Rupture of the anterior cruciate ligament (ACL) and posterior of the knee
The cruciate ligaments are two in number, located in the knee : the anterior cruciate ligament (ACL) – nicknamed sports ligament – and the posterior cruciate ligament (PCL), which cross in the center of the knee and allow its stability.
“The lesions of the cruciate essentially concern the anterior ligamentwhich is stretched from the inner cheek of the lateral femoral condyle to in front of the tibial spines”, describes Dr. Miniot. It has the particularity of stretching or relaxing depending on the degree of flexion of the knee joint, and has two essential roles:
- he is a brake on excessive anterior movement – or translation – of the tibia in relation to the femur, this is the famous anterior drawer;
- il prevents excessive rotation between the tibia and the femur.
Dr Jean-Christophe Miniot, sports doctor: This ACL is therefore particularly stressed in so-called contact pivot sports (ball and combat sports) and non-contact pivot sports (racket and sliding sports).
Rupture of the ACL therefore designates a ligament tearwho can be partial or total depending on its severity. It is most often consecutive to the practice of a sport, but can be caused by a bad fall or during a car or bicycle accident.
The women are on average two to six times more affected than humansbecause often more lax and less muscular than these. There is also a hormonal factor to this susceptibility. “Women are more fragile at the beginning of the hormonal cycle, because of the significant secretion ofestrogen which increase the laxity of the ligaments” explains the specialist.
What are the most common causes of injury?
The cruciate ligaments are particularly susceptible to damage during three types of injury mechanisms.
- Knee hyperextension : it is a trauma that occurs when the knee stretches beyond its normal range of motion. “Classically, it can occur during a violent shot in a ball”, describes Dr. Miniot. It can also be the consequence of poor landing during a jump or a fall.
- Rotation : the injury is then due to a change of direction or support (football or tennis), or an edge fault in skiing.
- Sudden raising following hyperflexion : it occurs for example during a fall, the buttocks on the heels in the skier who tries to get up so as not to fall.
Symptoms: can you walk with a ruptured cruciate ligament?
In most cases, the rupture of the cruciate ligaments causes sharp pain and immediate onset.
May be added to this pain:
- and creak felt, and sometimes audible at the moment of rupture,
- the knee swelling,
- a feeling of instability,
- a difficulty or inability to walk.
The significance and intensity of the symptoms depends on the severity of the rupture (total or partial) and the presence of associated lesions.
“It can also happen that a partial tear of the ACL passes almost unnoticedand be diagnosed several years following its occurrence, when a meniscus lesion appears due to the absence of the ACL”, adds the sports doctor.
Diagnosis: how do you know if you have a ruptured cruciate ligament?
As with any injury, the diagnosis goes through a careful clinical examinationwhich begins with a patient questionnaire: circumstances of the fall, description of the symptoms… Then two tests carried out by the doctor can highlight the rupture of the ACL.
The test de Lachman : it consists of grasping the thigh above the knee and the tibia below the knee and causing a translational movement of the tibia forwards. This test is performed in comparison with the patient’s healthy knee. If the anterior displacement of the tibia is significantly greater on the injured siderupture is suspected.
The rotary jump test : the patient is lying on his back, knees straight. The doctor grasps the limb to be tested by the ankle and the thigh. One hand causes a movement of medial rotation of the tibia and flexion of the knee, while the other applies a valgus movement on the knee. The practitioner is looking for a sensation of jumping of the lateral compartment of the knee.
“Generally, this clinical examination makes it possible to make the diagnosis of rupture of the ACL, without the need for medical imaging examinations“, says Dr. Miniot.
However, when the symptoms are severe and in case of functional impotencea x-ray even a IRM can be proposed to look for possible associated lesions. The standard X-ray makes it possible to highlight a possible fracture and the‘IRM other associated lesions: ligamentous, cartilaginous or meniscal. If there is a contraindication to MRI, CT arthrography can be proposed.
These different examinations allow the implementation of the therapeutic decision.
Treatment: how is a ruptured cruciate ligament treated?
Immediately post-traumatic, the patient is equipped with a splintknee immobilization, which takes the whole leg. Of the crutches and one anticoagulant treatment are also offered.
To fight pain, painkillers or anti-inflammatories are prescribed, and the application of ice packs can help reduce swelling.
He is then reviewed by a surgeon, a sports doctor or a rheumatologist, who will assess the seriousness of the injury and decide on the possibility of surgery.
Jean-Christophe Miniot: Surgery is not systematic, but it is frequent: nearly 30,000 operations are performed each year, ie in nearly three out of four cases.
Surgery: when to have cruciate ligament surgery?
Healing of the anterior cruciate ligament usually does not occur properly, which can have variable impact on knee stability. Certain specific movements will therefore be poorly performed and may eventually cause lesions of the cartilages, ligaments and/or menisci, with progressive degradation of the joint. This is what we try to avoid with surgical treatment.
The operation will be proposed in the following cases:
- subject that presents gait instability,
- person who has a pivotal activity : either in his sporting practice (rather for young subjects), or in his professional activity (firefighter, construction worker, etc.),
- top athlete who wishes return to competitive practice,
- in the presence of associated repairable meniscal lesions.
When surgery is decided on, it should not be done too early. “It is always appropriate towait at least 15 days to 1 month to get out of the inflammatory storm, which increases the risk of complications”, explains Dr Miniot. In addition, a pre-surgical rehabilitation can be implemented to improve the prognosis of the injury.
What does the surgery consist of?
The surgical operation consists of replace the ruptured ligament, we speak of ligamentoplasty. There are several methods, the best known and practiced of which consist in taking a tendon from another part of the body for an autograft:
- the intervention of Kenneth-Jones : the ACL is replaced by a graft taken from the ipsilateral patellar tendon:
- the DIDN’T (Internal right and semi-tendinosus) consists in replacing the cruciate ligament by hamstring tendons.
The Kenneth Jones technique would provide better results in terms of tendon stabilization, and the DIDT technique would have the advantage of being less harmful to graft take.
Both surgeries are done under arthroscopyallowing an opening of only a small centimeter, allowing an optical fiber to pass to control the operation.
They take place in three operating times :
- the first to remove the tendon which replaces the ruptured ligament,
- the second to put the graft in place,
- and the last to secure the new ligament.
What rehabilitation and convalescence following an ACL tear?
After the surgery, thesplint should be worn for regarding three weeks, which will be gradually unlocked in order to gradually release knee flexion. At the end of the third week, the patient can resume normal walking without any protection.
“The re-education is then proposed over several months with a certain indicative and variable time-line depending on the extent of the lesions and the patient’s ability to recover more or less quickly”, explains Dr Miniot.
And work stopping in between 1 and 3 months is generally offered, depending on the profession.