Arthroscopic Reconstruction of the Anterior Cruciate Ligament

Information for patients

ARTHROSCOPIC RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT

Arthroscopy is a minimum invasive surgical procedure which is used for diagnostics and treatment of joint injuries and diseases. It is a procedure which is technically more demanding than comparable classic surgical procedures. It also demands a high level of training and special technological equipment, but at the same time, provides several advantages.

Arthroscopic reconstruction of the cruciate ligament using an autologous tendon graft is a widely used method for treating a torn anterior cruciate ligament. During the procedure, the surgeon replaces the torn anterior cruciate ligament with a tendon graft, usually with the autologous tendon from the Semimembranosus or Gracilis muscle, which is harvested during the procedure from the thigh. The goal of the procedure is to improve the stability of the knee and reduce the risk of later complications of chronic knee instability such as repeated menisci injuries and wearing out of cartilage. Arthroscopic surgery has several advantages in comparison to the classic open reconstruction of the cruciate ligament. It enables significantly more precise positioning of the tendon graft in the joint, it preserves the surrounding soft joint tissue and notably reduces the risk for the development of post-operative infection of the joint.

At the same time, the post-operative pain is considerably milder. For a good result of the treatment, an individual high-quality post-operative rehabilitation, which lasts up to six months, is vital after the reconstruction of the anterior cruciate ligament.

Arthroscopic reconstruction of the anterior cruciate ligament procedure

The procedure is done in under general anaesthetic. After the patient is positioned on the operating table, the knee is sterilized. A pressure band is applied to the thigh which enablesrestricted blood flow in the operated leg during the procedure is case this is needed. Usually three incisions are needed for the arthroscopic reconstruction of the anterior cruciate ligament – one on the outer and inner side of the knee (similarly as in a classic knee arthroscopy), and an additional incision, which is a few centimeters long, in the part where the tendon graft is going to be harvested. When the tendons from the Semitendinosus or Gracilis muscle are used, an incision is made on the inner side of the shank, in its upper third. When the tendons from the kneecap are used, an incision is made on the front side of the knee. In order to insert the grafts with which the tendon is fixed to the bone tunnel, sometimes a few small additional incisions are needed on the inner and outer part of the knee. If during arthroscopy the surgeon finds other joint injuries, some additional incisions may be needed to treat them.

The surgical procedure usually starts with a diagnostic knee arthroscopy which is intended for a detailed examination of the knee and finding of accompanying injuries of other joint structures, such as medial or lateral menisci, cartilage surface or posterior cruciate ligament. During the procedure, the knee joint is filled with a sterile fluid Ringer laktata. This is a special solution of water and electrolytes which rinses the joint and slightly expands it and by this enables the surgeon to see more clearly the inside of the joint. If accompanying injuries are determined they are treated if possible. With torn meniscus this can mean a partial or complete removal of the meniscus, more rarely the stitching of it. With more extensive cartilage injuries, the surgeon may decide for slightly drilling the place of the injury or for microfracturing. This helps to achieve that the injured cartilage surface partly restores itself with fibrous cartilage. When injuries of the cartilage are extreme, the treatment of these can require an addition surgical procedure. In rare cases, when the wearing out of cartilage surfaces in the joint is an advance stage, the surgeon may decide not the carry out the reconstruction of the cruciate ligament.

Torn anterior cruciate ligament.

When the tendon graft is harvested, the preparation of the bone tunnels in the thighbone and shinbone is done, through which the tendon graft is going to be laid. In order for the procedure to succeed, it is very important to precisely determine the position of the bone tunnel in the thighbone as well as in the shinbone. In some cases, the surgeon decides to carry out a double-bundle reconstruction of the anterior cruciate ligament. Such reconstruction is possible with patients who have bigger knees and stronger tendons. The advantage of such a procedure is that the reconstruction more closely mimics the natural anatomy of the anterior cruciate ligament, which is made of two bundles – the anteromedial and posterolateral. In this way a better rotational stability of the knee should be achieved. The two-bundle technique does have some disadvantages such as a longer surgery, a more demanding surgical technique, a more difficult revision in case of a repeated torn cruciate ligament, a higher risk for surgical complications such as the breaking of the bone tunnel wall.

Tendon harvest from Semitendinosus Tendon harvest from the kneecap.

and Gracilis muscles.

In rare cases, during the diagnostic arthroscopy it is established that a part of the anterior cruciate ligament is still preserved. In this case, the surgeon can decide to preserve this part of the ligament and carry out a reinforcement of the existing tendon. The procedure is in this case very similar to the reconstruction of the anterior cruciate tendon procedure using the two-bundle technique, the difference being that only one bundle is reconstructed.The preserved part of the cruciate tendon represents the other bundle.

One of the key factors for a successful reconstruction of the anterior cruciate ligament is to very precisely determine the position of the bone tunnels through which the tendon graft is going to be laid. In determining this position, the arthroscopic examination of the joint has a huge advantage in comparison to a classic open surgery. When drilling the bone tunnels, special target instruments are used. The standard technique for the reconstruction of the anterior cruciate ligament demands the drilling of one bone tunnel with 8-9 millimeters in diameter through the shinbone and one bone tunnel of the same diameter through the thighbone. When using the two-bundle technique, two narrower bone tunnels with 5-6 millimeters in diameter must be made through the shinbone and two tunnels through the thighbone. When the tunnels are drilled, the leading stitch is initiated which is used to pull the tendon graft through the tunnel. At the end of the procedure, the tendon graft is fixed first on the side of the thighbone and then on the side of the shinbone. To fix the tendon graft on the side of the thighbone, interference screws from different materials can be used, as well as transverse resorption bolts or a special titanium button. On the side of the shinbone, the tendon is usually fixed with an interference screw. Before the procedure, the surgeon will explain which method of fixing the tendon graft is the most suitable for your knee. In some cases, a different method of fixing the tendon graft can be used due to changed circumstances during the procedure.

Drilling of the bone tunnels in Reconstructed anterior cruciate ligament.

the shinbone and thighbone.

Rehabilitation after the arthroscopic reconstruction of the anterior cruciate ligament

Due to minimum invasiveness, the rehabilitation after the arthroscopic reconstruction of the anterior cruciate ligament is faster than the one where a classic surgical procedure is performed. It is very important that the patient realizes and understands that the absence of pain, swelling and complete mobility of the knee does not mean that the knee is completely healed and ready to take full strain. With arthroscopic surgery we do achieve that post-operative pain is smaller, that the swelling of the knee passes faster and complete mobility is achieved more quickly in comparison with a classical open procedure. However, the growing into of the tendon graft in the bone cannot be speeded up. The same applies for the revascularization process of the tendon. Both mentioned processes need several months. As these are biological healing processes, adequate physical therapy and controlled strain do stimulate them, but they cannot be significantly shortened. Only complete growing into of the tendon graft and revascularization, which has for its consequence the restoring of the tendon vitality, enable that a reconstructed cruciate ligament can withstand the strains which appear during sports activities. This is usually achieved in 6 months after the surgery. Early uncontrolled and excessive straining of the knee in the first months after the operation can cause the tendon graft to stretch. This consequently means instability of the knee or even the loosening of the bone fixation of the graft.

Rehabilitation after the reconstruction of the anterior cruciate ligament is difficult and long. It is of key importance that it is done under control, under the supervision of a physiotherapist who is qualified and well familiar with the limitations and the goals of different recovery phases. It is highly recommended that physical therapy is individual and that the program is adjusted, to the extent that biological processes of tissue healing allow, to the progress and the abilities of the individual. After the surgery, repeated cooling of the knee with ice several times a day reduces post-surgery swelling and pain. In general, walking with fully straining the leg is allowed after the surgery. In the first day, patients usually help themselves with crutches when walking. Is it advisable to stop using them as soon as possible, as they contribute to weakening of the thighbone muscles. Every patient receives detailed instructions about post-operative check-ups and early stage rehabilitation.

Risks and complications related to the arthroscopic reconstruction of the anterior crucial ligament

As with all surgical procedures there are some risks and complications that can occur after the reconstruction of the anterior cruciate ligament. However, due to minimum invasiveness of the procedure, they are extremely rare.

There exist the following risks and potential complications:

• bacterial infection of the wound,
• bacterial infection of the joint,
• bleeding into the joint,
• long-term swelling of the joint and accumulation of fluid in the joint,
• breaking of the instruments, screws and other implants in the joint,
• nerve and vein damage in the joint,
• long-term limited mobility of the joint with accompanied pain,
• persistent chronic instability of the joint,
• the development of blood clots in the shank and possibly embolism as a consequence,
• wounds on the skin due to the pressure against the operating table, under the pressure band or as a reaction to the skin disinfectant and tape for sterile covering.
• Extremely rarely the above-mentioned complications can lead to a later additional surgical procedure or a conversion of the arthroscopic procedure into a classic surgical procedure.
• Due to bacterial infection, a surgical removal of the reconstructed cruciate ligament may be necessary.

Instructions before the surgery

A week before the planned surgical procedure, basic laboratory test have to be carried out at your personal physician (hemogram, electrolytes, PT, INR, ECG). Patients who are more than 40 years old and those who have chronic diseases, need additional x-ray pictures of the lungs.

Changes in your overall medical condition can influence the surgical procedure, so be sure to immediately notify the doctor who set the date for your procedure in case of any of the following conditions:

• sings of a cold,
• raised body temperature,
• eye, ear, throat, gum irritation or problems with teeth,
• wounds or cuts on the skin,
• digestive illnesses with problems such as nausea, vomiting, stomach-ache, diarrhea, excrement with blood,
• urinary system diseases with problems such as burning sensation during urination, kidney cramps, very frequent urination, blood in the urine,
• if there is a possibility that your are pregnant.

When you are admitted you must have all your existing medical documentation with you, including all the pictures/images and a signed procedure consent form for the surgical procedure. For people who are under age, the consent form must be signed by their parents or caretakers. Before the procedure be sure to notify the doctor about any know allergies or oversensitivity to medicine. Also tell the doctor which, if any, medicine you take regularly.

IMPORTANT INSTRUCTIONS BEFORE THE SURGERY

• You must not eat or drink for 6 hours before the surgery.
• On the day of the surgery, thoroughly scrub your knee with soap for at least five minutes.
• On the day of the surgery, take all your medicine that you regularly take, except if you were told otherwise by the doctor.
• On the evening before the surgery, take 1 pill of Arcoxia 120 mg (a non-steroidal anti-inflammatory medicine with long term effectiveness which will reduce the pain immediately after the surgery).
• Do not wear make-up on the day of the surgery. Remove nail polish.
• Wear comfortable clothes which are easy to take off and put on.
• If you have crutches or a knee brace that you have used up to know, bring them with you.
• Please leave at home all jewellery, your watch and other valuable things.
• It is essential that you are escorted by an adult for going home, as you must not operate motor vehicles immediately after the surgery. You will be discharged on the same day of your surgery.

For additional information please contact us on 040/799-622, 01/518-7063 or by e-mail .

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