Intratunnel versus extratunnel autologous hamstring double-bundle graft for anterior cruciate ligament reconstruction: a comparison of 2 femoral fixation procedures.

BACKGROUND: Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction provides excellent results for restoring normal kinematics to the knee. Nevertheless, strong evidence supporting an ideal method for fixation of the ACL graft is lacking. HYPOTHESIS: Intratunnel femoral fixation of the ACL graft via a cross-pin fixation technique would provide better clinical and objective results than the extratunnel femoral fixation with cortical buttons. STUDY DESIGN: Randomized clinical trial; Level of evidence, 2. METHODS: Seventy patients with a unilateral ACL-deficient knee were randomly assigned to 1 of 2 femoral fixation groups. Group A (35 patients) was fixed with 2 bioabsorbable Rigidfix pins, 1 cross-pin per bundle, while group B (35 patients) was secured with 1 EndoButton cortical button per bundle. All femoral tunnels were created via an anteromedial portal, and a bioabsorbable Biointrafix interference screw was used for tibial fixation for both groups. The evaluation of the patients was performed by history details, clinical examination findings, measurement of the joint laxity by KT-1000 arthrometer, and use of validated patient outcome questionnaires. Statistical analysis was carried out with Fisher exact and Mann-Whitney U tests, with P<.05 considered the cutoff level of significance. RESULTS: At a mean follow-up of 30 months, 34 and 32 patients of group A and B, respectively, were available for evaluation. There were no statistically significant differences between the treatment groups regarding the subjective and objective outcomes, except for KT-1000 arthrometer values. The median KT-1000 value of patients in the cross-pin fixation group was 1.30 mm, while the median value in the cortical button fixation group was 1.95 mm (P<.001). Four patients with ACL grafts that were fixed with cortical buttons demonstrated failure of stability via the instrumented knee laxity testing, while patients from the other group had no failures. CONCLUSION: Intratunnel femoral fixation of the double-bundle ACL graft from the cross-pin fixation technique provided better instrumented knee laxity results than did the extratunnel femoral fixation with cortical buttons. Future larger studies comparing these 2 techniques should be conducted to ensure the availability of stronger evidence supporting the findings of this study.

Surgical management of traumatic knee dislocation with posterolateral corner injury.

PURPOSE: To evaluate the results of our method of surgical treatment of traumatic knee dislocation with injury to the posterolateral corner by use of a standardized protocol. METHODS: Twenty-five consecutive patients presented with a grossly dislocated or reduced knee. Five of these patients were not included in this series. The remaining 20 patients were treated by primary arthroscopic reconstruction. The anterior cruciate ligament (ACL) was reconstructed using gracilis tendon reinforced with artificial ligament (Ligament Augmentation and Reconstruction System [LARS] ligament); the posterior cruciate ligament (PCL) was reconstructed with semitendinosus tendon and reinforced with LARS ligament; and the posterolateral corner was treated using the gracilis and semitendinosus tendons from the uninjured knee. Twenty patients returned for subjective and objective evaluation at a minimum of 24 months after surgery. Early mobilization through continuous and active exercise was started on the fourth day postoperatively. RESULTS: At a mean follow-up of 44 months, the mean Lysholm score was 90 points, the mean score on the survey of daily activities was 90 points, and the sports activities score on the knee outcome survey averaged 80 points. By the rating of Meyers et al. the results were excellent in 6 patients, good in 10 patients, fair in 3 patients, and poor in one patient. The final International Knee Documentation Committee (IKDC) rating was not normal in any knee. The mean loss of extension was 2° (range, 0° to 3°) and loss of flexion was 12° (range, 10° to 15°). CONCLUSIONS: By using the described method of arthroscopically assisted reconstruction of the cruciate ligaments and the posterolateral corner, 80% of the patients had good subjective results and functional stability, and according to the IKDC scale, 45% of knees were nearly normal, 45% were abnormal, and 10% were severely abnormal. No patient's rating returned to normal. LEVEL OF EVIDENCE: Level IV, therapeutic case series.