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Arthroscopic Ligament Surgery
Ligaments can be referred to as the band of tough and elastic connective tissue that provides support to the joint by surrounding it and limiting the movement of the joint. Ligament damage is primarily caused by sports injury which ultimately damaged the knee. The patient feels difficulty in turning and twisting the leg and surgery.
Arthroscopic Ligament Surgery is generally recommended to patients to repair a torn ligament if other medical treatments are not able to provide the desired relief. The 4 major ligaments in the knee are ACL (Anterior cruciate ligament), PCL (Posterior cruciate ligament), MCL (Medial collateral ligament), and LCL (Lateral collateral ligament).
How to diagnose if an ACL is torn?
The patient experiences pain and swelling with a cracking (pop) sound and it feels that the knee has moved in an odd way. The injury caused is considered a minor sprain. The feeling of instability restricts the individual from doing rigorous activities such as running, jumping, etc. People with low levels of physical activity can manage the condition with a ruptured ACL, but in players and others, potential weakness in the knee is felt.
Torn ACL can be diagnosed with the help of MRI although it is difficult to differentiate whether it is a partial or complete tear. To be more sure regarding torn ACL, arthroscopic viewing is recommended.
Treatment options for torn ACL
Non-Surgical (Physiotherapy):
Patients with low physical activity levels and who are not involved in activities like sports, running, etc. can go for physiotherapy for a torn ligament. Physiotherapy can help in controlling the excess pressure on the knee and thus, routine work can be done without much difficulty. But if physiotherapy does not provide desired relief to the patient, the problem can increase and the patient might need to undergo surgery like ACL Reconstruction.
ACL Reconstruction
Unlike other surgeries, a torn ligament cannot be repaired as it is a band-like structure having two ends that cannot be joined. What the surgeon can do is to make a new ligament/ reconstruct the new ligament by placing a secondary ligament (graft) near the torn ligament. The new graft fixes near the original ligament and once it gets completely incorporated and starts taking blood supply from the body, it acts as the natural ligament.
What is ACL Reconstruction Surgery
The surgery involves the reconstruction and replacement of the torn ACL. The knee joint is made up of thigh bone (femur), patella (kneecap), and shinbone (tibia). ACL is also a type of knee ligament and ACL injuries are quite common athletes. The surgery is recommended to patients as it helps restore stability, pain-free range of motion, and functionality to the knee joint that is damaged due to an ACL injury.
Arthroscopic ACL Reconstruction
ACL Reconstruction can be done through open surgery or arthroscopic i.e. key-hole surgery. Arthroscopy surgery has multiple benefits in terms of minimum scars, faster recovery, and shorter hospital stay. The procedure is also used for re-confirmation once it is already confirmed by the MRI reports.
The process involves obtaining the graft from the knee and designing it to shape the ligament. Thereafter, tunneling techniques are used for inserting the graft in the knee without opening it. With the availability of modern fixation devices, no extra efforts are required for cutting and the graft is fixed at the two ends. The largest cut is approx 1 inch and less relevant tendons such as Hamstring tendons are taken which are present on the side of the knee.
There are no side-effects due to the removal of these tendons. Efforts are made to preserve the torn ligament as it is quite beneficial for the knee in the long run. Thereafter, a necessary post-operative rehabilitation program is recommended for the patient for a faster and timely recovery.
Why is surgery needed?
For many patients, it is possible to lead a normal life despite knowing the fact that they are suffering from a torn ligament. Significant changes in the existing lifestyle means involving in low-impact physical and sports activity. The patients should avoid activities such as running, climbing stairs, walking on the irregular ground in case they continue with the torn ligament but patients such as players who want to engage in the active sports activity. Playing with a weak knee not only leads to repeated injuries but can permanently damage the knee. Therefore, timely action should be taken as ACL Reconstruction is not emergency surgery, and physiotherapy at the initial stages can provide relief to some extent.
Kinds of ACL surgery
The torn ACL does not heal on its own by just sewing the torn ligament back together. ACL Reconstruction Surgery utilizes connective tissue grafts such as ligaments and tendons for rebuilding and replacing the torn ACL ligament. The body gradually heals around the graft after a few months. There are different kinds of ACL surgery procedures which are as follows:
Autograft ACL Reconstruction:
In this kind of surgery, autograft which is the patient’s connective tissue is taken from the patellar tendon. This is the primary approach for ACL autograft reconstruction. The missing part of the patellar tendon grows over some time and heals itself. The other sites for autograft reconstruction include quadriceps and hamstring tendons. The healing is not as fast as the patellar tendon. As compared to allograft reconstruction, it involves a larger incision, more surgery time, and post-operative pain.
Allograft ACL Reconstruction:
The surgery requires using cadaver connective tissue such as a tendon which can be obtained from a tissue bank. Although there is a risk of infections such as Hepatitis and HIV, the method is more suitable than autograft surgery as it needs only one incision and is less painful.
Recovery Post ACL surgery
The recovery post-surgery is a gradual process and the patient is advised to wear a knee brace and use the crutches to provide enough support to the newly reconstructed ligament. The doctor will provide a complete rehabilitation program that includes physiotherapy and exercises to ensure better recovery of the patient. All this helps in developing knee strength and restoring range of motion. The recovery time also depends on several factors such as the type of surgery, the overall health conditions, age, kind of anesthesia used, etc. The complete recovery might take a year especially if the patient is engaged in sports activities.
Other ligaments
Posterior Cruciate Ligament (PCL)
Posterior Cruciate Ligament (PCL) is the ligament that joins the thigh bone (femur) to the shinbone (tibia). It controls the back and forth motion of the knee and is considered to be the strongest ligament after ACL. The pain due to PCL injuries generally arises behind the knee. Although ACL ligament injuries commonly occur PCL injuries also account for more than 20% of all knee injuries. PCL tear can occur due to trauma, road accidents, falling on the knee while bending at the time of playing any sports.
Based on the severity of the injury, surgical and non-surgical treatment can be recommended to the patient. Surgical: PCL Reconstruction surgery is suggested to patients with dislocated knee and multiple ligament injuries. Non-Surgical: The RICE protocol needs to be followed which includes Rest, Ice, Compression, and Elevation. This helps in reducing pain and swelling to a certain extent. A knee brace can assist by immobilizing the injured knee. Physical therapy can help in restoring knee motion and strength. Crutches can be used for avoiding weight on the affected leg.
The surgery is performed by taking autograft or allograft tissues for replacing the torn PCL ligament. Depending on the patient’s specific requirements and the lifestyle they follow, both kinds of surgeries can be performed. Younger patients who are indulged in athletic activities are treated with the autograft method while the patients who are older and do not have an active lifestyle are treated with an allograft procedure. The PCL Reconstruction is performed as a minimally invasive procedure in which the damaged ligament is replaced with a graft.
Medial Collateral Ligament (MCL)
The Medial Collateral Ligament (MCL) runs from the femur (thigh bone) to the top of the tibia (shin bone) and is located in the inner side of the knee joint. The MCL provides overall stability to the knee and therefore, MCL tear during any sports injury or due to a fall can lead to utmost discomfort to the patient. Although small tears can heal on their own, reconstruction or repair surgery may be required to heal severe MCL injuries. The reconstruction surgery restores the stability and function of the knee joint.
The surgery procedure is similar to those of ACL and PCL Reconstruction and uses a donor or hamstring graft that is harvested from the patient. This is useful for patients who are suffering from severe ligament tears. The graft replaces the torn ligament with new tissue and it is supported by screws that are placed in the bone. The surgery is considered to be highly effective in restoring knee stability and managing the affected area.
Unlike ACL, PCL, MCL injury, a multi-ligament injury occurs where there is potential damage to two or more ligaments of the knee due to any trauma or considerable force or a powerful blow to the knee. Along with the ligaments, the other structures of the knee are also damaged in a multi-ligament injury such as the tibia (shin bone), meniscus, patella (knee cap), femur (thigh bone), and the costochondral cartilage (inner surface of the knee joint) and the nearby soft tissues.
Multi-ligament injuries result in pain and knee instability and take much more time to recover than the injury in which a single ligament or structures are involved. A multi-ligament surgery is the only option to treat such injuries and the underlying conditions caused such as pain, improper functioning of the knee, the chances of development of diseases such as arthritis.
The multi-ligament reconstruction surgery is performed when multiple structures of the knee joint are damaged. Single or multiple grafts can be used for securing the ligaments and structures back into place. The surgery will be done keeping in mind several factors such as the technique used, the choice of graft and the structures that can heal on their own, and which ligaments require reconstruction surgery.