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Ligament Reconstruction

ACL Reconstruction

The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the center of the knee running from the femur to the tibia. When this ligament tears unfortunately, it does not heal and often leads to the feeling of instability in the knee.

ACL reconstruction is a commonly performed surgical procedure and with recent advances in arthroscopic surgery can now be performed with minimal incision and low complication rates.

ACL Reconstruction Hamstring Tendon

ACL Reconstruction Hamstring Tendon

Anterior cruciate ligament (ACL) reconstruction hamstring method is a surgical procedure that replaces the injured ACL with a hamstring tendon. Anterior cruciate ligament is one of the four major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and helps stabilize your knee joint. Anterior cruciate ligament prevents excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur) as well as limits rotational movements of the knee.

A tear of this ligament can make you feel as though your knees will not allow you to move or even hold you up. Anterior cruciate ligament reconstruction is surgery to reconstruct the torn ligament of your knee with a tissue graft.

Causes

An ACL injury most commonly occurs during sports that involve twisting or overextending your knee.  An ACL can be injured in several ways:

  • Sudden directional change
  • Slowing down while running
  • Landing from a jump incorrectly
  • Direct blow to the side of your knee, such as during a football tackle

Symptoms

When you injure your ACL, you might hear a loud "pop" sound and you may feel the knee buckle.  Within a few hours after an ACL injury, your knee may swell due to bleeding from vessels within the torn ligament. You may notice that the knee feels unstable or seems to give way, especially when trying to change direction on the knee.

Diagnosis

An ACL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays, MRI scans and arthroscopy. X-rays may be needed to rule out any fractures. In addition, your doctor will often perform the Lachman’s test to see if the ACL is intact. During a Lachman test, knees with a torn ACL may show increased forward movement of the tibia and a soft or mushy endpoint compared to a healthy knee.

Pivot shift test is another test to assess ACL tear. During this test, if the ACL is torn, the tibia will move forward when the knee is completely straight and as the knee bends past 30° the tibia shifts back into correct place in relation to the femur.

Procedure

The goal of ACL reconstruction surgery is to tighten your knee and to restore its stability.

Anterior cruciate ligament reconstruction hamstring method is a surgical procedure to replace the torn ACL with part of the hamstring tendon taken from the patient’s leg. The Hamstring is the muscle located on the back of your thigh. The procedure is performed under general anesthesia. Your surgeon will make two small cuts about 1/4-inch-long around your knee. An arthroscope, a tube with a small video camera on the end is inserted through one incision to see the inside of the knee joint. Along with the arthroscope, a sterile solution is pumped into the joint to expand it enabling the surgeon to have a clear view and space to work inside the joint. The knee is bent at right angles and the hamstring tendons felt. A small incision is made over the hamstring tendon attachment to the tibia and the two tendons are stripped off the muscle and the graft is prepared. The torn ACL will be removed and the pathway for the new ACL is prepared. The arthroscope is reinserted into the knee joint through one of the small incisions. Small holes are drilled into the upper and lower leg bones where these bones come together at the knee joint. The holes’ form tunnels in your bone to accept the new graft. Then the graft is pulled through the predrilled holes in the tibia and femur. The new tendon is then fixed into the bone with screws to hold it into place while the ligament heals into the bone. The incisions are then closed with sutures and a dressing is placed.

Risks and complications

Possible risks and complications associated with ACL reconstruction with hamstring method include:

  • Numbness
  • Infection
  • Blood clots (Deep vein thrombosis)
  • Nerve and blood vessel damage
  • Failure of the graft
  • Loosening of the graft
  • Decreased range of motion
  • Crepitus (crackling or grating feeling of the kneecap)
  • Pain in the knee
  • Repeat injury to the graft

Post-operative care

Following the surgery, rehabilitation begins immediately. A physical therapist will teach you specific exercises to be performed to strengthen your leg and restore knee movement. Avoid competitive sports for 5 to 6 months to allow the new graft to incorporate into the knee joint.

Anterior cruciate ligament reconstruction is a very common and successful procedure. It is usually indicated in patients wishing to return to an active lifestyle especially those wishing to play sports involving running and twisting. Anterior cruciate ligament injury is a common knee ligament injury. If you have injured your ACL, surgery may be needed to regain full function of your knee.

PCL Reconstruction

Posterior cruciate ligament (PCL), one of four major ligaments of the knee are situated at the back of the knee. It connects the thighbone (femur) to the shinbone (tibia). The PCL limits the backward motion of the shinbone.

PCL injuries are very rare and are difficult to detect than other knee ligament injuries. Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries. Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II there is partial tear of the ligament.  In grade III there is complete tear of the ligament and the ligament is divided into two halves making the knee joint unstable.

The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear.

Patients with PCL injuries usually experience knee pain and swelling immediately after the injury. There may also be instability in the knee joint, knee stiffness that causes limping, and difficulty in walking.

Diagnosis of a PCL tear is made based on your symptoms, medical history, and by performing a physical examination of the knee.  Other diagnostic tests such as X-rays and MRI scan may be ordered. X-rays are useful to rule out avulsion fractures wherein the PCL tears off a piece of bone along with it. An MRI scan is done to help view the images of soft tissues better.

Treatment options may include non-surgical and surgical treatment. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee. Crutches may be recommended to protect your knee and avoid bearing weight on your leg.

Generally, surgery is considered in patients with dislocated knee and several torn ligaments including the PCL. Surgery involves reconstructing the torn ligament using a tissue graft which is taken from another part of your body, or a cadaver (another human donor). Surgery is usually carried out with an arthroscope using small incisions. The major advantages of this technique include minimal postoperative pain, short hospital stay, and a fast recovery. Following PCL reconstruction, a rehabilitation program will be started that helps you resume a wider range of activities. Usually, a complete recovery may take about 6 to 12 months.

Medial Patellofemoral Ligament Reconstruction

Medial Patellofemoral Ligament Reconstruction

Medial patellofemoral ligament reconstruction is a surgical procedure indicated in patients with more severe patellar instability. Medial patellofemoral ligament is a band of tissue that extends from the femoral medial epicondyle to the superior aspect of the patella. Medial patellofemoral ligament is the major ligament which stabilizes the patella and helps in preventing patellar subluxation (partial dislocation) or dislocation. This ligament can rupture or get damaged when there is patellar lateral dislocation. Dislocation can be caused by direct blow to the knee, twisting injury to the lower leg, strong muscle contraction, or because of a congenital abnormality such as shallow or malformed joint surfaces.

Medial patellofemoral ligament reconstruction using autogenous tissue grafts is done by following the basic principles of ligament reconstruction such as:

  • Graft Selection: Strong and stiff graft should be selected
  • Location: The graft should be located isometrically
  • Correct tension: The tension set in the graft should be appropriate
  • Secure Fixation: Stable fixation of the graft should be achieved
  • Avoid condylar rubbing or impingement: The graft should not rub against condyle or cause impingement

Surgical Technique

The surgical procedure of medial patellofemoral ligament reconstruction involves the following steps:

Graft Selection and Harvest: Your surgeon will make a 4-6 cm skin incision over your knee, at the midpoint between the medial epicondyle and the medial aspect of the patella (knee cap). The underlying subcutaneous fat and fascia are cut apart to expose the adductor tendon. The tendon is then stripped using a tendon stripper and its free end is sutured. The diameter of the tendon graft is measured using a sizer.

Alternatively, a graft can be harvested from the quadriceps tendon.

Location of the femoral isometric point: The graft should be placed isometrically to prevent it from overstretching and causing failure during joint movements. A transverse hole measuring 2.5 mm is made through the patella. Then a small incision is made over the lateral side of the patella and a strand of Vicryl suture material is inserted through the hole. Over this strand, a 2.5 mm Kirschner wire (K-wire) is passed and then inserted into the bone besides the medial epicondyle.

An instrument called pneumatic isometer is inserted into the hole made in the patella and the Vicryl isometric measurement suture material is also passed along. The knee is taken through its full range of motion and any changes happening in the length between the medial epicondylar K-wire and the medial aspect of the patella is recorded on the isometer. The position of the K-wire will be adjusted until no deviations are read on the isometer during full range of motion. Once the isometric point is identified, a tunnel is drilled starting from the insertion of the adductor tendon uptil the isometric point is reached.  The graft is pulled through this tunnel, then exits at the medial condyle and again passed through another tunnel that is made through the patella.

Correct tension: The tension is set in the graft with your knee flexed up to 90º and the tension should be appropriate enough to control lateral excursion.

Secure fixation: After bringing the tendon graft from the medial to the lateral side through the bone tunnel, it turned onto the front surface of the patella where it is sutured.

Avoid condylar rubbing and impingement: After graft fixation, the range of motion is checked to make sure there are no restrictions in patellar or knee movements. The graft should not impinge or rub against the medial femoral condyle. If it is detected, the graft is replaced into proper position.

Post-operative care

A knee brace should be used during walking in the first 3-6 weeks after surgery. Avoid climbing stairs, squatting and stretching your leg until there is adequate healing of the tendon. Rehabilitation exercises, continuous passive motion and active exercises will be recommended.

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