Adjustable Suspensory Fixation Research Articles

Suture disc adjustable suspensory fixation device – A cost-effective technique for tibial cortical fixation in cruciate ligament reconstruction

Cruciate ligament reconstruction with adjustable suspensory devices at the femur and tibia allows graft tensioning at both ends, but it is costly due to the tibial suspensory device. To overcome the cost, the author describes a technique where the adjustable suspensory cortical fixation device can be made with a suture disc and an ultra-high-molecular-weight polyethylene suture, which is simple, cost-effective, and making it reproducible even with less experienced arthroscopy surgeons.

Clinical and radiological outcomes of a modified anatomic posterolateral corner reconstruction technique using a single semitendinosus autograft

PurposeWe aimed to assess the clinical and radiological outcomes of a modified anatomical posterolateral corner (PLC) reconstruction technique using a single autograft.MethodsThis prospective case series included 19 patients with a posterolateral corner injury. The posterolateral corner was reconstructed using a modified anatomical technique that utilized adjustable suspensory fixation on the tibial side. Patients were evaluated subjectively using the international knee documentation form (IKDC), Lysholm, and Tegner activity scales and objectively by measuring the tibial external rotation angle, knee hyperextension, and lateral joint line opening on stress varus radiographs before and after surgery. The patients were followed-up for a minimum of 2 years.ResultsBoth IKDC and Lysholm knee scores significantly improved from 49 and 53 preoperatively to 77 and 81 postoperatively, respectively. The tibial external rotation angle and knee hyperextension showed significant reduction to normal values at the final follow-up. However, the lateral joint line opening measured on the varus stress radiograph remained larger than the contralateral normal knee.ConclusionPosterolateral corner reconstruction with a hamstring autograft using a modified anatomical reconstruction technique significantly improved both the subjective patient scores and objective knee stability. However, the varus stability was not completely restored compared with the uninjured knee.Level of evidenceProspective case series (Level of evidence IV).

Morphological Changes in the Tibial Tunnel After ACL Reconstruction With the Outside-In Technique and Adjustable Suspensory Fixation.

Anterior cruciate ligament reconstruction (ACLR) using the complete tibial tunnel technique and adjustable-loop cortical suspensory fixation is known to leave a "dead space" that holds the loop device in the tibial tunnel. The consequence of the dead space and its effect on graft healing are still uncertain. To investigate morphological changes in the tibial tunnel and their effect on graft healing, and to identify factors affecting bone healing in the tibial loop tunnel after ACLR with a quadrupled semitendinosus tendon autograft using adjustable suspensory fixation. Case series; Level of evidence, 4. Included were 48 patients (34 male, 14 female; mean age, 25.2 ± 5.6 years) who underwent ACLR with a quadrupled semitendinosus tendon autograft using adjustable suspensory fixation. To evaluate tibial tunnel morphology, computed tomography was performed at 1 day and 6 months postoperatively. At 1 year postoperatively, graft healing was assessed on magnetic resonance imaging using the graft signal-to-noise quotient (SNQ). Multivariate regression and correlation analyses were performed to determine any associations between volumetric changes in bone healing and operative variables. At 6 months after ACLR, a mean of 63.2% of the tibial loop tunnel was filled by bone. Multivariate regression analysis showed that remnant preservation was significantly associated with the loop tunnel filling rate (P < .001). At 1 year after ACLR, the tibial loop tunnel was almost completely closed (98.5%). There were no correlations between loop tunnel volume and graft integration or graft SNQ. A significant but weak correlation was found between graft tunnel volume and intratunnel graft SNQ (P = .10) as well as integration grade in the tibial tunnel (P = .30). Excellent bone filling in the tibial loop tunnel was seen at 1 year after ACLR. Remnant preservation was significantly associated with the loop tunnel filling rate. A weak correlation was found between graft tunnel volume and intratunnel graft SNQ as well as integration grade in the tibial tunnel.

Tibial tunnel expansion does not correlate with four-strand graft maturation after ACL reconstruction using adjustable cortical suspensory fixation.

Anterior cruciate ligament reconstruction (ACLR) using a short, quadrupled semitendinosus (ST-4) autograft, fixed with an adjustable suspensory fixation (ASF), has several potential advantages. However, the construct is suspected to generate micromotion, tunnel widening and poor graft maturation. The aim of this study was to evaluate post-operative tibial tunnel expansion, graft maturation and clinical outcomes for this type of ACLR. One-hundred and forty-nine patients were reviewed at a minimum of 2 years following 4-ST ACLR, mean 25.6 ± 3.5months [24-55], with clinical follow-up and MRI scans. Graft maturity of the intra-articular part of the graft and the tibial tunnel portion was assessed using Signal-to-Noise Quotient (SNQ) and Howell score. Tibial tunnel expansion, bone-graft contact and graft volume in the tibial tunnel were calculated from the MRI scans. Mean tibial tunnel expansion was 13 ± 16.5% [12-122]. Mean SNQ for graft within the tibial tunnel was 3.8 ± 7.1 [ - 7.7 to 39] and 2.0 ± 3.5 [ - 14 to 17] for the intra-articular portion of the graft. The Howell score for graft within the tibial tunnel was 41% Grade I, 37% Grade 2, 20% Grade 3, 2% grade 4, and for the intra-articular part 61% Grade 1, 26% Grade 2, 13% Grade 3 and 1% Grade 4. The mean tibial tunnel bone-graft contact was 81 ± 23% [0-100] and mean graft volume was 80 ± 22% [0-100]. No correlation was found between tibial tunnel expansion and graft maturity assessed at both locations. Graft maturity was correlated with higher graft-bone contact and graft volume in the tibial tunnel (p < 0.05). ST-4 ACLR with ASF had low levels of tunnel enlargement at 2years. No correlation was found between graft maturation and tibial tunnel expansion. Graft maturity was correlated with graft-bone contact and graft volume in the tibial tunnel. Level III.

“Y” Graft Double Bundle Anterior Cruciate Ligament Reconstruction

Single-bundle (SB) anterior cruciate ligament (ACL) reconstruction has been a standard procedure. However, residual rotary instability in approximately 20% of the cases (irrespective of the graft choice and the surgical technique) forces the surgeon to improve the biomechanical quality of the reconstruction. In parallel, adjustable suspensory fixation (ASF) devices have arisen. Biomechanics has defined (both anatomical and functional) the anteromedial (AM) and posterolateral (PL) bundles that work synergistically. In the unsymmetrical “anatomic” SB ACL reconstruction, the distribution of the ACL graft fibers (for AM or PL behavior) is not under the control of the surgeon. Furthermore, different sizes of the original footprints (depending on height) suggest the need to customize the graft footprint. This customization is only possible if distances are measured during surgical procedures. We present an inside-out technique for DB ACL reconstruction (“all-inside” also possible). Semitendinosus is folded to obtain a Y-shaped trifurcate configuration graft, distributing their bundles in two different areas. Used as measuring instruments, we used the “offset” guides as measuring instruments, allowing the surgeon to know the distance between the centers of the AM and PL tunnels. It may be carried out by means of common “offset” guides and any marketed ASF devices, while generating customized footprints. ClassificationI: knee; II: ACL

Minimally Invasive Quad Harvest Featuring Endoscopic Closure and Preparation With Adjustable Suspensory Fixation Device Incorporated With Braided Suture

The quad tendon has increasingly became a very common option for anterior cruciate ligament reconstruction. Minimally invasive approaches are one of the many advantages to the quad tendon graft. One of the issues with a small incision is assuring appropriate proximal closure. In this technique, we use the arthroscope to view proximally and a Scorpion (Arthrex) device to close our proximal quad harvest. We also describe the updated preparation of the quad tendon with FiberTag TightRope (Arthrex) and FiberTag ABS (Arthrex). These implants have FiberTag incorporated to the suspensory devices that creates a stable construct that is faster to incorporate into the quad with the slotted clamp. Together, these updates to the preparation and harvest should make the construct more reproducible and decrease donor-site morbidity respectively.

Adjustable suspension versus hybrid fixation in hamstring autograft anterior cruciate ligament reconstruction

BackgroundThere has been increased use of adjustable suspensory fixation (ASF) for anterior cruciate ligament reconstruction (ACLR). Potential benefits are the ability to use a shorter graft and to prevent graft displacement and damage. The purpose of this study was to establish the efficacy of this fixation method and assess whether it leads to less tunnel widening, and avoids known complications of screw fixation. MethodsThirty-eight patients who underwent ACLR with ASF on both the femoral and tibial sides met the inclusion criteria and were propensity matched demographically with 38 patients who underwent hybrid fixation with femoral suspensory and tibial screw and sheath. At one-year, KT-1000 knee laxity measurements were recorded and detailed MRI analysis looking at tunnel aperture widening, tunnel appearance, graft integration within the tunnels, and graft healing. ResultsMRI comparison between ASF and hybrid cohorts revealed no significant differences in graft signal or integration, and clinically there were no differences in knee laxity between cohorts (mean 1.5 mm ± 2.0 and 1.5 mm ± 2.3 (n.s.) in the ASF and hybrid fixation respectively). Significantly less aperture tibial tunnel widening (2.2 mm versus 4.4 mm, p < 0.0001) and tibial cysts (2 versus 9, p = 0.047) were observed in the ASF cohort, whilst mean femoral tunnel widening was comparable between both cohorts (ASF 2.8 mm, hybrid 3.2 mm; n.s.). ConclusionsHamstring autografts for ACLR fixed using either ASF or a hybrid fixation technique provided comparable knee stability and MRI graft signal intensity. Tibial ASF demonstrated significantly less tibial aperture widening and tunnel cyst formation when compared to screw and sheath fixation.

Cicatrisation des greffes de DT4 dans le tunnel tibial et dans l’échancrure : évaluation clinique et IRM à 4 ans minimum des DT4 fixés par fixation de suspension versus vis d’interférence

Success of ACL reconstruction requires Graft healing in the joint and a solid graft incorporation within the tunnels. Resorbable interference screws (RIS) provide limited tendon-bone contact because much of the tunnel circumference is occupied by the screw itself, while adjustable suspensory fixation (ASF) systems provide larger contact zones and stiffer fixation which favor graft healing. Purpose To evaluate ligamentization of four-strand semitendinosus (4ST) using MRI, fixed with ASF compared to RIS. Study Design Prospective comparative study; Level II. Methods The authors prospectively enrolled 57 patients undergoing primary ACL reconstruction using single bundle 4ST. The femoral graft was fixed using suspensory fixation in all knees. The tibial graft was fixed using ASF in 28 knees and using RIS in 29 knees. The groups were similar in term of age and gender. Minimum 4 years postoperatively, GNRB® knee laxity measurements were taken and MRI scans were performed to assess graft incorporation within the tibial tunnel and in the notch. Results There was not significant difference on the Functional results IKDC and Lysholm. The IKDC Global score A + B 96.4 % was better in the ASF group than in RIS 82.1 % (p = 0.04). Mean side to side Laximetry test was none significant p = 0.18 (−0.13 vs 0.35). Tunnel enlargement was no significant between the two groups 10.7 mm in ASF group and 11.5 mm in RSI group. Howell graft signal assessment in the notch was excellent (Grade I + II) in 91 % of cases in the ASF Group and in 73 % of cases in the RIS group (p = 0.04). In the tibia the SNQ was 2.25 ± 4.05 in the ASF group and 10.28 ± 18.98 in the RIS group (p = 0.02). In the notch the SNQ was 2.57 ± 2.80 in the ASF group and 6.62 ± 10.99 in the RIS group (ns). There were 6 consistent tibial cysts related to the screw (20 %) in the RSI group and no cyst in the ASF group. Conclusion ASF provides more favorable conditions than RIS for incorporation and ligamentization of 4ST grafts within the tibial tunnel with more residual cysts in the RSI group. In the notch, the Howell grade was better in the ASF group, although the SNQ were not significatively better. the objective IKDC Score was significatively better in ASF group, however functionals results are similar.

Outcome of Adjustable Suspensory Fixation for Femoral Graft in ACL Reconstruction

Background: The incidence of torn anterior cruciate ligament (ACL) has greatly increased, with today’s increasing enthusiasm for sports activities. As a result, reconstruction of the torn anterior cruciate ligament became a common surgical procedure in orthopaedic surgery. Objective: To evaluate short term clinical outcome of adjustable suspensory fixation for femoral graft in ACL reconstruction. Methods: All patients treated for ACL reconstruction with an ipsilateral hamstring between March 2017 and March 2018 were evaluated. Subjects were assigned to TightRope™ (TR) femoral fixation. All patients were evaluated with the Lachman test, pivot-shift test, 2000 International Knee Documentation Committee (IKDC) knee examination. The subjective evaluation was performed using the Lysholm knee score. CT examination was performed to evaluate femoral and tibial tunnels enlargement at four different levels. All patients were assessed at a 12 month follow-up visit. Power analysis was performed a priori in accordance with the femoral and tibial tunnels enlargement values from the CT scans. Results: The group was homogenous at baseline with regard to age, gender, BMI, dominance and disease duration. At the final follow-up, no statistically significant differences were found according to subjective and objective clinical outcome measures. According to the femoral tunnel enlargement, no statistically significant difference was found between tunnel at operation and 12 months later. Conclusion: In transtibial ACL reconstruction, the use of adjustable-loop length device products, on the femoral side, led to better clinical and radiological results

Patellar Tendon Reconstruction Using Hamstring Tendon and Adjustable Suspensory Cortical Fixation

Chronic patellar tendon rupture is a rare injury; extensor mechanism impairment leads to great disability in daily life. The delayed diagnosis and reconstruction of chronic patellar tendon ruptures are technically challenging. Numerous surgical procedures have been described with bone-tendon-bone graft, hamstring graft, artificial ligament, and allograft. We describe safe, reproducible anatomic reconstruction of the patellar tendon using hamstring tendon and adjustable suspensory fixation. After harvesting of the hamstrings, the graft is prepared with 2 adjustable suspensory fixation devices. Then, a complete tibial tunnel and a patellar tunnel with a socket are drilled with the appropriate diameter, and the graft is pulled through the tunnels. Finally, the suspensory fixation devices on the tibial and patellar sides are tensioned. The aim of this procedure is to obtain complete mobility of the knee, using a procedure similar to anterior cruciate ligament reconstruction in graft preparation.

Biomechanical Testing of Three Alternative Quadrupled Tendon Graft Constructs With Adjustable Loop Suspensory Fixation for Anterior Cruciate Ligament Reconstruction Compared With Four-Strand Grafts Fixed With Screws and Femoral Fixed Loop Devices

Background: Quadrupled semitendinosus (ST) grafts for anterior cruciate ligament (ACL) reconstruction have advantages of greater graft diameter and gracilis (G) preservation compared with doubled ST-G grafts. However, a paucity of biomechanical data are available regarding different preparation techniques for these constructs. Purpose: To biomechanically analyze 3 alternative tendon constructs fixed with adjustable suspensory fixation devices on the femur and tibia compared with a matched 4-strand construct fixed with a tibial screw and femoral fixed loop device. Study Design: Controlled laboratory study. Methods: Three alternative quadrupled tendon preparation techniques with suspensory fixation (grafts constructs A, B, and C) were compared with a 4-strand screw-fixed loop device construct (graft construct D) in matched diameter bovine tendon graft and porcine tibia models. Graft constructs were tested with a 3-stage cyclic loading protocol (1000 cycles in position control and 1000 cycles each from 10 to 250 N and from 10 to 400 N), followed by a pull to failure. In graft construct A, the graft ends were whipstitched and tied over the tibial button; in graft construct B, the graft ends functioned as pulleys; and in graft construct C, a continuous loop was created. Initial, dynamic, and total elongation, stiffness, and ultimate failure load were recorded. Results: Graft construct D had the highest initial (0.51 ± 0.29 mm) and total (3.53 ± 0.98 mm) elongation compared with the 3 quadrupled constructs (P < .001 each). Graft construct B had lower total elongation (2.13 ± 0.31 mm) compared with graft construct A (2.40 ± 0.30 mm) (P = .004) and graft construct C (2.53 ± 0.21 mm) (P = .007). Graft construct C had a higher ultimate failure load (1097 ± 79 N) compared with graft construct A (988 ± 112 N) (P = .001), graft construct B (973 ± 137 N) (P = .022), and graft construct D, which had the lowest failure load (767 ± 182 N) (P < .001). Conclusion: The 3 quadrupled tendon suspensory fixation constructs exhibited small yet statistically significant biomechanical differences among each other. Constructs that used tibial screw fixation had lower ultimate failure load and higher total elongation compared with the quadrupled tendon constructs. Clinical Relevance: Total elongation for the screw fixation group was higher than the threshold of clinical failure, which may allow for graft construct elongation during the postoperative rehabilitation phase. Biomechanical properties of the 3 quadrupled tendon suspensory graft constructs may be clinically comparable, albeit statistically different.

Clinical and Functional Outcomes of Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years Using Adjustable Suspensory Fixation in Both the Femur and Tibia: A Prospective Study.

Background:The success of anterior cruciate ligament (ACL) reconstruction requires reliable and rigid graft fixation. Cortical suspensory fixation (CSF) devices have become an acceptable alternative to interference screws for soft tissue ACL grafts. However, CSF devices have been reported to be associated with tunnel widening and increased postoperative anterior laxity compared with interference screw fixation. Adjustable CSF devices were introduced to avoid these problems but have been associated with graft lengthening and inconsistent outcomes.Purpose:To (1) report the side-to-side difference (SSD) in anterior laxity at 150 N, clinical scores, and failure rates 2 years after ACL reconstruction with 4-strand semitendinosus autografts using an adjustable CSF device and (2) determine the preoperative factors associated with clinical outcomes.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 131 patients who had undergone primary ACL reconstruction, performed with 4-strand semitendinosus grafts that were secured using Pullup adjustable-length CSF devices with femoral and tibial fixation techniques, were prospectively enrolled in this study; 34 patients were excluded because of contralateral instability or ipsilateral knee injuries that required additional surgery. This left a cohort of 97 patients who were evaluated preoperatively and at 6, 12, and 24 months. The evaluation consisted of measuring the SSD in anterior laxity and patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Lysholm scores). Regression analyses were performed to determine associations between these outcomes and 9 preoperative variables.Results:Only 2 patients could not be reached, 2 could not be evaluated because of contralateral ACL tears, and 2 had graft failure. At 2-year follow-up, the remaining 91 patients had a mean SSD in anterior laxity of 0.8 ± 1.8 mm (range, –4.2 to 5.3 mm), mean IKDC score of 87.6 ± 10.6 (range, 43.7-100.0), and mean Lysholm score of 90.8 ± 9.3 (range, 56.0-100.0). At final follow-up, compared with knees with partial ruptures, those with complete ruptures had equivalent laxity (P = .266) and Lysholm scores (P = .352) but lower IKDC scores (P = .009). Multivariable regression revealed that the IKDC score decreased with increased preoperative laxity (β = –1.35 [95% CI, –2.48 to –0.23]; P = .019).Conclusion:The novel adjustable-length CSF device produced satisfactory anterior laxity and clinical outcomes, with a failure rate of 2.1%, which compare favorably with those reported for nonadjustable CSF devices.

Évaluation IRM comparative des greffes de DT4 fixées par vis résorbable vs. fixation de suspension ajustable

Background Success of ACL reconstruction requires solid graft incorporation within the tunnels to enable graft remodeling. Resorbable interference screws (RIS) provide limited tendon-bone contact because much of the tunnel circumference is occupied by the screw itself, while adjustable suspensory fixation (ASF) systems provide larger contact zones which favor ligamentization. Purpose To evaluate ligamentization of four-strand semintendinosus (4ST) within the tibial bone tunnel using MRI at 6 postoperative months, fixed with ASF compared to RIS. Study design Prospective comparative study; level II. Methods The authors prospectively enrolled 121 consecutive patients undergoing primary ACL reconstruction using single bundle 4ST. The femoral graft was fixed using suspensory fixation in all knees. The tibial graft was fixed using ASF in 67 knees and using RIS in 44 knees. Six months postoperatively, knee laxity measurements were taken and MRI scans were performed to assess graft incorportation within the tibial tunnel. Results At 6 months follow-up, MRI scans of 109 knees were available for analysis. Tunnel enlargement in the ASF group was 2.3 ± 1.1 mm (range, 0.5–6.0), while in the RIS group it was 4.7 ± 2.8 mm (range, 0.5–19.0) ( P > 0.001). Howell graft signal assessment was excellent in 97% of cases in the ASF Group and in 25% of cases in the RIS group ( P > 0.001). The SNQ was 0.078 ± 0.62 in the ASF group and 0.671 ± 0.83 in the RIS group ( P > 0.001). Conclusion ASF provides more favorable conditions than RIS for incorporation and ligamentization of 4ST grafts within the tibial tunnel. The ASF system used showed very little tunnel widening, which suggests that it grants stabilization. The SNQ was also considerably better in the ASF group, mainly due to tight graft folding that prevented synovial fluid penetration in the graft-bone interface. Clinical relevance The findings are relevant for choice of tibial fixation device for ACL reconstruction particularly in patients that need to resume athletic activities.

Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction

BackgroundThis paper reports the outcomes of patients undergoing ACL reconstruction using a TransLateral single bundle, all-inside hamstring technique at a minimum of two year follow-up. MethodsThe semitendinosus alone is harvested, quadrupled and attached in series to two adjustable suspensory fixation devices. Femoral and tibial sockets are produced using a retrograde drill. The graft is deployed, fixed and tensioned on both tibia and femur. Patients were evaluated preoperatively using the KOOS, Lysholm and Tegner scores and at six, 12 and 24months postoperatively. Objective assessment of knee laxity was performed using the KT-1000 along with goniometric measurement of range or motion. ResultsOne hundred and eight patients, mean age 30.9years (range 15 to 61) were included. Mean follow-up 49.8months (range 30–66). The mean increase in KOOS at two years was 30.3 points; Lysholm, 33.1 points; Tegner Activity scale, 2.0 levels. These were all statistically significant (p<0.001). Range of motion in the reconstructed knee approximated the uninjured knee by 12months and was restored by two years. KT-1000 showed significant reduction in side-side difference to no more than 2.4mm at all postoperative time points (p<0.001). Re-rupture rate in this series was 6.5%, all following episodes of significant additional postoperative trauma to the knee. ConclusionsTransLateral all-inside ACL reconstruction demonstrates good medium term subjective and objective outcomes with a low complication and failure rate.

Incorporation of Hamstring Grafts Within the Tibial Tunnel After Anterior Cruciate Ligament Reconstruction

Background: The success of anterior cruciate ligament (ACL) reconstruction requires solid graft incorporation within the tunnels to enable graft remodeling. Resorbable interference screws (RIS) provide limited tendon-bone contact because much of the tunnel circumference is occupied by the screw itself, while adjustable suspensory fixation (ASF) systems provide larger contact zones, which favor ligamentization. Purpose: To evaluate ligamentization of a 4-strand semitendinosus (4ST) graft fixed with ASF compared with RIS within the tibial bone tunnel at 6 months postoperatively using magnetic resonance imaging (MRI). Study Design: Cohort study; Level of evidence, 2. Methods: We prospectively enrolled 121 consecutive patients undergoing primary ACL reconstruction using a single-bundle 4ST graft. The femoral end of the graft was fixed using suspensory fixation in all knees. The tibial end of the graft was fixed using ASF in 67 knees and RIS in 54 knees. Six months postoperatively, knee laxity measurements were taken, and MRI was performed to assess graft incorporation within the tibial tunnel. Results: At 6-month follow-up, MRI scans of 109 knees were available for analysis. The mean tibial tunnel enlargement in the ASF group was 2.3 ± 1.1 mm (range, 0.5-6.0 mm), while in the RIS group, it was 4.7 ± 2.8 mm (range, 0.5-19.0 mm) (P < .001). The Howell graft signal assessment findings were excellent in 97% of knees in the ASF group and in 25% of knees in the RIS group (P < .001). The mean signal-to-noise quotient (SNQ) was 0.078 ± 0.62 in the ASF group and 0.671 ± 0.83 in the RIS group (P < .001). Conclusion: ASF provides more favorable conditions than RIS for the incorporation and ligamentization of 4ST grafts within the tibial tunnel. The ASF system used showed very little tunnel widening, which suggests that it grants stabilization. The SNQ was also considerably better in the ASF group.

Predicting Hamstring Graft Diameter Using MRI and Anthropometry

Objectives:Graft diameter is one variable that may affect outcome of ACL reconstruction. The ability to predict the size of a graft in a given patient pre-operatively may help guide graft selection and preparation technique. Various papers have correlated anthropometric data and MRI tendon measurements to intraoperative graft diameter, although no papers have investigated these together. The intra-operative diameter of a hamstring autograft will be influenced by graft preparation technique. Our study aimed to investigate the prediction of intraoperative graft diameter of 2 different graft construct techniques (4-strand semitendinosus versus quadrupled semitendinosus) using anthropometry and MRI measurements.Methods:Retrospective review of two groups of ACL reconstruction using different graft preparation techniques was performed. “Conventional” 4-strand gracilis + semitendinosus with fixed suspension at the femur and screw fixation at the tibia were compared with quadrupled semitendinosus grafts with adjustable suspensory fixation at each end (Graftlink). Cross-sectional areas (XSA) of the semitendinosus and gracilis tendons was measured in the axial slice of a T2 weighted MRI image using a region-of-interest tool. Stepwise linear regression using intraoperative graft diameter as the dependant variable was performed using MRI XSA of the semitendinosus and gracilis tendons, gender and height as predictors.Results:129 ACL Reconstruction in 127 patients were done in the time period, 89 of which were done conventionally, and 40 which employed the Graftlink construct. The median graft diameter in the Graftlink group (8.5mm IQR8-9) was greater than that of the conventional group (8mm, IQR 7.5-8) (p < 0.001). MRI XSA of semitendinosus and height were statistically significant predictors of diameter in the Graftlink group (R2 = 51%), whilst MRI XSA of semitendinosus + gracilis and gender were predictors in the conventional group (R2 = 36%).Conclusion:Graftlink ACLRs produced a greater graft diameter than conventional 4-strand semitendinosus and gracilis constructs. Gender and tendon XSA were statistically significant predictors of graft diameter in conventional four-tailed ACLRs, whilst height and tendon XSA predicted Graftlink ACLRs. A greater degree of the graft diameter variance could be predicted pre-operatively in the Graftlink group compared to the conventional construct.

An Anterior Cruciate Ligament Reconstruction Technique With 4-Strand Semitendinosus Grafts, Using Outside-In Tibial Tunnel Drilling and Suspensory Fixation Devices

We describe an anatomic single-bundle anterior cruciate ligament reconstruction using a 4-strand semitendinosus graft fixed with 2 Pullup adjustable suspensory fixation systems (SBM, Lourdes, France). Outside-in full tibial tunnel drilling represents a secure option for length management of the graft. The preferred graft choice is a 4-strand semitendinosus autologous graft. A special technique is used to stitch the graft with a figure-of-8 stitch to load the 4 strands. The Pullup adjustable loop is equipped with 2 buttons of different sizes: a small button for the standard Pullup system on the femoral side and a large button for the Pullup XL system on the tibial side. With this method, graft tension is equally distributed among the 4 strands and the graft cannot bottom out in the tibial tunnel in case of inadequate graft length.

Double-Bundle “All-Inside” Posterior Cruciate Ligament Reconstruction

The procedure for repairing the posterior cruciate ligament (PCL) has a steep learning curve and entails numerous difficult steps during surgery, because of the proximity of the neurovascular bundle, difficult passage of the graft through the posterior capsule, and risk of poor tibial fixation because of the long intramedullary trajectory of the graft. The use of instruments for retrograde reaming and a new device for adjustable cortical suspensory fixation allows for a safe, reproducible all-inside double-bundle PCL reconstruction by simplifying these difficult steps. We used anterior tibial allograft or hamstring autograft together with adjustable suspensory fixation devices that allow tensioning (after fixation) of the posterolateral bundle in extension and the anteromedial bundle in flexion.