Retorno deportivo luego de reconstrucción primaria de ligamento cruzado anterior con injerto hueso-tendón patelar-hueso autólogo: análisis de factores relacionados / Return to play after anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: analysis of related factors

OBJECTIVE: Analyze return to sports and related factors after primary anterior cruciate ligament reconstruction. METHODS: Observational descriptive study. 173 patients operated by the same surgeon and standardized technique (patellar autograft) who answered a questionnaire at least 12 months post procedure were included. Questionnaire included Subjective IKDC, Tegner activity level (Pre and Postoperative) and questions elaborated by the group. RESULTS: Mean age was 30.8 years, 85% were men, 73% practiced soccer and median postoperative IKDC was 71. Follow up until questionnaire response was 28 months. Males had a better return to sports than females (70% vs 48%, p » 0.037). Tegner preinjury level was 5 vs 4.3 postoperative, (p < 0.001). Return to sports was 67% according to Tegner scale and 66% by self-assessment. Return to similar previous activity level was 57% by Tegner scale but 24% by direct questions. Of those patients, 51% have fear of reinjury and 26% by reasons other than knee or surgery. We didn't find association between meniscal injuries and return to sports rate. Patients with chondral injuries had lower rates in return to sports (35% vs 60%, p » 0.002). Subjects that returned to sports had higher IKDC scores (73.5 vs 64.3, p < 0.001). CONCLUSIONS: We found 67% return to sports and 57% to the preinjury level. Positive return to sports factors were male sex, absence of chondral injury and better functional outcome. Psychological factors such as fear of injury is frequent in patients who don't achieve previous levels of activity.

OBJETIVOS: Analizar el retorno deportivo y factores asociados tras la reconstrucción primaria de ligamento cruzado anterior (LCA). MÉTODOS: Estudio observacional descriptivo. Se incluyeron 173 operados entre 2014 y 2017 por el mismo cirujano, los cuales contestaron un cuestionario al menos 12 meses después de la cirugía. El cuestionario incluye IKDC subjetivo, Tegner activity level (pre y post operatorio) y preguntas de elaboración propia. RESULTADOS: La edad promedio es 30,8 años, el 85% son hombres, el 73% practicaba fútbol y la mediana del IKDC fue 71. La media de meses hasta responder el cuestionario fue de 28 meses. Tegner pre-lesión promedio fue de 5 vs 4,3 postoperatorio, p < 0,001. Según la escala Tegner el 57% retorna al mismo nivel previo, sin embargo, de acuerdo con el cuestionario propio solo el 24% lo haría. De ese subgrupo, el 51% tiene temor a lesionarse de nuevo y el 26% reporta razones no relacionadas a la rodilla. No encontramos asociación entre lesiones meniscales y la tasa de retorno. Aquellos que retornan tienen menor prevalencia de lesiones condrales (35% vs 60%, p » 0,002). Los pacientes que retornaron tuvieron un IKDC superior (73,5 vs 64,3, p < 0,001). El sexo masculino tiene una tasa de retorno de 70% vs 48% de su contraparte femenina (p » 0,037). CONCLUSIONES: El 67% retorna al deporte y el 57% lo hace al mismo nivel. Factores positivos relacionados al retorno fueron sexo masculino, ausencia de lesión condral y mejor resultado funcional. Factores psicológicos con el miedo a lesionarse de nuevo son frecuentes en pacientes que no recuperan el nivel previo.

Técnica de figueroa para evitar la discrepancia injerto-túnel en la reconstrucción de ligamento cruzado anterior: acortamiento del injerto del tendón patelar / Figueroa technique to avoid graft-tunnel discrepancy in anterior cruciate ligament reconstruction. shortening of patellar tendon graft

La utilización de autoinjerto hueso–tendón patelar–hueso, para la reconstrucción del ligamento cruzado anterior es considerado por muchos cirujanos como el estándar de oro en pacientes jóvenes con fisis cerrada. Sin embargo, una de las complicaciones técnicas es el riesgo de obtener un injerto de mayor longitud a la deseada, perdiendo la ventaja de mantener el fragmento óseo distal del injerto dentro del túnel tibial. En este trabajo se describe una técnica quirúrgica que permite acortar la longitud del injerto, realizando una migración proximal del fragmento óseo distal (tibial), logrando disminuir la discrepancia entre la longitud del injerto y la longitud de la reconstrucción, sin sacrificar ninguno de los fragmentos óseos, conservando las ventajas del injerto.

The use of autograft bone–patellar tendon–bone, for the reconstruction of the anterior ligament cruciate is considered as a gold standard in procedures in young patients with closed physis. However, one of the technical complications is the risk of obtaining a graft with greater length than expected which leads to a disadvantage of maintaining distal bone fragment of the graft within the tibiae tunnel. This work describes a surgical technique that allows to reduce the length of the graft through a proximal migration of the distal bone fragment (tibia) therefore shortening the discrepancy between the longitude of the graft and the longitude of the reconstruction without sacrificing none of the bone fragments and conserving the benefits of the graft.

Comparison of two methods of femoral tunnel preparation in single-bundle anterior cruciate ligament reconstruction: a prospective randomized study / Comparação entre dois métodos de preparação de túnel femoral na reconstrução do ligamento cruzado anterior em feixe único: estudo prospectivo randomizado

PURPOSE: To prospectively compare therapeutic effect of femoral tunnel preparation through the tibial tunnel and the anteromedial (AM) portal in single-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: Between June 2008 and October 2010, 76 patients underwent single-bundle ACL reconstruction by autogenous grafting of semitendinosus and gracilis tendon. All cases were randomly divided into two groups according to the method of femoral tunnel preparation: transtibial (TT) group (n=38) and anteromedial (AM) group (n=38). Lysholm knee score and the KT-1000 anterior laxity at 30° of pre-and post-operation were assessed for two groups. RESULTS: Sixty-five patients (TT group, 34; AM group, 31) were followed up for more than 12 months, with a follow-up rate of 86%. The Lysholm knee score and the KT-1000 anterior laxity 12 months after operation were significantly better than before reconstruction. The Lysholm knee score and the KT-1000 anterior laxity were not significantly different between the TT and AM groups after operation. CONCLUSION: Femoral tunnel preparation through tibial tunnel or the anteromedial portal in single-bundle anterior cruciate ligament reconstruction shows same therapeutic effects.

OBJETIVO: Comparar prospectivamente o efeito terapêutico da preparação do túnel femoral através do túnel tibial (TT) ou da porta ântero-medial(AM) na reconstrução do ligamento cruzado anterior(LCA) em feixe único. MÉTODOS: Entre junho de 2008 e outubro de 2010, 76 pacientes foram submetidos à reconstrução do LCA em feixe único pelo enxerto autógeno de tendão semitendíneo egrácil.Todos os casos foram divididos aleatoriamente em dois grupos de acordo como método de preparação do túnel femoral: grupo transtibial (TT) (n=38) e grupo ântero-medial (AM) (n=38). Foi usado o escore Lysholm para joelho. O relaxamento anterior do joelho a 30° sob força tênsil de 133,32N foi determinado com o medidor KT-1000 no pré e no pós-operatório nos dois grupos. RESULTADOS: Sessenta e cinco pacientes (grupo TT, 34; grupo AM,31)foram acompanhados por mais de 12 meses, com uma taxa de follow-up de 86%.A pontuação do Lysholm para joelho e do relaxamento anterior medido pelo KT-1000 aos 12 meses de pós-operatório foi significativamente melhor do que antes da reconstrução.As pontuações de Lysholme do relaxamento KT-1000 não foram significativamente diferentes comparando os grupos TT e AM após a operação. CONCLUSÃO: A preparação do túnel femoral através do túnel tibial ou da porta ântero-medial na reconstrução do ligamento cruzado anterior em feixe único mostrou os mesmos efeitos terapêuticos.

Anterior Cruciate Ligament Reconstruction in Patients with Generalized Joint Laxity

Generalized joint laxity is a genetically determined component of overall joint flexibility. The incidence of joint laxity in the overall population is approximately 5% to 20%, and its prevalence is higher in females. Recently it was noticed that individuals with generalized joint laxity are not only prone to anterior cruciate ligament injuries but also have inferior results after a reconstruction. Therefore, an anterior cruciate ligament reconstruction in patients with generalized laxity should be undertaken with caution due to the higher expected failure rate from the complexity of problems associated with this condition. It is also necessary to identify the risk factors for the injury as well as for the post operative outcome in this population. A criterion that includes all the associated components is necessary for the proper screening of individuals for generalized joint laxity. Graft selection for an anterior cruciate reconstruction in patients with ligament laxity is a challenge. According to the senior author, a hamstring autograft is an inferior choice and a double bundle reconstruction with a quadriceps tendon-bone autograft yields better results than a single bundle bone-patella tendon-bone autograft. Future studies comparing the different grafts available might be needed to determine the preferred graft for this subset of patients. Improved results after an anterior cruciate ligament reconstruction can be achieved by proper planning and careful attention to each step beginning from the clinical examination to the postoperative rehabilitation.

Resultado de la reconstrucción del ligamento cruzado anterior con el ligamento patelar bajo control artroscópico con un seguimiento superior a 15 años / Arthroscopic reconstruction of the ACL using the patellar tendon follow-up more than 15 years

Los resultados a largo plazo de las reconstrucciones del LCA por artroscopia son raros. Nosotros presentamos los resultados de un estudio de 57 pacientes con un seguimiento superior a 15 años. La reconstrucción es realizada bajo control artroscópico. Nosotros utilizamos un injerto hueso ligamento rotuliano hueso. El túnel femoral es realizado de afuera hacia adentro. La fijación femoral obtenida por "pressfit" y la fijación tibial es realizada con un tornillo de interferencia metálico. 240 pacientes fueron operados con esta técnica en 1992. Nosotros pudimos ver 57 de estos pacientes con un seguimiento promedio de 182 meses. Todos los pacientes fueron evaluados con el formulario IKDC. La laxitud diferencial fue medida con el Rolimeter (aircast). Un examen radiológico completo fue realizado a todos los pacientes. A 15 años de seguimiento 43 por ciento de pacientes fueron clasificados como A, 40 por ciento B, 10 por ciento C 5 por ciento y D según el formulario IKDC objetivo. El IKDC subjetivo promedio fue de 85,8/100. La laxitud diferencial instrumental promedio fue de 1,8 mm. 86 por ciento de los pacientes presentaron radiografías normales y solamente 5 por ciento de artrosis. Este estudio demuestra que esta técnica permite obtener buenos resultados en cuanto a la laxitud y la artrosis.

The results of the ACL by arthroscopy in the long term are rare. The following are the results of a study we made of 57 patients with a folloe-up of more than 15 years. The reconstruction was carried out by arthroscopy. We used a patellar ligament bone graft. The femoral tunnel procedure is outside-inside. The femoral attachment was by "pressfit", and the tibial attachment using a metalic interference screw. 240 patients were operated on in 1992 using this technique. We reviewed 57 of these patient with a mean follow-up time of 182 months. All the patients were evaluated using the IKDC formula. The laxity differential was measured using the Rolimeter (aircast). A complete radiological examination was carried out on all the patients. After 15 years follow-up 43 percent of the patients were classified A 40 percent, B 10 percent, C 5 percent and D using the IKDC formula objective. The mean IKDC subjective score was 85,8/100. The mean instrumental laxity diferrential was 1,8 mm. 86 percent of the patients had normal X-rays and only 5 percent had arthritis. This study demonstrates that using this technique good resultd can be obtained with regard to laxity and arthritis.

Anterior cruciate ligament reconstruction through mini-arthrotomy using bone - patellar tendon - bone autograft

48 ACL reconstructions were performed using a bone - patellar tendon - bone autograft through the same incision used to harvest the graft [mini-arthrotomy]. The patients were mainly serious football amateurs, 19 to 32 years of age and the injury - surgery interval ranged from 2 to 18 months. The graft was inserted from distal to proximal, snuggly fit into the tibial tunnel without the use of implants and fixed into the femoral tunnel by an interference screw introduced from outside-in after graft tensioning. An accelerated rehabilitation program was followed with early weight-bearing and rapid return to sports activities. At an average follow-up period of 2 years, 94% of the patients were rated normal, or nearly normal, according to the IKDC clinical evaluation form