Cruciate Ligament

CRUCIATE LIGAMENT

Cruciate ligament rupture (ACL tear): The knee specialists at the SPORTambulatorium Wien – Center for Orthopedics and Sports Traumatology, under the guidance of highly experienced knee surgeon Dr. Christian Gäbler, provide expert and personalized care of ligament injuries to your knee using the most modern arthroscopic surgical methods, as well as non-surgical treatment whenever possible.

CRUCIATE LIGAMENT INJURIES

>> More detailed state-of-the-art article, please click here (.pdf 207 KB)

The knee is a rolling-sliding joint. The cruciate ligaments are the central and most important stabilisers in the knee joint. The anterior cruciate ligament prevents excessive sliding of the lower leg forwards. The posterior cruciate ligament tightens during the bending movement and prevents the lower leg from moving backwards.


ANTERIOR CRUCIATE LIGAMENT

Injuries of the anterior cruciate ligament are particularly common and occur in the context of external rotation movements of the leg with static lower leg and simultaneous flexion (especially common in football, but also in skiing, combat sports, in-line skating etc.) or as a result of hyperextension injuries (especially common in skiing).
Note – a cruciate ligament tear does not have to be extremely painful and is sometimes trivialised by those affected, see also PDF / courier article from Dec. 2010

Diagnosis is initially carried out clinically by means of an examination, X-ray and magnetic resonance imaging (MRI) can be used as supporting investigations.

The main problem in the case of a cruciate ligament tear is instability. The patient feels as though the knee is giving way. As a result of the (mostly chronic) instability of the knee joint, there is overexertion of the other stabilisers of the knee joint, therefore further injuries and cartilage damage occur more often in the knee, particularly in sporty patients. For these reasons, an operation is generally recommended for top and recreational athletes.

Even though many recreational athletes (and professional athletes too) have good musculature and are able to stabilise the knee very well in the beginning, types of sport with rapid turning movements or sudden stopping (stop-and-go) cause enormous gravitational forces, which very quickly lead to meniscus and cartilage destruction in the knee joint without a stable cruciate ligament. The occurrence of high shearing forces, however, also affects people who enjoy hiking or mountain climbing (as a result of the high strain when coming downhill) and also runners who do not run solely on flat ground.

It is recommended that athletic patients undergo cruciate ligament surgery as soon as possible in order to keep the recovery time short. Another advantage of early surgery is that it makes the immediate rehabilitation of common injuries to the meniscus possible. Injuries to the medial collateral ligament (MCL) do not usually need to be operated, unless the MCL is torn through.

Image: Typical cruciate ligament tear seen with arthroscopy

I sometimes see patients in my office who have been told, at a ski resort for example, that a cruciate ligament tear must be operated on within 24 hours, as massive knee problems can otherwise arise and, in a worst-case scenario, the knee could become stiff. This is not true and not in line with the current state of research. If you have ever felt pushed in this way to undergo an acute operation, I would highly recommend that you arrange to see a trusted doctor of your choice immediately.

Current research clearly shows that it is possible to undergo cruciate ligament surgery up to 7-10 days after the injury. See, for example, a study on the topic published in late 2018 by the renowned Karolinska Institute in Stockholm: “No risk of arthrofibrosis after acute anterior cruciate ligament reconstruction” (Knee Surg Sports Traumatol Arthrosc. 2018)

What is indeed important, of course, is that a clinical examination and definitive MRI diagnosis are undertaken as soon as possible, because only with a rapid diagnosis will it be possible to stay within the tight time window of 7-10 days in which an operation is possible. If you are in need of an urgent appointment at the Sportambulatorium, contact us at: 01 4021000.

After 10-14 days (and sometimes much earlier), an inflammatory reaction occurs in the knee joint, causing increased swelling, inflammation, and reduced mobility of the knee. If a new cruciate ligament is implanted at this stage, there is a high risk of postoperative mobility restriction, or arthrofibrosis. This means that after the initial operation window described above, the next possible time to operate is about 6-8 weeks later. Your surgeon can use arthroscopy to see if your knee is already — or still — too inflamed to operate, in which case a decision can be made to do reconstructive surgery at a later date.

However, it may in some cases be recommended to undergo knee surgery during the phase when ACL replacement surgery is not possible, for example, when the ACL is torn off at the bone and can be sutured again (see below, cruciate ligament suture (reinsertion or refixation) ) or if an MRI shows a meniscal tear in addition to the ACL injury. In this case, the meniscus is sutured in an initial operation, and once the inflammation has subsided the ACL is reconstructed.

The operation must be assessed in a detailed discussion and geared towards the athletic requirements, occupational physical exertion and the age of the patient. If there is the indication for surgical treatment, the cruciate ligament is replaced using an autologous tendon, as direct suturing of the cruciate ligament has not proven successful. Either two hamstring tendons (STG) , the middle third of the patellar tendon (BTB), or the quadriceps tendon are used as a replacement tendon.

The choice of replacement cruciate ligament tendon is determined by factors such as level of activity, additional injuries or previous damage, degree of instability etc. and is discussed in detail with the patient.

In over 90% of patients, the cruciate ligament replacement operation can restore full function, movement and strength. However, the cruciate ligament is home to receptors that constantly send information to the brain regarding the position of the body in a space (= proprioception), and therefore also activate different muscle groups. Disappearance of these receptors alone causes a certain deterioration in fine motor skills and coordination and very often causes the knee to suddenly feel very different for the patient for months or as a patient once said to me, "...it is as though my knee no longer belongs to me...". Depending on how consistently patients carry out coordination training (e.g. on a multifunction testing board), this feeling usually disappears within 6 – 24 months, as a result of the new formation of receptors.

Our primary goal is always to retain the ACL whenever possible. However, this is only a possibility in the 10–20% of cases in which the ACL is torn at the very top of its anchoring point and blood flow to the ACL has thus not been interrupted. This is more common with children and adolescents than with adults. In such cases, the ACL can be reattached with a type of dowel pin (reinsertion) and can then heal and reattach. See below for more about cruciate ligament reinsertion and refixation.

THE OPERATION METHODS
  • STG (semitendinosus and gracilis transplant):

The term STG technique comes from the shortened names of the tendons used (semitendinosus and gracilis tendons).

Both these tendons are hamstring tendons that can be removed without a significant loss of strength and function for the knee joint.

The advantage of this technique is the high tractive force of the tendon used and the fact that the bone blocks heal very quickly and the patient therefore achieves optimal stability of the knee joint very quickly and therefore can be reintegrated into training relatively soon.

The disadvantage of the technique is that patients complain of pain at the extraction sites of the bone blocks (anterior knee pain) at a rate of approx. 10%, predominantly during activities that involve kneeling. Moreover, complications such as patellar fractures and tendon tears are described. The main problem with the method, however, is that long-term studies clearly prove that almost all patients with a BTB transplant demonstrate more or less pronounced retropatellar arthrosis (= cartilage damage behind the patella) after 20 years.

The operation begins with arthroscopy (any meniscus or cartilage damage that may be present is also treated at this time) and removal of the remnants of the ruptured cruciate ligament (if a good cruciate ligament stump is available, however, this can be left to retain the body's own receptors). The bone is then debrided in the areas of attachment of the cruciate ligament.

Contrary to the BTB transplant, an incision of only approx. 3 cm under the patella is required, via which the two hamstring tendons are taken and also through which the bone canal is drilled in the lower leg.

Then drilling is carried out for the attachment of the transplant in the femur, the STG transplant is inserted and fixed into position using a special technique. Bioresorbable screws are usually used in this method. These are screws that slowly dissolve after a few years or are re-absorbed by the body.

I prefer the all-inside technique, without the use of screws, as the self-dissolving screws can result in certain complications, such as excessive antibody production or bone cavity development.

Image: copyright Arthrex

"All inside" technique
To ensure that the operation is as gentle as possible with less pain and a lower operation risk, I prefer the “all inside” technique for a cruciate ligament tear: during this, a tendon sutured four times (gracilis or semitendinosus) is inserted into bone recesses using smaller incisions (in contrast to the continuous bone canals used in the earlier methods, which significantly traumatise the bone and the skin on the leg and are naturally linked to significantly more pain and postoperative problems). Tissue damage is lower and the cosmetic result is significantly better as a result of the smaller incisions. I am often surprised myself by how much better the injured athletes are after an “all inside” operation in comparison to the conventional methods.

Anchoring in the “all inside” technique is carried out using endobuttons - it is therefore also the method of choice when treating cruciate ligament tears in children.

Immobilisation of the knee is only required in the case of concomitant injuries.

  • BTB (Bone-Tendon-Bone):

The name BTB technique comes from Bone-Tendon-Bone and means that the transplant consists of a bone block, a section of tendon and another bone block.

The tendon used in this technique is the patellar tendon, i.e. the tendon that connects the patella to the lower leg and therefore has an important extension function.

The advantage of this technique is the high tractive force of the tendon used and the fact that the bone blocks heal very quickly and the patient therefore achieves optimal stability of the knee joint very quickly and therefore can be reintegrated into training relatively soon.

The disadvantage of the technique is that patients complain of pain at the extraction sites of the bone blocks (anterior knee pain) at a rate of approx. 10%, predominantly during activities that involve kneeling. Moreover, complications such as patellar fractures and tendon tears are described. The main problem with the method, however, is that long-term studies clearly prove that almost all patients with a BTB transplant demonstrate more or less pronounced retropatellar arthrosis (= cartilage damage behind the patella) after 20 years.

The operation begins with arthroscopy (any meniscus or cartilage damage that may be present is also treated at this time) and removal of the remnants of the torn cruciate ligament.

The bone is debrided in the areas of attachment of the cruciate ligament. Many surgeons now make a larger incision over the tendon, through which the whole operation area is viewed and the tendon can be recovered. As injuries to nerves with a feeling of numbness often occur, I prefer two small incisions over the bone blocks and recovery of the middle section of the tendon and sections of bone (bone blocks approx. 1.5 cm in length and 8 mm wide from the tip of the patella and the tibial plateau) using a minimally-invasive technique (keyhole technique).

The drill holes for the attachment of the bone blocks in the region of the former attachment and origin of the anterior cruciate ligament are then carried out, the cruciate ligament is then inserted and fixed into its location using special screws (interference screws made from titanium).

Immobilisation of the knee is only required in the case of concomitant injuries.

  • Cruciate ligament suture (reinsertion and refixation):

If the ACL is torn at the top of its anchoring point (which occurs in about 10-20 % of cases and occurs more often in children and adolescents), it is possible to reaffix it using special dowel bolts. This method has the advantage of being much gentler than other methods. The ACL and all its receptors are preserved, and no tendons must be removed.

An ACL reinsertion can be elegant and minimally invasive, requiring only three very small incisions 4–5 mm in length. During the procedure, the ACL is looped with a special retention stitch and then reaffixed with a dowel pin at the correct point (see Fig. 1).

In order for healing to progress optimally, I make tiny incisions in front of, above, and behind the cruciate ligament (see Fig. 2). These incisions can allow stem cells to emerge from the bone. These cells stimulate a natural healing response that supports ACL recovery right where it is needed. I have used this technique on several hundred patients already and have had excellent results. The re-rupture rate (i.e., the likelihood that treatment fails) is less than 0.5% if the diagnosis was correct.

  • Synthetic ligament:

To avoid destroying the autologous receptors and also to avoid the disadvantages of the aforementioned methods, an synthetic ligament (LARS) can also be used in certain cases (if a good cruciate ligament stump is available). In this technique, the synthetic ligament should not replace the cruciate ligament (that would not function in the long-term), but rather stabilise the cruciate ligament until it is healed. Numerous studies have shown in recent years that the results using this synthetic ligament are very good and the complication rates are very low (if it is used correctly). If placed incorrectly, however, problems can develop rapidly - this method should therefore only be used by experienced knee surgeons (who are also trained in this technique).

An indication that presents an exception for the synthetic ligament are athletes for whom several operations have failed, and in whom the synthetic ligament is then used as a cruciate ligament prosthesis; or older people with unstable knee joints, who do not have very good tendons of their own, yet they still want to remain active in sport.

  • Quadriceps tendon:

This section of tendon placed over the patella is used in revision operations if STG and BTB have already been removed or are not available for other reasons.

POSTERIOR CRUCIATE LIGAMENT

Injuries to the posterior cruciate ligament mainly occur as the result of significant trauma, such as car accidents or ball sports (American football, handball, etc.).

These injuries are essentially rare for a tear of the anterior cruciate ligament and can be healed surgically but also without an operation. The operation depends on the degree of instability, the symptoms and primarily the sporting requirements of the patient.

In the case of fresh injuries, the use of the synthetic ligament (LARS) is extremely promising and gentle for the athletes affected. In chronic cases, I use a quadriceps tendon in the inlay technique or an STG transplant (see above for removal, advantages and disadvantages, etc.)


CRUCIATE LIGAMENT INJURIES IN CHILDREN

Cruciate ligament injuries in children are rare and are therefore often initially overlooked in the investigation. It is important that specialists carry out an investigation into persisting symptoms and an MRI in all cases. The majority of children are initially immobilised using a splint, so that the anterior cruciate ligament has the opportunity to heal (this also works in approx. 50% of cases). Another clinical examination is carried out six to eight weeks after injury and another after approx. three months. If the knee joint remains unstable, early operation is recommended to the parents and the child, as additional injuries to the menisci and cartilage occur very frequently, due to the high activity potential of children - which sets a course for rapid and premature destruction of the knee. 

If a knee is clearly unstable, I recommend immediate surgery. ACL suture or reinsertion is often possible, especially for children, and the sooner surgery is performed, the higher the chances of success. Alternatively, an ACL replacement (all-inside) is also possible.


CRUCIATE LIGAMENT INJURIES IN THE ELDERLY

Cruciate ligament injuries in the elderly are rare and are often not operated on due to the predominantly low degree of activity. The primary treatment is immobilisation and muscle strengthening (physical treatment) - old and untreated cruciate ligament injuries with complications (arthrosis)are often the problem. The increasing number of senior citizens who are very active, who want to go hiking in the mountains with a stable knee or battling on the tennis court, is an exception. This group obviously needs a stable cruciate ligament and the method should be discussed on a case-by-case basis (STG or synthetic ligament).


REHABILITATION

50% of operation successes are achieved by means of subsequent rehabilitation and physical therapy. Full range of movement, muscle strength and coordination are only regained with this appropriate postoperative treatment.

Please note that medical indications and therapies are constantly changing. Partly, these changes happen more quickly when I am able to update my homepage. Some information on dosage, administration and drug compositions may have changed in the meantime. Reading a website can not replace a visit to the doctor - it may be that other information will be communicated to you through new scientific findings in a study and subsequent discussion by your doctor.

Reviews

DocFinder Profile

Kreuzband reinseriert

Ich kam zu Dr. Gäbler nach einem Telemarkunfall im Februar um mein Kreuzband zu behandeln. Da es meine erste Operation war, stieg die Nervosität doch beträchtlich. Dr. Gäbler nahm mir diese jedoch durch seine entspannte, freundliche und kompetente Art rasch. Die OP verlief ausgezeichnet. Beugung des Knies mittlerweile vollständig möglich, keine Schmerzen und Belastbarkeit ist gegeben. Ich darf mich auch auf diesem Wege für die ausgezeichnete Behandlung bedanken.

Sportambulatorium Wien
2020-01-14T14:10:41+01:00
Ich kam zu Dr. Gäbler nach einem Telemarkunfall im Februar um mein Kreuzband zu behandeln. Da es meine erste Operation war, stieg die Nervosität doch beträchtlich. Dr. Gäbler nahm mir diese jedoch durch seine entspannte, freundliche und kompetente Art rasch. Die OP verlief ausgezeichnet. Beugung des Knies mittlerweile vollständig möglich, keine Schmerzen und Belastbarkeit ist gegeben. Ich darf mich auch auf diesem Wege für die ausgezeichnete Behandlung bedanken.

Ein Arzt Ihres Vertrauens

Mein Knie wurde von anderen Ärzten schon zweimal operiert, die Schmerzen hörten nicht auf und es gab keinerlei Verbesserung. Auf Empfehlung kam ich dann zu Prof. Christian Gäbler und das war das beste, das mir passieren konnte! Ich musste noch mehrmals operiert werden, bekam dann im Oktober 2018 ein TEP Kniegelenk und seitdem geht es täglich besser und ich kann nun wieder Dinge unternehmen, von denen ich nur träumen konnte!! (radfahren, tanzen, wandern...)
Die wertschätzenden Gespräche vor und nach den Operationen waren äußerst kompetent, menschlich, wertschätzend und sehr, sehr hilfreich! Danke nochmals an Prof. Christian Gäbler und sein gesamtes Team!!!

Von einem DocFinder Nutzer

Sportambulatorium Wien
2019-11-19T10:05:21+01:00

Von einem DocFinder Nutzer

Mein Knie wurde von anderen Ärzten schon zweimal operiert, die Schmerzen hörten nicht auf und es gab keinerlei Verbesserung. Auf Empfehlung kam ich dann zu Prof. Christian Gäbler und das war das beste, das mir passieren konnte! Ich musste noch mehrmals operiert werden, bekam dann im Oktober 2018 ein TEP Kniegelenk und seitdem geht es täglich besser und ich kann nun wieder Dinge unternehmen, von denen ich nur träumen konnte!! (radfahren, tanzen, wandern...) Die wertschätzenden Gespräche vor und nach den Operationen waren äußerst kompetent, menschlich, wertschätzend und sehr, sehr hilfreich! Danke nochmals an Prof. Christian Gäbler und sein gesamtes Team!!!

“The kind of sports doctor you really wish for!

From rapid diagnosis to effective and efficient treatment, even if an operation turns out to be inevitable, I have only the best to report. My experience comes from multiple injuries and, unfortunately, surgeries due to being an ambitious recreational athlete. My most recent surgery was a prosthetic knee (TEP), and although this was a major operation, the surgery itself and subsequent care was so good that I was able to begin light training sessions (ergometer and gymnastics) within a few weeks.
Zusammengefasst: ein Top-Arzt!

Von einem DocFinder Nutzer

Sportambulatorium Wien
2019-11-19T10:11:20+01:00

Von einem DocFinder Nutzer

Von der raschen Diagnose bis zur effektiven und effizienten Behandlung, bzw. auch wenn eine OP unumgänglich ist, kann ich nur das Beste berichten. Diese Erkenntnis basiert auf vielen Verletzungen und leider auch OPs die ich als ambitionierter Freizeitsportler gehabt habe. Die letzte OP war eine Knie-Prothese (TEP) und selbst diese große Operation und nachfolgende Behandlung war derart gut, daß ich schon nach wenigen Wochen mit leichten Trainingseinheiten (Ergometer und Gymnastik) beginnen konnte. Zusammengefasst: ein Top-Arzt!

Beeindruckende Professionalität

Nachdem wir das Problem unseres Sohnes zunächst unterschätzt hatten, war am Tag 11 nach der Verletzung mit der Diagnose Meniskuseinriss und Kreuzbandriss plötzlich "Feuer am Dach".


Ab dem Erstkontakt mit der Sportordination ging es dann sehr schnell: Anruf um 8:00, Termin mit exakter Diagnose und Beratung um 16:30, Operation am nächsten Tag 13:00, Entlassung aus dem Krankenhaus am Tag darauf. Dr. Gäbler konnte das (eigene) Kreuzband "refixieren" - sofortiger Start mit Physiotherapie - sofort "mobil" - schmerzfrei nach drei Tagen - zwei Wochen nach der Op. kann unser Sohn sich problemlos ohne Krücken (nur mit Orthese) im Alltag bewegen.


Das gesamte Team der Sportordination vermittelt beeindruckende Professionalität verpackt in sehr freundliche und wertschätzende Patientenkommunikation.

Sportambulatorium Wien
2020-01-14T13:45:47+01:00
Nachdem wir das Problem unseres Sohnes zunächst unterschätzt hatten, war am Tag 11 nach der Verletzung mit der Diagnose Meniskuseinriss und Kreuzbandriss plötzlich "Feuer am Dach". Ab dem Erstkontakt mit der Sportordination ging es dann sehr schnell: Anruf um 8:00, Termin mit exakter Diagnose und Beratung um 16:30, Operation am nächsten Tag 13:00, Entlassung aus dem Krankenhaus am Tag darauf. Dr. Gäbler konnte das (eigene) Kreuzband "refixieren" - sofortiger Start mit Physiotherapie - sofort "mobil" - schmerzfrei nach drei Tagen - zwei Wochen nach der Op. kann unser Sohn sich problemlos ohne Krücken (nur mit Orthese) im Alltag bewegen. Das gesamte Team der Sportordination vermittelt beeindruckende Professionalität verpackt in sehr freundliche und wertschätzende Patientenkommunikation.

SEHR Kompetent! Es macht Sinn, nur die Besten zu wählen!

Nach einem Skiunfall erlitt ich einen Meniskus-Einriss und Kreuzbandriss.


Die OP - durchgeführt von Dr. Gäbler - war sehr erfolgreich, komplikatonsfrei und der Heilungsverlauf war für mich überraschend schnell und ebenfalls sehr gut. Bereits nach 7 Monaten habe ich wieder volle Sportfreigabe.


Man fühlt sich bei Dr. Gäbler einfach von Beginn an sehr gut aufgehoben & kompetent beraten. Das gesamte Team ist einfach fabelhaft. Es macht schon Sinn, sich die Besten zu wählen.


Der Erfolg macht es sichtbar !

Sportambulatorium Wien
2020-01-14T13:47:29+01:00
Nach einem Skiunfall erlitt ich einen Meniskus-Einriss und Kreuzbandriss. Die OP - durchgeführt von Dr. Gäbler - war sehr erfolgreich, komplikatonsfrei und der Heilungsverlauf war für mich überraschend schnell und ebenfalls sehr gut. Bereits nach 7 Monaten habe ich wieder volle Sportfreigabe. Man fühlt sich bei Dr. Gäbler einfach von Beginn an sehr gut aufgehoben & kompetent beraten. Das gesamte Team ist einfach fabelhaft. Es macht schon Sinn, sich die Besten zu wählen. Der Erfolg macht es sichtbar !
0
0
Sportambulatorium Wien