Therapy options
As almost always in therapy, there are two options: either conservative or surgical. The therapy must be based on the individual circumstances and requirements of the patient. A competitive athlete will want to get on his feet as quickly as possible and will want a stable knee even under heavy load situations.
The 60-year-old chess player is more likely to be able to do without it and thus be happy without surgery. Some physicians are of the opinion that after cruciate ligament rupture without surgery, arthrosis always occurs, it is only a question of time. Therefore the different therapies are hotly discussed again and again. Therefore, an overview is given below. Affected patients must discuss the advantages and disadvantages in detail with their treating physician.
The surgical therapy
The decision to have cruciate ligament rupture surgery depends on many factors: The most common surgical methods for a torn cruciate ligament are the so-called cruciate ligament plastics. In this operation, a piece of the body’s own tendon is implanted in the knee as a replacement. These should not be performed immediately, as the risk of joint scarring with restricted mobility is particularly high in the first days after the accident.
The previously common cruciate ligament sutures are left out except for the bony tear and the treatment of the posterior cruciate ligament. But the operation alone is not everything, a similarly strenuous post-operative treatment of the torn cruciate ligament is necessary and the six weeks that are always supposed to be sufficient for our soccer stars should be the laudable exception. In general, 3 months is a good average.
How is an anterior cruciate ligament rupture treated? In the case of an anterior cruciate ligament rupture, it is important to restore the lost inner support of the joint. For this purpose, the anterior cruciate ligament must be reconstructed as anatomically as possible.
The new cruciate ligament should imitate the properties and function of the natural anterior cruciate ligament as much as possible. As a replacement material, we have mainly used the so-called patellar tendon (patellar tendon) and the so-called hamstring (seeing the semitendinosus and gracilis muscles). Which of the available techniques of cruciate ligament replacement is ultimately used in cruciate ligament rupture surgery depends on many factors such as age, gender, sports activity, height, weight and tissue structure.
The fixation is either done with so-called interference screws (also available in dissolvable materials) or with titanium clamps. Although the technique appears relatively complicated, the success rates after such procedures are good, especially if there are no significant additional injuries. This aspect also speaks in favor of repairing such a situation as early as possible.
- Age
- Activity
- Profession
- Accompanying injuries (torn meniscus)
- The patellar tendon: An approximately 1 cm wide piece of tendon is taken from the middle third of the patellar tendon, with a 2 x 1 cm wide block of bone attached to both ends. The advantage of using this patellar tendon is the good fixation possibility: The attached bone blocks are fixed in the drill channels with so-called interference screws made of titanium or sugar. Nowadays, the graft is inserted and fixed purely arthroscopically (by means of a knee joint endoscopy).
- The semitendinosus tendon (tendon taken from the inner thigh near the knee joint).
These tendons are removed through a small incision in the skin of the inner tibial head and doubled in each case, resulting in a quadruple graft. The primary tear strength of a quadruple hamstring graft (quadruple-laid tendon graft) is approximately twice that of the tear strength of the normal human anterior cruciate ligament. The advantages of semitendinosus and gracilis grafts in cruciate ligament rupture surgery are the low complication rate, the reduced pain after removal of the tendons and the only small, cosmetically favorable skin scar.
Furthermore, this transplant is more likely to achieve stiffness than a normal anterior cruciate ligament. Movement restrictions are proven to be less frequent. The maximum tear strength of the quadruple hamstring graft is even higher than that of the patellar tendon.
A disadvantage is the slower healing of the tendons into the bone channels compared to the patellar tendon.The bone blocks of the patellar tendon grow in within 3-6 weeks, the flexor knee tendons need 10-12 weeks for this.
The anatomical reconstruction of the original course of the anterior cruciate ligament is decisive for the surgical success of anterior cruciate ligament surgery using the semitendinosus tendon or patellar tendon. The optimal course of an inserted semitendinosus plasty can be seen on the right as an example. The ends of the tendon are fixed to the bone with a so-called Endobutton.
This initially fixes the graft only temporarily, but in the postoperative course the tendon graft must then grow into the bone. The two standard transplants for cruciate ligament surgery are the patellar tendon and the semitendinosus tendon. For patellar tendon replacement, the middle third of the patellar tendon is generally removed with a block of bone at both ends. To remove the semitendinosus tendon, the tendon is separated from the bone through a small skin opening and then detached from its muscle belly with the stripper. The remaining tendon scars without significant demonstrable loss of function with the surrounding area.
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