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ABSTRACT Objective: To determine, by biomechanical analysis, safe patellar cut limits in anterior cruciate ligament (ACL) reconstruction that minimize fracture risks. Methods: From three-dimensional reconstruction, triangular cuts were made in the patella, with a depth of 6.5 mm and variable width and length (10 to 20 mm and 8 to 12 mm, respectively, both with an interval of 1 mm). The combinations of cuts constituted 55 models for tests, with five variations in width and 11 variations in length, tested with the finite element method (FEM). Results: The mean of the localized principal maximum (traction force) values was 4.36 Pa (SD 0.87 ± 0.76) and the localized principal minimum (compression force) was −4.33 Pa (SD 1.05 ± 1.11). Comparing width and length to the tension force of the values of the main maximum, we found statistical significance from 11 mm for width and 13 mm for length. Conclusion: In ACL reconstruction, the removal of the patellar bone fragment is safe for fragments smaller than 11 mm in width and 13 mm in length, which corresponds to 24% of the width and 28% of the length of the patella used. Level of Evidence II, Comparative Prospective Study.
RESUMO Objetivo: Determinar, por meio de análise biomecânica, os limites de corte patelar seguros para a reconstrução do ligamento cruzado anterior (LCA) e que minimizem riscos de fratura. Métodos: A partir de reconstrução tridimensional, foram feitos cortes triangulares na patela, com profundidade de 6,5 mm e largura e comprimento variáveis (8 a 12 mm e 10 a 20 mm), respectivamente, com intervalo de 1 mm). As combinações dos cortes constituíram 55 modelos para ensaios, com 5 variações de largura e 11 variações de comprimento, ensaiados por meio do método dos elementos finitos (MEF). Resultados: A média dos valores da máxima principal localizada (força de tração) foi de 4,36 Pa (DP 0,87 ± 0,76), e a mínima principal localizada (força de compressão) foi de −4,33 Pa (DP 1,05 ± 1,11). Comparando largura e comprimento à força de tensões dos valores da máxima principal, houve significância estatística a partir de 11 mm para largura e 13 mm para comprimento. Conclusão: Na reconstrução do LCA, a retirada do fragmento ósseo patelar mostrou-se segura para fragmentos menores que 11 mm de largura e 13 mm de comprimento, o que corresponde a 24% da largura e 28% do comprimento da patela utilizada. Nível de Evidência II, Estudo Prospectivo Comparativo.
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The anterior cruciate ligament (ACL) injury is a common sports injury, which can lead to the knee unstable, make it difficult for the patient to return to sports, and cause post-traumatic osteoarthritis. The difficulty of its clinical diagnosis and treatment has always been the focus of sports medicine research. In August 2022, the American Association of Orthopaedic Surgeons updated and published "evidence-based clinical practice guideline on management of ACL injuries (2022 version)" based on the "evidence-based clinical practice guideline on management of ACL injuries (2014 version)". In the prevention, diagnosis and treatment of ACL injuries, the new guideline offers 8 recommendations and 7 options according to different evidence strength. To assist clinicians in the diagnosis and treatment of ACL injuries, this article provides an interpretation of the new guideline. In comparison to the 2014 version, the new guideline does not recommend allografts any more, shortens the time for reconstruction after ACL injury from 5 months to 3 months, adds advice that ACL reconstruction can be combined with anterolateral ligament reconstruction or lateral extra-articular tenodesis, and does not recommend ACL repair. The new guideline also shares many similarities with the domestic "clinical evidence-based guideline for the diagnosis and treatment of anterior cruciate ligament injury (2022 version)", both of which advocate history and physical examination at diagnosis, early reconstruction, the use of autologous bone-patellar tendon-bone or hamstring tendon, and either single-bundle or double-bundle ACL reconstruction. The new ACL guidelines of the American Association of Orthopaedic Surgeons lack specific recommendations on artificial ligaments, techniques for bone tunnel creation, and rehabilitation programs, all of which are of concern to domestic physicians because they are based on evidence-based research from abroad. Therefore, in order to improve the diagnosis and treatment of ACL injuries in China, clinicians should not only follow the new ACL guidelines of the American Association of Orthopaedic Surgeons, but also combine the characteristics of Chinese patients, clinical practice, and pertinent domestic guidelines when diagnosing and treating ACL injuries.