions measuring just 2 x 0.5 cm. This means that injuries to the cartilage surface and meniscus tears can also be treated.
"All-in-side" technique using hamstring tendon
The “all-in-side” technique is one of the gentlest methods for cruciate ligament ruptures. The new cruciate ligament is pulled into short, pre-drilled channels using two metal plates in a pulley technique and fixed to the bone. Compared to conventional techniques, which often require two tendons, the semitendinosus tendon is sufficient here – the second hamstring tendon remains untouched.
The tendon is removed through a 2-3 cm long skin incision just above the popliteal fossa (post-medial tendon removal). This spares a cutaneous nerve (infrapatellar ramus), which is damaged in up to 10 % of cases with conventional methods, which can lead to loss of sensitivity on the inside of the lower leg.
The graft is prepared with two adjustable suture loops (Tightrope) and metal plates and moistened in an antibiotic solution to reduce the risk of infection to almost zero. Two bone channels are then created in the thigh and tibial plateau (at the anatomical origin of the cruciate ligament). Once the transplant has been inserted, the metal plates “flip” on the outside of the bone and fix the ligament securely in place.
ADVANTAGES OF THIS TECHNOLOGY
Anatomical positioning
Particularly strong primary fixation
Individually strong graft can be selected
Quadriceps tendon
For minimally invasive quadriceps tendon harvesting, an approx. 3-4 cm skin incision running vertically from the kneecap upwards is usually sufficient. Thanks to the special harvesting tool, a graft of varying thickness can be selected depending on body and bone size. Once part of the tendon has been removed, the resulting gap is closed. I also use a special suture loop for the quadriceps tendon, which is firmly sutured to the tendon. A small metal plate is attached to the adjustable suture loop (tightrope), against which the tendon can be firmly tightened using the pulley technique after it has been pulled into the bone. The quadriceps tendon graft is screwed into the tibial plateau with a bioabsorbable (= biodegradable polymer) interference screw.
Rehabilitation after cruciate ligament surgery
After arthoroscopic cruciate ligament surgery, patients can usually leave the hospital on the second day after the operation. Physiotherapeutic treatment takes place during the inpatient stay, but must be continued immediately afterwards in order to regain full freedom of movement as soon as possible.
A splint is not usually necessary. For accompanying meniscus sutures or cartilage surgery, immobilization with a motion orthosis and partial weight bearing with crutches is necessary during the first 6 weeks.
After a cruciate ligament injury, there is a higher risk of re-injury to the same knee, but also to the other knee. A cruciate ligament prevention program is therefore essential for further sporting activities.
Frequently asked questions about cruciate ligament surgery
Healing time after cruciate ligament surgery?
A cruciate ligament that has been operated on must first heal back into the bone before it can provide good long-term stability. This takes several months.
Milestones in rehabilitation:
- Full load within the first 2 weeks
- The patient is usually fit for work after 6-8 weeks
- Cycling is permitted after approx. 6-8 weeks
- Running only after 3 months
- It is possible to return to your usual sport after 6 months
- Ready for competition after 9-12 months at the earliest
How long do you need crutches after cruciate ligament surgery?
After a simple cruciate ligament replacement, you only need crutches for 2 weeks. If the meniscus has also been sutured, you usually have to use crutches for 6 weeks.
How soon after a cruciate ligament rupture does surgery need to be performed?
The operation should be performed eitherin the first 10 days or after the primary irritationhas subsided(approx. 6 weeks). If surgery is performed during the irritation phase, the likelihood of severe scarring of the entire joint (=arthrofibrosis) increases.
Does a cruciate ligament rupture always require surgery?
Cruciate ligament ruptures do not always have to be operated on immediately! If the joint is unstable after a cruciate ligament rupture , surgery should be performed. If you are young and active in sports, surgery should be favored in order to avoid permanent damage. If the requirements are low, the patient is older and has little sporting ambition, and there is no tangible instability, conservative treatment can be chosen without any problems.
Can a cruciate ligament rupture heal without surgery?
The function of the cruciate ligament can sometimes be well compensated for by a strong muscle sheath. As the cruciate ligament lies in the middle of the joint and the joint is filled with synovial fluid, no haematoma can form, which is so important for healing. In individual cases, scarring can occur with the posterior cruciate ligament. However, functional healing of the anterior cruciate ligament after a complete tear is very unlikely.
How long in hospital after cruciate ligament surgery?
You should expect to stay in hospital for 1-2 days after a cruciate ligament reconstruction.