Anterior Cruciate Ligament Repair and Reconstruction

What Is the Anterior Cruciate Ligament and What Does an Injury Mean?

The anterior cruciate ligament (ACL) is a strong ligament located in the center of the knee joint that connects the thigh bone (femur) to the shin bone (tibia). Its primary function is to prevent the tibia from sliding forward relative to the femur and to provide stability during the knee’s rotational movements.

An anterior cruciate ligament injury means the ligament has been stretched (sprained) or partially or completely torn. Tears usually occur in the middle portion of the ligament, but sometimes they can occur as a detachment (avulsion) from where it attaches to the bone. The severity of the injury is classified according to the degree of damage to the ligament. Complete tears are the most common and generally require surgical treatment.

Repair or Reconstruction?

• Anterior Cruciate Ligament Repair: This is the procedure of suturing the torn ligament back together. However, because the ACL’s blood supply is poor, this method can only be applied in very specific situations (e.g., bony avulsion, certain proximal tears where the ligament ends can be brought back together) and usually only in the early period after the injury.
• Anterior Cruciate Ligament Reconstruction: This is the procedure of creating a new ligament using a tendon taken from another part of the patient’s own body (autograft) or a tendon taken from a donor (allograft), to replace the torn ligament that has lost its function. Today, reconstruction is generally the standard surgical treatment for ACL tears.

Causes and Risk Factors of Anterior Cruciate Ligament Tears

Anterior cruciate ligament tears usually occur as a result of traumatic events. The most common mechanisms are as follows:

• Sudden Stopping and Changing Direction: Suddenly stopping while running and turning in a different direction (pivoting movement).
• Unstable Landing After Jumping: Uncontrolled inward or outward rotation of the knee upon landing after a jump, particularly in sports such as basketball and volleyball.
• Sudden Deceleration: Suddenly slowing down while running fast.
• Direct Blow to the Knee: Particularly impacts received to the side of the knee.

Risk Factors:

• Type of Sport: Sports involving sudden changes of direction and jumping, such as football, basketball, volleyball, handball, and skiing, carry a higher risk.
• Gender: Due to anatomical and hormonal differences, female athletes have a higher risk of ACL tears than male athletes.
• Previous ACL Injury: Individuals who have had an ACL tear in one knee have an increased risk of a repeat tear in the other knee or the same knee.
• Muscle Imbalances and Poor Conditioning: Strength imbalances between leg muscles or insufficient training can increase the risk.
• Playing Surface and Footwear: Unsuitable sports shoes or the condition of the playing surface can also affect the risk.

The high level of sports activity in large cities such as Ankara causes this type of injury to be seen frequently.

What Are the Symptoms of an Anterior Cruciate Ligament Tear?

People who experience an anterior cruciate ligament tear generally experience the following symptoms at the moment of injury:

• A “Pop” Sound: Hearing a clear popping or snapping sound from the knee at the time of injury.
• Sudden, Severe Pain: Feeling a sudden, sharp pain in the knee when the tear occurs.
• Rapid Swelling: Noticeable swelling in the knee within the first few hours after injury (due to bleeding within the joint).
• Feeling of Giving Way (Instability): A feeling of the knee “giving way,” “slipping,” or “being unstable.” Particularly the sensation that the knee moves out of control when going down stairs or making sudden movements.
• Restricted Range of Motion: Difficulty fully bending or straightening the knee.
• Inability to Bear Weight: Inability to put weight on the leg due to pain and swelling after the injury.

If you are experiencing one or more of these symptoms, it is important to consult an orthopedic specialist.

How Is an Anterior Cruciate Ligament Tear Diagnosed?

An accurate diagnosis is the first step in creating an effective treatment plan. At his clinic in Ankara, Prof. Dr. Murat Bozkurt evaluates patients presenting with suspected ACL tears using the following methods:

• Patient History (Anamnesis): How the injury occurred, the symptoms experienced (sound, pain, swelling, feeling of giving way), and any previous knee problems are questioned in detail.
• Physical Examination: Tenderness, swelling, and range of motion in the knee are assessed. Special examination tests are performed to test the integrity of the anterior cruciate ligament. The best known of these are the Lachman Test, the Anterior Drawer Test, and the Pivot Shift Test. During these tests, abnormal movement in the knee (forward sliding or rotation) is assessed. The menisci and other ligaments are also examined.
• Magnetic Resonance Imaging (MRI): This is the gold-standard method for confirming an ACL tear, determining whether the tear is complete or partial, and detecting other accompanying injuries (meniscus tear, cartilage damage, other ligament injuries, bone edema).
• X-ray: This is usually requested to assess whether there is a fracture or a bony avulsion-type injury.

Based on these evaluations, the diagnosis of an ACL tear is confirmed, accompanying injuries are identified, and the most appropriate treatment plan is created.

Treatment Options for Anterior Cruciate Ligament Tears

Treatment for an ACL tear is personalized according to the patient’s age, activity level, expectations, the type of tear, and any accompanying injuries. There are two main treatment approaches: non-surgical (conservative) treatment and surgical treatment.

• Non-Surgical Treatment: This may be an option for older patients, those with a low activity level, or those who do not want surgery. This approach includes the use of a knee brace, ice application, pain relievers, and intensive physical therapy. The goal of physical therapy is to reduce the feeling of instability in the knee by strengthening the muscles around the knee and improving balance. However, this method does not heal the torn ligament and is generally insufficient for active individuals who want to return to sports in particular. The risk of meniscus and cartilage damage continues in the long term.
• Surgical Treatment: This is the standard treatment method, particularly for young, active patients who want to return to sports and for those with a pronounced feeling of instability in the knee. There are two main options for surgical treatment:
  
  • Anterior Cruciate Ligament Repair: As mentioned above, this method is only possible in very select cases (e.g., bony avulsion-type tears, certain proximal tears) and in the early period after injury. Prof. Dr. Murat Bozkurt may consider this technique in suitable cases.
  • Anterior Cruciate Ligament Reconstruction: This is the most commonly performed surgical method. A new ligament is created using a graft in place of the torn ligament. The grafts used may include:
    
    • Autografts (from the Patient’s Own Body): Hamstring tendons (muscle tendons behind the knee), the patellar tendon (tendon below the kneecap), and the quadriceps tendon (muscle tendon above the kneecap) are the most commonly used autografts. Each has its own advantages and disadvantages, and the choice is made based on the patient.
    • Allografts (from a Cadaver): These are tested and prepared tendons obtained from a tissue bank. They may be preferred particularly in revision (repeat) surgeries or in multi-ligament injuries.

Prof. Dr. Murat Bozkurt determines the most appropriate surgical method and graft choice for his patients in Ankara, taking into account each patient’s individual needs and goals.

Anterior Cruciate Ligament Surgery: Repair, Reconstruction, Risks, Benefits, and Recovery

ACL surgery is usually performed using the arthroscopic (closed) technique. In this method, the procedure is carried out by inserting a camera and surgical instruments into the knee joint through small incisions. Arthroscopic surgery offers advantages such as less pain, smaller scars, and faster recovery.

• Reconstruction Surgery: The selected graft is prepared. Tunnels are drilled in the femur (thigh bone) and tibia (shin bone). The graft is passed through these tunnels and fixed to the bone at the appropriate tension using screws, buttons, or other fixation devices. The goal is to replicate the anatomical position and function of the original ACL.
• Repair Surgery: In suitable cases, the ends of the torn ligament are reattached to the bone or to each other using special suturing techniques and, sometimes, supportive materials.

Benefits:

• Regaining knee stability and eliminating the feeling of the knee giving way.
• Reduced pain and improved knee function.
• The ability to return to the desired activity level and sport (after appropriate rehabilitation).
• A reduced long-term risk of meniscus and cartilage damage.
• Improved quality of life.

Risks:

• General Surgical Risks: Infection, deep vein thrombosis (DVT – a blood clot in the leg), pulmonary embolism, anesthesia complications.
• Risks Specific to the Surgery: Knee stiffness (limited range of motion), post-operative pain, graft failure or re-tearing, problems related to fixation devices, nerve or vascular injury, infection, anterior knee pain (particularly after patellar tendon grafts).

Recovery Process:

• Following ACL surgery, rehabilitation is a part of treatment that is at least as important as the surgery itself and is the key to success.
• The recovery process is long and gradual, generally taking 6 to 12 months or longer.
• In the early post-operative period, the goal is to control pain and swelling and regain the knee’s range of motion. The use of crutches and a knee brace may be required.
• In later stages, muscle strength (especially of the quadriceps and hamstrings), balance, and proprioception (the ability to sense the joint’s position) exercises are performed under the guidance of physiotherapy.
• Return to sports occurs gradually, only after certain criteria (muscle strength, range of motion, functional tests) have been met, with the approval of the doctor and physiotherapist. Early and uncontrolled return to sports increases the risk of re-injury.

Anterior Cruciate Ligament Treatment in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Anterior cruciate ligament tears are injuries that require expertise and are frequently encountered, particularly in cities with an active population such as Ankara. The success of treatment depends on an accurate diagnosis, the selection of the appropriate treatment method, the quality of the surgical technique, and the effectiveness of post-operative rehabilitation.

Prof. Dr. Murat Bozkurt has extensive experience and expertise in the diagnosis and treatment of anterior cruciate ligament injuries in Ankara. He offers his patients up-to-date and effective treatment options using modern arthroscopic surgical techniques (both reconstruction and repair in suitable cases).

Prof. Dr. Bozkurt’s approach to ACL treatment:

• Accurate and Comprehensive Diagnosis: Understanding the mechanism of injury, performing a detailed physical examination, and clearly identifying the ACL tear and any possible additional injuries using MRI.
• Personalized Treatment Plan: Deciding on surgical or non-surgical treatment, and, if surgery is to be performed, the most appropriate technique (repair/reconstruction) and graft option, taking into account the patient’s age, activity level, expectations for returning to sports, lifestyle, and other knee problems.
• Patient Education: Explaining the treatment options, surgical process, risks, benefits, and especially the importance of the long rehabilitation process to the patient in detail.
• Meticulous Surgical Technique: Performing arthroscopic surgery using the most up-to-date techniques and a high degree of precision.
• Close Follow-Up and Rehabilitation Coordination: Closely monitoring the post-operative recovery process and working in coordination with physiotherapists to ensure the patient undergoes a successful rehabilitation process.

If you live in Ankara and suspect you have an anterior cruciate ligament tear, or if you would like to get a second opinion on this matter, you can benefit from the expertise of Prof. Dr. Murat Bozkurt.