How do anterior cruciate ligament injuries occur, what are the treatment stages?

The anterior cruciate ligament is one of the structures that connects the femur and tibia bones in the knee joint. This ligament, which is very important for the normal function of the knee, is the most important structure that prevents abnormal forward displacement of the tibia bone.

Anterior cruciate ligament injuries take the first place among the injuries that occur during sports and cause athletes to stay away from sports for more than 4 weeks. Anterior cruciate ligament injuries are followed by medial meniscus and medial lateral ligament injuries. It has been determined that approximately 200,000 anterior cruciate ligament injuries occur annually in the United States. It is expected that this frequency will increase with the increase in the interest of the society in sports. Although there are no reliable data in our country, it is estimated that around 3 thousand anterior cruciate ligament injuries occur annually.


Anterior cruciate ligament injuries usually occur during sudden rotation on a fixed foot. It often happens during a movement performed by the athlete himself. Less commonly, anterior cruciate ligament injuries can occur after direct blows to the knee, traffic accidents, falls from height, and industrial accidents. In this case, injuries to the posterior cruciate ligament, lateral ligaments and menisci can be added to the anterior cruciate ligament injuries. Due to the structural characteristics of female athletes, anterior cruciate ligament injuries are more common than male athletes. While injuries in adults are in the form of rupture of the ligament from the body, injury in children may be in the form of a piece of the ligament from where it attaches to the bone.


During an anterior cruciate ligament injury, severe pain occurs with a sudden rupture sensation in the knee. Some athletes can hear the sound of the ligament breaking and often fall to the ground. Swelling occurs due to the rapidly developing bleeding inside the knee joint. The athlete usually cannot continue the sport and has to leave the competition. Depending on pain and swelling, limitation of motion in the knee occurs and limping occurs. Some athletes may feel their knees popping in and out.

Within a few days-weeks, swelling and pain in the knee joint are reduced. Knee movements are gained and the limp disappears. However, this time, there is a feeling of space and insecurity in the knee, especially during sudden turns, during sudden deceleration and when descending the stairs. Sports such as swimming and cycling can be done on knees with anterior cruciate ligament rupture; However, it is not possible to perform sports such as football, basketball, handball, volleyball, skiing with sudden jumps, turns and accelerations at a high level. If the athlete wants to continue these sports without the anterior cruciate ligament, the risk of new injuries and increased damage to the knee is very high.


Anterior cruciate tear should be considered in every athlete who has severe pain and swelling after a sudden rotational movement in the knee. Immediately applying ice to the knee and wrapping an elastic bandage will reduce swelling and pain. The athlete must not be allowed to return to the competition. The athlete should leave the field without putting any weight on the relevant leg and use crutches until a definitive diagnosis is made.


The diagnosis of an anterior cruciate ligament tear begins with a detailed description of the way the injury occurs. This is followed by a careful examination. Only with this history and examination, the diagnosis of anterior cruciate ligament tear can be made at a rate of over 90%. Sometimes, an adequate examination may not be performed because the knee is very painful at first. In this case, a second examination within 10 days is diagnostic. If an early diagnosis is required in high-level professional athletes, MRI is helpful in diagnosis.

X-rays should be obtained in all patients with a serious knee injury and it should be investigated whether there are any fractures in the bones. X-rays are usually normal in anterior cruciate ligament injuries. Magnetic resonance imaging has an accuracy rate of over 90% in the diagnosis of anterior cruciate ligament tears. In addition, concomitant meniscus, lateral ligament and cartilage injuries and bone edema can be diagnosed. However, although rare, MRI can be misleading. Although the ligament is injured to a point where it cannot function, it can be seen that the continuity of the ligament is preserved on MRI. Therefore, MRI is not the only determinant when deciding on treatment, examination and history findings should also be taken into account.


In recent years, many important developments have occurred in anterior cruciate ligament injuries. First, it has been shown that the risk of ligament injury can be reduced, especially in female athletes, when certain exercise programs are applied. Your doctor, who is interested in this subject, will give you information about how you can apply these programs in the company of trainers and physiotherapists. The second development is the understanding that the ligament is structurally in the form of two bundles and that these bundles have different functions. As a result of this development, two bundle anterior cruciate ligament repair techniques have been developed that better mimic the original structure of the ligament, and it has been possible to obtain these successful results. Another improvement has occurred in better recognition of partial anterior cruciate ligament injuries. When necessary, techniques have been developed to surgically repair the ruptured part of the ligament by preserving its intact fibers. Anterior cruciate ligament surgery has become possible in children whose growth has not yet been completed, using special techniques. In this way, the risk of growth defect was minimized, and secondary meniscus and cartilage injuries that could develop were prevented by ligament repairs.


The treatment of anterior cruciate ligament injuries in young people who play sports or have an active lifestyle is surgery. Surgical treatment may not be performed in individuals of advanced age who are not at a high level of activity, do not do sports, and do not have complaints such as gaps and insecurity in the knee in daily life.

In children who did not complete their growth, it was recommended to wait until the growth was completed and then surgical treatment was recommended. However, nowadays, after it has been seen that irreversible meniscus and cartilage injuries occur in the knee in children who do not undergo surgical treatment, the pointer has shifted to the direction of performing surgery at an earlier age.

If non-surgical treatment is chosen, muscle strengthening programs are recommended to reduce the feeling of insecurity and emptiness that may occur in the knee, and protective knee pads can be used in sports that require the knee. However, when severe strain occurs, neither can prevent the knee from dislodging, and additional injuries to the knee may occur.


The aim in individuals with anterior cruciate ligament injury is to eliminate the feeling of space and insecurity in the knee, and to obtain a knee that the person can press safely during sports or strenuous activities. Another aim is to protect the meniscus if it was not damaged during the first injury and to prevent the wear and tear that may occur in the knee in the following years by repairing the meniscus tears that can be repaired. Another purpose of surgery is to return athletes to the level of sport they were in before the injury and to prevent new injuries to the knee.


If the anterior cruciate ligament is separated by tearing a piece of bone from where it was attached, the broken bone piece is fixed in place. In this case, which is mostly seen in children, fixation can be done with screws or sutures. This procedure is mostly done arthroscopically, in rare cases open surgery may be necessary.

Arthroscopic suture fixation of the anterior cruciate ligament, which is separated from its attachment by a bone fragment.

In adults, the anterior cruciate ligament is torn, mostly by separating the fibers in its body. It is not possible to repair the ligament in the form of a fringed tissue, and the ligament must be repaired with a new tissue during surgery. The tendons of the muscles around the knee are often used for ligament repair. The most commonly used tissue for this is the patellar tendon, which is located in the front of the knee and taken with a bone block at both ends.

Patellar tendon removal

The second most frequently used tissue is the tissues located at the back of the knee and known as the hamstring tendons. There is no bone block at the ends of the hamstring tendons.

Removal of hamstring tendons

In some cases, tissues taken from cadavers and sterilized and ready for use can be used. These tissues, called allografts, are usually injured when more than one ligament is injured and the person’s own tissues are not enough; It can be preferred in cases where surgery has been performed before and their own tissues have been used, and in very young children. Synthetic bonds, which were popular in the eighties, have been abandoned due to unsuccessful results.


First, the tissue to be used in ligament repair is taken, this tissue is called a graft. Then, knee arthroscopy is performed to evaluate other structures within the joint. If there is injury to the meniscus and articular cartilage, necessary intervention is made. Then, tunnels are opened to the bones in the knee joint and the path for the new ligament to pass is prepared. The graft is passed through these tunnels and fixed in the bone tunnels at the appropriate tension. For this, metal or fusible screws, cross nails and u-shaped nails are used. As long as these screws and nails that hold the ligament in place do not cause discomfort, they can remain in the body for life and do not need to be removed.

Arthroscopic single-bundle anatomical anterior cruciate ligament repair.

The surgery can take between 40 minutes and 1 hour. A thin plastic tube called a drain is placed to take out the blood that has accumulated in the knee joint, this drain is usually removed during the dressing 24 hours after the surgery.


Depending on the characteristics of the patient’s knee, the experience and preference of the surgeon, one or two bundles of anterior cruciate ligament repair can be performed. Double-bundle ligament repair can be performed to better reconstruct the original fan structure of the ligament, especially in large patients. In these patients, instead of 2, 4 separate tunnels are opened and 2 graft tissues are fixed by adjusting their tension at different angles. Although it was found to be superior to single beam in experimental studies, no significant difference was found in patient applications.


The length of stay in the hospital after surgery may vary between 1-3 days. It is possible to stand up with crutches after the effect of the anesthesia wears off. Knee movements are started on the same day or the next day and it is aimed to bend your knee up to 90 degrees. It may be necessary to protect the knee from overload by using crutches for several weeks after surgery. Within three weeks, full knee motion should be gained. If the patient’s own exercises are not sufficient, rehabilitation can be performed under the guidance of a physiotherapist. It takes 6 weeks for the implanted graft tissue to adhere to the bone tunnels by fusing. After this period, it is possible to walk and drive normally. It takes one year for the implanted tissue to fully mature and solidify, but it is possible to start sports activities after the 5th month.


Success rates reported in our country and in the world after anterior cruciate ligament surgery are between 80-90%. Adequate success may not be achieved in 10-20% of patients due to technical problems, newly formed injuries, and the tissue placed in the knee does not mature as a new ligament. In some of these, re-ligament surgery may be necessary.


During the anterior cruciate ligament surgery, anterior cruciate ligament surgery was avoided in children in the 1980s, since the operation was performed in the vicinity of the growth cartilages. The path followed in the child whose anterior cruciate ligament ruptured was to avoid sports and recommend exercise until growth was completed. However, as it was seen that untreated anterior cruciate ligament tears cause serious irreversible cartilage and meniscus injuries in children, surgical treatment became preferred in this age group as well. Anterior cruciate ligament repair can be performed using different surgical techniques, depending on the age of the child, the expected growth rate, and the condition of the growth cartilages. Surgical techniques applied in children are different from adults and the risk of causing a growth defect is very low when done carefully.

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