Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft

We studied 58 knees that underwent anterior cruciate ligament (ACL) reconstruction using a patella tendon autograft. The mean age at reconstruction was 30.4 (18–58) years, and the average follow-up was 11.2 (8.6–13.8) years. The presence of osteoarthritis was assessed radiographically using Kellgren and Lawrence’s classification. Osteoarthritis was detected in the medial compartment in 25 cases and in the lateral compartment in 14 cases. Significant independent predictors of osteoarthritis were: accompanying meniscal injury [odds ratio (OR) 9.19), p<0.001], an interval of more than 6 months from injury to reconstruction (OR 4.77, p=0.021), and age more than 25 years at reconstruction (OR 3.37, p=0.034). However, no statistically significant correlation was found between the development of osteoarthritis and clinical outcome or radiological stability.

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Résumé Nous avons étudié 58 genoux qui ont subi reconstruction du ligament croisé antérieur par une autogreffe du tendon rotulien. L’âge moyen à la reconstruction était de 30,4 (18–58) ans, et le suivi moyen était de 11,2 (8.6–13.8) ans. La présence d’arthrose a été controlée radiographiquement en utilisant la classification de Kellgren et Lawrence. L’arthrose a été détectée dans le compartiment médial dans 25 cas, et dans le compartiment latéral dans 14 cas. Les éléments indépendants prédictifs de l’arthrose étaient: la lésion méniscale associée, un intervalle de plus de 6 mois entre le traumatisme et la reconstruction, et l’âge supérieur à 25 ans à la reconstruction. Cependant, aucune corrélation statistiquement significative n’a été trouvée entre le développement de l’arthrose et le résultat clinique ou la stabilité radiologique.

     

Flipped patellar tendon autograft anterior cruciate ligament reconstruction.

To determine the efficacy of an anterior cruciate ligament (ACL) graft that customizes length and facilitates anatomic outlet fixation, a prospective study of the "flipped" patellar tendon autograft ACL reconstruction began in 1995. This technique shortens the tendon portion to match the intra-articular length by rotating 1 bone plug 180 degrees proximally onto the tendon, thus flipping the bone plug over its ligamentous insertion. Bioscrews (poly L-lactic acid; Linvatec, Largo, FL) secured the grafts. All patients undergoing this procedure with a minimum 21 months follow-up were reviewed. Preoperative and postoperative Tegner, Lysholm, and IKDC activity scores, and Lachman and pivot shift tests were obtained. Postoperative KT testing and radiographs were obtained. Fifty patients were followed-up for an average of 28 months (range, 21 to 39 months). Average patient age was 34 years (range, 16 to 52 years). Tegner scores increased from 2.0 preoperatively to 6.0 postoperatively. Lysholm scores increased from 46 preoperatively to 93 at follow-up, with 86% excellent (66%) or good (20%). IKDC activity scores increased from 3.1 preoperatively to 1.7 postoperatively. KT manual-maximum difference at follow-up averaged 0.7 mm, with 74% less than 3-mm, 18% 3- to 5-mm, and 8% greater than 5-mm difference. Postoperative Lachman results were 0 in 45 patients and 1+ in 5 patients. Postoperative pivot shift was absent in all but 1 patient. Full extension was achieved in all cases and flexion averaged 136 degrees with no patient having less than 120 degrees flexion. No lytic bone changes or tunnel widening were seen. The flipped patellar tendon autograft reduces graft length to its intra-articular portion, increasing graft stability, isometry, and stiffness, and avoiding tunnel graft mismatch with clinically excellent results.     

Anterior cruciate ligament reconstruction with patellar autograft tendon

There are many techniques, graft choices, and outcome studies evaluating anterior cruciate ligament reconstruction. The current authors specifically look at reconstruction with the patellar tendon from a scientific perspective. Miniopen, endoscopic, and two-incision operative techniques in addition to hamstring versus patellar tendon autograft reconstructions are compared via randomized prospective studies. A review of all studies evaluating arthroscopically-assisted anterior cruciate ligament reconstruction with patellar tendon was conducted. The authors found arthroscopically-assisted anterior cruciate ligament reconstruction to have a high short-term stability rate, extremely high patient satisfaction level, and a low postoperative complication rate. When the endoscopic technique was compared with the two-incision technique, there were no major differences. The difference between patellar tendon and hamstring autograft reconstruction can be described best as subtle, except for the consistent finding of an increased activity level in the patellar tendon group. When the principles of anterior cruciate reconstruction are followed, one can expect consistent results with patellar tendon autograft reconstruction.     

Ten year follow-up after single incision anterior cruciate ligament reconstruction using patellar tendon autograft

AIM: We evaluated 74 patients 10 years after arthroscopically assisted ACL reconstruction using the central third of the patellar tendon as autograft. METHOD: IKDC, Tegner and Lysholm scores were used for clinical evaluation. Ligament stability was tested using the Rolimeter instrument. For statistics we used the Chi square test. RESULTS: At follow-up the Tegner activity level was 5.2, the Lysholm score was 93.6 points. Subjective assessment for function was rated normal or nearly normal in 83.7 %, for stability in 71.6 %. The side-to-side difference measured with the Rolimeter was normal in 87.8% and nearly normal in 12.2 %. Pivot shift was proven to be negative in 94.6 %. 29.7 % of patients showed degenerative changes in X-rays at follow-up. There was a significant correlation between time interval from injury to surgery and the grade of degenerative changes. Arthrosis significantly correlates with the rate of meniscus injury. Acute operative treatment increases the rate of arthrofibrosis significantly. CONCLUSION: To avoid osteoarthrosis we recommend an early (subacute) ACL reconstruction and meniscus refixation in the case of meniscus injury.     

Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon autograft

Purpose: The purpose of this study was to prospectively evaluate changes in the tibial bone tunnel following endoscopic anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft. We used computed tomography (CT) sequentially to monitor the time course of these changes over a 2-year period and correlated the results to clinical outcome and instrumented laxity measurements. Type of Study: Case series. Methods: Thirty-four patients (11 women, 23 men; mean age, 26.4 ± 4.5 years) who underwent endoscopic patellar tendon ACL reconstruction, were evaluated clinically according to IKDC, Lysholm, and Tegner scores as well as with respect to changes in tibial tunnel morphology over a 2-year period. Subsequent CT scans were performed at 1 and 6 weeks and at 3, 6, 12, and 24 months postoperatively. The tibial bone tunnel was measured in the sagittal and coronal planes at 5 different levels (L1 to L5). Results: The diameters of the tibial tunnel increased an average overall by 30.6% in the sagittal plane and 16.4% in the coronal plane within 2 years. The enlargement was significantly higher (P <.05) in the mid portion of the tunnel (L 2/3: 44.0% and 47.9% in the sagittal and 29.8% and 29.9% in the coronal plane, respectively), which resulted in a uniform cavity-type appearance. The percentage of change in tunnel size was significantly higher (P <.05) within the first 6 weeks following surgery compared with all other time intervals. No correlation between the amount of tunnel enlargement and the clinical results or between tunnel enlargement and KT-1000 measurements could be detected. Conclusions: Endoscopic ACL reconstruction is associated with tibial tunnel enlargement, which is already present within weeks following surgery. However, no negative effects on the clinical results were found over a 24-month period in our study population.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 138–143     

Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction: A 5-year follow-up

Purpose: To compare the long-term results of allograft versus autograft central one-third bone–patellar tendon–bone reconstruction of the anterior cruciate ligament (ACL), 2 groups of 30 patients were evaluated subjectively and objectively at an average follow-up of 63 months (range, 55 to 78 months). Type of Study: A prospective nonrandomized study. Methods: All surgeries were performed endoscopically by a single surgeon using metal interference screw fixation between May 1991 and November 1992. Early aggressive rehabilitation was employed and follow-up visits at 3, 6, 12, 24, and 60 months noted swelling, pain, range of motion, and patellofemoral crepitus, and Lachman test, pivot shift test, and side-to-side arthrometer differences. Results: Results were analyzed using 2-sample t test and χ-square analysis. Average age at surgery for autografts was 25 years (range, 14 to 49) and for allografts was 28 years (range, 14 to 53). The presence of meniscal tears were similar (allografts, 23 tears; autografts, 19 tears). At follow-up, no statistically significant difference was found for the presence of pain, giving way, effusion, Lachman and pivot shift results, or arthrometer measurements. Two patients, 1 allograft and 1 autograft had complete rupture of their grafts. There was no late stretching out of either graft and patients stable at 2 years were stable at 5 years, with the exception of the 1 ruptured graft in each group. Conclusions: A trend toward a greater incidence of glide on pivot testing was seen in the allografts (4 allografts v 2 autografts) but was present at 2 years and did not change at 5 years. A trend toward greater loss of extension in autografts (2.47°) than allografts (1.07°) was seen at 5-year follow-up, not seen at 2 years.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 9–13     

Shortening of the patellar tendon after anterior cruciate ligament reconstruction

In this prospective study, patellar height changes were investigated after anterior cruciate ligament (ACL) reconstruction with a mean follow-up of 22.4 months. A total of 114 patients were included. Fifty- two patients (group A) were treated by multiple suture repair, 27 patients (group B) underwent acute ACL reconstruction, and 35 patients (group C) underwent ACL reconstruction > or =6 weeks after injury with a patellar tendon graft. The patellar vertical height ratios (VHR) were evaluated preoperatively (VHR 1), 6 months postoperatively (VHR 2), and at follow-up (VHR 3). For the studied questions, the following answers were obtained: (1) The change of the patella height was the same in all three groups (i.e., disregarding the different surgical procedures). (2) The time elapsed between injury and ACL reconstruction did not influence the shortening of the patellar tendon. (3) Women showed a more pronounced shortening of the patellar tendon than did men. (4) A significant shortening of the patellar tendon occurred in 30% of our patients, and the process of shortening was finished 6 months postoperatively. (5) Anterior knee pain was present in 27.2% of our patients and occurred significantly more often after patellar tendon graftings. (6) Age had no influence on the changes of the patellar height.Arthroscopy 1998 Sep;14(6):592-6     

膝关节镜下采用挤压螺钉固定骨-髌腱-骨自体移植重建前交叉韧带

目的　探讨采用关节镜下微创手术的方法重建膝关节前交叉韧带。　方法　在膝关节镜下采用挤压螺钉固定骨 髌腱 (中 1/ 3) 骨复合体自体移植重建前交叉韧带 ,术后 1年以上者 2 0例 ,平均随访时间 1年 5个月。　结果　按关节功能评定标准 ,本组 2 0例中 ,优 13例 ,良 5例 ,可 2例 ,优良率 90 % ;9例术后关节镜观察重建前交叉韧带的形态结构 ,7例塑形改建良好。　结论　关节镜下重建前交叉韧带手术创伤小 ,骨道定位准确、固定牢固 ,可做到等长重建 ,有利于早期康复 ;由于利用了自体骨 髌腱 骨组织 ,重建的韧带经塑形改建后可获得牢固的生物学固定     

自体腘绳肌腱重建前交叉韧带后肌腱再生的MRI研究

目的应用MRI观察半腱肌腱及股薄肌腱取材重建前交叉韧带(anterior cruciate ligament,ACL)后肌腱再生情况。方法对2007年9月-2009年9月,52例采用单侧自体半腱肌腱、股薄肌腱重建ACL患者进行研究。男29例,女23例;年龄19～42岁,平均31.6岁。左膝34例,右膝18例。损伤原因:交通事故伤11例,运动伤38例,重物砸伤2例,其他伤1例。伤后至手术时间为6d～31个月,中位时间为11.4个月。关节疼痛19例,关节不稳28例,关节肿胀5例。股部肌肉萎缩(双股部周径差>1cm)7例,关节活动部分受限2例。浮髌试验阳性5例,Lachman试验阳性51例,轴移试验阳性49例,前抽屉试验均为阳性。膝关节活动度为(127.77±5.73)°,Lysholm评分为(52.40±3.45)分,国际膝关节文献委员会(IKDC)评分为(49.50±4.08)分。合并内侧半月板损伤23例,外侧半月板损伤6例,滑膜皱襞2例,游离体1例。结果术后患者切口均Ⅰ期愈合。患者均获随访,随访时间12～18个月,平均14.9个月。术后12个月时前抽屉试验均呈阴性,Lachman试验阳性1例,轴移试验阳性1例。膝关节活动度为(131.91±1.81)°,Lysholm评分为(94.98±2.77)分,IKDC评分为(93.65±2.42)分,与术前比较差异均有统计学意义(P<0.05)。术后12个月,屈膝90°抗阻力试验检查显示39例腘窝内侧可见绷紧的组织条带;MRI检查提示:10例半腱肌腱及股薄肌腱均有再生,29例半腱肌腱再生、股薄肌腱未再生,2例半腱肌腱未再生、股薄肌腱再生,11例半腱肌腱及股薄肌腱均未再生。半腱肌腱再生率为75.0%(39/52),股薄肌腱再生率为23.1%(12/52),总半腱肌腱和股薄肌腱再生率为78.8%(41/52)。结论半腱肌腱及股薄肌腱取材重建ACL后MRI检查提示部分患者有肌腱再生现象。     

Endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

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

Arthroscopic anterior cruciate ligament reconstruction with patellar tendon.

Anterior cruciate ligament reconstruction using a bone-patella tendon-bone free autologous graft was performed with an arthroscopic technique in 73 patients with chronic insufficiency. Sixty-nine (94.5%) were available for personal follow-up 3-5 years after the operation. Six patients (8%) had had postoperative difficulties in regaining a complete range of motion. Symptoms of giving-way were cured in 97% of the cases, and 89% had returned to vigorous activities. Residual anterior laxity (defined as pivot shift 2+, and/or Lachman 2+, and/or KT-1000 > 5 mm at the manual maximum) was found in 13% and was more frequent in patients with an uncorrected varus laxity. Patellofemoral crepitus was present in 17% of the knees and was associated with pain and/or swelling in a further 4%; it correlated with radiographic evidence of patellofemoral incongruence (p = 0.009). Comparison of the results with those of a previous series performed by arthrotomy revealed a decreased incidence of limited range of motion, severe patellar symptoms, and changes in patellar height. Stability was the same.     

Biomechanics of patellar tendon autograft for reconstruction of the anterior cruciate ligament in the goat: Three-year study

This study examined the biomechanics of anterior cruciate ligament-patellar tendon autografts for as long as 3 years after surgery. Twenty-seven adult female goats were tested; four served as controls and the others received an autograft to the right knee with each left knee serving as an additional control. The animals with grafts were tested at 0 week (n = 4), 6 weeks (n = 4), 12 weeks (n = 4), 24 weeks (n = 3), 1 year (n = 5), and 3 years (n = 3) after surgery. The anteroposterior laxity of the knee joint, load-relaxation, and structural and material properties of the graft were tested. The anteroposterior laxity was significantly greater than that of the controls for all groups except at 3 years. Load-relaxation was greater than that of the control anterior cruciate ligaments, but in the 1 and 3-year grafts load-relaxation was less than that of the patellar tendons with 5 minutes of sustained loading. Between 12 and 52 weeks, the stiffness and modulus of the grafts increased 3-fold, but the improvement was slow afterward. At 3 years, the strength and stiffness of the grafts were 44 and 49% those of the control ligaments, respectively; the modulus was 37 and 46% that of the control anterior cruciate ligaments and patellar tendons, respectively. The persistent inferior mechanical performance at 3 years suggests that anterior cruciate ligament grafts may never attain normal strength.     

Reconstruction of the anterior cruciate ligament using a patellar tendon autograft

Summary. Three hundred and eighty-four athletes with chronic anterior cruciate instability were treated by a free autologous graft of the lateral third of the patellar tendon. Evaluation 5 to 9 years after operation was carried out in 334 cases by physical examination, the KT-1000 arthrometer and the Tegner and Lysholm scoring scale. There were 89.5% satisfactory results and 10.5% were unsatisfactory. Global instability, advanced osteoarthritis and restricted movement after operation were the reasons for a poor outcome. In 9 cases, histological examination showed good incorporation of the graft.

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Résumé. Trois-cent-quatre-vingt-quatre patients qui poursuivaient des activités sportives et qui présentaient une instabilité chronique du genou due à une rupture du Ligament Croisé Anterieur ont eu une reconstruction de ce ligament, realisée par le même chirurgien, qui a utilisé une partie du mécanisme d’extension en autoplastie. Trois-cent-trente-quatre des patients ont étéévalués de 5 à 9 ans après l’ opération par: examen clinique, arthromètre KT 1000 et l’échelle Tegner et Lysholm. Suivant les résultats de cette échelle, des résultats satisfaisants ont été obtenus pour 89.5% et non satisfaisants pour 10,5% des patients. Instabilité globale, altérations arthrosiques avancées et restriction de la motilité postopératoire ont été les raisons principales des mauvais résultats. L’examen histologique chez un groupe de neuf patients était encourageant puisqu’il témoigna d’une bonne incorporation du greffon.

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Accepted: 1 October 1995     

Failure of osteointegration of hamstring tendon autograft after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) reconstruction is completed after implantation, when the graft material used undergoes extensive biologic remodelling and osteointegration. Failure of the osteointegration between the graft tendon and bone decreases the graft strength and induces anterior instability. We experienced 2 cases of failed osteointegration between tendon and bone after ACL reconstruction using 4 strands of the hamstring tendon. Surprisingly, osteointegration between the bone and tendon junction was not shown by intraoperative findings. The histologic findings also presented no evidence of osteointegration or biologic remodeling of the tendon. Two cases of failure of osteointegration are reported, with a review of the literature.     

关节镜下四股自体腘绳肌肌腱移植重建前交叉韧带的中期疗效

目的回顾性总结关节镜下4股自体?N绳肌肌腱移植重建前交叉韧带(ACL)的中期临床疗效。方法对2001年5月～2003年6月收治的56例ACL损伤患者进行术后至少2．5年的随访。采用前抽屉试验、Lachman试验、膝关节运动范围、Lvsholm功能评分、Tegner运动评分及手术并发症统计等来评价关节镜下4股自体?N绳肌肌腱移植重建ACL的临床疗效。结果56例患者术后获2．5～4．5年(平均3．8年)随访。前抽屉试验:0级38例,占67．9％,1级12例,占21．4％,2级6例,占10．7％;而术前均在1级以上。Lachman试验:0级41例,占73．2％,1级9例,占16．1％,2级6例,占10．7％;而术前均在1级以上。膝关节运动范围缺失均在10°以内,其中过屈受限3例,过伸受限4例。Lysholm评分优37例,良15例,可3例,差1例,优良率为92．9％。Tegner运动评分平均为6．7分(3～9分)。无关节感染、?N窝血管神经损伤、小腿筋膜间隙综合征等严重并发症发生,无关节软骨、半月板等意外损伤发生。隐神经髌下分支损伤导致小腿上段内、外侧皮肤麻木6例,发生率为10．7％,关节功能未受影响。结论关节镜下4股自体?N绳肌肌腱移植重建ACL,可以取得比较满意的中期临床疗效。     

Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

Current tibial endoscopic ACL reconstruction techniques provide functional stability, but fall short of the ultimate goal of ACL reconstruction, to restore normal knee kinematics. Vertical graft placement results in restoration of normal anteroposterior stability with a negative Lachman exam, but may not produce a stable knee in rotation, noted by a positive pivot shift. The Clancy anatomic endoscopic ACL reconstruction technique utilizes flexible reamers to achieve anatomic graft placement to more closely reproduce normal knee function. The overall results of arthroscopic anatomic endoscopic ACL reconstruction are essentially the same as we have reported using our previous open and rear-entry, two-incision techniques for anatomic graft placement. The long-term benefits of a more physiologic single incision endoscopic ACL reconstruction are not yet determined; however, short-term results are encouraging.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon composite autograft

At present, no single graft option clearly outperforms another. Autografts (patellar tendon, hamstring) and allografts (Achilles tendon, patellar tendon) are the grafts most often used. However, each grafts has advantages and disadvantages. Quadriceps tendon graft for anterior cruciate ligament reconstruction is not new, but an alternative composite graft is introduced here that consists of quadriceps tendon–patellar bone and bone obtained from a coring reamer used to create the tibial tunnel. This composite graft retains reduced morbidity while allowing the secure bone-to-bone fixation associated with bone–patellar tendon–bone graft.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 546–550