Ruptura de tornillo tibial interferencial biodegradable posterior a reconstrucción de ligamento cruzado anterior / Broken bioabsorbable interference tibial screw of anterior cruciate ligament reconstruction

Se presenta un reporte un caso con una ruptura de tornillo interferencial biodegradable tibial luego de la reconstrucción de ligamento cruzado anterior (LCA) con injerto cuádruple autólogo de semitendinoso y recto interno. Doce meses postoperatorios luego de una recuperación satisfactoria inicia con síntomas de bloqueo y dolor de rodilla. La Resonancia magnética (RM) mostró ruptura del tornillo tibial sin pérdida de la ubicación ni continuidad de la plástica de LCA. Se realizó extracción de la parte rota del tornillo por vía artroscópica. La paciente tuvo una recuperación completa de su rodilla. Éste caso describe posibles causas de ruptura del tornillo biodegradable y se sugiere tomar en cuenta los cuidados necesarios para evitar dicho problema.

We report a case of broken screw from the tibial site of anterior cruciate ligament reconstruction using an autologous ipsilateral semitendinosus-gracilis quadruple graft. Twelve months after initially successful ACL surgery the patient felt locking symptoms and knee pain. MRI showed a broken bioabsorbable interference tibial screw without loss of location or continuity of the ACL graft. At revision arthroscopy the broken part was removed. The patient had full recovery. This case describes possible causes of bioscrew rupture in ACL surgery and we suggest the necessary precautions to avoid this problem.

Comparison of Poly-L-Lactic Acid and Poly-L-Lactic Acid/Hydroxyapatite Bioabsorbable Screws for Tibial Fixation in ACL Reconstruction: Clinical and Magnetic Resonance Imaging Results

BACKGROUND: The purpose of this study was to compare the clinical and radiological results of 2 different tibial fixations performed using bioabsorbable screws with added hydroxyapatite (HA) and pure poly-L-lactic acid (PLLA) screws in anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 394 patients who underwent arthroscopic ACL reconstruction between March 2009 and June 2012 were retrospectively reviewed. Of those, 172 patients who took the radiological and clinical evaluations at more than 2 years after surgery were enrolled and divided into 2 groups: PLLA group (n = 86) and PLLA-HA group (n = 86). Both groups were assessed by means of the Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity score. Stability was evaluated using the KT-2000 arthrometer. Magnetic resonance imaging was performed to evaluate tibial tunnel widening, screw resorption, osteoingeration, and foreign body reactions. RESULTS: The PLLA-HA group showed significant reduction in the extent of tibial tunnel widening and foreign body reactions and significant increase in screw resorption compared to the pure PLLA group (p < 0.001 for both). In contrast, postoperative Lysholm score, Tegner activity score, IKDC score, and side-to-side difference on the KT-2000 arthrometer showed no significant differences between groups (p = 0.478, p = 0.906, p = 0.362, and p = 0.078, respectively). The PLLA group showed more significant widening in the proximal tibial tunnel than the PLLA-HA group (p = 0.001). In the correlation analysis, proximal tibial tunnel widening revealed a positive correlation with knee laxity (r = 0.866) and a negative correlation with Lysholm score (r = −0.753) (p < 0.01 for both). CONCLUSIONS: The HA added PLLA screws would be advantageous for tibial graft fixation by reducing tibial tunnel widening, improving osteointegration, and lowering foreign body reactions. Even though no clinically significant differences were noted between the pure PLLA group and PLLA-HA group, widening of the proximal area of the tibial tunnel showed a tendency to increase knee laxity measured using the KT-2000 arthrometer.

Graft tendon slippage with metallic and bioabsorbable interference screws under cyclic load: a biomechanical study in a porcine model

Introduction The rupture of the anterior cruciate ligament (ACL) is the most common type of knee injury. Reconstructive surgery is the ‘gold standard’ treatment. During the immediate post-operative period, the fixation of the graft is entirely dependent on the ability of the grafted implant to be secured inside the bone tunnel under the cyclical loads associated with daily tasks. Poor fixation can lead to graft slippage, thus impairing the healing and integration of the graft. The aim of this study was to evaluate the biomechanical performance of tendon graft fixation devices with metallic and bioabsorbable interference screws. Methods Twenty ACL reconstructions were carried out in porcine tibias using deep flexor tendons to fix 9 × 20 mm metallic (n=10) and PLLA 70/30 bioabsorbable screws (n=10). To verify the ability of a construct to resist immediate postoperative (PO) rehabilitation protocols for immediate load bearing, a cyclic loading test was applied with 50-250 N of tensile force at 1 Hz for 1000 cycles, and the displacement was measured at 10, 50, 100, 500 and 1000 load cycles to quantify the slippage of the graft during the test. After the cyclic loading test, a single-cycle load-to-failure test was applied. Results The slippage of the graft using metallic screws did not differ (P = 0.616) from that observed when using bioabsorbable screws. Conclusion The results obtained in this experiment indicate that metallic screws may promote a similar amount of graft slippage during low cyclic loading as bioabsorbable screws. Additionally, there was no difference in the biomechanical performance of these two types of screws during high failure loads.

Tibial Tunnel Cyst Formation after Anterior Cruciate Ligament Reconstruction Using a Non-Bioabsorbable Interference Screw

Tibial cyst formation following the use of bioabsorbable interference screws in anterior cruciate ligament (ACL) reconstruction is well-described; however, cyst formation after the use of metallic interference screws is not well-documented. We describe a case of osteolytic lesion of the proximal tibia presenting to us 20 years after ACL reconstruction using an autologous bone-tendon-bone graft. The original graft fixation technique was interference fixation with a metal screw in the tibial and femoral tunnels. A two-stage revision reconstruction of the ACL was undertaken with curettage and bone grafting of the tibial lesion in the first stage and reconstruction using a four-strand hamstring tendon in the second stage. The patient recovered satisfactorily with complete healing of the cyst and returned to pre-injury level of activities. We have reviewed case reports and case series that describe the aetiology of intra-osseous cyst formation following ACL reconstruction.

Broken Bioabsorbable Tibial Interference Screw after Anterior Cruciate Ligament (ACL) Reconstruction using a Semitendinosus-gracilis Graft: A Case Report

When a patient presents with knee pain and locking after an anterior cruciate ligament (ACL) reconstruction, a new meniscal injury or an osteochondral loose body are usually considered for differential diagnosis. We present the case of a 22-year-old female with just these complaints 6 months after ACL reconstruction surgery. Magnetic resonance imaging (MRI) of the knee showed a broken screw tip which was later arthroscopically removed. At arthroscopy, an 11mm long broken bioabsorbable interference screw tip was found lying in the intercondylar notch; this resulted in a 0.5cm Outerbridge grade II chondral ulcer located at midpatella. Both menisci and cruciate ligaments were intact and no other loose bodies were found in the knee joint.

Anatomic Reconstruction of the Lateral Ankle Instability Using the Semitendinosus Allograft Tendon and Interference Screws / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical outcome of the anatomic reconstruction of the lateral ankle instability using the semitendinosus allograft tendon and the interference screws. MATERIALS AND METHODS: This study is based on the 12 feet of lateral ankle instability that had been treated with anatomic reconstruction of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) using the semitendinosus allograft tendon and the interference screws. The majority of patients were young and physically active. We evaluated the patients' VAS pain scores, AOFAS scores and Karlsson-Peterson ankle scores for the 11 feet involved with at least 12 months follow up, both pre- and post-operative. In addition, we evaluated patient satisfaction. We measured the talar tilt angles and the talar anterior translations from ankle stress views. RESULTS: The average age at surgery was 25.9 years old (19-57 years); patients had symptoms of recurrent sprain for average 31.4 months before surgery. The average follow up period was 14 months. For reconstruction, we used 4.0mm thick allograft semitendinosus tendon and interference screws. VAS pain scores decreased from 6.0 to 1.1 (p<0.05) and AOFAS scores improved from 70.4 to 90.4 postoperatively (p<0.05). Karlsson-Peterson ankle scores improved significantly from 54.6 to 92.4 (p<0.05). Radiographic talar tilt decreased from 15.7degrees to 3.2degrees postoperatively (p<0.05). Eighy-two percent of the patients were satisfied with the results and the patients had returned to their jobs by 3.7 months after surgery. CONCLUSION: Anatomic reconstruction of the ATFL and the CFL in the lateral ankle instability patients using the semitendinosus tendon and the interference screws is an ideal surgical option especially for young athletes with high grade instabilities.

Short-Term Results of Subpectoral Tenodesis of the Proximal Biceps Tendon Using by Interference Screw

PURPOSE: Our purpose was to retrospectively analyze clinical results of subpectoral tenodesis of the proximal biceps tendon using an interference screw. MATERIALS AND METHODS: We reviewed 23 cases of patients receiving tenodesis of the proximal biceps tendon between January 2008 and January 2009 for whom we had follow-up data for at least 1 year. Twenty-three cases were operated on using subpectoral tenodesis; 16 of these cases had a rotator cuff tear. The results were judged using a visual analog scale (VAS), ASES, tenderness on the biceps groove, fixation failure and the degree of deformity (BAD). RESULTS: VAS and ASES scores were significantly improved in all patients by the time of the final observation. There were no significant complications or fixation failures. The patients without a tear of the rotator cuff had a better result than patients with a tear of the rotator cuff, but the difference between the two groups was not significant (p>0.05). CONCLUSION: In patients with pathology of the long head of the biceps brachii, benefits of subpectoral interference screw tenodesis include pain relief, maintenance of functional biceps, muscle strength, and cosmesis. Subpectoral biceps tenodesis using interference screw fixation appears to be a promising, reproducible, reliable technique for addressing anterior shoulder pain related to pathology of the long head of the biceps brachii.

Tenodesis of Long Head of the Biceps Brachii Tendon with Bioabsorbable Interference Screw

Purpose: This study reports the clinical results of the tenodesis of long head of the Biceps brachii tendon with bioabsorbable interference screw by minimal open procedure. Materials and Methods: Ten cases of 10 patients (7 male, 3 female) were included in this study. The average age was 45.8 years old and the average period from the symptom onset to operation was 13.7 months. Average preoperative ASES score was 38.5. The causes of injury was; sports activities in 4 patients, unknown in 4 patients, industrial accident in 1 patient and traffic accident in 1 patient. The average follow up period was 12.1 months. Tenodesis with bioabsorbable interference screw by minimal open precedure was performed in all cases. Results: The ASES score improved to 87.5 at last follow up period and 6 cases had full range of motion of the shoulder. 4 cases had mild limited range of motion of the shoulder without any problem in normal daily activity. Conclusion: It was assumed that tenodesis of long head of the biceps brachii tendon with bioabsorbable interference screw by minimal open precedure was one of the good methods with good clinical results.

Arthroscopic reconstruction of anterior cruciate ligament with preservation of the remnants / 中国矫形外科杂志

[Objective]To evaluate the technique and outcome of arthroscopic reconstruction of anterior cruciate ligament (ACL) with preservation of the remnents.[Method]From June 2005 to May 2006, 28 knees with ACL tear in 28 patients were verified with arthroscopy in this department.Of them,8 knee were combined with lateral meniscus tear and 6 combined with medial meniscus tear. All the damaged ACLs were reconstructed with single bundle of autogenous quadrupled hamstring tendons under arthroscopy without remove of the remnants of ACL. Bioabsorbable interference screw was used for direct anatomic fixation of the reconstructed ligament.[Result]No severe complication occurred in early stage after operation in the 28 patients.All of them were followed up for 12 to 24 months with an average of 18 months. Lysholm score was remarkablely improved from 46～80 (mean 60.75?9.54) preoperatively to 85～100 (mean 95.89?6.24) at the latest follow up (P

Comparison of Bioabsorbable and Metallic Interference Screws in Arthroscopic Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft

PURPOSE: To compare the postoperative results between the patient group which used bioabsorbable interference screw and metallic interference screw during ACL reconstruction surgery. MATERIAL AND METHODS: Out of 105 patients for whom the postoperative follow-up was possible for one year, authors took 80 patients who underwent arthroscopic ACL recostruction with bone-patellar tendon-bone autograft between December of 1996 and December of 2000. 60 patients fell into group 1 where the patients received bioabsorbable interference screw for fixation at femur and tibia, and 20 patients were classified as group 2 where the patients received metallic interference screw on both the femur and tibia. KT 2000 arthrometer was performed and Lysholm knee score was taken before and after the operation, and the patients underwent the same examination at 6 weeks. 3 months, 6 months, and 1 year after the operation, and the results were compared. RESULT: The average Lysholm knee score of group 1 was 59, and 57 for group 2. During the final follow up examination, the average score improved to 90 for group 1, and group 2. Compared to the healthy side, KT 2000 arthrometer showed the average in group 1 was 6.9 mm and 7.2 mm in group 2 preoperatively, at the final follow up visit after the operation, the value improved to 3.0 mm for both group 1 and 2. Unlike group 2, there were statistically significant relaxation symptoms in group 1 when the exams were performed up until 6 weeks after the operation(P<0.05). CONCLUSION: The usage of bioabsorbable interference screw has many advantages. However, unlike metallic interference screw, it shows laxity within 3 months after the operation. Therefore, when using bioabsorbable interference screw, one has to consider the patients'activity, occupation, or life-style.

Arthroscopic ACL Reconstruction using Bone-patellar Tendon-bone Autograft and Bioabsorbable Interference Screw / 대한정형외과학회잡지

PURPOSE: We report the results of arthroscopic ACL reconstruction using a bone-patellar tendon-bone (BPTB) autograft and a bioab-sorbable interference screw (Bioscrew, poly L-lactic acid, Linvatec co., USA). MATERIALS AND METHODS: From January 1998 to December 1998, we performed 39 cases of arthroscopic ACL reconstruction using BPTB autograft and a bioabsorbable interference screw. The average follow-up period was 2 years and 8 months. We performed KT-2000 testing and measured the IKDC, Tegner and Lysholm scores preoperatively and compared these with the results of a final evalua-tion. We performed second-look arthroscopy on 4 cases and observed the degree of degradation of the bioabsorbable interference screw. RESULTS: Preoperative evaluation revealed an average range with a KT-2000 of 8.1 +/-3.4 mm, a Lysholm score of 66.2 +/-16.3, an IKDC score below C in all cases and a Tegner score of 3.7 +/-0.9, but final results showed a KT-2000 of 2.8 +/-2.2 mm, a Lysholm score of 91.7 +/-7.5, an IKDC score above B in all except 3 cases and a Tegner score of 6.9 +/-1.1. Second-look arthroscopy at 3 and 12 months post-operatively showed no degradation of the bioabsorbable interference screw, but there was partial degradation of the bioabsorbable inteference screw at 21 and 33 months. CONCLUSION: Bioabsorbable interference screws seems a reasonable alternative to metallic screws in ACL reconstruction. Bioab-sorbablescrew implanted in humans may take much longer to degrade than expected, more study is needed.

Comparison of Bone Tunnel Widening after ACL Reconstruction between Bioabsorbable Interference Screw and Metallic Interference Screw Fixation

PURPOSE: We evaluated the relationship among the radiographic enlargement of femoral and tibial bone tunnels, fixation material, clinical results and period of follow-up after anterior cruciate ligament(ACL) reconstruction with single incision arthroscopic technique using bone-patella tendon-bone. MATERIALS AND METHODS: We evaluated 91 knees of arthroscopic ACL reconstruction during the period of June 1993 to February 2001 excluding combined posterior cruciate ligament(PCL) injury. Average follow-up period was 44 months(12-78 months). We classified these cases into bioabsorbable screw group and metal screw group according to the screw materials. We took anteroposterior and lateral X-ray films at postoperative 3 months, 1 year, final follow up and measured the size of femoral and tibial tunnel. We evaluated the side-to-side difference using KT-2000 arthrometer and clinical results with Lysholm score. RESULTS: Eight cases of 47 cases in bioabsorbable screw group had bony cystic changes at femoral tunnel and 44 cases in metal screw group had not. Tibial tunnel widening was seen in 38 cases of absorbable screw group and 31 cases of metal screw group. Cases which had femoral and tibial tunnel widening had no knee joint instability clinically. CONCLUSION: There were femoral tunnel widening in bioabsorbable screw group, but not in metal screw group. Delayed inflammatory reaction in bioabsorbable screw may make this phenomenon but there was no correlation between femoral tunnel widening and clinical results. More longterm follow-up will be needed for futher degenerative changes and graft failure.

Fixation with Biodegradable Interference Screw and Bone Block to Femoral Tunnel in Arthroscopic ACL Reconstruction using Autogenous Hamstring Tendon

PURPOSE: The purpose of this study is to report the postoperative clinical results after arthroscopic ACL reconstruction using quadrupled hamstring autograft fixed with biodegradable interference screw and bone block in the femoral tunnel. MATERIALS AND METHODS: Between January and December 1997, we performed an arthroscopic ACL reconstruction with quadrupled hamstring autograft in twenty one patients. To enhance the mechanical stability in the femoral tunnel the graft was fixed with a biodegradable interference screw and cortical bone block which was harvested from the proximal tibial metaphysis. The tibial side of graft was tied at the post of an AO cortical screw. Postoperatively the patients were permitted an accelerated rehabilitation with motion brace. The results were evaluated with IKDC form, complications and radiologic findings. The average follow-up was 36 months. RESULTS: Patient subjective assessment was graded normal in 4, nearly normal in 8, abnormal in 7, severe abnormal in 2. Ligament evaluation was graded normal in 16, nearly normal in 3, abnormal in 1, severe abnormal in 1. Harvest site pathology was graded normal in 16, nearly normal in 4, abnormal in 1. Functional test was graded normal in 6, nearly normal in 8, abnormal in 4, severe abnormal in 3. Radiologic findings showed an average 22% increase in the tibial tunnel diameter. Postoperative complications were one recurrent patholaxity, deep infection and arthrofibrosis required operation in each. CONCLUSION: Arthroscopic ACL reconstruction using quadrupled hamstring autograft fixed with biodegradable interference screw and bone block in the femoral tunnel provided with excellent ligament stability and permitted the early accelerated rehabilitation.

Radiologic and Clinical Evaluation after Arthroscopic Reconstruction of Anterior Cruciate Ligament Using Autogenous Bone-Patellar Tendon-Bone Graft

PURPOSE: The purpose of this study was to correlate radiological analysis(as divergence of femoral tun-nel and interference screw and tunnel placement) with clinical results(as physical examination, Lysholm knee scoring scale, and side to side difference of anterior displacement in an arthrometer). MATERIALS AND METHODS: This study reviewed radiological and clinical results in 48 endoscopic single-incision ACL reconstruction, using autogenous bone-patellar tendon-bone graft and interference screw fixation, between January 1995 and October 1997. We measured the femoral divergence in antero-poste-rior and lateral views of the knee(APD/LD), the angle between a line through the longitudinal axis of dis-tal femoral shaft, and the axis of femoral tunnel in antero-posterior and lateral views(APFT/LFT). We also measured the placement of a tunnel in antero-posterior and lateral views. RESULTS: Significant correlation was present between APD and APFT(negatively) and between LD and LFT(positively), while other variables had no significant correlation. Furthermore, there was no signifi-cant correlation between divergence and clinical results. Clinical results correlated positively with posteri-or femoral tunnel placement on lateral radiographs and negatively with excessive anterior tibial tunnel placement. Therefore, when femoral tunnels were placed at least 60% posterior along the Blumenssat's line and tibial tunnels were placed at least 20% posterior along the tibial plateau, 77.1% of the patients had good or excellent Lysholm score and 80% of the patients had a KT-2000 Arthrometer maximum manual side-to-side difference of 3 mmor less. When the above criteria were not met, however, only 53.8% of the patients had good or excellent Lysholm score and 53.8% had a KT-2000 Arthrometer maximum manual side-to-side difference of 3 mmor less. CONCLUSIONS: This close correlation indicated that satisfactory radiographic tunnel position influences the outcome of an ACL reconstruction.

Comparision of Results after ACL Reconstruction between Bioabsorbable Interference Screw and Metallic Interference Screw Fixation

PURPOSE: To analysis clinical results after arthroscopic ACL reconstruction between bioabsorbable interference screw fixation and metallic interference screw fixation. MATERIALS AND METHODS: We evaluated the results of arthroscopic ACL reconstruction with patellar tendon autograft between two groups, of which group 1 is used metallic interference screw, group 2 is used bioabsorbable interference screw. All of 53 patients underwent arthroscopic patellar tendon auto-grafts with one incision technique. A minimum 12 months follow-up is available on 31 patients in group 1 and 22 patients in group 2. The average age was 28.4 years(19 to 47 years) in group 1 and 29.7 years(18 to 55 years) in group 2. The average period, from trauma to operation, was 20.7 months in group 1 and 24.6 months in group 2. The average follow-up period was 24.1 months in group 1 and 13.1 months in group 2. In terms of the results of pivot shift test, Lachman test, anterior drawer test, Lysholm score, Arthrometer(KT-2000), Cybex test, simlpe X-ray and MRI findings of group 1 compared with group 2. RESULTS: At the final follow-up, KT-2000 test showed that average maximum manual side-to-side dif-ference(STSD) was 2.7mm for group 1 and 2.7mm for group 2. Average muscle power of injured quadri-ceps muscle compared with normal leg by Cybex test was average 82% for group 1 and 79% for group 2. Lysholm score was average 90 for group 1 and 89 for group 2. 3 cases of group 1 and 2 cases of group 2 were showed instability in physical examination, but there were no evidence of synovitis of knee joint or rerupture of anterior cruciate ligament in the follow-up MRI. CONCLUSIONS: No statistical difference was found between the bioabsorbable interference screw fixation group and the metallic interference screw fixation group. Short-term data support that bioabsorbable interference screw is a reasonable alternative to metallic interference screw.

Bone Tunnel Enlargement after Endoscopic ACL Reconstruction by Autogenous Bone - Patellar Tendon - Bone Graft / 대한정형외과학회잡지

Radiographic increase in the size of tibial and femoral tunnels has been observed following the reconstruction of the ACL with a bone-patellar tendon-bone autograft. The purpose of this study is to determine if any differences exist in the amount of enlargement of the bone tunnel with the clinical results and to know the factors which affected to the enlargement of the bone tunnels. Total 27 patients were retrospectively reviewed for tunnel enlargement radiographically at one year after operation. Anteroposterior and lateral x-ray were obtained and the tunnel were measured by two independent observers. The measurements were made at the widest part of the tunnel. The distance between tibial interference screw and knee joint line also measured. Correction for magnification was performed by comparing the measured width of the interference screw used for fixation of the graft with its actual width. Statistical analysis was performed with Wilcoxon rank sum test. The radiographic tunnel enlargement was an average of 1.7+/-1.3mm for the femur and 1.9+/-0.8mm for the tibia. The proximal migration of the tibial interference screw was an average of 2.3++/-1.1 mm. There was no statistically significant correlation between the changes in tunnel diameter and either the modified Hughston knee score, Lysholm knee score, or the joint laxity measured by a KT-2000 arthrometer, Lachman test. There were no correlations between the mild proximal migration of the tibial interference screw and the clinical results. Conclusively, the tunnel enlargement and mild proximal migration of the interference screw did not appear to affect the functional outcome adversely. It needs longer follow up for the evaluation of etiology and natural history of this tunnel enlargement.

Divergence of Femoral interference screw versus Knee Flexion Angle during Endoscopic ACL Reconstruction

The endoscopic single-incision technique using interference fit screws to secure patellar tendon-bone plugs in the femoral and tibial tunnels has been very popular method for ACL reconstruction. However, several potential complications has been reported such as violation of the posterior wall of the femoal tunnel, laceration of graft during femoral screw insertion, protrusion of the tibial bone block distally due to a lengthy graft and more frequently divergence of the femoral interference screw. We performed 56 consecutive endoscopic ACL reconstruction. In Groi.p I, femoral tunnel drilling were performed at 70-80 degrees of knee flexion. In Group 11, they were done at $5 degrees of knee flexion. Postoperative radiographic analysis of bone-interference screw divergence angle shows 5.9 degrees in AP view, 6.21 degrees in Lateral view in Group I and 3.14 degrees, 3.35 degre.s in Group II respectevely. In conclusion, Bone-interference screw divergence can be decreased with less knee flexion about 45 degree during preparing femoral tunnel.