Partial Anterior Cruciate Ligament Reconstruction Research Articles

Primary Partial Transphyseal Anterior Cruciate Ligament Reconstruction in Children with Open Physes

The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is increasing, with ACL reconstruction preferred as it has been shown to have chondroprotective benefits in this population. Due to concerns with growth disturbances following ACL reconstruction in skeletally immature patients, results of various physical-sparing, partial-transphyseal, or complete-transphyseal techniques have been explored. Currently, there is no consensus on the most effective ACL reconstruction technique in skeletally immature patients. Therefore, the purpose of this study was to report the outcomes of a partial-transphyseal, over-the-top (OTT) ACL reconstruction in a cohort of skeletally immature patients. All patients with radiographic evidence of open tibial and femoral physes that underwent primary ACL reconstruction using the partial-transphyseal OTT technique between 2009-2018 at a single tertiary-care institution were retrospectively reviewed. Patient demographics, physical examination findings, graft ruptures, return to sport, and Tegner activity levels were analyzed. Statistical significance was defined as p <0.05. Overall, 22 males and 2 females (25 knees) with a mean age of 13.0 years (Standard Deviation [SD], 1.7 years) were included in the study. The mean postoperative follow-up was 2.1 years (SD, 1.7 years). There were four cases of ACL graft rupture (16%). All patients successfully returned to unrestricted sport at an average time of 7.3 months. Preinjury and postoperative Tegner activity levels were documented in 22 knees, of which 21/22 (95%) returned to the same or higher level. There were no documented cases of clinically significant longitudinal or angular growth disturbance. Partial transphyseal ACL reconstruction using a transphyseal tibial tunnel and an extra-articular, OTT position on the femur in skeletally immature affords minimal risk of growth disturbance with a graft rupture rate of 16% and a 95% return to sport at the same or higher level.

Partial Transphyseal Anterior Cruciate Ligament Reconstruction: Clinical, Functional, and Radiographic Outcomes

Background: With a steadily increasing rate of anterior cruciate ligament (ACL) injury and reconstruction in the pediatric population, disagreement remains regarding the optimal reconstruction technique for patients with ACL injury and ≥2 years of growth remaining. Purpose: This study aims to quantify the incidence of linear and angular growth disturbance of adolescents undergoing partial transphyseal ACL reconstruction (ACLR) while assessing graft failure rates, reoperation rates, and functional outcomes in the population. Study Design: Case series; Level of evidence, 4. Methods: Consecutive patients undergoing partial transphyseal ACLR by 2 surgeons were retrospectively reviewed. Radiographic outcomes, including bilateral limb length, mechanical axis deviation (MAD), mechanical lateral distal femoral angle (MLDFA), and medial proximal tibial angle (MPTA), were measured on long standing anterior-posterior view radiographs postoperatively. Growth disturbance was defined as ≥1-cm leg length discrepancy, ≥1-cm difference in MAD, or 5° difference in MLDFA or MPTA as compared with the nonoperative side and as MAD, MLDFA, or MPTA outside the established range of reference values. Clinical outcomes, including graft failure and reoperation, were recorded at each follow-up visit. Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected electronically after last follow-up. Results: Twenty-four patients (mean ± SD age, 12.3 ± 0.9 years; 79.2% male) with a mean follow-up of 31.5 ± 17.1 months met inclusion criteria for the study. Overall postoperative growth disturbance incidence was 16.7% (4 of 24), but the incidence of growth disturbance was 66.7% (2 of 3) for those patients with >5 years of growth remaining. Seven patients (29.2%) required reoperation, most frequently for hardware removal. Two patients (8.3%) had graft failure with subsequent revision ACL reconstruction. One patient underwent bilateral medial distal femur hemiepiphysiodesis for genu valgum that was present before ACLR, but no other patients required guided growth procedures. In the subset of patients who completed a Pedi-IKDC questionnaire, the mean score was 94.8 ± 5.3. Conclusion: Overall, partial transphyseal ACLR has good functional outcomes and graft failure and reoperation rates, comparable with those seen with transphyseal and all-epiphyseal techniques. While postoperative growth disturbance occurred in 16.7% of the cohort, the severity was mild and well tolerated without necessitating secondary procedures. There is a high rate of growth disturbance of patients with >5 years of growth remaining (66.7%). Partial transphyseal ACLR represents a valid recommendation for adolescent patients with ACL injury and ≤5 years of growth remaining.

PARTIAL TRANSPHYSEAL ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: CLINICAL, FUNCTIONAL, AND RADIOGRAPHIC OUTCOMES

BACKGROUND Partial transphyseal anterior cruciate ligament (ACL) reconstruction is a technique utilized in the skeletally immature population. The femoral tunnel is placed in the distal femoral epiphysis whereas the tibial tunnel is placed in a transphyseal fashion medial to the tibial tubercle. This technique was introduced in an effort to lessen insult to the distal femoral physis of skeletally immature adolescents while also avoiding the technical difficulty of placing an intra-epiphyseal tunnel in the proximal tibia which at times can be non-anatomic. There is limited literature examining this technique. In this study we analyzed the concurrent surgical procedures, re-operation and graft failure rates, and radiographic outcomes in adolescents undergoing partial transphyseal ACL reconstruction. METHODS Consecutive patients undergoing partial transphyseal ACL reconstruction by the two senior authors (NP and CA) were retrospectively reviewed. Inclusion criteria consisted of patients with symptomatic ACL rupture with open distal femoral physes and at least two years of growth remaining by chronologic and physiologic age as determined by growth and pubertal history. All patients received hamstring autograft. Femoral tunnels were drilled in an intra-epiphyseal location utilizing small angle guides under fluoroscopic guidance. Transphyseal tibial tunnels were drilled in standard fashion with a tip-aiming guide while minimizing thermal damage from slow reaming, avoiding horizontal tunnel placement, and using extraphyseal graft fixation to lessen insult to the proximal tibial physis. Radiographic outcomes including bilateral limb length (LL) and alignment as judged by mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle (MPTA) were measured on long standing anterior-to-posterior (AP) view radiographs. Growth disturbance was defined as = 1 cm leg length discrepancy, = 1 cm difference in MAD, or 5-degree difference in mLDFA or MPTA as compared to the non-operative side and MAD/mLDFA/MPTA outside of established range of normal values. Clinical outcomes including graft failure and need for repeat operation were recorded at each follow-up visit. Operative extremity alignment measurements were compared to non-operative extremity measurements utilizing a paired students t-test. RESULTS Twenty-four patients with average follow up of 31.5 ± 17.1 months met inclusion criteria for this study. Five female and 19 male patients were enrolled consisting of 13 left and 11 right knees. Average age at time of surgery was 12.3 ± 0.9 years (10.1-13.8 years). The average ACL graft size was 7.8 mm ± 0.5 mm (6-9 mm). Ten patients (41.7%) had concurrent meniscal surgery, with seven (29.2%) undergoing partial lateral meniscectomy, two (8.3%) lateral meniscus repairs, and one patient (4.2%) with medial and lateral meniscal repairs. Six patients (25.0%) required re-operation at an average of 29.2 ± 17.3 months (1.5-49.5 months) for removal of hardware (n=3), revision ACL reconstruction (n=2), and meniscus surgery (n=1). Two patients had ACL graft failure (8.3%) during sporting activity and underwent revision ACL reconstruction at 19.7 months and 49.5 months post-operatively. There were no contralateral ACL tears. As shown in Table 1, comparison of the mean alignment and limb length measurements between all patients’ operative to nonoperative extremity revealed no significant difference in femur length, MAD, MLDFA, or MPTA. There was a small but statistically significant difference in operative versus non-operative tibia length (390.2 cm versus 392.4 cm, p=0.0004) and limb length (880.9 cm versus 884.0 cm, p=0.02). In analyzing individual patients’ limb length or alignment differences, five patients (20.8%) were identified with a growth disturbance. One patient had isolated shortening of the operative extremity, two with significant lateral deviation of the MAD, and two with both shortening and lateral MAD translation. No patients had significant side-to-side difference in mLDFA or MPTA. Femoral shortening accounted for the majority of the limb length discrepancy in two of the three patients with significant limb length discrepancy. All patients returned to sport. CONCLUSIONS / SIGNIFICANCE Partial transphyseal ACL reconstruction has a 25.0% re-operation rate, most often for hardware removal, and an 8.3% graft failure rate. Overall, approximately 20% of patients undergoing partial transphyseal ACL reconstruction had a growth disturbance but none required surgical intervention for these disturbances. While the partial transphyseal technique spares the distal femoral physis, femur-dominant limb length discrepancy can still occur. Drilling and graft placement across the tibial physis appears to be safe. Further studies are needed to directly compare the radiographic, functional, and clinical outcomes of partial transphyseal ACL reconstruction with transphyseal and all-epiphyseal techniques in the pediatric population. [Table: see text]

Intra-Articular Biocompatibility of Multistranded, Long-Chain Polyethylene Suture Tape in a Canine ACL Model.

The purpose of this study was to assess intra-articular use of a nonabsorbable braided suture tape for its biocompatibility when implanted adjacent to the native anterior cruciate ligament (ACL) in a canine model. Establishing biocompatibility of suture tape in the knee is an important foundational step for clinicians considering use of suture tape augmentation for ACL reconstruction or repair. The study hypothesis was that a nonabsorbable braided suture tape would be biocompatible in the knee with no resultant adverse functional consequences, and no significant intra-articular synovial reactions or articular cartilage degeneration attributable to direct exposure to the suture tape, whether intact or transected. Nonabsorbable braided suture tape was arthroscopically implanted adjacent to the native ACL of dogs (n = 6). The suture was intact in half of the dogs and was transected in the other half as a "worst-case" scenario. Dogs were assessed for postoperative complications and morbidity. Arthroscopic grading of synovium and cartilage was performed at 4 and 6 months. Histologic assessments were performed at the 6-month endpoint and compared with the ACL partial tear (n = 9) and ACL reconstruction (n = 5) cohorts as well as historical sham controls. No postoperative complications were noted. No animal developed lameness or clinical dysfunction, and there were no severe inflammatory or immune responses, cartilage erosions, or premature osteoarthritis noted. Arthroscopic assessments revealed no to mild synovitis and no apparent cartilage damage in either group. Histologically, both the intact and transected suture tape groups were associated with significantly (p ≤ 0.05) less synovial and articular cartilage pathology compared with the partial ACL transection and patellar bone-tendon-bone ACL autograft reconstruction cohorts, and matched historical sham controls. The hypothesis was accepted as study results support the biocompatibility of suture tape in the canine knee.

Effects of pre-operative knee laxity on clinical outcomes after partial anterior cruciate ligament reconstruction

BackgroundThe effects of retaining residual bundles on surgical outcomes has not been observed, so we evaluated the effects of preoperative knee laxity on clinical outcomes after partial anterior cruciate ligament (ACL) reconstruction for partial ACL rupture in this study. PurposeTo evaluate the effects of preoperative knee laxity on clinical outcomes after partial anterior cruciate ligament (ACL) reconstruction for partial ACL rupture. MethodsThe data of 47 patients, who had partial ACL rupture and underwent partial ACL reconstruction, were retrospectively analyzed. According to preoperative kneelax arthrometer and pivot shift test, the 47 patients were divided into group A (kneelax arthrometer ≤5mm and pivot shift test <II grade, n=26) and group B (kneelax arthrometer >5mm and/or pivot shift test ≥II grade, n=21). The minimum follow-up duration lasted 2 years. The clinical outcomes were evaluated using IKDC (International Knee Documentation Committee) scoring systems, Lysholm knee scoring scale, Tegner activity rating, Lachman test, Pivot shift test and the kneelax arthrometer. ResultsThe function and stability examinations for the affected knee joint were significantly improved in both groups after partial ACL reconstruction as compared with preoperative ones (all P<0.01). There were no significant differences in the post-operative Lysholm and Tegner scores, Lachman and Pivot shift test results between both groups (all P>0.05). However, there were significant differences between the two groups in terms of the post-operative IKDC scoring system and kneelax arthrometer examination result (all P<0.05). ConclusionsIn the patients with partial ACL rupture, the mechanical strength of the remnant ligament has significant influence on the therapeutic effects of partial reconstruction. The patients with kneelax arthrometer >5mm and/or pivot shift test ≥II grade still have anterior instability in the affected knee after partial reconstruction.

CT assessment of femoral tunnel placement after partial ACL reconstruction

IntroductionWhen one of the anterior cruciate ligament (ACL) bundles is torn, it seems appropriate to preserve the remaining bundle to improve the vascularization and proprioception of the graft, and to reproduce the attachment sites of the torn bundle. After ACL reconstruction, the functional result is worse when the tunnels are positioned further away from the native ACL's isometric attachment points. The goal of this study was to use CT 3D reconstructions to analyse the position of the femoral tunnel following partial ACL reconstruction and to compare it to complete ACL reconstruction cases. We hypothesized that the femoral tunnel positioning was optimal during partial ACL reconstruction. MethodsIn this prospective single-centre study, 16 patients who underwent isolated anteromedial bundle reconstruction were evaluated during the immediate postoperative period using 3D reconstruction of CT images. During this same period, 180 patients who underwent complete ACL reconstruction in the same surgery unit served as a control group. ResultsIn the partial ACL reconstruction group, 6 tunnels (37.5%) were in the optimal position and 10 tunnels (62.5%) were not. In the complete ACL reconstruction group, 124 femoral (68.9%) were in the optimal position and 56 (31.1%) were not (P<0.05). DiscussionFemoral tunnel positioning is not always optimal in patients who undergo partial ACL reconstruction. Three-dimensional CT reconstruction is a good tool to help surgeons detect and learn from their errors. Level of evidenceIII (case-control study).

Partial Anterior Cruciate Ligament Knee Reconstruction with Accelerated Anterior Cruciate Ligament Rehabilitation

Objectives:The primary purpose of this study is to determine whether or not a partial Anterior Cruciate Ligament (ACL) reconstruction with accelerated rehabilitation produced similar outcomes to that of the conventional ACL reconstruction with its traditional rehabilitation program timeframe. An improved understanding of these outcomes can change the way partial ACL injuries are treated surgically and return patients back to their chosen activities quicker without compromising their graft.Methods:Level III, therapeutic, retrospective study. Participants who were two years post partial ACL reconstruction with accelerated rehabilitation by were contacted. They filled out IKDC, Modified Cincinatti and Tegner Lysholm knee score questionnaires and were measured using a KT-1000 arthrometer for side-to-side instrumented laxity >2 mm as well as indicating if there partial ACL reconstruction had re-ruptured, requiring further surgical intervention.Results:All three measurements in this study, including re-rupture rates, side – to – side instrumental laxity and satisfaction scores via questionnaires, were statistically significant, thus showing a partial ACL reconstruction with accelerated rehabilitation is a viable choice for the treatment of a patient with a partial ACL tear of his knee.Conclusion:Partial ACL reconstruction with accelerated rehabilitation is a viable choice for the treatment of a patient with a partial ACL tear of his knee.

Surgical treatment of partial anterior cruciate ligament lesions: medium-term results

this study was conducted to evaluate subjective and objective clinical outcomes of partial reconstruction of the anterior cruciate ligament (ACL) in comparison with complete ACL reconstruction. three groups, each comprising 20 patients, were evaluated at a minimum follow-up of 12 months. The group 1 patients underwent partial ACL reconstruction, while those in group 2 and group 3 underwent complete ACL reconstruction, performed using either bone-patellar tendon-bone (BPTB) or quadrupled hamstring tendon (HT) grafts, respectively. The subjective outcome was evaluated using the Lysholm knee scale and the subjective International Knee Documentation Committee (IKDC) scoring system. A visual analog scale (VAS) was used for pain assessment and sporting activity was rated using the Tegner activity scale. Objective evaluation was performed using the IKDC objective form, KT-1000 arthrometer and KiRA triaxial accelerometer. at the follow-up evaluation, the mean subjective IKDC score was 86.1±10.3 in group 1, 85.2±11.1 in group 2, and 82.7±7.8 in group 3. The Lysholm score was 91.3±7.3 in group 1, 91.7±9.6 in group 2, and 89.4±6.1 in group 3. KT-1000 tests showed a mean side-to-side difference of 1.1 mm ± 1.5 mm (range, 0-5 mm) in group 1; 0.79 mm ± 0.8 mm (range, 0-2mm) in group 2; and 1.45 mm ± 1 mm (range, 0-3 mm) in group 3. The differences between groups were not statistically significant. both subjective and objective outcomes of partial ACL reconstruction were comparable to those of complete reconstruction, but partial reconstruction in the presence of a partial lesion of the ACL is considered by the authors to be more respectful of the native vascularization, innervation and anatomy of the ACL, conferring an advantage in terms of recovery of the complete function of the knee. Level III, retrospective comparative study.

Partial ACL reconstruction with preservation of the posterolateral bundle

Over the past decade, our understanding of the anterior cruciate ligament (ACL) has evolved considerably. Based on this knowledge, ACL reconstruction techniques have changed and selective reconstruction procedures have been developed for partial tears. Our hypothesis was that stability and function can be restored to the knee with selective bundle reconstruction of partial ACL tears and preservation of the residual fibers. This was a multicenter retrospective study of 168 partial reconstructions of the anteromedial (AM) bundle of the ACL with preservation of the posterolateral (PL) bundle. All patients underwent a clinical evaluation based on the objective and subjective IKDC scores and the Lysholm score after a mean follow-up of 26 months (12-59 months). Preoperative and postoperative instrumental measurement of knee laxity was performed by arthrometer and/or by (Telos(®)) stress radiography. Statistical analysis and comparison was performed between pre- and postoperative results. The preoperative and postoperative subjective IKDC scores were 63.7 and 90.5 at the final follow-up respectively (P<0.001). The preoperative and postoperative Lysholm scores were 80 and 95.5 respectively (P<0.001). Preoperatively, most patients were classified C on the objective IKDC score. At the final follow-up 92% of the patients were classified A or B (P<0.001). Differential preoperative laxity was 5.5mm (range: 0-14 mm) and 1.1mm (range: 0-4mm) at the final follow-up (P<0.00001). Our study confirms that selective reconstruction of the AM bundle of the ACL with preservation of the PL bundle restores stability and function to the knee. Special attention should be paid to the size of the graft used to avoid excess tissue in the intercondylar notch.

Knee rotational laxity and proprioceptive function 2 years after partial ACL reconstruction

The aim of our study was to evaluate knee rotational laxity and proprioceptive function 2years after partial anterior cruciate ligament (ACL) reconstruction. According to our hypothesis, partial ACL reconstruction could restore knee laxity and function to the intact level. We conducted a study in fifteen consecutive patients undergoing partial ACL reconstruction. Fifteen anteromedial bundle tears were identified intraoperatively. Partial ACL reconstructions were performed by the same senior surgeon using a single-incision technique. A bone-patellar tendon-bone graft was used in 13 cases and a double-stranded semitendinosus graft in 2 cases of chronic patellar tendonitis. The mean age at surgery was 29years. The time between ACL tear and surgery averaged 7.8months (range 2.5-29.5months). We developed an original device designed to assess knee proprioception (passive and active) and measure weight-bearing rotational laxity in full extension and at 30°, 60° and 90° of knee flexion. All measurements were taken on both the reconstructed and healthy knee. The mean follow-up of the study was 3.4years (range 2.6-4.4). No statistically significant difference in rotational laxity, active or passive proprioception could be observed between the reconstructed and healthy knee. External rotation was significantly greater than internal rotation in full extension and at 30° of flexion in the reconstructed and the healthy knee (P<0.05). For each knee, active proprioception was found to be significantly different (higher) than passive proprioception (P<0.05). Our study did not detect any difference in rotational laxity and proprioception between the reconstructed and the healthy knee. Therefore, partial ACL reconstruction appears to restore satisfactory knee laxity and function in case of partial ACL tear. IV.

Self-Reported Patient Outcomes at a Minimum of 5 Years After Allograft Anterior Cruciate Ligament Reconstruction With or Without Medial Meniscus Transplantation: An Age–, Sex–, and Activity Level–Matched Comparison in Patients Aged Approximately 50 Years

Patient outcomes at a minimum of 5 years after medial meniscus transplantation and primary anterior cruciate ligament (ACL) reconstruction via allograft tissues were compared with those of age-, sex-, and activity level-matched patients who underwent meniscal repair or partial meniscectomy and primary ACL reconstruction via allograft tissues. Eight patients (mean age, 51 +/- 5 years; three women and five men) at 5.5 +/- 0.5 years after medial meniscus transplantation and ACL reconstruction (group 1) and eight matched patients (mean age, 50 +/- 5 years; three women and five men) at 5.1 +/- 0.5 years after meniscal repair or partial meniscectomy and ACL reconstruction (group 2) completed the meniscus allograft clinical registry questionnaire, which combined the modified Lysholm knee scoring scale, the 1999 International Knee Documentation Committee subjective knee evaluation, and the knee pain level score on a 10-cm visual analog scale. Both groups displayed similar improvements in the modified Lysholm knee scoring scale components of pain, knee stability, squatting, stair climbing, and limping, as well as overall score (P < .05). Only group 2 displayed significant reductions in swelling. The groups displayed similar improvements in the 1999 International Knee Documentation Committee subjective knee evaluation components of sitting, rising from a chair, running, jumping, and stopping quickly, as well as overall score (P < .05). They also displayed significant improvements in the visual analog scale knee pain level score; however, group 1, which displayed greater preoperative pain levels, had considerably larger reductions. Most group 1 patients (7/8 [87.5%]) and all group 2 patients (8/8 [100%]) considered their surgery to be a success and would undergo the same procedure again if necessary. Although group 1 had greater preoperative knee pain levels, their pain levels at 5 years postoperatively were comparable to those in group 2. With the exception of swelling, comparable improvements were observed between groups for all other variables. Level III, retrospective, case-control study.

Assessment of osteoarthritis after reconstruction of the anterior cruciate ligament

We used single-photon emission computed tomography (SPECT) to determine the long-term risk of degenerative change after reconstruction of the anterior cruciate ligament (ACL). Our study population was a prospective series of 31 patients with a mean age at injury of 27.8 years (18 to 47) and a mean follow-up of ten years (9 to 13) after bone-patellar tendon-bone reconstruction of the ACL. The contralateral normal knee was used as a control. All knees were clinically stable with high clinical scores (mean Lysholm score, 93; mean Tegner activity score, 6). Fifteen patients had undergone a partial meniscectomy and ACL reconstruction at or before reconstruction of their ACL. In the group with an intact meniscus, clinical symptoms of osteoarthritis (OA) were found in only one patient (7%), who was also the only patient with marked isotope uptake on the SPECT scan compatible with OA. In the group which underwent a partial meniscectomy, clinical symptoms of OA were found in two patients (13%), who were among five (31%) with isotope uptake compatible with OA. Only one patient (7%) in this group had evidence of advanced OA on plain radiographs. The risk of developing OA after ACL reconstruction in this series is very low and lower than published figures for untreated ACL-deficient knees. There is a significant increase (p < 0.05) in degenerative change in patients who had a reconstruction of their ACL and a partial meniscectomy compared with those who had a reconstruction of their ACL alone.