RECONSTRUCTION OF THE PREVIOUS CROSSOVER LIGAMENT

For all traumatic or chronic diseases of the musculoskeletal system, the Centrokinetic private clinic in Bucharest is prepared with an integrated Orthopedic Department, which offers all the necessary services to the patient, from diagnosis to complete recovery.

The Department of Orthopedic Surgery of Centrokinetic is dedicated to providing excellent patient care and exceptional education for young physicians in the fields of orthopedic surgery and musculoskeletal medicine.

Centrokinetic attaches great importance to the entire medical act: investigations necessary for correct diagnosis (ultrasound, MRI), surgery, and postoperative recovery.

Discover the open MRI imaging center in our clinic. Centrokinetic has a state-of-the-art MRI machine, dedicated to musculoskeletal conditions, in the upper and lower limbs. The MRI machine is open so that people suffering from claustrophobia can do this investigation. The examination duration is, on average, 20 minutes.

Anterior cruciate ligament rupture (ACL) is the most common ligament injury of the knee, causing over 50,000 ligament reconstructions per year in the United States. The risk of this injury has increased greatly among the average population, due to increased participation in sports activities.

Most of the time, the rupture (ACL is due to a rotational mechanism. The repercussions of the ACL rupture must be very well understood because the rupture of the anterior cruciate ligament has no consequences on the flexion-extension movements of the knee. The patient completely regains this movement after 4-6 weeks of physical therapy and does not feel instability when performing this movement (eg knee bends). Instead, the knee is vulnerable to rotational and torsional movements: the patient feels instability in rotational movements of the body with the foot locked to the ground (pivoting sports), but also in everyday life when performing these rotational movements. Clinical examination of the patient is very important to detect these instabilities: sagittal and rotational. Rotational stability is provided by ACL and ALL (anterolateral ligament of the knee), there are situations in which both ligaments rupture and rotational instability are very high. That is why the clinical examination and the patient's anamnesis (detailed description of the accident) are very important.

The surgical technique is an extremely controversial problem, which has undergone many changes in the last 3 decades, and currently, anatomical reconstruction of the ligament is opted for. This reconstruction aims to position the graft as close as possible to the natural ligament, but this idea is difficult to achieve because the natural ligament has both an origin and an insertion, wider than the graft used; it has a double orientation towards the graft and it has 2 strips with a well-defined position and roles, compared to the graft which is a single strip. Therefore, this surgery fails to fully reach the desired parameters, ideal in terms of graft positioning.

There are many methods of reconstructing the LIA, among which we mention:

• Autograft harvested from the patient is the most commonly used graft, it is cheap, it is very good because it integrates best, but it does not always have the desired dimensions: length and thickness. The autograft is of several types: hamstrings, patellar tendon (BTB), quadriceps tendon, fascia lata. Currently, the most commonly used as the first intention is the hamstrings type, and the BTB type is used in revisions (when the initial graft is also broken). However, a category of athletes in whom the BTB graft is recommended as the first intention is footballers. In the USA, for high-performance athletes (soccer, American football, even basketball, although this category due to repeated jumps, patellar tendinopathy occurs later), the graft used is BTB.
• Allograft (obtained from suppliers specialized in sports medicine): it is an ideal graft in terms of size and structure, being an Achilles tendon. The graft has the desired thickness, the tendon is very resistant, but the chances of integration are lower than in the case of autografts. That is why this graft, in the world, is much less used, being an option only in certain cases.
• Artificial graft (graft made of synthetic material, used in performance athletes, because it ensures a quick return to sport)

The preparation of the tibial canal depends on the modulus that fixes the graft:

• If the fixation involves the use of an interference screw, then the preparation is done with a special guide through which a brooch is inserted into the joint cavity. By knee extension, it is checked if there is an impingement with the femoral condyle or the posterior cruciate ligament. Depending on the distal thickness of the graft, a drill (number by number) is used to create the tibial tunnel to the level of the joint surface.

• If the fixation involves the use of an adjustable endobutton (all inside technique), then we use a retrograde brooch, and the tunnel will have a diameter equal to that of the graft. Our medical team has been performing the all-inside technique for about 4 years, with excellent results. The advantages are the increased contact of the graft with the bone, by the lack of the screw, which gives much greater chances of graft integration.