Remnant Preservation Technique Research Articles

Preferences in anterior cruciate ligament reconstruction: A survey among orthopedic surgeons in China.

The purpose of this study was to reveal the current trends and preferences of Chinese orthopedic surgeons regarding anterior cruciate ligament (ACL) reconstruction through a nationwide web-based survey conducted in China. The survey questionnaire was distributed via WeChat to the chairmen of provincial orthopedic and sports medicine organizing committees in China, who then shared it in their respective WeChat workgroups. The questionnaire consisted of 52 multiple-choice questions covering 8 sections. Data collection was implemented by Questionnaire Star. A total of 812 valid questionnaires were returned: 94.21% of the respondents preferred single-bundle reconstruction of ACL, while 61.70% preferred autogenous semitendinosus plus gracilis reconstruction; 76.35% of the respondents preferred establishing the femoral tunnel first, while 47.29% preferred establishing the femoral tunnel through a medial auxiliary approach; and 85.10% of the respondents recommended patients to undergo surgery within 3 months after ligament injury. Besides, the vast majority of respondents chose to retain the ligamentous remnant bundle (92.98%) and recommended routine use of knee braces postoperatively (94.09%). It is recommended to perform arthroscopic single-bundle ACL reconstruction with the remnant preserving technique using a hamstring autograft within 3 months of ACL rupture, with support of postoperative functional braces.

Effect of a new remnant-preserving technique with anatomical double-bundle anterior cruciate ligament reconstruction on MRI-based graft maturity: a comparison cohort study.

To investigate the effects of a new remnant-preserving double-bundle anterior cruciate ligament reconstruction (ACLR) technique, focused on avoiding remnant damage and preserving continuity of remnants, on graft maturity using magnetic resonance imaging (MRI). A total of 169 patients were divided into three groups: 41 in the preservation group, 70 in the resection group, and 58 in the absent group. In the preservation group, rather than passing the graft through the remnant tissue, the graft was reconstructed such that the anteromedial and posterolateral bundles sandwiched the remnant to avoid damage to the remnant and maintain its continuity. Based on 1-year postoperative MRI, the grafts were divided into three regions: distal, middle, and proximal. The signal/noise quotient (SNQ) of each region of interest was calculated to evaluate the signal intensity of the graft and was compared among the three groups. Additionally, to identify factors influencing graft maturity, a multiple regression analysis was performed with SNQ as the dependent variable and patient demographics, bone morphology, and surgical factors as independent variables. In a three-group comparison of mean SNQs, the distal region was 3.3 ± 3.4, 8.9 ± 8.3, and 9.0 ± 8.6 (p < 0.001), the middle region was 5.3 ± 3.7, 10.9 ± 11.1, and 11.3 ± 10.2 (p < 0.001), and the proximal region was 6.8 ± 4.5, 11.1 ± 8.8, and 11.7 ± 10.8 (p = 0.017), in order of the preservation, resection, and absent groups, respectively. That indicated that the remnant-preserving ACLR was more hypointense than ACLR with remnant resection or absent in all three regions. Multiple regression analysis showed that remnant preservation remained the relevant factor affecting SNQ of the graft at the distal and middle levels. The new remnant-preserving anatomic double-bundle ACLR had significantly better graft maturity, measured by SNQ on MRI, than the remnant resection and absent groups. The remnant procedure was the relevant factor affecting graft maturity. Level III.

ACL stump and ACL femoral landmarks are equally reliable in ACL reconstruction for assisting ACL femoral tunnel positioning.

This study aimed to comparatively evaluate the accuracy of femoral tunnel positioning after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction performed with the remnant preservation (RP) technique versus the non-remnant preservation (NRP) technique. A retrospective review of 145 patients who underwent ACL reconstruction from May 2020 to May 2022 were performed in this single-surgeon study. A total of 120 patients met the inclusion criteria and were allocated into two groups according to the surgical technique (i.e. RP group and NRP group). The relative location of the femoral tunnel in the lateral condyle was evaluated as a percentage using a standardized grid system on the three-dimensional computed tomography (3D-CT) image. The accuracy and precision of the RP group were assessed based on published anatomical data in direct comparison with the NRP group. According to the surgical procedure, 57 of the 120 patients included were allocated into the RP group, and 63 into the NRP group. Significant differences were observed between the two groups in terms of tunnel position (posterior-to-distal (PD): 28.4 ± 5.4% (RP) vs. 31.8 ± 5.3% (NRP); P = 0.01), (anterior-to-posterior (AP): 32.6 ± 7.7% (RP) vs. 38.8 ± 7.7% (NRP); P = 0.00), while no significant differences were found in terms of the accuracy (8.6% (RP) vs. 8.9% (NRP); n.s) and precision (4.4% (RP) vs. 5.6% (NRP); n.s) of femoral tunnel positioning between the two groups. From this single-surgeon study, it was concluded that there were no differences in the creation of ACL femoral tunnel between the RP technique and the non-remnant preserving technique. Meanwhile, the RP technique would not sacrifice the ideal position of the femoral tunnel and is able to retain the possible benefits of the ACL stump. Level III.

A new remnant preservation technique reduces bone tunnel enlargement after anatomic double-bundle anterior cruciate ligament reconstruction.

To investigate the effect of a new remnant preservation technique with a focus on remnant continuity on postoperative femoral and tibial tunnel enlargement after anatomical double-bundle anterior cruciate ligament reconstruction (ACLR). A total of 150 knees were divided into three groups: Preservation Group (Group P: 49 knees), wherein the remnant continuity remained after tunnel creation; Resection Group (Group R: 47 knees), wherein the remaining remnant was resected, and Absent Group (Group A: 54 knees), wherein the remnant had no femoral attachment before tunnel creation. In Group P, the remnant maintained continuity, and the anteromedial (AM) and posterolateral (PL) bundles were positioned anterior and posterior to the remnant, respectively. Computed tomographic scans were performed at 1week and 1year after surgery, and the cross-sectional area of each tunnel aperture was measured. Tunnel enlargement was compared among the three groups by one-way analysis of variance (ANOVA) and the Bonferroni test. Univariate and multivariate logistic analyses were performed to identify the risk factors for tunnel enlargement in demographic and radiographic data. For femoral AM tunnels, the tunnel enlargement of Group P was significantly smaller than Groups R and A (p < 0.001), femoral PL (p < 0.001 vs. R and A), tibial AM (p < 0.001 vs. R, 0.002 vs. A), and tibial PL (p < 0.001 vs. R, 0.002 vs. A). There was no significant difference between Groups R and A. Multivariate logistic analysis showed that remnant preservation was a significant factor in reducing tunnel enlargement in the femoral AM, femoral PL, tibial AM, and tibial PL. The new remnant-preserving anatomical double-bundle ACLR, which preserves the continuity of the remnant, prevented all bone tunnel enlargement at 1year postoperatively. Level III.

Rate of Tibial Tunnel Malposition Is Not Changed by Drilling Entirely Within the Stump of Preserved Remnants During ACL Reconstruction: A Prospective Comparative 3D-CT Study.

Background:Remnant preservation during anterior cruciate ligament (ACL) reconstruction (ACLR) is controversial, and it is unclear whether the stump aids or obscures tibial tunnel positioning.Purpose/Hypothesis:The aim of this study was to determine whether the rate of tibial tunnel malposition is influenced by remnant preservation. The hypothesis was that using a remnant-preserving technique to drill entirely within the tibial stump would result in a significant reduction in tibial tunnel malposition as determined by postoperative 3-dimensional computed tomography (3D-CT).Study Design:Cohort study; Level of evidence, 2.Methods:Patients undergoing ACLR between October 2018 and December 2019 underwent surgery with a remnant-preserving technique (RP group) if they had a large stump present (>50% of the native ACL length) or if there was no remnant or if it was <50% of the native length of the ACL, they underwent remnant ablation (RA group) and use of standard landmarks for tunnel positioning. The postoperative tunnel location was reported as a percentage of the overall anteroposterior (AP) and mediolateral (ML) dimensions of the tibia on axial 3D-CT. The tunnel was classified as anatomically placed if the center lay between 30% and 55% of the AP length and between 40% and 51% of the ML length.Results:Overall, 52 patients were included in the study (26 in each group). The mean tunnel positions were 36.8% ± 5.5% AP and 46.7% ± 2.9% ML in the RP group and 35.6% ± 4.8% AP and 47.3% ± 2.3% ML in the RA group. There were no significant differences in the mean AP (P = .134) and ML (P = .098) tunnel positions between the groups. Inter- and intraobserver reliability varied between fair to excellent and good to excellent, respectively. There was no significant difference in the rate of malposition between groups (RP group, 7.7%; RA group, 11.5%; P ≥ .999).Conclusion:Drilling entirely within the ACL tibial stump using a remnant-preserving reconstruction technique did not significantly change the rate of tunnel malposition when compared with stump ablation and utilization of standard landmarks.

Single-Bundle Anatomical Posterior Cruciate Ligament Reconstruction With Remnant Preservation

Remnant always exists following injuries of the posterior cruciate ligament (PCL). To improve the clinical outcomes of PCL reconstruction, preservation of the remnant has long been a consideration. However, how to make the remnant-preservation technique simple and more effective is of concern. We describe a single-bundle anatomical PCL reconstruction technique with remnant preservation in which the posteromedial and posterolateral portals are used, the graft is placed at the lateral side of the remnant, and pulleys are used to facilitate graft passage at the 2 killer turns of the grafting routes. We consider introduction of this technique will provide reasonable choices in PCL reconstruction.

A technique for repairing rotator cuff transtendinous tears with a remnant attached to the footprint

BackgroundSome unusual rotator cuff (RC) tears are located in more proximal tendinous portions, with substantial remnant tissue attached to the footprint. The two options for surgical repair are sacrificing or preserving the remnant tissue. We introduce a surgical repair technique that preserves as much of the remnant footprint as possible.Surgical techniqueA double-loaded suture anchor is inserted into the subchondral bone at the medial portion of the RC footprint; the lateral remnant tissue is preserved. Each strand is shuttled and repassed through the medial portion of the tendon in a mattress fashion using a suture hook device. Then, multiple no. 1 PDS sutures are passed through the medial and lateral stumps and left untied. Strands from the suture anchor are first tied in a double mattress fashion. Then, the repair is completed by tying the remaining no. 1 PDS sutures.ConclusionsWe propose a remnant-preserving RC repair technique for transtendinous RC tears with sufficient tissue remaining within the RC footprint. This technique appears advantageous in terms of re-establishing an environment that promotes tendon healing after repair.

Sandwich-Style Anterior Cruciate Ligament Reconstruction: Double-Bundle Anterior Cruciate Ligament Reconstruction With In-Between Remnant Preservation

Various degree of remnant tissues exists following anterior cruciate ligament (ACL) injury. Making use of these tissues may be helpful for the reconstructed ACL from many aspects. There are many methods of remnant preservation and use, as well as many types of combined ACL reconstruction. However, the most effective methods of remnant reuse as well as ACL reconstruction are still being pursued. We introduce an anatomical double-bundle transtibial ACL reconstruction with in-between remnant preservation technique named sandwich-style ACL reconstruction. The indication of this technique is complete ACL tear with a large volume of connectable remnant. The main tricks of this technique are proper ligation of the remnant, proper location of the anteromedial-bundle tibial tunnels, and passing the anteromedial bundle through the shallow side of the remnant. We believe the introduction of this technique will provide more options for remnant preservation and ACL reconstruction.

All-Inside Anterior Cruciate Ligament Reconstruction With Augmentation Using the Native Anterior Cruciate Ligament Remnant by Suture Approximation

Anterior cruciate ligament (ACL) rupture remains a debilitating orthopaedic pathology with a substantial economic and psychological burden on patients, especially athletes. The purpose of ACL reconstruction is to attain maximum joint stability and functionality, allowing patients to resume their previous level of activity. Several graft options and techniques are available for ACL reconstruction. The all-inside remnant-preservation technique is a minimally invasive approach aiming for improved proprioception, better graft integration, and increased graft strength via ACL augmentation by suture approximation with an optimal anatomic reconstruction. ACL augmentation is associated with a decreased risk of rerupture. Moreover, enhancement of knee proprioception via the presented technique allows an early return to activity by patients because weight bearing (with a brace) can be initiated as early as day 1 postoperatively. Patients can resume running activities by 2 months postoperatively and return to pivot sports by 3 months postoperatively. Despite this surgical procedure being technically demanding, it is associated with improved clinical outcomes and functional capacities. Patients are also found to better tolerate the postoperative rehabilitation protocol.

Remnant preservation provides good clinical outcomes after anterior cruciate ligament reconstruction

PurposeTo evaluate the association of remnant preservation (RP) and non-RP (NRP) with patient-reported outcome measures and subsequent graft rupture at a minimum 2-year follow-up after anterior cruciate ligament (ACL) reconstruction.MethodsPatients in this retrospective study underwent primary isolated ACL reconstruction by the RP or NRP technique with a four- to five-strand hamstring tendon graft. Multivariate linear or logistic regression and Cox regression analyses were performed to compare the physical and psychological outcomes by the International Knee Documentation Committee subjective knee form (IKDC-SKF) and the Japanese Anterior Cruciate Ligament questionnaire 25 (JACL-25), respectively; satisfaction rate; and prognosticators of graft rupture.ResultsIn total, 120 patients (mean age, 30.6 ± 12.7 years; 54 RP, 66 NRP) with a mean follow-up of 3.2 ± 1.6 years were enrolled in this study. At the latest postoperative follow-up, the RP group showed a mean IKDC-SKF score of 92.3 ± 8.5 and mean JACL-25 score of 13.2 ± 11.2, while these scores in the NRP group were 86.4 ± 12.2 and 24.4 ± 19.5, respectively (P = 0.016 and 0.007, respectively). No significant differences were found in the return-to-sports rate (RP vs. NRP, 79.5% vs. 67.5%) or satisfaction rate (RP vs. NRP, 89.2% vs. 74.4%) (n.s.); however, a significant difference was found in the rate of return to the preinjury sports level (RP vs. NRP, 64.1% vs. 37.5%; P = 0.014). The graft rupture rate was significantly higher in the NRP than RP group (9/66 vs. 1/54; hazard ratio 9.29; 95% confidence interval 1.04–82.81). Younger age (≤ 18 years) was the other important risk factor for graft rupture (hazard ratio 8.67; 95% confidence interval 2.02–37.13).ConclusionPatients who underwent ACL reconstruction with the RP technique obtained somewhat better physical and psychological results than those who underwent ACL reconstruction with the NRP technique. With respect to clinical relevance, patients treated with the RP technique may obtain better outcomes in terms of graft rupture and return to the preinjury sports level than those treated with the NRP technique, but with no differences in overall return to sports or satisfaction.Level of evidenceIV.

A modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction: medium-term clinical and radiologic results comparable with open reconstruction.

The aim of this study was to compare clinical and radiologic outcomes of a modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction with traditional open reconstruction. From January 2012 and March 2016, 60 eligible patients with chronic lateral ankle instability (CLAI) received all arthroscopic remnant-preserving reconstruction or open reconstruction of the anterior talofibular ligament and calcaneofibular ligament using semitendinosus autograft. They were divided into the arthroscopic group (n = 28) and the open group (n = 32). The American Orthopaedic Foot and Ankle Society (AOFAS),visual analog scale (VAS), and Karlsson scores and ankle range of motion (ROM) were used to evaluate clinical outcomes pre-operatively and at six and 12 months and the final follow-up of at least 24 months post-operatively, with SF-36 physical component summary (PCS) and mental component summary (MCS) scores evaluated for quality of life, and the anterior talar translation and talar tilt measurements for radiologic outcomes. There was no difference in pre-operative demographics between two groups (P > 0.05). At the final follow-up, the AOFAS, VAS, Karlsson, SF-36 PCS, and MCS scores improved significantly in both groups (P < 0.05). However, no significant difference was found in AOFAS (91.9 ± 6.8 vs 91.1 ± 5.5), VAS (2.7 ± 1.7 vs 2.5 ± 1.6), Karlsson (95.3 ± 6.7 vs 94.8 ± 6.5), SF-36 PCS (53.2 ± 6.1 vs 52.9 ± 5.7), and MCS scores (55.7 ± 5.8 vs 54.2 ± 5.4) between the two groups (P > 0.05). There was no significant difference in post-operative operated/non-operated ankle ROM between two groups (P > 0.05). No significant difference was observed in talar tilt angle (7.6 ± 4.1° vs 6.8 ± 3.6°) and anterior talar translation (5.8 ± 1.7 mm vs 5.7 ± 1.5 mm) between the two groups at the final follow-up (P > 0.05), although these two variables improved significantly in both groups (P < 0.05). No severe complications were encountered in both groups during the follow-up period. The modified all-inside arthroscopic remnant-preserving technique of lateral ankle ligament reconstruction could produce excellent clinical and radiologic outcomes comparable with open reconstruction.

Preservation of the Tibial Remnant in Anterior Cruciate Ligament Reconstruction May Improve Postoperative Proprioceptive Function.

The purpose of this study was to retrospectively compare clinical results, including proprioceptive function, after anterior cruciate ligament (ACL) reconstruction between 2 groups using techniques that preserve and eliminate the tibial remnant. Forty-eight patients who were followed for at least 24 months after ACL reconstruction with 4-strand hamstring tendon autografts were enrolled in this study. They were then divided into 2 groups: the remnant-preserving group (group A, 26 patients), in whom more than 7 mm of the remnant tibial stump (approximately 20% of the mean length of the ACL) was preserved; and the remnant-eliminating group (group B, 22 patients), in whom the tibial remnant was eliminated during ACL reconstruction. The average duration of follow-up was 25.5 months. At last follow-up, patients were evaluated using the International Knee Documentation Committee scale, Hospital for Special Surgery score, Lachman test, arthrometer, reproduction of passive positioning (RPP) test, threshold to detection of passive motion (TTDPM) test, one-leg hop test, and single-limb standing test. The clinical results between the 2 groups were statistically compared. Group A showed significantly better results on the RPP test at 15° (P=.040) and 30° (P=.010), one-leg hop test (P=.017), and single-limb standing test (P=.007) compared with group B. The other results showed no significant differences. The remnant-preserving technique in ACL reconstruction yields better proprioceptive and functional outcomes and may help achieve postoperative patient satisfaction. [Orthopedics. 2020;43(4):e231-e236.].

Comparative Study Between Remnant Preserving Vs Remnant Sacrificing Rotator Cuff Repair

Clinical outcomes of remnant preserving VS remnant sacrificing repair techniques were statistically no differences in the scoring system and range of motion. However, the incidence of the good tendon quality after cuff repair was higher in the remnant preserving group. Comparative study between remnant preserving VS remnant sacrificing rotator cuff repair. Among some cases of the full thickness rotator cuff tears, the remnants of torn rotator cuff were still present on the footprint of the greater tuberosity. Many surgeons tried to remove all the cuff remnants of the greater tuberosity and reapir the retracted cuff to the bare greater tuberosity. The purpose of this article is to report the clinical outcomes of the remnant preserving repair technique in the small to medium sized rotator cuff tears. Between April 2008 and May 2015, 127 patients who had small to medium sized rotator cuff tears with cuff remnants of the footprint at least 1cm width had an arthroscopic suture bridge rotator cuff repair performed by the senior author. Group I included the group with cuff remnant preserving technique and group II included the repair group with cuff remnant sacrificing technique and decorticated greater tuberosity. The outcome measurements included respectively UCLA, ASES, KSS, SST, CSS for subjective and objective satisfaction measurement and MRI at 6, 12th months after operation. Also we evaluated the retear rate and tendon quality (good quality: Sugaya's classification 1,2 grade and poor quality : 3,4,5 grade). In group I, KSS, UCLA, ASES, SST, CSS was increased from 56.6, 19.6, 53.4, 5.4, 62.7 preoperatively to 86.7, 31.3, 86.2, 10, 74.3 postoperatively at 1 years, and in group II, from 53.6, 18, 47.0, 4.9, 62.7 to 87.5, 31.5, 87.3, 10.2, 88.3 at 1 years. There was no differences between 2 groups in the ROM. The post-operative MRI demonstrated that retear rate by Sugaya’s classification(G4,5 as retear) was no differences (p>0.05). Good quality (Sugaya grade 1 and 2) was higher in the remnant preserving repair group than the remnant sacrificing group (70% vs 54%) (p<0.05). Clinical outcomes of remnant preserving VS remnant sacrificing repair techniques were statistically no differences in the scoring system and range of motion. However, the incidence of the good quality tendon after cuff repair was higher in the remnant removing group. Therefore, If there are relative fresh remnants on footprint through arthroscopic examination, the remnant preserving repair technique could be considered. Remnant preserving repair technique could reduce the tension mismatch of the repaired tendon and also increase repair tendon integrity and quality. These could a good choice for small to medium size tear with footprint remnant at least 1cm width.

The remnant preservation technique reduces the amount of bone tunnel enlargement following anterior cruciate ligament reconstruction.

The aim of the present study was to investigate the correlation between postoperative tunnel enlargement after ACLR and remnant tissue preservation using the hamstring tendon. One hundred and ninety-two subjects (male, n=101; female, n=91; mean age 27.1) who had undergone double-bundle ACL reconstruction were included in the present study. The patients were divided into two groups: the remnant tissue preservation group (Group R) and the non-remnant tissue preservation group (Group N). Computed tomographic scans of the operated knee were obtained at 2weeks and 6months after surgery. The area of the tunnel aperture for the anteromedial femoral tunnel (FAMT), posterolateral femoral tunnel (FPLT), anteromedial tibial tunnel (TAMT), and posterolateral tibial tunnel (TPLT) was measured. The area at 2weeks after ACLR was subtracted from the area at 6months after ACLR and then divided by the area at 2weeks after ACLR. The differences in the outcomes and characteristics of the two groups were evaluated. Seventy-seven knees were classified into Group R, and 115 knees were classified into Group N. The age, gender, and body mass index did not differ to a statistically significant extent. The percentages of FAMT and TAMT enlargement in Group R were significantly smaller in comparison with Group N (P=0.003 and P=0.03, respectively). The percentage of FPLT and TPLT enlargement in the two groups did not differ to a statistically significant extent. The remnant-preserving technique reduces the amount of bone tunnel enlargement. The present findings indicate the advantages of the remnant-preserving ACLR technique, and therefore the remnant-preserving technique should be recommended. II.

Clinical and arthroscopic outcome of single bundle anterior cruciate ligament reconstruction: Comparison of remnant preservation versus conventional technique

BackgroundThe purpose of this study was to compare the clinical outcomes and second-look arthroscopic findings of remnant preservation technique with those of conventional anterior cruciate ligament (ACL) reconstruction in single bundle ACL reconstructions. MethodsOne hundred sixty two consecutive patients underwent ACL reconstruction by one surgeon, with 93 patients receiving remnant preservation technique (Group A) and 69 patients receiving conventional ACL reconstruction (Group B). The mean follow-up was 15months. Clinical outcomes were assessed using Lysholm scores and the International Knee Documentation Committee form (IKDC form) evaluation. Post-operative knee stability was evaluated through manual knee laxity evaluation, pivot-shift test, and a Telos device. ResultsDifferences in post-operative stability (manual knee laxity, pivot shift test and Telos device) were not significant between the groups (p=0.681, p=0.610, p=0.696). And also no significant differences were noted with respect to the IKDC form and the latest Lysholm scores. But in the second-look arthroscopic findings, synovial coverage was confirmed to be excellent in 36% (22/61) of Group A patients and 23% (7/30) of Group B patients. ConclusionsACL reconstruction with both techniques was found to result in acceptable stability, clinical outcomes and second-look arthroscopic findings. With regard to synovial coverage, the remnant reservation techniques were found to be superior to conventional ACL reconstruction. Level of evidenceLevel III, retrospective comparative study.

Immunohistochemical and immunocytochemical study of mechanoreceptors in anterior cruciate ligament reconstruction with the remnant-preserving technique using Achilles tendon allografts

BackgroundAttempts have been made to validate the significance of remnant preservation with anterior cruciate ligament (ACL) reconstruction using immunohistochemical and immunocytochemical techniques. The purpose of this study was to examine the expression of mechanoreceptors in the remnant tissue of ACL reconstruction performed with the remnant-preserving technique.MethodsTissue samples were obtained from 10 patients who underwent ACL reconstruction with the remnant-preserving technique. The specimens were obtained from remnant ACL tissue and Achilles allografts superficially and at the tibial attachment. The control group consisted of three normal ACLs procured from young males who underwent partial meniscectomy. Tissues and cells from the ACL remnants and Achilles allografts were characterized using hematoxylin and eosin (H&E) staining and immunohistochemical, immunocytochemical, and immunoblotting assays. In particular, the sensitivity of neural cell validation was improved using nerve growth factor (NGF) to stimulate the expression of neural cells.ResultsThe results are summarized as follows. (1) In H&E staining and immunohistochemical assays, no neural cells were detected in remnant or allograft tissue. (2) In the immunocytochemical study, neural cells were detected in remnant tissue. (3) The increased proliferation of remnant ACL cells with NGF treatment suggested their identity as neural cells. (4) NGF treatment also stimulated protein and RNA expression of Nestin (a specific marker for neural cells) in remnant ACL cells.ConclusionsThe improved immunocytochemical methodology proved useful. Although mechanoreceptors were detected relatively less frequently than expected, the authors consider that this finding does not negate the necessity of remnant-preserving ACL reconstruction.

All Arthroscopic Remnant-Preserving Technique to Reconstruct the Lateral Ankle Ligament Complex

Arthroscopic lateral ankle ligament reconstruction has been recently advocated. But this technique has not been popularized because of the technical complexity and potential iatrogenic injury. Because the talocalcaneal and calcaneofibular ligaments are extra-articular structures, how to efficiently view and address them is a difficult task. Limited dissection outside the capsule to form a working space is required, but aggressive dissection is harmful for tissue healing although it is helpful for visualization and instrumentation. Because almost the entire talar body is covered by articular cartilage, it is very difficult to safely make a bone tunnel without damaging the cartilage. The remnants of the lateral ankle ligament have proprioceptive sensors that are important for functional stability, but it is difficult to perform anatomical reconstruction arthroscopically while preserving them because of the narrow working space. Furthermore, how to properly tension the reconstructed ligaments in such a narrow working space is also a very difficult task. We have designed a technique that preserves the remnants of lateral ankle ligaments, and all of the above-mentioned problems have been successfully addressed. We have used this technique clinically, and only minor complications occurred.

Study of neuroreceptors in native ACL stump and autologus hamstring tendon graft

BackgroundAnterior cruciate ligament (ACL) reconstruction is a very common arthroscopic surgery. All around the world the commonest autograft preferred is hamstring tendon. Present trend is more in favor of retaining the native ACL stump as the available neuroreceptors in the stump might help in early recovery of proprioception after ACL reconstruction. MethodsThis is a prospective study done on 56 cases. We took biopsy samples from knee joints of patients who had undergone arthroscopic ACL reconstruction at our hospital from native ACL stump as well as the graft (Semitendinosus) and sent them for immunohistological examination using S-100 Protein and NFP (Neural filament protein). ResultsChronicity of ACL deficient knee’s (injury to surgery more than 6 months) revealed poor positivity for neuroreceptors in sample A. After 3 months of injury there was a gradual decrease in positivity for neuroreceptors with persistence of these neural elements upto 6 months within remnant ACL stump. ConclusionThe results suggest that complete or partial ACL tears should be addressed by early arthroscopic ACL reconstruction using remnant-preserving technique, as the number of mechanoreceptors gradually deteriorates with time following injury.

Remnant Tissue–Preserving Technique for Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction

Preservation of the anterior cruciate ligament (ACL) remnant tissue has attracted notice in ACL reconstruction. Remnant preservation has been expected to have several potential advantages to improve postoperative knee stability such as enhanced graft coverage, accelerated cell repopulation, and revascularization. Recently, we have developed a new remnant-preserving technique for anatomical double-bundle ACL reconstruction using the semitendinosus tendon. The anterior laxity values and the results of the pivot-shift test were significantly better in the remnant tissue–preserving procedure than in the remnant tissue–resecting procedure. The arthroscopic evaluation showed that the remnant-preserving procedure was significantly better than the remnant-resecting procedure concerning postoperative laceration or tear of the grafts as well as synovial and fibrous tissue coverage of the grafts. However, to establish the clinical use of remnant tissue preservation, further randomized clinical studies are needed to objectively examine the effects on rotatory stability and the long-term survival of graft function.

Does the tibial remnant of the anterior cruciate ligament promote ligamentization?

BackgroundThe purpose of this study was to clarify the difference in ligamentization between the remnant-preserving (RP) and remnant-sacrificing (RS) techniques in anterior cruciate ligament (ACL) reconstruction using magnetic resonance imaging (MRI). MethodsA retrospective comparative study was carried out on 98 patients undergoing ACL reconstruction using either an RP (n=56) or RS (n=42) technique. MRI was performed at one of four time points postoperatively, and the signal intensity of the ACL graft was analyzed using the signal to noise quotient (SNQ) ratio and inter-bundle high signal intensity, along with an analysis of the survival rate of remnant tissue. ResultsThe mean SNQ ratio of grafted tendons in the RP group was significantly higher than that seen in the RS group in the proximal and middle regions two to four months after surgery (P<0.05) and was significantly lower than that seen in the RS group in all regions at 12 –18months (P<0.05). The inter-bundle high signal intensity was observed more frequently in the RP group (73.7%) at two to four months. Tibial remnants were observed on postoperative MRI regardless of when MRI was conducted. ConclusionThe ACL graft of the RP group showed higher signal intensity in the early stage and lower signal intensity in the late stage compared to that of the RS group. The ligamentization of grafts in the RP group proceeded more quickly. Preserving the remnant in ACL reconstruction appears to have a positive effect on ligamentization.