关节镜下保留与切除残迹前交叉韧带重建的远期临床比较

目的 评估比较关节镜下保留与切除残迹的前交叉韧带(anterior cruciate ligament,ACL)重建的技术方法 与远期临床效果. 方法 自1999年10月至2005年5月采用经典的经胫骨技术,常规切除ACL残迹,4股胭绳肌腱移植物重建ACL术87例.自2005年6月至2010年5月采用由外向内建立骨隧道,保留ACL残迹,4股胭绳肌腱移植物重建ACL术221例.仅选择两种手术处理中单纯ACL重建,并有完整3年以上随访记录的患者进行对比分析,保留残迹组66例,切除残迹组39例. 结果 两组患者术后随访均为36～ 60个月,两组随访时间比较差异无统计学意义(P＞0.05).术前资料比较,两组在年龄、性别、损伤至手术时间、关节不稳定程度、膝关节功能评分等方面差异均无统计学意义(P＞0.05).随访资料比较,两组双侧股部周径差值、两组Lachman试验稳定程度差异均无统计学意义(P＞0.05).保留残迹组的关节活动度优于切除残迹组(P＜0.05),Lysholm评分显著高于切除残迹组(P＜0.05),前抽屉试验稳定性显著优于切除残迹组(P＜0.05),轴移试验稳定性显著优于切除残迹组(P＜0.05),国际膝关节文件编制委员会( IKDC)评级显著优于切除残迹组(P＜0.05). 结论 关节镜下由外向内建立骨隧道、保留残迹ACL重建术的远期临床效果,包括关节稳定性和关节功能,优于经典的经胫骨技术、切除残迹ACL重建术.     

自体、同种异体肌腱重建前交叉韧带术后骨隧道扩大的对比研究

目的 探讨自体胭绳肌腱、同种异体肌腱对重建前交叉韧带(anterior cruciate ligament,ACL)术后骨隧道的变化和疗效差异. 方法 选择2008年6月- 2009年11月收治的行关节镜下ACL重建术61例ACL损伤患者.根据移植物不同分为两组:同种异体肌腱重建组(A组,27例)和自体胭绳肌腱重建组(B组,34例).术后1周、6～12个月进行MRI检查,测量矢状位骨隧道开口、开口1 cm、骨隧道最宽处三点骨隧道直径,以术后1周对应部位骨隧道直径为衡量标准,对其差值进行统计学分析.采用Lysholm评分评估各组临床疗效. 结果 术后随访:A组平均8.4个月,B组平均8.5个月.两组患者资料术前比较差异无统计学意义.术后MRI随访发现股骨侧、胫骨侧骨隧道直径均有不同程度的增宽,其中胫骨侧较股骨侧增宽明显,两组在股骨、胫骨三个不同测量部位骨隧道增宽差异无统计学意义.所有患者关节稳定性良好.术后Lysholm评分两组比较差异无统计学意义(P＞0.05). 结论 移植物不同是影响ACL重建术后骨隧道扩大的因素之一.自体肌腱、同种异体肌腱对ACL重建术后骨隧道扩大差异无统计学意义,与术后临床疗效无相关性.     

8股及4股自体腘绳肌移植物重建治疗低度轴移的膝关节前交叉韧带损伤的疗效对比研究

目的：比较应用8股腘绳肌移植物及4股腘绳肌移植物重建合并低度轴移（轴移1+）的前交叉韧带（ACL）损伤的临床效果。方法：回顾性分析从2019年10月至2021年3月北京积水潭医院收治的ACL损伤患者，入选患者术前麻醉下检查轴移试验为1度且有术后一年以上随访结果。采用8股腘绳肌移植物重建ACL的患者为A组，4股腘绳肌移植物重建ACL的患者为B组。评估术前及术后最少1年随访时，Lachman试验、KT-1000侧-侧差值、轴移试验、Lysholm评分以及国际膝关节文献委员会（IKDC）评分的组内和组间变化。结果：A组患者50例，平均随访时间14.8±6.2个月；B组患者50例，平均随访13.7±3.3个月。末次随访时，两组患者的主客观评估指标均较术前显著改善（P<0.05）。组间比较显示，末次随访时A、B两组患者的Lachman试验、KT-1000侧-侧差值、Lysholm评分以及IKDC评分差异无统计学意义（P>0.05）;A组轴移试验均为阴性，B组轴移试验44例阴性，6例1+，差异有统计学意义（P<0.05）。结论：合并低度轴移（轴移1+）的ACL损伤患者，应用8股自...     

反复冻融同种异体跟腱重建兔前交叉韧带后移植物生物力学研究

目的:研究反复冻融对同种异体跟腱重建兔前交叉韧带(ACL)后移植物的生物力学特性是否有影响。方法:取成年雄性新西兰白兔异体跟腱,经密封包装和Co60照射灭菌后,-80℃和室温20℃反复冻融。选用36只体重2.0～2.5kg成年雄性新西兰白兔行ACL重建手术,其中18只左、右膝分别用冻融1次(对照组)、2次的移植物,另外18只左、右膝分别用冻融3次、10次的移植物。术后6周、12周分批宰杀取材。每一时段各组随机取4条重建ACL行生物力学拉伸试验(各组剩下5个膝关节用于形态学研究),检测重建前交叉韧带最大载荷、刚度、最大载荷能量、最大应力、最大应变、弹性模量和能量密度。结果:6周时冻融10次组最大载荷(26.38±4.71N)及最大载荷能量(0.52±0.07N·m)明显高于其他三组(P<0.05),其余指标各组间无显著性差异(P>0.05)。12周时各组间的所有力学指标均无显著性差异(P>0.05)。结论:虽然术后6周反复冻融10次同种异体跟腱重建的兔膝ACL的抗拉强度高于冻融次数少组,但术后12周不同反复冻融次数对重建ACL生物力学的影响无明显差异。     

保留残端前交叉韧带重建对膝关节本体感觉恢复的影响临床研究

目的:观察关节镜下保留残端与非保留残端前交叉韧带(ACL)重建对膝关节本体感觉恢复的影响。方法:选择2012年2月至2013年10月期间行关节镜下ACL重建的患者136例为研究对象。将患者随机分为两组,每组68例,分别行保留残端重建及非保留残端重建。两组患者均选择自体半腱股薄肌腱为移植物。术前及术后3、6、9、12个月采用Lysholm评分评价膝关节的主观感觉及基本运动能力;采用被动活动察觉阈值、被动角度再生试验评估患者膝关节的本体感觉。比较分析两组患者的差异及患侧与健侧肢体的差异。结果:术后有104例患者获得12个月以上随访,平均随访时间19.75±6.21个月,其中保留残端组55例,非保留残端组49例。两组患者术后3、6、9及12个月的Lysholm评分显著高于术前(P<0.01),被动活动察觉阈值、被动角度再生试验显著低于术前(P<0.01)。术后3个月及6个月保留残端组膝关节的Lysholm评分高于非保留残端组(P<0.05),被动活动察觉阈值、被动角度再生试验低于非保留残端组(P<0.05)。术后3、6、9及12个月保留残端组患者被动活动察觉阈值、被动角度再生试验与健侧未见明显差异(P>0.05),术后3个月、6个月非保留残端组患者被动活动察觉阈值、被动角度再生试验高于健侧(P<0.05)。结论:ACL保残重建有利于患者术后膝关节功能及本体感觉的早期恢复。     

关节镜下重建前交叉韧带术后留置引流与否的对比临床研究

目的:对比关节镜下自体腘绳肌腱重建前交叉韧带(ACL)术后留置引流与否的临床结果。方法:将2008年2月~2013年2月54例陈旧性ACL断裂在关节镜下行自体腘绳肌腱重建术的患者分为2组,一组不留置引流(27例),一组留置引流(27例),采用相同的手术技术和术后处理,比较两组患者的疼痛评分、肢体周径增加、关节活动度、下肢深静脉血栓发生率、血肿形成、感染、伤口愈合不良等临床结果。结果:无引流组在术后2周患膝周径与术前相比差值显著大于有引流组(P<0.05),术后4、6周患膝周径与术前相比差值差异均无统计学意义。无引流组术后2周患膝关节活动角度显著小于有引流组(P<0.05),两组术后4、6周患膝关节活动角度差异均无统计学意义。两组在术后1、2、3天,2周VAS评分差异均无统计学意义。两组均未出现术后下肢深静脉血栓、血肿、伤口感染不愈合等并发症。结论:关节镜下前交叉韧带重建术后常规不留置引流可能是更好的选择。     

前交叉韧带重建术后移植物愈合的临床研究

目的:探讨前交叉韧带(ACL)重建术后韧带移植物愈合情况及其影响因素。方法:选取2014年1月至12月期间的膝关节镜下ACL重建手术患者,记录患者的性别、年龄、体重、身高、体重指数(BMI)、关节松弛度评分(Beighton评分)和ACL断裂病程时长。术后6个月、1年和2年随访时进行核磁检查,测量韧带移植物近端、中部和远端的信号强度,并计算信噪比(SNQ),用以评估重建韧带的愈合情况。对数据进行统计分析,探讨韧带移植物的愈合情况及其影响因素。结果:共计87例ACL重建患者入选研究,结果显示韧带移植物近端和中部的SNQ值随时间延长逐渐减小,尤其近端的SNQ值2年与6个月、1年对比有显著性差异(P<0.05);韧带远端的SNQ值在术后6个月、1年和2年时间节点上无明显差异。性别、年龄、体重、身高、BMI、Beighton评分和ACL断裂时长等因素对韧带移植物的SNQ数值均无显著性影响(P>0.05)。结论:ACL重建术后韧带移植物的愈合情况随时间延长而逐步改善。     

前交叉韧带重建中不同入路制备股骨骨道的对比研究

目的:比较改良经胫骨隧道(TT)入路和前内侧(AM)入路两种方法解剖位重建前交叉韧带(ACL)术后,股骨隧道的定位情况及临床疗效。方法:回顾性分析2016年1月～2017年12月我科收治的42例单侧前交叉韧带损伤患者的临床资料。其中24例采用改良TT入路技术重建ACL,18例采用AM入路技术重建ACL。术后1周内行膝关节CT平扫+三维重建评估股骨骨道位置,术后3个月时扫描MRI并测量JGS、JGC角;术前及术后12个月评估患者国际膝关节文献委员会(IKDC)评分、Lysholm评分、膝关节前方松弛度及轴移试验结果。结果:术前两组患者性别、年龄、病程、IKDC评分、Lysholm评分、膝关节前方松弛度、轴移试验阴性率,差异均无统计学意义(P>0.05)。末次随访时,两组患者IKDC评分、Lysholm评分,前方松弛度,轴移试验阴性率相较术前均显著改善,差异具有统计学意义(P<0.05);组间比较,差异无统计学意义(P>0.05)。CT三维重建分析显示,两组股骨骨道内口位置无明显差异(P>0.05),MRI测量JGS、JGC角,组间无明显差异(P>0.05)。结论:采用改良经胫骨隧道入路和前内侧入路重建ACL,均可获得良好的股骨解剖中心隧道定位,骨道位置无明显差异,术后早期疗效令人满意。     

滑膜切除对同期双侧全膝关节置换术后失血及功能恢复的影响

目的:探讨同期双侧全膝关节置换术(TKA)时行滑膜切除术对术后失血量及膝关节功能恢复的影响。方法:2014年11月至2017年12月间因患原发性膝骨关节炎在我院行同期双侧全膝关节置换的患者62例,其中32例术中进行滑膜切除(实验组),30例术中不进行滑膜切除(对照组)。对比两组患者手术时间、术中出血量、住院时间、术后第3天血色素较术前降低值、术后隐性出血量、术后输血率以及术后4周、12个月疼痛视觉模拟评分(VAS)和美国膝关节协会评分(KSS)。结果:两组患者均获得12个月随访。两组患者手术时间、术中出血量差异均无统计学意义(P>0.05);实验组术后输血率明显高于对照组(25%vs. 10%),但差异无统计学意义(P>0.05);实验组住院时间、术后第3天血色素较术前血色素降低值、隐性失血量均高于对照组,差异有统计学意义(P<0.05)。两组术后4周及术后12个月VAS评分、KSS评分(包括临床评分、功能评分)均较术前明显改善,差异有统计学意义(P<0.05)。两组间术前、术后4周及术后12个月VAS评分及KSS评分(包括临床评分、功能评分)差异无统计学意义(P>0.05)。结论:在行同期双侧全膝关节置换治疗骨性关节炎时,与保留滑膜相比,滑膜切除在缓解术后疼痛及改善膝关节功能方面未带来明显获益,且增加了隐性失血量及术后输血率。     

3D打印个性化股骨侧定位导向器辅助前交叉韧带重建疗效观察

目的评价3D打印技术设计个性化股骨侧定位导向器应用于前交叉韧带(ACL)重建手术的临床效果。方法收集2014年1月至2016年1月应用3D打印个性化股骨侧定位导向器辅助行关节镜下ACL重建术患者40例为3D组,术前进行3D建模、ACL股骨侧止点定位。应用常规经膝关节前内侧入路手动进行股骨侧定位的ACL重建术患者40例为常规组。比较两组患者术后Lysholm及国际膝关节文献委员会膝关节评估表(IKDC)评分。结果两组患者手术过程顺利,均未出现并发症。3D组术前均建模顺利,术前定位股骨侧隧道口后,股骨侧隧道长约(42.1±3.3)mm,常规组测量股骨侧隧道长约(39.5±3.9)mm,两组间比较,差异无统计学意义(P>0.05)。两组患者随访时间6~13个月,平均10个月。术后10个月,两组患者Lysholm及IKDC评分均较术前明显提高,差异有统计学意义(P<0.05);两组间Lysholm及IKDC评分比较,差异均无统计学意义(P>0.05)。结论应用3D打印技术设计个性化股骨侧定位导向器进行ACL重建手术有助于精准定位股骨侧解剖点、控制导针方向,利于腱骨愈合,缩短手术时间,加快术后康复。     

关节镜下保留残端与非保留残端重建前交叉韧带的临床疗效分析

目的探讨关节镜下保留残端与非保留残端重建前交叉韧带的方法与疗效。方法 2012年6月~2015年12月收治前交叉韧带断裂患者48例,采用自体腘绳肌肌腱重建,可吸收挤压螺钉固定重建肌腱。保残前交叉韧带重建20例,保留断裂的前交叉韧带残端;非保残前交叉韧带重建28例,断裂的前交叉韧带完全清理。两组均术后随访24个月,采用KT-2000胫骨前移距离、Lysholm膝关节评分、被动活动察觉阈值进行疗效评估。结果在术后24个月的随访中,术后3、6个月KT-2000胫骨前移距离同期保残组显著高于非保残组(T=5.290,P=0.000;T=3.754,P=0.000),术后12、24个月Lysholm膝关节评分同期保残组显著高于非保残组(T=3.187,P=0.003;T=3.781,P=0.000),术后12、24个月被动活动察觉阈值同期保残组显著高于非保残组(T=4.229,P=0.000;T=3.105,P=0.003)。结论纤维关节镜下保留残端前交叉韧带重建比不保残重建在恢复膝关节运动功能方面具有更好的优势。     

Expression of vascular endothelial growth factor and angiogenesis in patellar tendon grafts in the early phase after anterior cruciate ligament reconstruction

The aim of this study was to clarify vascular endothelial growth factor (VEGF) expression and angiogenesis in the patellar tendon (PT) autograft in the early phase after anterior cruciate ligament (ACL) reconstruction using a rabbit model. The right knees of 30 Japanese white rabbits underwent ACL reconstruction using the medial third of the PT complex. We evaluated the grafted tendon at 1, 2, 3, 4, and 8 weeks after ACL reconstruction by immunohistology for proliferating cell nuclear antigen, VEGF, and CD31, which is a marker for vascular endothelial cells. At week 1 , few cells were observed at the midsubstance of the grafted tendon. A number of proliferating cells were observed at the surface area of the PT graft 2 weeks after graft transplantation, while no vessel formation was observed in the graft at the same time. VEGF was highly expressed 2-3 weeks postoperatively. Vessel formation in the PT graft increased with time from 3 to 8 weeks after ACL reconstruction. The rates of proliferating cells and VEGF-expressing cells decreased with time from 3 to 8 weeks. This study has suggested that VEGF is involved in the graft remodeling process particularly at the early phase after ACL reconstruction.     

ACL reconstruction with semitendinosus tendon autograft without detachment of its tibial insertion: a histologic study in a rabbit model

The purpose of this study was to evaluate the histologic changes that occur between 3 and 12 weeks in an intra-articular, semitendinosus autograft, which was harvested without detachment of its tibial insertion and was placed through tibial and femoral drill holes, in a rabbit model. About 30 New Zealand white rabbits underwent ACL replacement using a semitendinosus tendon autograft. The normal ACL was transected at its femoral and tibial insertions. The tendon graft was harvested without detachment of its tibial insertion and its free end was secured with sutures. The graft was then passed through one tibial and one femoral tunnel and secured at the lateral femoral condyle. All animals were divided into three groups and were killed at 3, 6 and 12 weeks after surgery. Nine more animals underwent ACL reconstruction using a free semitendinosus tendon autograft. These animals were used as controls. The intra-articular portion of the graft and the interface between the bone tunnel and the graft was evaluated postoperatively for gross morphology and histological appearance. Results of this study showed that in a rabbit model the semitendinosus tendon autograft retained its viability when harvested without detachment of its peripheral insertion. On contrary, at the control group, necrosis of the graft was observed 3 weeks after surgery and progressively revascularization and maturation occurred 6 and 12 weeks after surgery. Retaining the tibial insertion of the semitendinosus autograft seems to preserves its viability and bypasses the stages of avascular necrosis and revascularization that occurs with the use of a free tendon autograft.     

The effect of intraosseous graft length on tendon-bone healing in anterior cruciate ligament reconstruction using flexor tendon

The current study was performed to understand the relationship between graft length placed within the bone tunnel and intraosseous graft healing in anterior cruciate ligament (ACL) reconstruction. Twenty-four adult beagle dogs were divided into two groups of 12 animals each. In each animal, ACL reconstruction using a 4-mm diameter autogenous flexor tendon graft was done in the left knee. In groups I and II, the graft having a length of 15 and 5 mm, respectively, was placed within the tibial tunnel. The proximal end of the graft was placed through the over-the-top route in all animals. In each group, five animals were sacrificed immediately after surgery, and the remaining seven were sacrificed at 6 weeks postoperatively. Biomechanical and histologic evaluations were performed. In pull out testing, the ultimate failure load and the linear stiffness of the graft-tibia complex harvested at 6 weeks were significantly greater than those harvested at the time-zero period. There were no significant differences in those parameters between groups I and II at 6 weeks. In each group, the perpendicular collagen fibers connecting the tendon to the bone tunnel wall were observed only in the narrow area located close to the intra-articular tunnel outlet. In conclusion, excessively long placement of the flexor graft within the bone tunnel does not result in an additional increase of anchoring strength and stiffness of the graft in ACL reconstruction.     

Effects of local administration of vascular endothelial growth factor on mechanical characteristics of the semitendinosus tendon graft after anterior cruciate ligament reconstruction in sheep

BACKGROUND: Vascular endothelial growth factor (VEGF) is a potent mediator of angiogenesis. HYPOTHESIS: An application of VEGF may enhance angiogenesis in the grafted tendon in anterior cruciate ligament (ACL) reconstruction, and the application may affect mechanical characteristics of the ACL graft. STUDY DESIGN: Controlled laboratory study. METHODS: Eighteen sheep were divided into groups I and II. In group I, the harvested semitendinosus tendon was soaked in VEGF solution, and the right knee then underwent ACL reconstruction using this tendon. In group II, the right knee underwent identical procedures to those of group I except that the harvested tendon was soaked in phosphate-buffered saline. All animals were sacrificed 12 weeks after ACL reconstruction. RESULTS: Histologic findings showed that newly formed vessels and infiltrative fibroblasts were more abundant in group I than in group II. The anterior-posterior translation of the knee during an anterior-posterior force of +/- 100 N was significantly larger in group I than in group II by 2.58 mm (95% confidence interval, -1.76 mm to 1.76 mm) (P = .002). The linear stiffness of the femur-graft-tibia complex in group I was significantly lower than that in group II by 41.5 N/mm (95% confidence interval, -32.2 N/mm to 32.2 N/mm) (P = .017). CONCLUSION: This study has revealed that VEGF as administered in this study promotes angiogenesis in the ACL graft and significantly reduces the stiffness of the ACL graft with increased knee laxity at 12 weeks after ACL reconstruction. CLINICAL RELEVANCE: Exogenous VEGF application for ACL reconstruction can induce an increase in knee laxity and a decrease in the stiffness of the grafted tendon at least temporarily after ACL reconstruction. These potentially negative mechanical effects need to be taken into account when considering clinical use of VEGF.     

Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study

The purpose of the present investigation was to evaluate physical outcome after anterior cruciate ligament (ACL) reconstruction with early versus late initiation of open kinetic chain (OKC) exercises for the quadriceps in patients operated on either patellar tendon or hamstring grafts. Sixty-eight patients, 36 males and 32 females, with either patellar tendon graft (34 patients) or hamstring graft (34 patients) were enrolled in this study. All patients were randomly allocated to either early (the 4th postoperative week) or late (the 12th postoperative week) start of OKC exercises for the quadriceps, resulting in four subgroups: patellar tendon reconstruction, early start (P4) or late start (P12) of OKC quadriceps exercises, hamstring tendon reconstruction, early start (H4) or late start (H12) of quadriceps OKC exercises. Prior to surgery and 3, 5 and 7 months later, assessments of range of motion (goniometer), anterior knee laxity (KT-1000), postural sway (KAT 2000), thigh muscle torques (Kin–Com dynamometer) and anterior knee pain (anterior knee pain score) were evaluated. No significant group differences were found in terms of range of motion 3, 5 and 7 months postoperatively. The H4 group showed a significantly higher mean difference of laxity over time of 1.0 mm (CI: 0.18–1.86) than the P4 group (P = 0.04). Within the same type of surgery, the H4 against the H12, the mean difference over time was 1.2 mm (0.37–2.1) higher in the H4 group than in the H12 group (P = 0.01). There were no significant group differences in terms of postural sway or anterior knee pain at the different test occasions. Significant differences in trends (changes over time) were found when comparing the four groups, for both quadriceps muscle torques (P < 0.001) and hamstring muscle torques (P < 0.001). All groups, except the P4 group, reached preoperative values of quadriceps muscle torques at the 7 months follow-up. In the H4 and the H12 groups, significantly lower hamstring muscle torques at the 7 months follow-up compared with preoperative values were found. In conclusion, early start of OKC quadriceps exercises after hamstring ACL reconstruction resulted in significantly increased anterior knee laxity in comparison with both late start and with early and late start after bone–patellar tendon–bone ACL reconstruction. Furthermore, the early introduction of OKC exercises for quadriceps did not influence quadriceps muscle torques neither in patients operated on patellar tendon nor hamstring tendon grafts. On the contrary, it appears as if the choice of graft affected the strength of the specific muscle more than the type of exercises performed. Our results could not determine the appropriate time for starting OKC quadriceps exercises for patients who have undergone ACL reconstruction with hamstring tendon graft. Future studies of long-term results of anterior knee laxity and functional outcome are needed.     

Isokinetic evaluation of anterior cruciate ligament reconstruction: quadriceps tendon versus patellar tendon

AIM: The goal of this prospective randomized study was to compare the isokinetic recovery of thigh strength after anterior cruciate ligament (ACL) reconstruction by using patellar or quadriceps tendon as graft at the 6th month follow-up. METHODS: The authors evaluated 48 patients who underwent arthroscopic ACL reconstruction using patellar tendon (PT group) or quadriceps tendon (QT group) as autograft after a 6 months follow-up undergoing the following tests: the Ergojump Bosco System springboard and Universal's FITNET computerized isokinetic system. RESULTS: The counter movement jump (CMJ) test showed a 24% (p<0.01) strength deficit in patients operated with patellar tendon and 11% in the quadriceps tendon group. Also in the leg press test the greater differences in strength (p<0.05) were verified in the patellar tendon group, above all the peak torque (PT) test carried out at 3 repetitions (15%). CONCLUSIONS: The strength deficit found in the subjects operated with quadriceps tendon were statistically lower in comparison to that verified in the patellar tendon group. A good recovery in thigh strength after 6 months in patients operated with quadriceps tendon could encourage the use of this kind of graft in order to achieve an easier rehabilitation and a faster release of the patient to daily and sports activity.     

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.     

Measurement of the graft angles for the anterior cruciate ligament reconstruction with transtibial technique using postoperative magnetic resonance imaging in comparative study

The aims of this study were to quantify the angle and placement of an anterior cruciate ligament (ACL) grafted with a single incision ACL reconstruction technique using postoperative magnetic resonance imaging (MRI), and to compare the results with those with a native ACL. Between February 1996 and May 2004, 96 consecutive patients, who had undergone postoperative MRI of the knee followed by an arthroscopically assisted ACL reconstruction with either a hamstring tendon or bone-patellar tendon-bone (BTB) autograft, were enrolled in this study. The femoral tunnel was drilled using the transtibial technique. The patients were divided into two groups; the hamstring tendon graft group (group H; 50 patients) and the BTB graft group (group B; 46 patients). All the patients including both groups in this study underwent postoperative MRI and were followed up for a minimum of 2 years. The control group (group C) consisted of 50 patients whose meniscus tear had been operated on by arthroscopy and whose ACL was intact. The orientation of the ACL ligament or graft was measured using three different methods: the sagittal ACL angle, the ACL-Blumensaat line angle, and the coronal ACL angle. The mean sagittal ACL angle in group C (58.7 ± 3.8°) was significantly lower than in groups H (64.6 ± 4.2°) and B (71.3 ± 6.0°). The mean ACL-Blumensaat line angle in group C (8.6 ± 3.6°) was also significantly lower than in groups H (12.8 ± 5.2°) and B (18.0 ± 5.3°). The mean coronal ACL angle in group C (65.9 ± 4.4°) was lower than that in groups H (73.5 ± 2.4°) and B (75.2 ± 2.9°). The grafted ACL of the hamstring tendon and BTB grafts on the postoperative MRI showed a significant vertical angle in the coronal and sagittal plane compared with the native ACL. In the sagittal plane, the hamstring tendon graft was positioned more obliquely than the BTB graft, which had a larger angle of the tibial tunnel, in an attempt to prevent a graft-tunnel mismatch. The postoperative MRI study showed that the more horizontally the angle of the tibial tunnel can be placed in a single incision ACL reconstruction, the more efficiently it can produce a graft closer to the native ACL.     

Biomechanical evaluation of using one hamstrings tendon for ACL reconstruction: a human cadaveric study

Harvesting both the semitendinosus and gracilis tendons for anterior cruciate ligament (ACL) reconstruction has a negative impact on muscle strength as well as knee function and stability. With a new “All-inside” technique, using only one hamstrings tendon (semitendinosus or gracilis) is possible because of a reduction in length requirements. The research question of this in vitro study was whether the use of only one hamstrings tendon (semitendinosus or gracilis) could restore knee kinematics and in situ force in the ACL to the level of an intact knee. Ten human cadaveric knees were tested in the following conditions: (1) intact, (2) ACL-deficient, and (3) ACL reconstruction with the “All-inside” technique using the (a) single semitendinosus tendon graft, or (b) single gracilis tendon graft. Using a robotic testing system, external loads, i.e. (1) an anterior tibial load of 134-N and (2) combined rotatory loads of 10-Nm valgus and 5-Nm internal tibial torques, were applied. The multiple degrees of freedom knee kinematics and the in situ forces in the ACL and ACL grafts were determined. In response to a 134-N anterior tibial load, the use of either graft could restore anterior tibial translation to within 1.3 mm of the intact knee. The in situ forces in the two grafts were not significantly different from those of the intact ACL. Under the combined rotatory loads, both grafts could restore knee kinematics as well as the in situ force in the grafts to the level of the intact ACL. The “All-inside” technique using either the semitendinosus or gracilis tendon for ACL reconstruction could satisfactorily restore time-zero knee kinematics and the in situ forces in either graft to those for the intact ACL, supporting clinical findings.