Knee Cruciate Ligament Reconstruction Procedure (ACL)

Dr Jan Paradowski

I invite you to take part in an arthroscopy reconstruction of the Anterior Cruciate Ligament (ACL) using the latest operational techniques - in Cracow. As a medical doctor with experience with the Polish Football Association, my goal is the patient’s earliest and safest return to full activity.

Table of Contents:

1. Types of ACL reconstruction
2. ACL anatomy
3. Injury description
4. Symptoms
5. Medical Examination
6. Reconstruction and treatment of ligaments
7. Nonoperational treatment
8. Operational treatment – the most commonly recommended form of treatment
9. Return to sport period
10. Treatment procedure
11. Knee rehabilitation after treatment or operation

Types of ACL reconstruction

In keeping with the newest guidelines for knee surgeons in Europe and the USA, I conduct innovative reconstruction procedures that are used only in a few of the best orthopedic centers:

1. Immediate ACL reconstruction for fresh injuries (within 14 days!), with the use of artificial implants as a bridge to the regeneration of the innate ligament (internal bracing technique – internal bands, orthosis). This technique is characterized by a significantly faster return to complete activity in comparison to the classic method (about 12 weeks) It also retains one’s own cruciate ligament which may regain an appropriate capacity. The risk of arthrofibrosis (excessive fibrosis of the joint after operation) is comparable to treatments that are delayed in time, which have been conducted until now three months after the injury. It is the latest and least invasive operation technique, characterized by the quickest return to activity.

2. ACL reconstruction with the use of an artificial implant of the latest generation- Neoligaments Jewel ACL – thanks to the innovative artificial ligaments you can return to sport after 3 months after operation! To date classic procedures conducted with the use of one’s own semitendinosus tendon or gracilis tendon (ST and GT) have permitted return to sport after about one year, and an earlier return caused the loosening of the ligament and its failure (a transplanted ligament is weakest after six weeks from operation, but even after many months it can be strained and lose capacity). With time, the innovative artificial ligament grows through the body’s own tissue, becoming a new, own ligament. The new technique offers the opportunity to quickly return to sport, particularly for professional athletes.

3. ACL reconstruction together with other ligaments (dual and multiple ligament reconstruction) addressing meniscus and cartilage injury (coexisting in more than 50% of ACL injury cases) according to the ICRS guidelines (International Cartilage Repair Society). Stem Cells are often used during the operation.

4. Classic reconstruction of the anterior cruciate ligament with the use of one’s own tissue kneecap ligament or semitendinosus tendon ST and gracilis tendon GT) addressing coexisting injuries.

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One of the most common and serious injuries of the knee is the torn anterior cruciate ligament. 

Athletes performing sports disciplines such as football, handball or basketball are most susceptible to damaging the anterior cruciate ligament. Skiers – both professional and amateur – also are susceptible to the ACL injury.

In the case of damage to the anterior cruciate ligament (ACL), the injury most often requires operation to return complete capacity to the knee and safeguard it from premature irreversible osteoarthritis, because in the unstable knee the cartilage undergoes heavy friction and the meniscus can burst. The most recent guidelines point to the necessity of ACL reconstruction, not only in athletes and young people but also in the elderly and less physically active. This is a significant change in the guidelines, which has taken place in recent years.
The choice of the type of operation depends on several factors including the level of damage of the ligament itself, coexisting injuries (mensicus, cartilage…), the level of sport activity and patient expectations. The rehabilitation period and return to full sport activity depends on the chosen operation.

ACL Anatomy

Four bones meet in the knee joint: the femur, tibia, fibula and patella. The patella is found directly in front of the knee joint, guaranteeing protection and increasing the strength of the four-headed femur. The ligaments guarantee the connection between the bones and the stability of the joint. There are four main ligaments in the knee. They act as strong, relatively elastic tapes.

Collateral ligaments

These are located on the external walls of the knee. The Medial Collateral Ligament (MCL) is found on the internal side, whereas the Lateral Collateral Ligament (LCL) is external. They control sideways movements of the knee and prepare it for atypical movements.

Cruciate ligaments

These are found on the inside of the knee joint. Each of them crosses with the other, creating an "X" – hence its name. The cruciate ligaments control the back-and-forward knee movement (excessive sliding of the tibia to the front and back).
The anterior cruciate ligament runs diagonally toward the center part of the knee. It prevents the outward sliding of the tibia bone in front of the femur, and also guarantees the rotational stability of the knee.

Injury description

About one half of all injuries to the anterior cruciate ligament occur in coexistence with damage to other knee structures such as the joint cartilage, meniscus and other ligaments.

We distinguish 3 grades of ACL injury, depending on the level of severity:

• Grade 1 injury: the ligament is lightly damaged. It was overstretched but is functional enough to guarantee knee stability.

• Grade 2 injury: The ligament is overstretched to the point that it becomes loose and partly dysfunctional. This state is often described as a partly torn ligament. Knee stability is weakened.

• Grade 3 injury: this is complete dysfunctionality of the anterior cruciate ligament – tearing (discontinuation) or complete dysfunctionality due to excessive stretching (extension) of the ligament. This means that the knee joint is unstable. This leads to the significant risk of further damage to the internal joint structure and development of knee arthrosis.

Unfortunately a significant number of ACL injuries are complete or nearly complete laceration. In addition to this, coexistence of additional injuries becomes an indication to conduct arthroscopy of the knee joint.

The anterior cruciate ligament may be damaged as a result of several situations:

• sudden change in running direction
• sudden stop/slowing during running
• poor landing on the surface after a jump
• direct contact or collision with something hard (a foul on the football field, etc.)

Numerous studies prove that damage to the anterior cruciate ligament is more common among female athletes than male. According to researchers this is due to differences in physical condition, muscle strength and neuro-muscular control. Other proposed causes are differences in the pelvic and lower limb structure, increased ligament loosening or the effect of estrogen on the properties of the ligament.

Symptoms

In the case of a damaged ACL, you may feel pain, notice swelling of the joint, hear rattles or clicks in the bone. Many patients feel an instability, as if the knee gives way.

• Pain with swelling. During 24 hours the knee may swell and the pain increase. These symptoms may go away after about 2 weeks. But return to sport without a complete diagnosis and treatment may cause the knee to be unstable, which increases the risk of further injury and serious interior joint damage, i.e., to the cartilage and meniscus. 

• Loss full movement ability in the knee joint. A complete straightening and increased bending of the knee joint may be painful.

• Pain along the knee joint.

• Discomfort while walking.

Medical examination

During the first visit we examine the specific symptoms and conduct an interview regarding injuries. During the physical examination all structures of the contused knee are examined and compared to healthy structures in the other knee. Most ligament injuries may be diagnosed during a fundamental medical exam.

Visualizing exams may assist in confirmation of the physical exam diagnosis or bring to light coexisting damage to other structures:

- X-ray exam: While this exam does not make ACL damage visible, it may indicate whether the injury is connected with a break (e.g. Segond’s fracture, very often accompanying a damaged ACL) or, for example, rear instability as in the damaged Posterior Cruciate Ligament (PCL).

- Magnetic Resonance (MRI): This exam most precisely illustrates soft tissue, to which the Anterior Cruciate Ligament belongs. Magnetic resonance is not necessary for the diagnosis of a fracture or ACL dysfunction.

- Ultrasound (US) – the ultrasound exam of the knee joint illustrates well the majority of internal and proximal joint structure. It also allows a movement exam (dynamic US) to be conducted, and here prevails over magnetic resonance (MRI).

Read more about the medical exam and see how a Knee ultrasound is conducted by Dr. Jan Paradowski.

Reconstruction and treatment of Ligaments

Treatment of the Anterior Cruciate Ligament (ACL) after its damage depends on the individual expectations of the patient, their activity and the degree of damage to the ligament. For example, a young athlete performing an agility-based sport that requires frequent pivoting (rotational knee movements, change in running direction – e.g., tennis, football), will require an arthroscopic operation, because only this operation allows for a safe return to sport. Methods of treating a torn ACL using the arthroscopic technique (minimally invasive) are introduced below and in the introduction of this text.
Less active, usually older people, may sometimes return to daily activity without operation. In keeping with the latest guidelines, however, the operation is indicated even for less active, older patients. Instability of the knee leads to irreversible changes in the cartilage and meniscus, which results in irreversible development of arthrosis of the entire joint. This state may be the cause of increased pain in the future and result in the need to introduce an endoprosthesis.

Nonoperational treatment

Conservative treatment of the damaged Anterior Cruciate Ligament (ACL) does not return the knee to complete function. It may be used, however, in the case of individuals very advanced in age with a very low level of activity, and those with other illnesses (unable to be operated on). If the injury has not led to complete dysfunction of the ACL, a simple nonoperational means of treatment may be recommended, for example:

- Use of an external stabilizer (orthosis) – the stabilizer will never return complete joint stability, although it might partially help. Patients are recommended to walk with orthopedic crutches during the first days after injury in order not to overstrain the  knee (particularly when additional damage or a partly dysfunctional ligament is suspected in internal injuries – as the only option offering an opportunity to create scar tissue and recreate ACL continuity).

- Physiotherapy – appropriate physiotherapy treatment is recommended from the very moment after the injury. Specific exercises aim to return movement to the knee and strengthen the muscles that increase stability in the knee.

Operational treatment – the most common form of treatment

 - Recreation of ligament continuity – Until recently it was deemed that most torn Anterior Cruciate Ligaments were not able to be sewn. The latest data indicate, however, that sewing the ACL and introducing an artificial tape as an internal brace allows for the regrowth of the cruciate ligament. An artificial tape guarantees immediate return of stability and with time it overgrows one’s own tissue and becomes a new recreated ligament. The procedure is undertaken most often up to 14 days after the injury, that is, very quickly – the patient does not need to wait as until now, about 3 months after the injury. It is characterized by minimal damage and quickest return to sports activity. This method owes its success to the huge progress in material engineering, thanks to which it has been possible to produce modern implants – internal bracing tapes. This procedure is conducted through minimally-invasive arthroscopy.

Read more about the knee arthroscopy procedure - click here.

- Reconstruction of the Anterior Cruciate Ligament (ACL) with the use of artificial ligaments, Neoligaments Jewel-ACL – this is the second current form of reconstruction. It may be used particularly when the internal bracing technique may not be used or a quick return to professional sport is required. The procedure is conducted arthroscopically (minimally invasional).

 - Classic arthroscopic reconstruction of the Anterior Cruciate Ligament – during the operation the torn ACL ligament is exchanged for transplanted tissue. This transplant acts as a type of scaffolding for regeneration of the new ligament. We use the patient’s own semitendinosus tendon ST and gracilis tendon GT or the meniscus ligaments. The disadvantage of using the patient’s own tissue to form the transplant is the insignificant weakening of the muscular strength and low limitation of the medial knee (tendon) stability, or in approx. 10% of cases pain in the anterior part of the knee joint with the transplant of 1/3 of the medial meniscus ligaments. The period of time required to regain full biomechanical capacity for this kind of ligament is also longer – after about 6 months from the transplant it is its weakest (weaker than at the moment of operation – due to the reconstruction).   

- ACL reconstruction with the use of an allograph (ligament transplant from a dead donor) – an often-used technique in revision surgery due to a repeated tear of an already once transplanted ligament.

Return to sports time

After ACL reconstruction the time to return to sports activity is dependent on the method of reconstruction chosen and on progress in rehabilitation. With the choice of the classic method, it is 9-12 months (the often-cited 6 month period is related to the high risk of straining the transplanted ligament and its resultant dysfunction). Methods using artificial implants (internal bracing or Neoligaments JewelACL) allow a return to sport after about 3 months.

Treatment procedure

The Anterior Cruciate Ligament reconstruction operation is conducted using an arthroscope inserted through 2 small (4-5 mm) cuts in the skin of the knee. This medical procedure causes minimal damage to tissues, is less painful, least invasional and safer. This treatment does not require a long period of hospitalization (1 day) and guarantees faster return to ability.

The ACL reconstruction procedurę is increasingly performerdseveral days after injury, and not approx. 3 months later. The risk of arthrofibrosis (excessive fibrosis of tissues) after reconstruction is a rare complication.

Rehabilitation of the knee after a procedure or operation

The course of rehabilitation depends on whether treatment includes an operational procedure or not, in both cases it plays a crucial role. An introduced physiotherapy program may help to regain muscle strength and knee movement without subjecting the knee to further internal joint damage.

Postoperation, physical therapy initially focuses on returning the appropriate range of movement in the knee joint. Next, the patient undergoes a program of strengthening the muscles around the knee to protect the reconstructed ligament (particurally the quadricep muscle and thigh bicep). The final stage of rehabilitation focuses on the actual return to activity, adapted to the type of sport performed. At that point we also reconstruct the so-called deep proprioceptive sensing – which protects the knee on the basis of neuro-muscular reflex arcs.

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