Knee Injury Awareness and Treatment – Anterior Cruciate Ligament Injury
1. Do all ACL injuries require surgery?
The ACL is an important anterior stabilizing structure of the knee joint, and after injury, it can produce significant anterior instability of the knee joint, which can seriously affect the function of the knee joint and cause damage to the articular cartilage, meniscus and other major structures, leading to joint degeneration and early onset of osteoarthrosis.
MR of the knee is an important auxiliary examination for ACL injury, but due to the influence of instrumentation, operating techniques, intra-articular fluid bleeding and doctors’ experience in reading films, its clinical diagnosis is limited and there is a certain rate of misdiagnosis, so it cannot be used as a basis for clinical diagnosis, and must be based on medical history, physical examination by a specialist and arthroscopic surgery if necessary to further clarify the diagnosis.
Young patients with a diagnosis of ACL injury need to undergo ACL reconstruction surgery if any of the following are present.
① Repeated sprains of the knee joint.
(2) A feeling of knee instability, (easy to play soft leg or sprain, whether this is caused by ACL injury need to exclude other factors).
③ Combined injury to the meniscus of the knee or other important stable structures.
④There is clear cartilage damage in the knee joint that needs to be repaired.
Patients who do not require surgical treatment for ligament reconstruction or for whom surgical reconstruction of the ligament would be of little help.
①No indication for surgery as described above and no joint instability.
②The ligament has been ruptured for many years and the cartilage damage is so severe that other treatment measures should be taken on a case-by-case basis. However, if a complete rupture of the anterior cruciate ligament occurs in children, adolescents and the elderly, there are special features. The skeletal development of children and adolescents is not yet mature, and reconstructive surgery is likely to damage the epiphyseal plate and lead to unequal angular deformity of the limb. Due to such considerations, many physicians advocate conservative treatment until skeletal maturity, and then perform ACL reconstruction if symptoms are still present. The purpose of ligament reconstruction is to prevent premature joint wear and aging. Most elderly patients with ACL rupture have worn out joints and have little motion, which is associated with more trauma from surgery than conservative treatment, causing more severe aging, and it has been reported that the older and less active the conservative treatment group is, the better the conservative treatment will be. In cases of partial rupture of the ACL or complete rupture in the elderly and children, conservative treatment can be performed without surgery as much as possible.
(iii) In patients with multiple ligamentous laxity, preoperative diagnosis cannot be made on the basis of unilateral MR and specialist physical examination; a detailed history must be taken and a specialist physical examination of each joint must be performed for comparison.
The anterior cruciate ligament of human knee is mostly treated by early surgical reconstruction for anterior cruciate ligament rupture because it has no synovial covering, poor blood flow and poor self-healing ability, which is not effective by conservative braking and other means. Reconstruction surgery timing.
① Patients with simple ACL rupture can receive surgery after the acute period, when the swelling of the joint has basically decreased and the mobility of the joint is basically normal. If surgery is temporarily not possible, functional exercises should be performed under the guidance of a physician to prevent muscle atrophy and joint stiffness and to restore joint mobility.
② Combined sutureable meniscus injury or cartilage injury requiring repair should be operated as early as possible for the chance of meniscus or cartilage repair.
③If there is meniscal injury with symptoms of symphysis, strive for early surgery to avoid difficulties in functional exercise after surgery.
④If there is a combined medial collateral ligament injury that needs to be sutured, it is best to operate within 2-3 weeks. After the acute period, the medial collateral ligament ligament basically cannot be sutured, and its reconstruction is not as effective as sutured, and the trauma and cost are greater.
2.Can the surgery completely solve the joint pain?
Most patients with ACL rupture do not have pain as the main symptom, but joint instability is their main manifestation. ACL reconstruction does not mean that the function of the knee joint can be restored, it is only the beginning of the functional recovery of the knee joint. Strict postoperative rehabilitation is the key to the success of ACL reconstruction surgery. ACL combined with meniscal and cartilage injuries are common and are a common cause of knee pain.
Due to the lack of awareness of ACL injury and meniscus and cartilage injury, patients fail to receive early diagnosis and timely and effective treatment, making the meniscus and cartilage injury more and more serious and eventually unable to preserve the meniscus and repair the cartilage. Although the anterior cruciate ligament has been reconstructed, the knee joint is subjected to abnormal loads and stresses, resulting in osteoarthritis of the knee joint and causing knee pain.
3. Does everyone have good surgical results?
Due to the different mechanisms of injury in patients with ACL injuries, some patients have a combination of intra-articular cartilage debridement, meniscal injury and lateral collateral ligament injury. Therefore, while reconstructing the ACL of the knee, it is important to manage the combined injuries according to the actual condition of the affected limb. Patients with combined injuries take longer to rehabilitate after surgery than patients with ACL injuries alone and have poorer recovery of knee function.
Complications: Post-operative complications after ACL reconstruction can be caused by preoperative, intraoperative, and postoperative factors. Preoperative factors include the timing of surgery, appropriate preoperative status and muscle strength, and the choice of graft and fixation method. The most common postoperative complications are limitation of motion and persistent anterior knee pain. Preoperative, intraoperative, and postoperative factors can all contribute to loss of motion after ACL reconstruction. Preoperative joint swelling, limitation of motion, and concomitant other ligament injuries are more likely to increase the likelihood of postoperative limitation of motion. Incorrect intraoperative bone tract position can lead to graft impingement, which can result in loss of knee extension. Postoperative factors include prolonged braking and inadequate or inappropriate rehabilitation.
Postoperative rehabilitation.
(1) Brace wear
The brace is worn 24 hours a day for the first month, can be removed at night during the second month, and is worn when walking around during the third month. In some patients with good knee muscle strength, the decision to end the brace early should be made by the surgeon. The main function of the brace is to maintain the stability of the knee joint and to protect the reconstructed ligaments from excessive strain; of course, if the protection is excessive, the knee muscles will atrophy, and the trade-off between the two must be discussed with the doctor.
(2) Knee flexion exercises
The pain associated with knee flexion varies from person to person. Patients who follow a strict rehabilitation program will generally have no problems. Patients who have also had surgery to repair other stable structures of the knee, such as meniscal sutures and medial collateral ligaments, may have some difficulty flexing the knee and experience slightly more pain. It is important to note that the knee flexion exercises should not be performed too quickly from extension to the prescribed knee flexion angle, and are generally performed for 10-20 minutes, with a 5-10 minute stay at the established angle, and ice can be started while staying. A small number of patients who are not comfortable with one day of practice may have their knee flexed every two days or even every three days, depending on the situation, by their physician. In general, if excessive knee flexion causes severe swelling or stiffness of the knee muscles and joint capsule, violent pushing must be eliminated, and it is best to rest for 2-3 days and seek prompt medical attention.
The most important thing in knee flexion exercises is relaxation. Some patients relax very well and the knee flexion goes smoothly, the pain is mild when the knee is flexed, and the pain stops when the knee is finished. Some patients are more nervous, mainly because they are afraid of pain, and have difficulty bending the knee. Patients in the latter group who have not been able to relax for a long period of time and have a slow knee flexion process, mainly because the knee “hurts” every time it is flexed and the pain in the knee is greater than 5 minutes after flexion, need to seek help from the surgeon.
Patients in the former category should not be rushed, as too rapid a flexion process, especially at about 6 weeks post-operatively, can cause laxity of the reconstructive ligaments. It is important to note that at 6 weeks postoperatively, some patients feel well enough to jog or run with or without a brace, which can easily cause ligamentous laxity.
(3) Ice
Ice is closely related to the process of knee flexion. Ice should be applied when flexing the knee and after flexing the knee. Ice areas: front, inside and outside of the knee joint. Painful areas during knee flexion exercises must be incorporated into the ice pack. Note: Use a towel between the ice pack and the skin to prevent frostbite; apply ice at 40-60 minutes intervals between two ice packs, and 3-6 ice packs after one knee flexion exercise; adjust the number of ice packs according to the degree of knee swelling the next day, and gradually master the number of ice packs to suit yourself.
(4) Squatting exercises
Quiet squatting can not only practice the muscle strength around the knee joint, the correct quiet squatting posture for a long time on the lumbar spine, cervical spine, etc. are beneficial. The correct static squatting posture rehabilitation program has, here is to emphasize is: static squatting before the general to experience a period of straight leg exercises, pay attention to increase the time and load of straight leg lifts (weight on the calf), recommended straight leg lifts will be affected knee muscle strength to more than 80% of normal and then squatting exercises. When squatting, the knee flexion angle should not be too large, except for a few patients with strong muscle strength, the general knee flexion should not exceed 60°. When squatting, waist straight, head back, except for the knee muscle tension, the rest of the body must be relaxed.
After the exercise, pain in the front and medial knee muscles is a valid evidence of correct exercise posture. Increased pain within the knee joint after squatting is an abnormal performance that can cause damage to the knee joint and aggravate patellofemoral joint cartilage lesions. Where this occurs, attention should be paid to changing the way: first, the affected knee muscle strength is not improved enough, to strengthen the straight leg lift exercise. Secondly, the painful point is not avoided when squatting quietly. Exercises can be used to divert fatigue by various entertainment methods, such as watching TV and movies, listening to music, listening to audiobooks, etc.
(5) Internal ringing of the joint
Knee mobility exercises go smoothly at a later stage and you start walking normally. Some patients may notice a rattling sound in the knee joint, some of which are small and can only be felt, while others have a larger sound, a definite popping sound. There are many causes of rattling, meniscectomy, scarring of the fat pad area, and muscle atrophy are all common causes of popping after ACL reconstruction. These can be corrected by muscle strength exercises and adaptation training of joint activities. Most patients find the popping sound about 1 month after surgery, and it can gradually disappear about 6 months after surgery. In a small percentage of patients, the intra-articular scar is not easily softened. If the ringing still occurs 1 year after surgery and affects normal joint activities, it is recommended that a second arthroscopic excision of the scar be considered in consultation with the surgeon.
It is important to note that patellofemoral cartilage damage is a pathologic clinical condition that causes knee popping. These patients typically experience pain and soreness in the anterior knee area, especially when walking up and down stairs. Patients with these clinical manifestations must communicate frequently with their physicians to obtain timely treatment measures for chondromalacia patellae.
Causes of loosening.
Approximately 90% of ACL reconstructions result in excellent outcomes. However, there are still a small percentage of cases where the reconstructed ligament is lax or stretched, or even ruptured, due to surgical technical errors, poor quality of the grafted tendon or patellar tendon, inadequate fixation, incorrect ligament healing remodeling or post-operative rehabilitation, which prevent the reconstructed ligament from functioning as it should, resulting in the presence of long-term instability in the knee joint.
Ligament selection.
At present, two autografts, bone-patellar tendon-bone and four femoral N cord muscles, are still the first choice in ACL reconstruction, and various allografts and artificial tendons are gradually being widely used in clinical practice.
The advantages of bone-patellar tendon-bone are high ligament strength and good healing within the bone tract, which is still the first choice for revision. Disadvantages, complications in the donor area: mainly include postoperative patellar tenderness, patellofemoral arthropathy, patellar ligament and fat pad fibrosis, patellar fracture, patellar tendon contracture, patellar tendon rupture, patellar tendonitis, prepatellar pain, quadriceps atrophy, etc.
The advantages of quadriceps N cord reconstruction are that it is structurally closer to the anatomical structure of the ACL, less traumatic surgical incision, easier operation of taking the reconstruction and significantly reduced postoperative anterior patellar pain, and no interference with the knee extension device, while it can reduce the occurrence of postoperative donor area complications, and the disadvantage of individual differences.
The main advantages of allograft reconstruction of the ACL are: no donor area injury; no limitation on the amount of material taken; simplified surgical operation; and small surgical incision. The main disadvantages are: disease transmission; immune response; delayed healing; enlargement of the bone marrow tract; infection; and high cost.
The LARS artificial ligament is the only artificial ligament product in Europe that has passed the pull-torsion-flexion test and has an efficacy equivalent to that of autologous bone-patellar tendon-bone at 2 years postoperatively; however, its long-term results are still uncertain. The disadvantages are poor tendon bone healing and difficulty in revision.