Bone tunnel enlargement following hamstring anterior cruciate ligament reconstruction: a comprehensive review

Nowadays, bone tunnel enlargement (BTE) after anterior cruciate ligament reconstruction is a well-known phenomenon. It has been identified, investigated and described by many authors during the last thirty years. Nevertheless, the etiology of bone tunnel enlargement still remains unclear. It is known that the causes are multifactorial and may include the surgical technique, the method of fixation, materials used, type of graft as well as biological factors. Due to the recent popularization of the use of hamstring grafts in anterior cruciate ligament reconstruction, the bone tunnel enlargement phenomenon is becoming increasingly common. In this review article, the authors focus on compiling current knowledge about the etiology, diagnosis, and the possibility of reducing the occurrence of this phenomenon by using the latest methods of supporting reconstruction surgery.     

Simultaneous bilateral anterior cruciate ligament tears in a female beginner skier

We present a case of simultaneous bilateral ACL tears in a woman injured while skiing for the first time. We discuss the role of intercondylar notch stenosis as a high-risk factor for tearing the ACL, the injury mechanism, prevention measures, and the therapeutic strategy. Received: 10 January 2000 Accepted: 10 April 2000     

关节镜下自体四股腘绳肌腱重建膝前交叉韧带

目的评估关节镜下自体四股腘绳肌腱重建膝前交叉韧带(ACL)的技术和效果方法1999年10月-2003年12月共56例患者经关节镜检查证实为ACL断裂,26例伴半月板破裂,7例伴内侧副韧带损伤,12例伴后交叉韧带断裂。均于关节镜下行自体四股腘绳肌腱ACL重建术,采用Bionx生物可吸收挤压螺钉或钛挤压螺钉解剖位固定重建韧带。结果本组术后早期均未发生严重并发症。术后随访6-48个月,平均20个月,Lysholm膝关节功能评分由术前45-80分(平均58.36分),提高至随访时70-100分(平均92.77分)(P<0.01)。国际膝关节文件编制委员会(IKDC)综合评定由术前异常(C级)14例、显著异常(D级)42例,改进为随访时正常(A级)23例、接近正常(B级)29例、异常(C级)4例(P<0.01)。56例患者中,52例恢复伤前运动水平,4例运动水平较伤前降低。结论关节镜下自体四股腘绳肌腱重建膝ACL具有手术损伤较小、术后膝关节功能恢复良好的优点,值得采用。     

武警某部官兵经关节镜膝前交叉韧带重建56例疗效分析

目的评估关节镜下取自体腘绳肌腱重建膝关节前交叉韧带术治疗前交叉韧带断裂的临床疗效。方法回顾分析在关节镜下应用自体腘绳肌腱行前交叉韧带重建治疗前交叉韧带断裂56例的临床资料,对患膝手术前后关节功能进行评估。结果术后随访12~18(14±1.77)个月。Lysholm评分:术前(54.60±8.10)分,术后(88.50±6.43)分,手术前后评分比较差异有统计学意义(P<0.01)。结论关节镜下应用自体腘绳肌腱行前交叉韧带重建治疗前交叉韧带断裂,创伤小、康复快、疗效好,能有效恢复膝关节稳定性,降低致残率。     

关节镜下自体腘绳肌双股骨隧道重建后交叉韧带疗效分析

目的 对关节镜下自体腘绳肌双股骨隧道重建后交叉韧带的近期临床疗效进行观察和分析。方法选择20例后交叉韧带（posterior cruciate ligament,PCL）损伤度为3级的患者。通过自体腘绳肌腱双股骨隧道和单胫骨隧道的方法对PCL重建。术前屈膝活动度为（120.5±3.8）°。患者随访18~30个月,平均25个月。结果手术后患者屈膝的活动度为（117.3±2.7）°,相比于术前没有显著性差异（P〉0.05）,没有出现伸膝受限,且侧扳试验结果都是阴性。患者术后的后抽屉试验结果为（1.3±0.5）°,Lysholm的术前评分为（50.6±7.2）分,术后评分为（93.2±2.8）分,Tegner术前评分为（1.3±0.6）分,术后评分为（6.2±0.8）分。胫骨后移术前为（11.7±1.7）mm,术后为（2.7±1.3）mm,均有显著性差异（P〈0.05）。术后患侧膝关节前后方向的松弛情况通过KT-1000进行测量,平均为（2.4±1.2）mm,15例患者〈3mm,3例患者〉5mm。结论通过自体的腘绳肌腱经双股骨隧道对PCL的后交叉韧带进行重建, PCL的前外束及后内束均得以重建,与PCL的生理解剖结构相符,可以使关节功能得到良好恢复。     

Evaluation of hamstring muscle strength and morphology after anterior cruciate ligament reconstruction

This study aimed to clarify the relationship between knee flexor strength and hamstring muscle morphology after anterior cruciate ligament (ACL) reconstruction using the semitendinosus (ST) tendon and to determine the causative factors of decreased knee flexor muscle strength. Fourteen male and ten female patients who resumed sports activities after surgery participated in the experiment. Isometric knee flexion torque was measured at 30°, 45°, 60°, 90°, and 105° of knee flexion. Magnetic resonance imaging (MRI) was used to calculate ST muscle length and hamstring muscle volume, and to confirm the status of ST tendon regeneration. The correlation between the MRI findings and flexor strength was analyzed. Regenerated ST tendon was confirmed in 21 of the 24 patients, but muscle volume (87.6%) and muscle length (74.5%) of the ST in the operated limb were significantly smaller than those in the normal limb. The percentage of the knee flexion torque of the operated limb compared with that of the normal was apparently lower at 105° (69.1%) and 90° (68.6%) than at 60° (84.4%). Tendon regeneration, ST muscle shortening, and ST muscle atrophy correlated with decreased knee flexion torque. These results indicated that preserving the morphology of the ST muscle‐tendon complex is important.     

Knee extensor and flexor strength before and after anterior cruciate ligament reconstruction in a large sample of patients: influence of graft type

Objective: Hamstring and patellar tendon autografts are the most frequently-used graft types for anterior cruciate ligament (ACL) reconstruction, with no consensus on their respective effects on thigh muscle strength. The objective of this study was to re-examine isokinetic knee extensor and flexor strength before and after ACL reconstruction with patellar and hamstring tendon grafts using a single-center and a relatively large database, where surgical, rehabilitation and testing procedures were strictly standardized for all patients.

Methods: A total of 464 patients with a unilateral ACL rupture underwent arthroscopic ACL reconstruction with either patellar or hamstring tendon grafts. Isokinetic concentric strength was evaluated prior to surgery and at 5- and 9-month postoperative follow-ups in different patient subgroups (n = 140, 464 and 215, respectively).

Results: Knee extensor strength was lower in patients operated with the patellar tendon graft at the 5-month (p < 0.05) but not at the 9-month follow-up. Knee flexor strength was lower in patients operated with the hamstring tendon graft at both postoperative time points (p < 0.05). The prevalence of quadriceps weakness was high (66–91%) in both patient groups at both follow-ups.

Conclusion: Overall, postoperative recovery of thigh muscle function seems to be better with the patellar than with the hamstring tendon graft due to the fact that both, knee extensor and flexor strength, were more impaired after ACL reconstruction with the hamstring tendon autograft.     

Arthroscopic anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft

Tendon–bone incorporation of a tendon graft within the bone tunnel is of priority concern when using for anterior cruciate ligament (ACL) reconstruction. Superior healing process and stronger healing strength can be achieved when periosteum is sutured on the tendon inserted into a bone tunnel. We applied this idea to ACL reconstruction for enhancing tendon graft–bone tunnel healing. This is a prospective clinical outcome study with this surgical technique at minimal 2 years follow-up. Periosteum-enveloping hamstring tendon graft has been used in 68 patients. Data from 62 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of Lachman and anterior drawer test with a positive pivot-shift test. Clinical assessments included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented testing, thigh muscle assessment, and radiographic evaluation. The median Lysholm knee score was 59 (40–70) and 94 (60–100) points (P<0.01) before and after surgery. After reconstruction, 81% of patients were able to return to moderate or strenuous activity. Four (6%) patients were found to exhibit grade 2 or more ligament laxity. Complete range of motion could be achieved in 86% of patients. Three patients (5%) had positive pivot shift. Finally, 92% of patients were assessed as normal or nearly normal rating by IKDC guideline. Bone tunnels enlargement of more than 1 mm was identified in 5% of femoral tunnels and 6% of tibial tunnels. The study shows that a satisfactory result can be achieved with the periosteum-enveloping hamstring tendon graft in ACL reconstruction. Periosteum can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting. Besides the potential for improving tendon–bone healing, enveloped periosteum may help to seal the intra-articular tunnel opening in the early postoperative period, and thus avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be reduced.     

Revision of failed gore-tex anterior cruciate ligament reconstruction

The Gore-Tex synthetic knee ligament was widely used in the early 1980s because of encouraging early results. However, the long-term failure rate is unfavorable. Gore-Tex failures are divided into four categories: effusion, graft rupture, loosening/ osteolysis, and infection. Revision surgery is challenging and requires a systematic approach to achieve optimal results.     

高频超声测量前交叉韧带厚径与前交叉韧带损伤的相关性

 目的 探讨应用高频超声测量前交叉韧带(anterior cruciate ligament, ACL)厚径与ACL损伤的相关性。方法 选择单侧非接触性ACL损伤现役男性军人患者30例为ACL损伤组,另选择现役男性健康军人30名为对照组。应用高频超声测量ACL胫骨止点端厚径,ACL损伤组检查健侧ACL,对照组检查双侧ACL。对比分析对照组左侧、右侧ACL厚径,再对比分析ACL损伤组健侧、对照组ACL厚径。结果 对照组左侧、右侧ACL厚径分别为(8.11±0.64)mm、(8.03±0.61)mm,差异无统计学意义(P<0.05)。ACL损伤组健侧ACL厚径为(6.25±0.37)mm,小于对照组(8.07±0.61) mm,差异有统计学意义(P<0.05)。结论 ACL厚径小会增加ACL损伤的风险,高频超声测量ACL厚径可作为一项评估ACL损伤风险的筛查指标。     

Postural control — a comparison between patients with chronic anterior cruciate ligament insufficiency and healthy individuals

Postural control in the sagittal plane was evaluated in 22 patients with chronic anterior cruciate ligament (ACL) deficiency and the result was compared to that of a control group of 20 uninjured subjects. Measurement of the body sway was done on a fixed and sway-referenced force plate in both single-limb and two-limb stance, with the eyes open and closed, respectively. Further, an analysis of the postural reactions to perturbations backwards and forwards, respectively, was made in single-limb stance. The results demonstrated statistically significant deficits of the postural control in the patient group compared to the control group, but also within the patient group. There was a significantly higher body sway within the patient group when standing on a stable support surface on the injured limb than standing on the uninjured limb with the eyes open, but no difference with the eyes closed. When standing on a stable support surface, there was a significantly higher body sway in the patient group standing on the injured leg than in the control group, both with eyes open and closed. The patient group also showed a significantly impaired postural control compared to the control group when standing on the uninjured leg with the eyes closed. There was no difference between the groups in the two-limb stance. When standing on the sway-referenced support surface, the patient group had a significantly larger body sway than the control group when the eyes were open, but there was no significant difference between the groups with the eyes closed. The measurement of the postural corrective responses to perturbations backwards and forwards showed that the reaction time measured from the initiation of the force plate translation, and the amplitude of the body sway was significantly greater in the patient group than in the control group. We conclude that patients with a continuing chronic ACL insufficiency several years after injury have an impaired postural control in the anteroposterior direction in single-limb stance on their injured leg. They also show a greater body sway and a prolonged reaction time when subjected to anteroposterior perturbations when standing on their injured leg.     

关节镜下异体骨-髌腱-骨纤维束重建治疗前交叉韧带部分损伤

目的 探讨异体骨-髌腱-骨纤维束（B-PT-B）重建前交叉韧带（ACL）全部纤维束和部分纤维束的早期疗效。方法在187例采用B-PT-B术式重建ACL的患者中，获得随访的ACL部分束损者共25例，其中采用全部纤维束重建的患者6例，部分纤维束重建19例。术后行X线和KT-1000检查，并按照IKDC、Lysholm、Irgang、Larson评分进行疗效评价。结果 所有患者随访时移植物位置良好，KT-1000检查双侧膝关节前向松弛度差值〈3mm。部分束重建组与全部束重建组各评分系统和分项评分系统无显著性差异。结论 异体B-PT-B重建治疗ACL部分损伤可以取得良好的临床疗效，与ACL全部束重建术相比综合评定无明显差异。     

Outcome of patients with anterior cruciate ligament injuries selected for conservative treatment

In this retrospective study, 24 patients with acute isolated complete anterior cruciate ligament (ACL) ruptures selected for conservative treatment were re-examined a median of 45 months after injury. Selection for conservative treatment was made after careful patient information, taking into consideration desire for physical activity at work or leisure, interest in sports and muscular fitness. The reference group for the evaluation methods used included 50 students and 22 patients selected for surgical augmentation and reconstruction. In a subjective evaluation, the conservatively treated patients were satisfied, but objectively they had low functional scores and the pivot shift sign was often positive. Arthrometry showed that these patients had an increased anterior displacement of the tibia in relation to the femur in their injured knees. The patients who had a clearly positive pivot shift sign (grades III and IV) had an increased anterior laxity not only in the injured knees but also in the uninjured knees.     

Five-year outcome of 13 patients with an initially undiagnosed anterior cruciate ligament rupture

We evaluated retrospectively the 5-year outcome of 13 patients with an initially undiagnosed and thus untreated anterior cruciate ligament rupture. At follow-up, these patients experienced decreased knee function and moderate to severe knee instability. They had attempted to reduce their discomfort by decreasing their activity level during the follow-up period. Immediately after the 5-year examination, 6 of the patients decided to have a late reconstruction of the ruptured anterior cruciate ligament. These results agree with previous reports of the natural course of anterior cruciate ligament ruptures.     

Knee isokinetic performance following anterior cruciate ligament reconstruction: patellar tendon versus hamstrings graft

Objective: To compare knee isokinetic performance six months after reconstruction of the anterior cruciate ligament using grafts from either the patellar tendon or the hamstrings among patients who underwent the same rehabilitation protocol.

Methods: Thirty-four patients were evaluated (17 with grafts from the patellar tendon and 17 with grafts from the hamstrings). Operated and non-operated knees were compared with regards to the variables of peak torque, work and the hamstring/quadriceps relationship at velocities of 60º/s and 180º/s and power of 180º/s after six months of surgery.

Results: The patients with ACL reconstruction using the patellar tendon (BPTB) showed quadriceps deficits for all variables, but the flexor musculature was balanced. In the hamstring group, both the extensors and the flexors showed deficits for the variables analyzed, except for hamstring power at 180º/s.

Conclusion: Patients in the patellar tendon group had a greater quadriceps deficit compared with those in the hamstrings group. Patients in the hamstrings group had a greater muscular deficit in the flexor mechanism compared with the contralateral knee. An unbalanced H/Q ratio was observed regardless of graft type, but this was more evident in the BPTB group.     

One-stage anatomic double-bundle anterior and posterior cruciate ligament reconstruction using the autogenous hamstring tendons

This is the first report of an anatomic double-bundle ACL and PCL reconstruction procedure with the autogenous hamstring tendons. We prepare two pairs of the doubled tendon grafts, to which a polyester tape and an Endobutton-CL are attached using our original technique at the tibial and femoral ends, respectively. Under arthroscopic and fluoroscopic observations, two tibial tunnels for PCL reconstruction are created so that they pass through the posteromedial and anterolateral bundle attachments, respectively. Then, we create two tibial tunnels for anatomic double-bundle ACL reconstruction so that each tunnel axis is aimed at a targeted point on the femoral condyle. Using the outside-in technique, two femoral tunnels for PCL reconstruction are created so that the tunnel outlets are located at the center of the anterolateral and posteromedial bundle attachments. Then, two femoral tunnels for anatomic double-bundle ACL reconstruction are created with the trans-tibial tunnel technique. After the two grafts have been placed for PCL reconstruction, the two grafts are placed for ACL reconstruction. After all the femoral graft ends are fixed, the knee joint is reduced to the full extension position, and then, the four tibial tape portions are simultaneously fixed with the turn-buckle stapling technique.     

关节镜下自体半腱及股薄肌腱重建膝前交叉韧带

 目的 探讨关节镜下以自体半腱肌、股薄肌腱重建膝前交叉韧带(ACL)的手术方法及疗效.方法 自2006年3月～2007年12月,关节镜下绳肌腱修复膝前交叉韧带损伤39例.膝前小切口取半腱肌腱、股薄肌腱修整、对折后成四股,分别建立胫骨隧道及股骨隧道,用Endobutton和生物可吸收挤压螺钉固定肌腱,重建ACL的解剖结构和生理功能.术后即行功能锻练.结果 术后患者伤口均Ⅰ期愈合,8～10周膝关节屈伸功能恢复正常.随访时间3～15个月,平均8个月.抽屉试验和Lachman试验阳性者2例,可疑阳性者6例;余患者均为阴性.根据敖英芳临床判断标准,本组优23例,良11例,中3例,差2例.Lysholm评分术后(87.6±4.6),与术前(45.3±4.2)比较,差异显著(P<0.01).结论 绳肌腱具有良好的抗拉强度和刚度,在关节镜下用四股绳肌腱重建膝前交叉韧带是一种疗效可靠的治疗方式.     

One-stage bilateral anterior cruciate ligament reconstruction with use of hamstring tendon autografts: a case report

This article presents an unusual problem of a patient with chronic bilateral ACL-deficient knees and constitutionally very thin patellar tendons. Author decided to perform one-stage bilateral ACL reconstructions using hamstring tendon autografts so as not to weaken his quadriceps muscles by compromising his extensor mechanism.     

Force sharing between two grafts in the anatomical two-bundle anterior cruciate ligament reconstruction

The normal anterior cruciate ligament (ACL) can be generally divided into two main bundles, anteromedial bundle (AMB) and posterolateral bundle (PLB), and each bundle shared its function in response to external loads including anterior tibial drawer force. While we developed the anatomically oriented ACL reconstruction technique via two femoral tunnels and two parallel tibial tunnels (the “anatomical” two-bundle ACL reconstruction), there were few biomechanical studies about this technique. The purpose of this study was to investigate the force sharing between two separate grafts (anteromedial graft, AMG; posterolateral graft, PLG) in this anatomical two-bundle technique by measuring the force of each bundle in response to anterior tibial load. The anatomical two-bundle technique was performed on 11 patients via two tunnels at the supero-posterior portion of the AMB footprint and the supero-posterior portion of the PLB footprint on the posterior margin of the lateral femoral condyle and two tunnels created in the center of the AMB and the PLB tibial footprints. After two doubled semitendinosus grafts were fixed with two EndoButton-CL^®s on the femur, they were temporarily fixed to the tension-adjustable force gauge on the tibial cortex. After each bundle of the graft was settled at the tension of 25 N at 20°, the force exerted on the two bundles was measured with the force gauge during applied anterior tibial force of 134 N at 0°, 30°, 60° and 90° of flexion. While the AMG carried 42.3±5.7% of and the PLG shared 57.7±5.7% of the total force at 0°, the former took 64.1±11.1% and the latter was assigned 33.9±11.1% at 90°. This study has demonstrated that the force distribution between the two grafts in the anatomical two-bundle technique was similar to that between the two bundles in the normal ACL.     

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26–35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.