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The crucial cruciates hip and knee surgery

Mr Fares Haddad and Mr Sam Oussedik give an up-to-the-minute review of 'the footballer's injury'

Mr Fares Haddad and Mr Sam Oussedik give an up-to-the-minute review of 'the footballer's injury'

Case history

A 23-year-old woman presents to A&E one morning, complaining of right knee pain and inability to bear weight. She is a keen netball player, playing at county level. She describes playing in a match the previous evening and landing awkwardly following a jump. She had felt a 'pop' in her knee and was unable to play on. On the sidelines the knee began to swell rapidly. She thought it was probably just a severe sprain and went home. The next morning the swelling and pain were still present, and this had prompted her to come to A&E.

Diagnosis and management

The anterior cruciate ligament is a 3.5cm-long band of fibrous tissue that runs from the posteromedial lateral femoral condyle to the anterior tibial eminence. It is a primary restraint to translation of the tibia on the femur, and a secondary restraint to varus or valgus forces and tibial rotation. Common mechanisms of injury include:

  • Deceleration injuries, such as those seen when a footballer or basketball player suddenly changes direction, especially if the tibia is fixed in internal rotation
  • Flexion, valgus or external rotation injuries, such as when a boot gets stuck in the turf or a ski binding is not released
  • Hyperextension, as in the sportsman who lands awkwardly·Direct blows to the knee or tibia can also lead to anterior cruciate ligament disruption, often associated with injuries to other structures about the knee.

Assessment should include a detailed history of both the mechanism of injury and any previous trauma. Examination should proceed along the model of 'look, feel, move'.

Key points

  • Presence of a large effusion is common ­ due to ruptured ligament bleeding into the joint·Pain may impede further examination, in which case aspiration of the joint under aseptic conditions may be necessary
  • The presence of fat globules in the aspirate suggests an intra-articular fracture
  • About 80 per cent of the patients who attend A&E with acute haemarthrosis have anterior cruciate ligament injuries
  • About 60 per cent of those will have associated meniscal or chondral injuries
  • The average district general hospital catchment area has 100 ruptures of the anterior cruciate ligament a year
  • Clinical examination has a 100 per cent specificity and sensitivity for anterior cruciate ligament rupture in experienced hands·In 1996 only 9.2 per cent of injuries were being correctly diagnosed by the referring clinician, leading to an average 21-month delay in diagnosis
  • Initial X-ray assessment should include anterior-posterior and lateral views of the knee to detect any associated bony injuries·MRI is highly sensitive for anterior cruciate ligament injuries but is not usually necessary to confirm diagnosis
  • Examination of the contralateral knee for comparison, and the ipsilateral ankle and hip, is essential.
  • the Lachman test, where anterior tibial translation is assessed at 20° of flexion·the anterior drawer test, where anterior tibial translation is assessed at 90° of flexion·the pivot shift test, where the subluxed knee is reduced by flexing the knee with a valgus internal rotation stress.

On examination, our netball player's knee is able to bear weight. The right knee is swollen and has a grade III effusion. Initial examination is limited by pain, and the knee is therefore tapped and 25ml of blood aspirated under aseptic conditions. The aspirate contains no fat globules. Following aspiration, straight-leg raising is possible, Lachman's and anterior drawer test are positive, and a positive pivot shift test is also demonstrated.

Treatment options

  • referral for physiotherapy ­ to restore the full range of motion and strengthen quadriceps and hamstring·referral to the local knee or sports injuries clinic ­ for a management plan.
  • initial arthroscopy ­ in patients presenting with knee locking, or symptoms and signs of meniscal injury·reconstruction

The success of anterior cruciate ligament reconstruction is now well documented. The successful treatment of high-profile sportsmen and women has led to an increased public awareness of this injury, and an associated increased expectation about the outcome of treatment. This makes accurate and timely diagnosis of paramount importance. The procedure is available on the NHS and is carried out at most centres. The cost to have the procedure done privately is approximately £4,000.

Factors affecting move to reconstruction

The decision on whether or not to proceed with reconstruction depends on symptomatology together with the patient's expectations of future activity level. Determinant factors:

Does the patient want to return to the same level of activity/competitive sport? A knee in which the anterior cruciate ligament is deficient relies more heavily on the secondary restraints of anterior tibial translation, in particular the medial meniscus. This means that degenerative tears and the progression to osteoarthritis are more common in this group if the level of sporting activity is not adjusted. There remains no conclusive evidence linking reconstruction to a decrease in the risk of osteoarthritis, although this would appear logical in those patients who continue at pre-injury levels of activity. ·

A survey of British surgeons shows that the most important factors taken into account when considering reconstruction are the patient's subjective reporting of 'giving way', a positive pivot shift and the failure of conservative management .· Once a decision to reconstruct has been taken, delaying the procedure until inflammation has settled and a full range of motion is restored is currently favoured.

A number of reconstructive options are available. Currently two main graft types are in common use, the bone-patella tendon-bone graft and the four-strand semitendinosus-gracilis graft, although others are available. Post operatively the patient must make a commitment to a period of physiotherapy. Current trends are towards 'accelerated' rehabilitation. Even so, it is still at least six months, and more commonly nine, before a return to sporting activities can be expected.

Sam Oussedik is a research and clinical fellow at University College Hospital, London Competing interests None declaredFares Haddad is consultant orthopaedic surgeon specialising in knee and hip arthroscopy, reconstruction, joint replacement and revision, and clinical director at University College Hospital, LondonCompeting interests None declared

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