Bundle Anterior Cruciate Ligament Reconstruction Research Articles

Evaluation of anterolateral ligament healing in patients with anterior cruciate ligament injury without anterior cruciate ligament reconstruction and its relationship with clinical examination tests.

This study radiologically investigated the potential of preoperative recovery of the anterolateral ligament (ALL) in patients who did not undergo anterior cruciate ligament reconstruction (ACLR) surgery in the early stages despite surgical indication. The secondary aim was to investigate the relationship between ALL injuries in magnetic resonance imaging (MRI) and the results of Lachman and pivot shift tests performed preoperatively and postoperatively under anaesthesia amongpatients who underwent ACLR in acute and chronic stages. The study examined 100 patients aged 19-51 years who underwent anatomic single bundle ACLR using hamstring autografts for the ACL. Based on the time between the injury and ACLR, they were divided into acute (≤6 months) and chronic (>6 months) groups. The chronic group had three subgroups of ACLR times: 7-12, 13-24and >24 months. Complete recovery was defined as a change from grade B or C upon injury to grade A before surgery according to the Muramatsu MRI classification. The relationship between preoperative and postoperative Lachman grades and pivot shifting test results and the degree of ALL injury was evaluated. In the chronic group, 19/61 patients (31.1%) had preoperative grade A, and 4/61 patients (6.5%) had grade A at the time of injury. In the acute group, 22/29 patients with grades B and C (76%) had grade 3 preoperative pivot shifting. In the acute group, grades 1 and 2 were more common in patients with grades B and C (10/29, 35%) than grade A (0/10, 0.0%). The improvement rate was 24.6% amongpatients who did not receive ACLR in the acute phase and underwent ACLR in the chronic phase. In the acute group, the degree of ALL damage was related to the pivot shift results. However, the results in the chronic phase were not associated with the degree of injury. Level IV.

Higher Rates of Anatomical Insertion of Medial Hamstring Tendon Regeneration Post-Anterior Cruciate Ligament Reconstruction with Stump Preservation Graft Harvesting Technique: A Prospective, Randomized, Double-Blinded Clinical Trial with Magnetic Resonance Imaging Evaluation

Objective(s): The purpose of this study was to compare the regeneration of semitendinosus and gracilis tendons from two different graft harvesting techniques which are the stump preservation and conventional graft harvesting technique. We hypothesised that the stump preservation graft harvesting technique which preserved the distal attachment of tendons at their insertion would facilitate anatomical regeneration to the pes anserinus. MethodsThis is a prospective, randomised double-blinded study whereby thirty consecutive patients who underwent single bundle anterior cruciate ligament reconstruction with ipsilateral semitendinosus and gracilis autografts were recruited. The patients were randomly assigned to the stump preservation group (14 patients) or conventional group (16 patients). magnetic resonance imaging (MRI) evaluation was performed preoperatively and at 6-months postoperatively. ResultsAt 6-months follow-up, MRI evaluations showed a higher percentage of insertion of regenerated semitendinosus and gracilis at the pes anserinus in the stump preservation group (75.0%) than that in the conventional group (68.8%). There was significantly higher proximal shift of musculotendinous junction of semitendinosus (5.70 cm versus 3.36 cm, p = 0.029) and gracilis (5.28 cm versus 3.16 cm, p = 0.045) in the conventional group postoperatively. ConclusionThe stump preservation technique yields higher percentage of anatomical insertion of regenerated tendons and lesser amount of proximal shift of musculotendinous junction. Level of EvidenceIII – Prospective study with up to two negative criteria

Application of femoral I.D.E.A.L localization in anterior cruciate ligament reconstruction with single bundle anterior cruciate ligament

To evaluate the effect of femoral I.D.E.A.L localization in single bundle anterior cruciate ligament reconstruction (ACLR). From January 2019 to October 2022, 122 patients with anterior cruciate ligament injury were treated with ACLR, including 83 males and 39 females. The age ranged from 23 to 43 years old, with an average of (32.19 ±8.55) years old. The course of disease ranged from 1 week to 6 months. According to the different surgical schemes, the patients were divided into two groups, namely the traditional group, which adopted the over-the-top femoral lateral positioning scheme, including 64 patients. The I.D.E.A.L group adopted the I.D.E.A.L femoral lateral positioning scheme, including 58 patients. The patient has pain and dysfunction of knee joint before operation. MRI of knee joint indicates anterior cruciate ligament injury. The visual analogue scale(VAS), International Knee Documentation Committee(IKDC) scoring system and Lysholm scoring system were used to evaluate the knee joint function of the patient. KT-2000 was used to detect the recovery of knee joint after operation and to count the postoperative complications. The wounds healed well after operation. One hundred and twenty-tow patients were followed up for 15 to 46 months, with an average of (25.45±9.22) months. The knee joint stability of patients after operation was significantly increased. The VAS at 1 day and 1 week after operation of patients in the I.D.E.A.L group was significantly lower than that in the traditional group(P<0.05). The IKDC score and Lysholm score of patients in the I.D.E.A.L group were significantly higher than those in the traditional group(P<0.05). In the traditional group, there were 6 cases of short-term (<1 month) complications and 19 cases of long-term (≥1 month)complicatios. In the I.D.E.A.L group, there were 3 cases of short-term complications and 7cases of long-term complications(P<0.05). The single bundle anterior cruciate ligament reconstruction and femoral I.D.E.A.L positioning can achieve better early postoperative effect and reduce early postoperative pain.

COMPARISON OF FUNCTIONAL OUTCOME OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING PERONEUS LONGUS GRAFT AS AN ALTERNATIVE TO HAMSTRING TENDON

AbstractPurposeSince arthroscopic reconstruction of the anterior cruciate ligament (ACL) started, the use of peroneus longus grafts for primary ACL reconstruction (ACLR) was never thought of as there is very scant literature on it. So, our study aims to compare the functional outcome and complications in patients with ACL injury managed by ACLR with peroneus longus tendon (PLT) and hamstring tendons (HT) respectively.Materials and MethodsPatients with 16–50 years of either gender presenting with symptomatic ACL deficiency were admitted for arthroscopic single bundle ACLR and allocated into two groups (PLT and HT) operated and observed. Functional scores (IKDC and Lysholm score), clinical knee evaluation, donor site morbidity (AOFAS score) and thigh circumference were recorded preoperatively and at six months, one year post-operatively. The same post-op rehabilitation protocol was followed in both groups.Results194 patients (hamstring n=96, peroneus n=98) met the inclusion criteria. There were no significant differences between the pre-op, six months post-op and one-year postoperative score between the hamstring and peroneus longus groups in the IKDC (p=0.356) and Lysholm knee score (p=0.289). The mean for the AOFAS was 99.05±3.56 and 99.80±0.70 in the PLT and HT group respectively showing no statistical difference, with a significant improvement in thigh muscle wasting among the PLT group at final follow-up (p&lt;0.001).ConclusionWe observed similar knee stability, functional outcome and no obvious donor site morbidity among both groups and recommend that a PL graft may be a safe, effective, and viable option for arthroscopic single bundle ACL reconstruction.

Functional outcome of arthroscopic anterior cruciate ligament reconstruction with hamstring graft

Introduction Incidence of anterior cruciate ligament (ACL) injuries is increasing owing to increased participation in sports. We are presenting our case series in which we have done ACL reconstruction (ACLR) with autologous hamstring graft. Basic idea for this project was to increase the awareness regarding timely management of ACL injury and good to excellent outcome of this minimal invasive technique. Materials and Methods In this retrospective study, we included 10 patients who underwent arthroscopic transportal single bundle ACLR using hamstring autograft, between January 2019 to December 2021 in Isra university hospital Hyderabad. Patients were followed routinely and outcome was recorded with the help of Lysholm knee scoring questionnaire at 6 months and 12 months post procedure. Results Mean age of the patients was 28.2 years (22 to 35 years) (Table-1). Average duration between injury to surgical intervention was 12.3 months (6 to 26 months). Final outcome was excellent in 3 patients (60%), good in 6 patients (30%) and fair in one patient (10%). Conclusion Injury to ACL is a critical event for any individual. Its timely management is important not only to return the patient back to pre-injury activity level but also to prevent delayed consequences of ACL tear. Our study and the literature review shows satisfactory results of arthroscopic ACLR. Finally, one should follow the basic principles of arthroscopic surgical technique of ACLR along with postoperative supervised physiotherapy rehabilitation protocol to get the desired results.

Single Bundle Anterior Cruciate Ligament With Anterolateral Ligament Reconstruction Yields Similar Clinical and Radiographic Results at Minimum 2-Year Follow-Up Versus Double Bundle Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Controlled Trial

To compare the clinical, radiographic, and second-look arthroscopic outcomes between double-bundle (DB) anterior cruciate ligament (ACL) reconstruction (DB group) and combined single-bundle (SB) ACL and anterolateral ligament (ALL) reconstruction (SB+ ALL group) by a prospective randomized controlled trial. From May 2019 to June 2020, 84 patients were enrolled in this study. Among them, 10 were lost to follow-up. Thirty-six and 38 patients were successfully allocated to the DB (mean follow up 27.3 ± 4.2 months) and SB+ ALL groups (27.2 ± 4.5 months), respectively. The preoperative and postoperative Lachman test, pivot shift test, anterior translation on stress radiographs, KT-2000 arthrometer, Lysholm score, International Knee Documentation Committee score, and Tegner activity score were evaluated and compared. Graft continuity was evaluated using postoperative magnetic resonance imaging (MRI) (32 and 36 patients underwent MRI in the DB and SB+ ALL groups at 7.4 ± 3.2 and 7.5 ± 2.9 months after surgery, respectively), and second-look examinations (second-look examination and tibial screw removal were performed concomitantly when patients (1) had tibial screw-related irritation or (2) needed the screws removed, 28 and 23 patients underwent examinations in the DB and SB+ ALL groups at 24.0 ± 6.8 and 24.9 ± 8.1 months after surgery, respectively). All measurements were compared between the groups. Postoperative clinical outcomes significantly improved in both groups. (All variables showed P < .001) No statistically different outcomes were found between the 2 groups. Additionally, postoperative graft continuity on MRI and second-look examinations were not different between the 2 groups. The DB and SB+ ALL groups showed similar postoperative clinical, radiographic, and second-look arthroscopic outcomes. Both groups showed excellent postoperative stability and clinical outcomes compared with the preoperative measurements. Level II, randomized controlled trial.

Outcome Analysis of Arthroscopic Single Bundle Anterior Cruciate Ligament Reconstruction Using Semitendinosus and Gracilis as Quadrupled Graft in Adults – A Case Series Study

Anterior cruciate ligament (ACL) injury is the common knee injury consequent to contact sports. There are different techniques recommended for the ACL reconstruction, with different graft materials. The aim of this study is to evaluate the functional outcome of arthroscopic single bundle ACL reconstruction using hamstring tendon graft in ACL deficient knees in adults. Between 2014 and 2017, a prospective study was conducted in Thanjavur Medical College on 10 ACL deficient patients. All patients were evaluated preoperatively using the Lysholm and Gillquist score and IKDC - 2000 score. All patients underwent arthroscopic single bundle ACL reconstruction with hamstring tendon graft, which was fixed with an endo-button CL fixation system on the femoral side and an interference screw on tibial side. They were advised a regular rehabilitation protocol. All patients were evaluated post-operatively at 6 weeks, 3 months, 6 months, and a year by same assessment scores. Ten patients were available for follow up for a period of 6 months to 2 years. The mean follow-up period was 10.5 months. When compared with their respective pre-operative knee assessment scores, it was found that a definite improvement was there in their knee function. The results were good to excellent in 80% patients, fair in 10%, and poor in 10% cases. For young active adults, single bundle reconstruction by arthroscopic methods gives acceptable results. The problems which are faced post-operatively can be again settled arthroscopically. A long-term follow-up of these cases is a must to analyze if there is degeneration that happened in the time between injury and ligament reconstruction.

Outcome analysis of arthroscopic reconstruction of anterior cruciate ligament in adults

Background: Anterior cruciate ligament injury is the common knee injury consequent to contact sports. There are different techniques recommended for the ACL reconstruction, with different graft materials. The aim of this study is to evaluate the functional outcome of arthroscopic single bundle ACL reconstruction using hamstring tendon graft in ACL deficient knees in adults. AIM: To evaluate the functional outcome of arthroscopic single bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon (Gracilis and semitendinosus) autograft with endobutton as femoral fixation device and interference screw as tibial fixation device in ACL deficient knees in adults. Methodology: Between December 2020 to December 2022, a prospective study was conducted in Government Medical College, Kota on 21 ACL deficient patients (M =19, F = 2] but 1 male patient was lost to follow-up. All patients were evaluated pre-operatively using the Lysholm & Gillquist score and IKDC – 2000 score. All patients underwent arthroscopic single bundle ACL reconstruction with hamstring tendon graft, which was fixed with an endobutton fixation system on the femoral side and an interference screw on tibial side. They were advised a regular rehabilitation protocol. All patients were evaluated post-operatively at 6 weeks, 3 months, 6 months and a year by same assessment scores. Results: 20 patients were available for follow up for a period of 6 months to 2 years. The mean follow-up period was 10.5 months. When compared with their respective pre-operative knee assessment scores, it was found that a definite improvement was there in their knee function. The results were good to excellent in 80% patients and fair in 20%. Conclusion: For young active adults, single bundle reconstruction by arthroscopic methods gives acceptable results. The problems which are faced post-operatively can be again settled arthroscopically. A long term follow-up of these cases is a must to analyze if there is degeneration that happened in the time between injury and ligament reconstruction.

Investigation of the Importance of Knee Position during Femoral Tunnel Reaming; Figure 4 versus Hyperflexion.

Introduction:We aimed to compare whether the visualisation provided by arthroscopic hyperflexion and Figure 4 has an effect on femoral tunnel placement in patients undergoing single bundle Anterior Cruciate Ligament Reconstruction (ACLR).Material and methods:We retrospectively evaluated 93 patients who underwent single-band ACLR for Anterior Cruciate Ligament (ACL) injury between 2016 and 2019. Eighty patients met the inclusion criteria with a minimum follow-up of 12 months. We divided the patients into Group 1 (figure 4) and Group 2 (hyperflexion). We analysed the demographic, radiological and functional outcomes of the patients. The functional Lysholm score, operative time, radiological Quadrant method (% proximal-distal and % anterior-posterior) measurements, tunnel lengths, axial and coronal plane angles, and iatrogenic chondral injury in the medial femoral condyle were evaluated.Results:Iatrogenic chondral injury developed in the medial femoral condyle in a total of seven patients in both groups: one patient in group 1 (Figure 4) and six patients in group 2 (Hyperflexion). Although statistically insignificant, iatrogenic medial femoral condyle damage was less in group 1. The statistical analysis between surgical operation time (p = 0.046) and tunnel lengths (p = 0.042) was significant.Conclusion:The position of figure 4 provides visualisation of lateral intercondylar notch better than hyperflexion. In the reaming stage, the medial femoral condyle is less damaged in group 1 (Figure 4). In ACLR, which has a long learning curve, short surgery time is seen as an important advantage for surgeons who have just started doing ACLR. We think that it can be used as an alternative method to hyperflexion in the learning process and maybe shorten the learning curve process.

Acute Anterior Cruciate Ligament Rupture: Repair or Reconstruction? Five-Year Results of a Randomized Controlled Clinical Trial

Background: High-level evidence for short–term outcomes of contemporary anterior cruciate ligament (ACL) suture repair (ACLSR) in comparison with those of ACL reconstruction (ACLR) is scarce. High-level evidence for mid- and long–term results is lacking, whereas outcomes of ACLSR in several historical studies were shown to deteriorate at midterm follow–up after initial good short–term outcomes. Hypothesis: Contemporary ACLSR is noninferior to ACLR in the treatment of acute ACL rupture in terms of patient self–reported outcomes at 5 years postoperatively. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 48 patients were enrolled in the study and, after stratification and randomization, underwent either dynamic augmented (DA) ACLSR or anatomic single–bundle ACLR. The primary outcome measure was the International Knee Documentation Committee 2000 (IKDC) subjective score (IKDCs). Furthermore, the Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Scale score (TAS), visual analog scale score for satisfaction (VASs), IKDC physical examination score (IKDCpe), limb symmetry index for quadriceps (LSIq) and hamstrings (LSIh) strength and jump test battery (LSIj), Kellgren-Lawrence grade of osteoarthritis (OA), and rate of adverse events were recorded. Analyses were based on an intention–to–treat principle. Results: The lower limit of the 2–sided 95% CI for the median IKDCs of the DA ACLSR group (n = 23; 75.9) was lower than the prespecified noninferiority margin (n = 21; 86.6). Therefore, the null hypothesis was rejected. However, the upper limit of the 2–sided 95% CI of the DA ACLSR group (100.0) was higher than the median IKDCs of the ACLR group (96.6), rendering the result for noninferiority inconclusive. No statistical difference was found between groups for median IKDCs (repair, 90.2; reconstruction, 96.6). Furthermore, no statistically significant differences were found for any of the secondary outcome measures for the DA ACLSR compared with the ACLR group: KOOS Symptoms, 92.9 versus 96.4; KOOS Pain, 100 versus 97.2; KOOS Activities of Daily Living, 100 versus 100; KOOS Sport and Recreation, 85.0 versus 100; TAS score, 7.0 versus 6.5; VASs, 9.2 versus 8.7; IKDCpe, 81.8% versus 100%; LSIq, ≥91.6 versus ≥88.2; LSIh, ≥95.1 versus ≥90.7; LSIj, ≥94.2 versus ≥97.6; OA grade 0, 90.9% versus 77.8%; clinical ACL failure rate, 20.8% versus 27.2%; and repeat surgery rate, 37.5% versus 20.0%, respectively. Conclusion: It remains inconclusive whether the effectiveness of DA ACLSR is noninferior to that of ACLR in terms of subjective patient–reported outcomes as measured using the IKDCs. Although DA ACLSR may be a viable treatment option for patients with acute ACL rupture, caution must be exercised when considering this treatment for young, active patients, corresponding to the present study population.

Lower anatomical femoral ACL tunnel can be created in the large volume of femoral intercondylar notch.

The purpose of this study was to investigate the correlation between femoral intercondylar notch volume and the characteristics of femoral tunnels in anatomical single bundle anterior cruciate ligament (ACL) reconstruction. Fifty-one subjects (24 male and 27 female: median age 27: range 15-49), were included in this study. Anatomical single bundle ACL reconstruction was performed in all subjects using a trans-portal technique. Femoral tunnel length was measured intra-operatively. Three-dimensional computed tomography (3D-CT) was taken at pre and post-surgery. The intercondylar notch volume was calculated with a truncated-pyramid shape simulation using the pre-operative 3D-CT image. In the post-operative 3D-CT, the modified quadrant method was used to measure femoral ACL tunnel placement. Femoral tunnel placement was 47.6 ± 10.5% in the high-low (proximal-distal) direction, and 22.6 ± 5.4% in the shallow-deep (anterior-posterior) direction. Femoral tunnel length was 35.3 ± 4.4cm. Femoral intercondylar notch volume was 8.6 ± 2.1cm3. A significant correlation was found between femoral intercondylar notch volume and high-low (proximal-distal) femoral tunnel placement (Pearson's coefficient correlation: 0.469, p = 0.003). Femoral ACL tunnel placement at a significantly lower level was found in knees with large femoral intercondylar notch volume in the trans-portal technique. For the clinical relevance, although the sample size of this study was limited, surgeons can create femoral ACL tunnel low (distal) in the notch where close to the anatomical ACL footprint in the knees with large femoral intercondylar notch volume. III.

Clinical outcomes of single-bundle versus double-bundle ACL reconstruction in adolescent elite athletes: A retrospective comparative study.

The aim of the study was to evaluate the single bundle (SB) and double bundle (DB) anterior cruciate ligament (ACL) reconstruction in terms of graft survival, complications, and patient reported functional outcomes in adolescent athletes. In this retrospective study, 89 elite adolescent athletes who underwent either SB or DB ACL reconstruction were included. All patients were then divided into two groups: group 1 including 51 patients with SB ACL reconstruction (31 male, 20 female; mean age = 15.4 ± 1.03 years) and group 2 including 38 patients with DB ACL (30 male, 8 female; mean age = 15.7 ± 1.3 years). Clinical data were obtained, comprising skeletal maturity, sports type, ACL reconstruction technique, Lachman scores, KT-1000™ arthrometer measurement, additional meniscal procedures as well as International Knee Documentation Committee (IKDC) score, Cincinnati score, and graft size. The mean follow-up period was 53.1 ± 8.6 months in group 1 and 46.4± 9.1 months in group 2 (P = 0.61). The type of ACL reconstruction technique (SB or DB), gender, skeletal maturity, sports type, additional meniscal procedures and Lachman scores were not associated with the re-rupture of the ACL (P > 0.05). Moreover, ACL reconstruction technique did not effect the rate of re-rupture of an ACL. There were 21 re-ruptures (23.5%) and 11 (12.3%) contralateral ACL ruptures in total. Among 21 reruptures, 12 of them were in the DB group while nine of them in the SB group (P > 0.05). The groups did not differ with respect to age, the injured side, the time from injury to surgery, the postoperative follow-up time, or the preoperative physical examination results KT-1000 device (SSD), Cincinnati score, IKDC objective and subjective score,Lachman test and pivot-shift test). There are no differences in the re-rupture of an ACL, patient reported outcomes, and complications in adolescent elite players, when either an SB or DB technique is performed. Level III, Therapeuthic Study.

Computed tomographic evaluation of bone tunnel enlargement following single bundle anterior cruciate ligament reconstruction with hamstring autograft

&lt;p class="abstract"&gt;The purpose of this study is to evaluate tibial and femoral tunnel diameter following single bundle anterior cruciate ligament (ACL) reconstruction and correlation between tunnel enlargement and clinical outcome. Twelve patients who underwent primary arthroscopic single bundle ACL reconstruction with hamstring graft were included in prospective case series. Preoperative clinical evaluation was performed using international knee documentation committee (IKDC) subjective score and grade, Tegner knee score and Lysholm knee score. Computed tomography (CT) evaluation of the femoral and tibial tunnels were done on post-operative day (POD) 1 and at a mean follow up of 9 months (range 7-12 months) and were compared with functional scores. Our study shows significant tibial and femoral tunnel enlargement on CT scan at 9 months (range 7-12 months) postoperatively. All the clinical evaluation scales showed improvement postoperatively. The mean average femoral tunnel diameter increased significantly (p&amp;lt;0.001) from 8.17±0.57 to 9.08±0.660 (10%) and tibial tunnel diameter increased significantly (p&amp;lt;0.001) from 8.08±0.669 to 9.07±0.601 (11%) postoperatively at a mean follow up of 9 months (range 7-12 months). No statistically significant difference between tunnel enlargement and clinical values were found. In our current prospective CT based study, we conclude use of extracortical fixation of femoral tunnel with stronger fixation of the tibial tunnel, tunnel orientation and anatomic fixation close to the joint line along with less aggressive rehabilitation protocol with use of extension knee brace may result in minimization of tunnel widening with quadrupled hamstring autograft.&lt;/p&gt;

Variances of the intraarticular landmarks for anterior cruciate ligament tibial footprint: Tibial eminencies have less variability than lateral meniscus on sagittal magnetic resonance scans

Objective: The purpose of this study was to analyze the sagittal plane variations of intraarticular landmarks for single bundle anterior cruciate ligament (ACL) reconstruction including lateral meniscus, medial and lateral tibial eminencies. Methods: T2 weighted sagittal magnetic resonance (MR) scans of 80 skeletally mature patients aged between 18 to 60 years and without any sign of ligament and meniscal injuries were viewed. Midpoint of ACL, most posterior aspect of anterior horn of lateral meniscus (LMAH), tip of medial eminence (ME) and lateral eminence (LE) were identified on widest antero-posterior (A-P) distance of tibial plateau according to of Staubli-Rausching method and variances were compared. Results: Mean location of center of tibial footprint of ACL at sagittal plane was found as 38.0±4.2% (range, 29-51%) on A-P distance of tibial plateau. Location of posterior border of LMAH, ME and LE were 38.0±12.4% (range, 21-62%), 52.3±4.2% (range, 41- 60%) and 59.5±4.4% (range, 51- 69%), respectively. Difference between the variances of ACL midpoint and LMAH was large enough to be statistically significant (p=&lt;.001) with a large effect size (f=0.59), however differences between the variances of ACL midpoint and bony landmarks were not significant (ME, p=.65; LE, p=.33). Intra and interobserver agreement for measurement of all parameters were detected as moderate to good. Conclusion: There was no constant relationship between ACL midpoint and posterior border of LMAH on sagittal plane MR images. Difference of variances between ACL midpoint and ME and LE were significantly lower than of variances of LMAH.

Comparing post-operative pain between single bundle and double bundle anterior cruciate ligament reconstruction: a retrospective study

BackgroundIn anterior cruciate ligament (ACL) reconstruction, the clinical outcome and level of post-operative pain are important factors. To date there have been no studies evaluating differences in post-operative pain between single bundle and double bundle ACL reconstruction with a hamstring graft.Hypothesis/purposeWe hypothesized that post-operative pain in single bundle ACL reconstruction would be less than in double bundle ACL reconstruction. This study was to compare post-operative pain between patients undergoing single bundle versus double bundle ACL reconstruction.Study designCohort study.MethodsThis was a retrospective study comparing post-operative pain scores between single bundle and double bundle ACL reconstruction. Each patient was given our standard regimen of oral diclofenac (25 mg/tab) three times per day and paracetamol (500 mg/tab) six times per day for 1 day post-operatively. If the patient complained of moderate to severe pain (pain numeric rating scale (PNRS) > 3), 3 mg of morphine was injected intravenously every 3 h for 24 h and 1 mg of morphine as a rescue medication every 1 h for 24 h. PNRS and morphine consumption were recorded at 4-h intervals for 24 h.Results209 patients were included in this study of whom 102 and 107 patients received single bundle and double bundle ACL reconstruction, respectively. The average post-operative pain scores of the single bundle group were lower at all time points. Linear mixed effect regression analyses showed that the single bungle group had lower post-operative pain than the double bundle group after adjusting for confounders (beta = − 0.45; 95% CI = − 0.838, − 0.062) but there was no statistically significant difference between numbers of bundle ACL reconstruction with regard to morphine consumption.ConclusionSingle bundle ACL reconstruction had significantly lower post-operative pain scores than double bundle ACL reconstruction.Clinical relevanceDouble bundle ACL reconstruction results in higher post-operative pain, which may slow the start of rehabilitation and reduce patient satisfaction. In middle-aged adult patients with low-demand activities, we suggest performing a single bundle ACL reconstruction.

Surgical management of arthroscopic anterior cruciate ligament reconstruction using quadruple hamstring graft and assessment of its fuctional outcome

The knee joint is one of the most commonly injured joint in our body and the most commonly injured ligament is ACL. Due to ever increasing RTA’s and increased participation in sporting activities. There is increase in incidence of ligament injuries of knee. The ACL along with other ligaments, capsule is the primary stabilizer of knee and prevent anterior translation and restricts valgus and rotational stress to certain degree. Open reconstruction of ACL which was done earlier is not practiced now a day due to complications such as increased Post-operative pain, stiffness and lengthy rehabilitation phase. Arthroscopic reconstruction of the injured ACL has become the gold standard procedure. The ideal graft for ACL is still a topic of debate. The most commonly used graft are bone patellar tendon bone graft and hamstring graft. The hamstring graft is increasingly used now a day for the following reasons: . Advanced soft tissue fixation technique . Increased incidence of anterior knee pain with bone patellar tendon bone graft This study has been done to evaluate the functional outcome of arthroscopic single bundle anterior cruciate ligament reconstruction using quadrupled hamstring tendon (Gracilis and semitendinosus) autograft in anterior cruciate injuries.Methods: Twenty cases of arthroscopic anterior cruciate ligament reconstruction were regularly followed for an average period of 17.6 months in mamta medical college, Khammam from august 2019 to march 2021. Results: Among twenty patients treated with arthroscopic anterior cruciate ligament reconstruction 45% (9 patients) had excellent functional outcome while 40% (8 patients) had good functional outcome and remaining 15% (3 patients) had fair outcome according to LYSHOLM KNEE SCORE. One patient had superficial infection at the donor site which settled with intravenous antibiotics. One patient developed deep infection of the donor site with wound gaping which is managed with wound debridement and secondary closure and was given intravenous antibiotics which is healed well and the sutures removed after 10 days. One patient developed fixed flexion deformity of 10 degree with range of movements ranging from 10 to 90 degree. The patient had poor compliance to rehabilitation protocol. The mean pre-operative IKDC (international knee documentation 2000 score) score was 50.86 while the mean post-operative score was 87.66. there was significant improvement in post-operative IKDC score compared with pre-operative score with P value

TRANSTIBIAL VERSUS INDEPENDENT FEMORAL TUNNEL DRILLING TECHNIQUES FOR ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION EVALUATION OF FEMORAL APERTURE POSITIONING

Background: Although numerous clinical and cadaveric studies have compared transtibial (TT) versus tibial independent (TI) either anteromedial (AM) portal or Outside-in (OI) drilling techniques regarding anatomic femoral tunnel aperture placement in single bundle anterior cruciate ligament reconstruction (ACLR), there is no consensus on which technique offers the best anatomic position according to footprint position.Aim of the Work: The aim of this study is to conduct a systematic review and meta-analysis for studies comparing the anatomical position of femoral tunnel aperture in single bundle ACLR using TI and TT techniques. Methods: (PubMed, Cochrane library and Google Scholar) were searched for relative studies that evaluated femoral tunnel aperture position in patients and cadavers underwent arthroscopic single bundle ACLR. Meta-analyses were performed to pool 28 studies included in 15 outcomes measuring femoral tunnel aperture position by estimating the mean differences and their 95% confidence intervals from mean and standard deviation for each study. Results: 48 clinical and cadaveric studies compared femoral tunnel aperture position between TT and TI (AM and OI) techniques were obtained for final research. In these studies, 2384 clinical and cadaveric knees underwent arthroscopic single bundle ACLR, we qualitatively assessed the femoral aperture position in all 48 studies showing that the difference between TI and TT was non significant except in the direction perpendicular to Blumensaat's line (BL), but with low mean difference and anteroposterior (AP) anatomical axis. Conclusions: There was non-significant difference between TI and TT technique regarding placing femoral aperture position closer to footprint There was non-significant difference in femoral aperture sagittal plane position along BL or along (proximal-distal) PD axis. Regarding femoral aperture coronal plane placement in the axis perpendicular to BL; modified TT technique improved the femoral aperture position in this axis. While regarding femoral aperture placement in the anteroposterior (AP) anatomical axis; TI technique placed femoral aperture significantly more posterior than TT technique, this was proper position regarding anatomic ACLR, while according to the recent concept of ACL femoral footprint, this might be improper position.

Radiographic evaluation of the tunnel position in single and double bundle anterior cruciate ligament reconstruction.

Aim To evaluate tunnel positioning on radiographs in singlebundle (SB) and double-bundle (DB) anterior cruciate ligament (ACL) reconstruction, to evaluate if measurement is accurate and reproducible. Methods Radiographs of 30 SB and 30 DB ACL reconstruction were reviewed by two examiners who measured tunnel positioning with the quadrant method on the femur (a=depth, b=height) and the Amis and Jakob method on the tibia. Intra- and inter-observer reliability were evaluated with intra-class correlation coefficient (ICC). Results A radiographic analysis was completed in all patients in a SB-group and in 27 in a DB-group (p>0.05). Intra-observer reliability was almost perfect on femoral (ICC: a=0.85, b=0.83) and tibial (ICC=0.87) side in the SB-group. In the DB-group, it was almost perfect for tibial anteromedial (AM) and posterolateral (PL) bundles (ICC: AM=0.84, PL=0.81) and for femoral PL bundle (ICC: a=0.83, b=0.82), and substantial for femoral AM bundle (ICC: a=0.78, b=0.74). Inter-observer reliability was almost perfect on tibial (ICC=0.81) and femoral (ICC: a=0.81, b=0.87) side in the SB-group, and substantial on tibial (ICC: AM=0.71, PL=0.77) and femoral (ICC: AM a=0.73, b=0.78; PL a=0.74, b=0.76) side in the DB-group. Standard deviation (SD) was low (±9%) with respect to the centre of tunnel(s). Conclusion The quadrant method and the Amis and Jakob method are accurate and reproducible measurement methods. Also, as SD was low, an outside-in approach with a front-entry guide, which is free-hand positioned, can be postulated as a reliable method to locate the femoral tunnel in SB reconstruction and the AM bundle in DB reconstruction.

3D CT evaluation of femoral and tibial tunnels in anatomic double bundle anterior cruciate ligament reconstruction

BackgroundAn anatomical double bundle ACL reconstruction replicates the anatomy of native ACL as the tunnels are made to simulate the anatomy of ACL with AM and PL bundle foot prints. The goal of anatomic ACL reconstruction is to tailor the procedure to each patient’s anatomic, biomechanical and functional demands to provide the best possible outcome. The shift from single bundle to double bundle technique and also from transtibial to transportal method has been to provide near anatomic tunnel positions. PurposeTo determine the position of femoral and tibial tunnels prepared by double bundle ACL reconstruction using three dimensional Computed tomography. Study designA prospective case series involving forty patients with ACL tear who underwent transportal double bundle ACL reconstruction. MethodComputed tomography scans were performed on forty knees that had undergone double bundle anterior cruciate ligament reconstruction. Three-dimensional computed tomography reconstruction models of the knee joint were prepared and aligned into an anatomical coordinate axis system for femur and tibia respectively. Tibial tunnel centres were measured in the anterior-to-posterior and medial-to-lateral directions on the top view of tibial plateau and femoral tunnel centres were measured in posterior to anterior and proximal-to-distal directions with anatomic coordinate axis method. These measurements were compared with published reference data. ResultsAnalysing the Femoral tunnel, the mean posterior-to-anterior distances for anteromedial and posterolateral tunnel centre position were 46.8% ± 7.4% and 34.5% ± 5.0% of the posterior-to-anterior height of the medial wall and the mean proximal-to-distal distances for the anteromedial and posterolateral tunnel centre position were 24.1% ± 7.1% and 61.6% ± 4.8%. On the tibial side, the mean anterior-to-posterior distances for the anteromedial and posterolateral tunnel centre position were 28.8% ± 4.3% and 46.2% ± 3.6% of the anterior-to posterior depth of the tibia measured from the anterior border and the mean medial-to-lateral distances for the anteromedial and posterolateral tunnel centre position were 46.5% ± 2.9% and 50.6% ± 2.8% of the medial-to-lateral width of the tibia measured from the medial border. There is high Inter-observer and Intra-observer reliability (Intra-class correlation coefficient). Discussion and conclusionFemoral AM tunnel was positioned significantly anterior and nearly proximal whereas the femoral PL tunnel was positioned significantly anterior and nearly distal with respect to the anatomic site. Location of tibial AM tunnel was nearly posterior and nearly medial whereas the location of tibial PL tunnel was very similar to the anatomic site Evaluation of location of tunnels through the anatomic co-ordinate axes method on 3D CT models is a reliable and reproducible method. This method would help the surgeons to aim for anatomic placement of the tunnels. It also shows that there is scope for improvement of femoral tunnel in double bundle ACL reconstruction through transportal technique.

A CT based evaluation of femoral and tibial tunnel widening after double bundle ACL reconstruction

IntroductionAmong the postoperative phenomenon of ACL reconstruction, tunnel enlargement has been reported consistently, regardless of the technique used. It could be clinically relevant in post operative follow up and revision surgery. This study evaluated the magnitude of tibial and femoral bone tunnels enlargement after arthroscopic double-bundle anterior cruciate ligament (ACL) reconstruction by the Computed Tomography Scan. MethodsForty patients undergoing arthroscopic double-bundle ACL reconstruction using multistranded hamstring graft, were included in the study. CT scan was performed on second postoperative day and at follow-up of 6 month. Tunnels were evaluated by digitally measuring the widths, perpendicular to the long axis of the anteromedial (AM) and posterolateral (PL) tunnels, on an oblique coronal, saggital and axial plane at 3 levels: aperture, midway, and suspension point. Bony bridge thickness at aperture and minimum distance between two tunnels to anticipate communication was also computed. ResultsFemoral tunnel measurement showed statistically significant enlargement at aperture and midway. At the aperture, enlargement of AM and PL tunnel was 21.95% and 26.16% whereas at midway, enlargement was 20.05% and 24.5%. At the suspension point, enlargement was 3.97% and 7.1%. On tibial side, order of significant enlargement was midway of AM = 21.16% and PL = 31.78% followed by aperture of AM = 18.9% and PL = 28.84% and finally suspension point of AM = 17.84% and PL = 25.21%. Average bony bridge thickness at femoral and tibial aperture was 0.291 ± 0.059 and 0.231 ± 0.105 cm respectively with 10% of the patients showed merging of tunnels at aperture. ConclusionCT scan is an effective way to determine the tunnel position and enlargement after ACL reconstruction. There is a significant widening of femoral and tibial tunnels at 6 months follow-up of arthroscopic double bundle anterior cruciate ligament reconstruction. Tunnel widening could be a serious problem after double-bundle ACL reconstruction.