Arthroscopic single-bundle reconstruction of posterior cruciate ligament with quadrupled hamstring tendon

Objective： To evaluate the technique and outcome of arthroscopic sipy, le-bundie reconstruction of posterior crudate ligament （PCL） with quadrupled hamstring tendon. Methods： From April 2001 to October 2004, 49 knees with PCL tears in 49 patients were verified with arthroscope in this department. Of them, 13 were combined with anterior cruciate ligament tears, 14 with disruptions of the posterolateral comer, 6 with ruptures of the posteromedial corner and medial collateral ligament, 9 with lateral meniscus tears, 5 with medial meniscus tears and 2 with popliteal vascular tears. All the damaged PCLs were reconstructed with single-bundie of autogenous quadrupled hamstring tendons under arthroscope. Biodegradable interference screws or blunt titanium interference screws were used for direct anatomic fixation of the reconstructed ligament. Results： After operation, no severe complications occurred at early stage in the 49 patients. All of them were followed up for 10-52 months with an average of 22. 0 months ＋ 10. 7 months. Lysholm score was remarkably improved from 30-60 （ mean： 47.96 ＋ 8. 16） preoperatively to 70-95 （ mean： 89. 08 ＋ 6. 10 ） at the last postoperative follow-up （ P 〈 0.01 ）. Furthermore, there was a significant improvement in International Knee Documentation Committee （IKDC） score from abnormal （ Grade C） in 10 knees and severely abnormal （Grade D ） in 39 preoperatively to normal （ Grade A ） in 20, nearly normal （ Grade B） in 24 and abnormal in 5 at the last follow-up. Of the 49 patients, 40 returned to the same activity level as before and 9 were under the level. Conclusions： Single-bundle reconstruction of PCL with quadrupled hamstring tendons has the advantage of minimal trauma in surgery and satisfactory outcome.     

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     

Simultaneous reconstruction of anterior cruciate ligament and posterior cruciate ligament by using allogeneic patellar tendon under arthroscopy

With fast development of arthroscopic surgery inChina, simple reconstruction of ACL (anteriorcrucial ligament) or PCL has been reported in number. However , the methods concerningsimultaneous reconstruction of ACL and PCL are rarelyreported. Simultaneous …     

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.     

Hamstring tendon autograft versus fresh-frozen tibialis posterior allograft in primary arthroscopic anterior cruciate ligament reconstruction: a retrospective cohort study with three to six years follow-up

Introduction

Selection of various grafts for anterior cruciate ligament (ACL) reconstructions have been employed in order to improve on stability and function of the knee. This study aimed to compare stability and function of the knee after ACL arthroscopic reconstruction by single-loop tibialis posterior (TP) allograft and four-strand hamstring tendon (HT) autograft.

Materials and methods

The retrospective cohort study included 104 patients in the TP group matched with 118 patients in the HT group in terms of demographic characteristics, associated meniscus injury, subjective and objective knee characteristics. All patients were followed up for at least three years with regards to mentioned criteria and time of return to former activities.

Results

The mean (range) age of TP (88 males and 16 females) and HT (99 males and 19 females) groups was 34.4 (19–48) and 36.9 (20–51) years, respectively. Median (range) follow-up durations were 55 (37–71) and 56 (36–72) months, respectively. No significant differences were observed post-operatively, regarding subjective and objective evaluations. Additionally, time duration for return to former activity was similar in both groups. Post-operative paresthesia and numbness of medial aspect of the calf were observed for two months in eight patients of the HT group which persisted to the final visit in one case. No similar symptom was seen in the TP group.

Conclusion

In arthroscopic ACL reconstruction, fresh frozen doubled TP allograft compared to HT autograft was equally effective in restoring function and stability of knee, permitting return to former activities.

Level of evidence

Retrospective comparative, Level III

     

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     

Second-look arthroscopy after anatomic anterior cruciate ligament reconstruction: Bone-patellar tendon-bone versus hamstring tendon graft

PurposeThe purpose of this study was to compare the morphological and clinical outcomes between anatomic rectangular tunnel (ART) ACL reconstruction with a BTB graft and anatomic triple-bundle (ATB) ACL reconstruction with hamstring tendon (HST) grafts.MethodsThe anatomic ACL reconstructions were performed on 467 patients; 233 patients with ART technique and 234 with ATB procedure. ART procedure was predominantly indicated for athletes with higher motivation to return to sports and aggressiveness for muscle training. A total of 113 patients, with a mean age of 20.7 years, had consented to undergo second-look arthroscopy. The average time from ACL reconstruction to the second-look was 10.0 months. This study included 56 ART techniques and 57 ATB procedures. The grafts underwent meticulous probing, and were evaluated based on tension, graft damage, and synovial coverage. Moreover, the femoral tunnel aperture was also observed in detail to assess the space between the femoral tunnel and the graft. As clinical evaluation, knee effusion, range of motion, Lachman test, pivot shift test, KT side-to-side difference, and Lysholm score were assessed.ResultsThere was no significant difference in graft tension between two procedures, while HST graft in ATB procedure had more cases with graft damage (p = 0.05). Good synovial coverage was found in 98% in ART procedure and 70% in ATB procedure, showing a significant difference (P < 0.001). At femoral tunnel aperture, there were no cases with the space around BTB graft, while 33% showed the space around HST graft, again showing a significant difference (P < 0.001). There were no significant differences in clinical outcomes.ConclusionBTB graft with the ART procedure was superior to HST graft with the ATB procedure in morphology at second-look arthroscopy, while there was no significant difference in clinical outcomes between two procedures.     

Is quadruple semitendinosus tendon strands autograft a better choice than hamstring autograft for anterior cruciate ligament reconstruction? A comparative study with a mean follow-up of 3 years

European Journal of Orthopaedic Surgery & Traumatology - The purpose of this study was to compare the clinical outcomes of ST4 with those of STGs with a minimum follow-up of 3&nbsp;years....     

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     

ACL reconstruction using bone–patella tendon–bone autograft: press-fit technique vs. interference screw fixation

Purpose

The gold standard in ACL reconstructions has been the bone–patellar tendon–bone autograft fixed with interference screws. This prospective, randomized clinical trial aimed to compare two methods of fixation for BPTB grafts: press-fit fixation vs. interference screw, over a 12-month follow-up interval.

Methods

158 patients with an average age of 29.8 years, between 2011 and 2012, were treated for torn ACL. 82 patients underwent reconstruction with BPTB autograft with a press fit fixation technique, and in 76 cases an interference screw was used. At the time of final follow-up, 71 patients in press-fit group and 65 patients in interference screw group were evaluated in terms of return to pre-injury activity level, pain, knee stability, range of motion, IKDC score and complications.

Results

At 12-month follow-up, 59 (83 %) and 55 (85 %) in press-fit and screw group, respectively had good-to-excellent IKDC score (p > 0.05). The mean laxity assessed using a KT-1000 arthrometer improved to 2.7 and 2.5 mm in press-fit and screw group, respectively. Regarding Lachman and pivot shift test, there was a statistically significant improvement in the integrity of the ACL in both the groups, but no significant differences was noted between groups. There were no significant differences in terms of femur circumference difference, effusion, knee range of motion, pain and complications.

Conclusions

The press-fit technique is an efficient procedure. Its outcome was comparable with the interference screw group. Furthermore it has unlimited bone-to-bone healing, no need for removal of hardware, ease for revision and cost effectiveness.     

Anterior cruciate ligament reconstruction using hamstring autograft in over-40 patients. Does preoperative arthritic changes matter?

Introduction

The purpose of this study was to assess the effect of osteoarthritis on the outcome of arthroscopic anterior cruciate ligament (ACL) reconstruction, and to assess the effect of the procedure on the progression of osteoarthritis.

Material and methods

Forty-two patients, age above 40, presenting by symptomatic instability secondary to rupture of the ACL were enrolled in a prospective cohort study. Cases were divided into two groups according to the absence of osteoarthritic changes (group I, 19 patients) or presence of osteoarthritic changes (group II, 23 patients) in preoperative radiographs. ACL anatomic single bundle reconstruction by the anteromedial portal technique using hamstring autograft fixed by biodegradable interference fit screws was done for all patients, and a fixed postoperative rehabilitation protocol was applied. Data were recorded and statistical analysis of the preoperative, 1 year follow up, and final follow up (average 41 months in group I and 42 months in group II) results of both groups was conducted.

Results

The average patient age at the time of operation was 44.5 years in group I versus 46.4 years in group II. The follow-up median pain scores, ROM, modified Lysholm scores were significantly better in group I compared to group II. On the contrary, the difference between preoperative and 1 year postoperative scores and the percentage of improvement of the modified Lysholm score were significantly higher in group II. Deterioration of the radiographic grade of osteoarthritis in the final follow-up was declared in 15.8 % of patients of group I and in 21.7 % of patients of group II (P?=?0.71). Age, concomitant meniscus injury, and presence of preoperative arthritic changes, and cartilage defect had no statistically significantly effect on the success rate. Patients who had ACL reconstruction more than 2 years after injury and those with higher body mass index (BMI) had worse outcome than those who had earlier reconstruction and lower BMI.

Conclusion

Patients having preoperative mild to moderate arthritic changes will indeed benefit from ACL reconstruction at short term, although their overall functional outcome seemed to be inferior to the outcome of non-arthritic patients. However, osteoarthritic changes deteriorate over time in both groups especially when there is preoperative mild to moderate arthritic changes.     

Anterior cruciate ligament reconstruction with LARS™ artificial ligament results at a mean follow-up of eight years

Purpose

The aim of this study was to review patients that underwent ACL reconstruction with the LARS™ ligament in the First Orthopaedic Division of Pisa University during the period between January 2003 and December 2005.

Methods

Twenty-six patients were reviewed with an average follow-up of 95.3 months (7.9 years). The review protocol was articulated in three phases: (1) a subjective evaluation using three grading scales: VAS, KOOS and the Cincinnati knee rating scale, (2) a clinical and objective evaluation, and (3) a biomechanical evaluation of the knee stability.

Results

A global positive result was obtained in 92.3 % of the patients (16 optimal results and eight good results), with a fast functional recovery and a high knee stability. A global poor result was reported in two cases. In our series we did not record cases of infection or knee synovitis. We recorded only one case of mechanical graft failure. The results obtained from our study are encouraging and similar to those in the literature.

Conclusions

We conclude that the LARS™ ligament can be considered a suitable option for ACL reconstruction in carefully selected cases, especially for older patients needing a fast functional recovery.     

Overlapping systematic reviews of anterior cruciate ligament reconstruction comparing hamstring autograft with bone-patellar tendon-bone autograft: why are they different?

BACKGROUND: Systematic reviews published on the same topic during a similar period of time (i.e., overlapping reviews) on anterior cruciate ligament reconstruction complicate the choice between bone-patellar tendon-bone or hamstring tendon autograft. We aimed to evaluate reasons for differences among the overlapping systematic reviews and to assess the quality of reporting and internal validity. METHODS: We performed a search of MEDLINE, the Cochrane Database of Systematic Reviews, and EMBASE to identify systematic reviews in which bone-patellar tendon-bone graft was compared with hamstring tendon autograft for reconstruction of the anterior cruciate ligament. We evaluated cross-citations among the overlapping reviews and the authors' rationale for repeating the review. The quality of reporting was assessed with the Quality of Reporting of Meta-analyses (QUOROM) statement, and the internal validity was assessed with the Oxman and Guyatt index for methodological quality by at least two assessors. Assessor agreement was evaluated with intraclass correlation coefficients. We evaluated the sensitivity analysis that had been performed in the reviews. RESULTS: We identified eleven overlapping systematic reviews. Three reviews favored the patellar tendon graft for stability, and one favored the hamstring graft. Six reviews favored the hamstring graft to prevent anterior knee pain, and the rest were inconclusive. Only six reviews cited previously published systematic reviews on the same topic, and only two of these reviews cited all available systematic reviews that were available at that time. The quality of reporting ranged from 5 to 18 (median, 12; maximum score, 18). The internal validity ranged from 1 to 7 (median, 2; maximum score, 7). Reviewers reached almost perfect agreement (intraclass correlation coefficients, 0.83 and 0.94). Formal sensitivity analysis was utilized infrequently. The highest-quality review favored hamstring grafts to prevent anterior knee pain and showed weak evidence that bone-patellar tendon-bone grafts yielded better stability. CONCLUSIONS: When overlapping or discordant systematic reviews are encountered, each review must be appraised on the basis of its methodological quality before it can be used to guide clinical decision-making or policy making. The currently available best evidence, derived from a methodologically sound meta-analysis, suggests that hamstring tendon autografts are superior for preventing anterior knee pain, and there is limited evidence that bone-patellar tendon-bone autografts provide better stability.     

Hamstring tendon anterior cruciate ligament reconstruction: does gracilis tendon harvest matter?

Purpose

Hamstring tendon grafts are a popular choice for anterior cruciate ligament (ACL) reconstruction. Typical morbidity reported after hamstring tendon harvest is muscle weakness in flexion, and whilst still a matter for debate, this morbidity may be greater if the gracilis tendon is harvested in addition to the semitendinosus. This study sought to comprehensively compare the outcome of ACL reconstructions in which the semitendinosus was harvested alone (ST group) or with the gracilis (ST/G group).

Methods

Twenty patients (ten ST, ten ST/G) were assessed with a variety of measures that included subjective scores, function, strength and tibial rotation as measured by gait analysis during a pivoting task.

Results

Results showed that the graft diameter was significantly larger in the ST group, but there were no other differences between the groups for any other outcome measure.

Conclusion

Harvesting the gracilis in addition to semitendinosus does not appear to affect either the outcome or graft-related morbidity after hamstring ACL reconstruction.     

Tunnel enlargement 5 years after anterior cruciate ligament reconstruction: a radiographic and functional evaluation

Purpose

The aetiology and clinical significance of enlargement of bone tunnels following anterior cruciate ligament (ACL) reconstruction remains controversial. This phenomenon has been attributed to biological factors and mechanical factors. We wanted to study the amount of femoral and tibial tunnel enlargement 5 years post-ACL reconstruction. By standardizing the type of femoral fixation, we also wanted to determine whether the type of tibial fixation had any bearing to the amount of tibial tunnel enlargement.

Methods

All patients who underwent arthroscopic hamstring autograft ACL reconstruction between January 2000 and December 2000 were identified. All grafts were fixed with close-looped endobutton proximally. The grafts were fixed on the tibial side with staples or bioabsorbable interference screws. At a minimum of 5 years after surgery, these patients were recalled. They were assessed with Lysholm knee, Tegner activity and the IKDC Subjective and Objective forms and a KT-1000 arthrometer. The diameter of the bone tunnels and tunnel positions in the anterior–posterior and lateral radiographs were measured using digital callipers by a two blinded researchers.

Results

We found that the femoral tunnel enlarged more than the tibial tunnel. At 5 years, the mean tibial tunnel enlargement was 2.46 mm and the mean femoral tunnel enlargement was 3.23 mm. All 54 patients had endobutton femoral fixation. Of them, 34 patients had tibial graft fixation with staples (extracortical fixation) and 20 patients had tibial graft fixation with bioabsorbable interference screws (aperture fixation). The mean enlargement as measured by the two independent observers in the extracortical group was 1.98 mm (24.7 %)* and 1.51 mm (18.2 %)**compared to 3.27 mm (40.4 %)* and 2.92 mm (30.0 %)** in the aperture fixation group. This difference in tibial tunnel enlargement between the groups was significant (p < 0.001, mean difference 1.29 mm). However, this was not correlated with any significant difference in clinical outcome at 5 years.

Conclusion

We, like some authors, have shown that the use of interference screws in tibial fixation despite being aperture fixation actually has a greater amount of tibial enlargement. This lends weight to the biological theory to tunnel enlargement.     

A follow-up study of arthroscopic combined reconstruction of anterior and posterior cruciate ligaments with allograft patellar tendon

Objective： To evaluate the therapeutic effect of combined reconstruction of anterior cruciate ligament （ ACL ） and posterior cruciate ligament （ PCL ） simultaneously by using allograft patellar tendon under arthroscopy. Methods： From May 2003 to November 2005, 10 cases of ruptured ACL and PCL were fixated with compressed screws and reconstructed under arthroscopy with allograft patellar tendon simultaneously. The clinical results were evaluated according to IKDC, Lysholm, and Tegner clinical rating scales. Results. All patients were followed up for 12-30 months （mean： 18 months ）. At the last follow-up, there was no knee extension limitation and knee flexion was between 120° and 135°, with an average of 128.38°. The Lysholm score of the 10 cases was 66. 5 ± 5. 6 before operation and 89.8 ± 3.4 at last follow up. The difference was statistically significant （ P 〈 0.01 ）. The average Tegner activity score decreased from 6.9 ± 1.7 （ range ： 4-9 ） before injury to 5.5 ± 1. 6 （rang： 2-9） at the follow-up （P=0.53）. At the end of follow-up, IKDC score was graded as A in 4 cases （40.0 % ）, B in 5 （50.0 % ）, and C in 1 （10.0%）. Of the 10 patients, 8 returned to the same sports level as before injury and 2 were under the level. Conclusion. Arthroscopic combined reconstruction of ACL and PCL with allograft patellar tendon has the advantages of minimal trauma in surgery and reliable satisfactory outcome.     

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     

Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17–20 years

Purpose

The aim of our study was to review the clinical and radiological outcome of patients who had undergone anterior cruciate ligament (ACL) reconstruction in comparison to a group of non-operatively treated patients.

Methods

In a retrospective study we compared ACL reconstruction using a bone-patellar tendon-bone graft with a non-operatively treated group of patients 17–20 years later. Fifty-four patients that met the inclusion criteria, with arthroscopically proven ACL rupture, were treated between 1989 and 1991. Thirty-three patients underwent ACL reconstruction, forming group one. Eighteen non-reconstructed patients continued with rehabilitation and modification of activities (group two). The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms and the Lysholm and Tegner scale were used to assess the knees at follow-up. Radiographic assessment was performed using the IKDC grading scale.

Results

Follow-up results showed that 83% of reconstructed patients had stable knees and normal or nearly normal IKDC grade. Patients in the non-reconstructed group had unstable knees with 84% having abnormal or severe laxity. The subjective IKDC score was significantly in favour of group one: 83.15 compared to 64.6 in group two. The Lysholm and Tegner score was also significantly better in group one. Conservatively treated patients all had unstable knees and worse scores. The rate of osteoarthritis showed more severe changes in non-reconstructed patients with additional meniscus injury.

Conclusions

We can conclude that 94% of patients who underwent ACL reconstruction had stable knees after 15–20 years and there was a significantly lower percentage of osteoarthritis in comparison to conservatively treated patients.