Cruciate Ligament Surgery (Plastic Surgery)

After the rupture of the anterior or posterior cruciate ligament, there are various treatment options such as cruciate ligament surgery or the installation of a cruciate ligamentoplasty, respectively, in order to be able to guarantee the function of the knee joint and thus the mobility of the patient. The rupture (tear) can affect only the anterior or also the posterior cruciate ligament as well as both cruciate ligaments. Statistically, rupture of the anterior cruciate ligament is far more likely. The main function of both cruciate ligaments is to ensure the stability of the tibia (shin bone) against the femur (thigh bone). Only in interaction with the collateral ligaments, which are also part of the knee joint, is it possible to secure the joint against a varus (bow-leg) and valgus (x-leg) position. Due to the anatomical conditions, a person is able to perform a slight extension (knee extension) and a significant (flexion) knee bending, which, however, requires the presence of the cruciate ligaments to maintain stability. With the help of these ligaments, it is possible to reduce the displaceability of the tibia with respect to the femur, which subsequently effectively prevents the folding away of the lower leg. However, it must be differentiated that the anterior cruciate ligament primarily prevents ventral translation (forward displacement of the femur) and the posterior cruciate ligament prevents posterior translation (backward displacement of the femur), as this is what results in symptoms in the event of a rupture. Epidemiologically, a cruciate ligament injury is the most common clinically relevant injury of the knee joint. Mechanism of origin of cruciate ligament rupture

  • Damage to the anterior cruciate ligament (ACL) is largely due to a sudden and massive application of force to the lower leg, which is in flexion (bent). In addition to the flexion, a rotational movement occurs simultaneously. Flexion results in a reduction of the maximum force absorption, which significantly increases the risk of injury in the case of simultaneous rotation. In various sports, especially ball sports, the damage to the anterior cruciate ligament occurs under external influence in an anatomically-functionally unfavorable joint position.
  • In skiing, the rupture is in principle rather the result of an acute rotational movement, which results in a lesion (damage) in a fall due to the irregular position of the tibia to the femur.
  • To cause a tear of the posterior cruciate ligament (ACL), it usually requires a much stronger force on the cruciate ligament, which is usually only achievable in a traffic accident. Violent hyperextension can also result in a rupture of the posterior cruciate ligament.

Indications (areas of application)

  • Rupture of the cruciate ligaments
  • Lesions of the cruciate ligaments due to stress

Contraindications

  • There is no direct contraindication for conservative therapy. Against surgical therapy speaks a limited possibility of rehabilitation after surgery due to the physical condition.
  • In addition, interligamentary tears (damaged joint structure between the cruciate ligaments) should not undergo surgical intervention.
  • Fraying of the ligamentous stump is also a relative contraindication.

The procedures

In principle, in the case of damage to the cruciate ligaments, both conservative (without surgery) and surgical therapeutic measures can be initiated. Of particular importance for treatment is the fact that in the case of a rupture of a cruciate ligament, unlike a lesion of the collateral or internal ligaments, healing by scarring is not possible. The absence of the body’s own healing mechanisms and the risk of a degenerative appearance of the hyaline articular cartilage (wear and tear), can increase the risk of painful and mobility-limiting meniscal damage. This mechanism for the development of secondary damage has been demonstrated in various studies. Thus, in the absence of therapeutic intervention, the likelihood of suffering from progressive destruction of joint structures and frequent re-injury symptoms is considerably increased. The therapy used for healing depends, on the one hand, on the wishes of the patient and, on the other hand, on the picture of the damage to the cruciate ligament. Conservative treatment options

  • In Germany, the prevailing opinion among physicians is that not every torn cruciate ligament must be treated by surgical intervention under all circumstances. However, in addition to the lesion, the decision for conservative therapy must also depend on the age and activity behavior of the affected patient. An RCT study demonstrated that in physically active patients, early surgical intervention of cruciate ligament rupture is no more effective than rehabilitation plus delayed surgery. It may be possible to avoid more than 60% of cruciate ligamentoplasties.
  • With a conservative therapy measure, ten percent of patients feel negatively affected in everyday life.
  • Conservative treatment is primarily for patients with an anterior cruciate ligament (ACL) tear without concomitant injuries the adequate therapy option, provided that there is no desire for unrestricted sports load. The consequence of loading the cruciate ligaments after conservative therapy is the increased frequency of arthrosis (load-induced joint damage) compared to patients who have undergone surgery. This observation could be proven by means of various studies. A recognizable advantage of surgical intervention, especially in athletes, has been relatively clearly established. The primary reason for the higher incidence of osteoarthritis is thought to be the frequent rotational and hyperextension loading of the knee joint. However, studies are also available that have shown that conservative treatment of cruciate ligament rupture is associated with no discernible adverse effects in both athletically inactive and athletically active patients.
  • To increase the stability of the knee joint even during rotational movements, it is crucial to perform preventive exercise training before conservative therapy.
  • In addition to the deterioration of stability, conservative therapy is associated with another complication. More often than average, in up to 30 percent of cases, patients complain of the presence of joint effusions.

The surgical procedures

Healing response technique

  • This therapeutic option represents a semi-conservative orthopedic procedure that can be used in the case of anterior cruciate ligament tear from the femur. The principle of the procedure is based on the use of undifferentiated stem cells, which are believed to have the property of differentiating into tendinocytes when subjected to mechanical stress. In order to exploit this principle, an accompanying injury must be excluded or treated with the use of arthroscopy (arthroscopy).
  • If this is done, the bone marrow can be exposed with the help of a special preparation set in the cruciate ligament area, so that bone marrow cells can be released, especially the stem cells from the marrow. In order to be able to determine the success of the therapeutic measure, the treating physician should focus on a sufficient leakage of blood from the bone marrow. So that the necessary differentiation stimulus for the development of the stem cells is generated, the anterior cruciate ligament must be inserted at its point of attachment to the blood clot formed and an extension must be completed in the knee joint.
  • Following the approximately five-week fixation phase, intensive weight-bearing training is performed with the patient. In various studies with different designs (methods), it was shown that the success rate of 80 percent is considered relatively good. Currently, the treatment option of a rupture of the posterior cruciate ligament is reviewed.

Other surgical procedures

  • The most common indication for performing an invasive therapeutic procedure to treat a cruciate ligament tear is the recurrent occurrence of instability symptoms of the knee joint. However, the stability of the affected joint can improve with physical exercise, as muscle development supports the ligamentous apparatus. Based on this, patients with a cruciate ligament rupture should initially test for two to three months to see if there could be any detectable instability.
  • In many patients, a cruciate ligamentoplasty is necessary to maintain mobility and freedom from pain at the same time. A cruciate ligamentoplasty is a surgical procedure to reconstruct the damaged cruciate ligament.Surgical intervention with suture attempts is limited to very few exceptional cases. In many cases, a tourniquet is applied to the leg. Furthermore, it should be noted that the use of synthetic tapes as a result of insufficient results no longer occurs.
  • In cruciate ligament reconstruction, there is both the option of making a ligament replacement from autologous (the body’s own) or xenogenous (foreign to the body) material. All reconstruction techniques attempt to recreate the characteristics of the original cruciate ligament as closely as possible so that, as far as possible, no mobility restrictions become apparent. However, the exact structure of the cruciate ligaments cannot be achieved regardless of the origin of the implant. Accurate motion requires the ability of proprioception, which allows the position of the joint to be perceived by the brain. Also, precise force regulation via mechanoreceptors cannot be restored by reconstruction. Based on this, it is not at all possible that a current surgical technique for reconstruction of the cruciate ligament could restore the quality of the uninjured ligament.
  • Primary sources for grafting include, for example, the patellar tendon (patella tendon), the pes anserinus tendons (Latin : goosefoot; this is the name given to a tendon structure on the inner side of the lower leg), and the quadriceps tendon (the aforementioned tendons have an important physiological function in movement). Using any of these three options can ensure that a stable reconstruction of the cruciate ligament is feasible.

After surgery

Depending on the procedure, the patient must take adequate care of the reconstructed ligament. Stitches from the surgery can usually be removed after two weeks. Postoperative pain and swelling are very common, so analgesic therapy is necessary. In addition, in consultation with the attending physician, light exercise should be started on the reconstruction as early as possible. Training can also lower the weight, which can later significantly reduce the load on the reconstruction and thus prolong the length of stay of the reconstruction.

Potential complications

  • Graft failure – surgical errors, failure of the reconstruction to heal, and additional rupture of the cruciate ligament can cause the function of the graft to be reduced to the point that another surgical procedure is required to correct it.
  • Renewed instability – further trauma or incorrect placement may result in a reduction in the stability of the joint, often requiring correction with surgery.
  • Infection – postoperative inflammation remains a serious problem in ACL reconstruction. If infection is detected, direct irrigation of the wound area is necessary. The likelihood of bacterial infections occurring depends on various factors such as preoperative recumbency duration and age. Infections can cause far-reaching complications that can lead to sepsis (blood poisoning).
  • Arthrofibrosis – this clinical picture represents, according to the current state of research, a rare autoimmune disease characterized by a massively reduced mobility of the knee joint.
  • Cyclops syndrome – this syndrome is characterized by a connective tissue proliferation in the wound area, which can lead to pain during stress.
  • Anesthesia – the procedure is performed under general anesthesia or after performing spinal anesthesia, which results in various risks. General anesthesia can cause nausea (nausea) and vomiting, dental damage, and possibly cardiac arrhythmias, among others. Circulatory instability is also a feared complication of general anesthesia. Nevertheless, general anesthesia is considered a procedure with few complications. Spinal anesthesia is also relatively low in complications, but complications can occur with this method as well. Injury to tissue, such as nerve fibers, could lead to a long-lasting impairment of quality of life.

Further notes

  • The time between diagnosis and reconstruction of a ruptured anterior cruciate ligament determines the arthrosis rate: after an interval of six months, the arthrosis rate was 11.7%; after 18 months, 21.6%; and after 36 months, 45.3%.