Extra-articular Procedures Research Articles

Comparison of tensor fascia lata+semitendinosus tendon and free patellar bone - tendon - bone graft reconstruction of the anterior cruciate ligament deficient knee

The reconstruction of anterior cruciate ligament deficient knee is now almost universall accepted in young and physically active patient. If left untreated the risk for funther injury seems unavoidable. Many procedures have been described in the reconstruction of the anterior crucrate ligament (ACL) deficrent knee as the long term follow-up studies of extraarticular procedures have been unsatisfactory intraarticular procedures or a combination of the two are now the treatment of choice. Two separate techniques of reconstruction have been compared in this study. 20 ACL deficirent knees had been operated by tensor fascia Iata+semitendinosus (TFL - ST) technique between 1983-1987. The second group is made up of 20 patients who were treated with free patellar bone-tendon-bone greft. First group's mean, age was 28, 15 years and mean follow-up was 71 months. The second groups, mean age was 24, 55 years and mean follow-up 19, 2 months. Clinical testing, arthrometric testing (GENU COM Fore Medical Technologies inc.), and isokinetic muscle testing (LIDO ACTlVE isokinetic System LOREDAN Biomedical Inc. Cal) were done. For the first group jerk test was positive in 3 of patients (15%). For the second group Jerks was positive in 3 of patients (15%). Isokinetric muscle testing results have shown a good control of knee in the second group of patients. The results of group II are superrorto TFL-ST but follow-up period are not the same in both groups. Thus Iong term results should be verified.

Paradoxes in the History of the Anterior Cruciate Ligament

A historic review of anterior cruciate ligament (ACL) investigation reveals two important paradoxes. (1) Ideas and concepts recently proposed were first put forth much earlier. (2) Controversy regarding this ligament continues despite the increased amount of information available. Much of the recent ACL literature, although regarded as newly discovered, has its roots in far older, and apparently forgotten or overlooked, work. Examples include: (1) ACL intactness is best tested at full extension; (2) hemarthrosis and ACL rupture are closely associated; and (3) ACL rupture sometimes masquerades as a minor injury. Additionally, early investigators achieved notable advances in surgical techniques. These contributions disappeared from the literature for two major reasons. First, early investigators observed few patients, with typical practitioners rarely seeing ACL injuries, and consequently, little data existed to support their observations. Second, observations could not be confirmed until the advent of widespread, successful surgery. Undoubtedly, orthopedists now know much more about the ACL, yet many issues remain controversial. Does the ACL perform a vital function? What is the efficacy of operative versus nonoperative treatment? What are the relative merits of direct repair, intraarticular substitutes, and extraarticular nonanatomic procedures? The origins and continued existence of controversy stem from several sources, including the less than rigorous study design and the scarcity of natural history, long-term follow-up studies, and basic science studies. The perception of the ACL as a simple structural unit has also perpetuated this controversy.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the anterior cruciate ligament using allogeneic tendon

Eighty-four patients who underwent ACL reconstruction with fresh-frozen allogeneic tendon were reviewed and evaluated with subjective and functional rating scales, physical examinations, instrumented anterior drawer tests, isokinetic testing, and arthroscopy. The average followup was 57 months (range, 36 to 90 months) and the average age at operation was 22 years (range, 16 to 37 years). The subjective and functional results were rated as excellent in 48 patients (57%), good in 31 (37%), and fair in 2 (2%). Three patients (3%) experienced a retear of the ACL. Physical examinations and instrumented anterior drawer tests showed that satisfactory anterior stability was restored in 88% of the patients. Isokinetic evaluations demonstrated that the extension torque of the involved knee recovered to a slightly lower level than that of the controls, although the flexion torque recovered to a level equivalent to that of the controls. Arthroscopic evaluations revealed that the allografts were elaborately remodeled, viable, and taut. There was no sign of immunologic rejection at any time postoperatively. Additional extraarticular procedures, consisting of both pes anserinus transfer on the medial side and iliotibial band reinforcement on the lateral side, had no effect on the results.

Primary repair with semitendinosus tendon augmentation of acute anterior cruciate ligament injuries

A retrospective review of 72 acute ACL injuries in 70 athletically active patients (50 recreational and 20 competitive athletes) treated with primary repair and semitendinosus tendon augmentation was conducted (mean follow-up time, 38.5 months). All patients had open primary multiple loop depth-varying suture repair and semitendinosus tendon augmentation at a mean injury to surgery interval of 9.1 days. Fifty-one cases (70.8%) were supplemented with an extraarticular procedure consisting in all cases of an iliotibial band lateral sling reinforcement. All patients underwent 6 weeks of postoperative immobilization followed by a graduated rehabilitation regimen lasting a mean 7.2 months. In 22 of the ACL tears, no other associated injury could be defined at arthrotomy, while in 27, significant medial collateral ligament injuries were noted. Lateral meniscal injuries (24) were more commonly noted than medial meniscal injuries (19). Good to excellent subjective results were reported in 82%, while 77.1% returned to preinjury sport level and participation without limitation. One patient developed "giving way" symptoms and overall, only four patients did not return to sports participation. Objective examination revealed 93.1% to have a 1+ or less Lachman test and 86.1% to have a negative pivot shift. Of 60 knees tested, 93.3% had KT-1000 side-to-side difference values (measured at 25 degrees +/- 5 degrees of flexion with an 89 N load) of less than or equal to 3 mm of anterior displacement. A 100 point Hospital for Special Surgery ligament rating score was used with 25 points assigned to subjective, 45 points to objective, and 30 points to functional assessment. The mean score at followup was 93.1. Analysis of results in patients with or without an extraarticular reinforcement revealed no difference in objective outcome. The incidence of patellofemoral pain was 27.8%. Thirty knees had some degree of loss of range of motion. Loss of terminal flexion was noted in 29, while 5 had loss of terminal extension. No correlation could be found between patellofemoral pain and diminished range of motion. Generalized ligamentous laxity was found in 37.1% of the patients; this was not associated with a poor result. This study suggests that primary repair with semitendinosus tendon augmentation of acute ACL injuries with a graduated rehabilitation regimen provides good subjective, and excellent functional and objective, results in active patients that were followed for more than 3 years.

Intraarticular Versus Intraarticular and Extraarticular Reconstruction for Chronic Anterior Cruciate Ligament Instability

One hundred twenty-seven patients were evaluated for the results of surgical stabilization in chronic anterior cruciate ligament instability. Eighty-four patients had been treated with intraarticular reconstruction alone, while 43 patients had been treated with a combination of intraarticular and extraarticular stabilization. Patients were evaluated by questionnaire to assess subjective and functional status by clinical examination of objective findings, and by roentgenograms and instrumented ligamentous stability testing. The follow-up interval averaged 45.2 months for the entire group (range, 24-90 months). Using a 200-point scale, the rating for the group treated with intraarticular reconstruction alone was 169.1, while the average rating for the group treated with combined intraarticular and extraarticular stabilization was 166.2. Overall, an excellent or good result was obtained in 67% of patients in the intraarticular only group and in 70% of the patients in the combined reconstruction group. There were no significant differences between the two groups in terms of changes seen on roentgenograms or in terms of residual laxity measured by instrumented testing. Thus, there is no demonstrable benefit derived from combined intraarticular and extraarticular stabilization procedures for chronic anterior cruciate ligament instability, provided that a well-placed intraarticular substitute of sufficient strength is functional.

The Role of Lateral Extra-articular Procedures for Anterolateral Rotatory Instability

The goal of any surgical procedure to correct the instability caused by loss of the ACL is to control the abnormal anterior excursion of the tibia on the femur. Because the main problem is loss of the ACL, it would seem most reasonable to approach this problem by performing an intra-articular reconstruction of the ACL, thus approximating as closely as possible the normal anatomy of the ACL. The classic open intra-articular ACL reconstructions are technically demanding surgical procedures that usually require a significant "learning curve" to achieve a level of technical expertise and confidence. In addition, postoperative complications such as adhesions, loss of motion, prolonged muscle atrophy, and a long rehabilitation period are well known. Thus, it would appear that the extra-articular reconstructive procedures for the anterior cruciate-deficient knee would offer some advantage over these more formidable surgical procedures. Whereas the main problem is certainly the loss of the ACL, the extra-articular procedures are directed more toward the most symptomatic anterior excursion of the tibia on the femur, the pivot shift phenomenon, where the anterolateral portion of the tibia moves anterior in relation to the femur. Thus, the goal of the extra-articular reconstructive procedures for anterolateral rotatory instability is to eliminate functional instability. These goals are most readily achieved by positioning some portion of the iliotibial tract posterior to the transverse center of rotation of the knee to provide a reinforcement for the lateral tibial plateau as the knee approaches terminal extension. All of the extra-articular procedures discussed in this article have been used successfully as reported by the various authors. There are many technical details inherent in each of these surgical procedures, and the reader is referred to the original articles for a more explicit description of these surgical procedures. For the individual surgeon to participate in and view the actual surgical procedure that he or she intends to perform would be the ideal situation. Various workshops where surgical procedures of the knee are actually performed and studied are currently available and are of great value to the surgeon. Of equal importance to the technical demands of the various surgical procedures is selection of the appropriate procedure for each patient. The selection must be based on many factors. The most important factor is the identification of the patient with a high level of athletic activity who is unwilling to modify his or her activity level to compensate for a deficient ACL.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term followup of anterior cruciate ligament reconstruction using the quadriceps tendon substitution for chronic anterior cruciate ligament insufficiency.

At The Hospital for Special Surgery, the quadriceps tendon substitution (QTS), as described by Marshall, was performed for ACL insufficiency from 1973 to 1980. A review of the initial 60 patients with a minimum of 4 years followup (average, 5.5 years) has been concluded. Thirty-eight patients returned for examinations, and 11 returned questionnaires. Associated medial procedures were performed in 29 of the 38 examined patients. Medial meniscus surgery was performed in 86% and lateral meniscus surgery in 28.9%. At followup, giving way, which was the main preoperative complaint, was eliminated in 30/38 examined and 9/11 questionnaire patients (79%). In the examined group, three patients were clear failures and five had mild transient instability. The pivot shift was present in 17 of 38 (45%) patients examined: 21 patients were negative, 9 were 1+ or a grind, 8 were 2+, and none were 3+. We have concluded that the QTS procedure will eliminate symptomatic instability in 79% of our patients, but the high rate of a residual pivot shift (45%) and symptoms of instability (21%) require the addition of an extraarticular sling procedure. This appears to be related to the relatively poor strength characteristics of the tissue used in the QTS substitution.

Reconstruction of the anterior cruciate ligament using a torn meniscus.

In eighty of 100 patients, reconstruction of the anterior cruciate ligament using a torn meniscus was successful in restoring stability. The length of follow-up ranged from two to six years and the mean interval from injury to operation was two years. Preoperatively, all but one patient had a positive (2+ or 3+) Lachman test and a positive pivot-shift test. Only ten patients had evidence of major instability, as seen on either test. The result was the same regardless of whether the patient had had a concomitant extra-articular (Ellison) procedure. The results of arthroscopic biopsy in eleven patients did not support the hypothesis that the meniscus underwent metaplasia to ligamentous tissue. Although this procedure yielded results similar to those of other procedures in which autogenous tissues are used to reconstruct the ligament, the meniscus should rarely, if ever, be used for reconstruction of the anterior cruciate ligament. The procedure is indicated only for patients who, in addition to needing reconstruction of the anterior cruciate ligament, also have a torn meniscus that would otherwise have to be totally excised.

Intraarticular transfer of the iliotibial muscle tendon unit for anterior cruciate insufficiency

As an anatomic structure the iliotibial band (iliotibialis tractus) has been used for more intra- and extraarticular procedures than any other autologous tissue. Physiologically, however, the surgical technique has often violated its anatomy by devascularizing this substantial extension of the tensor fascia latae and gluteus maximus muscles. Biomechanically, the iliotibial band has been shown to be the strongest substitute for the deficient anterior cruciate ligament (ACL) when tested as a free graft. The controversy about its strength arises when unequivalent tests are made with free grafts secured by proximal and distal bone blocks, thus invalidating the comparison. This article describes the subtleties of the surgical technique with the intraarticular transfer of the iliotibial muscle tendon unit that has evolved over ten years. Improvements on an anatomic and physiologic basis require strict attention to detail, which we have demonstrated through our intraoperative photographs.

Reconstruction of the anterior cruciate ligament by allogeneic tendon graft. An operation for chronic ligamentous insufficiency.

We describe the use of allogeneic human tendon as an intra-articular replacement for the anterior cruciate ligament. Depending on the type and degree of functional instability we recommend the addition, in some cases, of supplementary extra-articular procedures. We have reviewed 31 patients at least two years after operation and have found that 30 of them had been able to return to full sporting activities. The indications for operation and the techniques are discussed and the use of allogeneic tendon is recommended.

The Anterior Cruciate Ligament: A Review of Recent Concepts

The anterior cruciate ligament (ACL) consists of a small anteromedial band and a larger posterolateral band. Recent findings have shown the ACL to play a major role in the function of the knee joint. The ACL prevents anterior luxation of the tibia, limits tibial rotation, and resists valgus and varus stress to the knee. The most common mechanism of ACL injury involves hyperextension of the knee with a rotational component. Diagnosis of an ACL lesion consists of an accurate history, clinical tests and often, arthroscopic investigation. Treatment of an ACL injury may consist solely of a rehabilitation program, may involve surgical intervention, or a combination of the two. Many surgical procedures both intra-articular and extra-articular, have been used in the past. The most successful approach at this time appears to be a combination of intra-articular and extra-articular procedures. A contemporary trend in rehabilitation following surgery is the use of graduated stages of treatment beginning immediately postsurgery and continuing through to full return to activity. J Orthop Sports Phys Ther 1986;8(3):110-122.

Eriksson-Ellison reconstructions. The results of a combined intra- and extra-articular procedure for anterolateral instability and a lesion of the anterior cruciate ligament.

A rupture of the anterior cruciate ligament will give rise to the signs and symptoms of anterolateral instability after secondary insufficiency of the lateral capsule and the iliotibial tract have developed. Untreated knee instability predispose to meniscal lesions, chondromalacia, and osteoarthritis of the knee. Other reasons for reconstruction are the patient's wish to return the knee to near-normal function and rejection of life-long utilization of a brace. A combination of an intra-articular Eriksson-Drez procedure and an extra-articular Ellison procedure was carried out in 27 patients with anterolateral instability. Follow-up evaluations were performed, with an average follow-up of 4 years and 5 months. The subjective and objective results are encouraging and similar to those obtained with other combined techniques.

膝前十字靭帯再建に対する基礎的臨床的検討

Using normal cadaver knees from adults, we studied the functional importance of the sites of attachments of the anterior cruciate ligament on the lateral femoral condyle as determinants of the length of the ligament at different amounts of knee flexion. The distance between the central point of the normal attachment area on the tibia and the point slightly proximo-medial to the normal central point on the femur was found to be most isometric with the full range of knee motion. We also studied the biomechanical strength of the two types of the patellar tendon graft (one, a free tendon, and the other, a tendon with its bone insertions at both ends), and found that the bone-tendon preparation achieved stronger fixation to the bone in earlier postoperative time than the free tendon.Between 1981 and 1984, we performed the anterior cruciate reconstruction on 27 patients using the patellar bone-tendon-bone graft. Results were analyzed on 15 patients who were followed for more than one year postoperatively. Eighty per cent of these patients showed excellent or good results. Objective results were better in the patients who had an extra-articular augmentation procedure than in those who had no augmentation.

Extra-articular Reconstruction of the Anterior Cruciate Ligament: Lateral Procedures

Several extra-articular procedures have been shown to be successful in controlling anterolateral rotatory instability. These procedures are performed as an extra-articular reconstruction alone or are combined with an intra-articular reconstruction. The common goal of these extra-articular procedures is the control of the abnormal anterior subluxation of the lateral tibial plateau and, thus, the elimination of the lateral pivot shift phenomenon. This goal is achieved most readily by placing some portion of the iliotibial tract posterior to the transverse center of rotation of the knee in order to provide a check-rein effect on the lateral tibial plateau to prevent anterior subluxation as the knee approaches terminal extension.

Reconstruction of the Anterior Cruciate Ligament: Historical Overview

The first reported surgical repair of anterior cruciate ligament-deficient knees was done by Mayo Robson in 1895. The earliest anterior cruciate ligament reconstructions were done by Hey Groves in 1917 and by Alwyn Smith in 1918. Both used an intra-articular strip of iliotibial band. At this same time, the first attempt to make an artificial anterior cruciate ligament was done. Corner used wire, while Alwyn Smith used multiple silk sutures. Both methods failed. The first extra-articular procedures to correct instability in anterior cruciate ligament-deficient knees were reported by Bennett in 1926 and Cotton and Morrison and Bosworth and Bosworth in the mid 1930s. All of these surgeons reconstructed the medial side of the knee with free strips of fascia. In 1936, Campbell described the intra-articular use of patellar tendon and stressed the need for anterior cruciate ligament reconstruction in young, athletic individuals with unstable knees. In the 1950s, O'Donoghue also emphasized the early repair of an injuried anterior cruciate ligament and did much to improve the care of the college athlete. The procedures described by Jones, Slocum, Larson, and Nicholas dominated the 1960s and early 1970s. Various rotatory knee instabilities were defined, and the Lachman and pivot shift tests were born. Descriptions of various tendon transfers and intra-articular graft techniques have been published over the last 10 years. Most of these are variations of procedures described decades ago. In 1918, Alwyn Smith used electrical stimulation to decrease postoperative quadriceps atrophy. In 1936, Mauck advised the use of a hinged knee cast after surgery for better rehabilitation. Finally, in 1938, Palmer described a drill guide for more anatomic placement of an anterior cruciate ligament graft in the femur. Although prosthetic materials may have a greater place in the 1980s, the foundation for such research was laid long ago by innovative surgeons such as Hey Groves and Alwyn Smith, the great-grandfathers of anterior cruciate ligament reconstructions.

Anterior Cruciate Ligament Insufficiency in Children

Anterior cruciate ligament (ACL) insufficiency is unusual in children younger than 14 years of age. Nontraumatic ACL laxity is found in two distinct groups of children: (1) those with generalized nonpathologic joint laxity, and (2) those with congenital absence or attenuation of the ligament, usually associated with other congenital anomalies in the same limb. ACL insufficiency secondary to trauma most often is associated with avulsion of the intercondylar eminence of the tibia. Excellent results have been obtained following anatomic reduction by either closed or open methods. In children, insubstance damage to the ACL, alone or associated with other ligamentous injuries, is distinctly unusual. In three patients younger than 14 years of age with midsubstance tears of the ACL, no other clinically evident ligamentous injury was noted. All three were treated by primary surgical repair without intra- or extra-articular augmentation procedures. Despite only mild subjective complaints at follow-up examinations, all three patients had at least moderate degrees of clinical ACL laxity, suggesting that midsubstance ACL injuries in children have no better healing potential than in adults.

Evaluation of hamstring strength following use of semitendinosus and gracilis tendons to reconstruct the anterior cruciate ligament.

Reconstruction of the anterior cruciate ligament using the semitendinosus and gracilis tendons combined with the appropriate extraarticular procedures has been performed by the authors in 482 cases. In 321 cases both the semitendinosus and gracilis tendons were used and in 161 the semitendinosus alone. This retrospective study was done to determine if the use of these two tendons resulted in any significant loss of hamstring strength. Evaluation of quadriceps strength was also done as a measure of postoperative rehabilitation. Fifty-one patients with an average follow-up time of 26.2 months were tested on the Cybex machine (Cybex Co., Ronkonkoma, New York) by two examiners using the same technique. The examiners had not participated in the surgery or rehabilitation of these patients. In the reconstructed knee in which both semitendinosus and gracilis were used, hamstring strength was found to average 99% compared to the normal knee. When the semitendinosus alone was used there was no difference (102%) from the normal knee. Quadriceps strength in both groups averaged 96% in comparison to the normal quadriceps. These results confirm that no significant loss of hamstring strength occurred when the semitendinosus and gracilis tendons were used to construct the anterior cruciate ligament. Further, quadriceps strength of 96% as compared to the normal knee indicated a very acceptable degree of postoperative rehabilitation in this series.

The technique of cruciate ligament reconstruction.

Our technique of reconstruction of the anterior and posterior cruciate ligament in both acute and chronic tears, using both the semitendinosus and gracilis tendons, is described in detail. Combined rotatory instabilities were carefully evaluated and corrected during the same operation. Reefing of the posteromedial capsular ligament was done for anteromedial rotatory instability, and for significant valgus instability, the O'Donoghue medial reconstruction was performed. The Ellison procedure was initially done for associated anterolateral rotatory instability, but has been replaced by the Losee procedure. This combination of anterior cruciate ligament reconstruction with the appropriate extraarticular procedures has produced our most stable knee joints. Posterior cruciate ligament reconstruction was also performed through an anterior incision using both the semitendinosus and gracilis tendons. When both cruciates were found to be incompetent, the gracilis was used to reconstruct the posterior cruciate and the semitendinosus for the anterior cruciate. In addition, all associated rotatory instabilities were corrected at the same operation. This technique has been performed on 372 patients (342 anterior and 30 posterior cruciate ligament tears) by one surgeon over a period of five years. The average follow-up was 22 months. Objective comparison of the reconstructed knee with the sound knee showed 84% good results.

Extra-Articular Stabilization of the Knee Joint for Anterior Instability

The results after one year or longer were evaluated in 76 patients with extra-articular reconstruction for functionally disabling anterior instability of the knee joint. The reconstruction was performed by a modification of the Ellison procedure for treatment of anterolateral rotatory instability. The various superimposed components of knee instability were managed by a variety of methods. Postoperatively,objective stability correlated well with subjective improvement. Patients with 2+ or greater anterior instability preoperatively had disappointing results in both subjective symptoms and objective signs. although extra-articular reconstruction may be sufficient for lesser grades of functionally disabling instability, knees with grade 2-3+ instability may require direct anterior cruciate ligament reconstruction in addition to the extra-articular surgical procedure.

Extra-articular reconstructive surgery for combined anterolateral-anteronnedial rotatory instability

The knees of 14 patients (12 male and 2 female) were treated surgically by extra-articular reconstruction for combined anterolateral-anteromedial rotatory instability. Healing and rehabilitation required approximately 8 months after the operations. Only after adequate rehabilitation, including return of full confidence, were the patients released to full activity (although contact sports are not recommended). Of the group, 12 patients returned for follow-up evaluations and one returned a questionnaire. One patient was lost to follow-up. One patient did not return to full activity because in the 3rd month postoperatively, he stepped in a hole while jogging, reinjured his knee, and refused further surgery. The functional improvement in this series by our extra-articular procedure (a combination of an anteromedial capsulorrhaphy and pes transfer medially with Ellison's modification of an iliotibial band rerouting and partial biceps advancement laterally) compares favorably with the reported anterior cruciate ligament reconstructions. Further comparisons with longer periods of time after surgical procedures are needed to determine whether extra-articular repair with interarticular reconstruction of the anterior cruciate ligament is significantly better than this technically easier extra-articular repair alone.