Knee isokinetic performance following anterior cruciate ligament reconstruction: patellar tendon versus hamstrings graft

Objective: To compare knee isokinetic performance six months after reconstruction of the anterior cruciate ligament using grafts from either the patellar tendon or the hamstrings among patients who underwent the same rehabilitation protocol.

Methods: Thirty-four patients were evaluated (17 with grafts from the patellar tendon and 17 with grafts from the hamstrings). Operated and non-operated knees were compared with regards to the variables of peak torque, work and the hamstring/quadriceps relationship at velocities of 60º/s and 180º/s and power of 180º/s after six months of surgery.

Results: The patients with ACL reconstruction using the patellar tendon (BPTB) showed quadriceps deficits for all variables, but the flexor musculature was balanced. In the hamstring group, both the extensors and the flexors showed deficits for the variables analyzed, except for hamstring power at 180º/s.

Conclusion: Patients in the patellar tendon group had a greater quadriceps deficit compared with those in the hamstrings group. Patients in the hamstrings group had a greater muscular deficit in the flexor mechanism compared with the contralateral knee. An unbalanced H/Q ratio was observed regardless of graft type, but this was more evident in the BPTB group.     

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.     

Anterior cruciate ligament reconstruction using hamstrings for a two-incision technique

Anterior cruciate ligament (ACL) reconstructions are most commonly performed through a single incision, using either a patellar tendon or a hamstring graft. This technique, however, may be problematic in circumstances such as revision ACL reconstructions or reconstructions in patients with open growth plates. In these cases, a second incision may be needed to avoid existing tunnels or an open physis. The two-incision ACL reconstruction technique described in this article incorporates a four-stranded, gracilis-semitendinosus graft. The four free tendon ends are fixed proximally in a figure-of eight fashion with two bicortical screws and soft tissue washers. The distal looped end is secured with three No. 5 sutures tied to a screw and post. This construct provides graft (2800–4500 N) and fixation (821 N) strengths exceeding that of a 10 mm patellar tendon graft with interference screw fixation. This technique allows for an accelerated rehabilitation program, has low graft harvest morbidity, and provides the freedom necessary for tunnel placement and orientation in complicated reconstructions. For these reasons, this technique should be familiar to surgeons specializing in knee ligament reconstruction.     

Relationship between muscle volume and muscle torque of the hamstrings after anterior cruciate ligament reconstruction

The muscle torque per unit volume of the hamstrings on the injured and uninjured sides in patients with ACL reconstruction were compared with participants with no history of knee injury to examine whether a similar mechanism leading to quadriceps weakness exists in the hamstrings of these patients. The study population consisted of 18 and 52 patients at ≤6 and 12 months after ACL reconstruction, respectively, and 35 healthy controls. The hamstring volume was measured on MRI. To identify the muscle torque per unit volume, the peak torque of knee flexion was divided by the hamstring volume. Most muscle torque per unit volume indexes were not significantly different between the patients at ≤6 months (injured side: 0.133 ± 0.03 N m/cm³, 60°/s; 0.107 ± 0.03 N m/cm³, 180°/s; uninjured side: 0.139 ± 0.02 N m/cm³, 60°/s; 0.107 ± 0.02 N m/cm³, 180°/s) and controls (0.170 ± 0.05 N m/cm³, 60°/s; 0.121 ± 0.05 N m/cm³, 180°/s). However, the muscle torque per unit volume of patients at 12 months in both injured (0.118 ± 0.03 N m/cm³, 60°/s; 0.092 ± 0.02 N m/cm³, 180°/s) and uninjured sides (0.120 ± 0.03 N m/cm³ at 60°/s; 0.094 ± 0.02 N m/cm³, 180°/s) were significantly lower than those of controls (P < 0.01). We found no evidence of recruitment disorder in the hamstrings of the patients. The results of this study indicated that the mechanism of muscle weakness of the hamstrings after reconstruction was different from that of the quadriceps, although the precise mechanism remains to be determined.     

Isokinetic and anterior cruciate ligament reconstruction with hamstrings or patella tendon graft: analysis of literature

We report isokinetic results of anterior cruciate ligament reconstruction with patellar tendon or hamstring graft from the literature analysis. The literature was defined from two search "textwords": Isokinetic and Anterior cruciate ligament reconstruction, and from three databases: Medline, Pascal, and Herasmus. Two independent physicians (Physical Medicine and Rehabilitation) carried out an analysis according to the French National Accreditation and Health Evaluation Agency recommendations. Fifty-three studies were selected: 29 reported isokinetic results after anterior cruciate ligament reconstruction with patellar tendon graft, 15 reported isokinetic results after anterior cruciate ligament reconstruction with hamstring graft, and 9 studies compared the two surgical procedures. After discussing different bias and in reference to prospective randomised and comparative studies, the anterior cruciate ligament reconstruction with patellar tendon graft involves a knee extensors deficit during several months. The hamstring surgical procedure involves a less important knee extensor deficit (from 6 to 19 % against 8 to 21 %). Knee sprain and intra-articular surgery involve a long-lasting knee extensors deficit. Anterior cruciate ligament reconstruction with hamstrings graft involves a knee flexors deficit over several months. The patellar tendon surgical procedure involves a less important knee flexors deficit (from 1 to 15 % against 5 to 17 %). In reference to isokinetic parameters, no difference between the two surgical procedures (patellar tendon graft or hamstring graft) is shown after more than twenty-four post-surgical months.     

Evaluation of hamstring strength and tendon regrowth after harvesting for anterior cruciate ligament reconstruction

BACKGROUND: It is generally thought that tissue regeneration and good functional recovery can be expected after anterior cruciate ligament reconstruction using the hamstring tendons. However, persistent strength deficit in deep knee flexion has also been reported. HYPOTHESIS: Morphologic regeneration of the harvested hamstring tendon is not necessarily associated with its functional recovery. STUDY DESIGN: Retrospective follow-up study. METHOD: Twenty-eight patients who underwent anterior cruciate ligament reconstruction with hamstring graft were evaluated after a minimum period of 2 years. Status of tendon regrowth was assessed by magnetic resonance imaging. To specifically analyze the functional deficit after graft harvest, the isometric hamstring strength was examined in a sitting position at 90 degrees of flexion and a prone position at 90 degrees and 110 degrees of flexion. Then, the strength data were correlated with the extent of tendon regeneration. RESULTS: In 22 of the 28 patients, a regrowth of the semitendinosus tendon was found, whereas regeneration of the gracilis tendon was observed in 13 patients. In the evaluation of hamstring strength, the isometric peak torque was reduced to 86.2%, 54.6%, and 49.1%, respectively, in the aforementioned 3 postures as compared with the contralateral side. CONCLUSIONS: Significant functional deficit of hamstring strength remains regardless of morphologic regeneration.     

Effect of muscle preserved on tendon graft on intra-articular healing in anterior cruciate ligament reconstruction

Purpose

The aim of this study was to determine the impact on intra-articular healing of muscle tissue retained on tendon grafts used for anterior cruciate ligament (ACL) reconstruction.

Methods

In an animal study on 40 New Zealand rabbits, a semi-tendon/semi-muscle graft (SSG) and a total tendon graft (TTG) were individually harvested from the Achilles tendons in each animal. After transecting the ACLs in both knees of each rabbit, SSG and TTG were randomly used on bilateral sides of the knee for ACL reconstruction. After 2, 4, and 8 weeks, functional scoring, gross observations, and histological evaluations of the repaired knees were performed (each time point; n = 10). Biomechanical testing was conducted on remaining animals at 8 weeks (n = 10).

Results

At 2, 4, and 8 weeks after surgery, there were no statistically significant differences in functional scores between the SSG group and TTG group (n.s.). As healing progressed, skeletal muscle on the SSG was gradually absorbed with a corresponding decrease in graft diameter, compared to TTG, at each time point (P < 0.001). However, healing and incorporation of the intra-articular graft in the SSG were more apparent than those in the TTG, based on histology. The vascularity and cellularity in the center of the sample were significantly greater in the SSG group than the TTG group at all the time points (P < 0.01). At 8 weeks, the SSG group’s ultimate failure load, yield load, and elongation at failure were significantly less than for the TTG group (P < 0.01). There were no significant differences in stiffness between the two groups with biomechanical testing (n.s.).

Conclusion

Results of this study indicate that muscle left on tendon grafts promotes intra-articular healing and remodeling of the graft in a rabbit model. However, excessive amounts of retained skeletal muscle weaken tendon graft’s strength for ACL reconstruction. Preserving small amounts of muscle on tendon grafts is feasible for improving the biological success of ACL reconstruction in humans.     

TransLateral ACL reconstruction: a technique for anatomic anterior cruciate ligament reconstruction

Anatomic placement of the femoral tunnel in anterior cruciate ligament (ACL) reconstruction confers biomechanical advantages over the traditional tunnel position. The anteromedial portal technique for anatomic ACL reconstruction has many well-described technical challenges. This paper describes the TransLateral technique. The technique produces anatomic femoral tunnel placement using direct measurement of the medial wall of the lateral femoral condyle and out to in drilling. All work is carried out through the lateral portal with all viewing via the medial portal. There is no need for an accessory medial portal or hyperflexion of the knee. Level of evidence Expert opinion, Level V.     

Central quadriceps free tendon for anterior cruciate ligament reconstruction

Central quadriceps free tendon provides an outstanding autograft alternative for routine anterior cruciate ligament (ACL) reconstruction, allowing preservation of hamstring tendons and eliminating the morbidity of bone plug harvest from the patella. Correct graft harvest technique, proper tunnel/graft sizing, accurate fixation, and adherence to the methods described will permit excellent ACL reconstruction with low morbidity.     

MRI of anterior cruciate ligament reconstruction.

Eleven asymptomatic patients 1-9 months after arthroscopic assisted anterior cruciate ligament (ACL) reconstruction with autogenous semitendinosus and gracilis tendons as a "neoligament" were studied by MR. Each neoligament was clinically intact. Examinations were performed at 1.5 T with T1- and T2-weighted sagittal and oblique spin echo images in the plane of ACL repair. On MR in 9 of the 11 patients (82%) the ACL neoligament appeared as a smooth well-defined band of low signal intensity along its entire course. In two patients (18%) the integrity of the neoligament could not be determined by MR. Ligaments in which integrity could not be determined demonstrated irregularity or a wavy contour, high signal intensity change within the ligament, or discontinuity of the ligament. We conclude that, contrary to previous reports, MR can demonstrate an intact ACL reconstruction.     

Evaluation of hamstring muscle strength and morphology after anterior cruciate ligament reconstruction

This study aimed to clarify the relationship between knee flexor strength and hamstring muscle morphology after anterior cruciate ligament (ACL) reconstruction using the semitendinosus (ST) tendon and to determine the causative factors of decreased knee flexor muscle strength. Fourteen male and ten female patients who resumed sports activities after surgery participated in the experiment. Isometric knee flexion torque was measured at 30°, 45°, 60°, 90°, and 105° of knee flexion. Magnetic resonance imaging (MRI) was used to calculate ST muscle length and hamstring muscle volume, and to confirm the status of ST tendon regeneration. The correlation between the MRI findings and flexor strength was analyzed. Regenerated ST tendon was confirmed in 21 of the 24 patients, but muscle volume (87.6%) and muscle length (74.5%) of the ST in the operated limb were significantly smaller than those in the normal limb. The percentage of the knee flexion torque of the operated limb compared with that of the normal was apparently lower at 105° (69.1%) and 90° (68.6%) than at 60° (84.4%). Tendon regeneration, ST muscle shortening, and ST muscle atrophy correlated with decreased knee flexion torque. These results indicated that preserving the morphology of the ST muscle‐tendon complex is important.     

Long-term followup of anterior cruciate ligament reconstruction using the quadriceps tendon substitution for chronic anterior cruciate ligament insufficiency

At The Hospital for Special Surgery, the quadriceps tendon substitution (QTS), as described by Marshall, was performed for ACL insufficiency from 1973 to 1980. A review of the initial 60 patients with a minimum of 4 years followup (average, 5.5 years) has been concluded. Thirty-eight patients returned for examinations, and 11 returned questionnaires. Associated medial procedures were performed in 29 of the 38 examined patients. Medial meniscus surgery was performed in 86% and lateral meniscus surgery in 28.9%. At followup, giving way, which was the main preoperative complaint, was eliminated in 30/38 examined and 9/11 questionnaire patients (79%). In the examined group, three patients were clear failures and five had mild transient instability. The pivot shift was present in 17 of 38 (45%) patients examined: 21 patients were negative, 9 were 1+ or a grind, 8 were 2+, and none were 3+. We have concluded that the QTS procedure will eliminate symptomatic instability in 79% of our patients, but the high rate of a residual pivot shift (45%) and symptoms of instability (21%) require the addition of an extraarticular sling procedure. This appears to be related to the relatively poor strength characteristics of the tissue used in the QTS substitution.     

Anatomic anterior cruciate ligament reconstruction: the two-incision technique

This article describes the anatomical two-incision reconstruction of anterior cruciate ligament (ACL) of knee. The major part of currently single incision tibial endoscopic techniques attempts to reproduce the most isometric anteromedial bundle of ACL. Often a relatively vertical femoral tunnel, respect to the notch, is drilled, which is not really efficacious in providing rotatory stability. The single incision technique was developed to obviate the necessity of the lateral femoral incision and dissection. This technical note describes a two-incision ACL reconstruction using an instrumentation, which avoids a large lateral femoral soft tissue dissection, and discusses the rational use of the two-incision ACL reconstruction technique.     

MRI of patellar tendon anterior cruciate ligament autografts.

Twenty-one MR examinations were performed in 15 patients with clinically stable knees after arthroscopic anterior cruciate ligament (ACL) reconstruction with patellar bone-tendon-tibial bone autografts. The postoperative interval ranged from 3 months to 3 years 3 months (average 9.5 months). Proton- and T2-weighted sagittal images with axial and oblique sagittal T1-weighted images were obtained. The MR appearance of the autografts was categorized depending on distribution of dark signal band into type 1 (continuous, two patients), type 2 (proximal half, eight patients), type 3 (distal half, two patients), and type 4 (nonvisualization, three patients). There was no change in appearance of the grafts in those who had a second imaging within 1 year postoperatively. We conclude that the normal ACL autograft has a variable appearance and that criteria used in evaluating the native ligament is inadequate to assess the autografts.     

Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts

BACKGROUND: The best choice of graft tissue for use in anterior cruciate ligament reconstruction has been the subject of debate. HYPOTHESIS: Anterior cruciate ligament reconstruction with patellar tendon autograft leads to greater knee stability than reconstruction with hamstring tendon autograft. STUDY DESIGN: Metaanalysis. METHODS: A Medline search identified articles published from January 1966 to May 2000 describing arthroscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring tendon autograft and with a minimum patient follow-up of 24 months. RESULTS: There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%). CONCLUSIONS: Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain.     

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。     

The double-bundle technique for anterior cruciate ligament reconstruction: a systematic overview

In traditional anterior cruciate ligament reconstruction, there is a subset of patients complaining of knee instability, especially rotational instability, and athletes not able to return to their preinjury level of sports activity. Currently, controversy exists over the usefulness of the double bundle technique (DBT) in addressing these problems. In order to evaluate the DBT, we completed a literature review from 1969 to February 2006 focusing on anatomy, magnetic resonance imaging, graft incorporation, biomechanics, kinematics, surgical techniques, complications and outcome. The DBT is not a standardized technique, which makes it difficult to compare results. Cadaver studies have proven biomechanical advantages with respect to ap-stability, but assessing the rotational stability remains difficult. There is a lack of available outcome studies with sufficient follow-up to demonstrate the potential advantages of DBT. The theoretical advantages of DBT require careful evaluation with outcome, biomechanical and kinematic studies. In addition, studies are needed to address issues such as graft incorporation and complications. An advantage offered by DBT is the possibility to identify rupture patterns that can lead to surgical preservation of an intact and augmentation of an injured bundle. The approach of augmentating a single bundle technique reconstruction with adequate anterior-posterior but poor rotational stability is promising.     

Isokinetic evaluation of anterior cruciate ligament reconstruction: quadriceps tendon versus patellar tendon

AIM: The goal of this prospective randomized study was to compare the isokinetic recovery of thigh strength after anterior cruciate ligament (ACL) reconstruction by using patellar or quadriceps tendon as graft at the 6th month follow-up. METHODS: The authors evaluated 48 patients who underwent arthroscopic ACL reconstruction using patellar tendon (PT group) or quadriceps tendon (QT group) as autograft after a 6 months follow-up undergoing the following tests: the Ergojump Bosco System springboard and Universal's FITNET computerized isokinetic system. RESULTS: The counter movement jump (CMJ) test showed a 24% (p<0.01) strength deficit in patients operated with patellar tendon and 11% in the quadriceps tendon group. Also in the leg press test the greater differences in strength (p<0.05) were verified in the patellar tendon group, above all the peak torque (PT) test carried out at 3 repetitions (15%). CONCLUSIONS: The strength deficit found in the subjects operated with quadriceps tendon were statistically lower in comparison to that verified in the patellar tendon group. A good recovery in thigh strength after 6 months in patients operated with quadriceps tendon could encourage the use of this kind of graft in order to achieve an easier rehabilitation and a faster release of the patient to daily and sports activity.