There are two important ligaments in the knee cavity, the anterior cruciate ligament and the posterior cruciate ligament, which are important stabilizing structures during knee motion. Anterior cruciate ligament injuries are more common in sports injuries. It can be injured alone or in conjunction with the collateral ligament and meniscus, i.e., a combined injury. The ACL is easily missed in clinical work and is often detected only during meniscal surgery or when there is significant knee instability, which is often accompanied by articular cartilage damage and significant muscle atrophy, and the results are still not very satisfactory after surgical reconstruction, so early diagnosis and timely repair are particularly important.
The sports base is relatively broad, and many patients suffer from knee injuries during sports every year, but less than 50 cases of ACL reconstructive surgery are performed each year in Liuzhou as a whole. This is mainly due to the late development of sports medicine in Liuzhou and Guangxi as a whole. Traditional orthopedic surgeons lack the corresponding theoretical knowledge, and the misconceptions of some patients and doctors cause delays: when the joint is sprained, if the x-ray does not show a fracture, the patient and the doctor will diagnose it as a “soft tissue injury” if there is no problem.
Commonly comforted by the phrase “a hundred days to move the bones”, they go home to do some cold compresses, plasters, Chinese medicine, or take some injury medicine, and when the swelling subsides, they think everything is fine. Not realizing that the essence of joint sprain swelling is serious intra-articular ligament rupture or osteochondral injury bleeding, and these injuries will not heal on their own, often 1-2 years after the aggravation of symptoms before coming to the clinic, neglecting the condition, delayed treatment, further aggravating the damage to the cartilage or meniscus. It is more difficult to treat. Postoperative efficacy is also inferior to early surgery.
Diagnosis
1. Medical history
Acute ACL ruptures have a history of trauma, mostly inversion or valgus sprains of the knee, but also can be injured by hyperextension injury flexion position support injury. The injury can have a sense of tissue tearing, followed by pain and joint instability, inability to complete the ongoing movement and walking, followed by joint bleeding and swelling, protective muscle spasm, refusal of any lifting or activity.
ACL injuries have specific symptoms: the patient’s complaints and history of injury are important. If the patient has a history of knee injury in either sports or traffic injuries, when X-rays show no fracture, if the injured person has joint swelling, blood accumulation, pain or dysfunction, 70-80% of such patients will have an ACL injury; even if the swelling has subsided after the injury and can continue to walk or run, the affected knee appears to be repeatedly sprained, or afraid to run at variable speed, afraid to turn and run, or afraid to participate in antagonistic sports However, even if the swelling subsides, the affected knee has repeated sprains, or is afraid to run with speed or bend, or is afraid to take part in antagonistic sports.
Another important reason for misdiagnosis is that some doctors rely too much on MRI results and ignore the basic physical examination, in fact, the highest correct rate of MR diagnosis of cruciate ligament injury is only 95%; another 5% of the difficult diagnosis requires a comprehensive judgment by experienced specialists, for those patients with high suspicion of ACL injury, even if the joint stability test is negative, it is not For those patients with high suspicion of ACL injury, even if the joint stability test is negative, it is not careless to let go.
2, auxiliary examination
(1) X-ray examination: simple X-ray plain film: can find the ligament stop with avulsion fracture or intra-articular osteochondral fracture, in addition to the avulsion fracture of the lateral joint capsule (Segond fracture) has diagnostic value for the rupture of the ACL.
(2) MRI: It is very valuable for the diagnosis of ACL rupture. The sensitivity of MRI is 91.5% and the accuracy is 93.6%. MRI has high sensitivity and specificity, so it is considered as the “gold standard” for imaging after ACL injury.
Treatment
At present, regardless of acute or old ACL rupture, early surgical treatment is advocated for those with a clear diagnosis, except for fracture repositioning and fixation for stop point avulsion fractures. The previous extra-articular reconstruction techniques and ligament suturing with poor clinical results have rarely been used. With the development of arthroscopic technology, minimally invasive ACL reconstruction has become mainstream.
Nowadays, most of the clinicians use single bundle reconstruction, i.e. one bone tract for femur and one bone tract for tibia to reconstruct the ACL. The clinical results prove that minimally invasive ACL reconstruction under arthroscopy is less invasive, faster recovery, and has good clinical results.
There are various reconstruction materials, which are roughly divided into 3 types.
①Autologous materials, such as bone-patellar tendon-bone complex, semitendinosus and thin femoral tendons, quadriceps tendon, etc.
(2) Allografts, such as allogeneic bone-patellar tendon-bone complex, allogeneic anterior tibial tendon, allogeneic Achilles tendon bone complex, allogeneic semitendinosus tendon, etc. The surgical technique and operation of applying allograft to reconstruct ACL is the same as applying autograft to reconstruct, the cleaning and preparation of graft is also the same as autograft, the tendon retrieval step is omitted and the operation will be faster, in addition it avoids the adverse effect of tendon retrieval on the patient, especially for patients with revision and compound injury has more advantages.
③Artificial material, the application in clinical practice is still not much.
【Postoperative rehabilitation
Arthroscopic ACL single bundle reconstruction rehabilitation guidance.
Postoperative brace protection is needed, and ankle pump exercises, quadriceps and N cord muscle strength exercises can be started early, and knee flexion functional exercises and weight-bearing exercises can be started after the acute trauma period. At 3 months after surgery, the splint protection could be removed and the knee flexion was basically normal. At 4 months postoperatively, we started to gradually resume all activities of daily life, strengthen muscle strength and joint stability, and gradually resume sports. During this period, the reconstructed ligaments are not yet strong enough, so exercises should be performed gradually and not reluctantly or blindly.
It is important to strengthen the muscles to ensure the stability and safety of the knee joint during sports, and to wear a knee brace for protection if necessary, but only during strenuous sports. After 7 months post-operatively, the patient should gradually resume sports or strenuous activities to strengthen the muscles and the stability of the joint during running and jumping. Gradually resume strenuous activities, or special training. Full return to sports will be possible when the mobility of the affected joint reaches normal and the muscle strength reaches 85% or more of the healthy side by testing.