Autogenous Bone-patellar Tendon-bone Graft Research Articles

Effect of Anterior tibiofemoral glides on knee extension after Anterior Cruciate Ligament Reconstruction

A 33 year old male patient presented to the department with the complains of pain and inability to bend and straighten the left knee since 1 month. The pain was present during Knee flexion and extension. Tenderness was present over medial knee joint line. Patient had a history of twisting his left leg and a third degree Anterior cruciate ligament tear for which he had underwent reconstruction surgery with autogenous bone-patellar tendon-bone graft after which he had been referred for Physiotherapy. During Physiotherapy treatment he was given Cryotherapy, Range of motion exercises, continuous passive movement exercises, followed by Anterior Tibiofemoral glides.strengthening exercises were given as home program.12 sessions of treatment were given and good reduction in pain and improvement in range of motion was observed in the last session. The purpose of this case report is to present the positive effects of mobilization techniques in the early post-op phases of rehabilitation on the subjects who underwent ACL reconstruction surgery.

Neuromuscular training optimises knee function after arthroscopic ACL reconstruction

Does neuromuscular training improve knee function more than traditional strength training following anterior cruciate ligament (ACL) reconstruction? Randomised controlled trial. Two outpatient rehabilitation clinics in Norway. 74 adults aged between 16 and 40 years (mean: 28 years), scheduled for arthroscopic reconstruction of the ACL using an autogenous bone-patellar tendon-bone graft. Exclusion criteria included age of ACL injury more than 3 years, meniscal damage requiring repair, or previous injury or surgery to either knee. Participants were allocated to one of two rehabilitation programs using concealed allocation. A 6-month rehabilitation program was commenced during the second week after surgery following a home program to restore knee range of movement and reduce swelling. Exercises were supervised by physiotherapists during clinic visits twice per week. Knee braces were not used at any time. The neuromuscular training group performed balance exercises, plyometric exercises, agility drills, and sportspecific exercises. The strength training group performed mainly strengthening exercises of the lower extremity (quadriceps femoris, hamstring, gluteus medius, and gastrocnemius muscles) based on the American College of Sports Medicine guidelines. Participants were assessed preoperatively and at 3 and 6 months postoperatively. The primary outcome measure was the Cincinnati Knee Score (CKS) which has a scale of 0 to 100 (100 = normal knee). Secondary outcome measures included pain intensity (100 mm VAS where 0 = no pain, 100 = worst imaginable pain), global knee function (100 mm VAS where 0 = worst possible knee function, 100 = preinjury knee function), isokinetic muscle strength, the 36-Item Short-Form Health Survey, hop tests, proprioception, and balance tests. The outcomes assessor was unaware of treatment allocation. 89% of participants underwent the 6-month assessment. At this time the CKS score was higher in the neuromuscular training group compared with the strength training group by 7 points (95% CI 2 to 13). Similarly, global knee function VAS scores at 6 months were higher in the neuromuscular training group by 13 mm (95% CI 2 to 24). The groups did not differ significantly on the pain VAS or other outcomes. Adherence to the rehabilitation program was higher in the strength training group (91% adherent) compared with the neuromuscular program (71%). Neuromuscular rehabilitation results in superior knee function at 6 months after ACL reconstruction compared with standard strength training.

Bone Mineral Density in the Proximal Tibia and Calcaneus Before and After Arthroscopic Reconstruction of the Anterior Cruciate Ligament

To monitor changes in bone mineral density (BMD) of the proximal tibia and the calcaneus in patients with anterior cruciate ligament (ACL) rupture before and after arthroscopic reconstruction of the ligament, related to clinical data. A 2-year prospective cohort study with assessment of patient evaluation of knee performance, clinical scoring of surgical results, and measurement of BMD in the tibia and calcaneus. Eighteen patients with a unilateral ACL rupture underwent an autogenous bone-patellar tendon-bone graft ACL reconstruction. The patients were examined before surgery and after 4, 12, and 24 months. BMD was assessed bilaterally in the proximal tibia and calcaneus using dual-photon absorptiometry and converted to a Z-score by use of BMD values from a group of healthy controls. Clinical evaluation included determination of Lysholm score, quantitative Lachman test, pivot-shift test, and the patients' self-reported highest level of activity and knee performance in sports and daily activities. There were significant declines in Z-score of the proximal tibia of the operated leg during the first year after surgery, whereas there was no change in the calcaneus and contralateral leg. In the lateral tibia, the Z-score was significantly lower at 24 months follow-up, compared with both controls and the noninjured side, whereas BMD of the medial tibia had returned to near normal levels. There were significant improvements in Lysholm score, highest level of activity, and knee performance in daily activities and sports. The patients' evaluation of improvement in knee performance in sports activities at 24 months follow-up was associated with an increase in Z-score of the injured leg. We found a partially reversible decline in BMD of the proximal tibia after arthroscopic ACL reconstruction. Improvement in knee performance in sports activities was associated with an increase in BMD of the injured leg. BMD of the calcaneus remained unaffected in both legs. Level III, therapeutic case control study.

Anatomy, Biology and Biomechanics of Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction

Summary: Autologous bone-patellar tendon-bone autograft is a common choice for anterior cruciate ligament reconstruction and from both biologic and biomechanical perspectives is well-suited for this purpose. A centrally harvested, 10 mm wide patellar tendon graft has an estimated initial load-to-failure of 2977 N, and interference screw fixation of associated bone blocks provides initial pull-out strength as high as 640 N. After reconstruction, both intraarticular and extraarticular portions of the graft experience significant changes. The intraarticular portion of the graft undergoes a prolonged histologic, morphologic, and structural evolution known as ligamentization. The extraarticular portion of the graft becomes rapidly incorporated into surrounding bone tunnels over the weeks after implantation. The use of biologics to accelerate this process holds promise. This review summarizes relevant data regarding the anatomy, biology, and biomechanics of the anterior cruciate ligament, patellar tendon, and anterior cruciate ligament reconstruction with autogenous bone-patellar tendon-bone graft.

Supracondylar Femoral Fracture After Arthroscopic Reconstruction of the Anterior Cruciate Ligament: A Case Report

R econstruction of the anterior cruciate ligament is one of the most frequently performed orthopaedic procedures, with more than 100,000 reconstructions performed annually in the United States alone1. Autogenous bone-patellar tendon-bone graft is the graft option that is most frequently utilized by orthopaedic surgeons in the United States, Canada, and Europe2. Complications have been reported to occur in association with 1.8% to 24% of anterior cruciate ligament reconstructions3-5. Serious complications have included arthrofibrosis, patellar fracture, patellar tendon rupture, tibial tubercle fracture, tibial plateau fracture, and osteonecrosis of the femoral condyles3-6. Femoral fracture following anterior cruciate ligament reconstruction is a devastating complication that has been reported only in isolated cases and has been attributed to technical errors or the creation of additional bone holes for supplemental fixation devices used with earlier reconstructive techniques7-12. We present a rare case of a supracondylar femoral fracture that occurred after an arthroscopic anterior cruciate ligament reconstruction that had been performed without supplemental fixation and had not been associated with intraoperative complications. The fracture occurred through an enlarged femoral tunnel following an injury of the involved extremity. Our patient was informed that data concerning this case would be submitted for publication. A thirty-three-year-old man sustained an injury of the left knee after falling off a mountain bike. He reported that he had lost his balance while in a standing position and had fallen onto the right side with hyperextension of the left knee after getting his foot caught in the pedal. He presented to the emergency room with left knee pain and the inability to bear weight on the affected leg. A review of the history revealed that an arthroscopic reconstruction of the left anterior cruciate ligament had been performed …

The Effect of Growth Factors on Biomechanical Properties of the Bone-Patellar Tendon-Bone Graft after Anterior Cruciate Ligament Reconstruction

Background No studies have dealt with the effect of growth factors on the free tendon autograft in anterior cruciate ligament reconstruction. Hypothesis Application of exogenous transforming growth factor-β and epidermal growth factor may affect the structural properties and histology of the bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction. Study Design Controlled laboratory study. Methods Twenty dogs underwent anterior cruciate ligament reconstruction with the autogenous bone-patellar tendon-bone graft in bilateral knees. In 10 animals, 12 ng transforming growth factor-β and 300 ng epidermal growth factor mixed with fibrin sealant of 0.6 mL were applied to the left knee. In the remaining 10 dogs, fibrin sealant alone was applied to the left knee. No additional treatments were applied to the right knee. Results The growth factor application increased the stiffness and maximum failure load of the femur-graft-tibia complex at 12 weeks (P = .016 and P = .012, respectively); the sham treatment did not significantly affect them. Histologically, most of the cells in the grafts treated with growth factors had spindle-shaped nuclei; cells in the other grafts had round-shaped nuclei. Conclusions Application of transforming growth factor-β and epidermal growth factor improves the structural properties of the autograft after anterior cruciate ligament reconstruction in the canine model. Clinical Relevance Application of growth factors is a possible strategy to prevent graft deterioration in anterior cruciate ligament reconstruction.

Muscle performance after anterior cruciate ligament reconstruction.

We measured muscle strength in 36 patients after anterior cruciate ligament (ACL) reconstruction with autogenous bone-patellar tendon-bone graft. Quadriceps and hamstring isokinetic strength was assessed during concentric contraction at 60 and 180 degrees /s and was measured at 1, 6, 12 and 24 months postoperatively. At 24 months quadriceps muscle strength had recovered to approximately 90% of the level of the uninvolved side, both at 60 and 180 degrees /s. In contrast, hamstring muscle strength had already recovered to approximately 90% at 6 months. Age, gender, activity level, and anterior tibial laxity did not affect the muscle performance. However, the recovery of muscle strength was delayed in patients with anterior knee pain.

The elongation behavior of the anterior cruciate ligament graft in vivo. A long-term follow-up study.

The relationship between the elongation values of an autogenous bone-patellar tendon-bone graft immediately after fixation and the anterior-posterior laxity of the knee 5 years later was studied in vivo. Immediately after fixation, the change in the graft midsubstance length during passive knee flexion-extension was measured using a Hall-effect transducer, and anterior-posterior knee laxity was measured with the KT-1000 arthrometer. Subjects were divided into group 1 (N = 6), with graft elongation values bounded by the 95% confidence intervals of the normal anterior cruciate ligament elongation values, and group 2 (N = 7), subjects with values outside these intervals. Immediately after reconstruction, the side-to-side difference in anterior-posterior laxity between the reconstructed and uninjured knees was not different between group 1 (-2.6 +/- 0.7 mm, mean +/- SEM) and group 2 (-1.7 +/- 1.0 mm) (P = 0.49). At 5-year follow-up, the difference was 1.2 +/- 0.7 mm for group 1, while for group 2 it was significantly greater at 4.7 +/- 0.6 mm (P = 0.004). At surgery, graft elongation values produced by flexion of the knee that are outside the limits of the anterior cruciate ligament result in significant increases in anterior knee laxity at long-term follow-up, while grafts with elongation values similar to the normal anterior cruciate ligament do not. Not only is restoration of anterior-posterior laxity values to within normal limits important, but the biomechanical behavior of the graft produced by flexion-extension of the knee should be appreciated.

Anterior cruciate ligament reconstruction in athletes with an ossicle associated with Osgood-Schlatter's disease.

We report a series of 20 athletes with an ossicle associated with Osgood-Schlatter's disease (OSD) who underwent anterior cruciate ligament (ACL) reconstruction using autogenous, central-10-mm patellar-tendon graft. All patients had an Osgood Schlatter's lesion with an ossicle as seen on a plain radiograph. The patients were reviewed at an average follow-up of 44 months (range, 24 to 108 months). The postoperative assessment included clinical examination, KT-1000 testing, isokinetic testing, and subjective score (using the modified Noyes' questionnaire). At the time of latest review, all 20 patients had a stable knee. The average side-to-side difference on manual maximum KT-1000 assessment was 1.9 mm (range, 0 to 5 mm). Average time to return to full sporting activities was 5.2 months (range, 2.6 to 8.9 months). All patients returned to their previous level of activity. The mean modified Noyes' knee score was 96 (range, 89 to 100). To date, no graft failure has occurred. Based on the results of this study, we believe that ACL reconstruction using the autogenous bone-patellar tendon-bone graft can be safely undertaken in athletes with an ossicle associated with OSD without compromising the final knee function.

Revision of failed prosthetic anterior cruciate ligament reconstruction.

Revision of failed prosthetic anterior cruciate ligament reconstructions will continue to be necessary as previously placed prosthetic devices fail with time. These patients often present with recurrent instability, pain, swelling, or effusions. Graft rupture and the generation of particulate debris are common causes of these symptoms. To effectively treat these patients requires careful preoperative evaluation and planning. Operative treatment includes removing the prosthesis and metal fixation devices, evaluating femoral and tibial bone stock, and determining adequacy of previous tunnel position. Staging of the operation may be a necessity if significant bone loss or poor tunnel position on either the femoral or tibial side requires bone grafting. The use of an autogenous bone-patellar tendon-bone graft is suggested and has proven to be effective in restoring knee stability in these revision cases. The ultimate outcome following revision of failed prosthetic ligaments may be limited by associated intraarticular pathology often seen in this patient population.

Current Concepts on Accelerated ACL Rehabilitation

It is well established that intra-articular anterior cruciate ligament reconstruction with autogenous bone-patellar tendon-bone graft provides satisfactory long-term stability. However, the rehabilitation programs employed following this surgical procedure have been a topic of considerable debate. This paper describes an accelerated rehabilitation protocol that is divided into four phases. The first phase encompasses the preoperative period, during which the patient will work to decrease swelling and restore range of motion and strength. The second phase involves Weeks 1 and 2 following surgery, with the patient emphasizing immediate terminal knee extension and weight bearing. The final two phases involve improving lower extremity strength and full return to daily and athletic activities. This accelerated rehabilitation protocol has resulted in an earlier return of range of motion and strength without compromising ligamentous stability.