DR. MED. ANDREAS KRÜGER (MD, POLODOC)
Specialist in Orthopaedic Surgery and Traumatology FMH
Torn cruciate ligament - typical ski injury - do you always have to operate?
Torn cruciate ligament - typical ski injury - do you always have to operate? Knee injuries are the most frequent ski accidents on the slopes, accounting for about 30% of all injuries. Right at the top of the statistics is the torn cruciate ligament. There are various criteria that are taken into account when making individual decisions about treatment. But which treatment is the right one for two of my patients? Both love skiing and both injure their anterior cruciate ligament. Their stories could not be more different. Former junior skier vs. hobby skier, surgery vs. conservative treatment.
Torn ACL: Treatment methods with and without surgery (1/3)
(Dr. med. Andreas Krüger in interview with Rosanna Di Bello @blog.hirslanden.ch)
Source: blog.hirslanden.ch
Knee injuries are the most frequent skiing accidents on the slopes, accounting for about 30% of all accidents. Right at the top of the statistics is the rupture of the cruciate ligament. There are various criteria that are taken into account when making individual decisions about treatment.
We were able to meet two patients of Dr. Andreas Krüger, attending physician at Klinik im Park and Klinik Hirslanden in Zurich. Both love skiing and both injured their anterior cruciate ligament. Their stories could not be more different. Former junior skier vs. hobby skier, surgery vs. conservative treatment.
How everything happened and which treatment was chosen can be found out in our two patient interviews:
Patient 1: "Torn ACL: I was treated conservatively without surgery"
Patient 2: "Torn ACL: I decided to have surgery"
In the following interview, Dr. med. Andreas Krüger explains to us why the torn cruciate ligament is a typical ski injury. At the same time, he explains when conservative and when operative treatment makes sense.
Dr. Krüger, we were pleased to meet two of your patients. Both suffered a cruciate ligament injury while skiing. What was surprising was the type of accident Mrs. Oehri had. A sporty young woman who fell over her own child in slow motion and tore her anterior cruciate ligament.
Does the athleticism of the person have an influence on the degree of cruciate ligament rupture injury?
Dr. Andreas Krüger: In many cruciate ligament ruptures, the athleticism (i.e. fitness) plays only a subordinate role. Decisive for the degree of injury are the accident mechanism and the force applied. Typical knee accidents when skiing happen not only on the piste, but also when standing in line at the lift, for example when a fall occurs with a fixed lower leg and the ski binding does not release.
Three mechanisms are frequently found:
The lower leg and the thigh are rotated against each other.
The knee experiences a x-leg malposition.
A combination to which the knee does not respond well with muscular stabilization.
In addition, it must be mentioned that mental and physical fatigue often has a significant influence on the degree of injury. In principle, accident rates are higher after lunch and on the last trip.
Is the torn cruciate ligament a typical skiing accident? Why is that?
Dr. Andreas Krüger: Skiing is one of the sports that puts a strain on the knees. Among skiers, both children and adults, the knee is the most frequently injured part of the body. According to the Swiss Council for Accident Prevention (bfu), around 69,000 skiers are injured on Swiss slopes every year, with around 1/3 of accidents involving the knee. The anterior cruciate ligament rupture with 38% of all knee injuries is the most frequently occurring specific diagnosis (Brucker et. al, Alpiner Skibreiten- und Skileistungssport, 2014).
Why this is so can be explained by the mechanism described above. Depending on the fall, the fixation of the lower leg and the rotation of the thigh can put a lot of strain on the knee and therefore also on the cruciate ligaments.
Is there anything that can be done before skiing to minimize the likelihood of injury?
Dr. med. Andreas Krüger: An essential factor is the preparation for the ski season and risk minimization. A well-trained musculature that knows when and how to function can help to reduce the probability of accidents in the risk area.
The right ski equipment and the correct adjustment of the binding by expert hands are actually a matter of course.
Two of your patients suffered a similar injury. But they chose different treatments. When is the surgical measure suitable, when the conservative measure?
Dr. med. Andreas Krüger: Whether a conservative or surgical measure is suitable for the patient depends on various criteria: biological age (how old does he feel), / actual age, presence of a meniscus injury, intensity of pain, sports practice (stop-and-go sports such as tennis, football or harmonious rhythmic movements such as swimming, golf), knee stability and last but not least the personal demands of the patient.
Crucial for the success of conservative treatment is the integrity of the meniscus and cartilage as well as the other ligaments in the knee. Recent studies have shown If the knee has a torn cruciate ligament as well as a meniscus and/or cartilage injury, the result is better if the knee is operated. The cruciate ligament is usually replaced by the body's own tendon. In this case, the operation also serves to protect the meniscus in order to avoid or minimise secondary diseases such as arthrosis, which is promoted by an additional meniscus injury.
That means in summary:
Good resilience directly after accident
Low performance requirements for the knee joint
No further injury to meniscus or cartilage
High requirement profile with stop-and-go sports, subjective instability
Additional injuries to meniscus, cartilage or other ligaments
Is one type of treatment less painful than the other?
Dr. med. Andreas Krüger: The surgical method is more painful directly after the operation only in individual cases, although this can be well controlled by modern anaesthetic procedures. Later, the course and symptoms are very similar.
What do you have to be aware of when you decide on one or the other measure?
Dr. med. Andreas Krüger: The Swiss Medical Board recommends treating cruciate ligament ruptures with conservative measures during the first three months, as there is a 30% chance that the cruciate ligament will heal without surgery. With good initial subjective knee stability, a knee joint that can be well loaded again without surgery can result. However, the factors time, muscular shrinkage and the risk of secondary meniscus injury with persistent instability must be considered. The secondary meniscus injury caused by the persistent knee instability is one of the most decisive factors for the long-term prognosis.
If the cruciate ligament does not heal during conservative treatment, secondary damage to the meniscus or cartilage may occur. In these cases, surgical treatment is also recommended.
According to the criteria of the international knee specialists, the recommendation for the surgical intervention is certainly the right decision for the patient Natalija Oehri.
How does the rehabilitation look like? Are there differences?
Dr. Andreas Krüger: The rehabilitation is divided into different phases.
In the first phase, the pain and swelling are mainly treated.
In the next phase, the focus is on promoting muscular stabilization.
The last phase is concerned with increasing the load on the knee. The knee is prepared specifically for the upcoming load. Before patients are allowed to resume their usual sports activities, they are subjected to the Ready-to-Sport test, in which at least 90% of the strength and stability of the uninjured opposite side must be achieved.
After the surgical treatment, walking sticks are used for three weeks to provide partial relief with full weight bearing in the extended position. With additional meniscus suture, the patient must relieve the load for four weeks and then gradually build up the load until the sixth week.
The non-surgical method requires a similar effort in physiotherapy, but the load is applied according to the complaints and swelling with permitted full load with the knee brace in place.
Torn cruciate ligament: Decision against surgery
Torn cruciate ligament: Decision against surgery. Patient (56 years old) fell while skiing and injured her knee. Diagnosis: Injury of the anterior cruciate ligament. From the beginning it was clear to her that surgical treatment was out of the question for her, provided there was an alternative, because every operation is associated with a certain risk. What happened in the accident, how she was treated and how she feels today, you will learn in the following interview.
Torn ACL: Treatment methods with and without surgery (3/3)
(Patient of Dr. med. Andreas Krüger in interview with Rosanna Di Bello @blog.hirslanden.ch)
Source: blog.hirslanden.ch
"Torn ACL: I was treated conservatively without surgery"
Patient (56 years old) fell while skiing and injured her knee. Diagnosis: Injury of the anterior cruciate ligament. From the beginning it was clear to her that surgical treatment was out of the question for her, provided there was an alternative, because every operation is associated with a certain risk. What happened in the accident, how she was treated and how she feels today, you will learn in the following interview.
What does freedom of movement mean to you?
Patient: Freedom of movement is essential for me. Exercise and sports are part of my physical and mental well-being.
How much exercise do you do?
Patient: I do sports every week and I also like to do it in nature.
You were in a skiing accident, what happened?
Patient: During the downhill run in the afternoon, we always have a race within the family, with the winner usually being decided between my husband and our sons. We also did this on the day of the accident in the Grindelwald ski region. At first I tried to keep up and not lose the connection. But when there were a lot of people on the piste in narrow passages and I had to avoid a ski school class, I braked and drove to the edge of the piste. An edge fault, the higher snow and the greatly reduced speed caused me to crash. A burning pain on the inside of my right knee made me immediately fear that something must have torn.
Were you transported directly to the emergency?
Patient: No, a skier helped me up on my legs and I drove slowly to the valley station. My right leg was alarmingly unstable. I arrived at the bottom with a lot of concentration and caution. We then immediately sought medical help for first aid.
What treatment did the doctors give you?
Patient: The doctor in Grindelwald prescribed a soft protective splint and recommended cooling and elevation. I then went to Zurich myself for further treatment, which took place a week later in Dr. Krüger's practice. Dr. Krüger examined me and then showed me the MRI image of my cruciate ligament injury on the iPad. Seeing this image in front of me somehow took the horror out of me.
He introduced me to the various treatment options. I wanted to avoid an operation if possible and instead opt for conservative treatment with a splint, if this was really an option. I think Dr. Krüger noticed this very quickly and did not urge me to have an operation. When he then drew my attention to the fact that I would be given a thrombosis injection in the conservative treatment because of the restricted mobility, I knew that I wanted to have my known mobility back as quickly as possible. So on the same day I took care of a sports splint and made sure that I moved as much as possible.
How long did the rehabilitation (splint fitting / physiotherapy) last?
Patient: I felt excellent during the whole therapy and was cared for very professionally. For me, the knee injury also meant a sporting challenge. The therapy demanded a lot from me and made me aware of how important my freedom of movement and sports are to me.
The splint fitting lasted six weeks in principle and immediately gave me great mobility. However, I used the rail a little longer, as it did not restrict me at all and gave me protection and safety. The physiotherapy finally lasted almost a year, but I was much fitter afterwards than before the accident. After all, I wanted to go skiing again the following winter.
How long did it take to get you mobile again?
Patient: I was already mobile with the splint after two weeks. I could put full weight on the knee after three to four months. Hiking, golf and cycling were then back in fashion. However, I still had some pain and limitations, especially when doing sports with rotational movements like golf.
Did you underestimate anything in the healing process?
Patient: Yes, I underestimated myself! What was difficult for me was that I was totally decelerated. I love the faster sports and these were temporarily no longer possible. At the same time, it was a great experience to see how consistently and ambitiously I have personally committed myself to my body and my recovery. The physiotherapists helped me to heal myself successfully. I had not expected this experience.
How are you feeling today?
Patient: I feel very well and have no complaints in my knee. But that is mainly because I always do muscle training to protect my knees and my body in general. I run a lot and always take the stairs, so I build a little training into my everyday life.
Do you feel safe on skis again or do you still have a queasy feeling?
Patient: I feel as safe as before, I am not afraid and after the accident I live with the knowledge that skiing fast is much healthier for the knee than falling down in slow motion.
Cruciate ligament rupture: Decision for surgery
Cruciate ligament rupture: Decision to operate. Patient (37 years old), a sporty young mother of two sons, was about to teach her youngest son to ski when she fell in slow motion. She noticed immediately: There was something wrong with her knee. But the village doctor from the ski region assured her that everything was fine. 8 1/2 weeks later she decided to have the cruciate ligament operated. You can find out how it came about in the following interview.
Torn ACL: Treatment methods with and without surgery (2/3)
(Patient of Dr. med. Andreas Krüger in interview with Rosanna Di Bello @blog.hirslanden.ch)
Source: blog.hirslanden.ch
"Torn ACL: I decided to have surgery"
Patient (37 years old), a sporty young mother of two sons, was about to teach her youngest son to ski when she fell in slow motion. She noticed immediately: There was something wrong with her knee. But the village doctor from the ski region assured her that everything was fine. 8 1/2 weeks later she decided to have the cruciate ligament operated. You can find out how it came about in the following interview.
What does freedom of movement mean to you?
Patient: Freedom of movement has always meant a lot to me. Until I was 19, I was in the junior skiing squad. I like to move around and I don't feel comfortable without regular sport.
How much exercise do you do?
Patient: During my career in the junior ski squad I trained either strength, endurance or speed five days a week. After my time in the squad I trained three times a week at home on my cross trainer. When the children came, two years followed in which I was no longer able to do sports as usual. But then the desire grabbed me again: cross-training at home, once a week on the tennis court and golfing every now and then. In winter I was found more regularly on the ski slopes again.
In the meantime I do strength exercises with my own body weight about three times a week instead of cross-training. The post-operative training after my operation has motivated me to do this.
You were in a skiing accident, what happened?
Patient: It happened on a family ski trip. My three-year-old son was wearing a so-called "Gstältli" and learned to ski. I held on to the straps and we went into a curve one after the other. My son fell and broke down. I was close behind him and braked abruptly. I caught the tip of my ski in the stem and it turned my right ski inwards. I felt a crack in my knee. I could already see myself lying on the operating table with a torn cruciate ligament and then limping around with crutches. After five minutes I gathered all my courage and stood up. Standing was possible without any problems. I had only slight pain. I just thought: Phew, lucky.
Were you transported directly to the emergency?
Patient: No, because I could still ski myself, we then went to the middle station in the ski area and took the chair lift to the valley station. To be on the safe side, I went to the village doctor and showed him my knee. But he more or less smiled at me and said that everything was fine. Relieved by his diagnosis, I went about my usual daily routine: playing tennis regularly and riding my bike to work. Although I was in slight pain, I didn't think anything of it.
After about two months of constant pain, I found the whole thing quite astonishing and went to a specialist to have my knee examined again. After a short examination of my knee, the diagnosis was clear for him, contrary to the village doctor's diagnosis: a torn anterior cruciate ligament. The very next day I had an MRI examination which confirmed his diagnosis.
What treatment have you had?
Patient: Dr. Krüger informed me very neutrally about the treatment options. I was uncertain whether I should decide for or against an operation. I expressed my concerns to Dr. Krüger and emphasized that it was important for me to be able to pursue my hobbies again without any problems, especially skiing and playing tennis. Dr. Krüger explained to me that in my case an operation was the better solution. Today I am sure that I have made the right decision.
How did you feel after the operation?
Patient: I had severe pain the first few days and found it very unpleasant that the knee could neither be straightened nor properly bent. In addition, I was often nauseous from the anesthesia and medication.
How long did the rehabilitation (splint fitting / physiotherapy) last?
Patient: On the second day after the operation I was able to get up again and go to the toilet on my own. From the first day on, I trained three times a day with the knee movement splint, the electrodes for muscle building and from the second day on, regular physiotherapy was added.
I wore the splint for about two months, it gave me a certain security. I went to physiotherapy once or twice a week for six months.
How long did it take to get them mobile again?
Patient: The swelling in the knee unfortunately did not go down as quickly as hoped. When we went on holiday to the sea six weeks after the operation, I was still using crutches and could not yet put full weight on them. The two weeks on the beach and the salt water did me good. When I returned to Switzerland, i.e. eight weeks after the operation, I was able to walk without crutches, put full weight on them and drive a car again without any problems.
Did you underestimate anything in the healing process?
Patient: The only difficulty was the demanding and strict physiotherapy, which I appreciated very much. I think the only reason I feel so well today is because my therapist regularly pushed me to my limits.