Comparative Study of Arthroscopic Anterior Cruciate Ligament Reconstruction by Quadrupled Semitendinosus-Gracilis and Tripled Semitendinosus Auto Graft

Background: The anterior cruciate ligament (ACL) is the most frequently disrupted ligament of the knee. Arthroscopic ACL reconstruction is one of the most common orthopaedic procedures now-a-days and has become the gold standard method of treatment in complete ACL tear. Though the choice of graft for ACL reconstruction and the methods of its fixation are matters of debate, hamstring tendon is considered as the favorable graft. Common options for the choice of graft are quadrupled semitendinosus-gracilis and tripled semitendinosus auto graft. Aim of our study is to compare the outcome of arthroscopic ACL reconstruction by quadrupled semitendinosus-gracilis and tripled semitendinosus auto graft.Material & Methods:In this prospective interventional study purposive sampling was done. Sixty patients with complete ACL tear were included in this study from May 2017 to August 2019 at NITOR, strictly considering the inclusion and exclusion criteria. Thirty of them treated with quadrupled semitendinosus-gracilis (group 1) and thirty with tripled semitendinosus (group 2) auto graft. Evaluation by Lysholm knee score was done before and after surgery. Final outcome was evaluated at 24th week post-operatively.Results:Preoperative Lysholm Knee Score was almost similar in group 1 (63.2�1) and in group 2 (63.1�5). This difference was not statistically significant (p=0.582). Postoperative Lysholm Knee Score at 24th week was slightly higher in group 1 (95.0�0) in comparison to group 2 (94.4�2). This difference was also not statistically significant (p=0.361). But excellent functional outcome was more in group 1 (80.0%) in comparison to group 2 (73.3%) whereas no poor or fair outcome was reported in group 1 but fair outcome was reported in 6.7% of patients in group 2. Overall complication rate was 6.67% with no significant intergroup difference.Conclusions:Quadrupled semitendinosus-gracilis auto graft has yielded more excellent results than tripled semitendinosus graft. But as this difference was not significant, it can be said that, both the procedure can be performed for arthroscopic reconstruction of ACL.

Bilateral Medial Tibial Plateau Fracture after Arthroscopic Anterior Cruciate Ligament Reconstruction

Tibial plateau fractures after arthroscopic anterior cruciate ligament (ACL) reconstruction are rare, and only isolated cases have been reported. The authors describe a case of bilateral medial tibial plateau fracture following a minor motorcycle accident in a patient who underwent arthroscopic ACL reconstruction in the past. Two years and four months before the accident, the patient underwent an arthroscopically assisted ACL reconstruction using double-bundle technique on his left knee at a hospital. He had the same surgery using single-bundle technique on his right knee about eight months ago at another hospital. The fractures in his both involved knees occurred through the tibial tunnel and required open reduction with internal fixation. At three weeks after fixation, a second-look arthroscopy revealed intact ACLs in both knees. At five months follow-up, he was able to walk without instability on physical examination. Follow-up radiographs of the patient showed callus formations with healed fractures.

Popliteal Pseudoaneurysm after Arthroscopic Posterior Cruciate Ligament Reconstruction

This report presents the case of a 30-year-old motocross (BMX) cyclist with a third-degree posterior cruciate ligament rupture. The technique used for reconstruction was the transtibial single-bundle autologous hamstring technique. Unfortunately, the procedure was complicated by a popliteal pseudoaneurysm, which was located in line with the tibial canal. The pseudoaneurysm was treated with an end-to-end anastomosis and the patient recovered without further complaints. In this case, the popliteal artery was damaged most probably by the edge of the reamer or the guide wire during removal. Vascular complications can be limb- and life-threatening. This case report aims to increase the awareness of this serious complication with a review of the literature.

Tratamiento artroscópico de las fracturas avulsión de espina tibial anterior. Nueva técnica CrossFix con arpones BioSwivelock con FiberTape sin nudos: técnica quirúrgica / Arthroscopic surgery of anterior tibial avulsion fractures

Describimos una técnica quirúrgica sin nudos (Knotless) con arpones Bioswivelock con sutura FiberTape (Arthrex inc. Naples Florida) con técnica cruzada; denominándola técnica CrossFix para reducción y osteosíntesis artroscópica de las fracturas avulsión de espina tibial anterior, logrando reducción anatómica estable, mínimamente invasiva sin la necesidad de realizar la extracción del implante al final del tratamiento. Nuestra técnica es aplicable tanto en pacientes con inmadurez esquelética como en adultos ya que no daña la fisis o cartílago de crecimiento y no requiere una segunda intervención para el retiro del implante; combinando las ventajas de la fijación con suturas de alta resistencia FiberTape, con la tecnología de los implantes sin nudos.

We describe a new surgical technique without knots (knotless technique) with Bioswivelock anchor and FiberTape suture (Arthrex inc. Naples Florida) with crossing technique, calling it CrossFix technique for arthroscopic reduction and internal fixation of avulsion fractures of the anterior tibial tubercle, achieving anatomic reduction, stable, minimally invasively without the need for removal of the implant at the end of treatment. Our technique is applicable to both patients adult and skeletal immaturity as not damage the cartilage growth plate or fisis and does not require a second surgery to remove the implant, combining the advantages of fixation with high strength sutures like the FiberTape, with an implant technology without knots like Bioswivelock.

Tibial Tunnel Changes after Arthroscopic ACL Reconstruction using Autogenous Bone-Patellar Tendon-Bone

PURPOSE: We analysed radiographic changes of bone tunnels after anterior cruciate ligament(ACL) reconstruction and evaluated the correlation between measurements and clinical variable. MATERIALS AND METHODS: Fifty patients were examined retrospectively. The interval between surgery and examination ranged from 12 to 48 months with a mean of 18 months. We measured the area and width of tibial tunnel from the radiographs of anteroposterior(AP) and lateral views of the knee after arthroscopic ACL reconstruction using computer program "Image-Pro ExpressRfi". The proximal, middle, distal one third of tibial tunnel area and maximum diameter of tibial tunnel were measured on AP and lateral radiographs. Each measurements were done on immediate postoperative, and postoperative 3, 6, 9, 12, 24, 36 months. RESULTS: The size of tibial tunnel was larger on lateral than AP radiograph. The proximal part was found to be the largest and the size decreased as it moved distally. The area of proximal one third was increased from postoperative 3 months and that of distal one third was decreased from postoperative 3 months. The shape of tibial tunnel area on the last follow-up was cylinder type in 33(66%) and 17(34%) on AP and lateral radiograph, mallet type 8(16%) and 4(8%), reverse bottle type 5(10%) and 11(22%), reverse triangle type 4(8%) and 18(36%) respectively. CONCLUSIONS: The tibial tunnel change was not correlated with clinical variable such as Lysholm score.

The Result of Arthroscopic Anterior Cruciate Ligament Reconstruction Using Autogenous Hamstring Graft with and Without it's Tibial Detachment / 대한정형외과학회잡지

PURPOSE: To analyze comparatively the results of arthroscopic ACL reconstructions using autogenous hamstring tendon with (group II) and without (group I) it's tibial detachment. MATERIALS AND METHODS: A retrospective study of 22 patients (group I; 10, group II; 12) treated with arthroscopic reconstruction using autogenous hamstring tendon was performed. The average follow-up period was 18 months. Functional and clinical results were evaluated according to Clancy's criteria and the Lysholm knee scoring scale. Postoperative anterior laxity was measured using a KT-2000 arthrometer. Using the group I technique, an animal study was done to compare the tension strengths of the afferent and efferent limbs of the graft material. RESULTS: The mean Lysholm knee score was 82.5 points in group I and 87.8 points in group II at the last follow up. Anterior laxity was 2.9 mm in group I and 1.9 mm in group II at the last follow up. Functional evaluation using Clancy's criteria, showed that 7 patients (70%) in group I and 11 patients (91.6%) in group II had an excellent or a good result. In the animal study, a difference was found between the tension strengths of the the afferent and efferent limbs. CONCLUSION: The results of ACL reconstruction in group II were better than those of group I, and the group II technique had the advantage of an graft even tension.

Effect of Ligament Fixation and Rehabilitation on Clinical Results in Arthroscopic PCL Reconstruction

The purpose of this study is to compare the effects of intraoperative fixation and postoperative rehabili-tation on postoperative results in arthroscopic PCL reconstruction. We analyzed the posterior stability of the knee on 47 patients(48 knees) with posterior cruciate liga-ment injury whose posterior cruciate ligament had been recostructed arthroscopically and followed for minimum 1 year period at Asan Medical Center from March 1993 to May 1998. The patients were divided into the two groups according to intraoperative fixation and postoperative rehabilitation. In A group, one interference screw or staple fixed in distal femur and proximal tibia irre-spective to bone quality and fixation strength during screw insertion, and rehabilitation was started as early as anterior cruciate ligament reconstruction. In B group, additional screw or staple was fixed if fixa-tion strength was weak during screw insertion, and delayed rehabilitation program was performed as schedule. Lysohm knee score was 65.3 in group A and 75.8 in group B preoperatively but 86.0 in group A and 86.5 in group B at last follow up postoperatively. posterior stability was determined by difference in pos-terior tibial translation between the injured and the opposite knee with Telos device. Differences in poste-rior tibial translation on average were 6.9 and 3.0 mmin group A and B, respectively. Conclusively, arthroscopic posterior cruciate reconstruction with firm fixation strength and delayed rehabilitation program is effective to restore more reliable posterior stability.

Muscle Strength and Functional Capacity after Arthroscopic ACL Reconstruction using Patellar Tendon Autograft / 대한정형외과학회잡지

Traditionally, evaluation after ACL reconstruction has been focused on physical characteristics and measures of knee stability. Recently, however, reliance on such criteria has been refuted based on the lack of a strong relationship between these measures and both the patient s perception of knee function and return to sports activity. In present study, preoperative and postoperative physical examinations, isokinetic dynamometer, arthrometer test and functional tests were performed on 17 patients with chronic anterior cruciate ligament tears treated by arthroscopic reconstruction using autogenous bone-patellar tendon-bone graft with at least 1 year of follow-up. Muscle power, joint stability and functional recovery were checked for functional evaluation by specific methods. Lysholm score rating scale and functional tests (single leg hop test, vertical jump test, timed single jump test) were performed preoperatively and 6, 12 months postoperatively. Pivot-shift test, Lachman test, anterior drawer test, thigh circumference index and Cybex II+ isokinetic dynamometer test were done preoperatively and at 3, 6, 12 months postoperatively. KT-2000 arthrometer test was done at last follow-up. Lysholm score has showed increasing tendency at 6, 12 months postoperatively (p < 0.01). In Cybex study, deficit percentage of peak torque and total work of the quadriceps and hamstrings was same or slightly decreased at 3, 6 months, but have decreased at 1 year follow-up (p < 0.01). Functional tests and physical examinations have also showed improving tendency at 12 months (p < 0.01). Arthrometer test revealed no significant laxity of the knee joint at last follow-up. In conclusion, muscle strengh and functional capacity in ACL reconstructed knee showed significant improvement at postoperative one year compared with preoperative status. It was considered that arthroscopic reconstruction using autogenous bone-patellar tendon-bone graft is one of the useful method for chronic anterior cruciate ligament injury.

Arthroscopic ACL Reconstruction with Quadrupled Semitendinosus Tendon and endobutton / 대한정형외과학회잡지

In anterior cruciate ligament (ACL) deficient knee, several treatment methods were recommended. Recently, arthroscopic reconstruction is widely used as the best treatment method. As the graft materials, bone-patellar tendon-bone (BPB) unit is a gold standard material. Whereas, it has many problems. The purpose of this study was to introduce the new arthroscopic ACL reconstruction technique with quadrupled semitendinosus tendon and Endobutton and to evaluate its results. Twenty one patients were prospectively reviewed after ACL reconstruction with quadrupled semitendinosus tendon and Endobutton at one year post-operation. The surgery was performed in the series of graft tendon harvest, graft preparation, tunnel drilling and Endobutton fixation. The outcomes showed improved knee functions. Endobutton technique with quadrupled semitendinosus tendon is useful method for the arthroscopic ACL reconstruction. Stability and functional outcomes were similar to those with patellar tendon but it showed less donor site morbidity, less pitfall of fixation and simple procedure.

Tibial Tunnel enlargement Following Arthroscopic ACL Reconstruction / 대한정형외과학회잡지

The roentgenograms following arthroscopic ACL reconstruction show the enlargement of bone tunnels. Many authors hypothesized the cause of the tunnel enlargement, either mechanical or biological causes. The purpose of this study was to find the factors which affected the enlargement of the tibial tunnel following arthroscopic ACL reconstruction with bone-patellar tendon-bone or hamstring tendon. Sixty patients were reviewed retrospectively for radiographic measurement of tibial tunnel at post-operative one year (27 patients received bone-patellar tendon-bone autograft, 12 patients received bone-patellar tendon-bone autograft and Kennedy LAD-ligament augmentation device, 21 patients received Semitendinosus and Gracilis tendons with Endobutton). Roentgenographic anteroposterior and lateral films were checked and the tunnel was measured by two independent observers using a digital caliper. Statistical analysis was performed using a one-way analysis of variance (ANOVA) and t-test. The tibial tunnel enlargement was only related to the position of the fixation of the tibial tunnel. We concluded that tibial tunnel enlargement following arthroscopic ACL reconstruction is attributed to the mechanical effect rather than the properties of grafts and the clinical results.

Intraoperative Complications of Arthroscopic ACL Reconstruction Using Patellar Tendon Graft / 대한정형외과학회잡지

Arthroscopically assisted anterior cruciate ligament(ACL) reconsturction provide a technique with less morbidity, less pin, less sacr, lower ris k of sepsis. The magnification offered by arthroscopic visualization also provide a clearer view, more precise location of anatomical landmarks, and the ability to place the graft in the exact anatomic sites. However, in order to accomplish all these goals, the surgeon must possess a high level of psychomotor skills, which take time and practice to develop. Wile this learning curve is being completed, there are occasion when complications will occur, and, realistically these may be difficult to avoid. The purpose of this study is to evaluate author's cases in which complication occurred during the endoscopic one-incision ACL reconstruction using the patellar tendon and to offer some tips on how to avoid them and how to salvage the situation if they do occur. We reviewed 22 complications (11 patients) out of 40 ACL reconstructions performed between May 1994 and December 1995. The complications were divergence(6), graft-tunnel mismatch(5), too anterior tibial tunnel(3), too anterior femoral tunnel(2), too posterior femoral tunnel(2), rotation of screw around the graft(2), guide pin breakage(1), bone plug retraction into the joint(1). It is suggested that arthroscopist should constantly try to avoid the intraoperative complications of arthroscopically assisted ACL reconstruction and follow the precautions and preventive measures recommended.

Femoral Tunnel Enlargements Following Arthroscopic ACL Reconstruction / 대한정형외과학회잡지

Enlargement of bone tunnels has been noted on plain X-rays following arthroscopic ACL reconstruction. The cause of this widening is unclear, but it has been hypothesized that it may be due to either mechanical or biological cases. Ishibashi et al. reported anatomical proximal fixation resulted in the most stable reconstructed knee, with increasing instability as the level of fixation moved away from the tibial plateau. The purpose of this study is to determine if any difference exists in the amount of enlargement of the femoral tunnel following arhotoscopic ACL reconstruction with position of interference screw fixation and instability, and to know the factors which affected to the enlargement of the femoral tunnels. Total 39 patients were retrospectively reviewed for tunnel measurements radiologically at one year post-operation. (27 patients received bone-patellar tendon-bone autograft, 12 patients received bone-patellar tendon-bone autograft and Kennedy LAD-ligament augmentation device). The surgery was performed using an arthroscopic single and double incision technique. AP and lateral X-rays were obtained and the tunnels were measured by two independent observers using a digital caplper. The measurements were made at the widest part of the tunnel. 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 using a one-way analysis of variance(ANOVA) and t-test. 1. Radiographic tunnel enlargement of femoral side was average 2.42 mm (bone-patellar tendon-bone autograft : 2.36 mm, Kennedy-LAD and autograft : 2.56 mm)(p>0.05). 2. According to the position of the interference screw, the femoral tunnel enlargement were 2.25 mm in anatomical fixation, 2.40 mm in mid-tunnel fixation, 2.62 mm in mid-tunnel fixation, 2.62 mm in outer-tunnel fixation(p < 0.05). 3. The femoral enlargement according to the overall results(Clancy, 1982) were 2.39 mm in above good result group and 2.50 mm in below fair result group(p < 0.05). Tunnel enlargement group of femoral side was related to a distance between femoral articular surface and the position of interference screw. We conclude that femoral tunnel enlargement following arthoscopic bone tendon-bone ACL reconstruction is related to the mechanical effect rather than the properties of grafts and the clinical results.

Arthrocopic Reconstruction of the Posterior Cruciate Ligment: The Effects of femoral attachment points and knee flexion angles at the time of graft fixation on posterior stability / 대한정형외과학회잡지

The purpose of this study is to compare the effects of the femoral attachment points of the graft and knee flexion angles at the time of graft fixation on stability of posterior cruciate ligament reconstruction. We analyzed the posterior stability of the knee on 23 patients(24 knees) with posterior cruciate ligament injury whose posterior cruciate ligament had been reconstructed arthroscopically and followed for minimum 1 year period at Asan Medical Center from May 1992 to June 1994. The patients were divided into the two groups according to femoral attachment points of the graft and knee flexion angles at the time of graft fixation. The distance from the junction of the intercondylar notch with trochlear groove of the femoral attachment points and knee flexion angles were 11mm and 0°-30° in group A and 7mm and 70°-90° in group B, respectively. 11 knees were included in group A and 13 knees in group B. Posterior stability was determined by difference in posterior tibial translation between the injured and the opposite knee with Telos device. In group A, 5 cases were at the range of 0-2mm, 3 cases 3-5 mm, 3 cases 6-10mm. In group B, 10 cases were at the range of 0-2mm and 3 cases 3-5mm, respectively. Differences in posterior tibial translation on average were 3.6mm and 1.7mm in group A and B, respectively. Conclusively, arthroscopic postrior cruciate ligament reconstruction with femoral attachment point at 7mm from the junction of interconlylar notch with trochlear groove and 70°