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Ligament surgery

The types of Ligament Surgery are listed below. Click on a link below to skip to a section:

Following a knee ligament injury the appropriate management may be rehabilitation with a structured physiotherapy programme, bracing or surgery.

If surgery is necessary then it may be possible to repair a damaged ligament. Often this is not appropriate in which case a "reconstruction" is then indicated. Here the torn ligament is removed and replaced with tissue that is "borrowed" from elsewhere to "make" a new ligament. This is called a "graft". The choice of grafts available to the surgeon include: the patient’s own tissue (autografts), donor tissue (allograft) and man-made tissues (prosthetic grafts). Graft choice is made according an individual's particular needs and is based on a number of factors which include: the type of injury, age of the patient and the tissue available.

If more than one ligament needs to be reconstructed then a combination of grafts from different sources may be used. The gold standard is to use a patients own tissue. A number of graft choices are available. The most commonly used grafts are either the hamstring tendons or a portion of the patella tendon (tendon connecting the kneecap to the shin bone). Grafts are usually harvested from the injured leg but are sometimes taken from the “healthy” leg.


ACL Reconstruction X-Ray

X-ray on a knee following an ACL reconstruction - the white screw is used to fix the new ligament to the shin bone

ACL

Not all patients with an ACL rupture require a surgical reconstruction. Some are able to achieve sufficient stability with an ACL directed physiotherapy rehab. Some patients take to wearing a stabilising brace when undertaking sporting activity such as skiing.


However, if you are experiencing episodes of your knee giving way during normal daily activity this can and does have detrimental long term effects on your knee. In an ACL deficient knee, any change in the direction when you are walking or running can lead to your knee giving way. High level athletes have a higher functional demand than most patients and are therefore more likely to have ACL reconstruction surgery.


The ruptured ACL is usually reconstructed using some of your own tissue from around the injured knee. Normally two of your own hamstring tendons though sometimes the middle third of the patella tendon is used, . The operation is mainly carried out with key-hole surgery, aside from a small incision through which the hamstring tendons are "borrowed". This incision is just below the knee. Holes are drilled in the femur and tibia and the new graft is securely fixed within so that immediate weight bearing without the need for a brace or plaster can occur.


Watch: All Inside ACL Reconsutruction using the Translateral Technique

Note: The following video shows graphic surgical scenes, produced for technical training.

 
Trans-lateral ACL Reconstruction - Scientific Paper
Team performing New ACL Reconstruction Technique Mr Wilson has developed a new surgical technique for carrying out anterior cruciate ligament (ACL) surgery

Read More...

 

Watch: ACL graft reinforcement

Note: The following video shows graphic surgical scenes, produced for technical training.

 

ACL repair

Watch the new ACL repair and internal brace procedure

 

ACL Repair explained

 

The anterior cruciate ligament (ACL) is the most commonly injured ligament and we see approximately 40,000 in the UK and one million ACL surgeries being carried out worldwide each year. The injury is devastating to sportsman as they can no longer twist or turn without the knee giving wan and collapsing. Currently the standard operation is to replace the torn ligament with a new ligament, this is called an ACL reconstruction.


The new approach in selected patients is ACL REPAIR where we stitch the torn ends together and repair the torn ACL. The advantage of a repair is once your own acl tissue has had a chance to heal you can get back to normal activities including sports such as football. And this healing response happens quickly..and if it is successful there is full healing at 3 months… This is very different too ACL replacement or reconstruction surgery (currently the standard practice) as it takes 12 months ( minimum) for the new ligament to become strong enough for any twisting sports. Sadly those that try to back sooner often end in failure. The body just has to be given time to turn the new ACL “graft” into a healed working ligament. New evidence suggests this healing process for a new ACL can take 2 years!


How has the new repair technique been developed?

For background the knee is stabilised by four main ligaments – the outer ligament or lateral ligament, the inner ligament, the medial ligament and the two that cross in the centre of the knee which are called the cruciate ligaments or crossing ligament of which we have an anterior ( ACL) at the front and a posterior (PCL) at the back.


In the 1970’s there was a push to try and repair as opposed to replace the torn ligament and the father of arthroscopic surgery, John Feagin, developed a technique for repairing and stitching the torn ligament back together. He tested this in US army recruits and one third did extremely well, but sadly two thirds failed and the technique was abandoned.


Since the 1970’s we have replaced or reconstructed the ACL; that is we have drilled tunnels in the knee and taken tissue from elsewhere in the body, most commonly the hamstring tendons, and from these made an ACL ‘Graft” or new ligament which is then implanted.


For this new ACL graft to heal, it has to have time and on average it takes nine to twelve months before we are comfortable allowing our patients to return to twisting activities. During that period the patients have to be very careful and do very little with their knee and this is very limiting for sportsman, particularly those who want to play sport such as football or rugby where there is a lot of twisting involved. Even elite sportsman have to wait until this time, otherwise they run the risk of the new ACL graft failing as it hasn’t healed properly. New research recently suggests that it may take as long as two years for this process of healing to be complete.


We have developed new techniques to make this ACL reconstruction surgery less invasive but it is still quite a big undertaking for patients. Mr Wilson is frequently asked to present his All Inside technique at meetings around the world to teach surgeons about the advantages and how to carry out the ALL Inside surgery. Mr Wilson has also published several scientific articles on this.


The Holy Grail is of course to not replace or reconstruct but rather to repair the ACL. That is stitch the torn ends back together again and achieve healing of the patient’s own tissue. Up until recently this hasn’t been possible to do in any meaningful way but over the last five years the instruments and implants that we have for fixing our ligament reconstructions have become much more sophisticated and over the last two years a technique has been developed to repair the ACL. This work has been pioneered by Professor Gordon MacKay from Glasgow who has been routinely repairing ACLs now for several years. Having seen his work, Mr Wilson has used his technique on appropriate patients with outstanding results.


Two cases of ACL repair Mr Wilson would like to highlight are as follows


Case one A 45 year old lady who tore her ACL dancing

She was very active and wanted to get back to sports as soon as possible and was appropriate for the repair technique. Here the ACL tissue inside the knee needs to be good quality. The repair can only really be done in the first month or two after the injury. After this the tissue effectively starts to dissolve and there isn’t sufficient tissue to actually stitch back.


The ACL Repair Technique

If we are able to get to the patients early enough and the tissue is good quality, it can be stitched back together and held with very strong suture material through tiny 3 millimetre tunnels that are made in the bones. To supplement this and to allow the ACL repair to heal, we also pass a 2-millimetre tape up through the tiny tunnels in the bones, across the repaired ACL and fix it in the thigh and shin with specially designed devices. This acts as an “internal brace” for the repair and is strong enough such that patients are allowed to walk normally and carry out normal activities, obviously, not sport, in the first few days and weeks after the surgery.


The Result

The 45 year old lady that I mentioned above was able to get back to surfing at thirteen weeks following surgery and was back on the squash court at four months with a totally stable and pain free knee. She was back playing field hockey with a pain free stable knee at 4 months.


Case 2 : ACL Repair in a 5 year Old

Another example of where this repair has been very successful in Mr Wilson’s practice is in a 5 year old girl who injured her knee whilst on a trampoline with her older sisters. Mr Wilson took her to the operating theatre and carried out a direct repair stitching the torn ACL tissue back together again and passing the small tape across the repair zone and fixing it as described. After surgery the patient did take it slowly as she was likely to be slightly unpredictable with her rehab and Mr Wilson kept her in a brace for four weeks and then he allowed her to go free.


The Result

Normally the tape is left and not removed, but in a five year old there were some concerns about what this might do to growth and therefore it was decided to remove the tape after twelve weeks. At this stage she had regained full function and was running without pain. Her parents were astonished at how little pain she had had after surgery and how quickly she had returned to normal function. At the second procedure when I removed the button, fixing the tape and the tape itself, I had an opportunity to look inside the knee and the ACL had repaired beautifully and the knee was completely stable when Mr Wilson examined her in the operating theatre.


At the two-week stage following this second procedure she was once more able to do normal activities such as running and jumping without pain. Her parents reported that she only required one or two paracetamol after surgery and this is a reflection of the fact that the repair of the ACL is so minimally invasive.


ACL repair is certainly back on the map and is growing in popularity around the world. Not everyone will be eligible, but for those who are it really is a truly great option for this very common injury.

 

ALL

This video demonstrates combined ACL reconstruction, using the 'All-Inside' technique with a single quadrupled semitendinosis, with an anatomic reconstruction of the anterolateral ligament (ALL) using the spared Gracillis tendon as a free graft. This is based upon the anatomy described by Dr Steven Claes, Prof. Johan Bellemans et al in their recent publication in the Journal of Anatomy. (1)

 

Following cadaveric work that was carried out between Dr Claes, Prof. Bellemans and myself, we have devised a surgical technique which we are now performing on selected patients. Steven very kindly joined me to shoot this video at the North Hampshire Hospital in Basingstoke. The video demonstrates our minimally invasive procedure for reconstructing "the anterolateral corner of the knee". For many years I have carried out a lateral tenodesis using a modified MacIntosh procedure for revision ACL cases and primaries with a high-grade pivot shift. Most knee surgeons are familiar with the Macintosh procedure which is an excellent option but is non anatomic. It is done through an extensile approach and involves taking a long strip of ITB to provide a check to excessive abnormal internal rotation of the knee.

 

With the anatomy and biomechanics that Steven has demonstrated, we have been able to develop a truly minimally invasive approach to carry out the ALL reconstruction.

 

The sockets are made via stab incisions and a free Gracillis graft is used for the new ALL ligament. The early results are looking very promising. We have performed over 30 cases in the last six months and there have been no complications relating to the surgery. In particular, there have been no failures, no residual clinical laxity, and no complaints of discomfort on the lateral side of the knee or any restriction of movement. It is obviously too early to draw any long-term conclusions but we believe this represents an excellent minimally invasive option for carrying out reconstruction of the anterolateral ligament.

 

1. Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. Journal of Anatomy. 2013;223(4):321-8.

  

Watch: All Inside ACL Reconsutruction using the Anterolateral Technique

Note: The following video shows graphic surgical scenes, produced for technical training.

all reconstruction

TriLink

A new technique for Double Bundle ACL Reconstruction

 
Mr Wilson in conjunction with Arthrex has developed a new technique for carrying out a double bundle ACL reconstruction. Here a single Hamstring tendon is harvested and then fashioned into double bundle graft on the femoral side and a single bundle on the tibia. Using ACL TightRope fixation the graft is fixed in a minimally invasive fashion. Using instruments developed with Arthrex Mr Wilson has developed the TriLink graft which allows " a footprint fill" on the femur and offers all the advantages of a double bundle reconstruction. This technique is less invasive and technically more straightforward than traditional double bundle procedures. It is bone soft tissue preserving.
 

Watch TriLink ACL Reconstruction

Note: The following video shows graphic surgical scenes, produced for technical training.

trilink graft
 
Mr Wilson launched this exciting technique at the recent Faculty forum meeting in January
2013, Naples Florida.
 
www.naplesnews.com

Watch: Trilink Presentation from North American Faculty Forum 2013

Note: The following video shows graphic surgical scenes, produced for technical training.

trilink graft



 
PCL Reconstruction - Keyhole View

Key-hole view of the newly reconstructed PCL

PCL

An isolated PCL injury does not usually warrant surgical treatment. If a PCL reconstruction needs to be carried out then a graft is made either from your own tendons or donor tendons and this graft is passed through pre-drilled holes in the tibia and femur (this is done under x-ray guidance) and fixed with screws. As the PCL is usually reconstructed in combination with other ligaments, the post-operative stay tends to be a day or two longer than in a simple ACL reconstruction.



All Inside PCL Reconstruction

 

Mr Wilson has adapted his all inside techniques to develop a new way of carrying out a minimally invasive procedure for PCL reconstruction. As with all inside ACL reconstruction this procedure is less invasive and takes less tissue and bone than the conventional technique. It requires the use of just one hamstring tendon instead of 2 which is currently the accepted way of doing a traditional PCL reconstruction. This is fashioned into a "GraftLink" which is loaded on to 2 ACL tightrope buttons. This makes a very challenging operation which only few knee specialists offer, much more straightforward.

 

Watch: Transmedial All-inside PCL Reconstruction

Note: The following video shows graphic surgical scenes, produced for technical training.

Transmedial All Inside PCL

 

PCL

An isolated PCL injury does not usually warrant surgical treatment. If a PCL reconstruction needs to be carried out then a graft is made either from your own tendons or donor or donor tendons and this graft is passed through pre-drilled holes in the tibia and femur (this is done under x-ray guidance) and fixed with screws. As the PCL is usually reconstructed in combination with other ligaments, the post-operative stay tends to be a day or two longer than in a simple ACL reconstruction.

MCL/LCL

Collateral ligament surgery is frequently carried out along with cruciate ligament reconstruction. Both collateral ligaments are amenable to repair, and this should ideally be carried out within 2-3 weeks of the injury. Examining the patients knee and their MRI scans gives the surgeon a good indication of whether ligament repair will be possible, but the decision whether to repair or reconstruct the ligament is sometimes made at the time of surgery.


This surgery is performed through incisions either on the inside (medial) aspect of the knee or the outside (lateral) aspect of the knee. If the collateral ligament tissues look in reasonable condition they can then be repaired. If the injury is diagnosed late and/or the collateral ligaments are too damaged, you will need to have a ligament reconstruction. The surgery is usually carried out using your own tendons (patella or hamstring tendons). If a number of ligaments need to be reconstructed, then the surgeon may need to turn to either donor tissue or artificial ligaments.


PLC

Postero-lateral corner of the knee is very rarely injured in isolation. More commonly, it is a part of a multi-ligament injury, along with one or both of the cruciate ligaments. Current recommendations are that a repair of the PLC should be attempted within 2-3 weeks of the injury.


Where repair is not possible, the ligaments need to be reconstructed. Tendon grafts are used to reconstruct the torn structures. The aim is to achieve an anatomical reconstruction and restore stability to the knee.


PCL and ACL Reconstruction - Multi-Ligament Surgery

MRI through the centre of the knee showing two new tunnels in the shin bone - for the newly reconstructed ACL and PCL

Multi-ligament surgery

Reconstruction of two or more ligaments may be carried out with one operation, or it may need to be staged (involve multiple operations) in order to achieve optimal results. Both planning and timing of this surgery is very important. Surgery involves a combination of any of the techniques described above. Anatomical reconstruction is the goal, and post-operative rehab is very demanding and crucial to the success of the operation.










Watch: Combined All Inside ACL Reconstruction with Minimally Invasive Modified Larson (PLC)

 

This is a minimally invasive surgical technique that Mr Wilson has developed based on the Larson posterolateral corner reconstruction.


Traditionally a large long incision is made on the outer aspect of the knee such that the entire outer aspect is dissected. Mr Wilson has developed a minimally invasive technique that can be done through a 2cm incision on the side of the thigh bone and a 3cm incision just behind the fibula which is the small bone on the outer aspect of the knee. Through these small incisions dissection is carried out to make appropriate tunnels for the new ligament.


Because Mr Wilson uses the all inside ACL procedure he preserves one hamstring tendon. Traditional techniques require both hamstring tendons to be taken on the inner aspect of the leg and folded in two to make the standard ACL graft. As Mr Wilson uses just the one, the other hamstring tendon is available for other procedures such as the anterolateral ligament or this minimally invasive reconstruction of the outer aspect of the knee. Mr Wilson combines this hamstring tendon with fibre tape to make it a hybrid graft which is strong and this accelerates rehabilitation and makes recovery quicker.


Please see below a video of the procedure being carried out.

 

Note: The following video shows graphic surgical scenes, produced for technical training.



 

Graft Compression Using The New Graft Compression Sleeves

 

Mr Wilson compression sleeves allow grafts to be compressed and made more compact. This means that smaller holes need to be drilled to implant a graft. The graft is pulled into the sleeve and after just a few minutes it is compressed to a smaller size and then pulled into a smaller sleeve and the compressed further. The sleeves are extremely effective. They allow surgeons to be less invasive, preserve bone because smaller tunnels need to be drilled.


Often when a graft has been prepared it has a different diameter at each end . This means that the surgeon has to prepare 2 different sized tunnels. This has obvious disadvantages. When a graft has been compressed it has the same diameter at both ends which means the tunnels made can be the same diameter.




 

 

Note: The following video shows graphic surgical scenes, produced for technical training.

Orthopaedic consultation

Orthopaedic consultation

Key-hole  knee surgery

Key-hole knee surgery

Mr Wilson carrying out knee arthroscopy surgery

Mr Wilson carrying out knee arthroscopy surgery

Scrub team before ACL surgery

Scrub team before ACL surgery

Arthroscopic knee surgery

Arthroscopic knee surgery

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction

Anaesthetist - Dr Nick J looking over the drapes

Anaesthetist - Dr Nick J looking over the drapes

ACL surgery

ACL surgery

ACL reconstruction

ACL reconstruction

Arthroscopic knee surgery

Arthroscopic knee surgery

Mr Wilson and team performing surgery

Mr Wilson and team performing surgery

Live knee surgery being filmed

Live knee surgery being filmed

Filming a live surgery with Mr Wilson and team

Filming a live surgery with Mr Wilson and team

Arthroscopic knee surgery

Arthroscopic knee surgery

Mr Wilson in surgery

Mr Wilson in surgery