Hamstring Anterior Cruciate Ligament Reconstruction Research Articles

Intratunnel Fixation Versus Extratunnel Fixation of Hamstring Anterior Cruciate Ligament Reconstruction –A Meta-Analysis

Hamstring anterior cruciate ligament (ACL) reconstructions fixed inside both bone tunnels have a shorter initial working length, and thus should be stiffer than those fixed outside both bone tunnels. We used meta-analysis to compare 4-stranded hamstring ACL reconstructions using the 2 fixation methods with reconstructions using patellar tendon autografts. A Medline database search of English-language articles published through June 2004 yielded 36 studies that met the inclusion criteria: 5 intratunnel fixation studies (569 patients), 10 extra-tunnel fixation studies (604 patients), and 24 patellar tendon studies (1592 patients). Three studies included both patellar tendon and hamstring reconstructions. Demographically, all 3 groups were similar. There was no significant difference in the percentage of knees restored to normal instrumented laxity measurements between the 3 groups, nor was there a difference in graft failure rate. Patient satisfaction and return to preinjury activity rates were similar between the intratunnel fixation and patellar tendon groups and were significantly lower for the extra-tunnel fixation group. Good International Knee Documentation Committee scores did not correlate with good patient satisfaction or return to preinjury activity.

Autologous Bone Effects on Femoral Tunnel Widening in Hamstring Anterior Cruciate Ligament Reconstruction

This study examines the hypothesis that autologous bone in the femoral tunnel for a hamstring anterior cruciate ligament (ACL) reconstruction will reduce femoral tunnel widening. Thirty-six patients undergoing hamstring autograft ACL reconstruction were randomized to 2 groups. One group underwent ACL reconstruction using EndoButton femoral fixation. The other group underwent the same procedure, with the addition of a bone plug placed at the aperture of the femoral tunnel next to the graft. Twenty-seven patients at > 6 months postoperatively (range, 6-12 months) had digitized anteroposterior (AP) and lateral radiographs of the involved knee. Tunnel widening was determined by comparing the radiographic tunnel diameters to the drilled tunnel diameters from surgery. The mean (+/- SD) tunnel enlargement on the AP radiographs in the standard and plug groups were 3.8 +/- 1.7 mm and 3.5 +/- 2.0 mm, respectively (P = .61). On lateral radiographic assessment, the mean (+/- SD) tunnel enlargement in the standard and plug groups were 3.3 +/- 1.9 mm and 3.4 +/- 2.2 mm, respectively (P = .90). Autologous bone plug graft during ACL reconstruction does not reduce femoral tunnel widening.

Radiological tunnel position as a predictor of clinical outcome of anterior cruciate ligament surgery

Aims: The aim of this study was to assess the reproducibility of intra-operative landmarks for tunnel placement in single bundle 4 strand hamstring tendon ACL reconstruction and establish its effect on long-term clinical outcome. Methodology: 200 patients undergoing isolated ACL reconstruction were prospectively followed for 7 years with full IKDC and radiographs. Results and conclusions: We recommend that optimal clinical outcome at 7 years is associated with radiological tunnel placement in the following orientation based on those patients who achieved an “ideal” clinical outcome.

The unpredictable material properties of bioabsorbable PLC interference screws and their adverse effects in ACL reconstruction surgery

The aim of this study was to look at the clinical outcome of polylactide carbonate (PLC) interference screws in knee ligament reconstruction surgery. We prospectively followed up 59 patients who underwent primary hamstring anterior cruciate ligament (ACL) reconstructions using PLC (Calaxo screw; Smith and Nephew, Andover, MA) screws to secure the graft in the tibial tunnel. The average age was 34 years (range 17-55 years, SD 8.93). Twenty-three (39%) patients presented with complications [synovitis in 15% (nine) patients, prominent tibial swelling in 34% (20) patients and both in seven patients]. In comparison, similar complications were not seen in two groups of 59 age and sex matched patients in whom PLLA (Bio RCI; Smith and Nephew, Andover, MA) screws or Titanium (RCI; Smith and Nephew, Andover, MA) screws were used by the same surgeon. The problems encountered in the PLC screw group did not adversely affect knee stability. Six patients underwent exploration of the tibial tunnel site. A sterile white cheesy substance was removed, leaving an empty tibial tunnel. The ACL graft was found to be well attached to tibial tunnel in all cases. The PLC screw diameter, surface area or tibial tunnel diameter did not have any correlation to the occurrence of complications. Two patients required multiple washouts, one of whom developed a deep infection. The degradation of PLC screws does not follow the gradual and controlled pattern demonstrated in the ovine model. The unpredictable screw degradation, and the reaction to it can lead to serious clinical consequences.

Comparison of the bioabsorbable and metal screw fixation after ACL reconstruction with a hamstring autograft in MRI and clinical outcome: a prospective randomized study

There has never been an MRI study of tunnel widening comparing bioabsorbable to metal screw fixation in autologous hamstring anterior cruciate ligament (ACL) reconstruction. We randomized 62 patients to hamstring ACL reconstruction with either a bioabsorbable (n=31) or metal screw (n=31) fixation. The evaluation methods were clinical examination, KT-1000 arthrometric measurement, the International Knee Documentation Committee and Lysholm scores, and MRI. There were no differences between the groups preoperatively. Fifty-five patients (89%) were available at a minimum of 2-year follow-up (range 24-36 months). There was tunnel widening in both groups, but the increase was significantly greater in the AP dimension of the femoral tunnel in the bioabsorbable screw group compared to metal group (P=0.01). The tibial tunnels showed no intergroup difference. Ninety-four percent of the knees were normal or nearly normal according to the IKDC scores and the average Lysholm score was 91 with no intergroup difference. The follow-up AP tibial tunnel diameter was smaller with normal knee laxity compared to abnormal knee laxity. The graft failure rate in the bioabsorbable screw group was 23% (7/31 patients) and 6% (2/31 patients) in the metal screw group. The use of bioabsorbable screws resulted in more femoral tunnel widening, and more graft failures compared to metal screws. The tunnel widening in the tibia was associated with the knee laxity (P=0.02).

Fluoroscopically-Assisted Hamstring ACL Reconstruction

The fluoroscope can be a valuable tool during hamstring ACL reconstruction when appropriate measures are taken to minimize radiation exposure risk to patients and operating room personnel.

The location-specific healing response of damaged articular cartilage after ACL reconstruction: short-term follow-up

Although many different interventions have been proposed for treating cartilage lesions at the time of ACL reconstruction, the normal healing response of these injuries has not been well documented. To address this point, we compared the arthroscopic status of chondral lesions at the time of ACL reconstruction with that obtained at second-look arthroscopy. We hypothesized that there might be a location-specific difference in the healing response of damaged articular cartilage. Between September 1998 and March 2000, 383 patients underwent arthroscopically-assisted hamstring ACL reconstruction without any intervention to the articular cartilage. Among these patients, 84 patients underwent second-look arthroscopy (ranging from 6 to 52 months following initial surgery) and make up the population of the present study. Chondral injuries, left untreated at ACL reconstruction, were arthroscopically evaluated using the Outerbridge classification, and were again evaluated at second-look arthroscopy. At second-look arthroscopy, there was significant recovery of chondral lesions by Outerbridge grading on both the medial and lateral femoral condyles. Among the recovered chondral lesions, 69% of cases of the medial femoral condyle, 88% of cases of the lateral femoral condyle were partial thickness injuries (grade I and II). Conversely, there was no significant recovery of chondral lesions observed at the patello-femoral joint or tibial plateaus. Our study revealed that there was a location-specific difference in the natural healing response of chondral injury. Untreated cartilage lesions on the femoral condlyes had a superior healing response compared to those on the tibial plateaus, and in the patello-femoral joint.

No difference in clinical results between femoral transfixation and bio-interference screw fixation in hamstring tendon ACL reconstruction: A preliminary study

Hamstring tendon autograft has become a popular graft choice for anterior cruciate ligament (ACL) reconstruction, but there is no consensus on the ideal technique of fixation. We performed a pilot randomized controlled study to compare the clinical and mechanical outcome of two femoral fixation techniques for anterior cruciate ligament (ACL) reconstruction using hamstrings graft. We recruited 30 patients with a chronic unilateral tear of the anterior cruciate ligament. In all patients, quadrupled hamstring graft was used for ACL reconstruction. In 15 patients, femoral graft fixation was performed using Bio-interference Screws fixation (Arthrex, Inc. Naples USA) (Group 1). In the other 15 patients, femoral graft fixation was performed using BioTransFix femur extra cortical transverse fixation (Arthrex, Inc. Naples USA) (Group 2). In both groups, tibial fixation was achieved with a Delta bio-absorbable interference screw (Arthrex). Both groups were comparable with regard to demographic data, pre-operative activity level, mechanism of injury, interval between the injury and the operation, and pre-operative knee laxity measurements. An independent observer, who was blinded with regard to the involved leg and the type of graft, performed the outcome assessment with the use of a Rolimeter® arthrometer (Aircast), and the International Knee Documentation Committee. At 13 months follow up, all patients except one had functionally normal or nearly normal IKDC objective scores. The mean IKDC subjective score was 83.38 ± 9.4 in Group 1 and 79.92 ± 11.01 in Group 2 ( P > .05). The side to side laxity as measured with the Rolimeter® arthrometer was 1.5 mm ± 1 (range 0–3) for Group 1, and 2 mm ± 1 (range 0–3) for Group 2 ( P > .05). Femoral Biotransfix fixation and Bio-interference Screws fixation provide comparable mechanical stability and clinical outcome at 13 months follow up. BiotransFix fixation is an effective alternative to other devices. Our preliminary study shows that there is no evidence to prefer femoral transfixation to the more traditional, technically less demanding, and more economical interference screw fixation. A full study requires 368 participants.

Influence sur les lésions méniscocartilagineuses du délai accident–reconstruction du ligament croisé antérieur chez les patients de plus de 40 ans

Anterior cruciate ligament (ACL) reconstruction is increasingly proposed for patients aged over 40 years. We report a retrospective analysis of a consecutive series of middle-aged patients who underwent ACL reconstruction surgery in order to analyze the development of meniscal and cartilage lesions and ascertain short-term outcome. Thirty-five patients aged over 40 years (mean 46.1 years) underwent hamstring ACL reconstruction, 19 for persistent instability after functional treatment and 16 after a recent tear in patients who wanted to resume their sports activities. Mean follow-up was 25 months. The IKDC 1993 score was noted as was the Arpege score for sports activity and Telos at 15 and 25kg. At the last follow-up, the IKDC score was A or B in 85% of patients. Among the first intention ligamentoplasties, 94% were scored A or B at last follow-up and all had a single leg jump test greater than 76%. Among patients operated on after failure of functional treatment, 79% were scored A or B (p>0.05) and 32% had a single leg jump test less than 75% (p<0.05). Intraoperative discovery of meniscal or cartilage damage was statistically less significant in first intention patients than after failure of functional treatment. Somewhat less than half of the active and motivated patients aged over 40 years who underwent a first intention operation were unable to resume their sports activities at the same level. However, patients who underwent ACL repair after failure of functional treatment unexpectedly recovered sports activities after an interruption of several months or even years. Age is not a barrier to ACL reconstruction. The time from injury to surgery is a prognostic factor predictive of meniscal and osteochondral damage. Early repair of the ACL preserves the knee's meniscal and cartilaginous stock. For active motivated patients aged over 40 years, who undergo a first-intention procedure, resumption of sports activities at the same level cannot be guaranteed after ACL. However, for patients who undergo surgery after failure of functional treatment, ACL reconstruction not only eliminates the troublesome laxity but also enables resumption of sports activities even after several months or years of interruption.

Prospective Randomized Comparison of Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction

Biomechanical studies show increased anterior and rotational stability with double-bundle (DB) compared to single-bundle (SB) anterior cruciate ligament (ACL) reconstruction. The aim of this study was to evaluate the clinical results of four-tunnel DB ACL reconstruction. Seventy patients undergoing arthroscopic hamstring ACL reconstruction were prospectively randomized to DB (n = 35) or SB (n = 35) groups. Each bundle fixation was by means of a femoral EndoButton CL and a tibial biodegradable interference screw. Demographic data were comparable between groups, and the average age of all patients was 29 years. The average follow-up was 19 months for both groups and included a history, clinical evaluation with knee scores, and radiographs. The subjective results were similar in groups. The subjective International Knee Documentation Committee (IKDC) 2000 score was 88 P for DB versus 90 P for SB; the Lysholm score was 90 P for DB versus 93 P for SB; and the Cincinnati knee score was 91 P for DB versus 92 P for SB. The objective IKDC was significantly higher for DB: 78% "A" (P < .000) and 19% "B" compared to 24% "A" and 68% "B" for SB. The average KT-1000 side-to-side difference was 1.0 mm for DB and 1.6 mm for SB (P = .054) and the pivot shift test was negative in 97% for DB (P = .01) and 71% for SB. The range of motion was comparable for both groups. Our study shows a significant advantage in anterior and rotational stability as well as objective IKDC for four-tunnel DB ACL reconstruction compared to SB ACL reconstruction. The subjective Cincinnati knee score, the Lysholm score, and the subjective IKDC 2000 did not show any statistical difference for one or the other technique. Level I, randomized controlled trial.

Isolated Anterior Cruciate Ligament Reconstruction in Patients with Chronic Anterior Cruciate Ligament Insufficiency Combined with Grade II Valgus Laxity

Background There is no consensus about whether isolated anterior cruciate ligament reconstruction using multistrand hamstring tendon with nonoperative treatment for chronic medial collateral ligament injury is sufficient. Purpose To assess clinical outcome for patients with chronic anterior cruciate ligament injury and accompanying grade II valgus laxity who received medial hamstring anterior cruciate ligament reconstruction alone. Results were compared with those of patients with isolated chronic anterior cruciate ligament injury without valgus laxity. Study Design Cohort study; Level of evidence, 2. Methods Two hundred eighty-nine patients with isolated anterior cruciate ligament injury were compared with 53 patients with accompanying valgus laxity (minimum follow-up, 24 months). The following parameters were compared between the 2 groups at the last follow-up: range of motion, KT-1000 arthrometer value, pivot-shift test result, Lysholm knee scale, knee extensor muscle strength, return to sporting activities, subjective recovery, and International Knee Documentation Committee grade. Differences in clinical outcome were evaluated between those with preoperative International Knee Documentation Committee grade B and grade C and between those with grade A and grade B or C at final evaluation. Results Postoperative KT-1000 arthrometer value averaged 1.2 mm for those with isolated anterior cruciate ligament injury and 1.6 mm for those with accompanying valgus laxity (not significant, P = .281). There was no significant difference between these 2 groups regarding the other items. In patients with preoperative valgus laxity, KT-1000 arthrometer values at final evaluation between patients with preoperative grade B and C were not significantly different. The value for subjects with grade A at final evaluation was 1.3 mm and for those with grade B or C at final evaluation was 2.7 mm (P = .065). Conclusion There was no clinically significant difference regarding outcome of anterior cruciate ligament multistrand hamstring reconstruction alone for 90% of patients with grade II valgus laxity who regained medial stability with nonoperative management compared with those who underwent the same anterior cruciate ligament reconstruction for an isolated anterior cruciate ligament tear.

Tibial Tunnel Widening after Hamstring Tendon Anterior Cruciate Ligament Reconstruction

Background Tibial tunnel widening is a common phenomenon seen with hamstring anterior cruciate ligament reconstruction. Concern exists that increased tunnel widening can lead to delayed graft incorporation, graft laxity, or difficulties in revision surgery. Hypothesis Supplemental aperture fixation with autogenous bone cores or bioabsorbable interference screws will decrease tibial tunnel widening in hamstring anterior cruciate ligament reconstruction. Study Design Cohort study; Level of evidence, 3. Methods One hundred twenty-nine patients were divided into 3 groups based on type of aperture fixation: none, bioabsorbable interference screws, and autogenous bone cores. Tibial tunnel diameters were measured on plain radiographs at a minimum of 3 months postoperatively based on the timeline of tibial tunnel widening suggested by Simonian et al, and tunnel widening was quantified by the increase in tunnel diameters relative to initial reamer size. Results Means for tunnel widening based on both anteroposterior and lateral maximum tunnel width measures were significantly different between the 3 groups (P < .05, 1-way analysis of variances); however, compared with the means for the group receiving no aperture supplementation, the means for the group receiving bioabsorbable interference screws were more than 0.8 mm wider, representing a significant increase (P < .05, Bonferroni-adjusted t tests), while the means for the group receiving autogenous bone cores were less than 0.6 mm wider than the group without aperture supplementation and not significantly different (P > .25, Bonferroni-adjusted t tests). Conclusion Tibial tunnel aperture supplementation does not appear to decrease tunnel widening in hamstring anterior cruciate ligament reconstruction and may actually increase the amount of tibial tunnel widening.

Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft

The purpose of this study was to determine whether current post-operative rehabilitation protocols return the strength of the contralateral uninjured limb knee flexors and extensors after an anterior cruciate ligament (ACL) reconstruction to those of an uninjured control group. Subjects with a hamstring tendon ACL reconstruction (n=12) were compared to an active control group (n=30). Comprehensive bilateral knee flexor and extensor isovelocity strength testing was performed (five speeds, 5-95 degrees , concentric and eccentric contractions). After hamstring tendon ACL reconstruction and rehabilitation, bilateral strength normalization (within 10% of the contralateral limb) is achieved by the knee extensors but not the knee flexors. When compared to the uninjured control group, large and statistically significant strength deficits were demonstrated in the knee extensors and knee flexors of both the anterior cruciate ligament reconstructed (extensors 24.8%; flexors 26.8%) and the contralateral uninjured (extensors 21%; flexors 13.5%) limbs. These findings suggest that improvement can be made in knee flexor rehabilitation after ACL reconstruction and limit the validity of the use of a contralateral leg as a rehabilitation endpoint or as a control in the ACL reconstructed population.

Observations on Bone Tunnel Enlargement After Double-Bundle Anterior Cruciate Ligament Reconstruction

The purpose of this study was to determine the amount of tibial and femoral bone tunnel enlargement after double-bundle anterior cruciate ligament (ACL) reconstruction. Twenty-five consecutive patients undergoing primary double-bundle hamstring ACL reconstruction were included in a prospective case series. Femoral fixation was performed by means of 2 EndoButton CL devices (Smith & Nephew Endoscopy, Andover, MA), and tibial fixation was done with 2 bioresorbable interference screws. Magnetic resonance imaging (MRI) was performed in all patients at a mean of 12.3 months postoperatively. Tunnel enlargement was determined by digitally measuring the widths perpendicular to the long axis of the anteromedial (AM) and posterolateral (PL) tunnels on an oblique coronal and axial plane. The MRI measurements were compared with the intraoperative drill diameter. The mean tibial AM bone tunnel diameter increased from 0.74 to 1.06 cm, and the mean PL diameter increased from 0.60 to 0.89 cm. The mean femoral AM bone tunnel diameter increased from 0.71 to 0.97 cm, and the mean PL diameter increased from 0.58 to 0.85 cm. Bone tunnel enlargement was 43% (P = .001) for both tibial tunnels and 35% (P = .001) versus 48% (P < .001) for the femoral AM bone tunnel versus the PL femoral bone tunnel. On the tibial side, communication of the bone tunnels occurred in 41% of patients. This study shows significant tibial and femoral bone tunnel enlargement on MRI after 4-tunnel double-bundle ACL reconstruction 1 year postoperatively. In 41% of patients separate tibial bone tunnel measurements were impossible because of tunnel communication caused by intraoperative bone tunnel drilling, screw contact, or postoperative bone tunnel enlargement. On the femoral side, no bone tunnel communication occurred. The short-term clinical results were good and were not influenced by tunnel communication. Level IV, therapeutic case series.

Tunnel Expansion After Anterior Cruciate Ligament Reconstruction With Autogenous Hamstrings: A Comparison of the Medial Portal and Transtibial Techniques

The purpose of this study was to evaluate the effects of 2 techniques of drilling the femoral tunnel in anterior cruciate ligament (ACL) reconstruction (medial portal v transtibial) on tunnel expansion. Autogenous hamstring ACL reconstructions performed by the senior author between July 1998 and July 2004, with a minimum 6-month radiographic follow-up, using the transtibial technique (41 patients) and the medial portal technique (34 patients), were evaluated. All procedures were performed via an endoscopic technique with identical postoperative rehabilitation and graft fixation. Lateral and 45 degrees posteroanterior (PA) radiographs were obtained for each patient at a minimum of 6 months postoperatively. The sclerotic margins of the femoral and tibial tunnels were measured at the widest dimension of the tunnel by 2 physicians and were compared with the initially drilled tunnel size after correction for radiographic magnification. Statistical analysis was performed to compare the 2 groups by use of the independent-samples t test, with significance set at .05. The mean percentage increase in the femoral tunnel was 38.20% +/- 17.76% for the medial portal technique and 53.96% +/- 21.72% for the transtibial technique on the PA view and 23.80% +/- 16.50% for the medial portal technique and 50.07% +/- 26.98% for the transtibial technique on the lateral view. This difference was statistically significant on both PA and lateral views. The mean percentage increase in the tibial tunnel was 31.81% +/- 14.39% for the medial portal technique and 36.31% +/- 17.81% for the transtibial technique on the PA view and 27.70% +/- 15.25% for the medial portal technique and 30.11% +/- 18.98% for the transtibial technique on the lateral view; however, these increases failed to reach statistical significance on either view. Femoral tunnel expansion for hamstring autologous ACL reconstructions is significantly lower for the medial portal technique when compared with the conventional transtibial technique. Level III, retrospective, comparative therapeutic study.

Time-Related Changes in the Cross-Sectional Area of the Tibial Tunnel After Compaction of an Autograft Bone Dowel Alongside a Hamstring Graft

Extensive tunnel expansion in hamstring anterior cruciate ligament (ACL) reconstruction can complicate revision surgery. The purpose of this study was to examine our hypothesis that compaction of a bone dowel into the tibial tunnel reduces the cross-sectional area of the tunnel on the day of surgery and limits tunnel expansion to that of the cross-sectional area of the reamer at 4 months and 1 to 2 years. A bone dowel averaging 23 mm in length and 7 mm in diameter was harvested from the tibial tunnel in 10 patients undergoing hamstring ACL reconstruction. The tibial tunnel was dilated, and the bone dowel was compacted anterior to the tendon graft. The cross-sectional area of the tibial tunnel was calculated on the day of surgery and at 4 months and 1 to 2 years postoperatively from computed tomography scans. On the day of surgery, the cross-sectional area of the tibial tunnel was 34% smaller than the 50-mm2 cross-sectional area of the 8-mm reamer used to drill the tunnel (P < .001). At 1 to 2 years, the cross-sectional area of the tibial tunnel was smaller than that of the reamer in 6 subjects, was slightly larger (53 to 56 mm2) in 3 subjects, and was substantially larger (80 mm2) in 1 subject. A surgeon who compacts an autogenous bone dowel into the tibial tunnel alongside a hamstring graft can expect little to no tunnel expansion in 90% of patients at 1 to 2 years. To our knowledge, the limitation of tunnel expansion to that of the cross-sectional area of the reamer has not been shown with other tibial fixation techniques. Level IV, therapeutic case series.

Hamstring ACL Reconstruction

ABSTRACT Introduction and History: Four-strand hamstring (4HS)Anterior Cruciate Ligament Reconstruction (ACLR) hasincreased in popularity recently. This is because newerfixation methods have increased the stability results toequal to or better than those of Bone Patellar TendonBone (BPTB) grafts. The hamstring harvest is generallythought to be the most difficult part of the procedure.Endobutton femoral fixation combined with corticalscrew tibial fixation has provided excellent stabilityresults with hamstring grafts.Posterior Mini-Incision Hamstring Harvest Approachfor ACLR: Some surgeons have chosen to useallografts instead of 4HS due to a lack of comfort withthe hamstring harvest. In particular, the hamstringtendons can be cut too short to use if inter-tendinouscross connections are not cut first. The posterior mini-incision harvest allows these cross-connections to beeasily visualized and sectioned where they existpostero-medially. It also allows easier identification ofthe tendons. Finally it allows the anterior incision to beshorter which should diminish the degree of anterior legnumbness that can occur and provides excellentcosmesis.Technique of 4HS ACLR with Endobutton and Whip-stitch/Post Fixation: This technique has provided excellentstability results and a zero perc ent incidence of graft failure.There have been no instances of hardware problems orremoval for symptoms.Meta-Analysis of BPTB and Hamstring Clinical Series:A meta-analysis of all English language Hamstring andBone-Patellar-Tendon-Bone clinical series is described.Four-strand hamstring grafts had the highest stability rates,followed by BPTB and then two strand hamstring grafts.Aperture fixation had no advantage over cortical fixationfor hamstring grafts. Good results were obtained with bothcortical and interference screws for BPTB grafts.Keywords: anterior cruciate ligament, hamstring, knee,stability, meta-analysis

5-Strand Hamstring ACL Reconstruction: A New Technique with Better Long-Term Stability Versus 4-Strand (SS-13)

Even in the highest stability four-strand hamstring (4HS) or BTB ACL reconstruction series, KT 1000 side-to-side differences of >2mm are generally seen in at least a third of all knees. We hypothesized that a stronger, stiffer five-strand HS graft using three-strand-Semitendinosus/two-strand-Gracilis, would result in higher stability rates than 4HS using two strand-Semitendinosus/two-strand-Gracilis. 20 consecutive patients had 5HS ACL reconstruction using 3ST/2Gr. 18 returned for evaluation 89-112 months postoperatively. Results were compared with a previously reported cohort of 133 knees reconstructed by the same surgeons using four-strand HS grafts evaluated at 24-104 months posteoperatively. Both had suspensory-cortical-femoral and whip-stitch-cortical-screw tibial fixation. KT-1000, Noyes, Lysholm and SANE rating were performed. All 5HS and 4HS knees were clinically stable, with no graft failures or re-injuries. Average KT-1000 side-to-side difference was 0.44mm for 5HS vs 1.0MM for 4HS for (p=0.01) A reconstructed knee laxity increase of <1mm versus the normal knee was found in 89% of %HS vs. 66% of 4HS (p=0.03; of 2-3mm in 11% 5HS vs. 31% 4HS; of 4MM in 0% 5HS vs. 3% 4HS; and of >4mm in 0% 5HS and 4HS. 5HS/4HS clinical ratings were high and did not significantly differ. 5HS ACLR had higher stability than a high stability 4HS cohort. Since sufficient ST graft is usually available to fashion a 3 strand-ST instead of 2 strand-ST graft to combine with the 2strand-Gr, we believe 5HS is preferable to 4HS for ACL reconstruction, especially for double bundle techniques. Key words: Anterior Cruciate Ligament, ACL Reconstruction, hamstring, stability, knee ligament.

Prospective randomized clinical comparison of femoral transfixation versus bioscrew fixation in hamstring tendon ACL reconstruction—a preliminary report

The purpose of this study is to clinically evaluate hamstring tendon anterior cruciate ligament (ACL)-reconstruction using femoral fixation with bioresorbable interference screws and with a bioresorbable transfixation device. The ACL-reconstruction using the transfixation device at the femoral side leads to less knee laxity and therefore to a better clinical outcome for the patient. Prospective randomized clinical outcome study. From February 2002 to December 2002, a total of 68 patients with hamstring ACL reconstruction using a femoral fixation once with TransFix (n=38; m:22 and f:16; median age=28.5 range 15-47) and the second with bioscrew (BS) (n=30; m:20, f:10; median age=25.5 range 13-61) completed the follow-up period. Patients in each group got a clinical assessment at 3, 6, and 12 months after surgery. The measurement of anterior translation of the tibia has been performed using the Rolimeter device. No significant differences in the knee laxity testing using the Rolimeter device were seen between both groups and over time within these groups. Ninety percent of all patients had functionally normal or near normal International Knee Documentation Committee (IKDC) knee ligament ratings. The TF-group included 17 grade A, 19 grade B, and 2 grade C knees, and the BS-group had 12 grade A, 13 grade B, and 5 grade C knees. The IKDC rating, the OAK-score, the Tegner-activity-score, and the Lysholm-score did not show significant differences between the TF-group and the BS-group. We disproved our hypothesis that the transfixation technique leads to less laxity and therefore to a better clinical outcome when compared to the use of BS. The clinical results in this study clarified that this technique is an effective and safe method for femoral hamstring fixation in ACL-reconstruction. However, this technique revealed no advantage compared to the bioscrew fixation technique within the short-term follow-up.

Pseudoaneurysm of the medial inferior genicular artery following anterior cruciate ligament reconstruction with hamstring tendon autograft

Vascular injuries associated with arthroscopic surgery of the knee are uncommon. Pseudoaneurysm of the medial inferior genicular artery after hamstring tendon ACL reconstruction has not been reported yet. Diagnosis can be obtained clinically if continuous filling of the drain, hard and painful swelling of the lower leg, pulsatile swelling or mass in the region of the affected joint, are present. Definitive confirmation of the diagnosis can be achieved by sonography and angiography. The method of treatment consists of simple surgical wound exploration and ligation of the affected vessel.