私は膝の専門家で前十字靭帯と人工膝関節の得意な整形外科医(スポーツドクター)です。

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2010/04/19

Anterior Cruciate Ligament (ACL) Injury (英語版)

What is the ACL injury? How is the ACL injury treated? What is the ACL reconstruction? 

Here are some pictures of ACL reconstruction including detailed pictures for inside knee are drawn, as anybody can understand ACL.                 

You can pop up all pictures to become bigger one. Please wait about two seconds. All knee pictures are drawn as right knee.

**Attention**
At first, the following content inform the personal opinion that based on the medical articles reported in the past and my experience .

◆There is the ACL inside knee. It plays a role that knee is prevented from anterior instability.

◆It starts from middle of tibia plateau to lateral wall of femoral condyle inside knee. The ACL is shown as yellow fibers (ligament).

◆The ACL is only one ligament. It has two bundles that have each different direction. They are anteromedial bundle (AMB) and posterolateral bundle (PLB), and allot a different respectively function according to the angle of the knee.

◆It occasionally cuts (tears) when the knee is made loading to be twisted due to sports and the traffic accident.

◆Although other person don’t contact with the person, the person will tear his ACL by himself, when knee is done pivot motion and stressed valgus, especially when he play the basketball and the soccer. He might be in condition that our feet fixed on a floor or the ground and rotate with the right knee counterclockwise (with left knee clockwise). >>>non-contact injury

◆There is not the state that the ligament becomes longer. The reason is because the fiber of the ligament isn’t elastic like rubber and stiff, and doesn’t almost lengthen, as a result, the ligament is torn.

◆The torn ACL cannot be connected naturally. Therefore, there is not the method except the operation then. It is necessary to perform ACL reconstruction.

◆Chiefly, there are methods used with knee the flexor tendon (hamstrings) or the patellar tendon (BTB) in the ACL reconstruction.

◆Patellar tendon (BTB) is a very good graft though the recent mainstream for ACL reconstruction is to use knee flexor tendon (hamstrings).

◆The knee flexor tendon includes the Semitendinousus tendon and the Gracilis tendon, and they are useful chiefly when the knee is deeply bent. It is assumed that power to bend deeply knee is reduced though it never has a hard time in sports and daily life if the tendons are gathered. However, it is found that the tendons often regenerate recently.

◆Pes anserinus is called the eagle's foot because three tendons of the sartorius tendon, the semitendinosus tendon, and the gracilis tendon gather and the tibial attachment of tendons look like the foot of eagle.

◆The method of using the knee flexor tendon includes the method of ACL reconstruction with one bundle or double bundles.

◆Though one bundle method is very good enough, the double bundles method can improve the function allotment of the ligament by getting close to the shape of the human body original, of anatomical double bundles, as an ideal.

◆In the results of the research paper, the results that a double bundles method are more stable than one bundle method in anterior drawer test is a main current. On the contrary, some papers reported that the anterior stability t is not different between one bundle method and double bundles method.

◆There is biomechanically no discussion in results of experiment immediately after having performed it to the double bundles reconstruction better than the one bundle reconstruction. In other words, the stability of double bundles reconstruction is higher in the biomechanics in stability immediately after the operation.

◆On the other hand, some authors reported that the subjective sense of reconstructed knee by double bundles is almost an original condition, though some papers reported that ACL reconstruction with one bundle and double bundles don’t have difference of the clinical outcome in the anterior instability after one year - two years. The ACL reconstruction by double bundles is nearer more original knee, and this is thought to be a reason that anatomical reconstruction with double bundle is nearer more original movement.

◆In addition, it is that not only the anterior stability but also the rotator stability is better that is the advantage of the double bundle reconstruction. It is not completely possible to prove the above because the methods to objectively examine are not enough,

◆If the double bundle ACL reconstruction is as good result as one bundle or better than it, you should choose double bundle. In my impression, there is possibility to take 90 points or more in the double bundle reconstruction on the satisfaction rate though 80 points in the one bundle reconstruction.

◆There are some persons who cannot be adapted the operation on the double bundle. The double bundle reconstruction is not adapted if they have too small knee or too short tendon or too thin tendon. In this case, the one bundle reconstruction is adopted.

◆The knee flexor auto-tendons are gathered in the anatomical double bundle reconstruction. The knee flexor tendons combine with the synthetic ligament when the tendon grafts are made.

◆Because torn ACL don’t improve the strength even if it is repaired with suture, it is easy to tear soon. Therefore, it is resected surgically because it’s useless one.

◆A bone tunnel is drilled into the position where the attachment of original ligament to after resection. The tendon grafts are inserted into the bone tunnel.

◆Finally the tendon grafts are fixed with two staples (double staples). In other words, it is fixed it by turnbuckle method (a method I turn down a belt, and to fix).

◆The ACL reconstruction(BTB method) apply the bone-patellar tendon-bone by width at center 1/3 of the patellar tendon, and, it is fixed with an artificial tendon and the screw as this tendon graft.

◆The anatomic double-bundle ACL reconstruction cannot be done in the BTB method (Or, it is very difficult). Moreover, because the BTB method are gathered bone and tendon from the knee front, it is reported that there are approximately 20% patients who occurs the pain in collection part (It is abundant in the woman).

◆The rehabilitation of the advantage of the BTB method is shorter time than the method with the knee flexor tendon, and earliness is feature in the sports return.

◆Patients using BTB method can return to sports for six months, whereas patients using the knee flexor tendon can return to sports for eight months.

◆However, it is necessary to undergo rehabilitation carefully because loosening of the knee occurs easily in an early extreme return.

※Please write the opinion and the question as follows.

※Please refrain from the diversion and the reprint no under of figure acceptable. It would be greatly appreciated if it could E-mail when using it. My best regards.

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