A ligamentoplasty involves replacing the ruptured ligament. Ligaments are made up of bundles of fibrous tissue that are whitish in color. Very resistant, they unite the elements of a joint: cartilages and bones. The knee and the ankle are two important joints, therefore made up, in particular, of ligaments, and highly stressed during sports practice, and in particular that of pivot sports. When ligaments are ruptured after trauma, in some cases surgery will be required, called a ligamentoplasty. Following a post-operative rehabilitation, the resumption of sports practice is then possible.

The knee is the joint between the lower part of the femur and the upper part of the tibia. The stability of the knee is ensured by ligaments, kinds of more or less elastic ribbons. It happens that this ligament is ruptured, in particular following a trauma. This causes instability of the knee. This also causes feelings of blockage. During the practice of a sport, or during the rotational movements of the leg, this instability is then strongly felt. Ligamentoplasty will consist of replacing the ruptured ligament. 

In fact, there are four main ligaments in the knee: two lateral ligaments (internal and external) located on each side of the knee, and two central ligaments called cruciate since they cross in the middle of the knee. There is an anterior cruciate ligament and a posterior cruciate ligament. The knee is, ultimately, a strong joint, but particularly exposed to various traumas. And the anterior cruciate ligament, which has the role of preventing the anterior translation of the tibia forwards and preventing the inward rotation of the tibia with respect to the femur, is particularly susceptible to rupture during the practice of many sports.

The ankle constitutes, for its part, the joint connecting the leg and the foot. It is made up of bones: the lower end of the tibia, the lower end of the fibula, and the talus, as well as ligaments. Within the ankle, there are also several ligaments: the external lateral ligament, which in fact comprises three ligaments, and the internal ligament, in the shape of a fan, little used during a sporting practice and which is only very rarely injured.

Ligamentoplasty is a surgical operation performed after a rupture of the ligaments at the level of the knee or the ankle: its purpose is therefore to reconstitute the ruptured ligament.

To diagnose a ligament tear, several tests can be done. They include a clinical examination, a standard radiographic assessment as well as an MRI. These make it possible to determine whether the ligament is partially or totally torn. Complete tears may require surgery.

• An ankle ligament reconstruction is an indicated procedure for chronic ankle instability. The goal is to prevent recurrence of sprains as well as the appearance of osteoarthritis;
• Knee ligamentoplasty includes, among the decision criteria, the professional and above all physical activity of the patient: thus, ligamentoplasty is particularly recommended in situations where the patient wishes to resume a pivotal sport, such as football, tennis, etc. skiing, badminton, etc.

The diagnosis of rupture of a ligament which will require a ligamentoplasty, for example that of the posterior cruciate ligament at the level of the knee, is therefore above all clinical and radiological. Thus, if radiologies are performed, it is above all MRI (magnetic resonance imaging, a medical imaging technique that allows two or three-dimensional views of the inside of the body to be obtained non-invasively) which confirms the diagnosis. In addition, for the rupture of the anterior cruciate ligament, the diagnosis is made with the search for an anterior drawer: thus, following a rupture of the anterior cruciate ligament, the knee will have a tendency to “dislocate” if the we pull forward. Abnormal mobility of the knee is therefore observed, which is called “anterior drawer”. In this case, to confirm the rupture of the anterior cruciate ligament, but also to look for lesions of the meniscus or the cartilage, an MRI, or even an arthro-CT of the knee will be necessary.

It is sometimes advisable to practice physiotherapy sessions before this surgery, in order to strengthen the muscles.

Finally, with regard to the anterior cruciate ligament in particular, several scenarios are possible:

• The young subject, who has important sporting motivations, represents the best indication for the operation of the anterior cruciate ligament;
• The subject who presents instability, even for everyday life, also represents an indisputable indication, whatever his age;
• On the other hand, a relatively old subject who does not practice intense sporting activity will not necessarily need a ligamentoplasty to continue his normal activities.

Ultimately, the decision to operate is always taken with the help of a specialist surgeon.

In fact, it is therefore the rupture of the anterior cruciate ligament which is the most common lesion in many sports disciplines: thus, in France, approximately 45 operations of the anterior cruciate ligament are performed each year. 

The procedure of a knee ligamentoplasty must take into account the fact that a ruptured ligament cannot be “repaired”: it must therefore be replaced. In order to perform this replacement, the specialist surgeon takes a graft from the knee. It is therefore he who, depending on the patient but also the sport practiced, will choose from which elements the graft can be performed: thus, the knee ligamentoplasty can be performed either from the patellar tendon, or from the hamstring tendons, where only one of the hamstrings is harvested.

The knee operation is performed arthroscopically, a surgical technique that works through a system of optical fibers introduced through a small hole. It allows you to see inside the knee, and helps to see lesions, and it also allows you to operate on those lesions through that little hole. Performing this operation arthroscopically therefore limits the incision. After the operation, rehabilitation is important for recovery.

As for the ankle ligamentoplasty, it consists in reconstructing the anterior bundle and the middle bundle of the external lateral ligament. Ankle ligamentoplasty lasts an average of one hour and requires approximately three days of hospitalization. It is performed either under loco-regional anesthesia or under general anesthesia. An incision, made on the external side of the ankle, will allow, following the removal of a part of the fundiform ligament which maintains the tendons of the toes, to reconstitute the middle bundle of the external lateral ligament.

After the operation of ligamentoplasty of the ankle, a splint then a resin boot are made. Pain treatment will also be implemented and adapted. For 6 weeks, walking is done using two canes, and without support. After the removal of the boot, support will be authorized, and rehabilitation can begin with the physiotherapist.

Ligamentoplasty, which must be followed by post-operative rehabilitation, gives satisfactory functional results, with resumption of sport in most cases, in patients who practiced sport before the operation.

Be careful, however, to resume sports activities, it is necessary to respect the post-operative instructions given by the surgeon as well as by the physiotherapist.

After the ligamentoplasty, the disappearance of pain, blockages as well as feelings of instability is rapid after the operation. It usually takes between 3 and 6 months for a complete recovery of mobility and muscle strength. The replaced ligament is no better than the original one, and so a new rupture can always occur. It is therefore necessary to be vigilant, in particular when playing a sport where the joints are strongly mobilized, such as, for example, tennis and football. Concerning the knee, its stability is generally completely recovered.

There are, of course, the risks of ligamentoplasty that are common to any surgical procedure, as well as risks associated with anesthesia. Some risks are more specifically related to ligamentoplasty, here are the main ones (the list is not exhaustive):

• Joint stiffness can develop, mainly if postoperative rehabilitation has not been well managed;
• Very rarely, exacerbated inflammatory reactions can occur: these sometimes correspond to algodystrophy. However, new treatments have appeared which make it possible to manage this complication;
• Sometimes it happens that the operated area bleeds and a hematoma forms. Depending on its importance, an evacuation may be necessary;
• Infections of the joint after ligamentoplasty are still very rare. This complication requires washing of the joint as well as a more or less long-term antibiotic treatment;
• Sometimes, small solidified blood clots can appear: they require anticoagulant treatment for several weeks.

It is strongly recommended not to smoke before the operation and also during the healing period: in fact, smoking undoubtedly increases the percentage of infection, phlebitis and poor healing of the skin and ligament, with a increased risk of rupture.

Fortunately, re-rupture is rare. It is possible in the event of a new shock, in particular with regard to the cruciate ligaments of the knee. Indeed, it happens that the repaired cruciate ligament does not heal satisfactorily, which can lead to a new rupture. Revision surgery will be necessary in this case.