Comparison of femoral fixation methods for anterior cruciate ligament reconstruction with patellar tendon graft: a mechanical analysis in porcine knees

The aim of the present study was to evaluate the structural properties of femur–patellar tendon graft complex in anterior cruciate ligament (ACL) reconstruction using different femoral fixation devices. Type of study is biomechanical testing. An ACL reconstruction was performed on 40 cadaver porcine knees, using patellar tendon (PT) graft. Specimens were divided into four groups according to the femoral fixation: interference absorbable screw (Group A), metallic setscrew (Group B), absorbable pins (Group C), and a combination of metallic setscrew and pin (Group D). Other ten knees were used as controls. On each sample, a cyclic loading test, then a load-to-failure test were performed. Elongation after 1,000 loading cycles, ultimate failure load, yield load, stiffness, deformation at the yield point, and mode of failure were recorded. Kruskal–Wallis test and Tukey test were used to compare the differences between groups. The lowest mean elongation after 1,000 load cycles was observed for Group B (1.7 ± 1.4 mm) and D (1.2 ± 0.3 mm). Ultimate failure load of Group D (1,021.8 ± 199.4 N) was comparable with that of normal ACL (1,091.2 ± 193.3 N) and PT graft (1,140.6 ± 285.7 N). All other groups were lower than the controls. For mean stiffness, all the groups, excepting for Group D (172.8 ± 40.4 N/mm), were significantly lower than PT control group (216 ± 78.4 N/mm). Mode of failure was graft pullout for Groups A and B, distal pin breakage for Group C, and midsubstance graft rupture in 80% of the cases for Group D. Only combined compression and suspension fixation did not show significantly different structural properties in comparison with normal ACL and PT graft. Furthermore, it showed no risk of graft pullout or hardware breakdown in comparison with other fixation devices.     

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 ± 7.0 mm², while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm², showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm², almost equal to the value at the final follow-up (49.8 mm²) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.     

Pullout strength of tibial graft fixation in anterior cruciate ligament replacement with a patellar tendon graft: interference screw versus staple fixation in human knees

The endoscopic single incision technique for anterior cruciate ligament (ACL) reconstruction with a femoral half-tunnel may lead to a graft/tunnel mismatch and subsequent protrusion of the block from the tibial tunnel. The typical tibial fixation with an interference screw is not possible in these cases. Fixation with staples in a bony groove inferior to the tunnel outlet can be used as an alternative technique. Current literature does not provide biomechanical data of either fixation technique in a human model. This study was performed to evaluate the primary biomechanical parameters of this technique compared with a standard interference screw fixation of the block. Fifty-five fresh-frozen relatively young (mean age 44 years) human cadaver knee joints were used. Grafts were harvested from the patellar tendon midportion with bone blocks of 25 mm length and 9 mm width. A 10-mm tibial tunnel was drilled from the anteromedial cortex to the center of the tibial insertion of the ACL. Three different sizes of interference screws (7 × 30, 9 × 20, 9 × 30 mm) were chosen as a standard control procedure (n = 40). For tibial bone-block fixation the graft was placed through the tunnel, and the screw was then inserted on the cancellous or the cortical surface, respectively. Fifteen knees were treated by staple fixation. A groove was created inferior to the tunnel outlet with a chisel. The bone block was fixed in this groove with two barbed stainless steel staples. Tensile testing in both groups was carried out under an axial load parallel to the tibial tunnel in a Zwick testing machine with a velocity of 1 mm/s. Dislocation of the graft and stiffness were calculated at 175 N load. Maximum load to failure using interference screws varied between 506 and 758 N. Load to failure using staples was 588 N. Dislocation of the graft ranged between 3.8 and 4.7 mm for interference screw fixation and was 4.7 mm for staples. Stiffness calculated at 175 N load was significantly higher in staple fixation. With either fixation technique, the recorded failure loads were sufficient to withstand the graft loads which are to be expected during the rehabilitation period. Staple fixation of the bone block outside of the tunnel resulted in a fixation strength comparable to interference screw fixation. Received: 2 September 1996 Accepted: 30 January 1997     

Anterior cruciate ligament patellar tendon reconstruction: it is probably better to leave the tendon defect open!

The purpose of our prospective study was to establish whether or not in anterior cruciate ligament (ACL) patellar tendon reconstruction the tendon defect has to be closed. In 50 consecutive ACL patellar tendon reconstructions, the tendon defect was randomly closed (group I) or left open (group II). The following data were recorded from all patients on the 4th and 14th days post operation: range of motion (ROM), pain at rest, pain and validity at isometric contraction, ability of bent leg raising (at 4th day) and straight leg raising (at 14th day). All the patients underwent ultrasonographic examination after 3 months and X-ray scanning at 6 months post operation. Forty patients underwent a CT-scan examination at 6 months. Thirty patients underwent isokinetic testing between 10 and 12 months post operation. Evaluating the immediate post operation data, no statistically significant differences emerged between the two groups. Ultrasonography showed in 68% of the knees of group I (defect closed) a thickened patellar tendon (PT), while in 60% of group II it was of normal thickness. No patients of either group developed patella infera by X-ray evaluation 6 months post operation. CT scans at 6 months showed that 100% of the knees of group I had a thickened PT in toto (nearly twice as thick as normal). Scar tissue was present not only in its central third but also in more than half of the cases in the medial and lateral third. In group II 75% of the patients had a normal thickness PT and 25% presented with only a minimal thickening. Scar tissue was distinguished only at its central third. Some 32% and 36% of the patients of group I and II, respectively, developed patellar irritability between the 5th and 8th month post operation. Isokinetic tests performed between the 10th and 12th months showed that the quadriceps deficit was slightly less in group II than in group I. Our study did not show very important clinical differences between the two groups but revealed that if the tendon defect is closed, an exuberant scar process arises involving the entire PT. This could mean, as reported in the literature, a high reduction in the biomechanical properties of the PT. For this reason it is probably better to leave the defect open.     

Tibial tunnel area changes following arthroscopic anterior cruciate ligament reconstructions with autogenous patellar tendon graft

We investigated radiographic changes in tibial tunnel area after ACL reconstructions with autogenous patellar tendon grafts on anteroposterior and lateral radiographs over 3 years. Fifty patients followed up for at least 1 year were included in the study. Radiographs were taken on the day of surgery and 3, 6, 9, 12, 24, and 36 months postoperatively. Tibial tunnels on both radiographs were divided into proximal, middle, and distal one-third. The area of each one-third and the greatest diameter of the tibial tunnel on both radiographs was measured using an image-processing software. According to the tunnel area changes, the shape of tibial tunnel was classified into one of four shapes; cylinder, mallet, reverse bottle, and reverse triangle. The correlations between area, diameter and shape of the tunnel, and clinical variables including arthrometer measurement and clinical score were determined. The areas of each one-third of the tibial tunnels on lateral radiographs was always greater than that on anteroposterior radiographs, although the diameters on the two radiographs did not differ significantly. The area of proximal one-third largest and that of distal one-third smallest on both radiographs at any time point. The enlargement and reduction occurred within 3 months and tended to continue for 9 months. Thereafter the tunnel change stabilized on both radiographs. The most common shape of the enlarged tunnels was cylindrical on anteroposterior radiographs reverse triangle on lateral radiographs. No negative effects of enlarged area, diameter, or tunnel shape on clinical results were found in our study.     

Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit

The most common graft in anterior cruciate ligament (ACL) surgery involves using the central one-third of the patellar tendon. Knowledge concerning the postoperative disability after harvesting the patellar tendon is, however, limited. The aim of this study was to evaluate the impact patellar tendon suture and bone grafting of the patellar bone defect might have in terms of functional outcome and patellofemoral pain after harvesting the bone-tendon-bone graft, compared with leaving the harvested site non-sutured and non-grafted. Sixty patients, scheduled for arthroscopically assisted ACL reconstruction, were randomly allocated to two groups. In group I, suture of the patellar tendon and bone grafting of the patellar defect were performed. In group II, the tendon gap and the patellar defect were left open. Preoperatively, there was no significant difference between the groups when comparing objective knee stability, as measured with a KT-1000 laxity meter, Lysholm score, Tegner activity level, IKDC score, or patellofemoral pain score. Both groups had a significantly improved Lysholm score at the 2-year follow-up, without any difference between them. Tegner's activity level was significantly lower at follow-up, compared with the pre-injury level in both groups. The patellofemoral pain score improved significantly after the reconstruction, without any difference between the groups. Ultrasonography did not reveal any difference between the groups in terms of healing of the tendon gap. This study revealed no differences in donor site morbidity, functional outcome, patellofemoral pain score or knee joint stability between the two treatment groups. The conclusion is that suture of the patellar tendon and bone grafting of the patellar defect do not improve the functional results or reduce donor site morbidity after arthroscopically assisted ACL. Received: 17 December 1996 Accepted: 30 July 1997     

Patellar tendon length after anterior cruciate ligament reconstruction: a comparative magnetic resonance imaging study between patellar and hamstring tendon autografts

Patellar tendon shortening after anterior cruciate ligament reconstruction may be associated with anterior knee pain or patellofemoral arthritis. The present study was designed to compare postoperative changes in patellar tendon length after anterior cruciate ligament reconstruction between patellar tendon and hamstring tendon autograft. Magnetic resonance images of both knees (operated and healthy) and functional outcome were documented at least 1 year postoperatively in 16 patellar tendon harvested patients and in 32 hamstrings harvested patients. Patellar tendon length, patella length and Insall–Salvati ratio were measured. The operated knee values were compared to the respective values of the non-operated control knees. A significant 4.2 mm or 9.7% patellar tendon shortening in patellar tendon group and a non-significant 1.14 mm or 2.6% shortening in hamstrings group was detected. No significant difference was detected in terms of major shortening—patella baja—(6% for the patellar tendon group vs. 0% for the hamsting group). There was no significant difference in anterior knee problems between the two groups as evidenced by the Shelbourne score (94 for the patellar tendon group vs. 98 for the hamsting group). Harvesting of the patellar tendon for anterior cruciate ligament reconstruction resulted in a significant shortening of the remaining tendon. In contrast harvesting of the hamstring tendons did not affect significantly the patellar tendon length. However, the incidence of patella baja and overall functional outcome was not significantly different between the two groups. Paper presented at the 12th ESSKA 2000 Congress, Innsbruck, Austria, 2006 and also presented at the 5th Biennial ISAKOS Congress, Hollywood, FL, USA, 2005.     

Interference screw fixation of hamstring vs patellar tendon grafts for anterior cruciate ligament reconstruction

The present study was designed to investigate the fixation strength of a quadruple semitendinosus-gracilis graft compared with a middle-third bone-patellar tendon-bone graft using a new interference screw developed to fix hamstrings grafts for ACL reconstructions (RCI, Smith & Nephew Donjoy). Five pairs of human cadaveric knees from donors with a mean age of 43 (range 33–52) years were used. One knee of each pair was randomly allocated to be reconstructed on the femoral side with a semitendinosus-gracilis graft from the same donor using RCI screw fixation. As the control, the contralateral knee was correspondingly reconstructed with a bone-patellar tendon-bone graft using the same interference screw. The grafts were pulled out at a velocity of 30 mm/s by an axially applied load using a MTS machine. The mean (SD) failure load for the bone-patellar tendon-bone graft fixations was 505 (25) N, 110% stronger than the mean failure load for the semitendinosus-gracilis graft fixations, which was 240 (47) N (P = 0.003). The stiffness for the patellar tendon-bone graft fixations was 46 (11) N/mm, 120% stiffer than the semitendinosus-gracilis graft fixations, which was 22 (11) N/mm (P = 0.01). This study shows that the interference screw principle used for ACL reconstructions with hamstrings tendons is inferior to that for bone-patellar tendon-bone reconstructions although the screw was developed especially for soft-tissue fixation in bone tunnels. Received: 14 August 1996 Accepted: 25 September 1997     

Graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction Intraoperative and cadaver measurement of the intra-articular graft length and the length of the patellar tendon

The results of a study conducted on 50 knees endoscopically reconstructed for an anterior cruciate ligament (ACL) lesion with a free bone-patellar tendon-bone graft and 9 cadaver knees are reported. The mean lengths of the patellar tendon (45.48 ± 4.71 mm) and intra-articular ACL graft (20.44 ± 1.98 mm) were measured in the operated knees. The mean length of the tibial bone tunnel (51.62 ± 2.60 mm) was also measured with a tibial guide at 55°. No statistically significant correlation was found between these three measurements. The length of the patellar tendon was weakly correlated with body height. Measurement of the tibial tunnel on the cadaver knees with increasing degrees of inclination revealed a mean length increase of 0.68 mm per degree (confidence limits: 0.49–0.86). Comparison between the tunnel lengths obtained with the guide and those measured with a Kirschner wire showed a mean difference of 2.3 mm. It is thus desirable to make the tunnel about 53 mm long to ensure excellent fixation of a 28 mm bone block with a 25 mm interference screw. Correct measurement of the anatomical structures involved is in any event an essential requirement for proper execution of the surgical technique. Received: 26 June 1997 Accepted: 12 November 1997     

Comparison of anterior cruciate ligament reconstruction in male and female athletes using the patellar tendon and hamstring autografts

Despite the higher incidence of anterior cruciate ligament (ACL) injuries in female than in male athletes few authors have studied the effects of gender on the outcome of ACL reconstruction. This prospective study compared the results of ACL reconstruction using the patellar tendon and hamstring techniques in men and women. We prospectively followed 80 comparable athletes (46 males, 32 females) from a population of 287 patients operated on at our institution for ACL reconstruction using either patellar tendon or hamstring graft. There were 26 males and 14 females in the patellar tendon group, and 22 males and 18 females in the hamstring group. All patients were operated on by the same surgeon within 6 months from injury and underwent the same rehabilitation program at the same center. After an average of 36 months the patients were assessed by clinical evaluation, computerized knee laxity analysis, and isokinetic and functional strength tests; standard knee scores were also used. Among patellar tendon patients there were no significant differences between males and females regarding knee evaluation form, laxity, or isokinetic and functional tests. Females in the hamstring group had significantly greater laxity, and isokinetic tests at 1 year revealed a significantly higher deficit of peak torque at 60°/s in flexion and extension. We suggest further studies on the clinical significance of these findings particularly on their possible ramifications in the areas of return to sports and rehabilitation of female athletes     

带血管蒂的自体骨髌腱骨重建前交叉韧带的临床研究

 目的观察"带与不带血管蒂的骨髌腱(PT)骨重建前交叉韧带(ACL)对早中期前交叉韧带完全断裂"的临床疗效.方法治疗组(A组)行带血管蒂骨髌腱骨重建前交叉韧带,对照组(B组)行不带血管蒂骨髌腱骨重建前交叉韧带.结果治疗组较对照组总有效率和显效率、前抽屉试验评分均高,两者间有显著性差异.结论带血管蒂骨髌腱骨重建前交叉韧带对治疗前交叉韧带损伤具有较好的治疗作用,可以明显缩短患者恢复时间,改善患者膝关节功能.     

Arthroscopic anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft

Tendon–bone incorporation of a tendon graft within the bone tunnel is of priority concern when using for anterior cruciate ligament (ACL) reconstruction. Superior healing process and stronger healing strength can be achieved when periosteum is sutured on the tendon inserted into a bone tunnel. We applied this idea to ACL reconstruction for enhancing tendon graft–bone tunnel healing. This is a prospective clinical outcome study with this surgical technique at minimal 2 years follow-up. Periosteum-enveloping hamstring tendon graft has been used in 68 patients. Data from 62 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of Lachman and anterior drawer test with a positive pivot-shift test. Clinical assessments included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented testing, thigh muscle assessment, and radiographic evaluation. The median Lysholm knee score was 59 (40–70) and 94 (60–100) points (P<0.01) before and after surgery. After reconstruction, 81% of patients were able to return to moderate or strenuous activity. Four (6%) patients were found to exhibit grade 2 or more ligament laxity. Complete range of motion could be achieved in 86% of patients. Three patients (5%) had positive pivot shift. Finally, 92% of patients were assessed as normal or nearly normal rating by IKDC guideline. Bone tunnels enlargement of more than 1 mm was identified in 5% of femoral tunnels and 6% of tibial tunnels. The study shows that a satisfactory result can be achieved with the periosteum-enveloping hamstring tendon graft in ACL reconstruction. Periosteum can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting. Besides the potential for improving tendon–bone healing, enveloped periosteum may help to seal the intra-articular tunnel opening in the early postoperative period, and thus avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be reduced.     

可吸收界面螺钉及腘绳肌腱重建前交叉韧带疗效分析

目的探讨关节镜下应用可吸收界面螺钉及腘绳肌腱对陈旧性膝关节前交叉韧带损伤的患者进行重建的临床疗效。方法对15例陈旧性前交叉韧带损伤患者行关节镜下重建手术,术后均随访1年,比较术前、术后膝关节稳定性、自觉症状、关节功能等,用Lysholm中的八项评分标准进行对比。结果 14例患者重建后膝关节的活动度及稳定性良好,1例差,优良率93.3%。结论关节镜下可吸收界面螺钉结合腘绳肌腱重建前交叉韧带是治疗陈旧性前交叉韧带的可靠术式,能够近期恢复膝关节的功能。     

关节镜下自体髌腱移植重建前交叉韧带的疗效观察

目的探讨使用自体骨-1/3髌腱-骨移植重建损伤的前交叉韧带(ACL)的临床疗效。方法本研究包括40例单纯性前交叉韧带断裂伴症状性胫骨前脱位的病例,均采用自体骨-1/3髌腱-骨重建。术后进行为期6个月的康复训练。术前和术后随访时行患侧膝关节X线检查,行体格检查及功能评分。结果总共36例(90%)获得随访,时间平均31个月。30例(83%)Lachman征及旋转移位试验阴性。Lysholm评分由术前平均(55.7±3.1)分增加至术后最后一次随访时的(90.1±2.7)分(P0.001)。而Tegner评分则由术前平均(5.0±1.4)分增加至术后(6.25±1.2)分(P0.001)。与术前X线检查相比,无退行性改变。结论采用自体骨-1/3髌腱-骨重建前交叉韧带后2年以上随访结果发现,83%的患者膝关节不稳现象消失,至术后最后一次随访时膝关节功能评分较术前显著增加。以该方法重建ACL有效地恢复了受伤膝关节功能。     

Reconstruction of anterior cruciate ligament using the doubled tendon graft technique: an experimental study in rabbits

In an attempt to assess reconstruction of the anterior cruciate ligament (ACL) by a new method, 18 New Zealand white rabbits underwent ACL replacement using the medial one-third of the patellar tendon and the semitendinosus tendon, thus partly reproducing the anatomical configuration of the ACL, with the semitendinosus tendon replacing the posterolateral bundle of the ACL and the patellar tendon replacing the anteromedial bundle. The Noulis-Trillat-Lachman test was performed before and after transection of the ACL, after reconstruction and before sacrifice. The animals were divided into four groups and were killed at 3, 6, 12 and 22 weeks after surgery. Femur-ligament-tibia complexes were evaluated postoperatively for gross morphology and histological appearance. The tendons of the first group showed compact parallel fibres with no definitive separation of their bundles and areas of disorganized collagen matrix. Tendons were surrounded by trabecular lamellar bone haphazardly arranged. The tendons of the second, third and fourth groups looked more like normal tendon. The trabecular bone surrounding the tendons formed a tunnel. The Noulis-Trillat-Lachman test result was negative before the procedure, 6.5±0.5 mm on average after transection of the ACL, 1.5±0.6 mm after the procedure, and negative again before sacrifice. The joints of the animals killed at 12 and 22 weeks showed signs of osteoarthritic lesions. Received: 29 May 1997 Accepted: 1 March 1998     

The tibialis tendon as a valuable anterior cruciate ligament allograft substitute: biomechanical properties

The study evaluates the biomechanical properties of single-strand and single-loop tibialis (anterior and posterior) tendon allografts. A comparison was made with bone-patellar tendon-bone (BPTB) allografts. Sixty-four tendon allografts were evaluated in this study. Sixteen of these were single-strand tibialis anterior (TA) and 16 single-strand tibialis posterior (TP) tendons. Sixteen single-loop TA and TP tendons were also tested. The fourth group was composed of 16 BPTB allografts. The biomechanical properties determined were maximal load, stiffness, cross-sectional area and elongation. The results of this study showed that the maximal load of the single-loop tibialis tendons (1,553 ± 62 N) was greater than of the BPTB (1,139 ± 99 N), TA (776 ± 43 N) and TP (888 ± 64 N) tendons. The stiffness of the single-loop tibialis tendons (236 ± 10 N/mm) was also greater than of the BPTB (168 ± 13 N/mm), TA (60 ± 2 N/mm) and TP (73 ± 5 N/mm) tendons. The cross-sectional area of the BPTB tendons was 67 ± 5 mm², of the single-loop tibialis tendons 36 ± 2 mm², of the TA tendons 20 ± 1 mm², and of the TP tendons 23 ± 1 mm². The elongation of the single-loop tibialis tendons and of the BPTB tendons was almost similar (7 ± 0.4 mm). The same applied to the TA and TP tendons (14 ± 0.6 mm). The results of this in vitro mechanical study suggest that fresh-frozen single-loop TA and TP tendons, and BPTB allografts are an acceptable substitute for hamstrings in anterior cruciate ligament reconstruction.     

Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon A 5–8-year follow-up

We reviewed 89 arthroscopically assisted patellar tendon anterior cruciate ligament (ACL) reconstructions for chronic isolated injuries with an average follow-up of 7 years (range 5.4 to 8.6 years). Pain was present in 7 knees (8%). Giving-way symptoms were reported by 7 patients (8%). A KT-2000 side-to-side difference over 5 mm at 30 lbs was recorded in 12 cases (16%). The pivot shift was glide in 17 cases (19%) and clunk in 10 (11%). A 3°– 5° extension loss compared with the normal side was present in 20 knees (22%) and 6°–10° in 4 knees (4%). The intra-articular exit of the femoral tunnel was misplaced in the anterior 50% of the condyles along the roof of the notch in 10% of the knees. This positioning significantly (P = 0.003) increased the frequency of graft failure (62.5%) compared with the cases with a more posterior placement (graft failure 12%). An anterior position of the intra-articular exit of the tibial tunnel (in the anterior 15% of the sagittal width of the tibia) significantly (P = 0.01) increased the frequency of extension loss > 5°. Medial meniscectomy was associated with a 35% incidence of narrowing of the medial joint space, which was significantly higher compared with knees with normal menisci (9%; P = 0.04) or with medial meniscal repair (7%; P = 0.05). In conclusion this study showed satisfactory anterior stability (KT-2000 side-to-side difference up to 5 mm and pivot absent or glide) in 83% of the knees. This percentage increases to 88% in the knees with a correct posterior and proximal femoral tunnel placement. Accuracy in tunnel positioning is essential for the success of ACL surgery. Meniscal repair was effective in decreasing joint space narrowing and should be attempted when possible. Received: 15 November 1996 Accepted: 17 March 1997     

Arthroscopic anterior cruciate ligament double-bundle reconstruction using hamstring tendon grafts-fixation with two interference screws: technical note

In this article, an original double-bundle anterior cruciate ligament reconstruction technique is described. The procedure is developed using hamstring tendon grafts while maintaining tibial osseous insertion. Two tibial tunnels are drilled and a simplified and precise outside-in double tunnel femoral drilling technique is utilized. The graft fixation is made using only two interference screws.     

Ankle morbidity after autogenous Achilles tendon harvesting for anterior cruciate ligament reconstruction

Although several alternative autografts with reduced morbidity of harvest site have been introduced, no donor site is free of morbidity concerns. The authors report on ankle status after autogenous Achilles tendon harvesting with a minimum 10-year follow-up. From October 1994 to October 1996, a consecutive series of 47 ankles underwent harvesting of the medial third or half of the ipsilateral autogenous Achilles tendon for primary anterior cruciate ligament reconstruction. Donor site statuses were evaluated using a modified Thermann’s scale. Postoperative isokinetic muscle strength testing was performed, and magnetic resonance images of donor sites were available for selected patients. Thirty-three ankles in the 32 patients were followed for more than 10 years. There were 27 men (84%) and 5 women (16%) with a mean age of 31 years (range 16–52 years) at the time of surgery. The mean duration of follow-up was 12 years and 1 month (range 10 years and 5 months to 13 years and 4 months). Mean postoperative modified Thermann’s scale score was 87 (range 45–95; SD 14.3). Twenty-five (76%) ankles achieved very good or good results. A slight decrease in calf circumference <1 cm was seen in the ten ankles, 1–2 cm in the four ankles. Nine ankles were mildly hypersensitive to meteorological changes. Peak torque of ankle plantar flexion was slightly lower on the index limb at both velocities in nine selected patients who carried out performance tests. However, there were no significant differences (5.2% at 30°/s and 2.7% at 120°/s, P = n.s. and P = n.s.). Of the 12 available follow-up magnetic resonance images, the average cross-sectional area of the remaining tendon was 82.01 mm² (range 69.05–107.35; SD 10.3), and their average thickness was 7.4 mm (range 6–10.35; SD 1.1). After a minimum 10-year follow-up, the harvesting of autogenous Achilles tendons was not found to significantly jeopardize ankle status. However, it also could not be independent of donor morbidity as an alternative. The level of evidence was retrospective level IV, as a therapeutic study.     

Dynamic joint loading following hamstring and patellar tendon anterior cruciate ligament reconstruction

This study compared lower limb dynamic joint loading after hamstring (HS) and patellar tendon (PT) anterior cruciate ligament (ACL) reconstruction. A three-dimensional motion analysis and force plate system were used to determine sagittal plane kinematics and kinetics in 20 subjects who had undergone ACL reconstruction (10 HS, 10 PT) whilst they performed both horizontal and vertical hopping tasks. Results for both activities showed significantly smaller knee flexion angles and external flexion moments in the operated than the non-operated limbs in PT subjects but no difference between limbs in HS subjects. There was no difference in the summated moment (hip plus knee plus ankle) between limbs for either graft type. The peak vertical ground reaction force was greater in the operated than the non-operated limb in PT subjects during the horizontal hop. These data show functional knee kinematic and kinetic differences between the two graft types that point to an earlier or better functional recovery in patients undergoing ACL reconstruction with HS graft than PT graft.