Semitendinosus-gracilis Graft Research Articles

A novel practical method to predict anterior cruciate ligament hamstring graft size using preoperative MRI

BackgroundPredicting hamstring graft size preoperatively for anterior cruciate ligament (ACL) reconstruction is important for preempting an insufficient diameter in graft size intraoperatively, possibly leading to graft failure. While there are multiple published methods using magnetic resonance imaging (MRI) picture archiving and communication systems (PACS), most are not feasible and practical. Our study aims to (1) practically predict the ACL hamstring graft size in a numerically continuous manner using the preoperative MRI from any native MRI PACS system, (2) determine the degree of correlation between the predicted and actual graft size, and (3) determine the performance of our prediction method if we define an adequate actual graft size as ≥ 8 mm.MethodsA retrospective review of 112 patients who underwent primary ACL reconstruction with quadrupled hamstring semitendinosus-gracilis grafts at a tertiary institution was conducted between January 2018 and December 2018. Graft diameter can be predicted in a numerically continuous manner as √[2*(AB + CD)], where A and B are the semitendinosus cross-sectional length and breath, respectively, and C and D are the gracilis cross-sectional length and breath, respectively.ResultsA moderately positive correlation exists between the predicted and actual graft diameter (r = 0.661 and p < .001). Our method yields a high specificity of 92.6% and a moderate sensitivity of 67.2% if we define an adequate actual graft size as ≥ 8 mm. An area under receiver-operating characteristic curve shows good discrimination (AUC = 0.856).ConclusionsWe present a practical method to predict the ACL hamstring graft size with high specificity using preoperative MRI measurements.

Influence of female sex and double-quadruple semitendinosus-gracilis graft on the incidence of postoperative symptomatic cyclops lesions after ACL reconstruction.

Risk factors for the development of symptomatic cyclops lesion after anterior cruciate ligament reconstruction (ACLR) surgery are not entirely identified yet. This study aimed to investigate whether the choice of hamstring graft (semitendinosus-gracilis; STG vs. semitendinosus; ST) affects the risk of developing a symptomatic cyclops lesion after ACLR. This retrospective cohort study included 1416 patients receiving either an ST graft (n = 1209) or an STG graft (n = 207) ACLR with a follow-up of at least 2 years. A persisting extension limitation was clinically determined, and cyclops lesions were confirmed by magnetic resonance imaging (MRI) and second-look arthroscopy. Graft-specific incidence of cyclops lesions was examined with χ2 test and combined with the factors number of graft bundles, graft diameter and sex evaluated with a binominal logistic regression model. In total, 46 patients developed symptomatic cyclops lesions (3.2%), with 36 having ACLR with an ST graft (3.0%) and 10 with an STG graft (4.8%) (n.s). The mean time from ACLR to the second-look arthroscopy for cyclops removal was 1.1 ± 0.6 years. Female patients were 2.5 times more likely to develop a cyclops lesion than male patients. Patients with an STG graft and larger graft diameters did not have a higher risk of developing cyclops lesions. Patients who received an STG graft with both tendons folded four times (double-quadruple) had significantly higher risk of developing a cyclops compared with all other numbers of graft bundles combined (8.3%, respectively 3.0%; p = 0.014). This study could not prove an increased risk of developing a symptomatic cyclops lesion for patients with an STG graft compared with an ST graft used for ACLR. However, patients with a double-quadruple ACLR had a higher percentage of cyclops lesions compared with all other numbers of graft bundles. Female sex was associated with an increased risk of developing cyclops lesions. Level III.

Comparison of “ligamentization” process between preserved insertion hamstring tendon autograft and bone-patellar tendon-bone autograft

BackgroundLigamentization is a complex process and effect of preservation of hamstring tendon graft insertion on this process is not well studied. Present study was conducted to analyze and compare the ligamentization of semitendinosus gracilis graft with preserved tibial insertion (STGPI) and bone-patellar tendon-bone (BPTB) autografts. MethodsA total of 50 sportspeople who underwent ACL reconstruction using either BPTB (group A; n = 25) or STGPI (group B; n = 25) autografts were included in the study. Contrast enhanced MRI was done at 8 months and 14 months post-ACL reconstruction to evaluate the ligamentization using Signal noise quotient (SNQ), graft intensity and enhancement index. Clinical outcomes (Lysholm score) and knee laxity were also assessed at 8 months and 14 months. Results18/23 (78%) patients in group A and 14/23 (61%) patients in group B had hyperintense graft signal at 8 months (n.s.) and at 14 months, 1/23 patients in group A and none of the patients in group B had hyperintense graft. SNQ at 8 months was 3.6 ± 2 and 3.7 ± 2 in group A and B respectively (n.s.) and at 14 months, SNQ was 2.5 ± 1.5 in group A and 2.4 ± 1.3 in group B (n.s.). Enhancement index at 8 months was 1.5 ± 0.3 and 1.2 ± 0.3 in group A and B respectively (p = 0.0001). Enhancement index at 14 months was 1.21 ± 0.2 in group A and 1.07 ± 0.2 in group B (p = 0.003). Functional outcomes and knee laxity were comparable in both the groups at 8 and 14 months (n.s.). ConclusionBoth the grafts i.e. BPTB and STGPI are similar in terms of rate and extent of ligamentization. Clinical outcomes and knee laxity are also comparable between two grafts.

Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review.

The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities. A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools. Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation. Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Anterior Cruciate Ligament Reconstruction With the All-Inside Technique: Equivalent Outcomes and Failure Rate at Three-Year Follow-Up Compared to a Doubled Semitendinosus-Gracilis Graft.

Purpose: To compare in terms of failure rates, clinical and functional outcomes the all-inside anterior cruciate ligament (ACL) reconstruction with double suspensory fixation and quadrupled semitendinosus autograft with anteromedial portal doubled semitendinosus-gracilis autograft with suspensory femoral and tibial interference screw fixation.Methods: Forty-four patients were sequentially allocated into two groups and followed up prospectively for a 3-year period. The first group was the all-inside group and the second was the “classic” AM portal with S-G graft. Each group comprised 22 patients. All patients underwent KT-1000 testing preoperatively and at a minimum of six months postoperatively. Visual pain analog was recorded preoperatively and during both the immediate postoperative period and throughout the follow-up. The Lysholm knee score was used comparing the preoperative and 24-month timepoints.Results: The visual analog scale (VAS) pain scores showed a significant difference at two weeks (2.4 vs 1.8, p < 0.01 ) in favor of the all-inside group, but that difference disappeared in the later follow-up visits. Similarly, there was no significant difference with Lysholm knee scores at two years and the side-to-side anterior translation measured with the KT-1000. At the three-year mark, there were no failures in either of the groups.Conclusion: The all-inside technique appears to be equivalent in terms of outcomes to the classic S-G technique, and given the less-invasive nature and versatility in graft choices is a safe and effective technique for primary ACL reconstruction.

A BIOMECHANICAL COMPARISON OF MATCHED FOUR-STRAND AND FIVE-STRAND SEMITENDINOSUS-GRACILIS GRAFTS

ABSTRACT Introduction: Recent studies have shown that the likelihood of semitendinosus-gracilis graft rupture is inversely correlated to its diameter. A graft can be prepared in a five-strand or four-strand fashion to increase its diameter. However, the biomechanical superiority of five-strand semitendinosus-gracilis grafts is still under debate. Objective: This study aimed to evaluate the biomechanical characteristics of matched four-strand and five-strand human semitendinosus-gracilis grafts. Methods: We evaluated semitendinosus-gracilis tendons harvested from ten fresh human male and female cadavers, aged 18-60 years. Four-strand or five-strand grafts were prepared with the tendons and fixed to wooden tunnels with interference screws. Each graft was submitted to axial traction at 20 mm/min until rupture; the tests were donor matched. Data were recorded in real time and included the analysis of the area, diameter, force, maximum deformation and stiffness of the grafts. Results: The diameter, area and tunnel size were significantly greater in the five-strand grafts than in the four-strand grafts. There were no significant differences in biomechanical properties. The area and diameter of the graft were positively correlated to stiffness, and inversely correlated to elasticity. There was no significant correlation between graft size and maximum force at failure, maximum deformation or maximum tension. Conclusion: Five-strand hamstring grafts have greater area, diameter and tunnel size than four-strand grafts. There were no significant differences in biomechanical properties. In this model using interference screw fixation, the increases in area and diameter were correlated with an increase in stiffness and a decrease in elasticity. Level of evidence V; biomechanical study.

Long-term outcome following anterior cruciate ligament reconstruction: preliminary results of a 25-year prospective study

Background: In 1993, Gillquist stated that the only effect of anterior cruciate ligament (ACL) reconstruction is to give the patient enough security to reach the goal of going back to strenuous sports and then ruining the knee. Very few long-term studies able to address this issue, exist. This prospective long-term study aims to investigate objective and subjective outcomes 25 years post-ACL reconstruction using either bone-patellar tendon-bone (B-PT-B) or semitendinosus/gracilis (STG) grafting. Methods: The first ten patients (7 males, 3 females, mean age 51 years, B-PT-B graft n=4, STG graft n=6) from a cohort of 62 patients operated on between 1996 and 1998 were assessed using the same measures as three previous time-frames. This cohort had followed comprehensive quadriceps-emphasised rehabilitation delivered by the same physiotherapist. Outcome measures included quadriceps and hamstring strength (Cybex 11), clinical and instrumented stability (KT1000), three agility tests (shuttle run, side-step, carioca), two hop tests (hop, triple hop), return to sport history, current sport involvement, and bilateral knee x-rays. Results: One patient ruptured their graft and contralateral patellar tendon; one patient tore their hamstring; one patient had two arthroscopies; and two patients ruptured their contralateral ACL, one of whom underwent bilateral total knee replacements (TKR). Mean quadriceps strength index (60°/sec) was 92%, and mean hamstring index was 90%. Mean KT1000 side-to-side difference (20 lbs) was 1mm. One patient had a positive pivot shift test and one a pivot glide. Excluding the patient with TKRs, nine patients performed the agility tests well. Mean hop indices were 94% for the hop and 96% for the triple hop (n=8). Nine patients had returned to competitive pivoting sport, three for nearly 20 years. Three patients continued to play competitive volleyball, cricket and soccer at Masters level. Six patients remained active in less vigorous activities (running, football coaching, golf, aerobics, gym). On x-ray, four patients had mild tibiofemoral osteoarthritis (TFOA), four had moderate TFOA and one had severe TFOA (Kellgren-Lawrence grading). Findings were similar for patellofemoral OA. No patient regretted having surgery. Discussion: The most important finding was the high level of strength, stability, function and sports participation found in this group, despite moderate-severe radiographic OA observed in half of the patients. Ongoing study of the full cohort will provide key information as to how clinicians can improve long-term results following ACL reconstruction. My co-authors and I acknowledge that we have no conflict of interest of relevance to submission of this abstract.

Comparison of Bone-Patellar Tendon-Bone Graft, Semitendinosus-Gracilis Graft and Semitendinosus-Gracilis with Preserved Tibial Insertion Graft in Anterior Cruciate Ligament Reconstruction in Sports Persons.

Introduction:Bone-patellar tendon-bone (BPTB) and semitendinosus–gracilis (STG) are the commonest grafts used for ACL reconstruction. However even after having been debated for years, there is no consensus about the ideal graft. Moreover, the literature is deficient about STG graft with preserved tibial insertion (STGPI) which preserves the proprioception. Our aim is to compare the outcome of BPTB, free STG and STGPI grafts after ACL reconstruction in professional sports persons. We compared the outcome in terms of mechanical stability, functional outcome, return to sports activity and degenerative changes.Material and Methods:Professional sports persons aged between 16-50 years operated for ACL tear using BPTB, free STG and STGPI grafts with minimum follow-up of two years were identified from hospital records. Patients with associated knee injuries were excluded. Patients, divided in three groups according to graft used, were compared in terms of mechanical stability (arthrometric examination KT-1000 score), functional outcome (Lysholm Score), return to sports activity (Tegner score and difference in thigh circumference) and degenerative changes (KL grading).Results:BPTB graft group was found to be better than free STG and STGPI graft groups in terms of KT-1000 score. There was no statistically significant difference among the groups in terms of Lysholm score, Tegner score, difference in thigh circumference and KL grading.Conclusion:BPTB graft is better than free STG and STGPI grafts in terms of knee stability. When compared for patient reported outcome, return to sports activity, osteoarthritic changes and graft failure there is no significant difference among the three types of grafts.

A STUDY OF THE OUTCOME OF “LIGAMENT CROISE ANTERIEUR" (ACL) RECONSTRUCTION USING AUTOLOGOUS HAMSTRING GRAFT

ACL injury is a widely recognized injury affecting the Genu-Joint Male to female ratio of “L ” injuries are, igament Croise Anterieur (ACL) as high as 9 :1 igament Croise Anterieur (ACL) . “L ” reconstruction with Hamstring grafts, is currently one of the most commonly used method nowadays. This Prospective study of 30 subjects treated by surgicalarthroscopic technique, wherein, Quadrupled Graft of Hamstring was used,for the femoral xation, an endo-button was used, and for the tibial xation, screw of the interference variety was used. Patients were on routine follow up,for at least a period of one year. All the subjects were subjected to post-operative AP and LAT X-rays, to ear mark the placement of the tunnel and positioning of the endo-button in the femoral sector and the interference screw in the tibial sector. Subjects were,upon a follow-up program, at 1,2,3months and there again at the end of 6 months and later on twice in a year. All subjects were evaluated with Tegner and Lysholm Knee Scoring Scale. The major Goal of “L ” recon, is towards re-establishing the stability of the knee. Succe igament Croise Anterieur (ACL) ssful functional outcomes following “L ” reconstruction,with a Semi-tendinosus Gracilis Graft, ha igament Croise Anterieur (ACL) s been reported in the literature. The optimal xation methodology for “L ” reconstruction is still evolving and the e igament Croise Anterieur (ACL) xisting xation devices which has been extensively used are the Endo-button and the “Biological Interference Screws, which has led to a better rehabilitation program postoperatively. In our study, all subjects were ordained to a proper rehabilitation protocol. 10% (n=3) subjects in the present study, had excellent results, 80% (n=24) of the subjects had good results and 10% (n=3) of the subjects had fair results. No subjects were reported to be, in the poor outcome category. Treatment of “L ” njuries necessitates, cautious pre-operati igament Croise Anterieur (ACL) i ve planning, selection of patients, radiological evaluation, selection of graft thickness, planning of timing of surgery, careful intra-operative care, good technique and post-operative rehabilitation, including thorough counselling for a good functional outcome.

A Comparison between Early and Delayed Arthroscopic Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study

Introduction: A complete Anterior Cruciate Ligament (ACL) injury can result in a progressively increasing symptomatic knee instability, which can cause recurrent intra articular damage and eventually results in osteoarthritis if not treated on time. Aim: To analyse the effects of delaying ACL reconstruction beyond a period of 12 weeks and compared the results with cases managed before that time period. Materials and Methods: A prospective cohort study was conducted between July 2017 to October 2019 in Government Medical College, Jammu on two groups of patients divided into early (&lt;12 weeks) and delayed (&gt;12 weeks) on the basis of interval between the injury and definitive surgery. ACL reconstruction was done using a quadrupled semitendinosus-gracilis graft. A standard rehabilitation protocol was followed and the results were compared. Patients were followed-up till one year postsurgery. Software used for statistical analysis was EpiInfo Version 3.0 and SPSS. Results: A total of 72 patients were included in the study. Forty patients were in the early group and 32 in delayed. Male patients outnumbered the females in both the groups and the incidence of injury was more on the right side. Sports injuries were the most common mode of injury, followed by falls and road traffic accidents in both the groups. The incidence of grade 3/4 medial and Lateral Meniscal (LM) tears was more in the delayed group and the association was statistically significant (p&lt;0.05). There was significant thigh wasting in the delayed group (p&lt;0.05). Two patients were lost to follow-up and were not included in the study. Conclusion: Delay in ACL reconstruction surgery predisposes to higher grade meniscal lesions and significant thigh wasting and hence the surgery should be preferably done within the first 12 weeks after injury.

Pre-operative Joint Inflammation has no Bearing on Outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction at 1-Year Follow-Up; a Prospective Study.

To study the effect of pre-operative joint inflammation on clinical outcome at 1year follow-up following ACL reconstruction surgery. Male patients, aged 18-40years, suffering from isolated ACL injury were included. All patients were randomly divided into two groups based on the type of graft used: Group A: semitendinosus gracilis graft with preserved insertions (STG-PI), Group B: bone-patellar tendon-bone graft (BPTB). Patients were categorised based on the time of presentation after injury: (a) within 6weeks of injury, (b) between 6 and 12weeks of injury, (c) after 12weeks of injury. Synovial fluid levels of Interlukin-1, Interlukin-6 and TNF-α were measured in all the ACL deficient knees by taking a joint fluid sample intra-operatively. The total number of patients in the study was 59; 23 in group A (STG-PI) and 36 in group B (BPTB). Mean age of patients was 26 ± 5.146years. 14 out of 59 (23.7%) patients presented within 6weeks of injury, 16 (27.11%) patients presented between 6 and 12weeks after injury and 29 (49.1%) patients presented after 12weeks of injury. IL-6 levels were significantly high in group with < 6weeks of injury than in group with > 12weeks since injury. IL-6 had significant correlation with VAS scores, KT 1000, Lysholm knee scores and Tegner level of activity. There was no difference in outcome (pain scores, mechanical stability, Lysholm knee score and Tegner level of activity) at 1year follow-up when patients with different time intervals since injury were compared. The clinical outcome in terms of pain score, mechanical stability, functional scores and return to sporting activity is comparable, irrespective of the time since injury, at short term follow-up.

Comparison of clinical results of anteromedial and transtibial femoral tunnel drilling in ACL reconstruction

BackgroundA femoral bone tunnel in ACL reconstruction can be constructed from the outside in or from the inside out. When doing it inside out, the approach can be via the anteromedial (AM) portal or through the tibial bone tunnel. It has been suggested that better results might be expected by doing it anteromedially. Clinical results after femoral tunnel drilling via the AM or transtibial (TT) techniques in reconstruction of anterior cruciate ligament (ACL) are presented.MethodsThree hundred patients with ACL injuries were chosen for this study from previously collected data on ACL reconstructions. They were divided into two groups: 150 patients treated with AM drilling and 150 treated with TT drilling. In the AM group, the reconstructions were performed using a semitendinosus graft with the Tape Locking Screw (TLS™) technique (n = 87) or Retrobutton™ femoral and BioScrew™ tibial fixation with a semitendinosus-gracilis graft (n = 63). In the TT group, the fixation method used was Rigidfix™ femoral and Intrafix tibial fixation with a semitendinosus-gracilis graft. The evaluation methods were clinical examination, knee scores (Lysholm, Tegner and IKDC) and instrumented laxity measurements (KT-2000™). Our aim was to evaluate if there was better rotational stability and therefore better clinical results when using AM drilling compared to TT drilling.ResultsAfter excluding revision ACL reconstructions, there were 132 patients in the AM group and 133 in the TT group for evaluation. At the 2-year follow-up, there were 60 patients in the AM group (45.5%) and 58 in the TT group (43.6%). There were no statistically significant differences between the groups in any of the evaluation methods used.ConclusionBoth drilling techniques resulted in improved patient performance and satisfaction. We found no data supporting the hypothesis that the AM drilling technique provides better rotational stability to the knee.Trial registrationISRCTN registry with study ID ISRCTN16407730. Retrospectively registered Jan 9th 2020.

Arthrodesis with Retrograde Intramedullary Nail for Recurrent Infected Total Knee Arthroplasty with Patellar Tendon Rupture: A Case Report and Literature Review

Patellar tendon rupture after total knee arthroplasty is a rare, but often catastrophic complication. In addition, infection is also a dreaded complication after total knee arthroplasty. We report an 84-year-old female that has late infected total knee arthroplasty with patellar tendon rupture treated with resection arthroplasty and then subsequent arthrodesis with retrograde intramedullary nail.Case Presentation:The 84-year-old female underwent left total knee arthroplasty 2 years ago and revision arthroplasty last year after trauma. She presented to the emergency department with painful disability of left knee. The septic arthritis of left knee was confirmed by bacterial culture through arthrocentesis which yielded methicillinsensitive staphylococcus aureus. Patellar tendon rupture was also noted by loss of extension mechanism and patella alta in plain films. Despite attempts on open debridement and parenteral antibiotics, the infection did not settle. Resection arthroplasty with vancomycin- impregnated cement spacer implantation was performed following by 4-week parenteral antibiotics therapy. The ESR and CRP level of serum improved gradually. Arthrodesis of left knee with retrograde locking intramedullary femoral nail through single incision of the knee was performed. Protected weight bearing was allowed in one week after arthrodesis. The patient discharged 2 weeks later without recurrent infection, but leg length discrepancy about 2cm was noted.Discussion:Patellar tendon rupture after total knee arthroplasty is a rare but disabling complication whose management is often difficult. It was reported that incidence of patellar tendon rupture in literature varies between 0.3- 12.4% for primary total knee arthroplasty and between 1-15% for revision total knee arthroplasty. Contributing factors are excessive dissection and knee manipulation, and trauma. In the literature, various different operative techniques and rehabilitation programs have been described indicating the lack of a golden standard treatment protocol. However, in patients with a total knee arthroplasty, the results have been discouraging. Reconstruction of the patellar tendon can be utilized semitendinosus-gracilis graft with an interference screw and a staple fixation in treating acute ruptures, whereas allografts and synthetic mesh are indicated for chronic cases. Nevertheless, treatment outcomes for ruptured patellar tendon are not good. Gold standard treatment of infected total knee arthroplasty was resection arthroplasty with antibiotic-impregnated bone cement spacer and parenteral antibiotics therapy and then second stage revision total knee arthroplasty until the infection is eradicated. The patella tendon repair and second revision arthroplasty were not suggested by Jake et al. Patellar tendon rupture is best treated with primary repair, but infected prosthetic knee with patellar tendon rupture seemed to be more difficult to manage. Arthrodesis but not revision arthroplasty may be the best choice after infection control to improve the patient’s level of function.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion": A Randomized Clinical Trial.

The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft. One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. Mean KT-1000 side-to-side difference at 1year was 2.31 ± 1.68mm in BPTB cohort and 2.52 ± 1.6mm in STGPI cohort (P = 0.4); and at 2years, it was 1.98 ± 1.62mm in BPTB cohort and 2.23 ± 1.6mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Comparison of Therapeutic Results of Open and Arthroscopic Surgery on Functional Level, Duration of Return to Daily Activity and Satisfaction with Treatment in Patients with ACL Rupture

Bone-Patellar Tendon-Bone autograft (BPTB) and four-strand semitendinosus-gracilis (hamstring) graft are the most common methods for reconstructing anterior cruciate ligament but there is still controversy over the best method. The aim of this study was to compare the therapeutic results of two methods of BPTB and four-strand semitendinosus-gracilis (hamstring) grafts using arthroscopic treatment in patients with anterior cruciate ligament (ACL) rupture. This retrospective study was performed on 85 patients with ACL rupture aged 17-45 years who referred to Imam Khomeini Hospital in Ahwaz from the beginning of 2016 to the end of 2017 who had undergone two years of ACL reconstruction surgery, either by bone-patellar tendon-bone autograft (BPTB) (open surgery) (n=23) or four-strand hamstring autograft (semitendinosus-gracilis) (by arthroscopy) (n=25). Lysholm score was used for knee functional status assessment, Lachman test for tendon laxity, and pivot shift test for strength evaluation. The 36-Item Short-Form Health Survey questionnaire (SF-36) was also completed and compared at the last follow-up. Patients were also evaluated by type of daily activity (heavy or light activity). There was no significant difference between the two groups in the Lysholm score (P&gt;0.05) and both groups were classified as “Good”. There was no significant difference between the frequency distribution of patients based on Lachman test results and pivot shift results (P&gt;0.05). None of the patients in the two groups had any rupture within two years after treatment. Both groups had good satisfaction with treatment and quality of life and there was no statistically significant difference between the mean SF-36 scores (P&gt;0.05). There was no significant difference between the two groups in the light and heavy activity groups. Although complication in short-term follow-up was more in patients undergoing open surgery, the functional level and treatment satisfaction in patients treated by open surgery (bone-patellar tendon-bone autograft) and arthroscopy (four-strand hamstring autograft) were not significantly different after two years. Therefore, according to the surgeon's diagnosis or the patient's choice, both methods can be selected; method with acceptable therapeutic outcomes in reconstructing the anterior cruciate ligament.

Application of two types of suspensory fixation in reconstruction of anterior cruciate ligament with a semitendinosus-gracilis graft: A randomized prospective study

Background/Aim. Injury to the anterior cruciate ligament (ACL) of the knee is the most common ligament injury that requires operative treatment. So far, multiple ACL reconstruction (ACLR) techniques using a variety of graft types and implants that fixate the grafts have been described. The aim of the study was to compare two different ACLR techniques using two implant types for suspensory graft fixation in the femoral tunnel. Methods. This randomized-prospective study encompassed 60 patients/subjects who underwent ACLR in the period between January 2015 and December 2017 at the Department of Orthopaedics and Traumatology of Military Hospital ?Dr Vladan Djordjevic? Nis. The ACLR in all patients included in the study was per-formed using a quadruple semitendinosus-gracilis (STG) graft with two types of suspensory fixation on the lateral femoral cortex, whereas the graft fixation in the tibial tunnel was performed using an osteoconductive bioresorbable screw. The post-operative knee stability was assessed 24 months after surgery using the Lachman test and the lateral pivot shift test, as well as the KT-1000 arthrometer test. Results. In patients whose graft was fixated using a fixed-length loop implant, the mean post-surgery knee stability, measured with the KT-1000, was 1.167 ? 0.780; in patients whose graft was fixated using an adjustable-length loop implant, the mean value of the KT-1000 was 1.100 ? 0.894 (p = 0.605). The mean post-surgery International Knee Documentation Committee (IKDC) score for the fixed-length loop group was 84.887 ? 9.0207, while for the adjustable-length loop the score was 88.327 ? 7.302. The mean Lysholm score was 93.50 ? 6.872 for the fixed-length loop group of patients and 94.00 ? 5.527 for the adjustable-length loop group of patients. Conclusion. Both types of implants can be used with success during ACLR, because the functional results of operative treatment using both implants were identical after surgery.

Poor Functional Outcome in Patients with Voluntary Knee Instability after Anterior Cruciate Ligament Reconstruction

BackgroudAnterior cruciate ligament reconstruction (ACLR) remains the gold standard treatment for anterior cruciate ligament (ACL) injury. However, a good functional outcome even after a successful surgery depends on multiple factors. It has been observed that certain patients with a chronic ACL injury demonstrate knee instability voluntarily. The authors observed that these patients might not perform well even after a successful surgery. This study aims to assess the outcome after ACL and other ligament reconstruction in patients with voluntary knee instability.MethodsFrom a total of 824 patients who underwent ACLR, 13 patients with a history of voluntary knee instability were selected, and data of these patients (demographic and clinical profile) were obtained. Outcomes of surgery in this group of patients were evaluated by using Lysholm score and Tegner activity level.ResultsAll patients were young men with a chronic ACL injury and manifested instability. Associated injuries were lateral meniscus tear in 3 patients, medial meniscus tear in 2, and posterolateral corner (PLC) injury in 3. ACLR was done using the semitendinosus-gracilis graft in all patients. Further, anterolateral ligament reconstruction was done in 2 patients and PLC reconstruction, in 3 patients. The mean Lysholm score was 54.76 (range, 48–62) preoperatively and 60.92 (range, 54–78) at a mean follow-up of 14.3 months (range, 11–26 months). The median Tegner activity level was 6 (range, 5–7) before injury and 4 (range, 3–5) at the final follow-up. Twelve of the 13 patients were able to demonstrate instability voluntarily at the time of the final follow-up.ConclusionsIn patients with ACL and other ligament injuries who demonstrated voluntary knee instability, the functional outcome even after successful ligament reconstruction was poor.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion:" A Randomized Clinical Trial.

Background:The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction.Purpose:This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone–patellar tendon-bone (BPTB) graft.Materials and Methods:One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score.Results:Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain.Conclusion:There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Foot rotation influences the activity of medial and lateral hamstrings during conventional rehabilitation exercises in patients following anterior cruciate ligament reconstruction

ObjectivesTo investigate the influence of internal and external foot rotation on medial and lateral hamstring electromyographic (EMG) activity during conventional hamstring exercises in patients following anterior cruciate ligament (ACL) reconstruction. DesignCross-sectional study. SettingEMG activity of medial and lateral hamstrings was recorded during prone leg curl, single-leg bridge and Nordic hamstring exercises with three different foot positions (neutral, internal rotation, external rotation), randomly presented. ParticipantsTwenty patients 9–15 months after ACL reconstruction with the semitendinosus-gracilis graft. Main outcome measuresConcentric and eccentric EMG activity normalized to the EMG activity recorded during a maximal voluntary contraction (MVC). ResultsCompared to the neutral position, the EMG activity of the medial hamstring during prone leg curl exercise was significantly increased by internal foot rotation (concentric: +8.7% MVC; eccentric: +5.9% MVC; p < 0.01; d = 0.88–0.99) and decreased by external rotation (concentric: 5.8% MVC; eccentric: 5.2% MVC; p < 0.05; d = 0.67–0.92). Foot position did not significantly affect hamstring EMG activity during single-leg bridge and Nordic hamstring exercises. ConclusionsActive internal rotation of the foot during prone leg curl exercise can help selectively maximize muscle activity of the medial hamstring portion. This may have implications for post-operative rehabilitation of ACL patients with a semitendinosus-gracilis graft.

Primary revision with replasty of the anterior cruciate ligament

Restoration of knee stability after rerupture of an anterior cruciate ligament (ACL) graft. Acute and chronic functional instability with rerupture of an ACL graft with subjective instability with anatomical or non-anatomical bone tunnel without tunnel widening. Partial anatomical bone tunnels of the previous operation, significant tunnel widening of anatomical bone tunnels, local infection of the knee joint, local soft tissue damage. Graft choices are hamstring tendons (semitendinosus muscle, gracilis muscle), the quadriceps tendon, patellar tendon and aperoneus tendon split graft. In cases with anatomical tunnels, careful debridement is performed down to the tunnel wall.In non-anatomical tunnels, anew femoral tunnel is drilled over adeep anteromedial portal with the knee flexed more than 110° in the insertion area of the ACL.Using drills and dilators, atunnel is prepared.At the tibia, the anterior horn of the lateral meniscus serves as alandmark in the absence of an ACL stump.The cortical tibial tunnel aperture is probed with aguide wire and the tunnel is drilled stepwise until the tunnel wall is reached, which is debrided with aspoon or synovial resector to remove graft residues and implants from the tunnel.The femoral fixation can either be done with aflip button, an interference screw or in the case of abone block graft implant-free. At the tibial side, the graft is fixed with aresorbable interference screw and fixation button. The rehabilitation program comprises 4-5phases. Inflammatory phase (weeks1-2): control of pain and swelling (cooling, isometric tension exercises, 20 kg partial load). Phase2 (weeks 2-6): increasing load and range of motion with closed chain exercises (target: extension/flexion 0-0-120°). Phase3 (from week6): strength and coordination exercises. Phase4: balance, strength and jump exercises. Return to competitive sport not before postoperative month 6-10. Included were 51patients with recurrent instability after ACL surgery where primary ACL replacement was performed with ipsilateral bone quadriceps tendon graft or contralateral semitendinosus-gracilis graft. All patients had anatomical or non-anatomical tunnel locations without significant widening (>11 mm). After 2years, the side-to-side difference for anterior tibial translation measured with the KT 1000 arthrometer was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group (P = 0.461). No difference in the rate of positive pivot shift tests (P = 0.661); no significant difference in the individual Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores or in the frequency of anterior knee pain.