The anterior cruciate ligament (ACL) is a fibrous cord found inside the knee, stretching from the shin-bone to the femur, that stabilises the joint during flexing or twisting movements. The lesion of ACL may be caused by sudden torsions or exaggerated hypertension of the leg, often while playing sports like soccer, basketball, tennis, skiing, etc.
The ACL lesion can be diagnosed with adequate clinical procedures; sometimes, arthroscopy is necessary. The lesion of the ligament does not heal by itself, not even through the immobilisation of the leg. It leads to a ligament insufficiency (lengthening) creating a feeling of instability of the knee, mainly perceived as a sudden yielding while flexing or twisting. Frequent yielding can cause new lesions to the ligaments (relaxation increases), meniscus lesions (blockings, pain, effusions) and/or cartilaginous lesions (pain and effusions).
In order to prevent new lesions that, in time, could irremediably jeopardize the functionality of the joint, such yielding episodes should carefully be avoided. This can be done by either strengthening the leg's muscles in a selective way, abstaining from sports and from any activity that would imply flexing-twisting movements of the knee, or by stabilising the joint through surgery.
As for stabilisation through surgery, there are mainly two options:
External repairs, such techniques aim at stabilising the knee through the use of muscular fascias or tendons that are taken from the external part of the knee and later made go around and outside the joint: we believe that, from our experience, such techniques are to be adopted mainly in the case of 35-40 year old people, or people who are not actively involved in sports since peripheral plastics, and medical literature agrees with this, if subject to too much stress, might lose efficiency and lead to a new case of relaxation. The advantages they have are rather short post-operative rehabilitation times (4-5 months) and that, consequently, the patient can go rapidly back to his/her job and/or sports life. Such techniques are used for young people and for those who require high level sports performance;
Intra-articular tenoplastic grafts. Such techniques imply the use of other tendons from the same patient (patellar tendon, medial flexor tendons of the knee, etc.). Once taken from where they are usually situated, such tendons are implanted inside the joint in the same position of the real cruciate ligament: most of the times we carry out the implant through arthroscopy, that is without opening the joint in order to speed up the rehabilitation of movements. Such techniques are particularly suitable for young and very active people although they require a longer rehabilitation time (7-8 months) and even a longer time (9-10) before the patient can go back to sports that have a strong impact on the knees: once implanted in the joint cavity, the tenoplastic graft dies before being slowly rehabilitated by the new tissue. Over this period of time, rehabilitation and the patient's general behaviour become extremely important for the natural evolution of this biological process. If not completed in the right way, in fact, it can jeopardise the successful outcome of the operation.
POST-OPERATIVE COURSE
Right after the surgery, the knee is immobilised in an orthopaedic knee brace while drainage rubber tubes drain the blood from the knee. The drainage is removed after 24 or 48 hours.
From the 2nd to the 20th day after the surgery:
The orthopaedic knee brace is blocked in fully extended position and needs to be always worn during the night and while walking;
the brace is taken off during the day so that the knee can immediately start the passive movement exercises of bending and extending the knee. The only active movement allowed is the bending of the knee;
Apart from a few exceptions, walking is allowed after 4-5 days with only 50% of the weight allowed, and with two artificial supports;
Ice needs to be applied on the knee various times a day (for 20 mins.) and always after rehabilitation exercises;
When the patient leaves the hospital the knee does not hurt anymore and can bend from 0° to 90°.
From the 21st to the 60th day::
The orthopaedic knee brace is blocked at 90° and is removed on the 42nd day;
The weight on the knee while walking gradually increases up to 100° with two artificial supports until the 30th day, then they are taken away;
Both passive and active rehabilitation in the gym needs to continue, better still in the special pool.
From the 60th day on::
After two and a half months, the patient can drive a car;
After 70 days, the patient can start swimming (no breast-stroke) and/or biking;
After 3-4 months, the patient can start running in a straight line;
The muscle strengthening program must continue for at least 6 months after the operation;
After 6 months, the patient can gradually start practicing twisting movements and jumping;
After 7-9 months, the patient can go back to his/her sports activities.
The most delicate moment for rehabilitation is the first three months: in this period of time the transplant is weak and an inadequate therapy can lead to its further relaxation.
POSSIBLE COMPLICATIONS LINKED TO THE RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT
LACK OF FULL EXTENSION: it could be the result of inadequate rehabilitation or of a prominent increase in the size of the new ligament that has occurred during the biological process of transformation. Around the 4th month, arthroscopic arthrolysis might become necessary.
LACK OF COMPLETE BENDING: it could be the result of a late or inadequate rehabilitation therapy. Usually, it does not create ailments nor the need for further surgery.
INFECTION: the signs are high fever and pulsing pain. The hospital must be alerted immediately: an examination will be done and after draining the fluid that might be present inside the knee, the patient will be put on an antibiotic therapy. An arthroscopic washing of the joint might be necessary if after two weeks of therapy no improvement is observed. Although very rare, this is a very dangerous complication that could jeopardize a successful operation and the complete rehabilitation of the joint.
PHLEBO-THROMBOSIS OF THE LEG: it indicates the inflammation of the veins of the operated leg (seldom the other one) which is revealed by a large swelling of the foot and of the leg itself, a strong sense of heaviness of the limb and calf pain. In order to decrease the occurrence of such a complication, it is necessary to carefully follow the heparin therapy recommended when discharged from the hospital, to avoid standing still for a long time, to start the rehabilitation therapy as soon as possible and follow it consistently.
PULMONAR EMBOLISM: it indicates the detachment of a thrombus that developed in one of the veins as a consequence of the previously described complication. The thrombus reaches the lungs and causes chest pain, difficulties in breathing, cough, sometimes bronchial catarrh containing a little bit of blood. This is a dreadful and very dangerous complication that requires immediate hospitalisation in an internal medicine ward. In order to prevent such complication from arising, the same preventive measures for phlebothrombosis need to be followed.
RELAXATION RELAPSE: may be the result of a rehabilitation therapy that is too aggressive, or of a new trauma occurred when the transplant cycle was not completed, or of a yet incomplete transplant. In this case, a new reconstruction operation appears to be necessary.
REJECTION OF THE TRANSPLANT'S SCREWS AND SECURING CLAMPS: this is a very simple complication that can be solved by removing the screws or the clamps with another very simple surgery that ensures fast rehabilitation, usually performed a year after the first operation.