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Häner M, Stoffels T, Guenther D, Pfeiffer T, Imhoff A, Herbort M, Stein T, Schoepp C, Akoto R, Höher J, Scheffler S, Stöhr A, Mehl J, Niederer D, Jung T, Kittl C, Eberle C, Vernacchia C, Ellermann A, Braun PJ, Krause M, Mengis N, Müller PE, Best R, Achtnich A, Petersen W. Management after acute injury of the anterior cruciate ligament (ACL). Part 3: Recommendation on surgical treatment. Knee Surg Sports Traumatol Arthrosc 2024; 32:223-234. [PMID: 38293720 DOI: 10.1002/ksa.12064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/28/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE The aim of this consensus project was to give recommendations regarding surgical treatment of the anterior cruciate ligament (ACL) injured patient. METHODS For this consensus process, an expert, steering and rating group was formed. In an initial online meeting, the steering group, together with the expert group, formed various key topic complexes for which multiple questions were formulated. For each key topic, a structured literature search was performed by the steering group. The results of the literature review were sent to the rating group with the option to give anonymous comments until a final consensus voting was performed. Sufficient consensus was defined as 80% agreement. RESULTS During this consensus process, 30 topics regarding the surgical management and technique of ACL reconstruction were identified. The literature search for each key question resulted in 30 final statements. Of these 30 final statements, all achieved consensus. CONCLUSIONS This consensus process has shown that surgical treatment of ACL injury is a complex process. Various surgical factors influence patient outcomes. The proposed treatment algorithm can be used as a decision aid for the surgeon. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Martin Häner
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
| | | | - Daniel Guenther
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, Trauma Surgery, and Sports Medicine, Cologne Merheim Medical Center, Witten/Herdecke University, Cologne, Germany
| | - Andreas Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | | | - Thomas Stein
- SPORTHOLOGICUM® Frankfurt am Main, Frankfurt, Germany
- Department of Sports Medicine, Goethe University Frankfurt, Frankfurt, Germany
| | - Christian Schoepp
- Department of Arthroscopic Surgery, Sports Traumatology and Sports Medicine, BG Klinikum, Duisburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
- Department of Orthopaedics, Trauma Surgery and Sports Medicine, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | | | | | | | - Julian Mehl
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Daniel Niederer
- Department of Movement and Training Science, Faculty of Humanities and Social Sciences, Institute of Sport Science, University of Wuppertal, Wuppertal, Germany
- Institute of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt, German
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Christoph Kittl
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | | | - Cara Vernacchia
- Department of Physical Medicine & Rehabilitation, Shirley Ryan Ability Lab, Chicago, Illinois, USA
- McGaw, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus, Berlin, Germany
| | - Matthias Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natalie Mengis
- ARCUS Sports Clinic, Pforzheim, Germany
- KSA Aarau/Spital Zofingen, Zofingen, Switzerland
| | - Peter E Müller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Raymond Best
- Department of Orthopaedic and Sports Trauma Surgery, Sportklinik Stuttgart, Stuttgart, Germany
- Department of Sports Medicine and Orthopaedics, University of Tuebingen, Tuebingen, Germany
| | - Andrea Achtnich
- Department for Orthopedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Wolf Petersen
- Department of Orthopedics, Sportsclinic Berlin, Martin Luther Hospital, Berlin, Germany
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Runer A, Hax J, Gelber P, Stadelmann VA, Preiss S, Salzmann G. Triple Hybrid Tibial Anterior Cruciate Ligament Graft Fixation. Arthrosc Tech 2023; 12:e2375-e2379. [PMID: 38196858 PMCID: PMC10773257 DOI: 10.1016/j.eats.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/13/2023] [Indexed: 01/11/2024] Open
Abstract
Optimal graft fixation in anterior cruciate ligament reconstruction is critical. Several direct and indirect methods of graft fixation exist, each with advantages and disadvantages. This Technical Note describes a tibial hybrid anterior cruciate ligament graft fixation technique combining direct and indirect fixation methods, including autologous bone augmentation of the drill tunnel using cancellous bone fragments.
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Affiliation(s)
- Armin Runer
- Department of Sports Orthopaedics, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jakob Hax
- Departments of Hip and Knee Surgery, Schulthess Klinik, Zürich, Switzerland
| | - Pablo Gelber
- Department of Orthopaedic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Stefan Preiss
- Departments of Hip and Knee Surgery, Schulthess Klinik, Zürich, Switzerland
| | - Gian Salzmann
- Departments of Hip and Knee Surgery, Schulthess Klinik, Zürich, Switzerland
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Shah A, Van Thiel G. Anterior cruciate ligament reconstruction with a biocomposite interference screw maintains graft fixation survival and improves clinical outcomes at 1 year: A multicenter prospective case series. Heliyon 2023; 9:e20921. [PMID: 37867815 PMCID: PMC10585286 DOI: 10.1016/j.heliyon.2023.e20921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
A biocomposite interference screw with an open architecture was developed to provide a greater available surface area for bone ingrowth compared with conventional solid interference screws. We herein describe a prospective, single-cohort study conducted using this interference screw in anterior cruciate ligament (ACL) reconstruction. Sixty subjects (mean age, 34.9 years; standard deviation, 10.6) undergoing ACL repair using the biocomposite interference screw were enrolled at 3 sites in the United States. Subjects were followed preoperatively (baseline) and postoperatively at 6 months and 1 year. The primary endpoint was graft fixation survival rate at 6 months and 1 year. Secondary endpoints included graft survival (failure defined as that occurring for any reason); International Knee Documentation Committee (IKDC) score (exam and subjective forms); Tegner Activity form; Lysholm score; and EQ (EuroQuol)-5D-5L index score and visual analogue scale. There was a 100 % rate of graft fixation survival at 6 months (54/54; 95 % confidence interval [CI]: 100-100) and 1 year (50/50; 95 % CI: 100-100). One patient experienced a complete tear of the ACL 5 months following index surgery, resulting in graft survival rates of 98.1 % (53/54; 95 % CI: 94.6-100) at 6 months at 98.0 % (49/50; 95 % CI: 94.1-100) at 1 year. Significant improvements (p < .0001) were obtained between baseline and 6 months for the majority of patient-reported outcomes, and were maintained out to 1-year follow up. There was no significant difference over baseline in the IKDC sub-scale of symptoms. Nine patients (15.0 %) experienced serious adverse events during the course of the study; three of these patients' adverse events were considered possibly or definitely related to the procedure device (ACL tear, pulmonary embolism/deep vein thrombosis, and a patellar fracture). In conclusion, this biocomposite interference screw has a favorable safety and efficacy profile at 1 year, with no failures of graft fixation, noted during that time.
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Affiliation(s)
- Anup Shah
- Orthopedic Surgery, Banner University Medical Group, Arizona, United States
| | - Geoffrey Van Thiel
- Orthopedic Surgery-Sports Medicine, OrthoIllinois, Illinois, United States
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Tátrai M, Halasi T, Tállay A, Tátrai A, Pavlik A. Low Femoral Tunnel Widening Incidence Rate After ACL Reconstruction Using Patellar Tendon Graft with Press-Fit Fixation. Indian J Orthop 2023; 57:596-602. [PMID: 37006732 PMCID: PMC10050510 DOI: 10.1007/s43465-023-00836-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 01/26/2023] [Indexed: 03/30/2023]
Abstract
Abstract
Background
Femoral tunnel widening after ACL reconstruction is a common phenomenon. We hypothesized that using a patellar tendon graft with a press-fit fixation technique without any fixation device reduces the incidence of femoral tunnel widening.
Methods
This study was conducted on 467 patients with ACL surgery between 2003 and 2015. Two hundred and nineteen of them had an ACL surgery with patellar tendon (PT) graft, and two hundred and forty-eight of them with hamstring tendon (HS). Exclusion criteria were history of previous ACL reconstruction of either knee, multiple ligament injury, or evidence of osteoarthritis on radiographs. The femoral tunnels were measured on the anteroposterior (ap) and lateral radiographs 6 months after the operation. Two independent orthopedic surgeons measured all radiographs twice and recorded the tunnel widenings. We hypothesized that using an implant-free press-fit technique with PT graft can reduce the femoral tunnel widening incidence rate.
Results
The mean incidence rate of the tunnel widening in the HS group was, on the AP and the lateral femoral views, 88% (n = 217) and 83% (n = 205), while in the PT group, 17% (n = 37) and 2% (n = 4), respectively. There was a significant difference both on AP and lateral radiographs (HS vs. PT: fem. AP: 89% vs. 17% p < 0.001; HS vs. PT: fem. lat: 84% vs. 2% p < 0.001).
Conclusion
The femoral tunnel widening incidence rate during an ACL reconstruction is significantly less when using PT tendon with femoral press-fit fixation than when using HT tendon with suspensory fixation method.
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Runer A, Keeling L, Wagala N, Nugraha H, Özbek EA, Hughes JD, Musahl V. Current trends in graft choice for anterior cruciate ligament reconstruction - part I: anatomy, biomechanics, graft incorporation and fixation. J Exp Orthop 2023; 10:37. [PMID: 37005974 PMCID: PMC10067784 DOI: 10.1186/s40634-023-00600-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.
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Affiliation(s)
- Armin Runer
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA.
- Department for Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Laura Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nyaluma Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hans Nugraha
- Department of Orthopaedic and Traumatology, Faculty of Medicine, University of Udayana, / Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Emre Anil Özbek
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Petersen W, Ohde J, Karpinski K, Bierke S, Häner M. Technique of ACL Reconstruction With Autologous Quadriceps Tendon Bone Graft and Femoral Press Fit Fixation. VIDEO JOURNAL OF SPORTS MEDICINE 2022. [DOI: 10.1177/26350254221122506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: Recently, there has been an increase in interest in the quadriceps tendon (QT) as an alternative autologous graft option for primary anterior cruciate ligament (ACL) reconstruction. Indication: Anterior cruciate ligament reconstruction in skeletally mature patients (high-risk patients for re-rupture and patients with medial instability). Technique Description: The QT graft is harvested with a 4-cm skin incision over the superior pole of the patella. A double knife and an oscillating saw are used to obtain the QT graft with a bone block from the patella (65 mm x 10 mm graft and 15 mm bone block). Then an arthroscopy is carried out with assessment of the ACL tear and treatment of further intraarticular injuries. ACL reconstruction begins with debridement of the femoral insertion to expose the land marks. The medial portal is used for femoral tunnel drilling with the knee in more than 110° of flexion. A special portal aiming device is introduced via the anteromedial portal and a guide wire is placed in the area of the femoral anteromedial insertion. This guide wire is gradually overdrilled with various drills and dilators of increasing size. The final diameter should be 0.5 mm smaller than the diameter of the bone block of the graft to allow for press-fit fixation. Then, the tibial tunnel is drilled using a tibial drill guide leaving the tibial stump of the original ACL intact. The graft is pulled into the joint through the tibial tunnel until the bone block stops at the femoral tunnel entrance. The bone block is then pushed through the medial portal into the femoral tunnel (press-fit fixation). The tibial fixation is performed with an interference screw and optionally with an extracortical button. Results: Prior studies with 2 years follow-up have shown that the clinical outcomes in primary and revision ACL reconstruction were not significantly different between the use of QT grafts with femoral press-fit fixation and the use of hamstring grafts with femoral suspension fixation. Discussion/Conclusion: Quadriceps tendon bone autograft and femoral press-fit fixation provides an excellent alternative as a graft choice in ACL reconstruction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
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Albishi W, Baltow B, Albusayes N, Sayed AA, Alrabai HM. Hamstring autograft utilization in reconstructing anterior cruciate ligament: Review of harvesting techniques, graft preparation, and different fixation methods. World J Orthop 2022; 13:876-890. [PMID: 36312526 PMCID: PMC9610869 DOI: 10.5312/wjo.v13.i10.876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/16/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023] Open
Abstract
Rupture of the anterior cruciate ligament (ACL) is a common orthopedic injury. Various graft options are available for the reconstruction of ruptured ACL. Using the hamstring muscle as an autograft was first described in 1934, and it remains a commonly harvested graft for ACL reconstruction. Hamstring autografts can be harvested using the traditional anteromedial approach or the newer posteromedial technique. An isolated semitendinosus tendon can be used or combined with the gracilis tendon. There are numerous methods for graft fixation, such as intra-tunnel or extra-tunnel fixation. This comprehensive review discusses the different hamstring muscle harvesting techniques and graft preparation options and fixation methods. It provides a comprehensive overview for choosing the optimal surgical technique when treating patients.
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Affiliation(s)
- Waleed Albishi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
| | - Baraa Baltow
- Department of Orthopedic Surgery, AlHada Armed Forces Hospital, Ministry of Defense, AlHada 26792, Saudi Arabia
| | - Nora Albusayes
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
| | - Ameer A Sayed
- Department of Orthopedic Surgery, King Fahad Armed Forces Hospital, Ministry of Defense, Jeddah 23311, Saudi Arabia
| | - Hamza M Alrabai
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
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Häberli J, Heilgemeir M, Valet S, Aiyangar A, Overes T, Henle P, Eggli S. Novel press-fit technique of patellar bone plug in anterior cruciate ligament reconstruction is comparable to interference screw fixation. Arch Orthop Trauma Surg 2022; 142:1963-1970. [PMID: 34462826 DOI: 10.1007/s00402-021-04137-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 08/20/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE Conventional press-fit technique for anterior cruciate ligament reconstruction (ACLR) is performed with extraction drilling of the femoral bone tunnel and manual shaping of the patellar bone plug. However, the disadvantages of this technique include variation in bone plug size and, thus, the strength of the press-fit fixation, bone loss with debris distribution within the knee joint, potential heat necrosis, and metal wear debris due to abrasion of the guide wire. To overcome these disadvantages, a novel technique involving punching of the femoral bone tunnel and standardized compression of the bone plug was introduced. In this study, the fixation strength and apparent stiffness were tested and compared to that of the gold-standard interference screw fixation technique in three flexion angle configurations (0°/45°/90°) in a porcine model. We hypothesized that the newly developed standardized press fit fixation would not be inferior to the gold standard method. METHODS Sixty skeletally mature porcine knees (30 pairs) were used. Full-thickness central third patellar tendon strips were harvested, including a patellar bone cylinder of 9.5 mm in diameter. The specimens were randomly assigned to 10 pairs per loading angle (0°, 45°, 90°). One side of each pair was prepared with the press-fit technique, and the contra-lateral side was prepared with interference screw fixation. Equivalent numbers of left- and right-sided samples were used for both fixation systems. A three-way multifactor ANOVA was carried out to check for the influence of (a) fixation type, (b) flexion angle, and (c) side of the bone pair. RESULTS The primary fixation strength of femoral press-fit graft fixation with punched tunnels and standardized bone plug compression did not differ significantly from that of interference screw fixation (p = 0.51), which had mean loads to failure of 422.4 ± 134.6 N and 445.4 ± 135.8 N, respectively. The flexion angle had a significant influence on the maximal load to failure (p = 0.01). Load values were highest in 45° flexion for both fixations. The anatomical side R/L was not a statistically significant factor (p = 0.79). CONCLUSION The primary fixation strength of femoral press-fit graft fixation with punched femoral tunnels and standardized bone plug compression is equivalent to that of interference screw fixation in a porcine model. Therefore, the procedure represents an effective method for ACL reconstruction with patellar or quadriceps tendon autografts including a patellar bone plug.
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Affiliation(s)
- Janosch Häberli
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland.
| | | | - Sebastian Valet
- Laboratory for Mechanical Systems Engineering, Empa, Swiss Federal Laboratories for Materials Science and Technology, 8600, Dübendorf, Switzerland
| | - Ameet Aiyangar
- Laboratory for Mechanical Systems Engineering, Empa, Swiss Federal Laboratories for Materials Science and Technology, 8600, Dübendorf, Switzerland
| | - Tom Overes
- Ignite Concepts, Hüslerhofstrasse 6, 4513, Langendorf, Switzerland
| | - Philipp Henle
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
| | - Stefan Eggli
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
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Xu J, Huang K, Han K, Wu X, Li Z, Zheng T, Jiang J, Yan X, Su W, Zhao J. The Plug-Type Patch Results in Immediate and Postoperative Advantages in Graft-to-Bone Integration for Bridging Massive Rotator Cuff Tears in a Chronic Rabbit Model. Am J Sports Med 2022; 50:2497-2507. [PMID: 35722823 DOI: 10.1177/03635465221101416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Various patches have been used to bridge massive rotator cuff tears (MRCTs) by reconnecting the cuff tendons to the humeral head, but the outcomes continue to be suboptimal. Notably, the graft-bone junction is a vulnerable site for failure, which requires optimization in patch design and techniques to enhance initial and postoperative fixation strength at the graft-bone interface. HYPOTHESIS The plug-type patch (Plug-Pat) through intratunnel fixation would optimize mechanical characteristics in initial graft-to-bone fixation and subsequently improve postoperative biomechanical and histological properties in graft-to-bone healing when compared with the routine rectangular patch (Rect-Pat). STUDY DESIGN Controlled laboratory study. METHODS A total of 60 mature male New Zealand White rabbits underwent acute rotator cuff defects to create chronic models with MRCTs. The fascia lata autograft was then harvested to prepare a Plug-Pat, which was distally rooted in the bone tunnel and proximally sutured to native tendons in a horizontal mattress fashion to reconnect the humeral head and cuff tendons. The control group was repaired with a routine Rect-Pat that was secured onto the bone surface for graft-bone fixation. After surgery, the cuff-graft-bone complexes of rabbits in both groups were harvested immediately (0 weeks) for time-zero initial fixation strength and refreshed contact area assessment, and at 6 or 12 weeks for postoperative biomechanical and histological evaluation. RESULTS The Plug-Pat significantly enhanced initial fixation strength in comparison with the Rect-Pat (mean ± SD; failure load, 36.79 ± 4.53 N vs 24.15 ± 2.76 N; P < .001) and decreased failure at the graft-bone interface of the construct at 0 weeks, with a significantly increased refreshed bone bed contact area (52.63 ± 2.97 mm2 vs 18.28 ± 1.60 mm2; P < .001) between the graft and bone. At 6 and 12 weeks postoperatively, the Plug-Pat similarly resulted in greater failure load (43.15 ± 4.53 N vs 33.74 ± 2.58 N at 6 weeks; P = .001; 76.65 ± 5.04 N vs 58.17 ± 5.06 N at 12 weeks; P < .001) and stiffness (10.77 ± 2.67 N/mm vs 8.43 ± 0.86 N/mm at 6 weeks; P = .066; 16.98 ± 2.47 N/mm vs 13.21 ± 1.66 N/mm at 12 weeks; P = .011), with less specimen failure at the graft-bone interface than the Rect-Pat. In histological analyses, the Plug-Pat had a higher postoperative graft-bone integration score than the Rect-Pat, showing a more mature intratunnel healing interface with fibrocartilage tidemark formation, improved collagen properties, and more oriented cells when compared with those at the surface healing interface in the Rect-Pat. CONCLUSION The Plug-Pat enhanced initial fixation strength and enlarged the refreshed contact area for graft-bone connection at time zero and subsequently improved postoperative biomechanical properties and graft-bone integration at the graft-bone healing interface when compared with the Rect-Pat. CLINICAL RELEVANCE The Plug-Pat using intratunnel fixation may be a promising strategy for patch design to optimize its initial and postoperative graft-bone connection for bridging reconstruction of MRCTs.
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Affiliation(s)
- Junjie Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kai Huang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Kang Han
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiulin Wu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ziyun Li
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ting Zheng
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Su
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Zhao J. Single-Bundle Anatomical Hardware-Free Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2021; 10:e1609-e1613. [PMID: 34258211 PMCID: PMC8252817 DOI: 10.1016/j.eats.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 02/03/2023] Open
Abstract
In anterior cruciate ligament (ACL) reconstruction, fixation of the graft with hardware is a routine procedure. However, in some cases when the hardware is not intended to be used or is unavailable, ACL reconstruction with hardware-free fixation must be the treatment of choice. We introduce a single-bundle anatomical hardware-free ACL reconstruction technique in which a set of Y-shaped femoral tunnels is created for the fixation of the proximal end of the graft over the bone bridge between the 2 outer orifices, and a transtibial ridge tunnel is created to set a suture loop with a knot for the fixation of the distal end of the graft at the suture loop. We believe the introduction of this technique will provide a reasonable option for single-bundle anatomical ACL reconstruction.
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Affiliation(s)
- Jinzhong Zhao
- Address correspondence to Jinzhong Zhao, M.D., Department of Sports Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, 600 Yishan Rd., Shanghai 200233, China.
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Yao S, Fu BSC, Yung PSH. Graft healing after anterior cruciate ligament reconstruction (ACLR). ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 25:8-15. [PMID: 34094881 PMCID: PMC8134949 DOI: 10.1016/j.asmart.2021.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/05/2021] [Accepted: 03/21/2021] [Indexed: 01/11/2023]
Abstract
Anterior cruciate ligament reconstruction (ACLR) is a commonly performed procedure in Orthopaedic sports medicine. With advances in surgical techniques providing better positioning and fixation of the graft, subsequent graft failure to certain extent should be accounted by poor graft healing. Although different biological modulations for enhancement of graft healing have been tried in different clinical and animal studies, complete graft incorporation into bone tunnels and the “ligamentization” of the intra-articular part have not been fully achieved yet. Based on the understanding of graft healing process and its failure mechanism, the purpose of this review is to combine both the known basic science & clinical evidence, to provide a much clearer picture of the obstacle encountered in graft healing, so as to facilitate researchers on subsequent work on the enhancement of ACL graft healing.
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Affiliation(s)
- Shiyi Yao
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Bruma Sai-Chuen Fu
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong
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Chen KH, Yang TC, Chiang ER, Wang HY, Ma HL. The Hill-Sachs interval to glenoid track width ratio is comparable to the instability severity index score for predicting risk of recurrent instability after arthroscopic Bankart repair. Knee Surg Sports Traumatol Arthrosc 2021; 29:250-256. [PMID: 32253482 DOI: 10.1007/s00167-020-05955-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/23/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this study was to clinically validate the Hill-Sachs interval to glenoid track width ratio (H/G ratio) compared with the instability severity index (ISI) score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. METHODS A retrospective evaluation was performed using data from patients with anteroinferior shoulder instability who underwent arthroscopic Bankart repair with a follow-up period of at least 24 months. A receiver operating characteristic (ROC) curve was used to determine the optimal cut-off values for the H/G ratio and the ISI score to predict an increased risk of recurrent instability. The area under the ROC curve (AUC) of the two methods and the sensitivity and specificity of their optimal cut-off values were compared. RESULTS A total of 222 patients were included, among whom 31 (14.0%) experienced recurrent instability during the follow-up period. The optimal cut-off values for predicting an increased risk of recurrent instability were an H/G ratio of ≥ 0.7 and ISI score of ≥ 4. There were no significant differences between the AUC of the two methods (H/G ratio AUC = 0.821, standard error = 0.035 and ISI score AUC = 0.792, standard error = 0.04; n.s.) nor between the sensitivity and specificity of the optimal cut-off values (n.s. and n.s., respectively). CONCLUSIONS The H/G ratio is comparable to the ISI score for predicting an increased risk of recurrent instability after arthroscopic Bankart repair. Surgeons are recommended to consider other strategies to treat anterior shoulder instability if H/G ratio is ≥ 0.7. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kun-Hui Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzu-Cheng Yang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - En-Rung Chiang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Yi Wang
- Department of Anaesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hsiao-Li Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan. .,Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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