| The Crucial Ligament Problem |
| It can happen in a friendly kickabout or in the first division; whenever the game is played with a bit of commitment (or lack of fitness in some cases), there is always a certain risk of getting injured. One of the most common problem is with the anterior crucial ligament in the knee, and the consequence is months of enforced rest. Dr. Urs Munzinger, orthopaedic surgeon at the Schulthess Clinic in Zurich, takes a look at risks, ruptures and rehabilitation. The cross into the center was perfect but that no longer mattered to the player out on the wing. The studs in his standing led were anchored in the ground and instead of the whole leg turning only the knee rotated, giving way under the strain. The pain was excruciating and fears about the premature end of a professional career soon rushed into mind (or months off work in the case of an amateur sportsman). In football especially, where the player often has to change direction abruptly and alters the position of his center of gravity in a fraction of a second, the risk of ligament damage is always present. During feinting or dribbling the knee is bent as well, and the effects of any external intervention can be even more serious, striking as they do at the weakest point. If the player is in a bandy-legged position at that moment, then ankle injuries are the likely result; if he has his knees more together, the knee and in particular the front crucial ligament will be the area to suffer. And the number of injuries is on the increase. A lack of technique, there are indications that it is the technically less gifted players who suffer this kind of injury more, and just plain bad luck are all factors that lead to problems, plus the effects of hard tackles or accidental blows to vulnerable points. Until a few years ago, a torn crucial ligament nearly always spelt the end of a career, and perhaps partial invalidity too. That there is a lot of current interest in the subject is shown by the fact that on 29 March an operation was shown live via the Internet; 60,000 subscribers to the World Wide Web watched the surgery taking place, though the picture sequence was a bit on the slow side. This was made possible by the advent of the arthroscopic technique, introduced in the 70s and refined steadily ever since. This kind of surgery involves no long incision round the whole joint, but inserts a miniature camera into the joint via a small cut and this enables treatment to be confined to the smallest area possible, either by removing damaged parts, by sewing them back together, by reconstructing them. The patient, however, still requires a lot of treatment, since post-operative care, stationary or ambulant, remains intensive. Decisive for the patient’s recovery is correct diagnosis. In the past, knee injuries were often vaguely categorized under the heading “sprains”, but today’s modern instruments and diagnostic apparatus mean that torn ligament can be detected with greater accuracy. THE ORTHOPAEDIST’S OPTIONS An experienced orthopaedist with finely-honed diagnostic skills, who can use his knowledge of specific symptoms and make comparisons with the patient’s sound knee, is a vital link in the chain. Among the symptoms looked for is one known as the pivot shift (it also goes under other names). In the case of a rupture of the front ligaments, when the leg is stretched there is a greater displacement of the head of the shin bone relative to the knee joint. If the patient starts to bend the knee, after a bend of about 30º the shin bone can move backwards quite quickly, the sensation being quite painful. When walking, the patient suffering from this “giving way” syndrome feels that the knee is not holding and is always buckling in. To confirm such manual diagnoses, the orthopaedist today can call upon certain picture techniques. In ctrast to classical X-ray methods which could only diagnose bone fractures, magnetic resonance tomography can produce pictures of the inner structure of the knee and the front ligaments, both longitudinally and in cross section. Since ligament injuries are not emergency problems in the medical sense and do not usually require immediate surgical intervention, the orthopaedist has a certain amount of time available, depending on the seriousness of the lesion, to discuss the appropriate treatment with the patient. In general, there are two possibilities; - Consevative therapy; since the los of a front crucial ligament does not lead to later limitations or complaints with every patient, in some cases surgical repair (sewing the ligament back together, inserting an implantation) can be avoided; here the body is allowed to self regenerate. Follow-up studies have shown that even after a period of many years, knee joints can show complete recovery from the damage and the patient’s range of activities is not impaired at all. An isolated damaged ligament with no secondary damage is usually given conservative treatment. In the case of footballers, however, operative therapy is necessary in most cases. - Operative therapy; carried out in cases where the consequences of the rupture (e.g., meniscus damage) would hamper proper functioning of the joint, and operative stabilization is unavoidable especially in the case of footballers who want to continue playing. EVALUATING EACH INDIVIDUAL CASE In order to decide whether an operation is necessary or not, specialist evaluation of the factors involved, such as the degree of risk and the level of activity the patient expects to attain after recuperation, is essential. Every such decision must be taken in the light of the patient’s personal situation; only the risk factors allow a certain degree of categorization. Pointing towards surgical intervention would be such factors as a high level in the joint just after the injury, serious collateral ligament damage and unfavourable physical symptoms, such as loose joints in general. If such factors are not predominant, then conservative treatment can have very good results. Strong leg musculature helps to stabilize the knee joint and to prevent secondary injuries. If surgery cannot be avoided, then the question arises of the best timing. While it was previously thought that early treatment of a new capsular ligament injury was best, there is increasing documentation today indicating that too rapid intervetion increases the risk that freedom of movement could be limited later, due to massive agglutination and formation of scar tissue (arthrofibrosis). The trend today is towards operating on new ligament ruptures only after the first acute signs of trauma have subjected, which in effect means 3 ~ 4 weeks after the injury. The operation is carried out when the patient can fully bend and stretch the knee without pain. However, if the damage is complex, with perhaps lateral ligament and meniscus damage and the joint is unstable, then the delay cannot be too long, since the functional treatment then would be too painful. Usually blood seeps from the tissue into the joint in these cases and has to be removed, otherwise further damage might be covered up. HIGH SUCCESS RATE Thanks to operative techniques which reduce the degree of trauma involved and also lead to better results, the decision is often made today to replace a damaged front ligament. The orthopaedic surgeon is acting as a precision mechanic in these cases, since the success of the operation is largely dependent on exact placement. The standard technique is to replace the ligament using free transplantation from the patellar sinew. The piece of sinew is taken out together with two pieces of bone which help in the fixation. Correctly carried out the success rate of this technique is 90%, success being taken as an objective restoration of stability in the joint. The hardest part of the road back to as complete a recovery as possible is the rehabilitation phase, which has to be planned very carefully, taking into consideration the patient’s present condition, his medical history and his future ambitions. It is of great importance to incorporate movement into the recuperation stage as early as possible. Initial steps are under the guidance of a physiotherapist and aimed at active exercise. Electrical devices are available which facilitate smooth and regular stretching of the leg, and these help to accelerate the process. The rehabilitation plan follows the principle of dealing with the complete muscle chain; the patient carries out the muscle training plan himself and it requires over 2 hours per day. A program is written up by the physiotherapist which is adjusted in consultation with the patient as the treatment progresses. Specialists suggest 6 months until a player can train again and 9 months before he is ready for competitive games. By means of isokinetic measurements which allow the performance of the recuperating knee to be compared with the sound one, the doctor can ensure that the difference does not exceed 20% in favour of the damaged joint, in order to avoid any imbalance. To what extent the athlete recovers his former ability depends on a number of factors. There are also long term effects to consider, since a damaged joint is more susceptible to problems later on, such post-traumatic arthrosis. However, the chances of avoiding such occurrences in the future are much better today than they were even a few years ago, thanks to advances in medicine and medical technology. |