Establishment of anterior cruciate ligament reconstruction model in cynomolgus monkey with autogenous hamstring tendon transplantation / 中国修复重建外科杂志

OBJECTIVE@#To investigate the feasibility of establishing an anterior cruciate ligament (ACL) reconstruction model using hamstring tendon autograft in cynomolgus monkeys.@*METHODS@#Twelve healthy adult male cynomolgus monkeys, weighing 8-13 kg, were randomly divided into two groups ( n=6). In the experimental group, the ACL reconstruction model of the right lower limb was prepared by using a single bundle of hamstring tendon, and the ACL of the right lower limb was only cut off in the control group. The survival of animals in the two groups was observed after operation. Before operation and at 3, 6, and 12 months after operation, the knee range of motion, thigh circumference, and calf circumference of the two groups were measured; the anterior tibial translation D-value (ATTD) was measured by Ligs joint ligament digital body examination instrument under the loads of 13-20 N, respectively. At the same time, the experimental group underwent MRI examination to observe the graft morphology and the signal/ noise quotient (SNQ) was caculated.@*RESULTS@#All animals survived to the end of the experiment. In the experimental group, the knee range of motion, thigh circumference, and calf circumference decreased first and then gradually increased after operation; the above indexes were significantly lower at 3 and 6 months after operation than before operation ( P<0.05), and no significant difference was found between pre-operation and 12 months after operation ( P>0.05). In the control group, there was no significant change in knee range of motion after operation, showing no significant difference between pre- and post-operation ( P>0.05), but the thigh circumference and calf circumference gradually significantly decreased with time ( P<0.05), and the difference was significant when compared with those before operation ( P<0.05). At 6 and 12 months after operation, the thigh circumference and calf circumference were significantly larger in the experimental group than in the control group ( P<0.05). At 3 and 6 months after operation, the knee range of motion was significantly smaller in the experimental group than in the control group ( P<0.05). Under the loading condition of 13-20 N, the ATTD in the experimental group increased first and then decreased after operation; and the ATTD significantly increased at 3, 6 months after operation when compared with the value before operation ( P<0.05). But there was no significant difference between the pre-operation and 12 months after operation ( P>0.05). There was no significant change in ATTD in the control group at 3, 6, and 12 months after operation ( P>0.05), and which were significantly higher than those before operation ( P<0.05). At each time point after operation, the ATTD was significantly smaller in the experimental group than in the control group under the same load ( P<0.05). The MRI examination of the experimental group showed that the ACL boundary gradually became clear after reconstruction and was covered by the synovial membrane. The SNQ at each time point after operation was significantly higher than that before operation, but gradually decreased with time, and the differences between time points were significant ( P<0.05).@*CONCLUSION@#The ACL reconstruction model in cynomolgus monkey with autogenous hamstring tendon transplantation was successfully established.

En la búsqueda de predictores que nos ayuden a obtener un mejor resultado en la cirugía de revisión de ligamento cruzado anterior / In the search for predictors that help us obtain a better result in anterior cruciate ligament revision surgery

Introducción: Los factores de riesgo de re-ruptura de LCA son errores técnicos, características del injerto, lesiones meniscales, condrales o lesiones no tratadas. El objetivo de nuestro trabajo fue reconocer predictores modificables que nos ayuden a obtener un mejor resultado en la cirugía de revisión de LCA. Materiales y métodos: estudio descriptivo transversal. Serie de pacientes tratados en nuestro centro entre 2011 y 2021 a los cuales se les realizó cirugía de revisión de LCA. Se registraron edad, sexo, falla de cirugía primaria traumática, o no, fijación utilizada, ubicación de ambos túneles, injerto utilizado en la cirugía primaria, lesiones articulares condrales y meniscales antiguas y nuevas y tipo de injerto utilizado en cirugía de revisión. Resultados: se analizaron un total de ciento nueve pacientes. Con mayor frecuencia, los pacientes masculinos se sometieron a revisión entre los veinte y los cuarenta años. La principal causa traumática fue la práctica deportiva (40.37%), seguida de accidente de tránsito o en domicilio (7.33%) y en ambiente laboral (24.8%), y sin causa demostrable (27.5%). La mala posición del túnel femoral aislada fue la falla técnica más común en un 41.29%, sin error técnico en 38.53%, y falla de colocación de túnel tibial aislada en 2.75%. En el total de los pacientes evaluados, el 28.44% (treinta y un pacientes) no presentó lesión meniscal previa ni actual; mientras que el 71.56% (setenta y ocho pacientes) evidenció algún tipo de lesión. La elección del injerto fue autoinjerto de H-T-H (30.28%), aloinjerto de tibial posterior (30.28%), aloinjerto de tibial anterior (19.27%), autoinjerto de ST-RI (11.01%), y otros aloinjertos Aquiles, Peroneos y ST (9.17%).Discusión: serán necesarios más estudios para determinar si esta tasa de falla persiste a pesar de nuestro mayor conocimiento de la técnica y diversos aspectos de la cirugía de revisión. Nivel de Evidencia: IV

Introduction: Risk factors for ACL rupture are technical errors, graft characteristics, meniscal and chondral injuries, or untreated injuries. The objective of our work was to recognize modifiable predictors that help us obtain a better result in ACL revision surgery. Materials and methods: cross-sectional descriptive study. Series of patients treated at our center between 2011 and 2021 who underwent ACL revision surgery. Age, sex, traumatic or non-traumatic primary surgery failure, fixation used, location of both tunnels, graft used in primary surgery, old and new chondral and meniscal joint injuries and type of graft used in revision surgery were recorded. Results: a total of one hundred and nine patients were analyzed. Most often, male patients underwent revision between the ages of twenty and forty. The main traumatic cause was sports practice (40.37%), followed by traffic accident or at home (7.33%) and in the work environment (24.8%), and without demonstrable cause (27.5%). Isolated femoral tunnel malposition was the most common technical failure at 41.29%, no technical error at 38.53%, and isolated tibial tunnel placement failure at 2.75%. In all the patients evaluated, 28.44% (thirty-one patients) did not present a previous or current meniscal lesion; while 71.56% (seventy-eight patients) showed some type of injury. Graft choice was H-T-H autograft (30.28%), posterior tibial allograft (30.28%), anterior tibial allograft (19.27%), ST-RI autograft (11.01%), and other Achilles, fibular, and ST allografts (9.17%) Discussion: more studies will be necessary to determine if this failure rate persists despite our greater knowledge of the technique and various aspects of revision surgery. Level of Evidence: IV

Reconstrucción de ligamento cruzado anterior con isquiotibiales manteniendo su inserción tibial / ACL reconstruction with hamstring autograft maintaining tibial insertion

Introducción: La no desinserción tibial de semitendinoso-recto interno (ST-RI) parece constituir una opción para evitar la necrosis avascular en el proceso de ligamentización. El objetivo de nuestro trabajo es hacer una comparación entre ST-RI desinsertado versus ST-RI no desinsertado. Materiales y métodos: estudio comparativo, prospectivo, randomizado, doble ciego, para el que se formaron dos grupos. El grupo de estudio, conformado por treinta y ocho pacientes con plástica de LCA sin desinserción tibial de ST-RI; el grupo de control, de treinta y nueve pacientes con desinserción tibial. Se realizaron evaluaciones de RM a los seis meses del postoperatorio, se evaluaron el Coeficiente Señal ruido (CS) y la orientación del neoligamento en planos sagital, coronal y axial. La valoración clínica, a través de IKDC, Tegner Lysholm y KT-1000, fue efectuada por médicos en forma ciega.Resultados: el CS valorado por RM a los seis meses mostró diferencias significativas entre el grupo de estudio (14.4) y el de control (24.9) con un valor p <0.001. No existieron diferencias en cuanto a la orientación del injerto entre ambos grupos, ni en el plano sagital, coronal, ni axial. En cuanto al IKDC y Tegner Lysholm, sin diferencias entre grupos a los nueve meses. En el KT-1000 tampoco se encontraron diferencias entre grupos (p = 0.518).Discusión: la no desinserción tibial de ST-RI es una opción válida que podría evitar la fase de necrosis avascular de la ligamentización. Nuestros resultados, sustentados en RM, nos estimulan a utilizarla como una opción con cierta ventaja biológica.

Introduction: Non disinsertion of hamstring autograft tendons may result in avoiding cellular necrosis at the early stage of ligamentization process. The aim of this study was to compare between disinserted vs non disinserted hamstring autograft. Materials and methods: in this prospective, double-blind, randomised controlled trial, two groups were created. In the study group, hamstring tendon retraction (n=39) was performed. In the control group, maintaining tibial insertion (n=38) harvesting technique was used. Patients were evaluated with MRI after six months of follow-up. Graft maturity was evaluated with the signal-to-noise quotient (SNQ) and graft direction and orientation with sagittal, coronal, and axial views. Clinical outcomes were assessment of IKDC, Tegner-Lisholm activity level score and KT-1000 evaluation from a blind ortopaedic surgeon.Results: signal-to-noise quotient (SNQ) was significantly lower in non disinserted hamstring group (study group 14.4 vs control group 24.9-p = 0.001). There were no differences in graft direction between both groups. KT-1000 measurements showed no difference, the same as clinical outcomes assessment of IKDC and Tegner-Lisholm scores.Discussion: non disinserting hamstring tendons autograft is a valid option and may avoid the necrosis phase in ligamentization process. Our results, sustained on MRI imaging encourage us to use it with some biological advantage.

Después de una cirugía de ligamento cruzado anterior, ¿cuándo puedo manejar? Evaluación postoperatoria de habilidades de conducción y de reacción de frenado / After anterior cruciate ligament surgery, when can I drive? Postoperative assessment of driving skills and braking reaction

Introducción: La mayoría de las personas que se someten a una reconstrucción del LCA están en edad de conducir, por lo tanto, es importante saber cuándo es seguro para el paciente reanudar la conducción. El objetivo de este trabajo es evaluar de manera prospectiva cuándo los pacientes recuperan las habilidades de manejo y de reacción de frenado después de la reconstrucción primaria de LCA, y compararlos con un grupo control de voluntarios sanos. Materiales y métodos: estudio prospectivo de una serie de pacientes que se sometieron a reconstrucción primaria del LCA utilizando injerto semitendinoso y recto interno. Se excluyeron pacientes en los que se empleó otro tipo de injerto o se les realizó otro gesto quirúrgico y laborales. Se evaluó la capacidad de volver a manejar de manera segura a las 2-3 semanas y a las 4-5 semanas postoperatorias mediante test de reacción simple y de resistencia a la monotonía, y se compararon los resultados con un grupo control de voluntarios sanos. Resultados: en total fueron ciento sesenta y seis pacientes, treinta fueron casos y ciento treinta y seis, controles. Se hallaron diferencias significativas (p = 0.03) entre los casos y controles en las pruebas realizadas tempranamente en cuanto a la aprobación, y no, de los test. Según el promedio en segundos obtenido en cada test realizado, se observan diferencias significativas en el primera prueba de resistencia a la monotonía (p = 0.0001) a favor del grupo control. Discusión: de acuerdo a la prueba de reacción simple y al test a la monotonía evaluados en nuestro trabajo, los pacientes que se someten a reconstrucción del LCA con autoinjertos de ST-RI están en condiciones de manejar un automóvil luego de las 4-5 semanas de la cirugía

Introduction: Most people who undergo ACL reconstruction are of driving age, it is important to know when it is safe for the patient to resume driving. The objective of this work was to prospectively evaluate when patients recover driving skills and brake reaction skills after ACL reconstruction and compare them with a control group of healthy volunteers. Materials and methods: prospective study of a series of patients who underwent primary ACL reconstruction using semitendinosus and medial rectus graft. Patients in whom another type of graft was used, or another surgical and labor gesture was performed, were excluded. The ability to return to driving safely at 2-3 weeks and 4-5 weeks postoperatively was evaluated using the simple reaction and resistance to monotony tests, and the results were compared with a control group of healthy volunteers.Results: a total of 166 patients, 30 are cases and 136 controls. Significant differences (p = 0.03) were found between cases and controls in the tests carried out early in terms of passing and not passing the tests. The relationship according to the average in seconds obtained in each test carried out, significant differences are observed in the first test of resistance to monotony (p = 0.0001) in favor of the control group. Discussion: according to the simple reaction test and the monotony test evaluated in our study, patients who undergo ACL reconstruction with ST-RI autografts are able to drive a car 4-5 weeks after surgery

High frequency transcutaneous electrical stimulation in the immediate postoperative period of anterior cruciate ligament reconstruction: a randomized clinical trial / Estimulação elétrica transcutânea de alta frequência no pós operatório imediato de reconstrução do ligamento cruzado anterior: um ensaio clínico randomizado

INTRODUCTION: The anterior cruciate ligament (ACL) is an important structure for knee stability. Transcutaneous electrical nerve stimulation (TENS) is an electrical current applied for significant pain relief. OBJECTIVE: To evaluate the effects of high-frequency TENS on the immediate postoperative period of ACL reconstruction. METHODS: 46 patients in the postoperative period of ACL reconstruction were randomly assigned to a control group (CG=23) and a TENS group (TG=23). Knee range of motion (ROM), pain, muscle strength, and drug intake were assessed before surgery and 24 and 48 hours after surgery. The TENS intervention protocol started in the recovery room, shortly after surgery, and was maintained continuously for the first 48 hours after surgery. RESULTS: The TENS group (TG) significantly controlled the increased level of postoperative pain (p<0.05) and significantly increased flexion ROM (p<0.05). When compared to the Control group (CG), the TENS group had a lower intake of ketoprofen (48.27%), diazepam (256.98%), and dipyrone (121.21%), morphine (320.77%), and tramadol (437.46%). CONCLUSION: Continuous high-frequency TENS significantly reduced pain intensity and significantly improved ROM, muscle strength, and drug intake in the postoperative period of ACL reconstruction.

Assessment of The Addition of Epinephrine to Intra-articular Bupivacaine for the Control of Acute Pain in Patients underwent to Anterior Cruciate Ligament Reconstruction / Avaliação da adição da epinefrina à bupivacaína intra-articular no controle da dor aguda em pacientes submetidos a reconstrução do ligamento cruzado anterior

Abstract Objective To evaluate postoperative pain, using the visual analog scale (VAS), in patients undergoing anterior cruciate ligament reconstruction (ACLR) and receiving intra-articular anesthetic solutions. Methods The present is a randomized clinical trial with a sample of 48 patients divided into 4 groups: Group I (n » 12) - 20 mL of saline solution (control); Group II (n » 12) - 20 mL of 0.5% bupivacaine; Group III (n » 12) - 20 mL of 0.5% bupivacaine þ 0.1 mg of epinephrine; and Group IV (n » 12) - 20 mL of saline solution þ 0.1 mg of epinephrine. These solutions were injected into the knee at the end of the surgery. Pain was assessed using the VAS immediately and 6, 12, 24 and 48 hours after the procedure. Results The VAS scores were highly variable among the groups. A Kruskal-Wallis analysis of variance (ANOVA), considering a level of significance of 5%, revealed that all intra-articular anesthetic solutions influenced the assessment of pain (p » 0.003), and that Group-III subjects presented less postoperative pain. There was no evidence of a higher or lower use of supplemental analgesic agents, or of adverse effects resulting from these anesthetic solutions. Conclusion Bupivacaine combined with epinephrine was the most effective solution for pain control in patients undergoing ACLR, but with no statistically significant differences when compared to Group II (p » 0.547). There was no decrease or increase in the use of supplemental analgesics or in the occurrence of adverse systemic effects (p > 0.05).

Resumo Objetivo Avaliar primariamente a dor pós-operatória, por meio da escala visual analógica (EVA), nos pacientes submetidos a reconstrução do ligamento cruzado anterior (RLCA) que receberam soluções anestésicas intra-articulares (IAs). Métodos Ensaio clínico randomizado com uma amostra de 48 pacientes, divididos em 4 grupos: Grupo I (n » 12) - 20 ml de solução fisiológica (controle); Grupo II (n » 12) - 20 ml de bupivacaína a 0,5%; Grupo III (n » 12) - 20 ml de bupivacaína a 0,5% þ 0,1 mg de epinefrina; e Grupo IV (n » 12) - 20 ml de solução fisiológica þ 0,1 mg de epinefrina, injetados no joelho ao término da cirurgia. A dor foi avaliada pela EVA imediatamente e 6, 12, 24 e 48 horas após o procedimento. Resultados Observou-se grande variabilidade nos resultados da EVA entre os pacientes avaliados em cada grupo. Verificou-se, pela análise de variância (analysis of variance, ANOVA) de Kruskal-Wallis, considerando um nível de 5% de significância, que as soluções anestésicas IAs de cada grupo influenciaram na avaliação da dor desses pacientes (p » 0,003), sendo os do Grupo III os que apresentaram menor dor pósoperatória. Não se evidenciou um maior ou menor consumo de drogas analgésicas suplementares, ou efeitos adversos das decorrentes das soluções empregadas. Conclusão A solução combinada de bupivacaína e epinefrina foi a mais eficaz no controle da dor nos pacientes submetidos a RLCA, mas sem diferenças estatisticamente significativas com relação ao grupo II (p » 0,547). Não se observou diminuição ou aumento no consumo de analgésicos suplementares, ou o aparecimento de efeitos sistêmicos adversos (p > 0,05).

Manejo del dolor en plástica de ligamento cruzado anterior. Bloqueo del nervio safeno interno. Estudio comparativo / Pain management in anterior cruciate ligament reconstruction. Saphenous Nerve block. Comparative study

Introducción: El manejo del dolor postoperatorio en pacientes que recibieron una reconstrucción del ligamento cruzado anterior (LCA) debe ser incluido como objetivo fundamental de toda estrategia quirúrgica. El bloqueo selectivo del nervio safeno interno mediante asistencia ecográfica se presenta como una alternativa eficaz para el control del dolor sin afectar la actividad motora del cuádriceps. El propósito de este estudio fue comparar el dolor postoperatorio en pacientes que recibieron una reconstrucción del LCA con injerto autólogo hueso-tendón-hueso (H-T-H), asistidos con anestesia raquídea, analgesia multimodal más bloqueo selectivo del nervio safeno interno versus pacientes que recibieron anestesia raquídea y analgesia multimodal. Materiales y métodos: se realizó un ensayo clínico no aleatorizado de pacientes consecutivos, comparados en dos grupos de trabajo según tipo de estrategia anestésica utilizada: treinta y seis pacientes en grupo 1 y cuarenta en el grupo 2. El promedio de edad fue de veintinueve años (20­42) en el grupo 1 y de treinta y dos años (18­49) en el grupo 2.Resultados: se encontraron diferencias estadísticamente significativas entre los valores promedio en la escala numérica verbal (ENV), se evidencian menores registros y mejor evolución de dolor en pacientes del grupo 1. También se hallaron diferencias estadísticamente significativas entre los niveles de satisfacción con el tratamiento del dolor a favor del grupo 1. Conclusión: el bloqueo selectivo del nervio safeno interno, asociado a la anestesia raquídea y a un esquema adecuado de analgesia multimodal, provee un excelente control del dolor y permite una externación rápida con alto grado de satisfacción en pacientes que recibieron una reconstrucción artroscópica del LCA con injerto H-T-H autólogo.

Introduction: Postoperative pain management in patients who underwent anterior cruciate ligament (ACL) reconstruction should be included as a fundamental objective of any surgical strategy. The internal Saphenous Nerve block with ultrasound assistance is presented as an effective strategy for pain control without affecting quadriceps motor activity. The aim of this study is to compare the postoperative pain management in patients who have received an arthroscopic autologous Bone Tendon Bone (BTB) ACL reconstruction, using spinal anesthesia, selective internal saphenous nerve block, and multimodal analgesia scheme versus patients who received spinal anesthesia and same multimodal analgesia scheme. Materials and methods: we performed a non randomized controlled trial, of two prospective series of patients by anesthetic strategy used: thirty-six patients in Group 1 and forty patients in Group 2. The average age by groups was twenty-nine years (range 20­42) in Group 1 and thirty-two years (18­49) in Group 2.Results: statistically significant differences were found between the average pain values reported by Numeric Rating Scale (NRS) in two groups, showing lower pain records in Group I, as well in the evolution of pain in favor of Group I. Statistically significant differences were found between the mean levels of satisfaction with pain treatment. Conclusion: in ACL reconstruction using BTB autologous graft, selective internal saphenous nerve block, with spinal anesthesia associated an adequate multimodal analgesia scheme, provides excellent pain control, allowing rapid hospital discharge with a high level of satisfaction

Reconstrucción secuencial de ruptura bilateral del ligamento cruzado anterior. Reporte de un caso / Sequential reconstruction of bilateral anterior cruciate ligament rupture. Case report

Cuando se presentan pacientes con ruptura bilateral del ligamento cruzado anterior y requieren cirugía reconstructiva, se puede optar por procedimientos de reconstrucción unilateral a la vez. Este tipo de abordaje terapéutico ha sido descripto en la literatura, sin embargo, existe muy poca evidencia acerca de la reconstrucción simultánea o secuencial de ambas rodillas en el mismo acto quirúrgico. En este trabajo se presenta un caso de reconstrucción secuencial en el mismo acto quirúrgico, con un solo tiempo anestésico, realizado por un solo equipo quirúrgico en un paciente con ruptura bilateral de ligamento cruzado anterior. Además, se desarrolla una actualización del tema y se compara este procedimiento con aquellos efectuados en dos actos quirúrgicos, desde el punto de vista económico, clínico y funcional, el plan de fisioterapia adoptado y los resultados a mediano plazo mediante la escala de Lysholm. Tipo de Estudio: Reporte de caso y actualización. Nivel de Evidencia: IV

When we face a patient with bilateral anterior cruciate ligament rupture and requires a ligament reconstruction, we can suggest a unilateral reconstruction procedure. This type of surgical management has been described in the literature; however, very scant evidence is published about simultaneous or sequential ACL reconstruction at one stage procedure.This paper presents a case report of a sequential ACL reconstruction made in a one-stage surgical procedure for the same surgical team in a patient with bilateral ACL rupture. A revision of the literature is made, a comparison with those made in two separate procedures is also reported, from a clinical, functional, and economic view, the rehabilitation program and the medium-term outcome by the score of Lysholm. Type of study: Case report and literature review. Level of Evidence: IV

Eleccion de injertos en la cirugía de reconstrucción del ligamento cruzado anterior: revisión de conceptos actuales / Anterior cruciate ligament reconstruction. Graft selection. Current Concepts

La ruptura del ligamento cruzado anterior (LCA) es una lesión frecuente en la población general, con una incidencia de hasta 75/100.000 personas por año. Hombres y mujeres jóvenes, involucrados en deportes de contacto y colisión, suelen ser los más afectados. La reconstrucción artroscópica se ha convertido en el estándar de tratamiento, con cerca de doscientos mil procedimientos por año en EEUU. Los injertos se clasifican según sus elementos constituyentes (hueso-tendón-hueso, hueso-tendón o tendón), o el origen del dador (autoinjerto o aloinjerto). A pesar de su alta prevalencia, el injerto ideal sigue siendo motivo de debate en la bibliografía. Consideramos que su elección debe basarse en la experiencia del cirujano con los diferentes injertos y en las características individuales de cada paciente

Anterior cruciate ligament (ACL) tear is a common injury in the general population, with an incidence of up to 75/100,000 annually, affecting mainly men and women involved in contact and collision sports. With nearly 200,000 procedures performed annually in the US, arthroscopic reconstruction has become the standard treatment. Grafts can be classified according to their constituent elements (bone-tendon-bone, bone-tendon or tendon) or the origin of the donor (autograft or allograft). Despite its high prevalence, today the bibliographic debate continues regarding which is the ideal graft. We consider that graft selection should be based on the experience and comfort of the surgeon and the individual patient characteristics

Estudio anatómico de las porciones tendinosas de los músculos semitendinoso y grácil, aplicado a la reconstrucción del ligamento cruzado anterior / Anatomical study of gracilis and semitendinosus muscles tendons applied to ACL reconstruction

Introducción: La reconstrucción del ligamento cruzado anterior (LCA) con injerto autólogo con la porción tendinosa de los músculos grácil y semitendinoso ha ganado popularidad. El emplazamiento de la incisión para cosechar dicho injerto y la cantidad de tejido disponible son claves a la hora de su utilización. El estudio cadavérico y ecográfico permite evaluar mejor sus propiedades con aplicación quirúrgica.Materiales y métodos: estudio descriptivo transversal. Se disecaron veinticuatro miembros inferiores de adultos, formolados. Se realizó ecografía de partes blandas en dieciocho miembros inferiores de adultos de ambos sexos. Se midieron los tendones de los músculos grácil y semitendinoso en longitud y diámetro. Se topografió su inserción en relación al borde anterior de la tibia (BAT) y a la interlínea articular (IA). Resultados: en el estudio cadavérico, la inserción promedio del grácil fue a 2.7 cm del BAT y 4.6 cm de la IA, y del semitendinoso fue a 2.7 cm del BAT y 5.7 cm de la IA. El diámetro y longitud de los tendones fue de 0.55 cm y 13.29 cm, respectivamente, para el grácil y de 0.68 cm y 16.42 cm para el semitendinoso. La ecografía mostró valores estadísticamente distintos en todas las variables. Se establecieron regresiones lineales significativas entre el largo de la pierna y la longitudes de los tendones, así como la distancia a la IA.Conclusiones: el presente estudio aporta información precisa sobre el punto de inserción de los dos músculos. Las propiedades morfológicas de ambos tendones se prestan para su utilización como injerto. La ecografía no mostró resultados comparables con los cadavéricos

Introduction: Anterior cruciate ligament (ACL) using autologous hamstring graft, with gracilis and semitendinosus muscles tendons, has gained popularity. Incision emplacement for harvesting the aforementioned graft, and tissue availability are key points when considering its utilization. Cadaveric and ultrasonography study allows a better evaluation of its properties, with surgical application.Materials and methods: descriptive cross-sectional study. Twenty-four adult formaldehyde-fixed lower limbs were dissected, there were limbs of both sexes. Soft tissue ultrasonography was performed in eighteen lower limbs of adults of both sexes. The tendons of the gracilis and semitendinosus muscles were measured in length and diameter. Their insertion was surveyed in relation to tibial anterior border (TAB) and joint line (JL). The results obtained were compared, with a p value <0.05 considered significant.Results: in cadaveric study, mean insertion site for gracilis was 2.7 cm medial to TAB and 4.6 distal to JI, and for semitendinosus it was 2.7 cm medial to TAB and 5.7 cm distal to JI. Diameter and length of tendon was 0.55 cm and 13.29 cm respectively for gracilis, and 0.68 cm and 16.42 for semitendinosus. Ultrasonography showed statistically different results for all variables. Significant lineal regressions were established between leg length and tendon length or distance of insertion to JI.Conclusions: the present study provides precise information on the insertion point of both muscles, applied to ACL reconstruction. Morphological properties of both tendons allow their use as grafts. Ultrasound did not show comparable results with cadaveric study

Clinical effects of arthroscopy-assisted anterior cruciate ligament tibial eminence avulsion fracture compared with traditional open surgery:a Meta-analysis / 中国骨伤

OBJECTIVE@#To systematically evaluate the clinical efficacy of arthroscopy and traditional incision in the treatment of tibial avulsion fracture of anterior cruciate ligament (ACL).@*METHODS@#From July 2010 to July 2020, clinical comparative trial about arthroscopy and traditional incision in the treatment of ACL tibial avulsion fracture was conducted by using computer-based databases, including Embase, Pubmed, Central, Cinahl, PQDT, CNKI, Weipu, Wanfang, Cochrane Library, CBM. Literature screening and data extraction were carried out according to the inclusion and exclusion criteria, and the quality of the included literature was evaluated by improved Jadad score and Ottawa Newcastle scale (NOS). The operation time, hospital stay, fracture healing time, knee range of motion, postoperative excellent and good rate, complication rate, Lysholm score, International Knee Documentation Committee (IKDC) score and Tegner score were statistically analyzed by Review Manager 5.3 software.@*RESULTS@#Finally, 16 literatures were included, including 1 randomized controlled trial and 15 non randomized controlled trials, with a total of 822 patients (405 in arthroscopy group and 417 in traditional incision group). Meta analysis showed that the operation time [MD=-9.03, 95% CI(-14.36, -3.70), P<0.001], hospital stay [MD=-5.81, 95%CI(-9.32, -2.31), P=0.001] and fracture healing time [MD=-14.61, 95% CI(-17.93, -11.28), P<0.001] in the arthroscopy group were better than those in the traditional incision group. The incidence of complications in arthroscopy group was lower than that in traditional incision group[OR=0.15, 95%CI(0.07, 0.33), P<0.001]. The postoperative excellent and good rate[OR=4.39, 95%CI (1.96, 9.82), P<0.001], knee mobility[MD=6.78, 95%CI(2.79, 10.77), P<0.001], Lysholm score[MD=11.63, 95%CI(4.91, 18.36), P<0.001], IKDC score[MD=7.83, 95%CI(6.09, 9.57), P<0.001] and Tegner score[MD=0.60, 95%CI(0.31, 0.89), P<0.001] in the arthroscopic group were higher than those in the traditional incision group.@*CONCLUSION@#Compared with the traditional open reduction and internal fixation, arthroscopic surgery in patients with ACL tibial avulsion fracture can shorten the operation time, hospital stay and fracture healing time, reduce the incidence of postoperative complications, and obtain good postoperative knee function. It can be recommended as one of the first choice for patients with ACL tibial avulsion fracture.

Mid-to-long term clinical outcomes and predictors after anterior cruciate ligament revision / 北京大学学报(医学版)

OBJECTIVE@#To assess the mid-to-long term clinical outcomes after anterior cruciate ligament (ACL) revision surgery and to analyze their predictors.@*METHODS@#The medical records of 235 patients undergoing ACL revision surgery between Jan. 2001 and Dec. 2015 at Department of Sports Medicine, Peking University Third Hospital were reviewed. Data were collected including demographic information, information related to revision surgery (time and cause of graft failure, date of revision surgery, surgical technique, combined injuries and management, etc.), as well as information related to primary ACL reconstruction (time, cause and mechanism of first-time ACL rupture, date of primary ACL reconstruction, surgical technique, combined injuries and management, etc.). Patients were followed up at least 2 years after revision surgery for clinical outcomes [Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective knee score]. Post-revision surgeries on the involved knee and the contralateral knee joint were also documented. Multivariate regression model was used to analyze the predictors of clinical outcomes after ACL revision surgery.@*RESULTS@#A total of 166 (70.63%) patients were followed up at a mean of (4.44±2.40) years (2.03-14.63 years). Clinical outcomes improved significantly at the last follow-up from pre-operative level, with the Lysholm, Tegner, and IKDC scores improving from 70.51±21.25, 3.39±1.77, 63.78±15.04 to 88.64±14.36, 4.67±1.739, 80.23±13.31 (P < 0.05), respectively. Three (1.81%) patients experienced infection while 39 (23.49%) patients underwent surgery after revision surgery during the follow-up. Compared with that those occurred during sports, graft failure that occurred during daily activities or due to surgical technical errors that led to poorer clinical outcomes, with the Lysholm, Tegner, and IKDC scores of 9.90 (95%CI: 1.49-18.31), 1.41 (95%CI: 0.10-2.72), 10.35 (95%CI: 0.17-20.54), and 8.53 (95%CI: 1.31-15.75), 1.28 (95%CI: 0.14-2.43), 9.39 (95%CI: 1.03-17.74) lower, respectively. Compared with antero-medial portal, transtibial technique for placement of the femoral bone tunnel showed poorer Lysholm scores of 11.18 (95%CI: 4.73-17.63, P=0.001). Concurrent repair of medial meniscus yielded higher IKDC scores of 11.06 (95%CI: 1.21-20.92, P=0.029) than those with intact medical meniscus. Other factors showed no significant effect.@*CONCLUSION@#ACL revision surgery is able to restore knee stability and improve knee function. Graft failure caused by sports, concurrent repair of medical meniscus and antero-medial portal technique predicts better outcomes after revision surgery.

Reconstrucción del ligamento cruzado anterior en niños preadolescentes con técnica extrafisaria intra y extraarticular con autoinjerto de bandeleta iliotibial / ACL reconstruction in skeletally immature patients with intra and extraarticular technique with iliotibial band autograft

Introducción: el propósito de este trabajo es hacer una evaluación retrospectiva clínica, funcional e imagenológica de una serie de pacientes con esqueleto inmaduro Tanner I y II intervenidos quirúrgicamente mediante la técnica de preservación fisaria de reconstrucción extra e intraarticular con autoinjerto de bandeleta iliotibial, técnica de Micheli. Evaluar si existieron alteraciones del crecimiento o angulares relacionadas con la cirugía. Materiales y métodos: se analizaron un total de veintidós rodillas en veinte pacientes con edad ósea promedio de 10.1 años y un seguimiento promedio de 5.6 años. Se realizó una evaluación clínica de movilidad, estabilidad incluyendo artrometría KT-1000, escalas funcionales y valoración por imágenes de discrepancia de longitud de miembros inferiores, alteraciones angulares y evaluación de integridad por resonancia magnética.Resultados: no hubo déficit de la movilidad con respecto a la rodilla contralateral, el test de Lachman, Pivot shift y la evaluación con KT-1000 fue normal en el 91, 95 y 95% de los pacientes, respectivamente. Se presentaron dos re-rupturas del injerto (9%). No hubo deformidades angulares del fémur o tibia ni discrepancia longitudinal de las extremidades inferiores. Las escalas funcionales mostraron un IKDC de 95.4 y un IKDC pediátrico de 92.3 en los pacientes a los que se les alcanzó a aplicar esta escala. Lysholm de 94.1 y un Tegner de 7 con un retorno al mismo deporte o actividad que causó la lesión del 90%. En la evaluación por resonancia magnética, el 100% de los pacientes que no presentaron re-ruptura tuvieron integridad del injerto. Conclusión: el procedimiento quirúrgico es seguro, reproducible, restaura la estabilidad anteroposterior y rotacional de la rodilla, sin causar alteraciones del crecimiento en este grupo poblacional, obteniendo excelentes puntajes en las escalas de valoración subjetivas, y un alto índice de retorno deportivo con un porcentaje menor de re-rupturas. Nivel de Evidencia: IV

Introduction: the purpose of this paper is to retrospectively evaluate clinical, functional and imagenological outcomes of a series of patients with skeletal immaturity Tanner 1 and 2, surgically intervened by physis preservation intra and extra articular reconstruction with iliotibial band autograft method described by Micheli. Evaluate growth or angular disturbances related to the surgical technique. Materials and methods: twenty-two knees in twenty patients with average bone age 10.1 years were evaluated with a 5.6 year follow up. Clinical evaluation of ROM and stability was made by arthrometry KT-1000, functional scales were applied, image evaluation of length discrepancy, angular deformity and integrity evaluation by magnetic resonance were also done. Results: no ROM deficit compared with the contralateral knee was observed, Lachman, Pivot shift tests and KT-1000 evaluation were normal in 91, 95 and 95% of patients, respectively. There were two cases of graft rupture (9%). No angular femoral or tibial deformities or length discrepancies were observed. Functional scales showed IKDC 95.4, pediatric IKDC 92.3 in patients who underwent the scale, Lysholm 94.1 and Tegner 7 with return to sports of 90% to pre level activity. 100% of patients without graft rupture had graft integrity in the RM evaluation. Conclusion: the surgical technique is safe and reproductible, restores anteroposterior and rotational stability of the knee without growth arrest in this population, obtaining excellent scores in subjective rating scales, high return to sports index with low rerupture rates. Level of Evidence: IV

Pérdida de tejido muscular en la extracción de tendones isquiotibiales en reconstrucción del LCA. Estudio experimental comparativo / Loss of muscle tissue during hamstring graft harvest in ACL reconstruction. Comparative experimental study

Introducción: En la reconstrucción del LCA, la pérdida de tejido muscular durante la extracción del injerto de tendones isquiotibiales dependerá del tamaño de stripper (tenótomo) que se utilice. El objetivo de este trabajo es comparar y cuantificar la pérdida de tejido muscular sano al realizar la extracción del injerto, y de esta forma poder evaluar una estrategia para reducir la morbilidad de la zona dadora.Materiales y métodos: realizamos un trabajo comparativo. Utilizamos diez preparados anatómicos (veinte rodillas) a los que se les realizó la extracción del injerto de isquiotibiales, semitendinoso y recto interno utilizando dos tenótomos (strippers) de distinto diámetro, de 5 y 7 mm. Evaluamos peso y volumen del tejido muscular resecado. Resultados: se compararon los resultados obtenidos, los que mostraron una diferencia estadísticamente significativa (p <0.01) tanto en el volumen como en el peso del material muscular extraído, en ambos músculos involucrados. Conclusión: nuestra hipótesis fue confirmada, encontramos diferencias que varían desde un 33 hasta un 65% más de peso de músculo sano extraído por la simple utilización de un tenótomo (stripper) de mayor diámetro al requerido. Recomendamos la utilización de tenótomo de 5 mm para disminuir la morbilidad de la zona dadora, y resecar menor volumen de tejido muscular. Nivel de Evidencia: III

Introduction: The loss of muscle tissue during hamstring graft harvest in ACL reconstruction, will depend on the size of the tendon stripper used. Our aim is to compare and quantify the loss of healthy muscle tissue when the graft is extracted, thus, be able to evaluate a strategy to reduce the donor site morbidity. Materials and methods: we harvested hamstring graft, semitendinosus and gracilis, in ten cadaver specimens (twenty knees) using two tendon strippers of 5 mm and 7 mm respectively. Then, we measured the weight and volume of the resected muscle tissue by each stripper. Results: outcome measures were compared, showing a statistically significant difference (p <0.01) in both, volume and weight of the extracted material, for both muscles involved.Conclusion: our hypothesis was confirmed. Results show a 33 to 65% higher weight and volume of healthy muscle tissue extraction, only by using a higher diameter stripper than the one required. We strongly recommend using a 5 mm stripper to reduce donor site morbidity and resect a lower volume of muscle tissue. Level of Evidence: III

Comparison of femoral tunnel and early curative effect analysis between arthroscopic three approach and traditional anteromedial portal for reconstruction of anterior cruciate ligament / 中国骨伤

OBJECTIVE@#To study the three-approach and traditional anterior medial technique to establish the femoral tunnel of position, length, and coronal angle and the early efficacy of anterior cruciate ligament reconstruction.@*METHODS@#Through retrospective research, from December 2018 to June 2019, a total of 36 patients diagnosed with simple anterior cruciate ligament tear and undergoing surgery were collected. All patients had a clear history of knee sprains and were divided into two groups. A group of 16 patients, including 11 males and 5 females, with an average age of (30.13±6.54) years and an injury time of 7 to 60 (30.19±15.78) days, three-approach technique was used to drill the femoral tunnel to reconstruct the anterior cruciate ligament. Another group of 20patients, including 15 males and 5 females, with an average age of (30.80±8.60) years, and an injury time of 7 to 60 (27.35±15.50) days, the traditional anterior medial approach was used to drill the femoral tunnel to reconstruct anterior cruciate ligament. CT 3D reconstruction technique was used to evaluate the femoral tunnel and the knee joint function was evaluated by Lysholm score of the knee joint.@*RESULTS@#All patients achieved primary healing after the surgical incision. No femoral tunnel fracture, vascular and nerve damage, difficulty in graft passage during the operation, and venous thrombosis occurred. All 36 patients were followed up on an outpatient basis, with a follow up period of 9 to 15 (12.00±2.83) months. Three-dimensional CT reconstruction was used to evaluate the femoral tunnel of the patients. The position of the femoral tunnel was described using the quartile method as the three-approach group:the lower (27.83±1.97) % of the femoral condyle and the posterior (25.57±3.20) %;the traditional approach group:the lower (28.38±3.21) % of the femoral condyle and the posterior (26.23±3.20) %. Bone tunnel length, three-approach group:(35.20±5.52) mm in total length, (23.20±2.07) mm in thick bone tunnel;traditional approach group:(34.60±4.26) mm in total length, (22.56±2.50) mm in thick bone tunnel. Coronal plane angle, three-approach group:(47.93±5.98) °;traditional approach group:(41.78±6.62) °. Knee joint Lysholm score, three-approach group:48.67±4.18 before surgery;97.00±2.48 at last follow up;traditional approach group:49.75±5.33 before surgery, 97.30±2.68 at last follow up, there were significant differences before and after surgery, no significant statistical difference between two groups.@*CONCLUSION@#The positions of the femoral tunnel drilled by the two methods were within the range of the anatomic stop of the anterior cruciate ligament, and there was no statistical difference. Compared with the traditional anterior medial approach, the coronal plane angle of the femoral tunnel drilled by the three-approach approach is relatively large, and there were no statistical differences in the length of the tunnel, the early postoperative effect of the two surgical methods, and the operation time. But the three approach has a wider and clearer vision. In addition, the knee flexion angle required for drilling the femoral tunnel during surgery is significantly smaller than that of traditional approach technology, which reduces the difficulty of surgery.

Bone tunnel positions in anterior cruciate ligament reconstruction evaluated by three-dimensional CT reconstruction based on Mimics software:modified transtibial versus anteromedial portal technique / 中国骨伤

OBJECTIVE@#To compare the femoral and tibial tunnel positions of anterior cruciate ligament reconstruction using the modified transtibial (MTT) technique and anteromedial (AM) portal technique.@*METHODS@#Between January 2017 and September 2020, 78 patients with anterior cruciate ligament rupture underwent single-bundle reconstruction with the modified transtibial technique in 39 cases (group MTT) and through anteromedial approach in 39 cases (group AM). There were 25 males and 14 females in group MTT, with an average age of (37.0±2.3) years old; 27 males and 12 females in group AM, with an average age of (37.5±2.2) years old. CT scan of the affected knee was conducted one week after the surgery to measure and compare the femoral tunnels positioning (Fx, Fy), tibial tunnels positioning in the frontal plane(Tx1), tibial tunnels positioning in the sagittal plane (Ty1), and tibial tunnels positioning in the axial plane (Tx2, Ty2) in patients undergoing anterior cruciate ligament reconstruction through Mimics software.@*RESULTS@#Three-dimensional CT reconstruction after the surgery showed that the average Fx and Fy were(25.2±2.1)% and (34.9±3.0)% respectively and the Tx1 and Ty1 were (45.5±3.3)% and (44.7± 3.0)% respectively, while the Tx2 and Ty2 were (47.0±3.0)% and (39.9±4.2)% respectively in group MTT. In group AM, the average Fx and Fy were (26.0±2.0)% and (36.1±3.9)% respectively and the Tx1 and Ty1 were (46.5±3.1)% and (45.6± 3.1)% respectively, while the Tx2 and Ty2 were (47.4±2.5)% and (39.6±3.9)% respectively. There were no statistically significant differences in the femoral and tibial tunnels between the two groups (@*CONCLUSION@#Both the MTT and AM technique can achieve good anatomical positioning of the femoral and tibial tunnels, without significant differences in the positioning of the bone tunnels.

Comparative study on posterior cruciate ligament reconstruction with autologous hamstring tendon and LARS artificial ligament in the treatment of KD-Ⅲ-M knee dislocation / 中国骨伤

OBJECTIVE@#To observe the curative effect of one-stage reconstruction of anterior cruciate ligament(ACL), posterior cruciate ligament (PCL) and medial collateral ligament (MCL) in patients with KD-Ⅲ-M knee injury, and to compare the operation time, hospitalization cost and curative effect after arthroscopic reconstruction of PCL with LARS artificial ligament and autogenous hamstring tendon, ACL reconstruction with autogenous hamstring tendon and MCL repair combined with limited incision.@*METHODS@#From March 2016 to January 2019, a total of 36 patients met the criteria of this study. Twenty patients in group A were treated with autogenous hamstring tendon reconstruction of ACL and PCL and repair of MCL, including 17 males and 3 females, with an average age of (34.7±9.2) years old. Sixteen patients in group B with LARS artificial ligament reconstruction of PCL, with an autogenous hamstring tendon reconstruction of PCL and MCL repair as before as group B, including 15 males and 1 female, with an average age of (36.8±8.6) years old. The operation time, hospitalization time and total hospitalization cost were compared between the two groups. The preoperative and postoperative functions of the two groups were evaluated by Hospital for Sepcial Surgery (HSS) score and Lysholm score respectively, and the curative effects were compared within and between groups.@*RESULTS@#All the patients in the two groups were followed up for at least 1 year. There were no complications such as infection and poor wound healing in both groups. There was significant difference in operation time between (120.25±9.55) min in group A and (106.63±8.85) min in group B (@*CONCLUSION@#There was no significant difference in the average hospitalization days between the two groups, but the operation time in group A was longerthan that in group B, and the hospitalization cost in group B was higher than that in group A. There was no difference in HSS score and Lysholm score before and follow-up for a certain period of time after operation.