The first treatments of the acl reconstruction icd 9 code rupture of anterior cruciate ligament with the atroscopio began in the early 1980s, icd 9 knee reconstruction receiving our service VIDEO MED international award in the Gold category, 1989, by the development of Arthroscopic anterior cruciate ligament repair technique.
His treatment has changed in the three decades, preferring to the substitution thereof, on active people, to decrease the risk of secondary cartilaginous or meniscal injury. Better knowledge of the anatomy and the mechanical function of this ligament, precision and low morbidity of current Arthroscopic techniques, as well as accelerated rehabilitation and pressure from patients to maintain their quality of life without limitations have led decisively the ACL surgery.
These responses are intended to reflect the issues most requested and set the current position of our service in the treatment of these injuries, although one cannot forget that each patient requires a solution tailored for has realized in consultation medical.
WHAT IS THE ANTERIOR CRUCIATE LIGAMENT?
It is a ligament located in the interior of the articulation of knee, small size but high functional importance.Cross by adopting that provision in the space, in relation to the so-called posterior cruciate ligament (PCL), and the axis of the knee, both in the frontal and sagittal or lateral plane is called. Both cruciate ligaments are the kingpin of the knee and control displacement of the tibia on the femur, both in the antero-posterior sense as rotational.
The anterior cruciate ligament has functions of:
- Avoid the movement towards the front of the femur on the tibia
- Stabilize the knee when the same rotation.
Anterior cruciate ligament reconstruction (ACL reconstruction) is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after anterior cruciate ligament injury. The torn ligament is removed from the knee before the graft is inserted. The surgery is performed arthroscopically.
IS FREQUENT RUPTURE OF ANTERIOR CRUCIATE LIGAMENT.
Rupture of the anterior cruciate ligament (ACL) is an injury common in sports and recreational activities. An ACL deficient knees are predisposed to injuries and the emergence of early degenerative signs.
Almost two thirds of the ACL injuries originate sports therefore, affecting a young and active population.
ACL lesions have a high prevalence, around 0.30/1000 inhabitants per year, in the general population (MIYASAKA). This incidence is markedly higher in contact sports and which demand to turn over the knee, as in soccer, basketball or skiing. In Spain, in 2001, the Spanish Association of Atroscopia made a study, calculating 16.821 ACL PLASTY per year, which would represent a prevalence of 4 cases per 1,000 people per year. One of every 5 arthroscopies performed in our country would have as objective reconstruction of the ACL (AEA).
Women who practice sport activities have, between 2 and 8 times, more tear ACL than men who play the same sports. Among possible causes have been pointed out the differences in the Q-angle, the morphology of the knee joint, pelvic dimensions, the training and the hormonal status during the menstrual cycle.
The lower protection of the muscles on the ligaments of the knee (WOJTTYS) has also been seen, it should not be forgotten that women show a joint increased laxity of the knee in response to minor quantities of torque that must be supported in relation to men (SCHMITZ).
We conclude that the injury of the anterior cruciate ligament is currently frequent, given the increase in physical activity that has taken place in today’s society.
DO YOU OPERATE ALL ACL BREAKS.?
In our service we recommend surgery of reconstruction of anterior cruciate ligament in a systematic way, in patients below 40 years if the lesion is accompanied by clinical manifestations of instability.
In patients over the age of 40 has nuance indication according to the degree of physical activity or profession, but always the criterion is given of the physician which must indicate in each case surgery adapting a concrete solution for each individual.
The reconstruction techniques require grafting autologous, in the central third of the patellar ligament with two pills Hosea at their ends (h-t – H), the Quad tendon or tendons of insertion from the ischiotibial muscles, especially the semitendinosus and the straight internal (ST-RI) and more and more, despite his absence, requested tendon Allografts with or without pills Hosea.
In the same surgical time must be repaired injuries chondral and meniscal that often accompany the rupture of anterior cruciate ligament by proceeding to the extent possible the biological reconstruction of the knee, repairing cartilage and suturing them meniscus.
Although failure to LCA does not always produce an important functional loss, this indicated its repair. Especially in athletes should repair the ligament broken not only to return to his sport but also, to prevent the risk of breakage of the meniscus and degenerative changes joint (SHELBURNE).
Breakage of the LCA isolated or combined with meniscal injuries or collateral ligaments, degenerative radiographic changes in 60 and 90% of the patients, from 10 to 15 years after the injury (HUGHSTON-KARHOLM – DREZ – LANE – LUKDSCHECK – MARSHALL – MCDANIEL – NEYRET – NOYES – SHERMAN – LIDÉN).
It is mostly cartilaginous and meniscal lesions at the time of the intervention which has a negative impact on the results, both objective and subjective, the reconstruction of the ACL (SHELBOURNE2000)
The LCA must be repaired to restore knee stability and thereby preserve meniscal and cartilaginous lesions that would lead it to early osteoarthritis.
AS WE KNOW THAT THE ACL IS BROKEN?
First medical history indicates a history of trauma, accompanied by twist of the knee, after which in the first few hours there is pain and inflammation. A puncture of the knee with haemarthrosis (blood in the joint) is, in 80% of cases, a break of the ACL.
In the Diagnostics doctor must prevail on the complementary tests clinical examination functional MRI, RX etc. Since exploration of a skilled professional is much more valuable, especially when it has been over one month since the accident, since complementary tests have a high rate of false negatives after four weeks since the accident.
WHAT A RUPTURED ACL IS HEALING WITH REST OR OTHER CONSERVATIVE TREATMENTS?
- No, the ligament is cordonal being the external blood supply and broken ligament fibers are unable to repair it alone.
- That is why the repair techniques replace broken by a graft ligament.
- This technique is indicated if there is a clinical instability and according to the criterion of the doctor.
However, sometimes by the special conditions of a patient may be recommended not to operate. But this does not mean that the ACL will be repaired if that person can function in their daily lives without ACL, avoiding contact sports, with changes of direction and turn on his knee, is not to say, assuming a substantial reduction in their physical activity. In any case if clinical manifestations of instability should occur in a future decision should be overturned and the spoken ill of his anterior cruciate ligament injury.
Therefore, that indication of surgery must be a consensual issue between the patient and the surgeon, must be considered a possibility of treatment the reduction of activity in those patients who are not sufficiently motivated or whose symptomatology is sparse.
In any case if in the future there are clinical manifestations of instability the decision should be reversed and the spoken ill of his ACL injury.
WHAT A RUPTURED ACL PROVIDE?
Any surgery is done because in 80% of patients with a ligament broken Cross and operated not fifteen signs degenerative meniscal and cartilaginous lesions to develop, and almost in the Middle they have had at this time in his knee.
The purpose of the treatment is to avoid episodes of inestabilidd joint that they can appear during physical activities, therefore have to be considered candidates for surgery to patients who show symptoms of anterior instability of knee examination. Knee joint instability produces a continuous loss of bone homeostasis and early degenerative changes (DANIEL – FRITSCHY).
However, other patients with a poor ACL may remain asymptomatic and free of degenerative changes without surgery if demands joint are small (BUSS).
Therefore, we must take into account some parameters at the time of sitting the indication (cowboy TRAUMA):
- Age: it is unlikely that young patients will modify its activity and in these case reconstructive ligament surgery is the best choice and universally accepted an indication. Above 45 years old age should not be a contraindication if we are with Active patients with no signs of major knee osteoarthritis who have recurrent episodes of instability.
- The emergence of a meniscal lesion in a patient who had tolerated the lack of ACL so far we should lean towards surgical recovery, especially if it is possible to perform a lesion of meniscus suture, since removal of the posterior Horn increases the instability of the knee and favors the appearance of episodes of failure you articulate and Therefore the degenerative phenomena.
- Concerning the time of the intervention, although there is no consensus, comparative studies seem to indicate that it is different surgery three weeks after the accident decreases the risk of stiffness articulate (MEIGHAN). However, time is not the important factor edema that is gone and the knee recover full mobility arc.
WHAT ARE THE COMPLICATIONS MORE FREQUENT AFTER ACL SURGERY?
Joint all surgeries require a readjustment with physiotherapy and a gradual integration to everyday and sporting activities.
In the case of reconstruction of ACL this must never be less than 6 months to achieve functional levels similar to the previous ACL tear.
After the reconstruction of the ACL occurs a weakness of the quadriceps, with differences greater than 20% of the force between the two sides. This muscle weakness can cause alterations in the March involving the action of the muscles of the lower extremities to respond appropriately to the ground reaction force.
Atrophy of the quadriceps after ACL surgery is a challenge for any programme of rehabilitation (ANFRIACCHI – BERCHUCK – NOYES – PATEL – TORRY). It has been suggested that the reduction in the quadriceps during the March muscle action is a subconscious protection mechanism to prevent an excessive previous translation in a knee ACL (ANDRIACCHI – BERCHUCK-TIMONEY). The strength of contraction of the quadriceps during the March reduces anterior tibial motion machinery and prevents the feeling of instability articulate (BERCHUCK).
The incorrect position of the tunnels, tibial and femoral, is the cause more frequent technical complications in the LCA PLASTY with single fascicle (GEORGE). No this of more thinking that carrying out four tunnels (in the case of the bifasciculares PLASTY) instead of two tunnels (single issue) increase the percentage of technical failures. Until now no study has had enough power statistics to refute this theory and, of course, the PLASTY to double fascicle would be technically more difficult if one has to make a revision surgery (ERIKSSON X 3 – HARNER 2004 – LEWIS 2008).
Surgery of ACL with PLASTY of replacement break has presented a high percentage of good results in the literature but also have pointed out some problems such as persistent pain and instability in follow-ups. Up to 30% of the surgery required a second surgery five years after the pdrimera intervention (BACH – O’NEILL – OTERO-SCAGLIONE119-122) and between 11 and 50% of those operated develop arthritis in the knee intervened (LIDEN – O´NEILL), though, without a doubt, anterior knee pain is the problem more common in this type of interventions (SHINO93 – AGLIETTI 92 – PLANCHER 98) was published.
In a systematic review (LEWIS) of 1024 ACL reconstructions with single issue associated with 495 meniscal tears, 95 chondral injuries and two breaks of the LCP, the rate of complications was 60% and 4% break graft. Restrictions in the flexion and extension are noted in 9 of the 11 studies analyzed while joint degenerative changes were observed in 7% of the trails.
In the review of the failures of the reconstruction of the ACL grafts, Vergis and Gillquist arrived at the conclusion that the failure of a graft has a multifactorial etiology that can be minimized by ensuring a correct surgical technique. The realization of a tunnel in the ideal position and the realization of a retouching of the notch, when necessary, diminish considerably the incidence of pinched post – operative of the graft avoiding partial or complete rupture of the same. Keep a good fixation of the graft from the outset is another important aspect to what is needed to engage the bone graft in the proper.
WHAT IS IMPORTANT TO PRESERVE THE MENISCUS?
It is very important to obtain a good result in the medium term be able to suture meniscal lesions that may arise for which intervention should not differ more than 4 weeks as it is when the meniscal sutures have the best success rate.
The Norwegian national registry of patients who underwent a break of the LCA, between 2004 and 2006, showed that of 3475 patients, 26% had cartilage lesions, 47% breaks meniscal and 15% had both.
In addition, they calculated that in an adult knee cartilage injury increases by 1% for each month that passes since the injury occurs until the day of the surgery and cartilage injuries are twice more frequent if there is a break of meniscal and vice versa.
In a systematic review to determine the relationship between osteoarthritis of the knee and breakage or repair of ACL, IESTAD ET to the saw in 7 studies and retrospective 24 that the prevalence of arthritis in patients with isolated ACL rupture was between 0% and 13%. For patients with ACL and meniscal lesion rupture prevalence was between 21% and 48%.