Tibial tunnel widening after anterior cruciate ligament reconstructions with hamstring tendons using Rigidfix femoral fixation and Intrafix tibial fixation

The purpose of this study was to evaluate tibial tunnel widening prospectively after anterior cruciate ligament (ACL) reconstruction with hamstring tendon grafts using Rigidfix (DePuy Mitek, Raynham, MA) femoral fixation and Intrafix (DePuy Mitek) tibial fixation. Fifty-six consecutive patients who underwent ACL reconstruction with a minimum of 2 years’ postoperative evaluation were reviewed. On the anterior–posterior (AP) and lateral radiographs, the diameter of the tibial tunnel was measured at proximal, middle, and distal positions, and the shape of the tibial tunnels were classified. Tunnel widening was defined as widening of greater than 2 mm. Group I was defined as cases with no tunnel widening, and group II was defined as cases with tunnel widening. Postoperative laxity evaluations were performed using Lachman test, pivot-shift test, and instrumented laxity testing using the KT-1000 arthrometer. On the AP radiographs, the average diameter of the tibial tunnel increased 8.8% at 6 months and 8.5% at 12 months postoperatively compared to the immediate postoperative day. On the lateral radiographs, the average diameter of the tibial tunnel increased 7.2% at 6 months and 8.1% at 12 months year postoperatively compared to the immediate postoperative day. The tunnel shape evaluation revealed predominantly linear type in 53 patients (95%). Group I was 42 patients (75%), and group II was 14 (25%). The average KT-1000 measurement was 1.0 ± 1.8 mm in group I and 2.1 ± 2.8 mm in group II (n.s.). The Lachman and pivot-shift tests showed no significant differences between the two groups. In conclusion, hamstring ACL reconstruction using Rigidfix and Intrafix fixation showed less widening of the tibial tunnels than observed in previously published studies.     

Comparison of the bioabsorbable and metal screw fixation after ACL reconstruction with a hamstring autograft in MRI and clinical outcome: a prospective randomized study

There has never been an MRI study of tunnel widening comparing bioabsorbable to metal screw fixation in autologous hamstring anterior cruciate ligament (ACL) reconstruction. We randomized 62 patients to hamstring ACL reconstruction with either a bioabsorbable (n = 31) or metal screw (n = 31) fixation. The evaluation methods were clinical examination, KT-1000 arthrometric measurement, the International Knee Documentation Committee and Lysholm scores, and MRI. There were no differences between the groups preoperatively. Fifty-five patients (89%) were available at a minimum of 2-year follow-up (range 24–36 months). There was tunnel widening in both groups, but the increase was significantly greater in the AP dimension of the femoral tunnel in the bioabsorbable screw group compared to metal group (P = 0.01). The tibial tunnels showed no intergroup difference. Ninety-four percent of the knees were normal or nearly normal according to the IKDC scores and the average Lysholm score was 91 with no intergroup difference. The follow-up AP tibial tunnel diameter was smaller with normal knee laxity compared to abnormal knee laxity. The graft failure rate in the bioabsorbable screw group was 23% (7/31 patients) and 6% (2/31 patients) in the metal screw group. The use of bioabsorbable screws resulted in more femoral tunnel widening, and more graft failures compared to metal screws. The tunnel widening in the tibia was associated with the knee laxity (P = 0.02).     

A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation

Changes in the femoral and tibial bone tunnel were studied prospectively after arthroscopic ACL reconstruction with quadruple hamstring autograft. To determine whether tunnel enlargement can be decreased by fixing the graft close to the joint line having a stiffer fixation construct we compared "anatomical" (one absorbable interference screw femorally, and bicortical fixation with two absorbable interference screws tibially) and extracortical fixation techniques (Endobutton femorally, and two no. 6 Ethibond sutures over a suture washer tibially). Over a 2-year period we evaluated 60 patients clinically (IKDC scale, Cincinnati Knee Score, KT-1000) and radiographically (confirmed by MRI). The operated knee was radiographed immediately postoperatively and 6 and 24 months postoperatively. The femoral and tibial bone tunnel diameter was measured on anteroposterior and lateral images, and the tunnel area was calculated and compared to the initial area calculated from the perioperative drill size. In the "anatomical" group the immediately postoperative bone tunnel area was 75% larger than the initial tunnel area, after 6 months it was increased another 31%, and between 6 and 24 months it remained basically unchanged. In the "extracortical" group there was no significant enlargement immediately postoperatively, but after 6 months it was 65% larger than the initial area of drill and graft size, and between 6 and 24 months it decreased to 47%. There was no correlation between the amount of tunnel enlargement and clinical scores or KT-1000 measurement. Arthroscopic ACL reconstruction with quadruple hamstring autograft is associated with bone tunnel enlargement. Using a purely extracortical fixation technique thus significantly increased the tibial and femoral tunnel area during the first 6 postoperative months, while it decreased slightly thereafter. The insertion of large interference screws apparently not only compresses the graft in the bone tunnel but also significantly enlarges the bone tunnel itself. The immediate enlargement at the time of the operation is followed by a reduced further enlargement at 6 months and then stabilization. Tunnel widening did not influence clinical outcome over a 2-year period.     

Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts

We report a prospective series evaluating the incidence and degree of tunnel widening in a well-matched series of patients receiving a hamstring or patella tendon graft for anterior cruciate ligament (ACL) deficiency. We correlated tunnel widening with clinical factors, knee scores, KT-1000 and isokinetic muscle strength to determine the clinical significance of this finding. Seventy-three patients at least 12 months post-ACL reconstruction were evaluated. Thirty-eight patients had received a doubled semitendinous and gracilis graft and 35 a bone-patella tendon-bone graft. All patients underwent a similar endoscopic procedure and accelerated postoperative rehabilitation. Tunnel widening was determined using standardized anteroposterior (AP) and lateral X-rays adjusted for magnification. A limited series of MRIs was performed to validate these measurements. There was a significant difference in the degree of tunnel widening between the two groups. The mean increase in femoral tunnel area in the hamstring group was 100.4% compared with a decrease of 25% in the patella tendon group (P = < 0.0001). In the tibial tunnel the mean increase in the hamstring group was 73.9% compared with a decrease of 2.1% in the patella tendon group (P = < 0.0001). The MRIs validated the plain film measurements. Tunnel widening did not correlate with the clinical findings, knee scores, KT-1000 or isokinetic muscle strength. Tunnel widening is marked in the hamstring group. Tunnel widening does not correlate with instability or a poor clinical outcome in the short term. The long-term implications of this finding are still to be determined. Received: 11 March 1998 Accepted: 14 September 1998     

Bone tunnel enlargement following anterior cruciate ligament reconstruction: a randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up

Radiographic tibial and femoral bone tunnel enlargement has been demonstrated following anterior cruciate ligament (ACL) reconstruction. This study investigated whether bone tunnel enlargement differs between four-strand hamstring (HS) and patellar tendon (PT) ACL reconstructions over the course of a 2-year follow-up. Patients undergoing primary ACL reconstruction (n = 65) were randomised to receive either a PT or HS autograft. Femoral fixation in both groups was by means of an Endobutton. On the tibial side the PT grafts were fixed using a metallic interference screw, and the HS tendons by sutures tied to a fixation post. The PT grafts were inserted such that the proximal end of the distal bone block was within 10 mm of the tibial articular surface, resulting in a portion of free patellar tendon in the femoral tunnel immediately proximal to the articular surface. Patients were reviewed after 4 months and 1 and 2 years. Tunnel enlargement was determined by measuring the widths of the femoral and tibial tunnels with a digital caliper in both lateral and anteroposterior radiographs. Because of the presence of the interference screw and the proximity of the bone block to the tibial articular surface, the tibial tunnel could not be reliably measured in the PT group. Measurements were corrected for magnification, and changes in tunnel width were recorded relative to the diameters drilled at surgery. Standard clinical measures were also noted. In 32% of patients in the PT group there was femoral tunnel obliteration from 4 months onwards. For the other patients there was a significantly greater increase in femoral tunnel width in the HS group than in the PT group at each follow-up, but no significant change with time. There was also a marked increase in tibial tunnel width in the HS group at 4 months but not thereafter. There was no relationship between tunnel enlargement and clinical measurements. Although tunnel enlargement is more common and greater with HS grafts, it does not appear to affect the clinical outcome in the first 2 postoperative years. Femoral suspensory fixation does not in itself appear to be the principal cause of femoral tunnel enlargement, at least for PT grafts.     

No bone tunnel enlargement in patients with open growth plates after transphyseal ACL reconstruction

Bone tunnel enlargement after ACL reconstruction has been described extensively in adults. However, little is known about this phenomenon in patients with open growth plates. Thus, the goals of the current study were to evaluate changes in bone tunnel size in patients with open growth plates after transphyseal ACL reconstruction with suspensory fixation and to correlate tunnel size with clinical outcome after medium-term follow-up. Fourteen patients with open growth plates were included that underwent primary transphyseal ACL reconstruction using hamstrings autografts and suspensory fixation. Mean follow-up time was 7 years. At the time of follow-up, MRIs of the operated knee were performed, and outcome was assessed using KOS-ADLS, Lysholm score, IKDC Subjective Knee Form score, Knee Examination Form score, and KT-1000 measurements. On MRI, the cross-sectional area of the bone tunnels was assessed using special axial cuts perpendicular to the axes of the tunnels. Two orthopaedic surgeons and two radiologists analysed the MRIs. Change in bone tunnel size from surgery to follow-up was calculated. No significant changes in bone tunnel size from surgery to follow-up were found. Regarding outcome measures, KOS-ADLS averaged 95%, Lysholm Score averaged 96 points, IKDC Subjective Knee Form averaged 95%, IKDC Knee Examination Form scores were 8A, 5B, 1C, and KT-1000 measurements averaged 1.8 ± 1.4 mm. No significant correlations were found between tunnel size at follow-up and outcome measures. Based on our study, bone tunnel enlargement does not occur in patients who have open growth plates and undergo ACL reconstruction using suspensory fixation.     

Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts

Thirty patients having had anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autograft and thirty patients having had ACL reconstruction with hamstring (HS) autograft were enrolled. All procedures were performed using an endoscopic technique with identical postoperative rehabilitation, such that the only variable was the type of graft and its fixation. Lateral and 45° posteroanterior (PA) weightbearing radiographs were performed in each patient at 6–12 (mean 9) months postoperatively in the HS group and 9–22 (mean 13) months postoperatively in the PT group. The sclerotic margins of the tunnel were measured at the widest dimension of the tunnel by a single observer and were compared with the initially drilled tunnel size after correction for radiographic magnification. For the BPTB group, all bone plugs appeared to be incorporated radiographically. On the femoral side, the bone plug was incorporated at the roof of the intercondylar notch, such that no tunnel measurement could be made. Well-defined sclerotic margins were always present at the tibial and femoral tunnels for the HS group and at the tibial tunnel for the BPTB group. The mean percentage increase in tunnel size in the PA view was 9.7% ± 14.7% for the BPTB tibial tunnel, 20.9% ± 13.4% for the HS tibial tunnel, and 30.2% ± 17.2% for the HS femoral tunnel. The mean percentage increase in tunnel size in the lateral view was 14.4% ± 16.1% for the BPTB tibial tunnel, 25.5% ± 16.7% for the HS tibial tunnel, and 28.1% ± 14.7% for the HS femoral tunnel. The difference in HS and BPTB tibial tunnel expansion on both the PA and lateral views was statistically significant (P = 0.003 and P = 0.01, respectively). Inter-observer variability was excellent with an intra-class correlation coefficient of 0.92. Tunnel expansion was significantly greater following ACL reconstruction using HS autografts than in those using BPTB autografts. The points of fixation for the HS grafts are at a greater distance from the normal insertion site and biomechanical point of action of the ACL than the points of fixation for BPTB grafts. We believe that this greater distance creates a potentially larger force moment during graft cycling which may lead to greater expansion of bone tunnels. Received: 17 March 1997 Accepted: 30 June 1997     

The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique

In this study, mid to long-term results of anterior cruciate ligament reconstruction with hamstring tendons and Transfix technique were evaluated. Anterior cruciate ligament (ACL) reconstruction with four-strand hamstring tendon was performed with Transfix technique on 271 (198 males, 73 females; mean age 25.7; 17–52) patients with anterior cruciate ligament ruptures. The patients were followed up with clinical examination, Lysholm and Tegner activity scales, IKDC scoring system, KT-1000 test and radiological examination. The mean follow-up period was 82 (48–100) months; 204 (75%) patients had no subjective complaints. According to the KT-1000 test, only 14 (5%) patients had more than 5 mm laxity postoperatively, whereas, 161 (59%) patients had more than 5 mm laxity preoperatively. In addition to this, only 19 (7%) patients had Lysholm scores less than 80 postoperatively, whereas 154 (57%) patients scored less than 80 preoperatively. When compared with Tegner activity scale, 189 (70%) patients scored <6 preoperatively and only 24 (8%) postoperatively; 78 (29%) patients scored D preoperatively and only 5 (2%) patients scored D postoperatively on the basis of the IKDC scoring system. Our functional results were found to be satisfactory in more than 90% of patients. Commonly seen problems in ACL reconstruction such as inaccurate graft placement and tunnel widening were found to be consistent with the values in relevant literature. However, we demonstrated that the functional results and the stability of the knee were not related with tunnel widening. This study concludes that the reconstruction of ACL with hamstring tendons and the Transfix technique is reasonably successful, safe and causes low morbidity. Furthermore, we believe that proper graft preparation, accurate tunnel placement, notch-plasty, fixation and rehabilitation program are all as important as the choice of graft and fixation material.     

The role of periosteal flap in the prevention of femoral widening in anterior cruciate ligament reconstruction using hamstring tendons

Tunnel widening in anterior cruciate ligament reconstruction has been reported for many years, whatever the type of plasty (allo- or autograft) or graft (patellar or hamstring tendons). Recently, the hypothesis has been formulated that widening would be responsible for later laxity of the knees. Micromobility of the graft or biological factors are classically responsible for the enlargement. In order to improve the biological conditions around the graft within the tunnel, we have developed a surgical technique using a periosteal flap. The periosteal flap is harvested at the superior and medial metaphysis of the tibia and wrapped around the proximal part of the four strands of gracilis and semitendinosus tendons near the outlet of the femoral tunnel. Forty-one patients with isolated rupture of the ACL were included in a prospective and randomized study: the first group of 20 patients had femoral fixation by Transfix and resorbable screw, the second group of 21 patients had femoral fixation by Transfix and periosteal flap. The diameters of the tunnel were measured between the sclerotic margins at the tunnel entrance and 1 cm above, and compared to the peroperative drill size. The percentage change in diameter was calculated as: (tunnel diameter–drill size)/drill size. The two groups of patients were comparable as to gender, side, age, KT-1000 side to side difference, femoral tunnel diameter and follow-up. At 2.5 months and 11 months postoperatively on average, there was a significant reduction of enlargement at the outlet of the tunnel with the use of a periosteal flap but widening was constant.     

Augmentation of femoral fixation in hamstring anterior cruciate ligament reconstruction with a bioabsorbable bead: a prospective single-blind randomized clinical trial

BACKGROUND: The EndoPearl is an adjunct to bioabsorbable interference screw fixation in the femoral tunnel in anterior cruciate ligament (ACL) reconstruction. The purpose of the study was to assess the clinical effectiveness of the EndoPearl using the KT-1000 Knee Arthrometer and the Mohtadi ACL Quality of Life (ACL-QOL) Questionnaire. HYPOTHESIS: The application of the EndoPearl in hamstring ACL reconstruction has no significant benefit when compared to conventional treatment in KT-1000 and ACL-QOL Questionnaire outcomes. STUDY DESIGN: Prospective single-blind randomized clinical trial. METHODS: ACL reconstruction with autogenous semitendinosus and gracilis tendons was performed on 35 patients. Preoperatively, 3 months, 6 months, and 18 months postoperatively, patients' knees were evaluated using the KT-1000 Knee Arthrometer and the ACL-QOL Questionnaire. RESULTS: Statistically significant differences were achieved in terms of KT-1000 side-to-side differences between the study group and the control group at 6 months and 18 months postoperatively; the mean side-to-side differences are significantly less in the study group when compared to the control group. Statistically significant differences were not detected when comparing the ACL-QOL Questionnaire between the two groups at all time intervals. CONCLUSION: The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased laxity up to 18 months postoperatively in terms of KT-1000 side-to-side differences.     

Intraoperative evaluation of anteroposterior and rotational stabilities in anterior cruciate ligament reconstruction: lower femoral tunnel placed single-bundle versus double-bundle reconstruction

Twenty-six patients with anteroposterior (AP) laxity of the knee, associated with torn anterior cruciate ligament (ACL), were prospectively randomized for arthroscopic lower femoral tunnel placed single- or double-bundle reconstruction using hamstring tendons. We evaluated AP and rotational stabilities under regular loads (a 100-N anterior load and a 1.5-N m external–internal load) before and after ACL reconstruction, comparing single- and double-bundle reconstruction with our original device for applying quantitative tibial rotation and the navigation system intraoperatively. No significant differences were found between the two groups in AP displacement and total range of tibial rotation at 30° and 60° of knee flexion. We found that a lower femoral tunnel placed single-bundle reconstruction reproduced AP and rotational stability as well as double-bundle reconstruction after reconstruction intraoperatively.     

Cross-pin femoral fixation in PCL reconstruction: a cadaver study

In PCL reconstruction many techniques have been described. Crucial item in pre-operative planning is graft choice and graft fixation. Compared to other grafts, hamstring is getting more popular because it is longer, has higher mechanical properties and doesn’t harm extensor apparatus of the knee. Furthermore the absence of the bone block makes easier hamstring insertion in the femoral tunnel. Hamstring greater disadvantage is fixation. Many fixation devices, used in ACL reconstruction, have been described for PCL procedure. One of these, recently proposed, is a cross-pin femoral fixation technique, for hamstring PCL reconstruction [10]. The authors drilled the femoral tunnel in an inside-out manner [11] (width 8 mm and depth 35 mm) and fixed the hamstring with the Rigidfix (Mitek, Norwood, MA), passing the device via the anterolateral (AL) portal. The aim of this anatomical cadaver study is to evaluate the entrance points of cross-pins and the possible iatrogenic damages, during transverse fixation via anterolateral portal. The device we used is the Rigidfix (Mitek, Norwood, MA), designed to use two biodegradable pins for ACL femoral fixation. Femoral drilling and cross pins insertion were performed on 20 (10 × 2) fresh frozen cadaver knees. The risk of chondral damage, evaluated during the knees dissection, is high.     

Instrumented measurements of knee laxity: KT-1000 versus navigation

The KT-1000 is widely accepted as a tool for the instrumented measurement of the antero-posterior (AP) tibial translation. The aim of this study is to compare the data obtained with the KT-1000 in ACL deficient knees with the data obtained using a navigation system during “in vivo” ACL reconstruction procedures and to validate the accuracy of the KT-1000. An ACL reconstruction was performed using computer aided surgical navigation (Orthopilot, B-Braun, Aesculap, Tuttlingen, Germany) in 30 patients. AP laxity measurements were obtained for all patients using KT-1000 arthrometer (in a conscious state and under general anaesthesia) and during surgery using the navigation system, always at 30° of knee flexion. The mean AP translation was 14 ± 4 and 15.6 ± 3.8 mm using the KT-1000 in conscious and under general anaesthesia, respectively (P = 0.02) and 16.1 ± 3.7 mm using navigation. Measurements obtained with the KT-1000 under general anaesthesia were no different from those obtained “in vivo” with the navigation system (P = 0.37). In conclusion this study validates the accuracy of the KT-1000 to exactly calculate AP translation of the tibia, in comparison with the more accurate measurements obtained using a navigation system.     

The effect of remnant preservation on tibial tunnel enlargement in ACL reconstruction with hamstring autograft: a prospective randomized controlled trial

Purpose

To investigate the effect of remnant preservation on tibial tunnel enlargement in a single-bundle anterior cruciate ligament (ACL) reconstruction with a hamstring autograft.

Methods

From 2006 to 2009, a total of 62 patients who underwent single-bundle ACL reconstruction with a quadrupled hamstring tendon autograft were enrolled in this study. The patients were randomly divided into two groups: the preserving-remnant group and the removing-remnant group. Plain radiographs were taken at 1 week, and 3, 6, and 24 months postoperatively, and tibial tunnel enlargement was evaluated. The postoperative clinical assessment included the Lysholm rating scale and KT-1000 measurement.

Results

In total, 27 patients in the preserving-remnant group and 24 patients in the removing-remnant group were followed up and the median follow-up was 24.5 months (range 24–27 months). Tibial tunnel enlargement occurred within 6 months postoperatively. Positive enlargement was observed in 8 patients (29.6 %) in the preserving-remnant group and 14 patients (58.3 %) in the removing-remnant group (P = 0.0388). The percentage of tibial tunnel enlargement was 25.7 ± 6.7 and 34.0 ± 8.9 % in the preserving- and removing-remnant groups, respectively (P = 0.0004). In the preserving-remnant group, the average Lysholm score increased from 60.3 ± 5.3 (51–69) to 93.0 ± 3.5 (88–100), and the side-to-side difference of the KT-1000 changed from 6.3 ± 0.9 (5.1–8.0) to 1.4 ± 0.6 (0.5–2.4) mm. In the removing-remnant group, the average Lysholm score increased from 58.7 ± 6.5 (48–71) to 91.1 ± 3.9 (85–100), and the side-to-side difference of the KT-1000 changed from 6.5 ± 0.8 (5.4–8.2) to 1.7 ± 0.6 (0.6–2.8) mm.

Conclusions

It is confirmed that remnant preservation in ACL reconstruction can resist tibial tunnel enlargement but that this technique does not affect the short-term clinical outcome of ACL reconstruction.

Level of evidence

I.     

Anterior cruciate ligament reconstruction using autografts and double biodegradable femoral cross-pin fixation: functional,radiographic and MRI outcome after 2-year minimum follow-up

Double biodegradable cross-pins are increasingly used for femoral fixation in arthroscopically assisted reconstruction of the anterior cruciate ligament (ACL). There are no studies combining functional outcome analysis, radiographs and magnetic resonance images (MRI) to evaluate this technique. The authors examined 45 patients after ACL reconstruction using double biodegradable femoral cross-pin fixation and biodegradable tibial interference screw fixation with a minimum follow-up of 24 months. Clinical evaluation included International Knee Documentation Committee (IKDC) and modified Lysholm score. Radiographic analysis included standard X-rays in anterior–posterior and lateral views and Telos stress device measurements. MRI was analyzed to obtain information about hardware, intra-articular graft, osseous graft-integration and cartilage. IKDC score revealed 28 (62.2%) patients with normal knee function (group A), 15 (33.3%) patients with nearly normal (group B) knee function and 2 (4.4%) patients with abnormal knee function (group C). The Lysholm score was 94.6 (±7.2) in the operated knee and 98.8 (±7.4) in the non-operated knee. Mean Telos stress device values were +4.6 (±2.6) in the operated and +3.9 (±2.4) in the non-operated knee. MRI showed an intact intra-articular graft in all but one patient. Complete femoral graft integration was seen in 88.9% and complete tibial graft integration in 86.7%. Biodegradable cross-pins were partially or fully visible in all patients. The biodegradable tibial interference screw was fully visible in 16 (35.6%) and partially visible in 20 (44.4%) patients. Thirty-one (68.9%) patients showed signs of cartilage degeneration on MRI at follow-up. The graft fixation with double biodegradable pin fixation appears to be a reliable technique for ACL reconstruction providing a stable close-to-joint graft fixation.     

Anterior cruciate ligament reconstruction with double-looped semitendinosus and gracilis tendon graft directly fixed to cortical bone: 5-year results

Forty-three patients who had undergone an anterior cruciate ligament (ACL) reconstruction using a doubled semitendinosus and gracilis graft were prospectively reviewed at 5-year follow-up. All had suffered subacute or chronic tears of the ligament. At surgery, the femoral tunnel was drilled first through the antero-medial portal. The correct position of the femoral and tibial guide wire was checked fluoroscopically. A cortical fixation to the bone was achieved in the femur with a Mitek anchor, directly passing the two tendons in the slot of the anchor, and in the tibia with an RCI screw, supplemented with a spiked washer and bicortical screw. Rehabilitation was aggressive, controlled and without braces. The International Knee Documentation Committee (IKDC) form, KT-1000 arthrometer, and Cybex dynamometer were employed for clinical evaluation. A radiographic study was also performed. At the 5-year follow-up all the patients had recovered full range of motion and 2% of them complained of pain during light sports activities. Four patients (9.5%) reported giving-way symptoms. The KT-1000 side-to-side difference was on average 2.1 mm at 30 lb, and 68% of the knees were within 2 mm. The final IKDC score showed 90% satisfactory results. There was no difference between the 2-year and 5-year evaluations in terms of stability. Extensor and flexor muscle strength recovery was almost complete (maximum deficit 5%). Radiographic study showed a tunnel widening in 32% of the femurs and 40% of the tibias. A correlation was found between the incidence of tibial tunnel widening and the distance of the RCI screw from the joint (the closer the screw to the joint, the lower the incidence of widening). In conclusion, we can state that, using a four-strand hamstring graft and a cortical fixation at both ends, we were able to achieve satisfactory 5-year results in 90% of the patients.     

Combined reconstruction for posterolateral rotatory instability with anterior cruciate ligament injuries of the knee

If posterolateral rotatory instability (PLRI) injury in patients with a torn anterior cruciate ligament (ACL) is not diagnosed and treated, ACL reconstruction can fail. We retrospectively evaluated the clinical outcome after reconstructions between 2002 and 2007 of both the ACL and the posterolateral corner (PLC) in 44 knees with combined ACL and PLC injuries. The median follow-up duration was 49 months (range, 24–68 months). ACL reconstruction employed autogenous hamstring grafts from the ipsilateral knee. For grade II PLRI, a posterolateral corner sling through the fibular head was placed obliquely from the anteroinferior aspect to the posterosuperior aspect using autogenous hamstring grafts of the contralateral knee. Clinical outcomes were evaluated using the OAK (Orthopadishe Arbeitsgruppe Knie) and IKDC (International Knee Documentation Committee) knee scoring systems. Anterior stability was measured on pull stress radiographs using a Telos stress device and the manual maximum displacement test using a KT-1000™ arthrometer with the knee flexed 30 degrees. PLRI was classified according to varus and rotational instability preoperatively and at final follow-up. Median OAK scores improved from 71 points (range, 48–86) to 93 points (range, 75–100). Satisfactory IKDC results were achieved in 39 knees (89%). As for anterior stability, as measured by anterior stress radiography, mean side-to-side displacement difference dropped significantly from 6.9 ± 1.9 preoperatively to 1.4 ± 1.1 mm at final follow-up. Forty patients (91%) had the same or better rotational stability compared to the normal side. Varus stress radiographs showed mean side-to-side displacement differences dropped from 1.8 ± 1.7 preoperatively to 0.4 ± 0.8 mm at final follow-up. Thus, chronic ACL deficiency is often accompanied by grade II PLRI and can be treated successfully by arthroscopic ACL reconstruction paired with posterolateral reconstruction employing a single sling through the fibular tunnel and a hamstring tendon autograft.     

Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft

Anterior cruciate ligament (ACL) reconstruction is becoming increasingly popular in active middle-aged patients with symptomatic instability. The purpose of this study was to retrospectively evaluate the results of ACL reconstruction in patients over the age of 40. Twenty-one patients with a median age of 44 (range 40–56) who had arthroscopically assisted reconstruction using four-stranded hamstring autograft were reviewed. RCI titanium interference screw fixation was used in the tibia, and Endobutton CL fixation in the femur. The clinical results were assessed at a mean follow-up of 2 years. The median value for the Lysholm knee score was 92 (range 74–100), and the median value for the International Knee Documentation Committee score was 83 (range 53–97). For the Tegner activity scale, the median value was 6 (range 4–8) at follow-up. The median side-to-side difference using the KT-1000 arthrometer was 2 mm (range 0–3.5 mm). Hamstring ACL reconstruction in appropriately selected middle-aged patients can yield successful and satisfactory results.     

Comparison of three techniques of anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Differences in anterior tibial translation and tunnel enlargement with each technique

BACKGROUND: Anatomic fixation of the graft in anterior cruciate ligament reconstruction has improved stability of the reconstructed knee joint in experimental studies. HYPOTHESIS: Anatomic fixation of the bone-patellar tendon-bone autograft will reduce tunnel enlargement and improve clinical results. STUDY DESIGN: Prospective cohort study. METHODS: Sixty patients were randomly divided into three groups: a nonanatomic fixation group (traditional single-incision reconstruction), an anatomic fixation group (reconstruction in which a bone plug was grafted into the tibial tunnel), and an anatomic fixation group with all-inside reconstruction. Stability of the knee joint was examined with a KT-1000 arthrometer at 2, 4, 6, 12, and 24 months after surgery. At 12 months, anteroposterior and lateral radiographs were made to assess tunnel enlargement. RESULTS: Although the magnitude of tibial displacement gradually increased after reconstruction in all three groups, the anatomic fixation group had significantly better stability than the groups undergoing nonanatomic fixation or all-inside anatomic fixation at 4 and 6 months after anterior cruciate ligament reconstruction. However, there was no significant difference between the three groups at 24 months. Regarding the tibial tunnel, residual rates and enlargement of tunnels were different between the reconstruction techniques. The nonanatomic reconstruction group had significantly greater tunnel enlargement. CONCLUSION: Anatomic fixation of the graft decreased the tunnel enlargement but had no effect on knee stability at 2-year follow-up.     

Anterior cruciate ligament reconstruction using the Bio-TransFix femoral fixation device and anteromedial portal technique

The cross-pin femoral fixation technique for soft tissue grafts is a popular option in anterior cruciate ligament (ACL) reconstruction. One of these devices is the Bio-TransFix (Arthrex Inc., Naples, FL, USA) which provides high fixation strength. According to the manufacturer, the femoral tunnel is created by placing the femoral aiming device through the tibial tunnel (transtibial technique). However, using this technique it is very difficult or even impossible to place the graft at the anatomical ACL attachment site at the “10 o’clock” position. In this report, we describe the use of the Bio-TransFix device with an anteromedial portal technique. Using this technique, the surgeon has more freedom to place the graft in an anatomical position, while combining the advantages of the excellent biomechanical properties of this device.