Cruciate ligament re-rupture
Cruciate ligament re-rupture
Despite the marked progress in the surgical treatment of a cruciate ligament tear, patients do repeatedly suffer a further tear of their reconstructed ligament
One reason is that returning to the previous level of performance in sport also brings back the risks of that sport.
Another is that further factors such as meniscal tears, bone tunnels that were not placed optimally, or the slope of the top of the shin bone can markedly increase the risk of a further cruciate ligament rupture.
What happens when the cruciate ligament tears again?
Definition
More than 2 million people suffer a cruciate ligament tear every year. The risk of an anterior cruciate ligament rupture is particularly high in dynamic stop-and-go sports with many changes of direction – football, handball, basketball and skiing, for example. The injury initially causes pain, fluid in the joint, restricted movement and usually instability of the joint.
Causes
Frequently in sports with high dynamics and changes of direction (football, handball, basketball, skiing). Frequently also in combination with other injuries such as meniscal damage, cartilage injuries or instability of the collateral ligaments.
How serious is it?
In the long term, instability of the knee joint leads to an increased risk of meniscal and cartilage damage, which can lead to early osteoarthritis. Athletes in particular are generally unable to compensate for the instability and, without surgical treatment of the cruciate ligament, mostly no longer reach their previous level of performance. Alongside the level of sporting activity, accompanying injuries also have a central role in the decision for or against surgery. Where there are injuries of the meniscus or the cartilage in addition to the cruciate ligament rupture, or where the collateral ligaments are unstable, surgical treatment is necessary.
Potential for healing
With non-surgical treatment the risk of further injuries remains. The risk of meniscal or cartilage injury rises by 1 % per month without an anterior cruciate ligament. With recurring episodes of instability this risk increases considerably. Further injuries can in turn significantly increase the risk of early osteoarthritis, while surgical treatment can markedly reduce this risk. The decision for or against an operation is therefore based on the sports played, the activity level, how pronounced the instability is and the accompanying injuries. Where patients have suffered no accompanying injuries, feel no instability and play no stop-and-go sports such as football, handball or basketball, non-surgical treatment can be a sensible option. If the aim is to return to these so-called level I sports such as football or handball, however, this is generally not possible without cruciate ligament surgery.
Symptoms
The symptoms of a cruciate ligament tear are usually clear, but they can vary in how pronounced they are. Typical is a sudden feeling of instability during sport, frequently accompanied by a cracking noise in the knee. The knee often swells rapidly, caused by bleeding into the joint. Pain that depends on load then follows, above all with changes of direction or when going down stairs. Where the injury has been present for longer, people frequently report a feeling of insecurity in everyday life. Repeated episodes of the knee "giving way" can also point to chronic instability.
Pain
The tear of the ligament and the instability are often experienced as very painful
Instability
Without the ACL, "giving-way" phenomena – moments of instability – can occur
Effusion
The torn ACL and any accompanying injuries make the joint swell
The knee joint in detail
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Treatment options for tears of the anterior cruciate ligament
As described under "cruciate ligament tear", a return to the original level of sporting performance very frequently succeeds after a first rupture. Despite the very successful developments in cruciate ligament surgery in recent years, this also carries a considerable risk of further injury. Additional surgical measures such as anterolateral stabilisation (see "cruciate ligament tear") have markedly reduced the risk of a further cruciate ligament tear. Ultimately, however, these are level I sports and mostly full-contact sports, which always carry a not inconsiderable risk of injury.
If patients suffer such a further tear of the reconstructed anterior cruciate ligament, non-surgical treatment is generally not advisable. For one thing, accompanying injuries of cartilage or meniscus occur quite frequently together with the re-rupture. For another, patients mostly have a noticeable subjective instability, which in turn carries a marked risk of early osteoarthritis. Alongside the decision to revise the reconstruction surgically, the point with a further cruciate ligament tear is therefore above all to analyse the underlying cause.
Alongside the decision to revise the reconstruction surgically, the point with a further cruciate ligament tear is therefore above all to analyse the underlying cause. First, the existing bone tunnels have to be assessed for their position and their diameter. If the tunnels are not optimally placed, or have widened over time, the tunnels may first need to be filled with bone before a new cruciate ligament reconstruction can be carried out in a second operation. Beyond that we analyse the accompanying injuries. Frequently there are new or persisting tears of the meniscal root or ramp. These are generally treated together with the new cruciate ligament reconstruction. Finally the geometry of the bone has to be analysed. It has been shown that a slope of the top of the shin bone beyond a certain degree in particular leads to a markedly increased risk of a further cruciate ligament rupture. Where the bone has this shape, it may be necessary to correct it with what is known as a slope correction. A wedge of bone is taken from the top of the shin bone in order to level it and so reduce the pressure on the future cruciate ligament graft. This correction of the bone is fixed temporarily with a plate, which is then removed during the cruciate ligament revision itself. After filling the tunnels with bone, after a slope correction, or after a combination of both, a new cruciate ligament reconstruction is generally possible four to five months later.
Where the original bone tunnels are optimally placed and show no substantial widening, and the geometry of the bone is optimal, the cruciate ligament revision can also be carried out directly in a single operation. In principle we try to use tendon material from the affected side for this revision. In individual cases it may nevertheless be necessary to take a tendon from the other leg. Finally, in many cases we combine this new, definitive cruciate ligament reconstruction with an anterolateral stabilisation (see "cruciate ligament tear") in order to keep the risk of a third cruciate ligament tear as low as possible.
Treatment options
Non-surgical and surgical – we will find the right approach for you
Physiotherapy and training on your own
Building strength, improving coordination and stability
Cruciate ligament revision
A new cruciate ligament reconstruction, frequently combined with an anterolateral stabilisation
Filling the bone tunnels
The tunnels are freshened and filled with bone material
Slope correction
Levelling the top of the shin bone to reduce the pressure on the cruciate ligament graft
Additional anterolateral stabilisation where appropriate
An additional strip of the iliotibial band is fixed on the outer side of the thigh or lower leg
Our knee specialists
Experienced consultants for cruciate ligament re-rupture and knee surgery
