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Ligament Preservation/Repair

ACL Primary Repair

Rupture of the anterior cruciateligament (ACL) occurs in more than 200.000 active adolescents and adults in theUnited States every year. While some patients can be treated without surgery,ACL reconstructive surgery is typically recommended for active individuals toallow for joint stabilization and to reduce long-term risk for meniscal tearsand osteoarthritis. Standard ACLreconstruction techniques use a tendon harvested from a different site in thebody and are often associated with morbidity from graft harvest, and extendedperiods time to full recovery and return to sports activity.

Traditionally, the concept of ACL repairwas felt to be insufficient due to limited healing potential of the ACL foundin studies in the 1990s. However, recent scientific analysis reveals thatcertain subgroups, especially tears directly from the femur bone can besuccessfully repaired with very encouraging clinical outcomes. Based onadvances in diagnostic imaging pre-operatively identification of tears that areamenable to repair, as well as development of modern arthroscopic surgicaltechnology and postoperative rehabilitation, primary repair of the ACL is currentlyemerging as an attractive alternative treatment option for eligible patientswith ACL tears of all ages and activity levels.

The technique of primary ACL repair hasseveral distinct clinical advantages compared to ACL reconstruction. Besides preservationof the complex anatomic attachments and dual bundle structure of the nativeACL, primary repair also preserves the nerve structures contained in the normalACL, thus retaining the normal biomechanical and proprioceptive function of theoriginal ACL which is otherwise lost with ACL reconstruction using a tendongraft. Most importantly, primary ACL repair can often be performed lessinvasively that ACL reconstruction and frequently allows for more proactive progressionof rehabilitation and faster return to athletic activity.

What is Ligament Reconstruction?

Ligament reconstruction is surgery to reconstruct a torn ligament using a graft or artificial prosthesis. Ligaments are tough, non-stretchable fibers that hold your bones together. Ligament reconstruction is performed to improve joint function and stability and may be indicated for shoulder, elbow and knee injuries.

Knee Ligament Reconstruction

What are the Ligaments that Support the Knee Joint?

Four major ligaments help stabilize the knee joint:

  • Anterior cruciate ligament or ACL
  • Posterior cruciate ligament or PCL
  • Medial collateral ligament or MCL
  • Lateral collateral ligament or LCL

The anterior cruciate ligament is the most commonly injured knee ligament.

What is Knee Ligament Reconstruction?

Knee ligament reconstruction involves replacing a torn knee ligament with part of a tendon taken from your leg. The goal of knee ligament reconstruction is to tighten the knee joint and restore its stability. It also helps you avoid further injury.

When is Knee Ligament Reconstruction Indicated?

Knee ligament reconstruction may be recommended if:

  • You have a severe ligament injury
  • Conservative treatments have failed to relieve knee pain and disability
  • You are an active adult who requires good knee stability for participation in work or sports

Procedure for Knee Ligament Reconstruction

The procedure is performed under general anesthesia. A tissue graft is harvested from the patellar tendon or hamstring tendon. The patellar tendon connects the bottom of the kneecap (patella) to the top of the shinbone (tibia). The hamstrings are muscles located on the back of your thigh.

For a patellar tendon graft, your surgeon makes an incision over the patellar tendon and takes out the middle third of the patellar tendon, along with its attachment to the bone. The remaining portions of the patellar tendon on either side of the graft are sutured back after its removal and the incision is closed.

For a hamstring tendon graft, a small incision is made over the hamstring tendon attachment to the tibia and the two tendons are stripped of the muscle and the graft is prepared.

Your surgeon will make two small incisions around your knee. An arthroscope, a small video camera, is inserted through one incision to see the inside of the knee joint. Along with the arthroscope, a sterile solution is pumped into the knee to expand it and enable your surgeon to have a clear view of the inside of the joint. The torn ligament is removed and the pathway for the new tissue graft is prepared.

The arthroscope is reinserted into the knee joint through one of the small incisions. Small holes are drilled into the upper and lower leg bones around the knee joint. These holes form tunnels in your bone to accept the new graft. The graft is then pulled through the predrilled holes in the tibia and femur. The new tendon is then fixed into the bone with screws to hold it in place while the ligament heals into the bone. The wounds are then closed with sutures and dressed.

Shoulder Ligament Reconstruction

Why is Shoulder Ligament Reconstruction Performed?

Shoulder ligament reconstruction is performed to:

  • Improve stability of the shoulder joint
  • Restore function
  • Prevent dislocations

What are the Commonly Injured Ligaments in the Shoulder?

Several ligaments support the shoulder joint. The ones commonly injured include:

  • Acromioclavicular ligament
  • Coracoclavicular ligament

What Happens During Shoulder Ligament Reconstruction?

Shoulder ligament reconstruction surgery involves the repair of torn or stretched ligaments so that they are better able to hold the shoulder joint in place.

Shoulder ligament reconstruction surgery can be performed arthroscopically through small incisions using tiny instruments. Some patients may need an open surgical procedure which involves a larger incision over the shoulder to perform the repair.

During the surgery, overstretched capsules and ligaments are tightened. A tissue graft or artificial prosthesis may be used to reconstruct a shoulder ligament. It is inserted into holes drilled in the bone and secured.

Elbow Ligament Reconstruction (Tommy John Procedure)

What are the Ligaments that Support the Elbow?

The elbow joint is supported by the:

  • Ulnar collateral ligament or UCL
  • Radial collateral ligament or RCL
  • Annular ligament or orbicular ligament

These ligaments provide stability and strength to the elbow joint.

What is Elbow Ligament Reconstruction?

Elbow ligament reconstruction is considered in patients with a ruptured elbow ligament. The first procedure was performed in 1974 on baseball pitcher Tommy John to repair the ulnar collateral ligament.

What are the Causes of Elbow Ligament Injuries?

The elbow ligaments may be injured due to a sprain or rupture resulting from repetitive stress, overuse or a direct injury.

Symptoms of Elbow Ligament Injuries

Elbow ligament injuries commonly cause swelling and pain, which may extend from the elbow to the forearm and palm and may be aggravated by movements of the wrist. Sometimes instability of the joint may also be seen.

Procedure for Elbow Ligament Reconstruction 

Your surgeon will make an incision over the elbow. Care is taken to move muscles, tendons, and nerves out of the way. The donor's tendon is harvested from either the forearm or below the knee. Your surgeon drills holes into the bones of the upper arm and forearm, around the elbow joint. The donor's tendon is inserted through the drilled holes in a pattern like that of the original ligament complex. The tendon is then attached to the bone surfaces with special sutures. The incision is closed with sutures and covered with a sterile dressing. A splint is applied to support the elbow for a few weeks. After the surgery, you might be advised for regular follow-up and a rehabilitation program for a better and quicker recovery.

Risks and Complications Associated with Ligament Reconstruction

As with any procedure, ligament reconstruction may be associated with certain risks and complications including:

  • Infection
  • Blood clots (deep vein thrombosis)
  • Nerve and blood vessel damage
  • Failure of the graft
  • Loosening of the graft
  • Joint Pain
  • Numbness
  • Joint stiffness
  • Decreased range of motion

  • American Academy of Orthopaedic Surgeons
  • American Orthopaedic Society for Sports Medicine
  • Arthroscopy Association of North America
  • International Cartilage Regeneration & Joint Preservation Society (ICRS)
  • American Academy of Regenerative Medicine