With the widespread development of national fitness, the incidence of sports injuries is also on the rise, with ACL injuries of the knee becoming increasingly common. Almost every clinic encounters several patients who are considering ACL rupture, and this article is written to answer the questions of these patients.
What is the anterior cruciate ligament and what is its function?
The ACL, also known as the anterior cruciate ligament, is located in the knee joint and connects the femur to the tibia. Its main function is to limit the excessive forward displacement of the tibia, and it works together with other structures in the knee joint to maintain the stability of the knee joint and enable the body to perform a variety of complex and difficult lower limb movements.
Disease Symptoms
Fresh and old ACL ruptures differ in their clinical presentation.
Fresh ACL rupture (onset less than 3 weeks) is characterized by.
(1) Tearing of the ligament is accompanied by tearing sound and joint misalignment sensation, intra-articular bleeding, resulting in swelling and pain in the joint, and most of them cannot continue to engage in the original movement, and even have limited extension and hyperflexion activities;
(2) Positive floating patellar test on physical examination, laxity and non-resistance on Lachman examination;
(3) Nuclear magnetic examination of the knee suggests intra-articular blood accumulation, swelling or interruption of the continuity of the anterior cruciate ligament, which can be seen in the stump, the lateral wall of the intercondylar fossa of the femur or the posterior aspect of the femoral epicondyle and the corresponding bone contusion manifestation of the tibial plateau. “
The main manifestations of old ACL rupture (onset >3 months) are.
(1) joint laxity and instability, the patient has a sense of knee joint misalignment or playing soft leg in sports, unable to stop and turn sharply, unable to use the affected leg for single leg support;
(2) The knee joint is easily and repeatedly sprained and painful during sports, and even repeatedly interlocked after causing meniscal damage;
(3) Physical examination: Lachman’s examination for relaxation without resistance, positive front drawer test;
(4) Knee MRI suggests: disruption of ACL continuity, stumps can be seen, and the femoral epicondyle and tibial plateau show bone contusion. In case of excessive time, the morphology of the ligament disappears and osteophyte manifestations appear.
(5) KT1000 and KT2000 can quantitatively examine the degree of anterior displacement of the knee joint, which is greater than 3mm compared to the contralateral side;
(6) Patients with repeated sprains often have secondary articular cartilage and meniscal injuries.
Why surgery is recommended to reconstruct the anterior cruciate ligament
The ACL is an important anterior stabilizing structure of the knee, and a rupture can produce significant knee instability and seriously affect knee function. If left untreated, repeated sprains of the joint can easily cause damage to the articular cartilage, meniscus and other important structures, leading to premature aging of the joint and osteoarthrosis.
Untreated or repeated sprains after ACL rupture can easily cause secondary damage to the knee joint.
Injuries to the medial and lateral meniscus of the knee joint
The meniscus is a crescent-shaped fibrocartilage within the knee joint, located between the joint surface formed by the tibia and femur, increasing the contact area between the femoral condyle and the tibial plateau, thus increasing knee joint stability. After rupture of the ACL, the presence of anterior instability in the knee joint, especially with repeated sprains, causes paradoxical movements of the meniscus, which in turn leads to secondary injury to the meniscus. Depending on the type of injury, it can be divided into longitudinal, transverse, laminar and compound fractures.
Knee cartilage injury
Long-term instability and repeated sprains lead to degenerative changes in the cartilage of the knee joint, including the patellofemoral cartilage and the cartilage of the medial and lateral compartments.
Osteochondral formation and chronic synovitis
The end result of knee degeneration leads to the development of osteoarthritis, particularly the formation of osteochondral redundancies at the margins of the intercondylar fossa cartilage, as well as intercondylar spine hyperplasia.
The appendix is the 2014 American Academy of Orthopaedic Surgeons recommendations for ACL injuries for the benefit of patients.
DISCLAIMER
This clinical practice guideline was developed and published by the AAOS Multidisciplinary Volunteer Task Force based on a systematic review of current scientific clinical research and prevailing diagnostic and therapeutic approaches. The guidelines are not intended to be a one-size-fits-all treatment plan, but should be adapted to the patient’s specific situation. Patients in clinical practice are not necessarily the same as those in clinical trials, and physicians should make independent judgments about the diagnosis and treatment of each patient on an individual basis.
Overview
This guideline was developed based on a systematic review of published research on adult and adolescent ACL injuries. In addition to providing recommendations for treatment, the guidelines suggest gaps in the literature and directions for future research.
The guidelines are intended for all practicing physicians and trained surgeons who treat ACL injuries, as well as for policy makers and other practice guideline developers.
Target Audience
This guide is intended for orthopaedic surgeons and physicians who treat ACLs by hand. Orthopaedic surgeons are defined here as those who have completed their medical training, orthopaedic residency training, and some who have completed orthopaedic subspecialty training. Because the guidelines incorporate the latest evidence on the treatment of ACL injuries, they can also be used as a reference by insurance companies, government agencies, and health policy makers. Physical therapists, occupational therapists, nursing staff, physical trainers, emergency room physicians, primary care physicians, rehabilitation physicians, physician assistants and other health care professionals who come into contact with these patients may also benefit.
The treatment of ACL injuries is based on decisions made by the physician and the patient after thorough communication about treatment options. After the patient has been informed of all available options, he or she then has a full conversation with his or her responsible physician. The clinician is in a better position to select the best individualized treatment plan for the patient based on his or her own skills and experience in conservative and surgical treatment.
History and Examination of Anterior Cruciate Ligament Injuries
Strong evidence supports that medical personnel should perform a skeletal muscle examination of the lower extremities along with a thorough history of the condition in question to help make an accurate diagnosis of an ACL injury.
Recommended intensity: strong
Radiological examination of the anterior cruciate ligament
Although reliable evidence is still lacking, the working group believes that in cases of knee injury where initial examination reveals relevant symptoms (weakness, pain, interlocking) and signs (joint effusion, joint instability on weight bearing, localized pressure, limitation of motion, pathological joint laxity), a front and side x-ray of the knee should be performed to clarify the presence of a fracture dislocation that requires emergency management.
Recommended Strength: Consensus
Magnetic resonance examination of the anterior cruciate ligament
Strong evidence supports that MRI can clarify the diagnosis of ACL injury and further detect combined injuries to other ligaments, menisci, or articular cartilage.
Strength of recommendation: strong
Anterior cruciate ligament in children
Limited evidence supports the need for surgical reconstruction of ACL injuries in skeletally developing minors, which may reduce functional limitations and recurrent joint instability during activity that might otherwise result in further injury.
Recommended intensity: limited
ACL in young adults with high activity levels
Moderate intensity evidence supports that surgical reconstruction should be performed in young patients (18-35 years of age) with high activity ACL tears.
Recommended strength: moderate
ACL and meniscal repair
There is limited evidence to support that in patients with combined ACL tears and repairable meniscal injuries, ACL reconstruction should be performed in conjunction with meniscal repair, which may result in improved patient function.
Recommended strength: limited
Recurrent instability of the joint due to ACL
Limited evidence comparing nonsurgical treatment of recurrent joint instability with ACL reconstruction has shown that ACL reconstruction can reduce pathological laxity of the joint.
Recommended strength: limited
Conservative treatment of the anterior cruciate ligament
Limited evidence supports the option of non-surgical treatment for patients with low activity and insignificant joint laxity.
Recommended intensity: limited
Timing of surgery for the anterior cruciate ligament
Moderate strength evidence supports that surgery should be performed within 5 months of injury for cases requiring ACL reconstruction to preserve articular cartilage and meniscus.
Recommended Strength: Moderate
ACL combined with medial collateral ligament injury
Limited evidence supports reconstruction of the ACL in cases with both ACL and medial collateral ligament tears, while non-surgical treatment of medial collateral ligament tears is an option.
Recommended strength: limited
Anterior cruciate ligament and interlocking knee
Although there is no reliable clinical evidence, the Working Group believes that patients with ACL tears that result in interlocking joints due to displaced meniscus tears should be treated immediately with “unlocking” of the knee to avoid fixed knee flexion contractures.
Recommended strength: consensus
Single or double bundle reconstruction of the anterior cruciate ligament
There is strong evidence to support that intra-articular ACL reconstruction can be performed with either single or double bundle reconstruction, with comparable outcomes.
Recommended strength: strong
Anterior cruciate ligament autograft source
Strong evidence supports that intra-articular ACL reconstruction can be performed with either a bone-patellar tendon-bone graft or an N-cord tendon graft, with comparable postoperative outcomes for both.
Recommended intensity: strong
ACL autograft or allograft
There is strong evidence to support that ACL reconstruction can be performed with either an autograft or a properly treated allograft, with comparable postoperative outcomes. However, this conclusion cannot be extrapolated to all allografts or to all patients, such as younger patients or those with high activity levels.
Recommended intensity: strong
Femoral tunnel technique for the anterior cruciate ligament
Moderate strength evidence supports that intra-articular ACL reconstruction can be performed with either an anteromedial or a transtibial approach when establishing a femoral tunnel, with comparable results for both.
Recommended strength: medium
Postoperative functional bracing of the ACL
Moderate strength evidence supports that functional knee bracing should not be routinely used after ACL reconstruction alone, and there is no evidence to support its effectiveness.
Recommended strength: moderate
Prophylactic bracing of the anterior cruciate ligament
There is limited evidence to support that prophylactic bracing should not be used to prevent ACL injury and that it does not reduce ACL injury.
Recommended intensity: limited
ACL and Neuromuscular Training
Moderate intensity evidence from a small sample (109 cases) supports that neuromuscular training can reduce ACL injury.
Recommended intensity: Moderate
Post-operative physiotherapy for the ACL
Moderate strength evidence supports the option of early, accelerated, and non-accelerated rehabilitation programs after ACL reconstruction, with all three having comparable outcomes.
Recommended intensity: moderate
ACL recovery exercises
Limited evidence supports that there is no need to wait a specific amount of time or gain a specific function to return to sports after ACL injury or reconstruction.
Recommended intensity: limited
The above text is compiled by me integrating the internet and medical related knowledge, with reference to the relevant information from Beihang Hospital and Dingxiang Garden, with thanks!