The Anterior Cruciate Ligament (ACL) Reconstruction with the Semitendinosus Tendon in case of ACL Rupture

SYMPTOMS

You have torn your anterior cruciate ligament (ACL). Patients experience the lack of the ACL in very different ways. Not all patients are restricted by this and need stabilizing surgery. Some adapt their sporting activities and get along well without complaints in everyday life. However, in around one third of patients, there is already a feeling of instability in daily life activities (e.g. giving way). Due to this instability, injuries to the meniscus and cartilage can occur, which must be prevented. A stable knee joint is essential for certain sports (contact sports, stop-and-go sports). The strain on the knee joint in pivoting sports (such as soccer, handball or basketball) is so great that one must advise against participation un-less there is sufficient ACL.
Whether you need a stabilizing operation as part of an isolated ACL rupture depends on whether you experience instability and whether you need a stable knee at work or during sporting activities. The following three factors are decisive: the extent of the subjective instability, the desired level of activity and possible accompanying injuries (i.e. meniscus, cartilage).

EXAMINATION

The clinical examination of your knee joint shows a sliding forward of your injured lower leg (drawer test) in comparison to the other uninjured lower leg. However, the so-called pivot shift test is also crucial as the rotational stability of the knee joint can be assessed. As part of an acute injury, this test can be uncomfortable or even painful. A strong rotational instability in the clinical examination is an important indicator for the decision-making about the correct therapy. If rotation instability is present, the joint should be stabilized using ACL reconstruction.

TREATMENT

Isolated injuries to the ACL can be treated primarily conservatively in patients without symptomatic instability and those who do not participate in sporting activities. Physiotherapeutic treatment can improve the muscular stabilization of the knee joint. If surgery is indicated due to the instability of the knee joint, due to the desired level of activity or due to accompanying injuries, the ACL will be reconstructed.

Various grafts are available for the reconstruction of the ACL. As a rule, the body’s own tendons are removed and used as an ACL replacement. Every graft and surgical technique has advantages and disadvantages. Accompanying injuries must also be taken into account when choosing the graft. We usually use the tendon of the semitendinosus muscle (hamstring) as the transplant of choice. In contrast to other techniques, the removal of this tendon is comparatively less disruptive or painful. This is also the reason why it is used most frequently for this operation worldwide. If the tendon is not sufficiently long or thick, the tendon of the gracilis muscle can also be removed.

The tendon can be folded twice and thus replace the ACL as a quadruply strong bundle of tendons.

The operation is performed arthroscopically via two small incisions at the front of the knee. An additional 5 cm incision is made on the inside of the shin head (tibia) to remove the tendon(s) and drill the tibial tunnel.

LEGEND

Arthroscopic view of the right knee
1 – Normal anterior cruciate ligament (ACL)
2 – Torn ACL
3 – Reconstructed ACL

Hospital Stay and Course of Treatment

On the day of the operation you will stand up in the accompaniment of the physiotherapist. At the beginning, the knee joint will be protected by a Velcro splint. This can be removed as soon as the knee joint can be stabilized muscularly. The in-house physiotherapist will support you.
As soon as you are ambulatory with crutches, you can be discharged. As a rule, patients stay in the hospital for 3 nights after this operation.

With an isolated ACL reconstruction without injuries to the menisci, the load can be increased quickly without a stabilizing splint. As a rule, most patients need crutches for around 4 weeks after the operation.

If the meniscus also had to be sutured in the same operation, partial weight- bearing on crutches may be necessary for 6 weeks.
Your family doctor can assess the wound after 2 weeks. It is not necessary to remove the stitches because the wound was sutured with self-absorbable threads. A check-up with an x-ray of the operated knee joint will take place
around 6 weeks after the operation.

SPORT

Bike riding, on the street: after 6 weeks
Jogging: after 3 months
Tennis: after 6 months
Soccer and Skiing: after 6–12 months

Risks

Anterior cruciate ligament reconstruction is a standard operation that we do very often. However, there are always risks and possible complications during operations. According to the literature, these risks can be summarized as follows:

• Risk of infektion: ~1%
• Damage to relevant blood vessels: less than 1%
• Damage to relevant nerves: less than 1%
• Thrombosis/Embolism: ~2%
• Re-Rupture (depending on your risk group): ~5–30%

pdf for download: ACL Reconstruction