Results of conservative treatment of partial tears of the anterior cruciate ligament

Summary The diagnosis of an acute partial tear of the anterior cruciate ligament was made in 56 patients who did not undergo surgical repair. After a period of up to 5 years, 39 returned for follow up evaluation. They were divided into three groups according to clinical analysis of the knee and the Lysholm-Gillquist score. Our aim was to determine their long term functional limitations. 56% had progressed to anterior cruciate ligament deficiency at the time of follow up. This came about not only after resuming sporting activities, but also occurred in those who were not so active. Our results suggests that a partial tear leaves an irreversible defect which may progress to a complete tear, especially in young athletes engaged in active sport.

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Résumé Chez 56 patients le diagnostic de rupture partielle du ligament croisé antérieur (LCA) a été confirmé par arthroscopie, mais n'a pas entraîné de traitement chirurgical. 39 de ces patients (70%) ont été revus après six ans. L'objectif était d'évaluer à long terme les séquelles de cette lésion dans la vie courante et les activités sportives. Après analyse de l'examen clinique du genou, les patients ont été classés en trois groupes, selon la cotation de Lysholm-Gillquist:Groupe I (4 patients): perte totale de la fonction du LCA,Groupe II (18 patients): diminution fonctionnelle du LCA,Groupe III (17 patients): fonction clinique conservée.56% des patients examinés ont donc évolué vers l'instabilité du genou. Cette évolution concerne non seulement l'activité sportive mais aussi l'utilisation du genou dans la vie courante. Même le groupe de patients ayant conservé une fonction clinique du LCA n'ont que 84 points sur la cotation de Lysholm-Gillquist. Ces constatations montrent que la rupture partielle du LCA constitue une lésion irréversible, comportant le risque d'évolution vers la rupture totale. La plastie ligamentaire est donc indiquée dans les ruptures partielles du LCA, en particulier chez les sujets jeunes et les sportifs professionnels.

     

Normal ligament properties and ligament healing

There is still a long way to go to achieve the goals of ligament replacement through modification of normal, intrinsic ligament healing processes. We are learning about the biology of ligamentous tissues, including the problem of regeneration, and that in itself is an all-important first step toward seeking solutions.     

The late course of acute partial anterior cruciate ligament tears. A nine to 15-year follow-up evaluation.

Twenty-two patients had an acute anterior cruciate ligament (ACL) tear. Nineteen patients were treated conservatively, except for associated injuries. In three patients, a reinsertion of the torn portion of the ACL was done surgically. All patients were reexamined after nine to 15 years with special emphasis on stability testing; this was done manually and with instruments. Knee function score and activity level were also measured. Standing roentgenograms with the knee in slight flexion were taken as well. At follow-up examination, none of the patients had needed ACL reconstruction. Knee function was good, with a mean Lysholm score of 93 points. Patients had changed activities from recreational team sports to light individual sports. Manual laxity values were similar to the values obtained at the time of initial injury. A 1-mm sagittal laxity increase was found on the injured knee with the Stryker laxity tester. Slight signs for osteoarthrosis were found in more than half of the knees, mainly in cases with chondral fractures or meniscectomy. In general, conservative treatment had a good long-term prognosis.     

Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency

In a prospective seven-year study, we treated 32 patients with partial ruptures of the anterior cruciate ligament (ACL) verified by arthroscopy. Twelve knees (38%) progressed to complete ACL deficiency with positive pivot shift tests and increased anteroposterior translation on tests with the KT-1000 arthrometer. Patients with partial ACL tears frequently had limitation for strenuous sports, while those developing ACL deficiency had additional functional limitations involving recreational activities. Three factors were statistically significant in predicting which partial tears would develop complete ACL deficiency: the amount of ligament tearing--one-fourth tears infrequently progressed, one-half tears progressed in 50% and three-fourth tears in 86%; a subtle increase in initial anterior translation; and the occurrence of a subsequent re-injury with giving-way.     

Knee dislocation following anterior cruciate ligament disruption without any other ligament tears.

We report a rare case of complete knee dislocation following anterior cruciate ligament (ACL) disruption without any other ligament tears. The pathology of the knee joint was torn ACL, intact other ligaments, osteochondral fractures and bone bruise of the lateral femoral condyle, and torn lateral meniscus. In this case, osteochondral fracture resulting from the anteriorly sublaxiation of the tibia following ACL disruption was considered to prevent from spontaneous reduction. This case suggests that anterolateral knee dislocation and spontaneous reduction may occur in ACL injuries.     

Management of chronic lunotriquetral ligament tears

Treatment of chronic disruptions of the lunotriquetral (LT) ligament is not well-defined. Eleven patients treated by LT fusion with use of a compression screw are reported. The injury frequently resulted from hyperextension of the wrist. Pain on the ulnar side of the wrist, limited motion, and tenderness over the LT joint exacerbated by ballottement were present. Standard radiographs were normal. Arthrography showed the ligamentous tear in all cases. After operation, immobilization was continued until fusion was apparent radiographically. Fusion was achieved in all cases between 2 and 5 months. Four patients were free of pain, four patients had pain only at the extremes of motion, and three patients had persistent pain. Mean wrist motion was as follows (preoperative/postoperative): flexion (53 degrees/45 degrees), extension (60 degrees/49 degrees), radial deviation (17 degrees/21 degrees), and ulnar deviation (25 degrees/18 degrees). Maximum grip strength as a percentage of the uninjured side was 73% preoperatively and 59% postoperatively. LT tears can exist de novo or as part of the ulnar impaction syndrome; a method for differentiation is presented.     

Scar formation and ligament healing

Ligaments are highly organized, dense, fibrous connective-tissue structures that provide stability to joints and participate in joint proprioception. Injuries to ligaments induce a healing response that is characterized by the formation of a scar. The scar tissue is weaker, larger and creeps more than normal ligament and is associated with an increased amount of minor collagens (types III, V and VI), decreased collagen cross-links and an increased amount of glycosaminoglycans. Studies have shown that certain surgical variables alter the healing of ligaments. Such factors include the size of gap between the healing ligament ends, the use of motion in a stable joint and the presence of multiple ligamentous injuries. Research on ligament healing includes studies on low-load and failure-load properties, alterations in the expression of matrix molecules, cytokine modulation of healing and gene therapy as a method to alter matrix protein and cytokine production.     

Effect of GDF-5 on ligament healing.

The effects of growth and differentiation factor-5 (GDF-5) on ligament healing were studied using a gap injury model of the medial collateral ligament in rat knee joints. The administration of GDF-5 once at the time of surgery significantly improved the mechanical properties of the femur-ligament-tibia complex. At 3 weeks after surgery, 30 microg of GDF-5 improved the ultimate tensile strength of the complex by 41%, and the stiffness by 60%, compared with the vehicle control (p < 0.05 for both; Fisher's PLSD test). The observation with a transmission electron microscopy revealed that GDF-5 increased the diameter of collagen fibrils in the repair tissue, which was considered to be a possible mechanism for the positive result in the biomechanical testing. Quantitative PCR and in situ hybridization revealed enhanced type I procollagen expression by GDF-5, and the PCR analysis also revealed that the GDF-5 treatment reduced the expression of type III procollagen relative to type I procollagen. The PCR analysis further showed that the expression of decorin and fibromodulin was relatively reduced against type I procollagen by the growth factor, which was considered to be responsible for the increase of collagen fibril diameter in the repair tissue. No adverse effects were observed, and the use of GDF-5 was considered a promising approach to facilitate ligament healing.     

Longitudinal split tears of the ulnotriquetral ligament

Unlike tears of the peripheral triangular fibrocartilage or avulsions of the distal radioulnar ligaments, longitudinal split tears of the ulnotriquetral (UT) ligament do not cause any instability to the distal radioulnar joint or the ulnocarpal articulation. It is mainly a pain syndrome that can be incapacitating. However, because the UT ligament arises from the palmar radioulnar ligament of the triangular fibrocartilage complex (TFCC), it is by definition, an injury of the TFCC. The purpose of this article is to describe the cause of chronic ulnar wrist pain arising from a longitudinal split tear of the UT ligament.     

The physiology of wound healing

Wound healing is a complex biological process which results in the restoration of tissue integrity. Physiologically, it can be broken down into four distinct phases of haemostasis, inflammation, proliferation and tissue remodelling. This article describes the cellular basis of wound healing and the extracellular signalling processes which control them. The function of platelets, neutrophils, macrophages and fibroblasts are considered in detail. The concept of healing by primary and secondary intention is discussed. Many factors are known to adversely affect healing including malnutrition, hypoxia, immunosuppression, chronic disease and surgery. It is essential that surgeons understand the key physiological processes involved in healing in order to minimize patient morbidity from delayed healing.     

The physiology of wound healing

Wound healing is a complex biological process which results in the restoration of tissue integrity. Physiologically, it can be broken down into four distinct phases of haemostasis, inflammation, proliferation and tissue remodelling. This article describes the cellular basis of wound healing and the extracellular signalling processes which control them. The function of platelets, neutrophils, macrophages and fibroblasts are considered in detail. The concept of healing by primary and secondary intention is discussed. Many factors are known to adversely affect healing including malnutrition, hypoxia, immunosuppression, chronic disease and surgery. It is essential that surgeons understand the key physiological processes involved in healing in order to minimize patient morbidity from delayed healing.     

The physiology of wound healing

Wound healing is a complex biological process which results in the restoration of tissue integrity. Physiologically, it can be broken down into four distinct phases of haemostasis, inflammation, proliferation and tissue remodelling. This article describes the cellular basis of wound healing and the extracellular signalling processes which control them. The function of platelets, neutrophils, macrophages and fibroblasts are considered in detail. The concept of healing by primary and secondary intention is discussed. Many factors are known to adversely affect healing including malnutrition, hypoxia, immunosuppression, chronic disease and surgery. It is essential that surgeons understand the key physiological processes involved in healing in order to minimize patient morbidity from delayed healing.     

Conservatively treated tears of the anterior cruciate ligament. Long-term results

Forty-nine patients who had a complete tear and forty-one who had a partial tear of the anterior cruciate ligament were examined as regards long-term healing. All had had a positive clinical diagnosis just after the injury, which was confirmed in the majority under anesthesia, at arthrotomy, on arthroscopy, or with a combination of these methods. The re-examination was performed an average of eight years after the injury. Besides a functional and objective evaluation, radiographic examination and evaluations of isokinetic and isometric strength were made. The multidimensional analysis revealed that in an unselected population the long-term results of the complete tears were poor, because of chronic instability. In many, reconstructive operations were needed, and post-traumatic arthritis was common. In the patients who had a partial tear, the results were quite good even if the stability of the knees had not improved when compared with the initial post-traumatic status. Conservative treatment of complete tears of the anterior cruciate ligament cannot be recommended as a treatment of choice, whereas partial tears can be treated by non-operative methods.     

Stability evaluation after isolated reconstruction of anteromedial or posterolateral bundle in symptomatic partial tears of anterior cruciate ligament

Objective

To evaluate the stability achieved in isolated reconstruction of each ACL bundles (minimum 2-year follow-up).

Materials and methods

Study group: 39 consecutive patients (28.1 years of mean age) underwent anteromedial (AM) and posterolateral (PL) bundle reconstruction surgery (31.71 months of mean follow-up). Control group: 36 non-concurrent patients using single-bundle (SB) technique (more than 2-year follow-up). Evaluation based on IKDC scores, taking anterior–posterior translation and rotational stability as primary endpoints, and epidemiological data, ischaemia time, waiting time for surgery and complications as secondary endpoints.

Results

SB, AM and PL groups showed an anteroposterior translation (APT) at 2 years of 2.3, 1.8 and 1.8 mm, respectively, with an APT reduction of 5.4, 2.9 and 2.3 mm, respectively, but with no difference between both types of partial reconstruction (p = 0.552). IKDC scores in the AM group were as follows: preoperative (11 cases in group A, 12 B, 3 C), postoperative (24 A, 2 B); IKDC in the PL group: preoperative (7 B, 6 C), postoperative (10 A, 3 B). Mobility restored in all cases, while in group B, 2 AM patients and 3 PL had a slight Pivot Shift. There were no differences in complications as compared to conventional techniques.

Discussion

All techniques showed global significant enhancement in rotational stability (p < 0.0005). Improvement in anterior–posterior translation in AM group and in rotational stability in PL group was achieved; both showed no relevant statistical significance. Residual translation shows directly proportional relationship with preoperative status, surgical ischaemia time and patient weight.

Conclusion

Reconstruction of one ACL bundle or the other can restore knee stability and function. Care should be taken to detect where the PL bundle reaches maximum tension and in improving patient preoperative status and ischaemia time.