Tendon-bone Anterior Cruciate Ligament Reconstruction Research Articles

Less Subsequent Revision Anterior Cruciate Ligament Reconstruction Following Primary Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation—A Retrospective Comparative Therapeutic Trial With 5-Year Follow-Up

To investigate patient outcomes, including revision rate, following primary bone patellar-tendon bone autograft (BPTB) anterior cruciate ligament reconstruction (ACLR) with and without suture tape augmentation (STA) in a young and active cohort. All eligible patients who received primary BPTB ACLR with a minimum of 2-year follow-up were included in this retrospective cohort study. All patients receiving STA were augmented with the same device. Patients completed the following patient-reported outcome measures (PROMs): the visual analog scale, the Single Assessment Numeric Evaluation, the Knee Injury and Osteoarthritis Outcome Score subscales, and the Tegner activity scale. Anteroposterior knee laxity was assessed using a KT-1000 arthrometer preoperatively and 1-year postoperatively. Posterior tibial slope, femoral tunnel angle, and tibial tunnel placement were calculated for all patients. Subsequent surgical interventions and return to sport (RTS) were obtained from each patient. One hundred fourteen patients (52 BPTB ACLR with STA, 62 traditional BPTB ACLR) with a mean patient age <19 years and a mean final follow-up of ≥5 years were included. Compared with the control group, the STA group demonstrated significantly less subsequent revision ACLR (0 vs. 5, P= .036). All PROMs and KT-1000 measurements improved at final follow-up (P<.001) and were comparable between groups. There were no differences seen in either posterior tibial slope or graft tunnel placement between groups. More than 85% of the patients were able to return to the sport that led to their injury at full capacity with no differences seen in RTS rate, time to RTS, or level of competition between groups. Compared with traditional BPTB ACLR, additional STA appeared to safely and effectively lead to less subsequent revision ACLR while maintaining acceptable PROMs and objective joint laxity measurements in a young and active patient population. Level III, retrospective cohort study.

Functional Anterior Knee Pain and Return to Sport Following Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction

Background: Bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction is a frequently used technique but has been associated with a high incidence of postoperative anterior knee pain. However, previous studies have not evaluated if this anterior knee pain is functionally limiting for patients. This study introduces the concept of functional anterior knee pain, or kneecap pain that limits patients' ability to return to their prior level of activity or sport. Methods: We reviewed BPTB ACL reconstructions from April 2013 to May 2017. Patients included in the analysis had a minimum of 1 year of clinical follow-up and 3 years of survey follow-up. Statistical analyses were performed using paired t tests and binomial test. Results: Sixty-seven patients met the inclusion criteria. Compared to the mean preoperative visual analog scale (VAS) pain score of 6.1, patients reported statistically significant reductions in VAS scores at 1 year and 3 years postoperatively to 0.9 and 1.8, respectively (P<0.01). The incidence (28.4%) of anterior knee pain was highest at the 3-month time point. This incidence decreased to 6.0% at 1 year and 7.5% at 3 years postoperatively. At 3 years postoperatively, 94% (63/67) of the patients in this study were not limited by functional anterior knee pain and returned to preoperative levels of activity and sport. Conclusion: To our knowledge, this investigation is the first to define and quantify the relationship between postoperative anterior knee pain and resultant functional limitations. This study shows that ACL reconstruction with BPTB autograft was not significantly associated with functional anterior knee pain in our population and that the incidence of postoperative anterior knee pain following BPTB ACL reconstruction may be less than previously reported.

Low percentage of patients passed the ‘Back in Action’ test battery 9 months after bone-patellar tendon-bone anterior cruciate ligament reconstruction

BackgroundAnterior cruciate ligament (ACL) reconstruction is recommended in patients who intend to return to high-level sports. However, there is only a 55–80% return to pre-injury level of sports after ACL reconstruction, with a re-injury rate up to 20%. The aim of this study was to determine the percentage of patients passing the Back in Action (BIA) test 9 months after primary bone-patellar-tendon-bone (BPTB) ACL reconstruction, and evaluate the association between passing the BIA test and patient reported outcome measurements (PROMs). MethodsPatients underwent the BIA test 9 months after BPTB ACL reconstruction. In total 103 patients were included. Passing the BIA test (PASSED-group) was defined as a normal or higher score at all sub-tests with limb symmetry index (LSI) ≥90% for the dominant leg and LSI >80% for the non-dominant leg. Patients who did not meet these criteria were defined as the FAILED-group. PROMs included the International Knee Documentation Committee, Knee injury Osteoarthritis Outcome Score and Anterior Cruciate Ligament-Return to Sport after Injury. ResultsEighteen patients (17.5%) passed the BIA test 9 months after BPTB ACL reconstruction. PROMs were not statistically significant different between the PASSED- and FAILED-group. ConclusionLow percentage of patients passed the BIA test 9 months after BPTB ACL reconstruction. Although current PROMs cut-off values were met, the BIA test results show persistent functional deficits. Therefore, the BIA test could be of additional value in the decision-making process regarding return to sport (RTS). This study highlights the need for additional rehabilitation as RTS in a condition of incomplete recovery may increase the risk of re-injury. Level of evidenceII.

Poster 256: The "N+10 Rule" to Avoid Graft Tunnel Mismatch in Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Using Independent Femoral Tunnel Drilling

Objectives: To determine the amount of tibial graft tunnel mismatch during application of the “N+10” rule in arthroscopic assisted anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) graft using independent femoral tunnel drilling.To compare actual (measured) tibial tunnel length and desired (calculated) tibial tunnel length when using the “N+10” rule for independent femoral tunnel drilling. Methods:Twenty paired knees from 10 fresh frozen cadaveric specimens (5 female and 5 male specimens) underwent arthroscopic assisted bone-patellar tendon-bone ACL reconstruction using independent femoral tunnel drilling with either a hyperflexion accessory anteromedial portal (n=10) or flexible reamer technique (n=10). The prepared patellar tendon graft bone blocks were trimmed to 10 x 20mm for all specimens and the intertendinous distance (N) between the bone blocks was measured. The “N+10 Rule” was used to set the angle of the ACL tibial tunnel guide to the appropriate degree setting for drilling. The amount of excursion or recession of the tibial bone plug in relation to the anterior tibial cortical aperture was measured in both flexion and extension. A +/-6mm threshold was used to assess this strategy based on prior biomechanical aperture fixation studies. As a secondary outcome, the intraarticular distance (IAD) and the actual tibial tunnel length (TTL) were measured and compared to the planned TTL based on the equation: IAD + TTL = N + 20 (size of bone plug in millimeters)Results:The average BTB ACL intertendinous distance (N) was 47.5mm (SD =5.5mm). The average measured IAD was 27.2mm (SD=3.0mm). Using the “N+10 Rule”, the average mismatch of the tibial tunnel was 4.9mm (SD=3.6mm) and 3.8mm (SD=3.5mm) in flexion and extension, respectively. Both values fall within the +/- 6mm threshold. When comparing the actual measured tibial tunnel length (TTL) to the desired TTL, there was an average difference of 5.4mm (SD=3.9mm)Conclusions:The “N+10” rule resulted in an acceptable average mismatch in both flexion and extension using the threshold of +/- 6mm for 20 cadaveric knees. Measured actual TTL compared to the desired calculated TTL were acceptable 61% of the time using the same threshold. The “N+10” is a simple and effective intraoperative strategy for achieving desired tibial tunnel length to avoid excessive graft tunnel mismatch.Figure 1:Derived formula for calculating ideal tibial tunnel length (TTL) using intraarticular distance (IAD), and the known values of the intertendinous distance (N) and lengths of the bone blocks (20mm).Figure 2:Intraoperative photo of BTB ACL graft measuring intertendinous distance between the bone plugs (N=55mm). Following the "N+10" ruleFigure 3:Intraoperative photo of tibial ACL guide measurement of tibial tunnel length at 50mm with guide set to 65 degrees.Figure 4:Intraoperative photo of the ACL tibial tunnel guide positioned on the anatomic tibial footprint set to 65 degrees (N=55mm). Using this setting for the guide, the tibial tunnel measured 50mm as seen in the zoomed in photo, as per the formula.

A Randomized Controlled Trial of Bone–Patellar Tendon–Bone Anterior Cruciate Ligament Reconstruction With and Without Lateral Extra-articular Tenodesis: 19-Year Clinical and Radiological Follow-up

Background: Arthroscopic anterior cruciate ligament (ACL) reconstruction (ACLR) with a bone–patellar tendon–bone graft (BTB) is a reliable surgical option for the control of anterior knee laxity after ACL injury. The addition of a lateral extra-articular tenodesis (LET) may improve control of rotation knee laxity and improve short-term graft survival in high-risk patients. Purpose: The aims of this study were to compare long-term patient-reported outcomes, graft survival, and risk of osteoarthritis between ACLR with and without LET. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: This study included 121 consecutive knees (120 patients) presenting to a single center with an ACL rupture between 1998 and 1999. In total, 61 knees were randomized to an isolated BTB ACLR, and 60 knees were randomized to a BTB ACLR with an extra-articular lateral tenodesis with gracilis tendon (modified Lemaire). Results: Eighty knees in 79 patients (66%) were available for follow-up at a postoperative mean of 19.4 years (range, 19-20.2). Of those patients, 43 had a clinical examination and completed patient-reported outcome questionnaires, and the other 37 patients were evaluated through the questionnaires alone. Standard radiographs were available for 45 patients and laximetry (TELOS) for 42 patients. Mean subjective International Knee Documentation Committee score at last follow-up was 81.8, and no differences were noted between the BTB and BTB-LET groups (P = .7). Two-thirds of patients were still participating in pivoting sports. A total of 17 knees (21%) experienced a graft failure, 5 of which (6%) underwent revision ACLR. There was no significant difference in graft failure risk between the BTB group (29%) and the BTB-LET group (13%; P = .1). Lateral tibiofemoral osteoarthritis was significantly more frequent in the BTB-LET group (59%) as compared with the BTB group (22%; P = .02). Lateral compartment osteoarthritis was correlated with partial lateral meniscectomy. Conclusion: There were no significant differences in long-term patient-reported outcomes after ACLR with or without an LET. LET may increase the risk of lateral compartment osteoarthritis at long-term follow-up. There was a trend toward decreased graft failure risk with the addition of LET but this study was underpowered to assess this outcome.

No difference in the prevalence of patellofemoral joint cartilage defects on MRI 2 years after bone-patellar tendon-bone anterior cruciate ligament reconstructions compared to the contralateral knee

No difference in the prevalence of patellofemoral joint cartilage defects on MRI 2 years after bone-patellar tendon-bone anterior cruciate ligament reconstructions compared to the contralateral knee

Augmentation of Anterior Cruciate Ligament Reconstruction With Bone Marrow Concentrate and a Suture Tape

The use of biological agents in sports medicine is increasing rapidly. The use of bone marrow concentrate has recently increased in popularity owing to the presence of mesenchymal stem cells. These stem cells combined with Allosync Pure (Arthrex, Naples, FL) could lead to better incorporation and healing. The mixture of bone marrow concentrate and Allosync Pure can be used in anterior cruciate ligament reconstruction, and we have developed a technique to use it in the femoral tunnel and deliver the medium arthroscopically. In this article we present a technique for using suture tape augmentation (InternalBrace; Arthrex) through the interference screw during a bone–patellar tendon–bone anterior cruciate ligament reconstruction.

Application of a Beta-Tricalcium Phosphate Graft to Minimize Bony Defect in Bone–Patella Tendon–Bone Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) reconstruction with a bone–patellar tendon–bone autograft yields good clinical outcomes. Despite appropriate clinical outcomes, the most common complaint after reconstruction with a bone–patellar tendon–bone autograft is anterior knee pain at the donor graft sites. Synthetic bone grafts, such as beta-tricalcium phosphate (β-TCP), have been previously used to fill the bony defect in fractures as well as removal of bony tumors, and have shown positive utility in improving anterior knee pain after ACL reconstruction. In this Technical Note, we describe the technique of placing a β-TCP graft in the donor graft site after bone–patellar tendon–bone ACL reconstruction. After standard arthroscopic ACL reconstruction, the β-TCP is appropriately sized with an osteotome and sagital saw before being placed into the patellar and tibial donor sites. A 0-Vicryl suture is used to suture the periosteum to secure the β-TCP graft at the donor sites. This described technique allows for appropriate sizing and secure placement of the graft to maximize bone regeneration at the donor site.

Efficacy of β-Tricalcium Phosphate Graft into the Bone Defects after Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction.

This prospective pilot study investigated whether grafting β-tricalcium phosphate (B-TCP) into the bone-patellar tendon-bone (BPTB)-harvesting site after anterior cruciate ligament reconstruction would accelerate bone and tendon regeneration in the grafted site. Overall, 19 patients agreed prospectively to undergo regular morphological and histological examinations of the B-TCP-grafted site. Postoperative radiographic, ultrasonographic, and magnetic resonance imaging (MRI) examinations were performed to evaluate the grafted site at 1, 3, 6, and 12 months. Postoperative knee function and donor-site morbidity were assessed at 12 months using the kneeling test. A histological examination was also performed at this time Radiographic examination and MRI showed that the grafted B-TCP was completely absorbed and remodeled into normal bone structure in the tibia and patella at 6 months postoperatively. Histological and ultrasonographic examinations of all subjects showed that the grafted B-TCP was substituted by normal bone tissue, and the patellar tendon - bone junction had regenerated at 12 months postoperatively. Clinical functional knee tests showed good recovery of the donor site. All patients could perform kneeling and knee walking on hard ground. The results of this pilot study suggest that grafting B-TCP into the BPTB-harvesting site promotes the remodeling process of the bone and patellar tendon structures. This surgical treatment would decrease an incidence of the anterior knee pain after ACLR using a BPTB autograft.

Femoral Screw Divergence via the Anteromedial Portal Using an Outside-In Retrograde Drill in Bone–Patella Tendon–Bone Anterior Cruciate Ligament Reconstruction: A Cadaveric Study

To assess screw divergence when inserting an interference screw for a bone-patellar tendon-bone graft using an outside-in technique with a retrograde drill to create the femoral tunnel. Ten cadaver specimens underwent anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft, with 23-mm-deep tunnels created by a retrograde drill outside-in technique. Drilling angles were based on a previous study that established the optimal angles to recreate the anterior cruciate ligament footprint. To ensure that screw insertion angles matched the angle of socket drilling, a marking pen was used to transpose 2 lines on the skin of the anterior knee corresponding to the drill inboth the coronal and axial planes with the knee held at 90° of flexion. The femoral-sided bone plug was affixed with a 7× 23mm interference screw through an anteromedial portal. Computed tomography scans were used to calculate coronal and sagittal screw-tunnel divergence. The median screw divergence in the coronal plane was 2.79°, with a range of 1.1° to 17.2°. Of 10 specimens, 8 had no divergence (0° to 5°), 0 screws were between 5° and 10°, 1 screw was between 10° and 15°, and 1 screw was between 15° and 20°. The 95% confidence interval was 3.73° to 11.69°. No screws had ≥20° of divergence. In the sagittal plane, the median screw divergence was 5.68°, with a range of 1.2° to 18.7°. Five specimens had no divergence (0° to 5°), 3 screws were between 5° and 10°, 0 screws were between 10° and 15°, and 2 screws were between 15° and 20° of divergence. The 95% confidence interval was 3.73° to 11.69°. No screws had ≥20° of divergence. The results of this study showed that 80% of screws diverted less than 5° in the coronal plane. In the sagittal plane, only 50% of screws were found to have divergence of 5° or less. No screw in either plane had divergence of greater than or equal to 20°. When using a retrograde drill, a skin marking technique is a useful aid in placing interference screws with acceptable angles of divergence when using an inside-out technique.

Double-layer versus single-layer bone-patellar tendon-bone anterior cruciate ligament reconstruction: a prospective randomized study with 3-year follow-up.

To evaluate the clinical results of a randomized controlled trial of single-layer versus double-layer bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Fifty-eight subjects who underwent primary ACL reconstruction with a BPTB allograft were prospectively randomized into two groups: single-layer reconstruction (n=31) and double-layer reconstruction (n=27). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery. Forty-eight subjects (24 in single-layer group and 24 in double-layer group) who were followed up for 3years were evaluated. Preoperatively, there were no differences between the groups. At 3-year follow-up, the Lachman and pivot-shift test results were better in the double-layer group (P=0.019 and P<0.0001, respectively). KT measurements were better in the double-layer group (mean 2.9 versus 1.5mm; P=0.0025). The Tegner score was also better in the double-layer group (P=0.024). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear. In ACL reconstruction, double-layer BPTB reconstruction was significantly better than single-layer reconstruction regarding anterior and rotational stability at 3-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the double-layer group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the double-layer group; however, there were no differences in the other subjective findings.

Real-time elastography of patellar tendon in patients with auto-graft bone-tendon-bone anterior cruciate ligament reconstruction.

Patellar tendon donor site has been previously evaluated in patients with auto-graft bone-tendon-bone (BTB) anterior cruciate ligament (ACL) reconstruction using either magnetic resonance imaging or B mode ultrasound. However, donor site patellar tendon strain ratio-reflecting structural features-has not been studied with US elastography. Here, we ascertain real-time elastography properties of patellar tendon donor site and clinical relevance of these properties in patients with auto-graft BTB ACL reconstruction in the postoperative period. Patients who underwent ACL reconstruction using BTB autograft were evaluated. Demographic, operative and clinical data (severity of pain, Lysholm Knee score, sit to stand test, packages/year for smoking amount) were noted. Patellar tendons of the operated knees were evaluated by ultrasound (length and thickness) and sonoelastography (strain ratio). The healthy knees of the patients constituted the control group. Eighteen patients (17 M, 1 F; mean age 30.9±7years) were evaluated. Mean postoperative follow-up period was 22.1±2.6 (range 18-26) months. Patellar tendons were shorter and thicker on the operated side when compared with the contralateral side (both p=0.001). Patellar tendon strain ratios of the operated side were lower than the contralateral side (harder tendon on operated side). While there was no correlation between strain ratios and clinical variables (age, BMI, postoperative time, severity of pain, Lysholm score, all p values>0.05), significant negative correlations were detected between strain ratios of proximal, middle and distal thirds of operated side and amount of smoking (p=0.008, r=-0.607, p=0.009, r=-0.598, p=0.023, r=-0.533, respectively). Patellar tendons on the operated sides seemed to thicken and shorten with decreased strain ratios at the donor side compared to the healthy side at an average of 2-year follow-up in patients with ACL reconstruction using BTB autograft, and amount of smoking had negative relationship with strain ratio of donor patellar tendon.

312 GENDER AND BODY MASS INDEX PREDICTWOMAC AND QUALITY OF LIFE SCORES IN KNEE OSTEOARTHRITIS

Methods: Data were obtained from information recorded in the medical records of sequential patients who underwent autologous bone-patellar tendon-bone graft ACL reconstruction by one of us (Levy) during the years 2003-2005. Injury to specific articular structures, as well as the effects of age, height, weight, body mass index (BMI), occupation, tobacco and alcohol use, gender, and timing of surgery relevant to the date of injury were assessed. Results: Eighty-six patients who underwent this procedure for ACL reconstruction were analyzed. Among them, 24 patients had medial meniscal tears (most commonly partial thickness, longitudinal and bucket handle tears in the posterior horns), 15 had lateral meniscal tears (most commonly radial and longitudinal tears in the posterior horns), and 7 had tears in both menisci. Nineteen patients suffered chondral injuries: 3 in the lateral femoral condyle, 8 in the patella, 9 in the medial femoral condyle, and 3 in the trochlea. Obese patients, (defined as a BMI of 30 or over), had an increased risk for patellar chondral lesions (2.3% versus 31.3%). Surgical delay greater than a year was associated with an increased risk for medial meniscal tears (29.7% versus 75%), but not lateral meniscal tears, as well as medial femoral condyle injuries (6.8% versus 33.3%). Patients over the age of 25 were more likely to have medial femoral condyle lesions (2.5% versus 17.4%). Gender, height, weight, occupation, and use of alcohol or tobacco showed no effect on chondral or meniscal injuries in patients with ACL tears. Conclusion: The observations recorded on this group of patients are very similar to those recorded by other orthopedic surgeons who have attempted to map meniscal and chondral lesions observed at the time of ACL repair procedures (Slauterbeck et al., 2009, Kaeding et al., 2005). The correspondence among these recordings supports their accuracy. Therefore, among patient groups with identical surgical interventions, it seems reasonable to undertake a large-scale study correlating recordings of initial injury patterns with biomarkers of cartilage extracellular matrix turnover, imaging studies of the menisci and cartilage, and clinical features of OA at 5 to 15 years of follow-up as a means of testing the hypothesis.

Stress avulsion of the tibial tuberosity after tension band wiring of a patellar fracture: a case report

IntroductionTo the best of our knowledge there is no other report of an elderly patient who was surgically treated for a patellar fracture with tension band wiring and who subsequently suffered from an avulsion fracture of the tibial tuberosity. The combination of a patellar fracture and avulsion of the patellar ligament has only been described as complication after bone-patellar tendon-bone anterior cruciate ligament reconstructions. However, due to demographic changes and more elderly patients treated this injury may become more frequent in future.Case presentationWe present the case of an 81 year old female who sustained an oblique patellar fracture after a direct contact injury of the left knee when falling on ice. Consequently the patellar fracture was openly reduced and stabilized with tension band wiring. The follow-up was uneventful till three months after surgery when the patient noticed a spontaneous avulsion fracture of the tibial tuberosity (Ogden type 3). The tibial tuberosity fragment was reattached with two non-resorbable sutures looped around two modified AO cortical 3.5 mm long neck screws. Intraoperatively multiple bone cysts were seen. Biopsies were not taken to prevent further fragmentation of the tibial tuberosity. The patient was followed up with anteroposterior and lateral full weight bearing radiographs and clinical assessment at 6, 12 weeks and 6 months after surgery. Recovery was completely pain free with full satisfaction.ConclusionIn conclusion in elderly patients with a patella fracture a possible associated but not obvious fracture of the tibial tuberosity should be ruled out and the postoperative rehabilitation protocol after tension band wiring of the patella might have to be individually adjusted to bone quality and course of the fracture.

Patella Fracture During Rehabilitation After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction: 2 Case Reports

Case report. Patellar fracture is a rare but significant complication following anterior cruciate ligament (ACL) reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. The purpose of these case reports is to describe 2 cases in which patellar fracture occurred during rehabilitation after ACL reconstruction using a BPTB. Both patients were 23-year-old males referred for rehabilitation after ACL reconstruction using a BPTB autograft. They were both progressing satisfactorily in rehabilitation until sustaining a fracture of the patella. One fracture occurred during the performance of the eccentric phase of a knee extension exercise during the sixth week of rehabilitation (7 weeks postsurgery), whereas the other fracture occurred during testing of the patient is quadriceps maximum voluntary isometric contraction in the ninth week of rehabilitation (10 weeks postsurgery). Both patients were subsequently treated with open reduction and internal fixation of the patella. During rehabilitation following ACL reconstruction using BPTB autograft, clinicians should consider the need to balance the sometimes-competing goals of improving quadriceps strength while providing protection to the healing graft, minimization of patellofemoral pain, and protection of the patellar donor site.

Reply to the letter by A. E. Salvi et al. on the article “Patellar fractures associated with medial-third bone-patellar tendon-bone autograft ACL reconstruction”

Reply to the letter by A. E. Salvi et al. on the article “Patellar fractures associated with medial-third bone-patellar tendon-bone autograft ACL reconstruction”

The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up

Aim To evaluate the functional and radiological outcome of a bone–tendon–bone anterior cruciate ligament reconstruction, at long-term follow-up. Methods A retrospective study of 148 patients, of which 103 were available for long-term follow-up. Complete functional and radiological evaluation (International Knee Documentation Committee scale) were performed in 89 out of the 103 patients [Anderson AF. Rating scales. In: Fu FH, Harner CD, Vince KG, (Eds.). Knee Surgery, Baltimore, Williams and Wilkins vol. 1, 1994; 12, pp. 275-296]. Results The mean follow-up time was 17.4 years. Subjectively, 88% of the patients were very satisfied or satisfied. According to the IKDC score 55% had type A symptoms, 29% type B, 12% type C, and 4% type D. The IKDC ligament evaluation showed 14.9% type A, 44.8% type B, 35.8% type C, and 4.5% type D. At the review 22.7% had a narrowing < 50% (C) and 4.7% a narrowing > 50% (D). Onset of osteoarthritis showed an association with the status of the medial meniscus. Knees with a preserved (healthy or sutured) medial meniscus had a significantly ( p < 0.05) better radiological outcome. Among these, 9% had a joint space narrowing < 50% (C) and 2% had a narrowing > 50% (D). Medial meniscectomy, residual laxity, and femoral chondral defects were associated with osteoarthritis. Conclusion The outcome of anterior cruciate ligament reconstruction plus extra-articular tenodesis is good in the very long term, particularly in knees with a preserved medial meniscus.

Continuous Femoral Nerve Block versus Intra-articular Injection for Pain Control after Anterior Cruciate Ligament Reconstruction

Background Continuous femoral nerve blocks have been recommended for postoperative pain control after anterior cruciate ligament reconstruction. Hypothesis A pain control protocol involving a continuous ropivacaine femoral nerve block will decrease pain and narcotic use in the first 24 hours after surgery compared with a postoperative pain control protocol involving an intra-articular injection of bupivacaine/morphine. Study Design Randomized controlled clinical trial; Level of evidence, 2. Methods Ninety subjects, aged 15 years or older, who were receiving arthroscopically assisted bone–patellar tendon–bone anterior cruciate ligament reconstruction were randomly assigned to 2 groups. The first group received a ropivacaine continuous femoral nerve block and oral hydrocodone (block group). The second group received an intra-articular bupivacaine/morphine injection and oral oxycodone (injection group). Patients in both groups could receive intramuscular injection of hydromorphone for breakthrough pain; most patients in the block group also received bolus doses of ropivacaine through the femoral catheter. Subjects rated their worst, average, and current pain levels using a visual analog scale and category-ratio scale the morning after surgery. Postoperative narcotic pain medication use was converted to morphine-equivalent doses. Results Postoperative pain ratings did not differ between the treatment groups. The largest difference in pain ratings between the groups was 0.5 cm for worst pain level (P = .345). Total narcotic use did not differ significantly between groups (1.1 morphine equivalent doses in both groups; P = .671). Conclusions Continuous femoral block with ropivacaine appeared to have no clinical advantage in the immediate postoperative period after anterior cruciate ligament reconstruction when compared with an intra-articular injection of bupivacaine/morphine. Both methods are effective for pain control after anterior cruciate ligament reconstruction.

Rehabilitation After Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction

Sumamry: Rehabilitation protocols after bone-patellar tendon-bone anterior cruciate ligament reconstruction have become significantly more aggressive over the past decade. Key concepts of an accelerated rehabilitation protocol include immediate full weight bearing, unrestricted range of motion, early closed kinetic exercises, and return to play by 4 months. Additional components of a successful rehabilitation program include appropriate timing of surgery, adequate postoperative analgesia, use of cryotherapy, and diligent surveillance for the development of postoperative motion complications. In addition to thorough patient evaluation and meticulous surgical technique, a comprehensive rehabilitation protocol for the reconstructed knee is an essential part of the overall treatment algorithm of the anterior cruciate ligamentinjured extremity. This article reviews a variety of different factors involved in successful rehabilitation after anterior cruciate reconstruction using patellar bone-tendon-bone autograft and presents a comprehensive rehabilitation protocol.

Bioabsorbable interference screws for bone-patellar tendon-bone anterior cruciate ligament reconstruction: clinical and computerized tomography results of four different models. A prospective study

We investigated the effectiveness of four bioabsorbable interference screws for bone block fixation in ACL reconstruction, and assessed their complete absorption and graft integration. We performed a prospective clinical evaluation with the IKDC form and computed tomography (CT) scans 3, 6, 9, 12, 18 and 24 months after arthroscopic ACL reconstruction with the bonepatellar tendon-bone (BPTB) technique. A total of 20 patients was divided into five groups according to the type of screw used for the femoral fixation (half-tunnel technique): group A, poly L-lactic acid; group B, polyglyconate copolymer; group C, lactic acid and glycolic acid copolymer; group D, polylactic acid; and group E (control), titanium. Proximal bone graft integration was always achieved within 6 and 12 months. Cystic bone absorption was observed in two group A patients. Ten screws were absorbed (9 completely; 1 partially): 1 completely and 1 partially in group A at 9 and 24 months; 4 in Group B between 12 and 18 months; 4 in Group C (2 each at 12 and 24 months); and none in Group D. The IKDC ratings were: group A, four patients with A; group B, 2 with A, 1 with B and 1 with C; group C, 2 with A, 2 with B; group D, 4 with A. Effusion that resolved within 6 months was noted in 2 group A and 2 group C patients. One patient in group B had a traumatic re-rupture of the graft; the screw was not found when he was re-operated at 18 months. The four bioabsorbable interference screws provided safe and effective bone block fixation during ACL reconstruction. Their 93.75% excellent and good overall IKDC results were in line with those achieved with metal interference screws. The fact that none of the group D screws (polylactic acid) were absorbed at 2 years indicates that absorption of polylactic acid is a slow biological process. This is also suggested by the absence of effusion in this group.