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     

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.     

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.     

自体骨-腱-骨移植物与LARS人工韧带重建前交叉韧带的比较

目的比较自体骨-腱-骨(BPTB)和LARS人工韧带重建前交叉韧带(ACL)的效果。方法对59例ACL断裂患者采用自体BPTB重建ACL 29例(BPTB组),采用LARS人工韧带重建ACL 30例(LARS组)。按Lysholm、Tegner、IKDC评分系统和KT-1000检查评估功能。结果 59例均获随访,时间30～36个月。术后BPTB组和LARS组Lysholm评分分别为92.90分±9.10分和94.00分±6.87分;Tegner评分分别为5.76分±1.12分和6.07分±1.14分;KT-1000检查松弛分别为2.63 mm±2.16 mm和2.36 mm±2.08 mm。术后IKDC评分:BPTB组正常14例,接近正常11例,不正常4例;LARS组正常18例,接近正常8例,不正常4例。两组各项结果比较差异无统计学意义(P>0.05)。结论自体BPTB和LARS人工韧带重建ACL均能够获得满意的临床效果。     

Origin of replacement cells for the anterior cruciate ligament autograft

A rabbit model for anterior cruciate ligament (ACL) reconstruction using autogenous avascular patellar tendon (PT) was utilized to study the early events of graft incorporation. Histological observations demonstrated that autografts were centrally acellular with a peripheral rim of cells at 2 weeks, a central focal proliferation of cells at 3 weeks, and a cellular homogeneous distribution by 4-weeks postoperation. Graft necrosis followed by cellular proliferation suggested that a different population of cells other than the native PT fibroblasts may be inhabiting the graft. The extrinsic contribution of cells was studied by selective destruction of native PT cells with liquid nitrogen immersion prior to reconstruction of the ACL. The intrinsic contribution of cells was evaluated by sequestration of the PT graft in a semipermeable membrane before it was used to reconstruct the ACL. Histological analysis of tissue that was liquid N2 treated, used as an autograft, and then harvested 3-weeks postoperation revealed fibroblastic incorporation of the graft. In contrast, no cells were observed in semipermeable membrane sequestered autografts. These data suggest that autogenous ACL autografts of PT origin are repopulated by cells of external origin. In vitro control studies that were carried out in parallel demonstrated that PT fibroblasts could survive in tissue culture, but not in the synovial environment of the ACL. This suggests that fibroblasts from different sources have different, tissue-specific nutritional requirements.     

Revision of anterior cruciate ligament reconstruction with a pedicled quadruple hamstring autograft

European Journal of Orthopaedic Surgery & Traumatology - Results of iterative ACL reconstructions are lower than after primary reconstructions. Our aim was to report the results of a...     

Quantification of mechanoreceptors in the canine anterior cruciate ligament

Ten canine anterior cruciate ligaments (ACLs) were harvested while preserving their bony attachments. Specimens were stained using a modified gold chloride technique, divided into thirds, and serially sliced at 0.5 microns. The slides were viewed to count the mechanoreceptors present. The average numbers of receptors found were: proximal 67, middle 43, and distal 18 (ANOVA: P < 0.001). The statistical test (Sheffé) revealed that the proximal third contained a greater mean number of receptors (S = 3.8). No significant difference was found between the number of receptors in the middle and distal thirds (S = 0.85).     

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     

膝关节镜下自体腘绳肌腱移植重建前十字韧带部分束损伤

目的探讨关节镜下自体腘绳肌腱单束移植重建前十字韧带（anterior cruciate ligament,ACL）部分束损伤的临床效果。方法2007年1月至2010年5月关节镜下行自体腘绳肌单束重建ACL部分束损伤16例。术前Ly．sholm评分平均为55．4±6．7分。结果全部获得随访,随访时间为12～23个月,平均18±4．3个月。术后Lysholm评分增至平均89．3±3．3分,有统计学差异（P〈0．05）。所有患者主观症状均消失,全部恢复正常工作与体育锻炼。结论应用自体腘绳肌腱重建ACL部分束损伤明显改善膝关节功能。     

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.     

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.     

Microscopical investigation of canine anterior cruciate ligament and patellar tendon: collagen fascicle morphology and architecture

The collagen structure of the canine anterior cruciate ligament (ACL) and patellar tendon (PT) was examined by using light and scanning electron microscopy. The collagen waviness known as a crimping was found to occur in ACL and PT fascicles. This waviness, seen at the periphery of fascicles, is very smooth, and its amplitude seems to decrease from the periphery toward the fascicular center. It appears as a periodic collapse of the fascicle in two dimensions. Two models of the architectural patterns of the ACL and PT wavy fascicles are presented. The constituent collagen fibrils are either parallel or twisted relative to the fascicle axis, giving rise to planar and helical wave patterns, respectively. There is a distinct difference between the ACL and PT collagen structure. The helical wave pattern occurs in both PT and ACL while the planar waveform is found only in the centrally located ACL fascicles. In addition, there is less variability in fascicular size and density over the PT cross-section than in ACL.     

Comparison of freeze-dried tibialis anterior allograft and four-strand hamstring autograft in anterior cruciate ligament reconstruction

Purpose

The aim of this retrospective study was to evaluate the clinical outcomes of the patients who underwent primary anterior cruciate ligament (ACL) reconstruction surgery with either hamstring autograft or freeze-dried tibialis anterior allograft, which performed by the same surgeon using the same fixation technique.

Four-strand hamstring tendon autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction

This retrospective study compared the results after anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (4SHG) versus Ligament Advanced Reinforcement System (LARS) artificial ligament in 60 patients between January 2003 and July 2004 with a minimum four-year follow-up. The KT-1000 examination, the International Knee Documentation Committee (IKDC) scoring systems and Lysholm knee scoring scale were used to evaluate the clinical results. The mean side-to-side difference was 2.4 ± 0.5 mm and 1.2 ± 0.3 mm in the 4SHG group and LARS group, respectively (P = 0.013). Although other results of ACL reconstruction, measured by IKDC evaluation, Lysholm scores and Tegner scores, showed using a LARS graft clinically tended to be superior to using a 4SHG, there were no significant differences calculated. Our results suggest that four years after ACL reconstruction using a LARS ligament or 4SHG dramatically improves the function outcome, while the patients in the LARS group displayed a higher knee stability than those in the 4SHG group.     

Reconstruction of chronic anterior cruciate ligament insufficiency in athletes using a bone-patellar tendon-bone autograft

Summary Thirty athletes (18 men and 12 women) were followed up for an average of 2.2 years after operative reconstruction for chronic anterior cruciate injuries with a mini-arthrotomy technique using a bone-patellar ligament-bone autograft. All the patients were active in sports, and the injuries in 40% occurred while playing soccer. The average delay between injury and reconstruction was 4.7 years; before this 26 knee operations had been carried out in 22 of the patients. At follow up, 20 patients were satisfied subjectively and 22 were classified objectively as excellent or good. Anteroposterior stability was good in 29 knees, and the Lachman and pivot shift tests were strongly positive in only one patient. Wasting of the thigh was more prominent in 9 patients who had a flexion deficit of 10° or more, than in the other 21. Of the 15 competitive athletes, who had all given up their sport after injury, 8 were able to return to sport. Reconstruction using a bone-patellar ligament-bone autograft is recommended for symptomatic chronic anterior cruciate ligament insufficiency in athletes.

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Résumé Trente athlètes (18 hommes et 12 femmes) ayant bénéficié d'une reconstruction pour insuffisance chronique du ligament croisé antérieur par une technique utilisant une miniarthrotomie et une autogreffe os-tendon rotulien-os ont été revus avec un recul moyen de 2,2 ans (de 1 à 4 ans). Tous les patients de cette étude étaient des sportifs, 15 d'entre eux étaient des compétiteurs et les 15 autres des sportifs de loisir. L'accident initial était survenu en pratiquant le football dans 12 cas (40%) et le baseball finlandais dans 3 cas (10%). Le délai entre l'accident et la reconstruction était en moyenne de 4,7 ans (de 0,5 à 20 ans). Avant la reconstruction 22 patients avaient eu 26 interventions. Lors de la révision 20 patients (73%) étaient satisfaits subjectivement de leurs résultats et d'après nos critères objectifs, 22 patients (73%) étaient cotés excellents ou bons. D'après la cotation de Lysholm, 16 patients (53%) étaient excellents ou bons. La stabilité antéropostérieure était bonne dans 29 genoux (90%), quant au test de Lachman et au pivot-shift, ils étaient fortement positifs (3+) chez un patient seulement. L'atrophie des muscles de la cuisse était plus marquée chez les 9 patients présentant un déficit de flexion de 10° ou plus (moyenne 1,6 cm) que chez les 21 autres (moyenne 0,7 cm) (p<0.05). Parmi les 15 compétiteurs qui avaient tous abandonné le sport après l'accident initial, 8 ont pu reprendre leur activité sportive après la reconstruction. En conclusion, la reconstruction du LCA par une autogreffe os-tendon rotulien-os peut être recommandée dans les insuffisances chroniques symptomatiques chez les athlètes.

     

Comparative study of autograft or allograft in primary anterior cruciate ligament reconstruction

Between December 1996 and December 2002, we treated 79 patients with arthroscopy-assisted anterior cruciate ligament (ACL) reconstructions. In 53 patients we used autografts and in 26 patients allografts. Patients were followed up for 38 (12–72) months. The two groups did not differ in preoperative sport activity level. The postoperative Lysholm score was 89.9±8.1 in the autograft group and 84.1±18.6 in the allograft group. Comparing the patients Lysholm score according to whether they had a low (1–5) or a high (6–10) postoperative Tegner score, we found no statistically significant difference between the groups. On one occasion, the allograft ruptured during the implantation procedure just prior to the fixation. Postoperatively, we performed three revisions—two in the allograft group and one in the autograft group—and three second-look arthroscopies. There were no bacterial infections and no cases of viral transmission. No immune rejection, resorption, or immunsynovitis occurred during the follow-up.

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Résumé Entre décembre 1996 et décembre 2002 nous avons traité 79 malades par reconstruction du LCA sous arthroscopie. Chez 53 malades nous avons utilisé une autogreffe et, pour 26, une allogreffe. Les malades ont été suivis 38 mois (12–72). Les deux groupes nétaient pas différents dans le niveau de lactivité sportive préopératoire. Le score Lysholm postopératoire était de 89,9±8,1 dans le groupe autogreffe et de 84,1±18,6 dans le groupe allogreffe. En comparant le score Lysholm des malades selon quils avaient un score postopératoire de Tegner haut(6–10) ou bas (1–5), nous navons pas trouvé de différence significative entre les deux groupes. Dans un cas lallogreffe sest rompue pendant la procédure dimplantation, juste avant la fixation. Après lintervention nous avons fait trois révisions, deux dans le groupe allogreffe et un dans le groupe autogreffe, et trois arthroscopies de seconde vision. Il ny avait pas dinfection bactérienne, aucuns cas de transmission virale. Aucun rejet immunitaire, résorption ou synovite immune ne se sont produits pendant le suivi.

     

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.