Discontinuities of the cruciate ligaments of the knee joint: causes, symptoms, diagnosis, treatment
Last reviewed: 23.04.2024
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ICD-10 code
S83.5. Sprain and rupture (posterior / anterior) of the cruciate ligament of the knee joint.
What causes ruptures of the cruciate ligaments of the knee joint?
The anterior and posterior cruciate ligaments keep the shin from displacement anteriorly and posteriorly. At rough violence on a tibia with a direction of impact behind and forward there is a rupture of an anterior cruciate ligament, with the application of force in the opposite direction a back cruciate ligament is torn. The anterior cruciate ligament suffers many times more often than the posterior one, since its damage is possible not only with the mechanism described, but also with excessive rotation of the tibia to the inside.
Symptoms of ruptures of cruciate ligaments of the knee joint
The victim complains of pain and instability in the knee joint, which appeared after the trauma.
Where does it hurt?
Diagnosis of ruptures of cruciate ligaments of the knee joint
Anamnesis
In the history - an indication of an appropriate injury.
Examination and physical examination
The joint is enlarged in size due to hemarthrosis and reactive (traumatic) synovitis. Movement in the knee joint is limited due to pain. The more free fluid that compresses the nerve endings of the synovium, the more intense the pain syndrome.
Reliable signs of a cruciate ligament rupture are symptoms of the "front and rear drawer", characteristic, respectively, for rupturing the same ligaments.
Check the symptoms as follows. The patient lies on the couch on the back, the injured limb is bent at the knee joint to the position of the plantar surface of the foot in the plane of the couch. The doctor sits face to the victim so that the patient's foot rests against his thigh. Having covered the upper third of the shin of the victim with both hands, the investigator tries to shift it alternately anteriorly and posteriorly.
If the lower leg is excessively displaced anteriorly, they speak of a positive symptom of the "front drawer", if posteriorly it is a "rear drawer". The mobility of the shins should be checked on both legs, for ballet dancers and gymnasts sometimes have a mobile ligament device simulating a rupture of ligaments.
The symptom of the "front drawer" can also be checked in a different way, in the manner suggested by GP. Kotel'nikov (1985). The patient lies on the couch. A healthy limb is bent at the knee joint at an acute angle. The patient's leg is placed on it by the region of the popliteal fossa.
Ask the patient to relax the muscles and gently push the distal shin. When the ligament ruptures, the proximal part of the leg is easily displaced anteriorly. This simple method can also be used during radiography as a documentary evidence of the presence of an anterior shin displacement. The technique described is simple. This is of great importance in the conduct of dispensary examinations of large groups of the population.
In old cases, the clinical picture of the cruciate ligament rupture consists of signs of instability of the knee joint (leg shunting during walking, impossibility of squatting on one leg), positive symptoms of the "drawer", fast fatigue of the limb, static pain in the thigh, lower back, healthy limb. An objective sign is the atrophy of the muscles of the injured leg.
Tight bandage of the knee joint or wearing a knee helps to make walking easier, gives confidence to the patient, reduces lameness. However, prolonged use of these devices leads to muscle atrophy, which reduces the result of surgical treatment.
Laboratory and instrumental research
With X-ray examination, a detachment of the intercondylar elevation can be detected.
[What do need to examine?
How to examine?
What tests are needed?
Treatment of ruptures of cruciate ligaments of the knee joint
Conservative treatment of cruciate ligament ruptures of the knee joint
Conservative treatment of gaps in the cruciate ligaments of the knee joint is used only for incomplete ruptures or in cases when the operation can not be performed for any reason.
The joint is punctured, hemarthrosis is eliminated, a 0.5-1% procaine solution is administered into the cavity in an amount of 25-30 ml. Then impose a circular gypsum dressing from the inguinal fold to the end of the fingers for a period of 6-8 weeks. UHF appoint from the 3rd-5th day. A static gymnastics is shown. Walking on crutches is allowed from the 10th to the 14th day. After removal of the plaster bandage, electrophoresis of procaine and calcium chloride is prescribed on the knee joint, ozocerite, rhythmic galvanization of the thigh muscles, warm baths, exercise therapy.
Features in the diagnosis and conservative treatment of knee ligament injuries.
- Symptoms indicating the inconsistency of the lateral or cruciate ligament, immediately after the injury can not be determined due to pain. The study is performed after removal of hemarthrosis and joint anesthesia.
- Be sure to undertake an X-ray examination to identify breakaway fractures and exclude damage to the condyles of the hip and shin.
- E s l and after the fall of edema, the cast plaster has weakened, it needs to be shifted (replaced).
Surgical treatment of ruptures of cruciate ligaments of the knee joint
Surgical treatment of cruciate ligament ruptures of the knee joint is to stitch the ruptured ligaments, but resort to it extremely rarely due to technical difficulties in performing the operation and low efficiency. In old cases, various types of plastic are used. The type of immobilization and timing are the same as for conservative treatment. Full load on the leg is allowed no earlier than 3 months from the moment of plastic.
Surgical treatment of injuries of cruciate ligaments of the knee joint. For the first time, the plasty of the anterior cruciate ligament was performed by I.I. Grekov (1913) according to his own method. It consisted of the following. A free graft from the wide fascia of the thigh, taken on the injured limb, is conducted through a channel drilled in the outer condyle of the thigh, and stitched with a torn ligament. This principle of operation was later used by M.I. Sitenko, AM Landa, Gay Groves, Smite, Campbell and others, who introduced fundamentally new elements into the technique of surgical intervention.
The most widely used method was Gay Groves-Smiths.
They open and examine the knee joint. The ruptured meniscus is removed. The cut along the outer surface of the thigh is 20 cm long. From the wide fascia of the thigh, a strip of 25 cm in length and 3 cm in width is cut out, stitched into a tube and cut off at the top, leaving a feeding leg down. Drill the channels in the external condyle of the femur and the inner condyle of the tibia, and the formed graft is performed through them. The end of the transplant is pulled and hemmed to the specially prepared bone bed of the inner condyle of the thigh, thus creating anterior cruciate and inner lateral ligament simultaneously. The limb is fixed with a plaster dressing when bending at the knee joint at an angle of 20 ° for 4 weeks. Then immobilization is eliminated and they begin rehabilitation therapy without the load on the limb, which is allowed only after 3 months from the moment of the operation.
In recent years, not only autografts, but also canned fascias, tendons taken from humans and animals, as well as synthetic materials such as lavsan, capron, etc., have been used to restore ligaments.
To restore cruciate ligaments with different degrees of instability of the knee joint, the clinic developed new and improved methods of operations, which can be divided into three groups:
- open - when the knee joint is opened during the operation;
- closed - through small incisions the instrument penetrates into the joint cavity, but does not perform arthrotomy;
- extraarticular - the tool does not enter the joint cavity.
Open methods of operations
Plastics of the anterior cruciate ligament of the knee joint with an internal meniscus.
In the literature methods of operations with the use of a meniscus are known. However, they did not receive wide dissemination.
In 1983, G.P. Kotelnikov developed a new method of plastic anterior cruciate ligament meniscus, recognized as an invention. Inner parapatellar incision of Pierre open the knee joint. They are guilty of it. If a meniscus is found to be damaged in the region of the hindbut or longitudinal rupture, it is mobilized subtotally to the place where the anterior horn is attached. The cut end is stitched with chromed catgut threads.
A thin awl-conductor 3-4 mm in diameter in the femur forms a channel with a direction from the place of attachment of the anterior cruciate ligament in the femur to the external condyle. Here, an incision is made of soft tissues 3 cm in length. The exit to the canal from the side of the joint is extended to a depth of 4-5 cm by another shilom equal in diameter to the size of the meniscus. The filaments are excreted by an awl-conductor through the canal at the external supracondylm. With their help, the horn of the meniscus is inserted into the canal, the optimal tension is applied, and the strings are fixed for soft tissues and periosteum of the femur. The limb is bent at an angle of 100-110 °.
Recently, the meniscus is sewn to improve the nutrition of hypertrophied fatty tissue, given that it is well-blooded. Long-term observations of patients allowed A.F. Krasnov draw an analogy between the fatty tissue of the knee joint and the epiploon 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 unbent at the knee joint to a 5-0 ° angle. Layered sutured wound catgut. Apply a plaster circular bandage from the fingertips to the upper third of the thigh.
Method of autoplasty of the anterior cruciate ligament with tendon of the semitendinous muscle. This method is successfully used in clinical practice. Such an operation can be performed if it is not possible to use the meniscus for autoplasty.
The incision is made at the attachment site of the "crow's foot" on the tibia (3-4 cm in length) or the Pair's cut is increased. The second incision is made in the lower third of the inner surface of the thigh 4 cm long. Here, the tendon of the semitendinous muscle is extracted, and it is taken on the holder.
A special tendon divider mobilizes the tendon subcutaneously to the place where the goose paw is attached. Sew the abdomen of the semitendinous muscle to the abdomen of a nearby tender muscle. The tendon part of the semitendinous muscle is cut off, the tendon is incised into the incision on the tibia. Retreat inside 1.5-2 cm from the tuberosity of the tibia and form a channel in the tibia and femur. The angle in the knee joint is 60 °. The third incision of soft tissues 3-4 cm long is made at the exit site of the sewing on the thigh. For the chrome threads, with which the end of the tendon was previously sewn, its conductor is cut into the cut on the thigh through the channels formed in the epiphyses of the bones. The joint is unbent to an angle of 15-20 °. The tendon is stretched and in this position is fixed for the periosteum and soft tissues of the thigh. The incisions are closed with catgut. Apply a gypsum circular bandage from the fingertips to the upper third of the thigh for 5 weeks.
Closed methods of operation
The whole history of the development of surgery - the desire of doctors to offer the most effective surgical methods of treatment, while causing minimal injury. Operative intervention in the pathology of the knee joint should also take into account the cosmetic effect.
The so-called closed methods of repairing the ligamentous apparatus were used by some domestic and foreign surgeons. However, many later abandoned these methods, putting forward, as an argument, the incompleteness of diagnosis of knee joint injuries and the difficulty of observing the exact topographic directions in the formation of canals. In recent years, in the literature once again there were isolated works on the use of closed ligament plasty. The term "closed plastic", however, does not quite correspond to reality, because during the operation, small incisions are made to introduce the shilts. Through the channels in the bones there are messages of the joint cavity with the external environment. Therefore, a "closed" surgery should be understood as intervention performed without arthrotomy.
At present, certain experience has been accumulated, new methods of closed ligament plasty have been proposed and indications for such operative interventions have been developed. As a rule, closed ligament plastic surgery is performed by patients with subcompensated and decompensated forms of post-traumatic instability of the knee joint.
Plasty of the anterior cruciate ligament. Before the beginning of the operation, a transplant is prepared: a canned tendon or (in its absence) a vascular lavsan prosthesis. At the end of the transplant, a special fixator, having the appearance of a trident, is fixed with lavsan or chromium catgut yarns. It is made of tantalum or stainless steel. The operation is as follows. The patient's leg is bent at an angle of 120 °, retreats from the tuberosity of the tibia to the inside by 1.5-2 cm and forms a channel towards the intercondylar deepening of the thigh, blindly ending it in the pituitary.
Remove the awl itself, and through the remaining tube in the canals of the tibia and femur, the tube leads the transplant with a trident by a special conductor. Take the tube out of the joint and pull the transplant. The teeth of the trident are opened and fixed for the cancellous bone of the canal walls. The patient's leg is unbent to an angle of 15-20 °, the transplant is fixed for the periosteum of the tibia with chrome catgut or lavsan threads. Sew the wound. Perform control radiography. Apply a gypsum circular bandage from the fingertips to the upper third of the thigh for 5-6 weeks.
Plastics of the anterior cruciate ligament with autosuns. To restore the anterior cruciate ligament, along with the described method, ligament plastics are used by the autosuchiosis of the semitendinous muscle with preservation of the attachment site in the "goose-foot" region on the tibia. The technique of surgery is the same as the cruciate ligament according to GP. To Kotelnikov. With the method of anterior cruciate ligament plasty performed openly. Arthrosis, of course, does not produce. The duration of immobilization is 5 weeks.
Extra-articular methods of operations
The option of closed methods of restoring ligaments of the knee joint is extra-articular plastic. When it is performed, the surgical instrument does not penetrate into the joint cavity at all. Indications for such operations are as follows.
- Previous operative interventions at the knee joint, when repeated arthrotomy is highly undesirable, as they accelerate the development of arthrosis.
- Instability in the joint against the background of deforming gonarthrosis II-III stage. In such cases, arthrotomy exacerbates the destructive-dystrophic process.
- Ruptures of ligaments of the knee joint without damage to other intraarticular formations. To clarify the diagnosis, a complex joint examination with arthroscopy is preliminary performed.
Plastics of the anterior cruciate and collateral ligaments. Of small incisions (2-4 cm) below the medial and lateral epicondyle and above the tuberosity of the tibia, bone channels are formed. The autograft from the wide fascia of the thigh on the feeding leg is subfascally extended through them. After tensioning the graft with a shin bent to 90 ° it is fixed at the entrance and exit to the periosteum. Circular gypsum bandage when bending at the knee at an angle of 140 ° is imposed for 5 weeks.
The method of dynamical plasty of the anterior cruciate ligament. When the anterior cruciate ligament ruptures, a good effect is given by an operation whose purpose is to create an actively acting extraarticular ligament ensuring dynamic congruence in the joint. The operation is prescribed to patients with subcompensated and decompensated forms of instability of the knee joint.
Two cuts of 1 cm make a transverse canal in the tibia 4-5 mm in diameter by 1 cm above its tuberosity. Conduct a transplant (a strip from the wide fascia of the thigh or a canned tendon) through it, fix it at the entrance and exit point with a chrome catgut.
Two other incisions of 4 cm are done on the hip in the projection of the tendon of the semitendinous muscle from the inside, the biceps one on the outside. The ends of the transplant are passed through tunnels formed on both sides, subcutaneously extracapsularly into the incisions. Bend the patient's leg in the knee joint at an angle of 90 °, tighten the transplant and fix it to the semitendinosus and biceps muscles with a chrome catgut. Wound the wounds. Apply a gypsum circular dressing from the fingertips to the upper third of the thigh (the patient's leg is bent at an angle of 140 ° in the knee joint).
This method of dynamic plastics allows the use of the strength of flexor muscles to actively keep its proximal part from moving anteriorly during walking. In the flexion phase of the tibia, when flexor muscles are straining, the graft having an U-shaped appearance is stretched, since one of its sections is fixed intimately, intraosseously (fasciola or tenodes), and the other two ends are connected externally and internally to muscle flexors. These fixation points are displaced adequately to the work of the muscles. Dislocation of the tibia anteriorly (anterior instability) often occurs in the bending phase of the joint, but the active ligament retains it, and at each stage of the movement the ligament receives the optimal tension and ensures the dynamic congruence of the articular surfaces. The newly formed ligament acts physiologically, without disturbing the biomechanics of movements in the joint.