Knee Ligament Surgery

Knee ligament surgeries have become quite common, ACL (anterior cruciate ligament) surgeries average 250,000+ surgeries alone every year (1)! These invasive surgeries have come under investigation in recent years, wondering the necessity, or need to be done. Today lets understand the knee a little better and take a look at the need for a knee ligament surgery, in addition, look into alternative treatments.

Your knee has 3 points of contact or compartments that house the cartilage of your knee:

1. Patella Femoral Compartment
2. Lateral (outside) Compartment
3. Medial (Inside) Compartment

These compartments are held together by a network of ligaments that hold each bone together and allow the knee to move properly.

Four Principle Knee Ligaments

There are four principal ligaments (2):

1. Anterior Cruciate Ligament (ACL),
2. Posterior Cruciate Ligament (PCL),
3. Medial (inside) Collateral Ligament (MCL), and
4. Lateral (outside) Collateral Ligament (LCL).

The collateral ligaments provide stability (3). You can think of these ligaments as the glue that holds the knee together or even the lug nuts that keep your knee together! The 2 most commonly torn ligaments of these are the MCL and ACL (4).

The most important of these ligaments is your ACL. In addition to providing stability to the joint, your ACL acts as a ‘proprioceptive organ” (4). Meaning the ligament has a direct connection to your nervous system via sensory receptors that monitor your knee position. If these sensors sense that the knee is in a bad position, it will activate your nervous system to contract the muscle around the knee to protect the knee as a protective reflex.

Knee ligament surgery is often recommended for the following conditions:

 Can a knee ligament heal without surgery?

The MCL is the most injured ligament of the knee and the ACL is the most commonly injured ligament in conjunction with the MCL. Most MCL injuries can be treated non-operatively (9). Even though the MCL can spontaneously heal without any additional treatment, the healing that does take place is typically incomplete (11) which can increase the risk of re-injuring the ligament over time.

A precise concentration of bone marrow concentrate can be a better alternative to waiting for the body’s natural healing response to kick in. You can see in before and after treatment that there is near complete healing of the MCL.

ACL reconstruction has become a standard of care for most ACL tears because the spontaneous healing rate of ACLs is less than 5% (10). But at The Centeno-Schultz Clinic we have created a novel treatment for ACL tears to prevent the need for a knee ligament surgery!  Utilizing your own body’s bone marrow concentrate containing stem cells, we can harvest and concentrate the cells, then precisely inject them into the injured ligament. This injection of your own healing cells allows your body to regenerate the ligament and effectively preventing the need for knee ligament surgery!  We have published multiple peer reviewed research papers demonstrating 7 to 8 out of 10 patients with an ACL tear can avoid the need for knee ligament surgery!

How long is recovery from knee ligament surgery

The main knee ligament surgery that is the most heavily researched is ACL reconstruction (5). Rehabilitation after reconstruction is key but the rehab course is extensive, taking 9-12 months to complete (5-8)!  Postoperative rehabilitation should continue for 9-12 months. During the rehabilitation, there are notable complications and side effects that present. Re-injuries reduced strength in both quadriceps and hamstrings. Loss of proprioception and up to a quarter (1 out of 4) will lose range of motion in both flexion and extension.

Comparing the recovery from the invasive surgery, our novel treatment has seen rehabilitation and return to activity reduced by 50%!

Is ACL surgery a major surgery

While most patients do well in the short term with ACL reconstruction surgery, many orthopedic surgeons fail to discuss the long-term consequences of having knee ligament surgery.

• 60% of patients will develop meniscal damage
• Loss of proprioception
• Loss of knee range of motion 23% of the time
• Quadriceps atrophy in a third of patients
• Hamstring weakness
• Chronic front of the knee pain in 50% of patient who have patella tendon graft

The worst is that within 15 years from surgery you will develop progressive knee arthritis and eventually be a candidate for a knee replacement

Here is the latest video on the current treatment options for ACL tears:

 Can you still walk with a torn ligament in your knee?

 Yes, you can still walk with a torn ligament but without one (or even two) of your main knee ligaments, walking and simple activities can become difficult. This highlights the need for a good physical therapist that can help you activate the muscles around the knee to allow a more functional knee!  Therapy is critical to help reduce the atrophy and help motor control. There are some individuals that are able to continue without the need of a knee ligament surgery or a PRP or bone marrow concentrate procedure where they can return to athletic activity, adapting without the ligament. We refer to these patients as “copers” (12). These are patients that can return to activity after a progressive rehabilitation with a physical therapist without pain or instability BUT research on biomechanics continues to show alterations in the normal mechanics of the knee.  Meaning that these patients are still at risk for additional complications such as Meniscal tears and post-traumatic arthritis!

THE UPSIDE

Knee ligament surgeries are not simple and have long-term consequences.  We have created treatment options for the majority of ACL and MCL tears to help our patients recover faster and get back to doing what they love sooner without the consequences of more invasive knee ligament surgeries!  If you have had a knee ligament injury or other injury and would like to be evaluated, please contact the link below and our staff will be happy to get you set up to see if are a candidate for treatment.

References:

1. Failla MJ, Arundale AJ, Logerstedt DS, Snyder-Mackler L. Controversies in knee rehabilitation: anterior cruciate ligament injury. Clin Sports Med. 2015;34(2):301‐ doi:10.1016/j.csm.2014.12.008
2. Flandry F, Hommel G. Normal anatomy and biomechanics of the knee. Sports Med Arthrosc Rev. 2011;19(2):82‐92. doi:10.1097/JSA.0b013e318210c0aa
3. Kazemi M, Dabiri Y, Li LP. Recent advances in computational mechanics of the human knee joint. Comput Math Methods Med. 2013;2013:718423. doi:10.1155/2013/718423
4. Hopf T, Gleitz M, Hess T, Mielke U, Müller B. Propriozeptives Defizit nach Kreuzbandschädigung–afferente Störung oder kompensatorischer Mechanismus? [Proprioceptive deficit following cruciate lesions–afferent disorder or compensatory mechanism?]. Z Orthop Ihre Grenzgeb. 1995;133(4):347‐351. doi:10.1055/s-2008-1039806
5. Yabroudi MA, Irrgang JJ. Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction. Clin Sports Med. 2013;32(1):165‐175. doi:10.1016/j.csm.2012.08.016
6. Zult T, Gokeler A, van Raay JJAM, et al. Cross-education does not accelerate the rehabilitation of neuromuscular functions after ACL reconstruction: a randomized controlled clinical trial. Eur J Appl Physiol. 2018;118(8):1609‐1623. doi:10.1007/s00421-018-3892-1
7. van Melick N, van Cingel RE, Brooijmans F, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med. 2016;50(24):1506‐1515. doi:10.1136/bjsports-2015-095898
8. Thoma LM, Grindem H, Logerstedt D, et al. Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study. Am J Sports Med. 2019;47(4):807‐814. doi:10.1177/0363546519825500
9. Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991;19(4):332‐336. doi:10.1177/036354659101900402
10. Razi M, Soufali AP, Ziabari EZ, Dadgostar H, Askari A, Arasteh P. Treatment of Concomitant ACL and MCL Injuries: Spontaneous Healing of Complete ACL and MCL Tears [published online ahead of print, 2020 Apr 8]. J Knee Surg. 2020;10.1055/s-0040-1708858. doi:10.1055/s-0040-1708858
11. Wan C, Hao Z, Wen S. The effect of healing in the medial collateral ligament of human knee joint: A three-dimensional finite element analysis. Proc Inst Mech Eng H. 2016;230(9):867‐875. doi:10.1177/0954411916656662
12. Iliopoulos E, Galanis N, Iosifidis M, et al. Anterior cruciate ligament deficiency reduces walking economy in “copers” and “non-copers”. Knee Surg Sports Traumatol Arthrosc. 2017;25(5):1403‐1411. doi:10.1007/s00167-015-3709-2