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Tears of cruciate ligaments of the knee joint: causes, symptoms, diagnosis, treatment
Last reviewed: 05.07.2025
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ICD-10 code
S83.5. Sprain and rupture of (posterior/anterior) cruciate ligament of knee joint.
What causes cruciate ligament tears in the knee?
The anterior and posterior cruciate ligaments prevent the shin from shifting forward and backward. With severe force on the tibia with a blow directed from behind and forward, the anterior cruciate ligament ruptures, and when force is applied in the opposite direction, the posterior cruciate ligament ruptures. The anterior cruciate ligament suffers many times more often than the posterior one, since it can be damaged not only by the described mechanism, but also by excessive rotation of the shin inward.
Symptoms of a torn cruciate ligament in the knee joint
The victim complains of pain and instability in the knee joint, which appeared following the injury.
Where does it hurt?
Diagnosis of cruciate ligament ruptures of the knee joint
Anamnesis
The anamnesis indicates a corresponding injury.
Inspection and physical examination
The joint is enlarged due to hemarthrosis and reactive (traumatic) synovitis. Movements in the knee joint are limited due to pain. The more free fluid compressing the nerve endings of the synovial membrane, the more intense the pain syndrome.
Reliable signs of a rupture of the cruciate ligaments are the symptoms of the “anterior and posterior drawer”, which are characteristic, respectively, of a rupture of the ligaments of the same name.
The symptoms are checked as follows. The patient lies on the couch on his back, the injured limb is bent at the knee joint until the plantar surface of the foot is on the plane of the couch. The doctor sits facing the victim so that the patient's foot rests on his thigh. Having grasped the upper third of the victim's shin with both hands, the examiner tries to move it alternately forward and backward.
If the shin is excessively displaced forward, it is called a positive "anterior drawer" symptom; if it is displaced backward, it is called a "posterior drawer". The mobility of the shin should be checked on both legs, because ballet dancers and gymnasts sometimes have a mobile ligamentous apparatus that simulates a ligament rupture.
The "front drawer" symptom can be tested in another way - using the method proposed by G.P. Kotelnikov (1985). The patient lies on a couch. The healthy limb is bent at the knee joint at an acute angle. The sore leg is placed on it with the popliteal fossa area.
The patient is asked to relax the muscles and gently press on the distal part of the leg. When the ligament is torn, the proximal part of the leg easily shifts forward. This simple method can also be used during radiography as documentary evidence of the presence of forward displacement of the leg. The described technique is simple. This is of great importance when conducting routine examinations of large groups of the population.
In chronic cases, the clinical picture of a cruciate ligament rupture consists of signs of instability of the knee joint (shin dislocation when walking, inability to squat on one leg), positive symptoms of a "drawer", rapid fatigue of the limb, static pain in the hip, lower back, and healthy limb. An objective sign is muscle atrophy of the injured leg.
Tight bandaging of the knee joint or wearing a knee brace temporarily makes walking easier, gives confidence to the patient, and reduces lameness. However, long-term use of these devices leads to muscle atrophy, which reduces the result of surgical treatment.
Laboratory and instrumental studies
X-ray examination may reveal a rupture of the intercondylar eminence.
[ What do need to examine?
How to examine?
What tests are needed?
Treatment of cruciate ligament ruptures of the knee joint
Conservative treatment of cruciate ligament ruptures of the knee joint
Conservative treatment of cruciate ligament ruptures of the knee joint is used only for incomplete ruptures or in cases where surgery cannot be performed for some reason.
The joint is punctured, hemarthrosis is eliminated, 0.5-1% procaine solution in the amount of 25-30 ml is introduced into the cavity. Then a circular plaster cast is applied from the inguinal fold to the end of the fingers for a period of 6-8 weeks. UHF is prescribed from the 3rd to the 5th day. Static gymnastics is indicated. Walking on crutches is allowed from the 10th to the 14th day. After removing the plaster cast, electrophoresis of procaine and calcium chloride on the knee joint, ozokerite, rhythmic galvanization of the thigh muscles, warm baths, and exercise therapy are prescribed.
Features of diagnostics and conservative treatment of knee joint ligament injuries.
- Symptoms indicating failure of the lateral or cruciate ligaments cannot be determined immediately after the injury due to pain. The study is carried out after the hemarthrosis has been eliminated and the joint has been anesthetized.
- It is imperative to undertake an X-ray examination to identify avulsion fractures and exclude damage to the condyles of the femur and tibia.
- If, after the swelling has gone down, the plaster cast has become loose, it needs to be repositioned (changed).
Surgical treatment of cruciate ligament ruptures of the knee joint
Surgical treatment of cruciate ligament ruptures of the knee joint involves suturing the torn ligaments, but this is rarely done due to the technical difficulties of performing the operation and low efficiency. In chronic cases, various types of plastics are used. The type of immobilization and the time frame are the same as for conservative treatment. Full weight-bearing on the leg is allowed no earlier than 3 months after the plastic surgery.
Surgical treatment of cruciate ligament injuries of the knee joint. I. I. Grekov (1913) was the first to perform anterior cruciate ligament plastic surgery using a technique he developed. It consisted of the following. A free graft from the broad fascia of the thigh, taken from the injured limb, is passed through a canal drilled in the outer condyle of the femur and sutured to the torn ligament. This principle of surgery was later used by M. I. Sitenko, A. M. Landa, Gay Groves, Smith, Campbell and others, who introduced fundamentally new elements into the surgical intervention technique.
The most widely used method is that of Gay Groves-Smith.
The knee joint is opened and examined. The torn meniscus is removed. The incision along the outer surface of the thigh is 20 cm long. A strip 25 cm long and 3 cm wide is cut out of the broad fascia of the thigh, sewn into a tube and cut off at the top, leaving the feeding pedicle at the bottom. Channels are drilled in the outer condyle of the femur and the inner condyle of the tibia, through which the formed graft is passed. The end of the graft is pulled tight and sutured to a specially prepared bone bed of the inner condyle of the femur, thus creating simultaneously the anterior cruciate ligament and the inner collateral ligament. The limb is fixed with a plaster cast with the knee joint flexed at an angle of 20° for 4 weeks. Then the immobilization is removed and rehabilitation treatment without weight-bearing of the limb is started, which is allowed only 3 months after the operation.
In recent years, not only autografts have been used to restore ligaments, but also preserved fascia, tendons taken from humans and animals, as well as synthetic materials: lavsan, nylon, etc.
To restore cruciate ligaments with various degrees of knee joint instability, the clinic has developed new and improved surgical methods that can be divided into three groups:
- open - when the knee joint is opened during surgery;
- closed - through small incisions the instrument penetrates into the joint cavity, but arthrotomy is not performed;
- extra-articular - the instrument does not enter the joint cavity.
Open methods of operations
Plastic surgery of the anterior cruciate ligament of the knee joint with the internal meniscus.
There are known methods of operations using meniscus in the literature. However, they have not received widespread use.
In 1983, G.P. Kotelnikov developed a new method of anterior cruciate ligament meniscus plastic surgery, which was recognized as an invention. The knee joint is opened with Payre's internal parapatellar incision. It is revised. If damage to the meniscus is detected in the area of the posterior horn or a longitudinal rupture, it is mobilized subtotally to the attachment site of the anterior horn. The severed end is sutured with chromic catgut threads.
A thin awl-guide with a diameter of 3-4 mm is used to form a channel in the femur with the direction from the attachment point of the anterior cruciate ligament at the femur to the lateral condyle. Here, a 3 cm long incision is made in the soft tissue. The exit to the channel from the side of the joint is expanded to a depth of 4-5 cm with another awl equal in diameter to the size of the meniscus. The threads are brought out with a guide awl through the channel at the lateral epicondyle. With their help, the posterior horn of the meniscus is inserted into the channel, optimal tension is applied, and the threads are fixed to the soft tissue and periosteum of the femur. The limb is bent at an angle of 100-110 °.
Recently, hypertrophied fatty tissue has been stitched to the meniscus to improve nutrition, given that it is well supplied with blood. Long-term observations of patients allowed A. F. Krasnov to draw an analogy between the fatty tissue of the knee joint and the omentum of the abdominal cavity. It is this property of fatty tissue that is now used in such operations. The further course of the operation is as follows. The patient's leg is carefully extended at the knee joint to an angle of 5-0°. The wound is sutured layer by layer with catgut. A circular plaster bandage is applied from the fingertips to the upper third of the thigh.
A method of autoplasty of the anterior cruciate ligament with the tendon of the semitendinosus muscle. This method is successfully used in clinical practice. Such an operation can be performed when it is impossible to use the meniscus for autoplasty.
The incision is made at the point of attachment of the "goose foot" on the tibia (3-4 cm long) or the Payra incision is enlarged. The second incision is made in the lower third of the inner surface of the thigh, 4 cm long. Here the tendon of the semitendinosus muscle is isolated and taken on a holder.
A special tendon extractor is used to mobilize the tendon subcutaneously to the point of attachment of the "goose foot". The belly of the semitendinosus muscle is sutured to the belly of the adjacent gracilis muscle. The tendinous part of the semitendinosus muscle is cut off, and the tendon is brought out through an incision on the tibia. A 1.5-2 cm step is made inward from the tibial tuberosity and a channel is formed in the tibia and femur. The angle in the knee joint is 60°. A third 3-4 cm long soft tissue incision is made at the exit point of the awl on the thigh. Using the chrome threads that were previously used to suture the end of the tendon, it is brought out through the incision on the thigh through the channels formed in the bone epiphyses. The joint is extended to an angle of 15-20°. The tendon is pulled and fixed in this position by the periosteum and soft tissues of the thigh. The incisions are sutured with catgut. A circular plaster cast is applied from the fingertips to the upper third of the thigh for 5 weeks.
Closed methods of surgery
The entire history of the development of surgery is the desire of doctors to offer the most effective surgical treatment methods, causing minimal trauma. Surgical intervention in knee joint pathology should also take into account the cosmetic effect.
The so-called closed methods of ligament apparatus restoration were used by some domestic and foreign surgeons. However, many subsequently abandoned these methods, citing as an argument the incompleteness of diagnostics of knee joint injuries and the difficulty of observing precise topographic directions when forming canals. In recent years, isolated works on the use of closed ligament plastic surgery have reappeared in the literature. The term "closed plastic surgery" itself, however, does not quite correspond to reality, since small incisions are made during the operation to insert awls. Through the canals in the bones, there are communications between the joint cavity and the external environment. Therefore, "closed" surgical intervention should be understood as an intervention performed without arthrotomy.
At present, a certain amount of experience has been accumulated, new methods of closed ligament plastic surgery have been proposed, and indications for such surgical interventions have been developed. As a rule, we perform closed ligament plastic surgery on patients with subcompensated and decompensated forms of post-traumatic instability of the knee joint.
Anterior cruciate ligament plastic surgery. Before the operation, a graft is prepared: preserved tendon or (if unavailable) a vascular lavsan prosthesis. A special trident-shaped fixator is fixed to the end of the graft with lavsan or chromium-plated catgut threads. It is made of tantalum or stainless steel. The operation is as follows. The patient's leg is bent at an angle of 120°, they retreat from the tibial tuberosity inward by 1.5-2 cm and form a canal in the direction of the intercondylar fossa of the femur, blindly ending it in the epiphysis.
The awl itself is removed, and the transplant is inserted through the tube remaining in the canals of the tibia and femur with a special guide, trident-first. The tube is removed from the joint and the transplant is pulled. The teeth of the trident are opened and secured to the spongy bone of the canal walls. The patient's leg is extended to an angle of 15-20°, the transplant is fixed to the periosteum of the tibia with chromic catgut or lavsan threads. The wound is sutured. A control X-ray is performed. A circular plaster bandage is applied from the fingertips to the upper third of the thigh for 5-6 weeks.
Anterior cruciate ligament plasty with autotendon. In addition to the described method, ligament plasty with autotendon of the semitendinosus muscle is used to restore the anterior cruciate ligament, preserving its attachment site in the area of the "goose foot" on the tibia. The surgical technique is the same as for the cruciate ligament according to G.P. Kotelnikov. with the open anterior cruciate ligament plasty method. Arthrotomy, of course, is not performed. The immobilization period is 5 weeks.
Extra-articular surgical methods
A variant of closed methods of knee joint ligament restoration is extra-articular plastic surgery. When performing it, the surgical instrument does not penetrate the joint cavity at all. Indications for such operations are as follows.
- Previous surgical interventions on the knee joint, when repeated arthrotomies are highly undesirable, as they accelerate the development of arthrosis.
- Instability in the joint against the background of deforming gonarthrosis of stage II-III. In such cases, arthrotomy aggravates the destructive-dystrophic process.
- Ruptures of the knee joint ligaments without damage to other intra-articular structures. To clarify the diagnosis, a comprehensive examination of the joint is first performed using arthroscopy.
Plastic surgery of the anterior cruciate and collateral ligaments. Bone canals are formed from small incisions (2-4 cm) below the medial and lateral epicondyles and above the tibial tuberosity. An autograft made of the broad fascia of the thigh is pulled through them subfascially on a feeding pedicle. After tensioning the graft with the tibia flexed to 90°, it is fixed at the entrance and exit to the periosteum. A circular plaster cast with the knee flexed at an angle of 140° is applied for 5 weeks.
Method of dynamic plastic surgery of the anterior cruciate ligament. In case of ruptures of the anterior cruciate ligament, a good effect is given by an operation, the purpose of which is to create an actively acting extra-articular ligament, providing dynamic congruence in the joint. The operation is prescribed to patients with subcompensated and decompensated forms of instability of the knee joint.
Through two 1 cm incisions, a transverse canal is made in the tibia with a diameter of 4-5 mm, 1 cm above its tuberosity. A transplant (a strip of broad fascia of the thigh or preserved tendon) is passed through it, fixed at the entry and exit points with chromic catgut.
Two other 4 cm incisions are made on the thigh in the projection of the semitendinosus tendon from the inside and the biceps tendon from the outside. The ends of the graft are passed through the tunnels formed on both sides, subcutaneously extracapsularly into the incisions. The patient's leg is bent at the knee joint at an angle of 90°, the graft is pulled and fixed to the semitendinosus and biceps muscles with chromic catgut. The wounds are sutured. A circular plaster bandage is applied from the fingertips to the upper third of the thigh (the patient's leg is bent at an angle of 140° at the knee joint).
This method of dynamic plastic surgery allows using the force of the flexor muscles of the lower leg to actively hold its proximal section from shifting forward during walking. In the phase of lower leg flexion, when the flexor muscles are strained, the U-shaped transplant is stretched, since one of its sections is fixed intimately, intraosseously (fascio- or tenodesis), and the other two ends are connected to the flexor muscles from the outside and inside. These fixation points shift adequately to the work of the muscles. Anterior dislocation of the lower leg (anterior instability) most often occurs in the phase of joint flexion, but the actively acting ligament holds it, and at each stage of movement the ligament receives optimal tension and ensures dynamic congruence of the articular surfaces. The newly formed ligament acts physiologically, without violating the biomechanics of movements in the joint.