Kostenanalyse für den implantatfreien vorderen Kreuzbandersatz

Replacement of the anterior cruciate ligament (ACL) is presently routinely carried out with autologous transplantation of the ligamentum patellae (LP), semintendinosus-gracilis (SGS) or quadriceps (QS) tendons. The anatomical positioning of the drilling canals, transplant fixation, complication rate, revision aspects as well as economic aspects are still under discussion. Fixation of the transplant can be carried out mechanically with various anchoring systems or using biological implant-free healing (free of cost). The compulsory and private health insurance companies as well as staff medical insurance associations guarantee a constant remuneration according to the EBM (uniform evaluation standard), GOÄ (scale of fees for physicians) or UV-GOÄ (accident insurance scale of fees for physicians). At present all health insurances accept the costs for implantations in outpatient areas (minus 25 Euro own contribution for compulsory health insurance). For inpatient treatment remuneration is according to the flat-rate scale (diagnosis-related groups). Costs for implants, which are increasing over the years, diminish the economic result in this case. The technique of implant-free replacement of ACLs is cheaper, with fewer complications and achieves functional results for fixation of the transplant which are comparable to techniques with implants. This also applies to the double bundle technique. Implant-free replacement of ACLs with the patellar tendon is a suitable, uncomplicated operation technique with comparably low costs and belongs to the state of the art according to Hertel, Petersen and other authors. This method already has a valuable place in surgery of the ACL.     

Experimental stability of a new implant-free fixation technique in ACL replacement

The purpose of the study is to establish data on the stability of an ACL replacement. In 40 human cadaver knees, either a mid patellar ligament third with a trapezoid bone block on one side was fixed on the femoral side in a 2-diameter drill hole, or a conventional interference screw fixation was applied. Average primary stability amounted to 570 N (+/- 100 N) for the bone-blocking technique, and to 402 N ( +/- 79 N) for the interference screw fixation. When statistically tested by variance analysis, stability was significantly higher for the bone blocking technique than with interference screw fixation (p < 0.05). Thus, when using a mid-patellar ligament third for ACL reconstruction, the new implant-free technique described here appears to be a practical and reliable method for femoral graft fixation.     

All-Inside Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An “all-inside” technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to “bottom out” the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques.     

Rigid-fix pins fixation and LCA reconstruction with semitendinosus/gracilis autograft

ACL reconstruction techniques highly developed during the decades and biomechanical tests for hamstrings graft showed much in advance loading and stiffness comparing BPTB grafting. We have made joint analysis of 30 patients with semitendinosus / gracilis ACL reconstruction. Choice for proximal fixation was Mitek Rigid-fix Pins technique and bioactive screws for distal fixation; in 18 cases bioactive screws were used for femoral and tibial graft fixation. Lysholm score and knee clinical tests were parameters used for outcome evaluation. Follow up averaged 6 months with assessment after 1, 3, 6 and 12 months. Our results showed excellent postoperative Lysholm score in 85% and very good in 15% of cases. Postoperative Lachman was 1+ in 15% and postoperative pivot shift was 0%. Full rehabilitation achieved 85% and with modifications in everyday activities 15% of patients. Donor localization morbidity was markedly reduced and we have no complications. On the basis of the improved results in graft compression as well as stability with this technique, applied method is highly recommended for the reconstruction in ACL deficient knees.     

Fremdmaterialfreie vordere Kreuzbandplastik mit der Patellasehne in Press-fit-Doppelbündeltechnik

Anterior cruciate ligament (ACL) reconstruction using autologous tendons (BTB patellar tendon, hamstrings, quadriceps tendon) in an implant-free fixation technique is becoming more and more popular due to biological and economical reasons. In1987 an implant-free press-fit fixation technique of a BTB graft from the medial side of the patellar tendon (via mini-arthrotomy) was introduced and first published during the 4th ESKA Conference 1990 in Stockholm. Special emphasis is given to the anatomical orientation of the BTB graft. During the inside-out femoral press-fit fixation the bone-ligament margin of the graft is placed directly into the femoral insertion line of the natural ACL adapting its double-bundle structure. The graft is fixed by press-fit within the tibial metaphysis and its ligamentous part is secured in the metaphysis by harvested cancellous bone blocks driven into the joint line from the outside. The postoperative regime includes weight-bearing as tolerated and free motion. Out of 159 patients 95 could be seen for follow-up after an average of 10.7 years. The final IKDC knee score revealed 22.1% in group A (very good) and 62.1% in group B (good). The Tegner activity level was 6.8 preinjury and 6.0 postoperatively. The average KT 1,000 side-to-side difference was 1.8 mm. Subjectively no patient complained of instability and 99% of the patients could kneel on hard ground with minimal or no complaints. ACL revision surgery due to graft failure was not necessary in any of the patients. Advantages of the described procedure are a narrow anatomical orientation including the double bundle structure of the ACL, rapid graft incorporation by bone-to-bone healing, lack of bone resorption at the graft-host interface, decreased donor site morbidity, cost-effectiveness and ease of possible revision surgery.     

Structural properties of a new fixation strategy in double bundle ACL reconstruction: the MiniShim

Introduction  

Double-bundle reconstruction of the ACL has become the focus of scientific and clinical interest in the last years. However, there is still a discussion about the most appropriate technique for graft fixation. Both, extracortical fixation systems like the Endobutton and aperture fixation by interference screws have advantages as well as disadvantages. Aim of this study was to analyze the biomechanical properties of a new small wedge shaped implant (MiniShim, Karl Storz, Germany) for the fixation of a soft tissue graft in double bundle ACL reconstruction and to compare it to an aperture fixation by interference screw and an extracortical fixation.     

Rekonstruktion des vorderen Kreuzbandes

The treatment of ruptures of the anterior cruciate ligament (ACL) plays an essential role for both clinicians and resident physicians. To date many questions regarding the outcome as well as ACL reconstruction techniques have not yet been conclusively clarified. Whether reconstruction of the ACL protects the knee from osteoarthritis is still unproven; however, it is well known that an unstable knee joint is more vulnerable to secondary injuries, such as meniscal tears. Thus, early ACL reconstruction is recommended to minimize the risk of these secondary injuries. Three alternative sources of material for autologous ACL reconstruction are commonly utilized. An accessory hamstring (i.e. semitendinosus tendon with or without the gracilis tendon), a central strip of the patellar tendon with bone blocks and a central strip of the quadriceps tendon with or without bone block are the most common donor tissues used in autografts. Besides selection of the type of graft, the tendon diameter also plays a crucial role. Some progress has recently been made with respect to tunnel placement. The aim is to find an anatomical tunnel position. Reconstruction of both the anteromedial and the posterolateral ACL bundles helps to rebuild the anatomy of the original ACL; however, scientifically this approach did not lead to any improvement in the results. For fixation techniques a differentiation is made between aperture, extracortical and implant-free fixation. Generally, re-ruptures are less common than revisions as a result of graft ruptures due to technical mistakes during surgery. The most common mistakes concern tunnel placement and graft fixation. Also overlooked instability can have a negative influence on the outcome of ACL reconstruction.     

Anterior cruciate ligament graft fixation

ACL reconstruction, when performed correctly, has become a reliable, reproducible surgical technique with a predictable outcome. Successful results can be achieved via anatomic reconstruction with rigid fixation of a strong graft. Fixation techniques continue to evolve, with biologic fixation of graft constructs gaining popularity over the past several years. The choice of fixation should be one that provides a firm construct where accelerated rehabilitation can be achieved on all isolated primary ACL reconstructions. The results should be reproducible and, most important, the surgeon should be comfortable and confident with the fixation device. Prior to selecting a particular fixation device, the surgeon should not only be aware of any potential problems noted on biomechanical testing but also have familiarity with the proper use of the device and any clinical follow-up studies in the literature.     

Endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

The patella tendon is the most commonly used graft source for ACL reconstruction because of its biomechanical strength and stiffness, the availability of bone-to-bone healing on either end, and the ability to firmly secure the graft within the tunnels. Consistently good results have been reported in the literature, with expectations to return to all activities at pre-injury levels of performance. We outline our technique for endoscopic ACL reconstruction using a patella tendon autograft. The technique is divided into the critical stages of pre-operative assessment, graft harvest, notch preparation, tunnel placement, graft passage, graft fixation, and rehabilitation. Methods for avoiding pitfalls and overcoming mishaps are described.     

Vordere Kreuzbandplastik mit proximaler Endobutton-Fixation eines Lig.-patellae-Transplantats

BACKGROUND: Interference screw fixation in ACL reconstruction with bone-patellar tendon-bone graft (BPTB) is a potential source of intraoperative complications such as graft laceration. Further problems are artifacts on MRI and screw removal in revision surgery. These problems can be avoided by using distant fixation with the EndoButton. We designed this study to evaluate the clinical as well as the subjective outcome of ACL reconstruction with BPTB graft and femoral fixation with the EndoButton. METHODS: A total of 51 patients (7 female, 44 male) were examined 2-5 years after ACL reconstruction with BPTB graft and femoral fixation with the EndoButton. We used the IKDC form, Lysholm score, Tegner activity score, and digital radiographs (AP, lateral, axial) for the evaluation. RESULTS: Of all the patients included in the study, 87% showed a "normal" or "nearly normal" knee function according to the IKDC score, Lysholm score 94.2+/-7.9, Tegner score 6.4+/-1.2, and subjective IKDC 89.9+/-11.9. Radiological signs of arthritic changes could be seen in ten cases. CONCLUSION: The clinical outcome of ACL reconstruction with EndoButton fixation is comparable to other studies on ACL reconstruction with interference screw fixation. However, since the EndoButton avoids potential problems of the interference screw fixation, we recommend this fixation technique for ACL reconstruction with BPTB graft.     

Editorial Commentary: All-Inside Anterior Cruciate Ligament Reconstruction: In Pursuit of Ideal Graft Fixation

With evolution of techniques in orthopaedic surgery, incremental improvements can be anticipated. All-inside anterior cruciate ligament (ACL) reconstruction represents a revolution in treatment of ACL injuries, and further technical modifications may result in gradual improvements. This process of continual optimization of our techniques is important for providing the best possible surgical outcomes. Supplemental fixation of the inner graft limbs may lead to improved time-zero biomechanical performance when all-inside ACL reconstruction is performed. However, in ACL surgery, optimal graft selection and fixation are still debated.     

Biomechanics and anterior cruciate ligament reconstruction

For years, bioengineers and orthopaedic surgeons have applied the principles of mechanics to gain valuable information about the complex function of the anterior cruciate ligament (ACL). The results of these investigations have provided scientific data for surgeons to improve methods of ACL reconstruction and postoperative rehabilitation. This review paper will present specific examples of how the field of biomechanics has impacted the evolution of ACL research. The anatomy and biomechanics of the ACL as well as the discovery of new tools in ACL-related biomechanical study are first introduced. Some important factors affecting the surgical outcome of ACL reconstruction, including graft selection, tunnel placement, initial graft tension, graft fixation, graft tunnel motion and healing, are then discussed. The scientific basis for the new surgical procedure, i.e., anatomic double bundle ACL reconstruction, designed to regain rotatory stability of the knee, is presented. To conclude, the future role of biomechanics in gaining valuable in-vivo data that can further advance the understanding of the ACL and ACL graft function in order to improve the patient outcome following ACL reconstruction is suggested.     

Supplemental Tibial Fixation for Anterior Cruciate Ligament Reconstruction

This report describes transosseous backup suture fixation for anterior cruciate ligament (ACL) grafts of all varieties, used to distally augment proximal screw fixation in the tibia. Using a simple suture configuration, this method secures the ACL graft to the tibial cortex in conjunction with a proximal interference screw. The technique is applicable for all graft configurations, including allograft, autograft, bone, and both 2- and 4-strand soft-tissue grafts. The described technique is intended to be used for secondary or backup fixation of the graft in the tibial tunnel and not as primary fixation. This construct can be reproducibly created, making use of the sutures that are typically present on the graft after the interference screw is placed. This technique for backup tibial fixation precludes the need for external hardware, which in many instances may be symptomatically proud. Furthermore, use of this technique may represent a potential cost savings because no additional devices or equipment is used or purchased. This technique is simple, fast, and inexpensive, making use of available constructs to enhance the security of graft fixation during ACL reconstruction.     

Editorial Commentary: Independent Suture Tape Reinforcement Could Be a Part of the Holy Anterior Cruciate Ligament Grail Puzzle?

The quest for improvement of anterior cruciate ligament (ACL) reconstruction results is a continuous struggle as we endeavor different technique adjustments that could form a missing piece of the holy ACL grail puzzle. Independent suture tape reinforcement (ISTR) is a small addition to the familiar ACL reconstruction technique with the potential to improve reconstruction results. Biomechanical studies show a decreased graft elongation and increased ultimate load to failure with ISTR. Clinical studies are scarce. In contrast to the ACL augmentation results in the 1980s, 2 retrospective comparative studies do not report negative results, which would support further research. Larger clinical trials will have to prove whether this small addition to ACL reconstruction will have a positive impact on ACL reconstruction results. For now, it is promising to note that no “red flags” have been described for ACL reconstruction with ISTR.     

Aperture Fixation in Arthroscopic Anterior Cruciate Ligament Double-Bundle Reconstruction

The native anterior cruciate ligament (ACL) consists of 2 bundles, which have distinct biomechanical yet synergistic functions with respect to anterior tibial translation and combined rotatory loads. Traditionally, most ACL reconstruction techniques have primarily addressed the restoration of the anteromedial bundle, and less consideration was given to the posterolateral bundle. Recently, various ACL double-bundle reconstruction techniques have been described. With most of these techniques, however, an indirect extra-anatomic fixation far from the articular surface was performed. Because extra-anatomic fixation techniques, rather than aperture fixation techniques, are associated with graft tunnel motion, windshield wiper action, and suture stretch-out, concerns may arise regarding delayed biological incorporation, tunnel enlargement, and secondary rotational and anterior instability. We, therefore, present a novel arthroscopic technique that reapproximates the footprints of native ACL with the use of double-strand semitendinosus and gracilis autografts for reconstruction of the anteromedial and posterolateral bundles, respectively. A separate femoral and tibial tunnel is drilled for each double-strand autograft. The femoral tunnel for the anteromedial bundle is drilled primarily through a transtibial technique, and the femoral tunnel for the posterolateral bundle is drilled via an accessory anteromedial portal with the use of a 4-mm offset drill guide in the anteroinferior aspect of the femoral tunnel for the anteromedial bundle. Bioabsorbable interference screws are used in aperture fixation for anatomic fixation of each bundle. This technique attempts to reproduce closely the native ligament and its biomechanical function.     

Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques,graft preparation,and different fixation methods

Rupture of the anterior cruciate ligament (ACL) is a common orthopedic injury. Various graft options are available for the reconstruction of ruptured ACL. Using the hamstring muscle as an autograft was first described in 1934, and it remains a commonly harvested graft for ACL reconstruction. Hamstring autografts can be harvested using the traditional anteromedial approach or the newer posteromedial technique. An isolated semitendinosus tendon can be used or combined with the gracilis tendon. There are numerous methods for graft fixation, such as intra-tunnel or extra-tunnel fixation. This comprehensive review discusses the different hamstring muscle harvesting techniques and graft preparation options and fixation methods. It provides a comprehensive overview for choosing the optimal surgical technique when treating patients.