无内固定物腘绳肌腱重建前交叉韧带临床探讨

目的探讨用无内固定物的绳肌腱重建前交叉韧带的临床运用和效果。方法自2002年12月～2004年6月对33例前交叉韧带损伤进行了无内固定物的绳肌腱重建前交叉韧带术,其中13例移植肌腱采用二股半腱肌腱和二股股薄肌腱,另20例仅为二股半腱肌腱,术前和术后进行Lachman试验评估膝关节的稳定性,用Lysholm评分方法评定膝关节功能。结果术前Lachman试验均为阳性,术后29例为阴性,4例为阳性。术前Lysholm评分为36～57分,术后Lysholm评分为71～96分。结论无内固定物的绳肌腱重建前交叉韧带为生物固定,固定可靠、费用少、短期效果好,中长期效果有待观察。     

Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction: THE GRAFT OF THE FUTURE!

Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopaedic surgeries performed on active people in the world. One of the most important surgical decisions is graft type for use in the reconstruction. Despite extensive research on optimal graft choice for ACL reconstruction, discrepancy exists among practicing surgeons' graft preference. Recently, the quadriceps tendon has gained popularity for use as a graft source for ACL reconstruction.The all soft tissue quadriceps graft offers many advantages over other autograft choices. Histologically it has 20% more collagen fibrils per cross-sectional area than the patellar tendon (PT). Biomechanically, its ultimate load is 70% > than that of a similar width PT graft, while its modulus is more similar to the native ACL than either the PT or hamstring graft. Anatomically the quadriceps tendon has significantly more volume than the PT. Thus, even after harvest of the quadriceps graft, the remaining quadriceps tendon is still 80% stronger than the intact PT!The length and cross-sectional area of the quadriceps tendon graft can be tailored to the needs of the patient. On any patient over 5 feet tall, a graft length of 7 cm can be obtained. Because the thickness of the tendon is almost twice the thickness of the same patient's PT, a graft diameter from 7 to 11 mm can easily be achieved. Thus, this graft can be customized for both primary and revision surgeries.Harvest site morbidity is minimal. An incision less than 2 cm in an area with no significant cutaneous nerves without harvest of any patella bone leads to no significant harvest site pain, numbness, or palpable defect.Clinical outcomes using this graft are excellent. Our prospective data on nearly 1,000 grafts, with a mean patient age of 20 years old, show a 4.2% failure rate. Thus, the all soft tissue quadriceps graft will be the surgical choice for ACL reconstruction for future athletes.     

Biomechanics of the anterior cruciate ligament and implications for surgical reconstruction

Abstract Injury to the anterior cruciate ligament (ACL) is regarded as critical to the physiological kinematics of the femoral-tibial joint, its disruption eventually causing long-term functional impairment. Both the initial trauma and the pathologic motion pattern of the injured knee may result in primary degenerative lesions of the secondary stabilisers of the knee, each of which are associated with the early onset of osteoarthritis. Consequently, there is a wide consensus that young and active patients may profit from reconstructing the ACL. Several factors have been identified as significantly influencing the biomechanical characteristics and the functional outcome of an ACL reconstructed knee joint. These factors are: (1) individual choice of autologous graft material using either patellar tendon-bone grafts or quadrupled hamstring tendon grafts, (2) anatomical bone tunnel placement within the footprints of the native ACL, (3) adequate substitute tension after cyclic graft preconditioning, and (4) graft fixation close to the joint line using biodegradable graft fixation materials that provide an initial fixation strength exceeding those loads commonly expected during rehabilitation. Under observance of these factors, the literature encourages mid-to long-term clinical and functional outcomes after ACL reconstruction.     

关节镜下异体与自体肌腱联合编织重建前交叉韧带

目的探讨关节镜下异体与自体肌腱联合重建前交叉韧带(anterior cruciate ligament,ACL)的临床疗效。方法自2006年5月至2009年12月2股异体肌腱及2股自体绳肌腱联合重建ACL并获得随访41例。通过随访,分析异体与自体肌腱联合重建ACL术后2年时膝关节应力试验情况及术后2年时膝关节Lysholm评分情况。结果 41例患者术后均未发生急慢性感染、排异反应、屈膝无力,轴移试验均为阴性,术后2年后前抽屉试验及Lach-man试验为阴性或度阳性,膝关节Lysholm评分(90.95±4.84)分,与术前膝关节Lysholm评分(52.34±8.45)分相比较差异有统计学意义(t=26.40,P=0.00)。结论异体与自体联合肌腱作为移植物重建ACL在临床上安全可靠,可作为前交叉韧带重建移植物的一种选择方式。     

Prospective clinical comparisons of semitendinosus versus semitendinosus and gracilis tendon autografts for anatomic double-bundle anterior cruciate ligament reconstruction

Background

The data available from the previously reported clinical studies remains insufficient concerning the hamstring graft preparation in double-bundle anterior cruciate ligament (ACL) reconstruction.

Objective

To test the hypothesis that there are no significant differences between the semitendinosus tendon alone and the semitendinosus and gracilis tendon graft fashioning techniques concerning knee stability and clinical outcome after anatomic double-bundle ACL reconstruction.

Methods

A prospective study was performed on 120 patients who underwent anatomic double-bundle ACL reconstruction according to the graft fashioning technique. The authors developed the protocol to use hamstring tendon autografts. When the harvested doubled semitendinosus tendon is thicker than 6 mm, each half of the semitendinosus tendon is doubled and used for the anteromedial (AM) and posterolateral (PL) bundle grafts (Group I). On the other hand, when the harvested semitendinosus tendon is under 6 mm in thickness, the gracilis tendon is harvested additionally. The distal half of the semitendinosus and gracilis tendons are doubled and used for the AM bundle graft, and the remaining proximal half of the semitendinosus tendon is doubled and used for the PL bundle grafts (Group II). Sixty-one patients were included in Group I, and 59 patients in Group II. The two groups were compared concerning knee stability and clinical outcome 2 years after surgery.

Results

The postoperative side-to-side anterior laxity averaged 1.3 mm in both groups, showing no statistical difference. There were also no significant differences between the two groups concerning the peak isokinetic torque of the quadriceps and the hamstrings, the Lysholm knee score, and the International Knee Documentation Committee evaluation.

Conclusion

There were no significant differences between the two graft fashioning techniques after anatomic double-bundle ACL reconstruction concerning knee stability and postoperative outcome. The present study provided orthopedic surgeons with important information on double-bundle ACL reconstruction with hamstring tendons.

Level of evidence

Level II; prospective comparative study.     

Changes in muscle torque following anterior cruciate ligament reconstruction: A comparison between hamstrings and patella tendon graft procedures on 45 patients

We designed a prospective study to examine the influence of graft type (hamstring or patella tendon) on thigh muscle torque recovery after anterior cruciate ligament reconstruction. 60 patients undergoing ACL reconstruction, using a hamstring or patella tendon graft, were studied and 45 were followed up to 1 year. Concentric and eccentric quadriceps and hamstring torque were recorded, using an isokinetic dynamometer preoperatively, 6 and 12 months after ACL reconstruction. We found an improvement in all muscle functions in both the operated and unoperated legs during the recovery period. Graft type had no effect on recovery. During the first 6 months, torque was restored to preoperative levels and continued to improve in all muscles and actions between 6 months and 1 year.     

Changes in muscle torque following anterior cruciate ligament reconstruction: a comparison between hamstrings and patella tendon graft procedures on 45 patients

We designed a prospective study to examine the influence of graft type (hamstring or patella tendon) on thigh muscle torque recovery after anterior cruciate ligament reconstruction. 60 patients undergoing ACL reconstruction, using a hamstring or patella tendon graft, were studied and 45 were followed up to 1 year. Concentric and eccentric quadriceps and hamstring torque were recorded, using an isokinetic dynamometer preoperatively, 6 and 12 months after ACL reconstruction. We found an improvement in all muscle functions in both the operated and unoperated legs during the recovery period. Graft type had no effect on recovery. During the first 6 months, torque was restored to preoperative levels and continued to improve in all muscles and actions between 6 months and 1 year.     

Editorial Commentary: Goldilocks and the Three Grafts: Managing Tendon Harvest and Graft Length Problems in Autograft Anterior Cruciate Ligament Reconstruction

Autograft hamstring tendon harvest in anterior cruciate ligament (ACL) reconstruction can occasionally result in a graft length that is inadequate for creation of a robust ACL graft. Patients at risk for an abnormally short hamstring may also be high risk for ACL reinjury. Graft augmentation with allograft may be a suboptimal solution to this problem. Therefore, a reliable means for preoperative estimation of hamstring tendon length by magnetic resonance imaging measurement could avoid this pitfall. However, even with a reliable correlation between magnetic resonance imaging measurement and actual harvested tendon length, establishing a simple, clinically relevant threshold below which hamstring grafts should be avoided remains elusive. By contrast, all-soft-tissue quadriceps autograft avoids the potential length problems inherent to both bone tendon bone (graft–tunnel mismatch) and hamstring tendon grafts, but intermediate- and long-term outcome studies are still needed to validate all-soft-tissue quadriceps autograft in ACL reconstruction.     

Editorial Commentary: How to Increase Hamstring Tendon Graft Size for Anterior Cruciate Ligament Reconstruction

The concept of a five-strand hamstring tendon autograft for anterior cruciate ligament reconstruction is not new. The concept of a five-strand hamstring tendon autograft was largely ignored until recent studies showed higher failure and revision rates for hamstring ACL reconstructions performed with graft diameters less than 8 mm. In the majority of patients in the United Arab Emirates, four-strand hamstring tendon autografts result in a graft diameter between 6.5-7.5 mm. As a result, since 2006, I have completely abandoned using four-strand hamstring tendon autografts in favor of five-and six-stranded hamstring tendon autografts for ACL reconstructions. The key to performing five-or six-strand hamstring tendon autografts lies in the ability to triple the semitendinosus tendon and in the case of six-strand hamstring tendon grafts, the gracilis tendon. Although, five-and six-strand hamstring tendon autografts can increase the diameter of hamstring tendon ACL grafts, the question of whether these grafts will reduce failure and revision rates remains unanswered.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. Bone patellar tendon-bone and the hamstring tendon generally have been used. In the present study, we describe an alternative graft, the quadriceps tendon-patellar bone autograft, by using arthroscopic ACL reconstruction. METHODS: From March of 1996 through March of 1997, a quadriceps tendon-patellar bone autograft was used in 12 patients with ACL injuries. RESULTS: After 15 to 24 months of follow-up, the clinical outcome for those patients with this graft have been encouraging. Ten patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. Recovery of quadriceps muscle strength to 80% of the normal knee was achieved in 11 patients in 1 year. CONCLUSION: The advantages of the quadriceps tendon graft include the following: the graft is larger and stronger than the patellar tendon; morbidity of harvest technique and donor site is less than that of patellar tendon graft; there is little quadriceps inhibition after quadriceps harvest; there is quicker return to sports activities with aggressive rehabilitation. A quadriceps tendon-patellar autograft is a reasonable alternative to ACL reconstruction in patients who are not suitable for either a bone-patellar tendon-bone autograft or a hamstring tendon autograft.     

Joint Infection Unique to Hamstring Tendon Harvester Used During Anterior Cruciate Ligament Reconstruction Surgery

Joint infection after anterior cruciate ligament (ACL) reconstruction is a rare but important clinical issue that must be resolved quickly to prevent secondary joint damage and preserve the graft. After careful analysis, we observed 3 infection cases within a 12-month period after ACL reconstruction, which represented an abnormally elevated risk. All reconstructions were performed by the same surgeon and used hamstring tendon allograft. For each surgery, the Target Tendon Harvester (DePuy Mitek, Raynham, MA) was used to harvest hamstring tendons. Through our review, we learned that this instrument was sterilized while assembled. It is our belief that ineffective sterilization of this hamstring graft harvester served as the origin for these infections. We have determined that appropriate sterilization technique involves disassembly of this particular hamstring tendon harvester before sterilization because of the tube-within-a-tube configuration. We have since continued to use the Target Tendon Harvester, disassembling it before sterilization. There have been no infections in the ensuing 12 months during which the surgeon performed over 40 primary ACL reconstructions via hamstring autograft. The information from this report is intended to provide arthroscopists with information about potential sources of infection after ACL reconstruction surgery.     

Fremdmaterialfreier Kreuzbandersatz mit Diamanthohlschleifen

Hamstring and patella tendons are usually used for anterior cruciate ligament (ACL) reconstruction and fixed with foreign material, partially executed far from the original point of insertion. Besides the biomechanical questions bone defects are a severe problem in cases of revision. We developed a biological method with diamond cutting instruments for graft fixation with bone dowels near the native insertion. The graft is tensioned and fixed in 120° knee flexion and is self-adapting in extension. The technique has been used in a large number of cases during a prospective study with a follow-up of 10 years for patella tendon and 4 years for hamstring tendon grafts. In this investigation 124 patients with bone-patellar tendon-bone (BPTB) grafts showed an International Knee Documentation Committee (IKDC) score A/B in 87% after a mean follow-up of 9.6 years, a Lachman test (maximum side-to-side difference) of 1.38±0.93 mm and a negative pivot shift test in 91% of the cases. Of the 147 patients with hamstring tendon grafts 89% had an IKDC score A/B after a mean follow-up of 4.3 years, a Lachman test of 1.14±0.76 mm and no pivot shift in 90% of the cases. The Tegner activity score decreased by ?1.8 in both groups. Conclusion: This method allows a reliable biological press-fit fixation for every kind of graft near the original point of insertion, preventing bone defects, allowing early intensive rehabilitation and low costs.     

An alternative cruciate reconstruction graft: The central quadriceps tendon

The central quadriceps tendon, above the patella, is thicker and wider than the patella tendon. Using precise technique, one can obtain a tendon graft for cruciate reconstruction with 50% greater mass than a patellar tendon bone-tendonbone graft of similar width. The central quadriceps tendon graft may be harvested by a second surgeon while the first surgeon is simultaneously accomplishing notchplasty and tunnel placement for cruciate ligament reconstruction. Consequently, this cruciate ligament reconstruction graft offers time savings as well as greater tendon volume. The central quadriceps tendon graft is difficult to harvest, with significant risk of entering the suprapatellar pouch and losing knee distension during ACL reconstruction. By careful adherence to the technique described in this article, the surgeon can obtain this reconstruction graft safely. It is important to recognize the anatomic subtleties of the proximal patella, which include a curved proximal surface, dense cortical bone, and closely adherent suprapatellar pouch. Proper technique is of utmost importance in obtaining this tendon graft safely and efficiently.     

Posterior Cruciate Ligament Reconstruction Using Hamstring Tendon Graft With Remnant Augmentation

Despite good early functional results, the posterior laxity of the knee is not completely eliminated after posterior cruciate ligament (PCL) reconstruction. The PCL can retain the normal tension only when the injured ligament is maintained anatomically. This article describes a technique of PCL reconstruction using hamstring tendon graft with PCL remnant augmentation. The harvested hamstring tendons were quadrupled, sized, and pretensioned before use. The PCL remnants and the synovium were preserved. Minimal debridement was performed to gain access to the insertion sites. The tibia and femoral tunnels were created with graft size–matched reamers. The graft was transfixed at 70° of knee flexion with a 15-lb anterior drawer force on the proximal tibia. This surgical technique has several advantages. The hamstring graft acts as an independent PCL reconstruction and maintains the PCL remnant tension. The PCL remnants and synovium may be beneficial to ligament healing and postoperative rehabilitation. The procedure is technically feasible and cosmetically acceptable. The selection of autograft precludes the risks of allograft and artificial ligament. The short-term results are encouraging, but long-term results are needed to confirm the value of this technique for PCL reconstruction.     

Implant-free ACL reconstruction: a review

Implant-free anterior cruciate ligament (ACL) reconstruction is the fixation of ACL grafts without the need for artificial implants. Our aim was to study the evolution of this technique, review the biomechanical evidence and summarise the results. Implant-free graft fixation for bone patella tendon ACL reconstruction was first described in 1987. This concept of implant-free graft fixation was adapted for hamstring and quadriceps tendons as alternative graft sources. Various biomechanical studies have reported that by adhering to certain technical details, this technique provides comparable fixation strength as conventional ACL fixation. The outcome studies of implant-free ACL reconstruction also report clinical results similar to ACL reconstruction with conventional implants.     

In vitro comparison of tension and stiffness between hamstring tendon and patella tendon grafts

Following anterior cruciate ligament reconstruction, grafts relax and warm from the temperature of the operating room to body temperature. The current study compared graft tension and stiffness between patella tendon and hamstring tendon grafts. Six quadruple strand hamstring tendon grafts and six patella tendon grafts were preconditioned and loaded to 105 N while at 20°C. Graft tension and stiffness were measured after 15 min, after an additional 4 h, and after increasing the temperature to 34°C. A two‐way repeated‐measures analysis of variance and a post hoc test were used to compare the measurements between the two types of graft and identify significant (p < 0.05) changes for each type of graft. Tension was significantly larger for the patella tendon grafts, although the stiffness values were not significantly different (p > 0.8). For both types of graft, tension and stiffness decreased significantly with time and the temperature increase. The lowest tension and stiffness measurements were 50 ± 11 N and 129 ± 35 N/mm, respectively, for the patella tendon grafts, compared to 18 ± 5 N and 115 ± 11 N/mm, respectively, for the hamstring tendon grafts. Both types of graft lose tension to relaxation and a temperature increase, but the tension loss is larger for hamstring tendon grafts. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:1506–1511, 2008     

Quadrupled bone-semitendinosus ACL reconstruction: a prospective clinical investigation in 100 patients

Abstract The hypothesis of our study was that a quadrupled bonesemitendinosus tendon graft could combine the advantage of bone-tobone healing with the high cross-sectional area of a quadrupled hamstring graft in ACL reconstruction. ACL reconstruction with a semitendinosus tendon graft was performed on 100 patients with isolated ACL injury from January 1996 to December 1999: femoral fixation was obtained with Endobutton and tibial fixation with Fastlok. Patients were evaluated for standard knee scores and functional strength tests, postoperative pain rating, knee radiographs taken after surgery and at final follow-up, magnetic resonance images at 3 and 6 months, isokinetic flexion-extension and internal-external rotation tests at 3, 6, and 12 months. Computerized laxity analysis was performed at final evaluation. Average surgical time was 85 minutes, including 13 minutes for graft preparation; 90% of the patients were discharged within 24 h. Subjective knee rating was 80%; kneeling test was positive in 7% and Werner score was 44 (range, 30–48). Lachman test was negative in 90% at final evaluation (mean follow-up, 38 months). Sensory changes at the anterior part of the proximal tibia were present in 30% at 3 months and 10% had definite hyposthesia. MRI showed graft incorporation at 3 months. Computerized laxity analysis revealed 90% with less than 3-mm side-to-side differences. Isokinetic testing showed normal hamstring and quadriceps peak torques at 12 months. The functional strength tests were normal by 6 months. Average Noyes score was 87.9, Lysholm score 93, and Tegner activity rating 6.0 (pre-injury, 6.1). IKDC score showed 90 normal or nearly normal knees, 9 abnormal, and one severely abnormal knee. Quadrupled bone-semitendinosus is a viable graft for ACL reconstruction and should be considered, especially in patients with pre-existing extensor mechanism problems.     

All-Inside Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An “all-inside” technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to “bottom out” the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques.     

膝关节镜下自体腘绳肌腱和同种异体肌腱移植重建前交叉韧带对比观察

目的：探讨关节镜下同种异体肌腱和自体腘绳肌腱重建前交叉韧带的疗效。方法：收集32例前交叉韧带损伤病例,单纯前交叉韧带（ACL）损伤29例,与后交叉韧带（PCL）同时损伤3例。分为2组,同种异体肌腱重建15例,男12例,女3例,年龄23～61岁;自体腘绳肌腱重建17例,男11例,女6例,年龄17～57岁。用可吸收或钛挤压螺钉固定,观察并记录治疗后的症状、体征变化和Lysholm评分以及术后6个月的功能康复情况。结果：全部病例均获得随访,时间6～8个月,所有病例无膝前区疼痛,临床症状消失,膝关节功能得到改善。同种异体肌腱重建前交叉韧带5例患者仍出现Lachman征阳性体征,其中1例产生严重的排斥反应,关节镜复查韧带完全吸收。2组患者治疗后Lysholm评分分别为平均（88.5±7.2）分和（93.2±8.5）分,差异无统计学意义（P〉0.05）。结论：关节镜下两种方法重建前交叉韧带都有较好的疗效,同种异体肌腱重建交叉韧带早期有更多的症状,有明显的个体差异,重建交叉韧带尽可能选用自体腘绳肌腱。     

Comparison of clinical results of anterior cruciate ligament reconstruction using two different procedures

During the last two decades the "golden standard" in reconstruction of anterior cruciate ligament knee was the middle third of patellar tendon, but now are more used hamstrings tendon autograft. The aim of this work was to compare our results of the artroscopic reconstruction ACL (anterior cruciate ligament) of the knee using two different technics. We were controling 60 patients within the period of two years after operation. Group A was composed of 39 patients which had reconstructed ACL done with bone-patella tendon- bone autografts, in the group B were 21 patients and at them as autographts have been used hamstring tendon. Difference between healthe and the ill knee by the Lachman's test after operation, in the group A was 2,4 mm, but in the group B was 2,2mm (p> 0,05 ). Postoperative middle value of the Lysholm and Gillquist score in the group A was 97,74, in the group B it was 96,67 (p>0,05). IKDC score results are following: Group A- mark A 32 patients (84,6%); mark B 5 (12,8%); mark C 1 (2,6%) and in the group B: mark A 17 patients (81%); mark B 3 (14,28%): mark C 1 (4,72%) (p> 0,05). Postoperative value for the Tegner and Lyscholm score activity in the A group was 8,23, in B group it was 8,81. The reconstruction of ACL with bone- patella tendon-bone grafts gave better results then the reconstruction with the hamstring tendon only according to Tegner score values. In other parameters between those two groups there was no statisticaly significant difference.