Implant-free press-fit fixation for bone–patellar tendon–bone ACL reconstruction: 10-year results

Objective

The aim of this study is to determine the outcome of anterior cruciate ligament (ACL) reconstruction without foreign material with patellar tendon bone graft in the fixation with bone dowels near the native insertion.

Materials and methods

Between 1998 and 1999, 189 patients were operated with ACL reconstruction with BTB patellar tendon graft. In a prospective study, 148 (78%) (91M, 57F) patients could be seen for a mean follow-up of 10.3 years. All had foreign material-free press-fit and a bottom-to-top (BTT) fixation in 120° knee flexion. All patients were evaluated with detailed history, clinical examinations, radiographic examination with weight bearing which could be compared to the time of surgery in 64 (43%) patients. Laxity testing was performed in Lachman position with the Rolimeter and pivot shift. All patients were graded according to the IKDC and Tegner activity score.

Results

87% of the patients achieved an IKDC score of A/B. The subjective IKDC score was A/B in 94.6% of the subjects. The average side-to-side difference was 1.42 ± 0.88 mm for the Lachman test, 97% of the patients were rated between 0 and 2 mm. The pivot-shift test was negative in 90% and was observed with a glide in 7% of the patients. Radiological joint space narrowing was found in the medial compartment in 8 (12.4%) cases, and laterally in 9 (14.1%) cases. All these patients had partial or total meniscus resections. The patello-femoral joint space was reduced in 21 (23%) cases. The Tegner activity score changed from 6.9 pre-injury to 5.0 at the 10-year follow-up.

Conclusion

The implant-free fixation of the graft with bone dowels and BTT implantation has good and excellent results after 10 years in more than 80% of the patients. Loss of the meniscus is a main factor contributing to osteoarthritis. Advantages of patellar tendon bone press-fit fixation include anatomical positioning and fast bone-to-bone healing, ease for revision surgery and cost effectiveness.     

Lateral collateral ligament reconstruction using quadriceps tendon–patellar bone autograft with bioscrew fixation

The lateral collateral ligament is the primary stabilizer against varus stress and is also an important contributor in maintaining posterolateral knee stability. Quadriceps tendon–patellar bone autograft has been used for anterior or posterior cruciate ligament reconstruction. We introduce a reconstructive procedure to restore the lateral collateral ligament using a quadriceps tendon–patellar bone autograft. The procedure is designed for unstable knees with concomitant cruciate ligament tear and posterolateral complex injury. This is a reasonable choice especially when allograft tissue is not available or in patients who are not suited for the use of bone–patellar tendon–bone autograft.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 551–554     

One-incision endoscopic technique for posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Quadriceps tendon–patellar bone autograft is an alternative graft choice for posterior cruciate ligament (PCL) reconstruction. A 2-incision technique with outside-in fixation at the femoral condyle is generally used. In this article, we describe a 1-incision endoscopic technique for PCL reconstruction with quadriceps tendon–patellar bone autograft. The graft consists of a proximal patellar bone plug and central quadriceps tendon. The bone plug is trapezoidal, 20 mm long, 10 mm wide, and 8 mm thick. The tendon portion is 80 mm long, 10 mm wide, and 6 mm thick, including the full-thickness of the rectus femoris and partial thickness of the vastus intermedius. Three arthroscopic portals, including anteromedial, anterolateral, and posteromedial, are used. All procedures are performed in an endoscopic manner with only 1 incision at the proximal tibia. At the femoral side, the bone plug is fixed by an interference screw. At the tibial side, the tendon portion is fixed by a suture to a screw on the anterior cortex and an interference bioscrew in the posterior tibial tunnel opening. Quadriceps tendon autograft has the advantages of being self-available, allowing for easier arthroscopic technique, and providing comparable graft size. The 1-incision technique provides a simple reconstruction method for PCL insufficiency without a second incision at the medial femoral condyle.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 329–332     

Arthroscopic posterior cruciate ligament reconstruction by using hamstring tendon autograft and transosseous screw fixation: minimal 3 years follow-up

Background

The aim of this trial is to prospectively evaluate the outcomes of PCL reconstruction by means of quadruple hamstring tendon autograft with a double-fixation method at minimal 3-year follow-up.

Materials and methods

Only patients who underwent PCL reconstruction without any other concomitant injury were included in this study. A hamstring tendon graft is composed of a quadruple-stranded gracilis tendon and semitendinosus tendon about 10 cm in length. An arthroscopic technique via a two incision and a double-fixation method was applied. Clinical evaluations were performed for 52 patients. Clinical assessment of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle evaluation, and radiographic investigation.

Results

On the Lysholm knee score, 90 % of the patients displayed good or excellent rating in the final assessment. In the IKDC rating analyses, 60 % of the patients demonstrated 3–5-mm ligament laxity. For the IKDC final rating, 81 % were normal or nearly normal. Seventy-nine percent of the cases revealed less than a 10-mm difference in thigh girth between their reconstructed and contra lateral limbs.

Conclusion

Arthroscopic PCL reconstruction using quadruple hamstring tendon autograft provides acceptable outcomes at a minimum 3-year follow-up. The four-stranded hamstring tendon graft is suitable in graft size and results in minimal harvesting morbidity. We recommend that quadruple hamstring tendon graft be chosen for PCL reconstruction to achieve good ligament reconstruction. A double-fixation method which has been applied in this trial can be used to provide rigid fixation.     

Arthroscopic double-bundled posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Summary: An arthroscopic technique for double-bundled reconstruction for posterior cruciate ligament with quadriceps tendon–patellar bone autograft is presented. Anterolateral and posteromedial tunnels were created to simulate and reproduce the double-bundle structure of the posterior cruciate ligament. The bone plug is situated at the tibial tunnel and fixed by a titanium interference screw. Each of the bundles of tendon graft is rigidly fixed at the femoral tunnel with a bioabsorbable screw.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 780–782     

Bone–patellar tendon–bone autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction

The optimized graft for use in anterior cruciate ligament (ACL) reconstruction is still in controversy. The bone–patellar tendon–bone (BPTB) autograft has been accepted as the gold standard for ACL reconstruction. However, donor site morbidities cannot be avoided after this treatment. The artificial ligament of ligament advanced reinforcement system (LARS) has been recommended for ACL reconstruction. The purpose of this study is to compare the midterm outcome of ACL reconstruction using BPTB autografts or LARS ligaments. Between July 2004 and March 2006, the ACL reconstruction using BPTB autografts in 30 patients and LARS ligaments in 32 patients was performed. All patients were followed up for at least 4 years and evaluated using the Lysholm knee score, Tegner score, International Knee Documentation Committee (IKDC) score, and KT-1000 arthrometer test. There were no significant differences between the two groups with respect to the data of Lysholm scores, Tegner scores, IKDC scores, and KT-1000 arthrometer test at the latest follow-up. Our study demonstrates that the similarly good clinical results are obtained after ACL reconstruction using BPTB autografts or LARS ligaments at midterm follow-up. In addition to BPTB autografts, the LARS ligament may be a satisfactory treatment option for ACL rupture.     

Does bone impaction technique reduce tunnel enlargement in ACL reconstruction?

The aim of this study was to investigate effects of bone impaction technique on tunnel enlargement after ACL reconstruction at a minimum 2 years follow-up. Two groups of patients who had been operated upon with the same arthroscopic technique with the exception of tibial tunnel constitution were compared. Twenty-one patients of group A (drilling to 6 mm followed enlargement to 8–9 mm by using dilators) and 23 patients of group B (directly drilling to the size of the graft) were evaluated clinically and radiographically based on multislice computerised tomography (MSCT) retrospectively. At follow-up, there was no statistical difference between tunnel diameters between two groups at the femoral site, but significant difference at the tibial site (p = 0.00192 for coronal; p = 0.0171 for sagittal diameter). Both groups were comparable according pre- and postoperative Lysholm and IKDC scores (p < 0.5 Mann-Whitney U test). Compacted tunnel walls may resist enlargement, suggesting this technique resulted in better tunnel diameter values especially with intratunnel fixation.

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Résumé  Le but de cette étude est d’analyser à 2 ans de recul les effets de la greffe osseuse impactée sur l’élargissement du tunnel, lors de la réfection du LCA. Deux groupes de patients ont été opérés par la même technique arthroscopique, nous avons comparé ces deux groupes. 21 patients du groupe A et 23 patients du groupe B ont été évalués cliniquement, radiographiquement et au scanner, cette analyse a été faite rétrospectivement. Dans le groupe A le tunnel a été foré avec une largeur de 8.57 mm et le groupe B de 8.73 mm (8–9 mm). Au suivi, il n’y a pas de différence de taille de tunnel entre ces deux groupes au niveau fémoral, par contre, il existe une différence significative au niveau tibial (p = 0.00192 pour le diamètre coronal et p = 0.0171 pour le diamètre saggital), ces deux groupes sont comparables, cliniquement en ce qui concerne les scores pré et post opératoire de Lysholm et de l’IKDC (p < 0.5 Mann-Whitney U test). La technique du tunnel avec os compacté permet de résister à la tendance à l’élargissement de celui-ci.

     

Is bone tunnel osseointegration in hamstring tendon autograft anterior cruciate ligament reconstruction important?

A 27-year-old man underwent anterior cruciate ligament (ACL) reconstruction using 4-strand hamstring autograft with femoral and tibial interference screw fixation. Four weeks after surgery, he developed a discharging hematoma through the graft harvest-tibial tunnel incision, which persisted. The patient required further surgical intervention 7 weeks after the initial surgery. The wound was debrided, the tibial interference screw was removed, and the tibial tunnel was completely cleared of graft remnants. Arthroscopy of the knee was performed, in which the ACL graft appeared healthy and viable. No evidence of intra-articular sepsis was found. Postoperatively, the rehabilitation program was uneventful and, at 36 months, the patient has unrestricted activity and no clinical evidence of excessive ACL laxity. This case supports the importance of marginal articular surface healing of the ACL graft, suggesting that tibial intratunnel healing becomes redundant.     

Biomechanical testing of quadriceps tendon–patellar bone grafts: an alternative graft source for press-fit anterior cruciate ligament reconstruction?

Introduction: Press-fit fixation of bone-patellar tendon–bone (BPTB) grafts in anterior cruciate ligament (ACL) reconstruction has been analyzed biomechanically in previous studies; however, the use of quadriceps tendon–patellar bone (QTPB) grafts has not been studied so far. It is hypothesized that QTPB grafts provide primary fixation strength comparable to BPTB grafts in press-fit ACL reconstruction with respect to bone plug length and loading angle. Materials and methods: Fifty-two QTPB grafts were harvested from fresh human cadaver knees (mean age 73.3 years) with the length of the patellar bone plug being either 15 mm (Group I) or 25 mm (Group II). The grafts were anchored within fresh porcine femora (mean age 12 months) using a press-fit fixation technique. Forty-eight specimens were loaded to failure at 10 mm/s with varying loading angles of 0°, 30°, and 60° until failure. A microradiographic pre–post-implantation analysis was conducted on four grafts. Results: The biomechanical testing showed a significant difference in the ultimate failure loads comparing Group I (mean 224±79.3 N) to Group II (mean 339±61.4 N), both showing mean ultimate failure loads to increase with rising loading angle. The predominant mode of failure was graft pullout at axial loading and tendon rupture at 60° loading angle. The microradiographic analysis revealed an iatrogenic damage of the bone–tendon junction on the cancellous aspect of the bone plug in all trials, corresponding with the site of impactor placement during implantation. Conclusion: QTPB grafts provide a loading capability comparable to BPTB grafts in press-fit ACL reconstruction. The broad and profound area of quadriceps tendon attachment to the patellar bone plug makes graft implantation demanding.     

Patellar tendon rupture 3 years after anterior cruciate ligament reconstruction with a central one third bone–patellar tendon–bone graft

Use of the central one third bone–patellar tendon–bone autograft is an accepted technique for anterior cruciate ligament (ACL) reconstruction. Patellar tendon rupture following ACL reconstruction is an acknowledged, although rarely reported, complication of this procedure. Of the limited patellar tendon rupture cases reported in the literature, most are described early in the postoperative period. We present a case of late patellar tendon rupture more than 3 years after uneventful ACL reconstruction in a 32-year-old man.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 648–652     

Does harvesting the medial third of the patellar tendon cause lateral shift of the patella after ACL reconstruction?

Many centers do not use the medial third of the patellar tendon as a graft for ACL reconstruction due to the apprehension that there may be post harvest maltracking of the patella towards the lateral side. We undertook a prospective study to evaluate patellar alignment in 30 patients in whom ACL reconstruction was done using the medial third of the patellar tendon. Q-angle assessment was the rough clinical parameter, and the Merchant view, Laurin views, and CT scans were used for radiological assessment. The assessment was done preoperatively and at six months post surgery, and the contralateral normal knees were used as controls. We observed no significant changes in the congruence angle (pre-op -13.86 degrees, postop -12 degrees) or the lateral patellofemoral angles in the pre-operative and postoperative knees as compared to the controls. CT scans were more sensitive for evaluating the congruence angles, and picked up an insignificant abnormal lateralisation of the patella in four cases. None of these patients however had any postoperative symptoms of misalignment. Although medial third graft harvesting did have a 13% change in patellar alignment, this was not statistically significant. Post harvesting local problems are inherent to the procedure, and are independent of the site of harvesting, as they were also seen in cases with no evidence of misalignment.     

Proprioceptive skills and functional outcome after anterior cruciate ligament reconstruction with a bone–tendon–bone graft

Several studies have shown that patients with anterior cruciate ligament (ACL) reconstruction have an improved proprioceptive function compared to subjects with ACL-deficient knees. The measurement of functional scores and proprioception potentially provides clinicians with more information on the status of the ACL-reconstructed knees. To evaluate proprioception in patients following ACL reconstruction with a bone–tendon–bone (BTB) graft, we used the angle reproduction in the sitting, lying and standing positions and the one-leg hop test. Forty-five patients between 19 and 52 years of age were investigated in a 36-month period after the operation. For functional performance measurement, the International Knee Documentation Committee (IKDC) score was used. Very good and good results were seen in 95% of cases. All patients returned to the same activity level as seen before ACL repair. There was a significant difference in the active angle reproduction test between the ACL-reconstructed knees and normal knees in the active sitting position. Tests with passive angle adjustment in the sitting, lying and active standing positions did not show any differences in proprioceptive skills. Good to very good results in the one-leg hop test we found in 95% of patients. After ACL reconstruction, deficiencies in the active angle reproduction test were very small but, nevertheless, were still observed. Overall, the functional and proprioceptive outcomes demonstrate results to recommend the procedure.

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Résumé  Plusieurs études ont montré que des patients ayant bénéficié d’une reconstruction du ligament croisé antérieur ont été améliorés sur le plan de la fonction proprioceptive surtout si on compare les sujets à des sujets non traités gardant un déficit au niveau du ligament croisé antérieur. La mesure des différents scores, fonction et proprioception, donne un certain nombre d’informations sur ces genoux qui ont été opérés. Nous avons évalué la proprioception de patients opérés par greffes du ligament croisé antérieur par un greffon de type BTB et évalué cette proprioception en position assise, debout, en appui monopodal et après tests de sauts.45 patients entre 19 et 52 ans ont été analysés sur une période de 36 mois après l’intervention chirurgicale. Le score IKDC a également été mesuré. Les résultats ont été considérés comme très bons dans 95% des cas. Les patients ont repris une activité au même niveau que celle qu’ils avaient avant la réparation. Il n’y a pas de différences significatives entre les genoux reconstruits et le genou normal, notamment en ce qui concerne les tests en positions assises. Un très bon résultat des tests de sauts est retrouvé chez 95% des patients. On peut considérer après reconstruction du ligament croisé antérieur, que la récupération fonctionnelle et proprioceptive est excellente et confirme la nécessité de reconstruire les ligaments après rupture.

     

In–out versus out–in technique for ACL reconstruction: a prospective clinical and radiological comparison

Background

Several studies have recently shown better restoration of normal knee kinematics and improvement of rotator knee stability after reconstruction with higher femoral tunnel obliquity. The aim of this study is to evaluate tunnel obliquity, length, and posterior wall blowout in single-bundle anterior cruciate ligament (ACL) reconstruction, comparing the transtibial (TT) technique and the out–in (OI) technique.

Materials and methods

Forty consecutive patients operated on for ACL reconstruction with hamstrings were randomly divided into two groups: group A underwent a TT technique, while group B underwent an OI technique. At mean follow-up of 10 months, clinical results and obliquity, length, and posterior wall blowout of femoral tunnels in sagittal and coronal planes using computed tomography (CT) scan were assessed.

Results

In sagittal plane, femoral tunnel obliquity was 38.6 ± 10.2° in group A and 36.6 ± 11.8° in group B (p = 0.63). In coronal plane, femoral tunnel obliquity was 57.8 ± 5.8° in group A and 35.8 ± 8.2° in group B (p = 0.009). Mean tunnel length was 40.3 ± 1.2 mm in group A and 32.9 ± 2.3 mm in group B (p = 0.01). No cases of posterior wall compromise were observed in any patient of either group. Clinical results were not significantly different between the two groups.

Conclusions

The OI technique provides greater obliquity of the femoral tunnel in coronal plane, along with satisfactory length of the tunnel and lack of posterior wall compromise.

Level of evidence

II, prospective study.

     

Is screw divergence in femoral bone-tendon-bone graft fixation avoidable in anterior cruciate ligament reconstruction using a single-incision technique? A radiographically controlled cadaver study

Summary: Interference screw fixation of patellar tendon bone-tendon-bone grafts for anterior cruciate ligament reconstruction has proven to be a method with high pullout strength if screw divergence is avoided. Twenty-four fresh-frozen cadaveric human knees were used to identify the ideal position for a portal and an optimal knee flexion angle to obtain parallel placement of screw and bone block. On all specimens, anterior cruciate ligament reconstruction was performed using a single-incision technique. In the first part of this study, screw placement was analyzed in the frontal plane. In the second part, screw placement was investigated in the sagittal plane, measuring the additional flexion required between femoral tunnel drilling (at 60° of knee flexion) and screw insertion to obtain parallel screw placement. For both part I and II, image intensification was used. In the third part, femoral screw placement was carried out through a paraligamentous approach and with additional flexion of 10°, 20°, 30°, 40°, 50°, and 60°. This study shows that screw placement with minimal divergence in the frontal and sagittal planes can be achieved by inserting the screw through a nearly central portal and flexing the knee an additional 35° to 40°.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 640–647     

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone–patellar tendon–bone graft. Part 1: Morphological change in the tibial tunnel

BackgroundThree-dimensional (3D) computed tomography (CT) is reliable and accurate imaging modality for evaluating tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the tibial tunnel enlargement including the morphological change after anatomic ACL reconstruction with a bone–patellar tendon–bone (BTB) graft using 3D CT models.MethodsEighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture and 5, 10, and 15-mm distal from the aperture. The CSA was measured at 3 weeks and 1 year after surgery and compared between the two time points. The locations of the center and the anterior, posterior, medial, and lateral edges of the tunnel footprint were also evaluated based on the coordinate system for the tibial plateau and compared between the two time points.ResultsAt the aperture, the CSA of the tibial tunnel at 1 year after surgery was significantly larger by 21.9% than that at 3 weeks (P < 0.001). In contrast, the CSA at 1 year was significantly smaller than that at 3 weeks at 10 and 15-mm distal from the aperture (P = 0.041 and < 0.001, respectively). The center of the tunnel footprint significantly shifted postero-laterally with significant posterior shift of the anterior/posterior edges and lateral shift of the lateral edge (P < 0.001).ConclusionThe tibial tunnel enlarged at the aperture by 22% 1-year after anatomic ACL reconstruction with a BTB graft, and the tunnel morphology changed in a postero-lateral direction at the aperture and into conical shape inside the tunnel.     

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone–patellar tendon–bone graft. Part 2: Factors related to the tibial tunnel enlargement

BackgroundFactors related to tunnel enlargement after anterior cruciate ligament (ACL) reconstruction should be evaluated by multivariate analysis, because the phenomenon has multifactorial characteristics. The purpose of this study was to elucidate the factors related to the tibial tunnel enlargement rate after anatomic ACL reconstruction with a bone–patellar tendon–bone (BTB) graft using multivariate analysis.MethodsEighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture. The CSA was measured at 3 weeks and 1 year after surgery, and the tunnel enlargement rate at the aperture was calculated. Multiple linear regression analysis was performed to detect the significantly related factors to the tibial tunnel enlargement rate at the aperture among potential factors consisting of preoperative demographic factors and predisposing factors with the tibial tunnel.ResultsThe tibial tunnel enlargement rate at the aperture was 21.9 ± 14.1% (mean ± standard deviation). Multiple linear regression analysis detected the tendon length inside the tunnel as a significantly independent factor related to the tibial tunnel enlargement rate at the aperture (standardized β = 0.726, P = 0.008). There was no significant relationship between the tibial tunnel enlargement rate at the aperture and postoperative side-to-side difference (SSD) of the anterior knee laxity or Tegner activity level scale under single linear regression analysis.ConclusionThe greater tendon length inside the tunnel was independently related to the higher tibial tunnel enlargement rate at the aperture 1-year after anatomic ACL reconstruction with a BTB graft under multiple linear regression analysis.