ACL reconstruction by patellar tendon

In 50 knees the length of the anterior cruciate ligament (ACL), the patellar tendon, and the distance between the tibial tuberosity and the femoral origin of the ACL were evaluated by means of three-dimensional magnetic resonance imaging (MRI), which permits subsequent reconstruction of any sectional view. The measurements showed that the patellar tendon was always markedly longer than the ACL (mean 14.4 mm), but always shorter than the distance between the tibial tuberosity and the femoral insertion of the ACL (mean 19.2 mm). The mean lengths of the ACL and the patellar tendon were 38.2 mm and 52.6 mm, respectively. The mean distance between the femoral ACL origin and the tibial insertion of the patellar tendon was 71.8 mm. These results demonstrate that a distally based patellar tendon autograft alone (with the patellar bone block but without extension into the periosteum of the patella or the quadriceps tendon) cannot be placed anatomically correctly to the isometric femoral insertion of the ACL. When the patellar tendon is used for ACL reconstruction, it must be implanted as a free autograft. Nevertheless, considerable variations of length must be taken into account.     

Le fratture articolari ed extra-articolari del ginocchio

Joint fractures of the knee include epiphyseal detachments of the distal femur and proximal tibia (types 3 and 4 according to Salter-Harris). Extra-articular fractures include: avulsion of the tibial spines, detachment of the anterior tuberosity and patellar fractures. Fractures involving the distal femoral and proximal tibial epiphysis are relatively infrequent but may lead to long-term complications owing to the formation of post-traumatic bone bridges. Unless the fracture is composed, surgical treatment is always indicated. Avulsion fractures of the tibial spines occur as a result of a chondro-epiphyseal detachment of the insertion of the cruciate ligaments (predominantly the anterior one). They are infrequent injuries (3 per 100,000 cases per year, 2% of all knee injuries). Accurate diagnosis and appropriate treatment prevent unfortunate outcomes. Adolescent tibial tubercle fractures are uncommon, high-energy injuries sometimes combined with patellar tendon rupture; they represent a frequently missed diagnosis. Open reduction/internal fixation is generally required. Patellar fractures are caused by direct trauma (primary osseous fractures) or by an eccentric load during extension of the knee (sleeve and avulsion fractures). Most fractures require open reduction/internal fixation. The complication rate is low but late reconstruction of missed injuries may result in an extensor deficit.

     

Tibial tuberosity avulsion-fracture associated with complete distal rupture of the patellar tendon: A case report and review of literature

BACKGROUNDFew cases of avulsion fractures of the tibial tuberosity with simultaneous rupture of the patellar tendon have been reported in the literature. Therefore, its mechanism and incidence have not been determined conclusively. This type of fracture is considered a serious injury that requires prompt diagnosis and early surgical repair. There is no therapeutic algorithm or standard method of treatment due to the infrequency of the injury. In this case report, we conducted an exhaustive review and synthesis of the existing literature including all previously reported cases.CASE SUMMARYWe present a 16-year-old male soccer player with a case of a tibial tuberosity fracture with distal avulsion of the patellar tendon 5 d prior to surgical treatment. The patient presented with a loss of the extensor mechanism of the knee, edema, the inability to walk, and pain. X-rays showed a high patella and a 180-degree avulsion of the tibial tuberosity. The diagnosis was confirmed by magnetic resonance imaging and computed tomography. The patient underwent open reduction and internal fixation of the fracture with a cannulated screw and washer as well as patellar tendon repair with two metallic anchors. The rehabilitation protocol consisted of initial immobilization in extension followed by passive mobility and muscle strengthening exercises. The patient demonstrated excellent postoperative outcomes and returned to regular activity without complications.CONCLUSIONThis case presentation and literature review comprise the most relevant clinical, radiographic, and treatment details described in the international literature to date, providing the reader with an overview of this rare condition.     

Bifocal disruption of the knee extensor mechanism: a case report and literature review

Bifocal disruption of the knee extensor mechanism is a rare injury. Bifocal proximal and distal avulsion fracture of the patella tendon is extremely rare in adults. Here, the authors report the case of an 84-year-old male patient who developed simultaneous avulsion fracture of the patella tendon from the inferior pole of the patella and the tibial tuberosity. Open reduction and internal fixation were performed, and at 12 months postoperatively, an excellent functional result was obtained.     

Revision anterior cruciate ligament reconstruction using the lateral third of the ipsilateral patellar tendon after failure of a central-third graft: a preliminary report on 10 patients

Long-term outcomes were reported for 10 (77%) of 13 cases of revision anterior cruciate ligament (ACL) reconstruction using the lateral third of the ipsilateral patellar tendon as a graft. All primary ACL reconstructions were ipsilateral central-third bone-patellar tendon-bone graft procedures. Mean age at follow-up was 30.7 years, and mean time from revision ACL surgery to follow-up was 42.9 months. At follow-up, average KT-1000 difference between knees was 2.4 mm. All patients had a negative pivot shift, extension within 5 degrees of the contralateral knee, and flexion within 15 degrees. Mean bilateral comparison ratios for isokinetic strength and hop testing were: extension, 83.5%; flexion, 96%; and single-leg hop 96.9%. No patella fractures or tendon ruptures had occurred. All patients had returned to their previous work level, and 8 of the 10 patients could participate in at least "moderate" sports activities (e.g., skiing and tennis). The results were comparable to published outcome reports for both primary and revision ACL reconstruction. The lateral third of the ipsilateral patellar tendon is a good graft option for revision ACL reconstruction.     

Quadriceps tendon-patellar bone autograft for anterior cruciate ligament reconstruction: a technical note

The quadriceps tendon autograft can be used for primary and revision anterior cruciate ligament (ACL) reconstruction. Despite several successful clinical reports, graft fixation issues remain, and the ideal technique for fixation continues to be controversial. We present a technique of ACL reconstruction with quadriceps tendon autograft (QTA) using a patellar bone block. The tendon end is fixed in the femoral tunnel and the bone plug in the tibial tunnel using reabsorbable interference screws. The advantages of this technique are related to the increase in stiffness of the graft, the achievement of a more anatomic fixation, and a reduction in synovial fluid leakage.     

自体中1／3髌韧带重建前十字韧带术后膝关节内并发症的探讨

目的探讨应用自体中1/3髌韧带移植重建前十字韧带术后膝关节内有关的并发症及其发病机制。方法1994年1月～1997年11月 ,对18例前十字韧带断裂的患者采用关节镜或小切口关节切开术 ,完成自体中1/3髌韧带移植重建前十字韧带。术后平均随访2年 ,对所有病例进行临床检查 ,确定膝关节疼痛部位 ,检查膝关节活动度及稳定性 ,并利用膝关节屈曲90°的侧位X线片测量髌韧带长度。结果随访18例患者 ,17例术后膝关节存在触发性或功能性疼痛 ,膝关节疼痛常位于髌股关节、髌骨下极、髌韧带供区及胫骨结节部位。8例患者术后患膝活动度有不同程度受限。6例患者髌韧带发生不同程度的短缩 ,平均短缩2.8mm。4例患者髌股关节间隙变窄。两种术式以上并发症的发生率及严重程度差异无显著性意义。结论应用自体中1/3髌韧带重建前十字韧带不仅应注意疼痛等并发症的发生 ,还应关注髌韧带供区及髌股关节并发症的发生 ,重视其发病的病理基础。髌韧带中1/3缺损可引起髌韧带短缩及髌股关节退变。     

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,¹ and an objective failure rate of 13.7% has been reported for revision ACLR.² Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.     

Simultaneous ipsilateral tibial tuberosity and patellar fractures in an adult patient

We present the case of a 56-year-old man who sustained a tibial tuberosity fracture with an associated patellar fracture. In the adult population there are only a few documented cases of tibial tuberosity fractures. This is only the second recorded case of bifocal patella tendon avulsion. The patient was managed successfully by fixation of the tibial tuberosity alone as the patella fracture was undisplaced and the patella retinaculum intact. A key point was screening the patella fracture at time of fixation to aid this decision. We achieved a good outcome at one year with internal fixation and early mobilisation.     

Influence of the postoperative activity level on tibial bone tunnel enlargement and functional treatment results following anterior cruciate ligament reconstruction using a patellar tendon autograft

AIM: This study was performed to evaluate the influence of the postoperative activity level on tibial bone tunnel enlargement following anterior cruciate ligament reconstruction using a mid-third patellar tendon autograft. METHODS: A clinical and radiological assessment was performed on 50 patients (21 male, 29 female, mean age 32 years, range 18 to 57 years) following ACL reconstruction using a patellar tendon autograft. The average follow-up examination was performed 18 (12 to 30) months after the operation. RESULTS: 33 patients (66 %) developed a tibial bone tunnel enlargement > 1 mm. We found a positive correlation (+ 0.59) of the grade of activity and the muscle status (+ 0.56) to the tibial bone tunnel enlargement. Patients with a major tibial bone tunnel enlargement performed at a higher (p < 0.05) postoperative activity grade (5.2 versus 4.1 in the Tegner grading), rated higher in the Lysholm (88 versus 77 points) and IKDC scores (p < 0.05) and reported a better subjective functional outcome (p < 0.05). There was no significant correlation of the results of the knee stability tests and the age of the patients to the grade of tibial bone tunnel enlargement. CONCLUSIONS: In ACL reconstruction using a patellar tendon autograft we recommend early rehabilitation as the concomitant tibial bone tunnel enlargement does not significantly influence the clinical outcome or knee stability.     

Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts

The authors review the current knowledge on donor site–related problems after using different types of autografts for anterior cruciate ligament (ACL) reconstruction and make recommendations on minimizing late donor-site problems. Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for patients. The selection of graft, surgical technique, and rehabilitation program can affect the severity of pain that patients experience. The loss or disturbance of anterior sensitivity caused by intraoperative injury to the infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site discomfort and an inability to kneel and knee-walk. The patellar tendon at the donor site has significant clinical, radiographic, and histologic abnormalities 2 years after harvest of its central third. Donor-site discomfort correlates poorly with radiographic and histologic findings after the use of patellar tendon autografts. The use of hamstring tendon autografts appears to cause less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also appears to be a regrowth of the hamstring tendons within 2 years of the harvesting procedure. There is little known about the effect on the donor site of harvesting fascia lata and quadriceps tendon autografts. Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction using patellar tendon autografts. Reharvesting the patellar tendon cannot be recommended due to significant clinical, radiographic, and histologic abnormalities 2 years after harvesting its central third. It is important to regain full range of motion and strength after the use of any type of autograft to avoid future anterior knee problems. If randomized controlled trials show that the long-term laxity measurements following ACL reconstruction using hamstring tendon autografts are equal to those of patellar tendon autografts, we recommend the use of hamstring tendon autografts because there are fewer donor-site problems.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 971–980     

Arthroscopy-assisted anterior cruciate ligament reconstruction with patellar tendon or hamstring autografts

Isolated ACL reconstructions were performed in 138 patients between 1994 and 1998. Patellar bone-patellar tendon-bone, and hamstring tendon autografts were used in 88 patients, and allografts were used in 50 patients. Eighty-eight knees of 88 patients with autograft reconstructions (17 female, 71 male) were included in this study and evaluation of the patients with allograft reconstruction reported separately. The mean age at the time of the operation was 32 years. All ACL reconstructions were performed arthroscopically. Twenty-seven bone-patellar tendon-bone, and 61 hamstring tendon autografts were used. The mean follow-up was 29 months. In the postoperative course the Lachman test was negative in 62 patients, 1+ in 22 patients, and 2+ in 4 patients. In 17 patients, anterior drawer sign were 1+ in comparison to the contralateral side. Pivot shift test was moderately positive only in 5 cases in the bone-patellar tendon-bone and hamstring tendon autograft groups postoperatively. There were 3 patients with subjective "giving way" symptoms. Second look arthroscopy revealed rupture of the neo-ligament. Arthroscopic washout and debridement were performed, and no revision ligamentoplasties were performed. Two of these patients improved with accelerated proprioceptive physical therapy, and one had to decrease his previous level of activity. There were no cases of arthrofibrosis, infection, or extension lag. Clinical results of patellar bone-tendon-bone and hamstring groups did not show any significant clinical difference. Avoiding the disturbance of the extensor mechanism of the knee is probably the most significant advantage of the hamstring autograft.     

Model predictions of increased knee joint loading in regions of thinner articular cartilage after patellar tendon adhesion

Patellar tendon adhesion is a complication from anterior cruciate ligament (ACL) reconstruction that may affect patellofemoral and tibiofemoral biomechanics. A computational model was used to investigate the changes in knee joint mechanics due to patellar tendon adhesion under normal physiological loading during gait. The calculations showed that patellar tendon adhesion up to the level of the anterior tibial plateau led to patellar infera, increased patellar flexion, and increased anterior tibial translation. These kinematic changes were associated with increased patellar contact force, a distal shift in peak patellar contact pressure, a posterior shift in peak tibial contact pressure, and increased peak tangential contact sliding distance over one gait cycle (i.e., contact slip). Postadhesion, patellar and tibial contact locations corresponded to regions of thinner cartilage. The predicted distal shift in patellar contact was in contrast to other patellar infera studies. Average patellar and tibial cartilage pressure did not change significantly following patellar tendon adhesion; however, peak medial tibial pressure increased. These results suggest that changes in peak tibial cartilage pressure, contact slip, and the migration of contact to regions of thinner cartilage are associated with patellar tendon adhesion and may be responsible for initiating patellofemoral pain and knee joint structural damage observed following ACL reconstruction. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1168–1177, 2011     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. Bone patellar tendon-bone and the hamstring tendon generally have been used. In the present study, we describe an alternative graft, the quadriceps tendon-patellar bone autograft, by using arthroscopic ACL reconstruction. METHODS: From March of 1996 through March of 1997, a quadriceps tendon-patellar bone autograft was used in 12 patients with ACL injuries. RESULTS: After 15 to 24 months of follow-up, the clinical outcome for those patients with this graft have been encouraging. Ten patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. Recovery of quadriceps muscle strength to 80% of the normal knee was achieved in 11 patients in 1 year. CONCLUSION: The advantages of the quadriceps tendon graft include the following: the graft is larger and stronger than the patellar tendon; morbidity of harvest technique and donor site is less than that of patellar tendon graft; there is little quadriceps inhibition after quadriceps harvest; there is quicker return to sports activities with aggressive rehabilitation. A quadriceps tendon-patellar autograft is a reasonable alternative to ACL reconstruction in patients who are not suitable for either a bone-patellar tendon-bone autograft or a hamstring tendon autograft.     

带骨瓣的髌腱中1/3重建前交叉韧带

目的　评价带骨瓣的髌腱中 1/ 3重建前交叉韧带的效果。方法　 1994年 4月～ 1996年 8月 ,共利用带骨瓣的自体髌腱中 1/ 3重建前交叉韧带 8例。结果　 8例均获得 5个月～ 3年随访 ,平均 2 6个月。优 4例 ,良 3例 ,可 1例。术前 5例有明显膝关节不稳定感 ,术后均消失 ;术前 8例均存在 L anchman试验或 /和前抽屉试验阳性 ,术后有 1例呈前抽屉试验阳性 ;所有患者均能基本满足日常生活要求 ,1例仍残存膝关节疼痛。 3例术后存在不同程度的膝关节僵直 ,经过 CPM康复训练后膝关节屈伸活动度可达 0°～ 90°以上。结论　带骨瓣的髌腱中 1/ 3重建前交叉韧带是恢复膝关节功能的理想方法。     

Extensor mechanism reconstruction: a novel technique for bone patella allograft post partial patellectomy failure

Extensor mechanism disruption, whether due to patella fracture or tendon rupture, generally occurs after low-energy trauma and frequently involves an indirect mechanism. When the fracture is comminuted and reconstruction is impossible, a partial or total patellectomy may be indicated. Although some authors advocate total patellectomy, partial patellectomy remains the standard treatment, especially for young and active patients. In the rare instance of a failed tendon repair after partial or total patellectomy, inadequate tissue is usually available for adequate restoration of the extensor mechanism. Extensor mechanism allograft, using the tibial tuberosity, patellar tendon, patella, and quadriceps tendon in continuity or the Achilles' tendon with calcaneal bone-block in continuity has been reported for extensor mechanism repair after total knee arthroplasty in patients who did not undergo patellectomy. We present a novel technique, using the bone patellar tendon bone allograft to reconstruct a posttraumatic defect of the extensor mechanism in a 28-year-old, active patient with a failed partial patellectomy following fracture of his patella. Union of the allograft was seen on x-ray after 4 months. After 6 months, the patient reached full range of motion and returned to his previous sporting activities.     

Protecting a Patellar Ligament Reconstruction after Proximal Tibial Resection: A Simplified Approach

Limb salvage in tumor surgery has encouraged the development of megaprostheses. However, reattaching the ligamentum patellae poses a particular problem: avulsion and/or extensor lag may lead to poor function. We describe a new technique of patellar ligament reconstruction. The technique involves reattachment of the patellar ligament to the tibial tuberosity of the proximal tibial megaprosthesis, which has a porous surface created, and the repair is protected with a cerclage wire through the patella and the prosthesis. In 10 consecutive patients, the range of motion averaged 95 degrees (median, 90 degrees ; range, 70 degrees -120 degrees ), and the mean extension lag averaged 4 degrees (median, 0 degrees ; range, 0 degrees -20 degrees ). We had one case of patellar ligament avulsion. This technique resulted in good quadriceps function and a low incidence of complications. LEVEL OF EVIDENCE: Level IV, therapeutic study.     

Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons,bone patellar tendon,or quadriceps tendon-graft with press-fit fixation without hardware. A new and innovative procedure

BONE--PATELLAR TENDON: The "no hardware" technique for ACL reconstruction is a new method that offers many advantages and is straightforward to perform. Its main innovative feature is that it does not require bone-block harvesting from the patella. This reduces donor site morbidity and prevents patellar fractures. The bone tunnels are made using tube harvesters and compaction drilling. This minimizes trauma and obviates the risk of bone necrosis. The articular entrance of the tibial tunnel is completely occupied by the grafts. This prevents a windshield-wiper effect and synovial fluid ingress into the tunnel, and enhances graft incorporation. The fact that no hardware is used with both patellar tendon or hamstring grafts significantly reduces the overall cost of the operation and facilitates revision surgery. The quadriceps tendon is also a very good graft. It is thick and has good biomechanical properties and low donor site morbidity. Its disadvantages are: weakness of quadriceps after the operation, an unsightly scar, and some difficulty in graft harvesting [58]. Also, postoperative MRI is not fraught with the problem of metal artifacts. It is difficult to decide which of the methods currently available for ACL reconstruction is the best because most of them give satisfactory results. In the future, assessments of knee ligament reconstruction techniques should look at long-term stability combined with low complication rates. Ease of revision surgery and low cost should also be taken into consideration, given the large annual volume of knee ligament reconstructions (50,000 in the United States alone) [59]. We believe that our technique addresses most of these issues, and that it constitutes a useful alternative method for ACL reconstruction. SEMITENDINOSUS--GRACILIS: This technique, which was used with 915 patients from June 1998 to February 2002, shows a particularly low rate of postoperative morbidity. The reason is probably to be found in the "waterproofing" of the bone tunnels, which lead to less postoperative bleeding and swelling. No drains were used. Rehabilitation follows the same protocol as used for the reconstruction using patellar tendon grafts (accelerated/functional). As expected, there was no widening of the femoral tunnels and little widening of the tibial tunnels. Interestingly, tibial tunnel enlargement was significantly less in a nonaccelarated rehabilitation group than in the accelerated group [60] without affecting stability. The measured internal torque of the hamstrings, as well as their flexion force, already had returned to normal 12 months postoperatively. In a prospective randomized (unpublished) study comparing this technique with ACL reconstruction with BPT grafts with medial or lateral third with only one bone plug (from the tibial tuberosity, see technique described above), we found no significant difference between both groups in subjective scores, stability, KT-1000 values, Tegner activity score, and IKDC at 1-year follow-up. Only the results of kneeling and knee walking testing were significantly better in the hamstring group [61]. In summary, the advantages of this presented technique are: (1) the knot of the graft is close proximally to the anatomic site of the insertion of the ACL, thus avoiding the Bungee effect.; (2) the press-fit tunnel fixation prevents synovial fluid entering the bone tunnels, windshield-wiper effect, and longitudinal motion within the tunnel; the intensive contact between the bony wall of the tunnel and graft collagen over a long distance without any suture material results in quick and complete graft incorporation; and (3) no fixation material means no hardware problems, facilitates revision surgery, and lowers overall costs.     

Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty

BACKGROUND: Rupture of the patellar tendon after total knee arthroplasty is a rare and debilitating complication. Proper surgical management of this condition remains controversial. The purpose of this study was to review the results of reconstruction of a ruptured patellar tendon with an Achilles tendon allograft following total knee arthroplasty. METHODS: We reviewed our experience with the use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to restore extensor function in nine patients with patellar tendon rupture following total knee arthroplasty (five primary and four revision). All patients were examined clinically and radiographically at an average of twenty-eight months. RESULTS: The average knee and functional scores improved from 26 and 14 points, respectively, before the surgery to 81 and 53 points after the surgery. The average extensor lag decreased from 44 degrees preoperatively to 3 degrees postoperatively, and the average range of motion of the knee increased from 88 degrees to 107 degrees. Two grafts failed in the early postoperative period. Both were repaired successfully. Radiographs showed an average proximal patellar migration of 17.8 mm, which did not appear to affect extensor function. CONCLUSIONS: This short-term follow-up study showed that once an Achilles allograft has healed, it can serve as a reliable reconstruction of a ruptured patellar tendon following total knee arthroplasty. This technique may be particularly suited for patients in whom the extensor mechanism was compromised by multiple prior operations. Continued follow-up is necessary to determine the long-term durability of these results.     

Bollen's jig and anterior cruciate ligament reconstruction

We report the design of a surgical instrument that facilitates the harvest of the autologous patellar tendon in anterior cruciate ligament (ACL) reconstruction. The advantage of this jig is that it is a simple, self-centring device resulting in a reproducible and consistent autograft. Its use also minimises the potential risks of donor site morbidity such as patellar fracture and tendon rupture. We briefly describe our technique and discuss its advantages.