Serial magnetic resonance imaging evaluation of operative site after fixation of patellar tendon graft with bioabsorbable interference screws in anterior cruciate ligament reconstruction.

Magnetic resonance imaging (MRI) is accepted as the imaging procedure of choice for showing internal derangement of the knee. In contrast to metal implants, bioabsorbable interference screws do not produce an artifact and provide an opportunity to expand the evaluation of the postoperative anterior cruciate ligament (ACL) ligament repair. There is the potential to evaluate the implant, the graft, the adjacent tissue, and the surgically created bone tunnels. The purpose of this study was to evaluate with MRI the postoperative site of ACL patellar tendon autografts in which bioabsorbable screws were used for fixation. It was hypothesized that a time line of bone tissue changes resulting from this type of surgery could be developed based on the expanded evaluation of MRI. From January 1993 through October 1997, 270 patients underwent surgical repair of a disrupted native ACL. There were 173 men 97 women; the average age was 25.1 years, (range, 17 to 50 years). There were 155 right knees and 115 left knees. In addition to the conventional postoperative clinical assessment and plain film radiographs, opportunistic MRIs were obtained with the patient's permission. The examinations were performed at different postoperative intervals from the third postoperative day to 4 years postoperatively. A total 206 MRIs from various time intervals were available for study. The study protocol was designed to look for loss of integrity of the screws, adjacent fluid collection, tunnel widening, and tunnel healing or narrowing. The hypothesis was substantiated in this study. The use of MRI provided observations not available by other imaging methods. The absence of metal implants for fixation provided an opportunity to examine the adjacent tissue in detail and to form a time line of the tissue response in this type of surgery.     

Shortening of the patellar tendon after anterior cruciate ligament reconstruction

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

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 …     

Anterior cruciate ligament reconstruction with patellar autograft tendon

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

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.

     

关节镜下中1/3髌腱移植重建膝后十字韧带

目的关节镜下应用中1/3髌腱移植重建后十字韧带,评估其近期临床治疗效果。方法采用骨-中1/3髌腱-骨组织移植重建膝关节后十字韧带,用于治疗后十字韧带损伤后关节不稳定。手术在关节镜下经前方入路完成。结果12例患者平均随访17.3个月。Larson评分由术前60.7分提高到93.4分,Lysholm评分由术前55.0分提高到91.6分。所有患膝术前后抽屉试验及Lachman试验均阳性,术后仅2例后抽屉试验弱阳性、1例Lachman试验弱阳性。结论在关节镜直视下,能准确定位后十字韧带解剖止点,钻制骨隧道,植入移植组织。该技术具有不切开关节囊,损伤小、关节粘连率低的优点。     

Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft

Purpose

The purpose of this study was to compare the outcomes of arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using autologous patellar tendon and hamstring tendon grafts.

Methods

From 1998 to 2007, 59 patients with symptomatic isolated posterior cruciate ligament injury were included in this retrospective study. Twenty-five knees were reconstructed using bone-patellar tendon-bone graft, and 34 knees were reconstructed using hamstring graft. In both groups, surgical techniques were similar, except material of fixation screws. Patients were evaluated pre-operatively and post-operatively at the latest follow-up with several parameters, including symptoms, physical examination, outcome satisfaction, functional scores, radiography and complications.

Results

Average follow-up period was 51.6 months in patellar tendon group and 51.1 months in hamstring tendon group. Significantly more kneeling pain (32 vs. 3 %), squatting pain (24 vs. 3 %), anterior knee pain (36 vs. 3 %), posterior drawer laxity and osteoarthritic change were shown in patellar tendon group than in hamstring tendon group post-operatively. No significant differences were found in other parameters between both groups.

Conclusions

Several shortcomings, including anterior knee pain, squatting pain, kneeling pain and osteoarthritic change, have to be concerned when using patellar tendon autograft. In conclusion, hamstring tendon autograft may be a better choice for transtibial tunnel PCL reconstruction.     

Anterior cruciate ligament reconstruction with fresh-frozen patellar tendon allografts

Summary A prospective study was performed on 30 patients who underwent an anterior cruciate ligament reconstruction with fresh-frozen patellar tendon allograft. An arthroscopic technique alone was used in 10 patients, and in the other 20 patients this was combined with a miniarthrotomy. After a mean follow up of 35 months, the overall functional results were satisfactory in 85%. There were no cases of infection, disease transmission or tissue rejection. Fresh-frozen patellar tendon allografts are a good method of anterior cruciate reconstruction.

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Résumé On a réalisé une étude prospective sur 30 patients traités, de 1988 à 1991, par reconstruction du ligament croisé antérieur (LCA) à l'aide d'allogreffes congelées fraîches de tendon rotulien (os-tendon-os). L'intervention, avec forage d'un tunnel fémoral et tibial, a été pratiquée sous simple arthroscopie dans 10 cas, tandis que chez les 20 autres patients elle a été associée à une mini-arthrotomie. Les opérés ont été suivis 35 mois en moyenne, avec un résultat fonctionnel global satisfaisant dans 85% des cas. Pour cette évaluation on a utilisé la cotation ARPEGE. On n'a observé aucun cas d'infection, de transmission de maladie ou de rejet immunologique. En conséquence nous pensons que les allogreffes congelées fraîches de tendon rotulien représentent une alternative valable dans le traitement des lésions du LCA.

     

Arthroscopic anterior cruciate ligament reconstruction with patellar tendon.

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

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.     

Isokinetic evaluation of anterior cruciate ligament reconstruction: hamstring versus patellar tendon.

The purpose of the study was to compare the hamstring and quadriceps isokinetic results 6 months postoperatively in patients having patellar tendon or hamstring anterior cruciate ligament (ACL) reconstruction. The study group was comprised of 106 randomly selected patients who had ACL reconstruction with either autogenous patellar tendon (PT), semitendinosus (ST), or semitendinosus and gracilis (ST/G). Hamstring and quadriceps isokinetic strength were assessed at 180 degrees/sec and 300 degrees/sec with the results of the operatively treated leg expressed as a percent compared with the nonoperative leg. The mean results for knee extension at 180 degrees/sec were 68.3%, 74.3%, and 78.1%; and at 300 degrees/sec were 70.7%, 76.7%, and 81.7% for PT, ST, and ST/G, respectively. The mean results for knee flexion at 180 degrees/sec were 86.1%, 80.6%, and 81.7%; and at 300 degrees/sec were 77.6%, 79.1%, and 75.6% for PT, ST, and ST/G, respectively. No statistically significant differences were found in regard to knee extension or flexion strength when evaluating the different tissue sources. The results show that selection of autogenous hamstring or PT used for ACL reconstruction should not be based solely on the assumption of the tissue source altering the recovery of quadriceps and/or hamstring strength. In addition, a majority of the patients had not achieved adequate strength to safely partake in unlimited activities at 6 months postoperatively.     

Patellar tendon defect during the first year after anterior cruciate ligament reconstruction: Appearance on serial magnetic resonance imaging

The purpose of this study was to use magnetic resonance imaging to evaluate various parameters of the patellar tendon during the first year after harvest for anterior cruciate ligament (ACL) reconstruction. Twelve consecutive patients were serially imaged on a 1.5 Tesla GE magnet (GE Medical Systems, Milwaukee, WI) with a dedicated knee coil at 3 weeks, 3 months, 6 months, and 1 year after undergoing ACL reconstruction using a central one-third patellar tendon autograft. The tendon defect was not closed primarily, but the paratenon was approximated. The following measurements were performed: tendon width, defect width, cross-sectional area of the tendon, and tendon length. In addition, the patellar bone harvest site was evaluated for healing. The width of the tendon defect decreased by 62% over 12 months (P < .05). Only two patients showed complete closure of the defect. Tendon width was noted to decrease by 6.5% (P=.017). The ratio of defect width to overall tendon width (designated R) decreased by 58% (P < .05). Tendon length was noted to decrease during this by 8% (P=.037). The tendon cross-sectional area was noted to increase by 9% at 1 year, but this was not found to be statistically significant (P=.39). One year after ACL reconstruction using a central one-third patellar tendon, the tendon defect has begun to reconstitute itself but there is still a significant gap. This persistent defect must be taken into consideration when planning revision ACL surgery using reharvest of the central one third of the patellar tendon. The entire tendon also exhibits a reduction in width and length, while cross-sectional area increases slightly. Complete healing of the graft defect can not be assumed at 12 months post-ACL reconstruction. (Arthroscopy 1998 Nov-Dec;14(8):804-9.)     

Knee evaluation in two systems and magnetic resonance imaging after operative treatment of posterior cruciate ligament injuries

We reviewed 30 patients operated on because of acute (n = 14) or chronic (n = 16) rupture of the posterior cruciate ligament (PCL) with an average follow-up time of 6.9 years. The clinical outcome was expressed using the OAK and the International Knee Documentation Committee (IKDC) evaluation forms. All patients had undergone posterior stress X-radiography, 14 patients had additionally undergone magnetic resonance imaging (MRI). OAK score showed good or excellent results in 93% of the acute and 38% of the chronic cases. The IKDC form, however, revealed nearly normal results in only 29% of the acute and 6% of the chronic cases. The length and thickness of the operated PCL on MRI correlated with the clinical result.     

Arthroscopic-assisted posterior cruciate ligament reconstruction using patellar tendon autograft: a technique for graft passage

During arthroscopic posterior cruciate ligament (PCL) reconstruction, passage of the graft into the knee joint may be difficult, especially when using the patellar tendon. Because of the angle of passage, the bone block ends may become entangled or caught on the superior edge of the posterior tibial tunnel when passing the graft from the tibia to the femur. The use of a blunt trocar through the posteromedial portal avoids impingement of the bone block against the edge of the tibial tunnel. This method uses the pulley principle and permits the graft to pass freely into the knee. This method has been used successfully by the authors in more than 40 PCL arthroscopic reconstructions.     

Magnetic resonance imaging of tunnel placement in posterior cruciate ligament reconstruction.

The aim of this study was to define a reproducible method for evaluating posterior cruciate ligament (PCL) reconstructions using magnetic resonance imaging (MRI). A 2-fold investigation was performed. In part I, the "footprints" of an intact PCL were located on MRI and their coordinates were defined. Measurements were made on the images of 50 subjects using axial, coronal, and sagittal planes. Interobserver variability was calculated by averaging the measurements of the 2 reviewers and using the Kappa coefficient. Three points of reference were located: tibial attachment on the tibial axial plane, and two femoral attachments on the sagittal and coronal oblique planes. In part II, stability of 20 PCL reconstructions with a bone-patellar tendon-bone (BPTB) autograft were evaluated and scored using the IKDC evaluation form after a 2-year follow-up. Stability was evaluated clinically and instrumentally using a KT-2000 arthrometer at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70 degrees . Seven cases were graded A (0 to 2 mm), 11 graded B (3 to 5 mm), and 2 graded C (6 to 10 mm). All patients had an MRI after an average of 16 months (range, 12 to 24 months, 2 SD). The previous measurements from part I of the study were used to make a correlation between achieved stability and tunnel location. A 1-factor analysis of variance (ANOVA), nonparametric ANOVA, and the Fisher Exact test were used to determine if clinical outcome of the 3 groups was influenced by graft placement. At MRI evaluation, excessive deep placement was observed in 4 cases and a correlation between improper femoral tunnel location and stability was statistically significant (P < .05). A correct placement of tibial tunnel was observed in all patients. In our analysis, proper location of the femoral tunnel seems to be more critical and difficult to achieve than tibial tunnel placement, probably because of the lack of specific anatomic landmarks during surgery.