The knee has four major ligaments surrounding it. There are two on either side that are outside the actual knee joint itself. The medial collateral ligament (MCL) is along the medial (“inner”) side of the knee whereas the lateral collateral ligament (LCL) is along the lateral (“outer”) side. In the interior of the knee, there are two ligaments that “crisscross” like a cross hence the term cruciate ligament. The ACL is the anterior cruciate ligament and the PCL is the posterior cruciate ligament.
In this article, I am going to discuss the ACL as it is probably the most important ligament in the knee and also the most common knee ligament, that when torn, requires surgery.
The ACL connects the anterior (front) part of the tibia (shin bone) to the posterior (back) part of the femur (thigh bone). It prevents the tibia from sliding forward on the femur but more importantly when cutting, pivoting or turning to the opposite side, it prevents that knee from giving out in a twisting fashion, which is very important for cutting and pivoting sports such as soccer, basketball, football, etc. This is the reason the ACL is so important in these types of sports.
When it is torn, many times, athletes in these sports cannot return to play without their knee continuously giving way on them. Each time the knee gives way it can cause further damage to the cartilage on the end of the bone (the articular cartilage) or more commonly the meniscus cartilage, which is the “shock absorber” cartilage in the knee that helps protect the articular cartilage.
If the articular cartilage wears down, that is what arthritis is.
Interestingly, the anterior cruciate ligament is about five to eight times more commonly torn in females vs. males. That will be the subject of another future article, where I plan to discuss preventative programs that can help reduce this increased risk in females.
When the anterior cruciate ligament tears, it is similar to a rope tearing in that the two ends are usually pretty much shredded and because the interior of the knee has fluid in it, those ends cannot connect together to heal. Therefore, when there is a complete anterior cruciate ligament tear, it just about never heals on its own.
In the distant past, surgeons have attempted to try to sew the ends together and repair it, however, shredded ends are difficult to repair and the mid portion of the ligament is somewhat avascular. The results of repair were probably no better than 50 to 80 percent at best. While repair did work at times, it often did not allow the athletes to get back to the same level they were at previously, which is really the most important factor.
Several surgeons, including William G. Clancy, whom I trained with in Birmingham, Ala., helped develop the procedure we call, anterior cruciate ligament reconstruction (making a whole new ligament from another biologic structure). There are several different grafts which can be used to reconstruct the anterior cruciate ligament, the most common being around a 1cm strip (middle third) of the patellar tendon (kneecap tendon) with a small attached piece of bone from the patella (kneecap) and a small attached piece of bone from the tibia (shin bone). That bone-patellar-tendon-bone graft is then utilized to reconstruct or make another anterior cruciate ligament.
Other graft sources that are utilized are the hamstrings, quadriceps tendon and even allografts (grafts taken from cadavers/ deceased patients).
The procedure is somewhat complicated, but the majority of it can be done arthroscopically (with the exception of taking the graft). A tunnel is drilled through the shin bone and a tunnel is also drilled in the thigh bone. The graft is pulled through so that the pieces of bone are in the tunnels and the tendon spans the area where the ligament used to span hence becoming the new ligament. The ends of the grafts are secured into position by any number of different fixation devices and eventually the bone heals back to the bone within the first six to eight weeks. New blood vessels and cells then grow into the graft making it “come to life” as a new ligament.
The patient is usually in some type of brace and crutches for a couple of weeks. After that they walk with a little bit of a limp. By six weeks, they are walking relatively normal. By three months, they can start running and jogging on it and can do activities such as playing golf. By four months, if all goes well, they can do activities such as play softball and usually by six months, if all goes well, they can do things like play soccer, football, basketball, etc.
Those are just averages. Some people take longer and some people can get back sooner.
The one thing that most patients will say is that it takes about a year “for the knee to feel back to normal again.” This type of surgery requires several months of rehabilitation/formalized physical therapy in addition to faithfulness to an extensive home exercise program/rehab program. The physical therapy and rehab are easily just as important, if not more important than the actual surgery itself.
Dr. Marc P. Pietropaoli is a board certified/fellowship trained
orthopedic surgeon/sports medicine specialist and is president of Victory Sports Medicine & Orthopedics in Skaneateles.
The ACL connects the anterior (front) part of the tibia (shin bone) to the posterior (back) part of the femur (thigh bone). It prevents the tibia from sliding forward on the femur but more importantly when cutting, pivoting or turning to the opposite side, it prevents that knee from giving out in a twisting fashion, which is very important for cutting and pivoting sports such as soccer, basketball, football, etc. This is the reason the ACL is so important in these types of sports.
When it is torn, many times, athletes in these sports cannot return to play without their knee continuously giving way on them. Each time the knee gives way it can cause further damage to the cartilage on the end of the bone (the articular cartilage) or more commonly the meniscus cartilage, which is the “shock absorber” cartilage in the knee that helps protect the articular cartilage.
If the articular cartilage wears down, that is what arthritis is.
Interestingly, the anterior cruciate ligament is about five to eight times more commonly torn in females vs. males. That will be the subject of another future article, where I plan to discuss preventative programs that can help reduce this increased risk in females.
When the anterior cruciate ligament tears, it is similar to a rope tearing in that the two ends are usually pretty much shredded and because the interior of the knee has fluid in it, those ends cannot connect together to heal. Therefore, when there is a complete anterior cruciate ligament tear, it just about never heals on its own.
In the distant past, surgeons have attempted to try to sew the ends together and repair it, however, shredded ends are difficult to repair and the mid portion of the ligament is somewhat avascular. The results of repair were probably no better than 50 to 80 percent at best. While repair did work at times, it often did not allow the athletes to get back to the same level they were at previously, which is really the most important factor.
Several surgeons, including William G. Clancy, whom I trained with in Birmingham, Ala., helped develop the procedure we call, anterior cruciate ligament reconstruction (making a whole new ligament from another biologic structure). There are several different grafts which can be used to reconstruct the anterior cruciate ligament, the most common being around a 1cm strip (middle third) of the patellar tendon (kneecap tendon) with a small attached piece of bone from the patella (kneecap) and a small attached piece of bone from the tibia (shin bone). That bone-patellar-tendon-bone graft is then utilized to reconstruct or make another anterior cruciate ligament.
Other graft sources that are utilized are the hamstrings, quadriceps tendon and even allografts (grafts taken from cadavers/ deceased patients).
The procedure is somewhat complicated, but the majority of it can be done arthroscopically (with the exception of taking the graft). A tunnel is drilled through the shin bone and a tunnel is also drilled in the thigh bone. The graft is pulled through so that the pieces of bone are in the tunnels and the tendon spans the area where the ligament used to span hence becoming the new ligament. The ends of the grafts are secured into position by any number of different fixation devices and eventually the bone heals back to the bone within the first six to eight weeks. New blood vessels and cells then grow into the graft making it “come to life” as a new ligament.
The patient is usually in some type of brace and crutches for a couple of weeks. After that they walk with a little bit of a limp. By six weeks, they are walking relatively normal. By three months, they can start running and jogging on it and can do activities such as playing golf. By four months, if all goes well, they can do activities such as play softball and usually by six months, if all goes well, they can do things like play soccer, football, basketball, etc.
Those are just averages. Some people take longer and some people can get back sooner.
The one thing that most patients will say is that it takes about a year “for the knee to feel back to normal again.” This type of surgery requires several months of rehabilitation/formalized physical therapy in addition to faithfulness to an extensive home exercise program/rehab program. The physical therapy and rehab are easily just as important, if not more important than the actual surgery itself.
Dr. Marc P. Pietropaoli is a board certified/fellowship trained
orthopedic surgeon/sports medicine specialist and is president of Victory Sports Medicine & Orthopedics in Skaneateles.
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