Arthroscopic anterior cruciate ligament double-bundle reconstruction using hamstring tendon grafts-fixation with two interference screws: technical note

In this article, an original double-bundle anterior cruciate ligament reconstruction technique is described. The procedure is developed using hamstring tendon grafts while maintaining tibial osseous insertion. Two tibial tunnels are drilled and a simplified and precise outside-in double tunnel femoral drilling technique is utilized. The graft fixation is made using only two interference screws.     

关节镜下运用4股腘绳肌腱同期重建前后交叉韧带损伤

目的 关节镜下运用Intrafix和可吸收界面螺钉固定自体4股腘绳肌腱，同期重建前交叉韧带（anterior cruciate ligament，ACL）、后交叉韧带（posterior cruciate ligament，PCL），评估其疗效。方法 ACL、PCL同时损伤的患者16例，关节镜下以自体4股胭绳肌腱作为重建移植物，应用可吸收界面螺钉固定移植物股骨端，Intrafix钉鞘和可吸收锥形钉固定胫骨端，同期行ACL和PCL损伤重建术。7例行内侧副韧带修补，4例行外侧副韧带复合结构修复，2例行内外侧同时修复。所有患者按照国际膝关节评分委员会（International Knee Documentation Committee，IKDC）评分标准进行术前评估，均为D级。术前Lysholm评分为（36．5±3．7）分。结果 随访时间为12～18个月，平均14．6个月。终末随访时，IKDC总体评价：A级6例（38％），B级9例（56％），C级1例（6％），无D级患者。Lachman试验0～2mm8例；3～5mm6例；6～10mm2例（P〈0．05）。屈70°前后总位移0～2mm10例；3～5mm5例；6～10mm1例（P〈0．05）。屈70°后位移0～2mm12例；3～5mm4例（P〈0．05）。术后2个月Lysholm功能评分为（90．4±2．9）分，终末随访时为（93．4±3．5）分，与术前相比差异均有统计学意义（P〈0．05）。结论 关节镜下以自体4股胭绳肌腱作为移植物，应用可吸收界面螺钉、Intrafix钉鞘和可吸收锥形钉固定股骨胫骨端同期重建ACL和PCL损伤，有利于早期积极的功能康复，膝关节功能恢复满意。     

Simultaneous anterior and posterior cruciate ligament reconstruction in chronic knee instabilities: surgical concepts and clinical outcome

The purpose of this study was to evaluate the clinical results of simultaneous arthroscopically assisted reconstruction of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) using autogenous tendon grafts in chronic knee injuries. Nineteen patients (17 men and 2 women) with chronic multi-ligamentous injuries underwent one-stage ACL and PCL reconstruction. ACL, PCL and medial collateral ligament were reconstructed in seven knees, and ACL, PCL and posterolateral structure were reconstructed in two knees. Function of the operated knee was evaluated according to the International Knee Documentation Committee (IKDC) and Lysholm scale. Anterior and posterior knee laxity was examined with a KT-2000 arthrometer. Eighteen of 19 patients were able to return for follow-up and were evaluated objectively and subjectively. The average patient age at surgery was 30.5 years, and the average postoperative follow-up was 3.5 years. No patients showed loss of knee extension more than 5 degrees , while three patients revealed loss of knee flexion more than 16 degrees . The mean postoperative total anterior-posterior side-to-side difference was 1.9 +/- 1.5 mm at 20 degrees and 2.1 +/- 1.9 mm at 70 degrees . The average of the Lysholm score was 95.1 points at the final follow-up. At the IKDC evaluation, three patients were grade A, 11 were grade B, 3 were grade C, and 1 patient was grade D. The results showed the effectiveness and safety of one-stage reconstruction of combined ligamentous injuries of the knee that can adequately restore satisfactory stability.     

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.     

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.     

Temporal change of joint position sense after posterior cruciate ligament reconstruction using multi-stranded hamstring tendons

A total of 29 patients who had undergone posterior cruciate ligament (PCL) reconstruction using multi-stranded hamstring tendons were prospectively followed-up for joint stability and proprioceptive function at a minimum of 24 months after surgery. We measured temporal changes of the posterior laxity by stress radiography and the KT-2000 arthrometer, and we also measured joint position sense for an average of 42 months (range 24–78 months). In terms of results, improvement of joint stability was observed postoperatively and maintained over 2 years after PCL reconstruction, although posterior stability in the reconstructed knee was not identical to the contralateral normal knee. Although joint position sense worsened just after reconstruction, it gradually recovered from 18 months after surgery. However, proprioceptive function after PCL reconstruction did not recover to the same level as in the contralateral normal knee even over 24 months after surgery.     

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.     

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.     

Anatomic anterior cruciate ligament reconstruction: the two-incision technique

This article describes the anatomical two-incision reconstruction of anterior cruciate ligament (ACL) of knee. The major part of currently single incision tibial endoscopic techniques attempts to reproduce the most isometric anteromedial bundle of ACL. Often a relatively vertical femoral tunnel, respect to the notch, is drilled, which is not really efficacious in providing rotatory stability. The single incision technique was developed to obviate the necessity of the lateral femoral incision and dissection. This technical note describes a two-incision ACL reconstruction using an instrumentation, which avoids a large lateral femoral soft tissue dissection, and discusses the rational use of the two-incision ACL reconstruction technique.     

Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts

Despite the higher incidence of anterior cruciate ligament (ACL) injuries in female than in male athletes few authors have studied the effects of gender on the outcome of ACL reconstruction. This prospective study compared the results of ACL reconstruction using the patellar tendon and hamstring techniques in men and women. We prospectively followed 80 comparable athletes (46 males, 32 females) from a population of 287 patients operated on at our institution for ACL reconstruction using either patellar tendon or hamstring graft. There were 26 males and 14 females in the patellar tendon group, and 22 males and 18 females in the hamstring group. All patients were operated on by the same surgeon within 6 months from injury and underwent the same rehabilitation program at the same center. After an average of 36 months the patients were assessed by clinical evaluation, computerized knee laxity analysis, and isokinetic and functional strength tests; standard knee scores were also used. Among patellar tendon patients there were no significant differences between males and females regarding knee evaluation form, laxity, or isokinetic and functional tests. Females in the hamstring group had significantly greater laxity, and isokinetic tests at 1 year revealed a significantly higher deficit of peak torque at 60°/s in flexion and extension. We suggest further studies on the clinical significance of these findings particularly on their possible ramifications in the areas of return to sports and rehabilitation of female athletes     

Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up

This study prospectively evaluates the outcomes at a minimum 4-year follow-up after PCL reconstruction using quadruple hamstring tendon autograft with an arthroscopic double fixation technique. During 1996–1999, hamstring tendon autograft graft has been used in 57 patients. Data from 52 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of posterior drawer test and posterior sag sign with MRI image confirmation. Twelve knees had combined posterior and posterolateral instability, which were simultaneously reconstructed. Clinical assessments included Lysholm knee score, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented test, thigh muscle assessment, and radiographic evaluation. The mean Lysholm score was 54 (40–65) and 91 (65–100) points (P<0.01) before and after surgery. Thirty (58%) patients could return to moderate or strenuous activity. The evaluation of AP translation has been performed with KT-1000. The average posterior displacement measured with KT-1000 was 11.69±2.01 mm preoperatively and 3.45±2.04 mm postoperatively. Forty-two (81%) patients demonstrated ligament laxity of less than 5 mm. Forty-two (81%) patients were rated as normal or nearly normal based on IKDC scores. Forty-six (88%) patients achieved a minimum of 80% recovery of extensor strength and 44 (85%) patients achieved a minimum of 80% recovery of flexor strength. Statistically significant differences existed in thigh girth, extensor strength, and flexor strength before and after reconstruction. Arthroscopic reconstruction for PCL with four-strand hamstring tendon graft produced satisfactory results. The semitendinosus and gracilis tendon graft is adequate in graft size, technically easier to perform and more reproducible, and had a satisfactory result.     

Outcome of double-bundle ACL reconstruction using hamstring tendons

The objective of this article is to describe the clinical outcome of the transitional double-bundle procedure for anatomical ACL reconstruction. Subjects included 78 patients (average age 25 years) who had undergone ACL reconstruction with the transitional double-bundle procedure with multi-stranded hamstring tendons. The femoral socket for the anteromedial (AM) graft was created at 5–6 mm from the mid-sagittal line of the intercondylar notch at 2:00 or 10:00, and that for the posterolateral (PL) graft was drilled adjacent to the AM socket at 3:00 or 9:00. For the tibial side, two tunnels were made at the center of the footprint of the AM and PL bundles of the normal ACL. Patients were evaluated at 24 months or longer postoperatively based on the IKDC Knee Examination Form. Subjectively, 32 knees (41%) were graded as normal; 41 (53%), as nearly normal; 4 (5%), as abnormal; and 1 (1%) as graft rupture by re-injury. The average side-to-side difference in anterior laxity at manual maximum force with the KT-2000 arthrometer was 0.9 mm ± 1.2. Seventy patients (93%) had a range between −1 mm and 2 mm. In conclusion the transitional double-bundle ACL reconstruction provided a satisfactory outcome after a short-term follow-up.     

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。     

关节镜下应用LARS人工韧带同时重建前、后交叉韧带

目的 探讨关节镜下应用LARS人工韧带重建前交叉韧带(ACL)、后交叉韧带(PCL)同时损伤的方法及疗效. 方法 关节镜下同时重建13例ACL、PCL损伤的患者,重建材料采用LARS人工韧带.术后随访12～36个月,采用国际膝关节文件编制委员会(IKDC)韧带标准评价表和Lysholm膝关节功能评分表评估患膝功能,通过KT-1000检查膝关节前后松弛度.结果 术后无膝关节感染发生;均无伸膝受限,屈膝活动度105°～125°,平均117°.术后随访时IKDC评分:A类10例(77%),B类3例(23%).屈膝25°位KT-1000检查:双侧膝关节前向松弛度差异＜2 mm 12例,3～5 mm 1例;屈膝70°位检查:＜2 mm 12例,2～4 mm 1例.术前Lysholm膝关节功能评分为(63.8 ±2.9)分(49～69分),终末随访时为(91.1±2.7)分(88～95分),差异有统计学意义(P＜0.01). 结论 关节镜下同时重建膝关节ACL、PCL是目前治疗ACL、PCL同时损伤的一种微创、安全、有效的手术方法,近期疗效佳.     

关节镜下双骨道多股自体腘绳肌腱解剖重建前交叉韧带

目的探讨关节镜下双骨道多股自体腘绳肌肌腱解剖重建前交叉韧带(ACL)的方法和疗效。方法31例ACL损伤患者,年龄18～45岁,平均27岁。在关节镜下应用两组骨道,用多股半腱肌腱在屈膝50°～60°位拉紧并固定重建前内侧束,用多股股薄肌腱在屈膝10°～15°位拉紧并固定重建后外侧束。结果31例患者术后进行3～13个月(平均5.2个月)随访,术后膝关节活动度均在正常范围。术后前抽屉试验和轴移试验均为阴性;Lachman试验:25例“-”,5例“1+”,1例“2+”。术后Lysholm评分为(88.7±9.4)分,较术前(47.4±9.6)分显著提高(t=3.14,P<0.01)。术后Tegner活动评分为(6.9±1.3)分,较术前(3.1±0.9)分显著提高(t=3.13,P<0.01)。结论双骨道多股自体腘绳肌腱重建ACL能够更好地恢复膝关节在不同伸屈角度的稳定性。     

关节镜下双束腘绳肌腱股骨双隧道和微型钢板纽扣重建后交叉韧带

目的探讨应用双束腘绳肌腱股骨双隧道和微型钢板纽扣固定法重建后交叉韧带(PCL)的临床效果。方法对13例单纯PCL断裂的患者在关节镜下用腘绳肌双束股骨双隧道和微型钢板纽扣固定法进行重建。其中男9例,女4例;年龄20-53岁,平均36岁;新鲜损伤9例,陈旧性损伤4例。全部取自体半腱肌腱和股薄肌腱作为移植物。根据PCL的解剖特点,将肌腱编织成"Y"形的两束。PCL两束股骨附着点分别钻孔,成双隧道。用微型钢板和纽扣分别固定股骨和胫骨端。结果术后3个月,所有患者均无伸膝受限,膝关节屈膝活动度均>120°。术后1年,屈膝70°时后抽屉试验Ⅰ度阳性1例,其余均为阴性;屈膝30°时后抽屉试验Ⅰ度阳性2例,其余均为阴性;膝关节功能Lysholm评分为(92.51±2.40)分。结论在关节镜下利用腘绳肌腱股骨双隧道和微型钢板纽扣法重建PCL能够更可靠地恢复膝关节功能。     

Patellar tendon length after anterior cruciate ligament reconstruction: a comparative magnetic resonance imaging study between patellar and hamstring tendon autografts

Patellar tendon shortening after anterior cruciate ligament reconstruction may be associated with anterior knee pain or patellofemoral arthritis. The present study was designed to compare postoperative changes in patellar tendon length after anterior cruciate ligament reconstruction between patellar tendon and hamstring tendon autograft. Magnetic resonance images of both knees (operated and healthy) and functional outcome were documented at least 1 year postoperatively in 16 patellar tendon harvested patients and in 32 hamstrings harvested patients. Patellar tendon length, patella length and Insall–Salvati ratio were measured. The operated knee values were compared to the respective values of the non-operated control knees. A significant 4.2 mm or 9.7% patellar tendon shortening in patellar tendon group and a non-significant 1.14 mm or 2.6% shortening in hamstrings group was detected. No significant difference was detected in terms of major shortening—patella baja—(6% for the patellar tendon group vs. 0% for the hamsting group). There was no significant difference in anterior knee problems between the two groups as evidenced by the Shelbourne score (94 for the patellar tendon group vs. 98 for the hamsting group). Harvesting of the patellar tendon for anterior cruciate ligament reconstruction resulted in a significant shortening of the remaining tendon. In contrast harvesting of the hamstring tendons did not affect significantly the patellar tendon length. However, the incidence of patella baja and overall functional outcome was not significantly different between the two groups. Paper presented at the 12th ESSKA 2000 Congress, Innsbruck, Austria, 2006 and also presented at the 5th Biennial ISAKOS Congress, Hollywood, FL, USA, 2005.     

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons

Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy’s tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years’ follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3–4 months and 27.5% in 4–6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this techinque and the possibility of guaranteeing functional behaviour in the knee. Received: 5 April 1997 Accepted: 25 July 1997     

Experience with the Leeds-Keio artificial ligament for anterior cruciate ligament reconstruction

Artificial anterior ligament reconstruction was very popular between 1975 and 1990. Recently, disappointing results have been published. We reviewed 68 patients who had received an artificial anterior cruciate ligament reconstruction 1 year and 5 years after their operation. The Leeds-Keio device was used as a scaffold. The ligament failed in 32 knees. This was arthroscopically confirmed in 20 cases. The other 12 knees were grossly unstable, with a reappearance of pivot shift, anterior drawer sign and high KT 1000. Generally, we found a marked increase in laxity over the period of investigation. Several biopsies were taken during arthroscopic examination of suspected ruptures. They showed lack of collagenisation and ingrowth.