Effects of a tensioned tendon graft in a bone tunnel across the rabbit physis

Children who sustain anterior cruciate disruption often are denied the standard reconstructive procedures because of the concern that drilling across the physis of the tibia and femur and compression from a tensioned graft will result in growth plate arrest. To test this concept and to assess whether a tendon placed in the tunnel would function in a manner similar to a fat graft after the resection of a physeal bar, tunnels were made across the proximal tibial physis and distal femoral physis in a group of immature rabbits. Four tunnel diameters were used from 1.95 to 3.97 mm, in three rabbits at each diameter, with patellar tendon autografts being used as the reconstruction of the anterior cruciate ligament in two of the animals. The knees were radiographed every 4 weeks, and the animals were euthanized 4 months after surgery. The surgically treated and control knees were salvaged, and each knee was examined grossly, radiographically, and histologically. Eight of the 11 animals had growth arrest of one or both physes. The larger the drill hole diameter the more marked was the deformity. The proximal tibial physis seemed to be the most vulnerable for growth arrest, occurring in eight of the knees. The insertion of a tendon did not seem to offer any protection to physeal arrest. Because of these findings, it is not recommended that tunnels involving 1% or more of the area of the physis be placed across the tibial and femoral physis to reconstruct the anterior cruciate in very skeletally immature children.     

Quadrizeps- und Patellasehnenrupturen

Ruptures of the quadriceps or patellar tendon are uncommon but extremely relevant injuries. Early diagnosis and surgical treatment with a stable suture construction are mandatory for a good postoperative clinical outcome. The standard methods of repair for quadriceps and patellar tendon injuries include the placement of suture loops through transpatellar tunnels. Reinforcement with either a wire cerclage or a PDS cord is used in patellar tendon repair. The PDS cord can also be applied as augmentation in quadriceps tendon repair. In secondary patellar tendon repair an autologous semitendinosus graft can be used. For chronic quadriceps tendon defects a V-shaped tendon flap with a distal footing is recommended. The different methods of repair should lead to early functional postoperative treatment. The clinical outcome after surgical treatment of patellar and quadriceps tendon ruptures is mainly good.     

Technical Note: Double tibial tunnel using quadriceps tendon in anterior cruciate ligament reconstruction

Summary: To avoid complications related to the use of patellar tendon and hamstring (semitendinosus and gracilis) tendon and to create a more anatomic reconstruction, we present a new technique based on the use of quadriceps tendon placed in a single half femoral tunnel and double tibial tunnels. The graft, harvested by a central longitudinal incision, possesses the following characteristics: (1) a bone plug 20 mm long and 10 mm in diameter; (2) a tendon component 7 to 8 cm long, 10 mm wide, and 8 mm thick; and (3) division of the tendon longitudinally into 2 bundles while maintaining the patellar insertion. Every bundle has a width and thickness of approximately 5 mm and 8 mm, respectively. The total length of the graft is 9 to 10 cm. A 10-mm half femoral tunnel is drilled through a low anteromedial portal with the knee flexed at 120°. A suture loop is left in place in the half tunnel. A double tibial tunnel is drilled in a convergent manner (from outside to inside) obtaining an osseous bridge between the 2 tunnels. Two suture loops are passed trough the tibial tunnels and retrieved in a plastic cannula (10 mm) positioned in the anteromedial portal to allow the passage of the 2 bundles in the tibial tunnels. The suture loop left in the half tunnel permits the transportation of the bone plug in the femoral tunnel. Fixation is achieved by an interference screw at the femoral side and by 2 absorbable interference screws (1 for each tunnel). The advantages of this technique are a more cross-sectional area (80 mm²), greater bone-tendon interface, and a more anatomic reconstruction. Theoretically, easier bone incorporation, decreased windshield wiper and bungee effect, fewer donor site problems, and less tunnel enlargement can also be possible.     

Repair of Patellar Tendon Rupture With Suture Anchors

Repair of a ruptured patellar tendon is usually performed with the use of sutures that are passed through intraosseous tunnels within the patella. However, a number of caveats pertain to this method. The Beath pin may penetrate the articular surface or may unduly injure the quadriceps through multiple passes. The already injured patellar tendon may be overly shortened after debridement and insertion into bony tunnels, and loosening through the tunnels may occur. Obliquely oriented bony tunnels may cause abnormal patellar tilt, leading to uneven force distribution. This technical note reports the details of an alternative repair with 3 suture anchors that is incorporated into a 6-stranded Krackow technique, with additional mattress sutures as needed. Because of the low-profile nature of the anchors, this technique more accurately re-creates the footprint at the inferior pole of the patella and avoids articular cartilage penetration and injury to the surrounding soft tissue. The possibility of loosening through bony tunnels or creation of abnormal stresses is eliminated. A smaller incision is used, and operative (tourniquet) time is diminished. Although pullout of the anchors may be a logical concern, previous studies have suggested that this construct is more than sufficient to withstand the forces to which it is subjected.     

Repair of Quadriceps and Patellar Tendon Tears

Tears of the quadriceps or patellar tendon usually occur after a sudden eabccentric contraction and are diagnosed by a palpable gap at the injury site combined with an inability to perform a straight leg raise. Bilateral knee radiographs may demonstrate patella alta with patellar tendon tears and patella baja with quadriceps tendon tears compared with the uninjured knee. Ultrasound and magnetic resonance imaging can be helpful when there is uncertainty in the diagnosis. Surgical treatment is indicated for complete tears and some high-grade, partial tears. Nonabsorbable high-strength sutures or suture tape are placed in running locking fashion along the injured tendon and secured to the patella with bone tunnels (i.e., transosseous) or suture anchors. The transosseous technique requires exposure of the length of the patella to drill 3 bone tunnels to shuttle the sutures and tie over either pole of the patella. The suture anchor technique allows for a smaller incision and less soft-tissue dissection and may use a knotted or knotless technique. Biomechanical testing with load to failure is not statistically different between the transosseous and anchor techniques, although anchors have been shown to have less gap formation at the repair site. Repair augmentation with a graft may be beneficial in mid-substance injuries, chronic tears, and in cases of compromised tissue quality. Rehabilitation usually can be initiated immediately with protected weight-bearing in an orthosis, safe-zone knee passive range of motion, and avoidance of active extension. After a period of 6 weeks, rehabilitation can progress with full range of motion and a concentric strengthening program.     

A novel technique for reconstruction of the medial patellofemoral ligament in skeletally immature patients

Habitual or recurrent dislocation of the patella in the skeletally immature patient is a particularly demanding problem since the etiology is frequently multifactorial. The surgical techniques successfully performed in adults with patellar instability may risk injury to an open growth plate if applied to children. We present a technique that preserves femoral and patellar insertion anatomy of medial patellofemoral ligament (MPFL) using a free semitendinosus autograft together with tenodesis to the adductor magnus tendon without damaging open physis on the patellar attachment of MPFL. A 3-cm long longitudinal skin incision is performed 10 mm distal to the tibial tuberosity on the anteromedial side. The semitendinosus tendon is harvested with the stripper. The semitendinosus tendon is placed on a preparation board and cleaned of muscle tissue. The usable part of the tendon should be at least 20 cm long and 4 mm wide. The two free ends of the graft are sutured with Krakow technique. A medial longitudinal incision 2 cm in length is made to expose the MPFL and to abrade the patellar attachment of vastus medialis obliquus. The first patellar tunnel is created with 4.5 mm drill at the mid aspect of the medial patella in the anteroposterior and proximal–distal direction. The drill hole is formed parallel to the articular surface of the center of the patella. The second tunnel is created with 3.2 mm drill and the entry point is localized at the center of the patella. These two tunnels intersect to form a single tunnel. The semitendinosus autograft is run through the bone tunnel in the patella. Double-stranded semitendinosus autograft is placed in the presynovial fatty plane between the second and the third layer of the medial retinaculum, and tenodesis to adductor magnus tendon is applied by a moderate medial force with the knee flexed at 30°. Aftercare includes immobilization of the joint limited to 30° flexion using an above-knee splint for 2 weeks. No recurrent dislocation was observed in three patients (4 knees) at a mean follow-up time of 17.7 months. Both range of motion and radiological finding were restored to normal limits.     

Quadriceps and patellar tendon ruptures

Ruptures of the quadriceps as well as the patellar tendon occur in low frequency, but cause major functional deficits of the leg. These injuries usually require operative treatment. Acute quadriceps tendon ruptures are treated by suture repair, using heavy sutures guided through bone tunnels in the patella. Chronic defects and neglected cases require a local tendon transfer, either by a quadriceps tendon turn-down or by a V-Y-plasty of the quadriceps tendon. Ruptures of the patellar tendon are treated by suture of the tendon stumps plus an reinforcement procedure protecting the tendon and avoiding secondary patella alta. Patello-tibial fixation may be achieved by a cerclage technique using wire or an autologous tendon strip, alternatively a patello-tibial external fixator can be applied. In chronic and neglected cases, patellar tendon reconstruction is performed with autologous tendon grafts or with soft tissue allografts. The graft must be protected by a patello-tibial fixation for the first weeks.     

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     

Anterior Cruciate Ligament Reconstruction: A New Technique for Achilles Tendon Allograft Preparation

We describe a new technique in Achilles tendon allograft preparation for use in anterior cruciate ligament (ACL) reconstruction that allows for secure bony interference fixation on each side of the joint and aperture fixation for all patients. In addition, preparation of the graft in this manner avoids some problems that are frequently encountered with patellar tendon allografts, including graft tunnel mismatch and limited availability. Previous studies have reported successful results with Achilles tendon allograft use in ACL reconstruction with soft tissue fixation in the tibial tunnel. Bony interference fixation on the tibial side can be achieved by suturing a free bone plug to the tendon end of an Achilles allograft. We use a 9-mm circular oscillating saw to harvest a free 30-mm length bone plug from the remaining calcaneal bone block. This is then sutured directly to the tendon end of a bone-Achilles tendon allograft with the use of No. 1 nonabsorbable suture placed through 3 equally spaced drill holes in the free bone plug. Tendon length between the bone plugs can be individually set for each patient at a distance equivalent to the length of the native ACL (intra-articular distance between the femoral and tibial tunnels). After graft passage, the construct is tensioned and secured with interference screws, similar to a traditional bone–patellar tendon–bone graft. The senior author (S.G.) has performed 40 procedures with excellent results and reports no cases of tibial fixation failure. Biomechanical and long-term follow-up studies are in progress.     

Acute patellar tendon rupture

Summary: The most common method used in the treatment of acute patellar tendon ruptures is primary end-to-end repair. The use of the Acufex ACL guide (Acufex Microsurgical, Mansfield, MA) provides efficient and accurate placement of transosseous drill holes in the patella and minimizes the risk, tourniquet time, and surgical time of acute patellar tendon repairs.     

Editorial Commentary: From Lateral Release and Medial Plication to Complex Medial Patellofemoral Ligament Reconstruction Techniques: Medial Quadriceps Tendon Femoral Ligament Reconstruction Is the Most Anatomic Repair

Patella instability and dislocation are common in younger patients, and 1 in 5 patients are at risk of recurrent dislocations. Conservative treatment should be considered for first dislocations unless other concomitant injuries are present. Historically, lateral patella release and medial plication techniques were used for repair but have been superseded by medial patellofemoral ligament reconstruction. Overconstraint is a potential problem and often related to nonanatomic femoral tunnel position and graft tension, which could result in increased patellar contact pressures and graft failure. The medial quadriceps tendon–femoral ligament reconstruction technique (MQTFL) avoids patellar tunnels without the risk of patella fracture. When comparing medial patellofemoral ligament, MQTFL, and the combination of both techniques in a cadaver model, MQTFL resulted in less constraint with no differences for patellar contact pressures. Medial quadriceps tendon femoral ligament reconstruction is the most anatomic repair.     

Repair of patellar tendon rupture using suture anchors

Acute isolated rupture of the patellar tendon traditionally has been repaired via transpatellar suture tunnels. This retrospective study evaluated the demographics and epidemiology of this injury as well as the effectiveness and complication rates of our suture anchor technique. Between 1993 and 2005, a total of 82 cases of patellar tendon disruption in 71 patients were repaired. Fourteen cases involved basic primary repair with suture anchors of an acute isolated rupture of the patellar tendon and had an average follow-up of 29 months (range: 3-112 months). There were 3 (21%) failures of repair. The remaining 11 patients had excellent range of motion and strength and returned to their preoperative level of function. These results are comparable with other reports in the literature. The suture anchor technique thus represents a viable option for repair of patellar tendon ruptures and should be investigated further with a randomized, controlled trial.     

Acute patellar tendon rupture: A new surgical technique

Summary: The most common method used in the treatment of acute patellar tendon ruptures is primary end-to-end repair. The use of the Acufex ACL guide (Acufex Microsurgical, Mansfield, MA) provides efficient and accurate placement of transosseous drill holes in the patella and minimizes the risk, tourniquet time, and surgical time of acute patellar tendon repairs.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 8 (November-December), 2000: pp 869–870     

Transossäre Naht der Patellarsehnenruptur

OBJECTIVE: Restoration of active knee extension. Restoration of active knee stabilization. Avoiding secondary patella alta. INDICATIONS: Acute rupture of the patellar tendon within 3-5 days. Chronic rupture of the patellar tendon. CONTRAINDICATIONS: Compromised general health status or associated injuries. Compromised local soft-tissue situation. SURGICAL TECHNIQUE: Exposure of the ruptured tendon. Coronal drill hole through the distal third of the patella and coronal drill hole through the tibial tuberosity. After anatomic positioning of the patella (adjusting correct height), patellotibial fixation with monofil or woven (Labitzke) cerclage wire or PDS cord. Suture repair of the patellar tendon and repair of the ruptured medial and lateral retinaculum. Drain insertion. Wound closure in layers. POSTOPERATIVE MANAGEMENT: Full load bearing in cylinder cast. Week 0-2: flexion restricted to 30 degrees , quadriceps muscle isometry. Week 2-4: flexion restricted to 60 degrees , strengthening of hip abductors and extensors. Week 4-6: flexion restricted to 90 degrees . After week 6: removal of cylinder cast. After week 12: return to sporting activities, removal of the cerclage wire. RESULTS: Good results after surgical therapy. Low rate of secondary rupture. Low rate of muscle weakness.     

Die anatomische Ersatzplastik des vorderen Kreuzbands in Einzelbündeltechnik

Objective

Restore the knee stability by ACL reconstruction of the anterior cruciate ligament.

Indication

Acute and chronic functional instability with rupture of the anterior cruciate ligament giving way phenomena, acute rupture of the anterior cruciate ligament with concomitant meniscus repair.

Contraindications

Local infection in the knee joint, local soft tissue damage, lack of cooperation of the patient.

Surgical technique

The operation begins with the examination under anesthesia. It follows an arthroscopic examination of the knee and the arthroscopic treatment of accompanying intra-articular lesions (meniscus and cartilage damage). The semitendinosus tendon is harvested via a 3 cm skin incision medial to the tibial tuberosity. A four stranded tendon graft is prepared with a minimum length of 6.5 cm. Alternetive grafts for this technique are the patellar tendon, quadriceps tendon, and allografts. The femoral tunnel for the ACL graft is drilled via a deep anteromedial portal under arthroscopic control. For precise placement of the guide wire a specific offset aimer is used. For drilling the knee must be flexed more than 110°. Landmarks are the intercondylar line and the cartilage-bone interface. The position of the guide wire is always controlled by the medial portal (medial portal view). The guide wire is overdrilled with a cannulated drill (4.5 mm when a flip tack is used). The drill diameter for the 30 mm long blind tunnel is choosen according to the graft diameter. A gentle tunnel preparation may be achieved with the use of dilators. At the tibia, the anterior horn of the lateral meniscus is used as a landmark in the absence of ACL stump. The guide wire is first overdrilled with a 6 mm drill. Slight adjustments to the tibial tunnel location can be archieved when the guide wire is overdrilled eccentrically with a larger drill. At the femur an extrakortikal fixation technique with a flip button is preferred. At the tibia, a hybrid fixation with absorbable interference screw and button is used.

Rehabilitaion

The rehabilitation program is divided into three phases. During the inflammatory phase (1st–2nd week) control of pain and swelling is recommended. The patient is lmobilized with 20 kg partial weigth bearing. During the proliferative phase (3nd–6th week), load and mobility are slowly increased. Goal of this phase is it full extension. Exercises should be performed in a closed chain. During the remodeling phase strength and coordination exercises can be started. Athletes should not return to competitive sports before the 6th to 8th month.

Results

In a prospective study, we have examined 21 patients treated with an anatomic anterior cruciate ligament reconstruction in single-bundle technique, after two years. As graft the semitendinosus was used. The postoperative MRI diagnosis showed that all tunnels were positioned anatomically. KT 1000 measurement showed that the difference of anterior translation decreased from an average of 6.4–1.7 mm. A sliding pivot shift phenomenon was detected in only one patient. The postoperative Lysholmscore was 94.2 points.     

Ideal tibial tunnel length for endoscopic anterior cruciate ligament reconstruction

A successful single-incision endoscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft requires attention to many technical details. The emphasis of placing the femoral bone plug flush with the opening of the femoral tunnel results in distal shift of the graft. Longer tibial tunnels are required to prevent excessive graft extrusion. The purpose of this study is to compare four direct and indirect measurement methods of tibial tunnel preparation to determine which method can be used to create consistently reproducible tibial tunnels that prevent excessive extrusion or recession of the graft within the tunnel. Tunnels placed at the empiric angles of 40 degrees, 50 degrees, and 60 degrees to the tibial plateau resulted in the incidence of acceptable tibial tunnel lengths of 44%, 83%, and 39%, respectively. Tunnels placed at an angle determined by the formula "N + 7" where 7 degrees is added to the patellar tendon length (N) resulted in acceptable tunnels 89% of the time. Direct measurement methods using the formulas "graft - 50 mm" and "N + 2 mm" resulted in acceptable tibial tunnels of 44% and 100%, respectively. We recommend using the "N + 7" in conjunction with the "N + 2 mm" formula to obtain the advantages of both indirect and direct measurement methods.Arthroscopy 1998 Jan-Feb;14(1):9-14     

Transosseous tunnels versus suture anchors for the repair of acute quadriceps and patellar tendon ruptures: A systematic review and meta-analysis of biomechanical studies

BackgroundMultiple techniques have been developed for the repair of acute quadriceps and patellar tendon ruptures with the goal of optimizing clinical outcomes while minimizing complications and costs. The purpose of this study was to evaluate the biomechanical properties of transosseous tunnels and suture anchors for the repair of quadriceps and patellar tendon ruptures.MethodsA systematic review of the PubMed and Embase databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using specific search terms and eligibility criteria. Meta-analysis was performed by fixed-effects models for studies of low heterogeneity (I² <25%) and random-effects models for studies of moderate to high heterogeneity (I² ≥25%).ResultsA total of 392 studies were identified from the initial literature search with 7 studies meeting the eligibility criteria for quadriceps tendon repair and 8 studies meeting the eligibility criteria for patellar tendon repair. Based on the random-effects model for total gap formation and load to failure for quadriceps tendon repair, the mean difference was 8.88 mm (95% CI, −8.31 mm to 26.06 mm; p = 0.31) in favor of a larger gap with transosseous tunnels and −117.25N (95%CI, −242.73N to 8.23N; p = 0.07) in favor of a larger load to failure with suture anchors. A similar analysis for patellar tendon repair demonstrated a mean difference of 2.86 mm (95% CI, 1.08 mm to 4.64 mm; p = 0.002) in favor of a larger gap with transosseous tunnels and −56.34N (95% CI, −226.75 to 114.07N; p = 0.52) in favor of a larger load to failure with suture anchor repair.ConclusionsTransosseous tunnels are biomechanically similar to suture anchors for quadriceps tendon repair. Patellar tendon repair may benefit from reduced gap formation after cycling with suture anchor repair, but the load to failure for both techniques is biomechanically similar. Additional studies are necessary to evaluate these and alternative repair techniques.Level of evidenceSystematic review and meta-analysis of biomechanical studies, Level V.     

Mehrzeitige Rupturen von Patellar- und Achillessehnen

Derivatives of testosterone or of 19-nor-testosterone are used as anabolics for the purpose of improving performance although the effect of anabolics is known still to be under discussion. The use of anabolic steroids continues among competitive athletes despite increased controls and increasingly frequent dramatic incidents connected with them. Whereas metabolic dysfunction during anabolic use is well documented, ruptures of the large tendons are rarely reported. Within 18 months, a 29-year-old professional footballer needed surgery for rupture of the patellar tendon and of both Achilles tendons. Carefully directed questioning elicited confirmation that he had taken different anabolic steroids regularly for 3 years with the intention of improving his strength. After each operation anabolic steroids were taken again at a high dosage during early convalescence and training. Minimally invasive surgery and open suturing techniques led to complete union of the Achilles tendons in good time. Training and anabolic use (metenolon 300 mg per week) started early after suturing of the patellar tendon including bone tunnels culminated in histologically confirmed rerupture after 8 weeks. After a ligament reconstruction with a semitendinosus tendon graft with subsequent infection, the tendon and reserve traction apparatus were lost. Repeated warnings of impaired healing if anabolic use was continued had been given without success. In view of the high number of unrecorded cases in competitive and athletic sports, we can assume that the use of anabolic steroids is also of quantitative relevance in the operative treatment of tendon ruptures.     

带线锚钉“8”字缝合固定髌骨下极骨折

[目的]介绍带线锚钉“8”字缝合固定髌骨下极骨折的手术技术和初步临床应用效果。[方法]2017年6月-2019年12月采用上述技术固定髌骨下极骨折38例。行膝前正中切口,暴露骨折端。于近髌骨置人1枚5.0 mm带线锚钉。锚钉旁使用2-0克氏针自髌骨前方分别斜向两侧钻孔至髌骨后方关节面,出针点在骨折断端上方约0.1 mm,使用硬膜外导针将锚钉上两股缝线的单边分别自上述钻孔中引出,锚钉线分别从髌骨下极两侧缝合编织在髌韧带上,自行打结收紧。然后将两股缝线上的另一单边自髌骨一侧锚钉处为起点,连续缝合至同侧髌韧带近端,绕髌韧带缝合至对侧,再缝合至起点处自行收紧打结。[结果]38例患者均顺利完成手术。骨折愈合时间14?16周,无内固定失效病例,膝关节稳定性良好。术后12个月Bostman髌骨骨折评级标准,优30例,良7例,优良率97.37%。[结论]带线锚钉治疗髌骨下极骨折,修复了伸膝装置,操作简单安全,术后膝关节功能恢复优良,且无需二次手术取出,疗效满意。