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Rupture of the anterior cruciate ligament - ACL rupture

ACL (recently also abbreviated as LCA) is short for «anterior cruciatum ligament». It is a very strong inner knee ligament, often injured in professional or recreational athletes, and the recovery is long and complicated.

In order to understand the importance of this ligament in the knee system, we must mention that the joint socket in the biggest joint of the human body (knee) is very shallow, and the ball resembles a cylinder. This allows for a greater mobility but also makes the entire system unstable and prone to injuries. To diminish the possibility of „ejecting“ the joint structures from their natural slots, the knee is surrounded by a few levels of defence. First of them are, of course, muscles, and those around the knee are the strongest in the body. Then there is an entire complex of outer ligaments that surround the joint and give him extra firmness. And finally, we have two inner ligaments, buried deep inside the knee, which are called anterior and posterior cruciate ligaments. ACL prevents the ball of the knee from going forwards in many sports and other activities. The injury mechanism (ACL rupture) is based on the trauma – the kind that directs the outside forces to the knee, making it extend and rotate. There are many examples of this, from falling while skiing,  landing in volleyball, changing direction in handball, all the way to lower leg blockage while the body is still moving (martial arts, slide tackle in football etc.). Almost always there is a presence of intense pain followed by swelling and diminished knee mobility. We must immediately use ice and elastic compress to prevent further swelling. Next step is providing a correct diagnosis.

In the first exam the doctor wil try to aspirate (evacuate) the swelling, and if there's blood, it is a first sign of a probable ACL rupture. Removing the blood from the knee also leads to diminished pain. After that, we must do a series of tests and establish a final diagnosis. Unfortunately, ACL rupture is rarely the only injury present.  Considering the connection of the joint structures, as well as the forces present in order for that injury to happen, damages to other knee structures happen, most often meniscus, then collateral ligament (one of the outer knee ligaments), sometimes the cartilage, and rarely the posterior cruciate ligament (PCL).  To establish the state of the knee (necessary for planning the treatment) there are two types of diagnostics. One is magnetic resonance (MR), which gives us insight into soft tissue in the joint. If the image is clear and undoubtedly shows the damage, further therapy can be considered. If there are doubts as to what exactly is damaged (not even MR is 100% correct), arthroscopy needs to be done, which is basically a small operating procedure where two probes enter the knee and visually check the damage.

After the final diagnosis of the ACL rupture, treatment follows, which is never simple nor fast. If we have a partial rupture, non-operating procedure follows, meaning physical therapy and kinesiotherapy. The goal is to remove the swelling if it is present, and gradually strengthen the muscles surrounding the knee, preparing them for everything that a sports activity brings (if the patient is an athlete). This whole process lasts for about 12 weeks, and it includes the techniques of improving endurance, speed of reaction, and balance.

When the complete rupture of ACL is present, things get more complicated, because this ligament cannot be simply „sewn“ together and repaired. It is a defficiency of a crucial knee stabilizer, so modern orthopaedics tries to do a so-called knee „plastic“. This operating procedure involves taking a part of patellar ligament or a part of the hamstring tendon, and implanting it in the place of the ruptured ACL. This procedure is very serious because it involves drilling through the upper and lower leg bones, and in those holes we put the ligament endings. In the end everything is fixated with bolts. Post-operating period involves a long rehabilitation, lasting 6 months, and involving everything mentioned for partial ruptures. We must also say that the success rate varies between 70% and 90%, depending on the provided studies. Successful results mean that patients (including athletes) can return to full scale physical activity they practice before the procedure.

It is important to say there is also an alternative to operating procedure. Non-operating procedure involves (just like in the case of partial rupture) enabling the muscular and ligament systems to take over a part of or a complete function of stabilizing the knee. A positive side of this approach is the fact that the operation is avoided and rehabilitation time shortened to three months. But the danger lies in the possibility that if „ejection“ of the knee happens again, it will lead to new injuries and instabilities in the knee (like meniscus, cartilage, or other ligaments). So we must carefully weigh the pro and con reasons for operating procedure in a specific case, and reach an agreement with the patient.

Generally speaking, ACL plastic is avoided with very young and very old patients. First ones because the growth isn't finished, and second ones because this type of injury will not affect their mobility in a very significant way. Pateint's physical activity is also very important. If we have a person that doesn't move a lot and has no sports affinities, operation will not be necessary. On the other hand, if we have an active or professional athlete (especially in sports like skiing, basketball, handball, or volleyball), ACL plastic can provide the best solution possible.
 
To tell the truth, there is a great number of athletes who returned into sports after this injury even without the operation. There are also many who tried, but were in the end forced to undergo the operating procedure. It all says that in the case of complete ACL rupture the decision onn treatment must be reached individually, respecting the patient's specific case.

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