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Jiang D, Ao YF, Jiao C, Guo QW, Xie X, Zhao F, Li N, Wang XX, Hu YL. The effect of cyclic knee motion on the elongation of four-strand hamstring autograft in anterior cruciate ligament reconstruction: an in-situ pilot study. BMC Musculoskelet Disord 2019; 20:321. [PMID: 31288779 PMCID: PMC6615292 DOI: 10.1186/s12891-019-2699-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/27/2019] [Indexed: 01/26/2023] Open
Abstract
Background Pretension of the viscoelastic graft by cyclic knee motion has been confirmed to decrease the graft creep and improve the outcome of anterior cruciate ligament (ACL) reconstruction. The purpose of the present study was to investigate the effect of cyclic knee motion on the elongation of the four-strand hamstring tendon autograft in situ and to explore the stable level cycle, in which the tendon length achieved a stable level. Methods The study was performed with 53 consecutive patients undergoing transtibial ACL reconstruction with four strand hamstring tendon from Aug 2013 to Apr 2015. 43 males and 10 females were included with mean age of 29 ± 10 years. The pretension of the tendons was operated by cyclical knee motion ranging from 0 to 110°after the femoral fixation with Endo-button. The tendon length after 10, 20, 30 and 40 cycles was measured respectively and compared by repeated measure ANOVA. Then multivariate logistic regression was used to investigate the effect of the patients’ parameters (age, gender, height, body weight, tendon length, etc.) on the elongation of the graft and the stable level cycle. Results The mean lengthening of the graft at 10, 20, 30 and 40 times was 3.0 ± 1.4 mm, 4.3 ± 1.5 mm, 4.8 ± 1.7 mm and 4.8 ± 1.8 mm respectively. No significant correlation was found between the elongation and the patients’ parameters. There was significant difference of the tendon length from 0 to 30 cycles (F = 264.8, df = 1.95, p<0.001). However, the tendon length achieved a stable level after 30 cycles and the median elongation from 30 cycles to 40 cycles was 0 (0–1) mm with no significant difference (F = 2.039, p = 0.159). The male and female tendon length achieved to a stable level at 20 cycles and 30 cycles respectively but with no significant difference (p = 0.074). Conclusions The four-strand hamstring tendon was elongated after cyclic knee motion and the elongation achieved a stable level after 30 cycles for the transtibial technique. Both of the tendon elongation and the stable level cycle were not correlated with patients’ gender, age, preoperative duration, graft diameter and length.
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Affiliation(s)
- Dong Jiang
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China
| | - Ying-Fang Ao
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China
| | - Chen Jiao
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China
| | - Qin-Wei Guo
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China
| | - Xing Xie
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China
| | - Feng Zhao
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, No.49 North Garden Road, Haidian, Beijing, 100191, China
| | - Xiao-Xiao Wang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, No.49 North Garden Road, Haidian, Beijing, 100191, China
| | - Yue-Lin Hu
- Institute of Sports Medicine, Peking University Third Hospital, Beijing Key Laboratory of Sports Injuries, Beijing, 100191, China.
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Wylie JD, Marchand LS, Burks RT. Etiologic Factors That Lead to Failure After Primary Anterior Cruciate Ligament Surgery. Clin Sports Med 2017; 36:155-172. [DOI: 10.1016/j.csm.2016.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Hirtler L, Ederer M, Faber M, Weninger P. The inferior medial genicular artery and its vascularization of the pes anserinus superficialis: A cadaveric study. Indian J Orthop 2016; 50:677-685. [PMID: 27904225 PMCID: PMC5122265 DOI: 10.4103/0019-5413.193476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND A common method for reconstruction of the anterior cruciate ligament (ACL) is it's replacement by a free avascular graft, using the gracilis and/or semitendinosus tendons. These grafts pass a vulnerable phase in the ligamentization-process during the 1st year after reconstruction. The aims of this study were first to evaluate the vascularization of the pes anserinus superficialis (PAS) by the inferior medial genicular artery (IMGA) and second to develop a pedunculated surgical technique for ACL reconstruction, to preserve a maximal amount of natural vascularization of the tendons inserting at the PAS. MATERIALS AND METHODS First, the vascularization of the PAS was assessed in 12 fresh-frozen lower extremities. The IMGA was identified at its origin at the popliteal artery and perfused with a methylene blue solution. Second, a pedunculated ACL reconstruction was performed in 5 fresh-frozen lower extremities under maintenance of the distal tendon insertion at PAS. RESULTS The PAS is a highly vascularized structure. Vessels originate from the IMGA, running along the three tendons of the PAS in the paratendinous tissue. Histologically intratendinous vessels exist; however, perfusion of the inserting tendons through intratendinous vessels was not proven macroscopically. The pedunculated grafts could be positioned and fixed successfully into the bone tunnels in all knees. CONCLUSION Although intratendinous vascularization of the tendons of the PAS via the IMGA was not proven, this study indicates a new possibility of ACL reconstruction. The described operation technique can be conducive to shorten the vulnerable phase of the graft-ligamentization after ACL reconstruction.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria,Address for correspondence: Mag. Dr. Lena Hirtler, Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Währinger Straße 13, 1090 Vienna, Austria. E-mail:
| | - Manuel Ederer
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Mike Faber
- Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Patrick Weninger
- Department of First Orthopedic, Orthopaedic Hospital Speising, Vienna, Austria
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Boguszewski DV, Joshi NB, Wang D, Markolf KL, Petrigliano FA, McAllister DR. Effect of Different Preconditioning Protocols on Anterior Knee Laxity After ACL Reconstruction with Four Commonly Used Grafts. J Bone Joint Surg Am 2015; 97:1059-66. [PMID: 26135072 DOI: 10.2106/jbjs.n.00665] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is currently unknown if preconditioning an anterior cruciate ligament (ACL) graft prior to fixation is helpful in eliminating possible increases in anterior knee laxity. The purpose of this study was to measure cyclic increases in anterior tibial translation of four commonly used graft tissues subjected to four preconditioning protocols. METHODS A robotic system was used to apply 250 cycles of anteroposterior force (134 N of anterior force followed by 134 N of posterior force) to ten intact knees (ACL controls) and then to a single knee reconstructed, for separate tests, with bone-patellar tendon-bone, bone-Achilles tendon, hamstring tendon, and tibialis tendon grafts following (1) no preconditioning, (2) preconditioning on a tension board (89 N of initial force held for twenty minutes), (3) preconditioning in situ (89 N of force applied to the tibial end of the graft during twenty-five flexion-extension cycles), and (4) a combination of protocols 2 and 3. RESULTS Over the 250 cycles, all grafts were associated with a progressive increase in anterior tibial translation that was approximately an order of magnitude greater than that of the ACL, and preconditioning had no significant effect on this increase in translation. There were some significant differences in the progressive anterior tibial translation increase among the graft tissues within a given preconditioning protocol, but these differences were no greater than 1.1 mm. First-cycle and cycle-250 anterior tibial translation varied among the graft tissue types, possibly reflecting an initial "settling in" process. Regardless of the tissue type, ≥75% of the total increase in the anterior tibial translation occurred within the first 125 cycles. CONCLUSIONS Preconditioning had no significant effect on the progressive increase of anterior tibial translation from the first cycle to cycle 250 for any of the graft tissues tested. CLINICAL RELEVANCE On the basis of these results, current preconditioning methods appear to be ineffective in reducing progressive increases in anterior knee laxity from cyclic loading.
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Affiliation(s)
| | - Nirav B Joshi
- UCLA Rehabilitation Center, 1000 Veteran Avenue, Los Angeles, CA 90095
| | - Dean Wang
- UCLA Orthopaedic Surgery, 1250 16th Street, Suite 3142, Santa Monica, CA 90404
| | - Keith L Markolf
- UCLA Rehabilitation Center, 1000 Veteran Avenue, Los Angeles, CA 90095
| | - Frank A Petrigliano
- UCLA Orthopaedic Surgery, 76-143 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095
| | - David R McAllister
- UCLA Orthopaedic Surgery, 76-143 CHS, 10833 Le Conte Avenue, Los Angeles, CA 90095
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Orrego M, Matas J, Abusleme S, Guzmán-Venegas R, Amenabar D. Effect of cyclic tension on the biomechanical properties of flexor tendon grafts. Results of an ex-vivo porcine study. Knee 2014; 21:1029-32. [PMID: 25266942 DOI: 10.1016/j.knee.2014.08.021] [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] [Received: 04/09/2013] [Revised: 07/03/2014] [Accepted: 08/13/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Autologous flexor tendons are widely used for anterior cruciate ligament (ACL) reconstruction. Pretension of the graft before fixation has been described as part of the surgical technique, nevertheless there is no consensus on the type and amount to tension needed to increase the stiffness without affecting its biomechanical properties.Our hypothesis is cyclic tension increases flexor tendon stiffness without affecting its ultimate failure at maximum loads (UFML). METHODS Forty-five flexor digitorum profundus tendons harvested from domestic pigs (Sus scrofa domestica) were randomly divided into three groups: E1 (n=15), E2 (n=15) and C (n=15). Groups E1 and E2 were subjected to 50 cyclic loads at a 1 Hz frequency, at 70N and 100N respectively, group C was not intervened. The three groups were then tested for UFML. Cyclic loads and measurements were performed using a Stress-Strain machine (SST 1.0 Kinetecnic). Results were analyzed using GrapgPad statistical software. Groups were compared using Mann-Whitney test with a 95% confidence interval. RESULTS Significant increased stiffness for group E1 (p=0.02) and group E2 ( p<0.01) when compared to group C. The stiffness of group E2 was also significantly higher than E1 (p=0.03). There was a significant reduction on the UFML between group E2 and C (p<0.01), which was not observed when comparing groups E1 and C. CONCLUSION Cyclic loads at 70N result in an increased stiffness of flexor tendons without affecting its ultimate failure at maximum loads. Cyclic loads at higher tensions might cause a deleterious effect on the biomechanical properties of flexor tendon grafts.
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Affiliation(s)
- Mario Orrego
- Department of Orthopedics, Faculty of Medicine, Universidad de los Andes, Santiago, Chile; Knee Surgery Unit, Clínica Dávila, Santiago, Chile; Knee Surgery Unit, Military Hospital, Santiago, Chile
| | - José Matas
- School of Kinesiology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile; Knee Surgery Unit, Clínica Dávila, Santiago, Chile; Knee Surgery Unit, Clínica Meds, Santiago, Chile
| | - Sebastián Abusleme
- Department of Orthopedics, Faculty of Medicine, Universidad de los Andes, Santiago, Chile.
| | | | - Diego Amenabar
- Department of Orthopedics, Faculty of Medicine, Universidad de los Andes, Santiago, Chile; Knee Surgery Unit, Clínica Dávila, Santiago, Chile; Knee Surgery Unit, Military Hospital, Santiago, Chile
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Chalmers PN, Mall NA, Yanke AB, Bach BR. Contemporary Anterior Cruciate Ligament Outcomes: Does Technique Really Matter? OPER TECHN SPORT MED 2013. [DOI: 10.1053/j.otsm.2012.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Smith GH, Huntley JS, Anakwe RE, Wallace RJ, McEachan JE. Tensioning of Prolene reduces creep under cyclical load: relevance to a simple pre-operative manoeuvre. J Hand Surg Eur Vol 2012; 37:823-5. [PMID: 22117015 DOI: 10.1177/1753193411427663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A longitudinal stretch or 'pre-tensioning' is a method employed by some surgeons to improve the handling characteristics of a suture. We used a tensile tester to assess the effect of pre-tensioning on the mechanical properties of two suture materials (3-0 Prolene and 3-0 Ethibond) commonly used for flexor tendon repair. A cyclical loading programme was used to simulate an early rehabilitation regime. All sutures were subsequently tested to failure (for ultimate tensile strength). The pre-tensioned Prolene sutures showed significantly less creep after cyclical loading in comparison to controls. Conversely pre-tensioning had no measurable effect on the deformation of Ethibond by creep. There was no effect on ultimate tensile strength for either material. The propensity of Prolene to creep (and thereby form a 'gap' in tendon repairs) can be reduced by pre-tensioning.
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Affiliation(s)
- G H Smith
- Royal Infirmary, Little France, Edinburgh, UK.
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