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.     

Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft

Purpose

The purpose of this study was to compare the outcomes of arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using autologous patellar tendon and hamstring tendon grafts.

Methods

From 1998 to 2007, 59 patients with symptomatic isolated posterior cruciate ligament injury were included in this retrospective study. Twenty-five knees were reconstructed using bone-patellar tendon-bone graft, and 34 knees were reconstructed using hamstring graft. In both groups, surgical techniques were similar, except material of fixation screws. Patients were evaluated pre-operatively and post-operatively at the latest follow-up with several parameters, including symptoms, physical examination, outcome satisfaction, functional scores, radiography and complications.

Results

Average follow-up period was 51.6 months in patellar tendon group and 51.1 months in hamstring tendon group. Significantly more kneeling pain (32 vs. 3 %), squatting pain (24 vs. 3 %), anterior knee pain (36 vs. 3 %), posterior drawer laxity and osteoarthritic change were shown in patellar tendon group than in hamstring tendon group post-operatively. No significant differences were found in other parameters between both groups.

Conclusions

Several shortcomings, including anterior knee pain, squatting pain, kneeling pain and osteoarthritic change, have to be concerned when using patellar tendon autograft. In conclusion, hamstring tendon autograft may be a better choice for transtibial tunnel PCL reconstruction.     

Hip abductor tendinitis after ACL reconstruction with patellar tendon graft in soccer players. A new clinical complication

Although ACL reconstruction remains a complex procedure with possible complications, affecting mainly the knee function, but no complications affecting the hip function have been already mentioned in the literature. Here in, we discuss the demographics, clinical course and outcomes of a rare complication such as hip abductors tendinitis, developed in soccer amateur athletes after ACL reconstruction with patellar tendon graft.     

Primary ACL reconstruction with fresh-frozen patellar versus Achilles tendon allografts

BACKGROUND: In recent years, there has been an interest in the use of allografts as an alternative graft for anterior cruciate ligament (ACL) reconstruction to reduce potential donor-site morbidity resulting from the harvest of autogenous tissue. Nevertheless, in the literature, the use of allografts for primary ACL reconstruction is controversial due to a higher failure rate and the potential risk of disease transmission. METHOD: In this retrospective study, we evaluated the clinical outcome of 251 fresh-frozen patellar vs Achilles tendon allografts for primary ACL reconstruction. Patients (average age 39 years) were operated on between 1993 and 1998, and the mean follow-up was 37.7 months (range 24-74 months). We were able to follow up 225 patients (89.6%). According to the different types of allograft, we divided the patients into two groups: group P with patellar bone-tendon-bone allograft (BTB; n=183) and group A with Achilles bone-tendon allograft ( n=42). Clinical evaluation consisted of a history, an examination, IKDC Score, Cincinnati Knee Score (CKS), Cincinnati Sports Activity Scale (CSAS), KT-1000 testing, and standardized X-rays. RESULTS: According to the IKDC, the outcome was normal or nearly normal in 75.3% in group P and 76.2% in group A. Overall rating according to the CKS was an average of 85 in group P and 82.9 in group A. CSAS was 79.6 in group P and 84.8 in group A. The objective stability measured with the KT-1000 showed an average side-to-side difference of 2.1 mm in group P and 2.0 mm in group A. 4.4% of group P and 2.5% of group A were considered a laxity failure, and 10.4% of group P and 4.8% of group A re-ruptured the reconstructed ACL. In summary, there was a significantly higher failure rate ( p<0.001) in group P compared with group A. CONCLUSION: Satisfactory clinical results can be achieved with the use of allografts for primary ACL reconstruction. Comparing Achilles tendon and patellar BTB allografts, the Achilles tendon-bone allograft seems to be advantageous for ACL reconstruction as the failure rate was significantly lower. Nevertheless, the total failure rate appears to be much higher compared with autogenous ACL reconstruction, indicating that the use of an allograft for routine uncomplicated primary ACL reconstruction offers few advantages. Therefore, autograft tissue remains our graft of first choice for this procedure. We advise reserving allografts for revision procedures where suitable autogenous tissues have been previously compromised, where a contraindication for autogenous tissue harvest exists, or for multiple ligament surgery.     

Mechanoreceptors of patellar tendon used for ACL reconstruction: Rabbit experiments

In 17 Japanese white rabbits (weighing 2.6-3.7kg), the anterior cruciate ligament of the right knee was resected and then reconstructed, using the lateral half of the patellar tendon. The contralateral side served as control. Rabbits were killed 10, 20, or 30 weeks postoperatively. Then the reconstructed ligament was harvested and stained, using a modified gold chloride method. Under the light microscope, sensory nerve endings in serial sections were counted after being morphologically identified.

With respect to the number of Pacinian and Ruffini corpuscles, there were no significant differences between the reconstructed ligament and the control patellar tendon at any time after surgery.     

Evaluation of bone incorporation of patellar tendon autografts and allografts for ACL reconstruction using CT

Anterior cruciate ligament (ACL) reconstruction is a relatively common orthopedic procedure, with patellar tendon frequently a graft source. However, controversy exists regarding the decision to use autograft or allograft patellar tendon tissue. This experimental study used computed tomography (CT) to compare the percentage of bone graft incorporation following ACL reconstruction using autografts and allografts. Fifty consecutive patients undergoing ACL reconstruction were included in the study. The tibial bone plug was imaged with CT 1 week, 2 months, and 5 months postoperatively. Four images from each completed scan were analyzed for percentage of incorporation of the bone graft. The results of autograft and allograft incorporation for each of the time intervals were compared. No statistically significant difference was found in the amount of bone incorporation at the tibial bone plug 1 week, 2 months, and 5 months. Clinical concerns regarding slower or less complete healing of allograft bone tissue compared to autograft are not supported with regard to the grafts studied.     

Femoral fixation of patellar tendon grafts using the bone-block locking technique in ACL reconstruction. A biomechanical study.

Anterior cruciate ligament (ACL) reconstruction relies on the security of graft fixation. K-wire fixation, heavy non-absorbable sutures tied to a screw staple post or endo-button are currently used for graft fixation. Kurosaka screw fixation may cause rupture of the graft due to excessive stress at the screw-graft interface in the femoral tunnel. To avoid inherent complications, a new bone-tendon-bone graft fixation technique for ACL reconstruction is described and biomechanically compared with the classical interference screw fixation in sheep knee models. A total of 13 pairs of fresh sheep knee specimens, obtained from a local slaughterhouse, were used in this study. Sheep knee specimens (n = 13) were divided into two groups. The right knees were Group I and the left knees were Group II. The right knees in Group I received interference screw systems and the left knees in Group II received the Bone Block Locking system (BBL). The average maximum load was found to be 275.01 +/- 10.75 N for the interference screw system and 389.92 +/- 7.54 N for the BBL system (p = 0.02). Our results indicate that the BBL technique allows a more secure fixation than interference screw fixation. The complications and technical pitfalls of interference screw fixation are not seen in BBL technique. We believe that the BBL technique is more advantageous in comparison to other fixation systems.     

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。     

A comparison of autogenous patellar tendon and hamstring tendon grafts for anterior cruciate ligament reconstruction

Several graft options exist for reconstruction of the deficient ACL. The most commonly used grafts are the BPTB and quadrupled hamstring tendon autografts. Based on a comprehensive review of the literature, one graft is not superior to the other. Advantages and disadvantages are associated with the use of each graft. Surgeons who perform ACL reconstruction should be familiar with the use of both grafts.     

Anterior cruciate ligament reconstruction using part of the patellar tendon as a free graft

We have reviewed 40 patients after replacement of a ruptured anterior cruciate ligament with a free graft of the medial third of the patellar tendon, combining this in 17 of the cases with a MacIntosh extra-articular tenodesis. The average age of the patients at operation was 25.4 years; instability of the knee had been present for 1.5 to 9 years, and the mean follow-up was 2.9 years. The results, assessed on subjective stability, were good in 29 patients, over half being able to return to their original sport, and fair in eight. The technique of operation for free patellar tendon grafting is described in detail and the indications for this and for an additional MacIntosh tenodesis are discussed.     

Acromioclavicular reconstruction using autogenous semitendinosus tendon graft: results of revision surgery in chronic cases

Revision surgery of acromioclavicular dislocation is challenging owing to the altered anatomic relationships and the lack of stabilizing structures. In this study, an autogenous semitendinosus tendon graft was used for revision acromioclavicular stabilization, aiming at anatomic coracoclavicular reconstruction, as these patients had previously undergone a Weaver-Dunn procedure, which failed. Twelve patients were followed up clinically and radiographically for a mean of 49.5 months. The primary diagnosis was acromioclavicular joint dislocation Rockwood type III in 6, type IV in 4, and type V in 2 cases. At follow-up, the mean Constant score averaged 76.4 points. Pain relief was statistically significant (P < .01). Radiologic coracoclavicular distance and posterior displacement of the lateral clavicle in the Rockwood type IV cases decreased significantly (P < .01). We conclude that with this new technique of autogenous semitendinosus tendon graft replicating the anatomic ligamentous properties, good to excellent results can be achieved in revision cases of acromioclavicular reconstruction.     

关节镜下中1/3髌腱移植重建膝后十字韧带

目的关节镜下应用中1/3髌腱移植重建后十字韧带,评估其近期临床治疗效果。方法采用骨-中1/3髌腱-骨组织移植重建膝关节后十字韧带,用于治疗后十字韧带损伤后关节不稳定。手术在关节镜下经前方入路完成。结果12例患者平均随访17.3个月。Larson评分由术前60.7分提高到93.4分,Lysholm评分由术前55.0分提高到91.6分。所有患膝术前后抽屉试验及Lachman试验均阳性,术后仅2例后抽屉试验弱阳性、1例Lachman试验弱阳性。结论在关节镜直视下,能准确定位后十字韧带解剖止点,钻制骨隧道,植入移植组织。该技术具有不切开关节囊,损伤小、关节粘连率低的优点。     

Arthroscopic-assisted posterior cruciate ligament reconstruction using patellar tendon autograft: a technique for graft passage

During arthroscopic posterior cruciate ligament (PCL) reconstruction, passage of the graft into the knee joint may be difficult, especially when using the patellar tendon. Because of the angle of passage, the bone block ends may become entangled or caught on the superior edge of the posterior tibial tunnel when passing the graft from the tibia to the femur. The use of a blunt trocar through the posteromedial portal avoids impingement of the bone block against the edge of the tibial tunnel. This method uses the pulley principle and permits the graft to pass freely into the knee. This method has been used successfully by the authors in more than 40 PCL arthroscopic reconstructions.