Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: A prospective study

Intraoperative evaluation of the anatomical double-bundle anterior cruciate ligament reconstruction with the OrthoPilot navigation system

The purpose of this study was to assess double-bundle anterior cruciate ligament (ACL) reconstruction, which reproduces the anteromedial bundle and posterolateral bundle, using a navigation system. In 32 patients, anteroposterior (AP) displacement and rotation of the tibia were measured before reconstruction and after posterolateral bundle fixation, anteromedial bundle fixation, and double-bundle ACL reconstruction (in posterolateral and anteromedial bundles fixation). The posterolateral bundle has an important role in the extension position, whereas the anteromedial bundle restricts AP displacement from extension to flexion. AP displacement after double-bundle ACL reconstruction was significantly improved compared to AP displacement after posterolateral bundle or anteromedial bundle fixation. Although traditional reconstruction for reproducing the anteromedial bundle is reasonable, double-bundle ACL reconstruction is recommended for improved knee stability.

Single femoral socket double-bundle anterior cruciate ligament reconstruction using tibialis anterior tendon: description of a new technique

The native anterior cruciate ligament (ACL) has been shown to consist of 2 functional bundles with independent behavior throughout range of knee motion. Conventional arthroscopic ACL reconstruction techniques selectively recreate the anteromedial bundle of the native ACL only. Numerous studies have reported the failure to restore normal knee kinematics in an ACL-deficient knee using a single-bundle reconstruction. It has been suggested that by reconstructing both the anteromedial and posterolateral bundles of the ACL, more normal knee kinematics may be achieved. Several authors have described surgical techniques to recreate the 2 functional bundles and they range from using 2 femoral tunnels to using a single femoral tunnel with the other bundle passed over the top. This article describes a new technique of recreating the 2 functional bundles of the ACL with tibialis anterior tendon allograft using a single femoral socket.

Anterior cruciate ligament graft impingement against the posterior cruciate ligament: diagnosis using MRI plus three-dimensional reconstruction software

OBJECTIVE

The purpose of this study was to evaluate anterior cruciate ligament (ACL) impingement against the posterior cruciate ligament (PCL) with the knee in an extended position, which arthroscopy cannot detect.

MATERIALS AND METHODS

Ten normal knees and 30 ACL-reconstructed knees were assessed using MR imaging. The three-dimensional reconstruction of the ACL, PCL, femur and tibia were carried out using commercially available three-dimensional reconstruction software. Anterior cruciate ligament impingement against the PCL was graded into three categories: Grade 1, some space between the ligaments; Grade 2, no space between the ligaments, and the reconstructed ACL ran straight; and Grade 3, the reconstructed ACL did not run straight. The angle of the reconstructed ACL against the tibial plateau was also measured.

RESULTS

All normal knees were classified as Grade 1. The 30 reconstructed knees were classified as follows: Grade 1, 12 cases; Grade 2, 7 cases; and Grade 3, 11 cases. The mean angle of the Grade 3 reconstructed ACL knees was significantly more vertical against the tibia as compared with the Grade 1 knees (P<.05). The postoperative KT-2000 side-to-side difference of the Grade 3 knees (2.8+/-4.5 mm) was larger than that of the Grade 1 knees (0.2+/-1.7 mm) and Grade 2 knees (-0.6+/-2.2 mm), but no statistically significant difference could be detected between the three groups in the postoperative KT-2000 data.

CONCLUSION

This method is useful to evaluate ACL impingement against PCL, which cannot be detected by conventional arthroscopy during the operation. The surgeon should pay careful attention to the coronal angle of the reconstructed ACL.

Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement

BACKGROUND

Locations of femoral tunnels for anterior cruciate ligament replacement grafts remain a subject of debate.

HYPOTHESIS

A lateral femoral tunnel placed at the insertion of the posterolateral bundle of the anterior cruciate ligament can restore knee function comparably to anatomical femoral tunnel placement.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten cadaveric knees were subjected to the following external loading conditions: (1) a 134-N anterior tibial load and (2) combined rotatory loads of 10-N.m valgus and 5-N.m internal tibial torques. Data on resulting knee kinematics and in situ force of the intact anterior cruciate ligament and anterior cruciate ligament graft were collected using a robotic/universal force-moment sensor testing system for (1) intact, (2) anterior cruciate ligament-deficient, (3) anatomical double-bundle reconstructed, and (4) laterally placed single-bundle reconstructed knees.

RESULTS

In response to anterior tibial load, anterior tibial translation and in situ force in the graft were not significantly different between the 2 reconstructions except at high knee flexion. For example, at 90 degrees of knee flexion, anterior tibial translation was 6.1 +/- 2.3 mm for anatomical double-bundle reconstruction and 7.6 +/- 2.6 mm for laterally placed single-bundle reconstruction (P < .05). In response to rotatory loads, there were no significant differences between the 2 reconstruction procedures (4.8 +/- 2.4 mm vs 4.8 +/- 3.0 mm in anterior tibial translation at 15 degrees of knee flexion, P > .05).

CONCLUSION

Lateral tunnel placement can restore rotatory and anterior knee stability similarly to an anatomical reconstruction when the knee is near extension. However, the same is not true when the knee is at high flexion angles.

CLINICAL RELEVANCE

To reproduce the complex function of the anterior cruciate ligament, reproducing both bundles of the anterior cruciate ligament may be necessary.

Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts

PURPOSE

To develop and evaluate an anatomic reconstruction procedure of the posterolateral and anteromedial bundles of the anterior cruciate ligament (ACL).

TYPE OF STUDY

Anatomic study and case series.

METHODS

The femoral attachment of the anteromedial and posterolateral bundles of the ACL was anatomically analyzed with 5 cadaveric knees. Using another 3 cadaveric knees, anatomic reconstruction of the posterolateral and anteromedial bundles was performed with the transtibial technique, and tunnel positioning and graft function in a range of knee motion was observed. Based on this anatomic study, an anatomic reconstruction procedure of the anteromedial and posterolateral bundles was developed using hamstring tendon autografts. This procedure was carried out in 57 consecutive patients with an ACL-deficient knee. The patients were followed-up for a minimum of 24 months.

RESULTS

We developed the arthroscopically assisted anatomic reconstruction procedure of the posterolateral and anteromedial bundles, involving a new method of creating the tibial and femoral tunnels for the posterolateral bundle. To visualize the femoral attachment of the posterolateral bundle, the medial infrapatellar portal was more useful than the lateral portal. In clinical results, the side-to-side difference of anterior laxity averaged 1.0 mm with a standard deviation of 0.9.

CONCLUSIONS

The anatomic reconstruction of the anteromedial and posterolateral bundles using hamstring tendon autografts is clinically practical in the treatment for the ACL-deficient knee.

LEVEL OF EVIDENCE

Level IV.

Reconstruction du ligament croisé antérieur par greffe de tendons de la patte d’oie à un ou à deux faisceaux

PURPOSE OF THE STUDY

We worked with cadaver specimens to evaluate control of anterior knee laxity after reconstruction of the anterior cruciate ligament (ACL) comparing double two-strand anterolateral and posteromedial reconstruction with the classical four-strand technique. We hypothesized that the double reconstruction would provide better control of anterior laxity in both flexion and extension.

MATERIAL AND METHODS

Sixteen cadaver knees were randomly assigned to reconstruction technique. Anterior tibial translation was measured with an arthrometer (Rolimeter) at maximal manual tension at 20 degrees, 60 degrees and 90 degrees flexion on the intact knee, after section of the ACL and after arthroscopic reconstruction using either the classical four-strand hamstring technique or a double two-strand anteromedial and posterolateral technique. An EndoButtonCL was used for the femoral fixation and a interference screw with staples for the tibial fixation. Variation in the length of each construct was measured between 0 degrees and 90 degrees flexion.

RESULTS

In the single reconstruction group, the length of the graft varied by 0.5 +/- 0.7 mm between 0 degrees and 90 degrees flexion. In the double reconstruction group, the length varied by 0.5 +/- 0.9 mm for the anteromedial construct and 3.4 +/- 0.5 mm for the posterolateral construct. When studied with an intact ACL, anterior laxity of the 16 knees was 3.2 +/- 1.1, 3.5 +/- 1.5 and 2.6 +/- 1.1 mm at 20 degrees, 60 degrees, and 90 degrees respectively. After section of the ACL, laxity increased significantly at all angles: 9.4 +/- 3.3, 6.1 +/- 2.5 and 6.8 +/- 2.9 at 20 degrees, 60 degrees, and 90 degrees respectively. After classical four-strand single graft reconstruction, the residual anterior laxity was 3.7 +/- 0.9, 3.1 +/- 1.1, and 2.3 +/- 1.6 mm at 20 degrees, 60 degrees, and 90 degrees flexion. Statistical analysis using parametric or non-parametric tests as appropriate showed a significant difference in laxity at 20 degrees, 60 degrees, and 90 degrees of flexion between knees with a cut ACL and knees with reconstructed ACL. At 20 degrees flexion, residual laxity was greater after single-construct reconstruction. At 60 degrees and 90 degrees there was no significant difference in anterior translation of the tibia in knees with intact or reconstructed ACL. After reconstruction with the dual-construct technique, laxity was 3.4 +/- 1.3, 2.6 +/- 1.5, and 2.4 +/- 1.2 mm at 20 degrees, 60 degrees and 90 degrees flexion respectively. Laxity was significantly greater with a cut ACL than after reconstruction at 20 degrees, 60 degrees, and 90 degrees flexion, but there was no significant difference in anterior translation of the tibia at 20 degrees, 60 degrees, and 90 degrees flexion between knees with an intact and a reconstructed ACL.

DISCUSSION

These results based on a clinical evaluation measuring anterior translation of the tibia with an arthrometer are in agreement with results in the literature using robots. Compared with the classical technique, reconstruction of the ACL with a dual-construct technique provides a statistically significant improvement in control of anterior tibial translation at 20 degrees of flexion. The advantage of the dual anteromedial and posteriolateral construct technique is thus not found in the control of anterior laxity but rather in control of rotation laxity.

CONCLUSION

Reconstruction of the ACL with a two-bundle graft technique provides control of anterior laxity at 20 degrees, 60 degrees, and 90 degrees flexion similar to that observed in knees with an intact ACL while the single construct technique re-establishes physiological laxity at 60 degrees and 90 degrees only. This improved control of anterior laxity with the two-bundle reconstruction is a small improvement regarding anterior laxity, the more potential advantage concerning rotational stability.

Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation

Knee ligament injuries often result in a premature end to a career in sports. The treatment after rupture of the anterior cruciate ligament (ACL) may be operative or conservative. In both cases, the goal is to reach the best functional level for the patient without risking new injuries or degenerative changes in the knee. Return to high level of athletic activity has been an indicator of treatment success. Rehabilitation is an important part of the treatment. Knowledge of healing processes and biomechanics in the knee joint after injury and reconstruction, together with physiological aspects on training effects is important for the construction of rehabilitation programmes. Current rehabilitation programmes use immediate training of range of motion. Weight bearing is encouraged within the first week after an ACL reconstruction. Commonly, the patients are allowed to return to light sporting activities such as running at 2-3 months after surgery and to contact sports, including cutting and jumping, after 6 months. In many cases, the decisions are empirically based and the rehabilitation programmes are adjusted to the time selected for returning to sports. In this article, some criteria that should be fulfilled in order to allow the patient to return to sports are presented. Surgery together with completed rehabilitation and sport-specific exercises should result in functional stability of the knee joint. In addition, adequate muscle strength and performance should be used as a critical criterion. Other factors, such as associated injuries and social and psychological hindrances may also influence the return to sports and must be taken into consideration, both during the rehabilitation and at the evaluation of the treatment.

Second-look arthroscopy of anterior cruciate ligament grafts with multistranded hamstring tendons

PURPOSE

The purpose of this study was to clarify the fate of intra-articularly transplanted multistranded hamstring tendon grafts used for anterior cruciate ligament (ACL) reconstruction.

TYPE OF STUDY

Consecutive samples.

METHODS

The subjects were 153 patients (156 knees) with a mean age of 24 years, who had been evaluated as experiencing clinical success. The patients consented to undergo second-look arthroscopy after ACL reconstruction with multistranded autogenous hamstring tendon grafts at 5 to 51 months previously. Ninety-six knees were surgically treated with the single-socket procedure, and the remaining 60 were treated with the bisocket procedure. None of the patients complained of instability of the index knee. The mean side-to-side difference at manual-maximum force in anterior displacement by KT-1000 on 107 patients was 1.2 +/- 1.1 mm (-1 to 4 mm). Arthroscopic evaluation was performed focusing on tension and thickness dividing into 3 groups based on the postoperative period. The chi-square and Mann-Whitney U tests were used for statistical analysis.

RESULTS

A total of 139 grafts (89%) were evaluated as taut and 17 (11%) as mildly lax or lax. Fifty-three (34%) showed some partial tear, and the other 103 (66%) appeared thick without partial tear. The percentage of mildly lax or lax grafts in the group of patients older than 2 years was higher than that in patients younger than 1 year, and no significant difference was found among the groups in the percentage of partially torn grafts. The patients with mildly lax or lax grafts showed statistically higher KT values, while those with partially torn grafts did not. No statistically significant difference was seen in any of these findings between the 2 procedures, although the bisocket procedure tended to show better tension or thickness.

CONCLUSIONS

Arthroscopically, 11% of the hamstring ACL grafts showed looseness and 34% had partial tear in the clinically successful knees.

LEVEL OF EVIDENCE

Level IV in therapeutic studies investigating the results of treatment.