Anterior knee pain following BPTB graft harvest. Reality or overhyped.

INTRODUCTION: The patellar tendon graft has long been the gold standard for ACL reconstruction. Recently semitendinosus and gracilis tendons graft have been used increasingly. We hypothetise that the Bone-Patella Tendon-Bone graft is a good and economical graft for the Indian population with no adverse effects of anterior knee pain or patellar tendon shortening. We believe that the early squatting and cross-legged sitting causes early and constant stretching of the tendon in our patients. This is responsible for the lesser incidences of adverse effects in the Indian population. MATERIAL AND METHOD: In a retrospective study, the hospital database was scrutinized to shortlist patients who had undergone a bone-patella tendon-bone harvest for ACL or PCL reconstruction before 2013. Each patient was evaluated using the Lysholm score and the KOOS Score. VAS was also used, to evaluate for the amount of pain experienced by patients. The analysis of the quadriceps power along with the presence or absence of any extensor lag was made too. The modified Insall Salvati index was also calculated. RESULTS: Forty-seven patients were shortlisted of which 25 patients were followed up with an average follow up of 94.5 months. Although some patients did complain of occasional pain with the average VAS score of 1.45; on analyzing the data it was evident that all our patients had excellent quadriceps power (5/5) with no extensor lag. The mean Lysholm score was 95.55, while the mean KOOS score was 94.17. The mean Insall index of 1.05 showed no significant patella baja in any of our patients. CONCLUSION: It is ascertained that no significant retro-patellar pain or shortening of the patellar tendon occurs following a bone patella tendon bone harvest. The bone patella bone tendon graft is a suitable graft for ligament reconstruction with good functional outcome, and no significant adverse effect of patella baja or anterior knee pain in the Indian patients. LEVEL OF EVIDENCE: Level IV.

ACL femoral avulsion repair using suture pull-out technique: A case series of thirteen patients.

PURPOSE: Anterior cruciate ligament (ACL) repair was first described in the mid 1900's. However, due to poorly selected patients led to unsatisfactory early results. We aim to study the outcome of ACL repair in a carefully selected cohort. METHODS: Thirteen consecutive patients of acute Type 1 (proximal ACL avulsion) were treated with arthroscopic ACL repair using a suture pull out technique. At the latest follow-up the patients were evaluated for Lysholm score, KT-1000 measurement and clinical assessment for any laxity. RESULTS: At a mean follow-up of 31.3 months, none of the patients had any subjective laxity. The mean Lysholm score was 95 and instrumented laxity measurement did not reveal any significant laxity compared to the opposite knee. CONCLUSION: The proximal ACL avulsion has healing potential similar to proximal MCL injuries. Performing microfracture of the lateral wall of the notch optimizes the healing environment by negating the effects of the synovial fluid. Performing ACL repair in a carefully selected patient leads to good short term results and saves the patient of a reconstruction procedure, at least in the immediate future.

Suture Pullout Technique of Acute Anterior Cruciate Ligament Femoral Avulsion Repair.

It was in the early 1900s that anterior cruciate ligament (ACL) repair was first described with its resurgence in the mid-1900s. It however failed to gain popularity because of unsatisfactory early outcomes as a result of poorly selected patients. We describe a suture pullout technique of acute ACL repair in a carefully selected cohort of patients. Healing capabilities similar to that of the proximal medial collateral ligament have been shown in the proximal ACL avulsions. Adding microfracture of the lateral wall of the notch further enhances the healing environment by countering the synovial fluid environment. Acute ACL repair when performed in a carefully selected patient leads to good results and saves the patient of a reconstruction procedure.

Pre-pubescent posterior cruciate ligament (PCL) reconstruction using maternal allograft.

PURPOSE: Posterior cruciate ligament (PCL) reconstruction is a challenge in the pre-pubescent and paediatric age group. It requires great skill in tunnel and graft placement and fixation through open physes. Another major concern is the source of graft, as the thickness of harvested hamstring graft is unpredictable in children and the bone patella tendon bone graft cannot be used due to un-ossified patella and tibial tuberosity. Quadriceps being an important agonist of PCL, we decided not to use it as a graft source. METHODS: PCL reconstruction was done in three pre-pubescent children aged 3.5, 7 and 10 years using maternal allograft with follow-up of 7, 9 and 7 years (the 10-year-old boy was lost to follow-up after 2013), respectively. RESULTS: All the patients showed excellent results with the median IKDC Pedi improving to 90 (85-92) at latest follow-up as against 29.9 (25-35) pre-operatively. The median Lysholm score improved from 45 (42-47) to 100 (95-100). The posterior drawer test showed no PCL laxity during the latest follow-up. The grafts were accepted well by all three with no evidence of graft rejection or tissue reaction. CONCLUSION: Living donor allografts may be a good option for paediatric ligament reconstruction. This, however, must be supported with more evidence from a larger study group and a longer follow-up until the closure of physes. LEVEL OF EVIDENCE: IV.