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Zhang L, Lin J, Zhao X, Liu M, Hou Y, Zhang Y, Zhao J, Wang S. Robotic-assisted anatomic anterior cruciate ligament reconstruction: a comparative analysis of modified transtibial and anteromedial portal techniques in cadaveric knees. Front Bioeng Biotechnol 2024; 12:1360560. [PMID: 38511128 PMCID: PMC10953503 DOI: 10.3389/fbioe.2024.1360560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 02/07/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction: This study employed surgical robot to perform anatomic single-bundle reconstruction using the modified transtibial (TT) technique and anteromedial (AM) portal technique. The purpose was to directly compare tunnel and graft characteristics of the two techniques. Methods: Eight cadaveric knees without ligament injury were used in the study. The modified TT and AM portal technique were both conducted under surgical robotic system. Postoperative data acquisition of the tunnel and graft characteristics included tibial tunnel position, tunnel angle, tunnel length and femoral tunnel-graft angle. Results: The mean tibial tunnel length of the modified TT technique was significantly shorter than in the AM portal technique (p < 0.001). The mean length of the femoral tunnel was significantly longer for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the tibial tunnel was significantly lower for the modified TT technique than for the AM portal technique (p < 0.001). The mean coronal angle of the femoral tunnel was significantly lower for the AM portal technique than for the modified TT technique (p < 0.001). The AM portal technique resulted in a graft bending angle that was significantly more angulated in the coronal (p < 0.001) and the sagittal planes (p < 0.001) compared with the modified TT technique. Discussion: Comparison of the preoperative planning and postoperative femoral tunnel positions showed that the mean difference of the tunnel position was 1.8 ± 0.4 mm. It suggested that the surgical navigation robot could make predictable tunnel position with high accuracy. The findings may support that the modified TT technique has benefits on femoral tunnel length and obliquity compared with AM portal technique. The modified TT technique showed a larger femoral tunnel angle in the coronal plane than the AM portal technique. Compared with the modified TT technique, the more horizontal trajectory of the femoral tunnel in the AM portal technique creates a shorter femoral tunnel length and a more acute graft bending angle.
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Affiliation(s)
- Ling Zhang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Jinpeng Lin
- Department of Orthopaedics, Guangdong Provincial Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuan Zhao
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Mingwei Liu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Yao Hou
- Shanghai Droidsurg Medical Technology Co., Ltd., Shanghai, China
| | - Yu Zhang
- Department of Orthopaedics, Guangdong Provincial Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shaobai Wang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
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Lee DW, Lee DH, Cho SI, Yang SJ, Kim WJ, Lee JK, Kim JG. Comparison of ACL and Anterolateral Ligament Reconstruction With Isolated ACL Reconstruction Using Hamstring Autograft: Outcomes in Young Female Patients With High-Grade Pivot Shift. Orthop J Sports Med 2023; 11:23259671231178048. [PMID: 37781636 PMCID: PMC10536865 DOI: 10.1177/23259671231178048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/10/2023] [Indexed: 10/03/2023] Open
Abstract
Background Inferior return to sports (RTS) and functional outcomes have been reported in women after anterior cruciate ligament reconstruction (ACLR). Purpose/Hypothesis The purpose was to evaluate the results of combined ACLR and anterolateral ligament reconstruction (ALLR) in young women with a high-grade pivot shift (grade ≥2). It was hypothesized that combined ACLR and ALLR would result in better RTS and rotational stability than isolated ACLR. Study Design Cohort study; Level of evidence, 3. Methods Two groups were retrospectively evaluated and compared. Group I (n = 39; mean age, 31.1 ± 5.7 years) underwent isolated ACLR using hamstring autografts; group C (n = 39; mean age, 30.4 ± 6.1 years) underwent combined ACLR and ALLR. Subjective outcome measures included the International Knee Documentation Committee subjective form, Lysholm, Tegner, and ACL-Return to Sport after Injury (ACL-RSI). Objective tests included a KT-2000 arthrometer stress test, a pivot-shift test, an isokinetic strength test, a Y-balance test, and a single-leg hop test. A postoperative questionnaire was administered to determine the rates and types of RTS, quality of sports performance, and reinjury and satisfaction rates. Subjective scores and clinical tests were performed at 2 years. Magnetic resonance imaging and second-look arthroscopy were conducted during the 1- and 2-year follow-ups, respectively. Results The mean follow-up for groups I and C were 30.4 ± 3.9 and 29.3 ± 3.5 months, respectively (P = .194). Patients in group C had better anteroposterior (P = .001) and rotational (P = .005) stability and higher ACL-RSI scores (P = .025) than those in group I. Group C had higher composite and posteromedial reach scores on the Y-balance test than group I (P = .014 and P = .010, respectively). A total of 26 (66.7%) patients in group C and 17 (43.6%) in group I returned to their prior level of sports (P = .040). Rerupture of the ACL graft and contralateral ACL rupture occurred in 2 (5.1%) and 2 (5.1%) patients in group I, respectively, compared with no rerupture or contralateral ACL rupture in group C. Conclusion Combined ACLR and ALLR in young women with a high-grade pivot shift was associated with better knee stability parameters, dynamic postural stability, and psychological readiness to RTS than isolated ACLR.
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Affiliation(s)
- Dhong Won Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Dong Hwan Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seung Ik Cho
- Sports Medical Center, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sang Jin Yang
- Department of Health and Exercise Management, Tongwon University, Gwangju-si, Gyeonggi-do, Republic of Korea
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan, Republic of Korea
| | - Joon Kyu Lee
- Department of Orthopaedic Surgery, KonKuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jin Goo Kim
- Department of Orthopaedic Surgery, Myongji Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
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Additional tying on the adjustable-loop device improves the outcomes of anterior cruciate ligament reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2022; 30:3673-3680. [PMID: 35445328 DOI: 10.1007/s00167-022-06936-1] [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: 08/20/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to verify the efficacy of a novel technique for additional tying on the adjustable-loop device to prevent stress concentration on the graft loop end and gradual loop lengthening. METHODS A total of 124 patients who underwent anterior cruciate ligament reconstruction using hamstring autografts from 2014 to 2017 were included in this retrospective study. After 1:1 propensity score matching, two groups were formed (group I: 50 patients without tying vs. group II: 50 patients with tying). Anterior laxity was evaluated using side-to-side differences. Tunnel length, loop length, and graft-tunnel gap were measured using follow-up magnetic resonance imaging. The signal-to-noise ratio was calculated at the loop end, loop inner side, tunnel entrance, and graft mid-substance. The clinical outcomes were assessed using the International Knee Documentation Committee score, Lysholm score, pivot shift test, and Lachman test. RESULTS The average follow-up period was 63.2 ± 4.8 and 53.8 ± 11.9 months in groups I and II, respectively. Anterior laxity showed that side-to-side differences improved significantly 6 months postoperatively in both the groups. Although the anterior laxity improved in group II (2.9 ± 1.0 to 1.6 ± 0.8, p < 0.001), it deteriorated in group I (2.5 ± 1.5 to 3.3 ± 1.3 mm, p < 0.001) at the final follow-up. The graft-tunnel gap was significantly larger in group I (p < 0.001). The signal-to-noise ratios of the loop end and loop inner side were significantly higher in group I (p < 0.001 and p = 0.020, respectively). The clinical outcomes at the final follow-up were not significantly different between the groups. CONCLUSION The additional tying on the adjustable-loop device was not superior to the control group in clinical stability examination or outcome. However, it was effective in anterior laxity measured by stress radiographs, preventing stress on the adjustable-loop device, and gradual graft loop lengthening. LEVEL OF EVIDENCE Level III.
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Chen N, Wang C, Li D, Jiang Y, Ao Y. Effect of Joint Infection After Arthroscopic Single-Bundle ACL Reconstruction With Autologous Hamstring Tendon: A Retrospective Matched MRI Study. Orthop J Sports Med 2022; 10:23259671221125493. [PMID: 36263310 PMCID: PMC9575462 DOI: 10.1177/23259671221125493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Joint infection after anterior cruciate ligament (ACL) reconstruction is a
rare but serious complication. Purpose: To assess the effect of joint infection on the graft, cartilage, and bone
tunnel using magnetic resonance imaging (MRI) after arthroscopic
single-bundle ACL reconstruction with autologous hamstring tendons. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective matched cohort study included 26 patients who underwent
arthroscopic single-bundle ACL reconstruction with hamstring tendon graft at
the authors’ institute between January 2002 and December 2017 and developed
postoperative joint infection. These patients were matched 1:3 to patients
who did not sustain joint infection after ACL reconstruction (control
group). MRI scans were collected at the time of follow-up. The following
parameters were evaluated: graft signal-to-noise quotient (SNQ); graft
signal intensity at the bone-graft interface and within the knee joint; bone
tunnel enlargement at the tunnel aperture, midsection, and exit of the
tibial and femoral tunnels; and cartilage integrity. Results: The average follow-up time was 47.8 months in the infection group and 48.5
months in the control group. Compared with the control group, the infection
group had a significantly higher SNQ (20.01 ± 12.08 vs 7.61 ± 6.70;
P = .014) as well as a higher signal intensity at the
bone-graft interface (P = .037) and higher Howell grade
(P = .031). The mean enlargement at the femoral tunnel
aperture was 31.20% ± 26.76% in the infection group and 19.22% ± 20.10% in
the control group (P = .037). The articular cartilage of
the patellofemoral and lateral femorotibial joints showed more degenerative
change in the infection group. Conclusion: Study findings indicated that graft ligamentization and incorporation graft
maturity were inferior in patients who experienced a joint infection after
ACL reconstruction compared with patients who did not.
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Affiliation(s)
- Nayun Chen
- Department of Sports Medicine, Peking University Third Hospital,
Beijing, China.,Institute of Sports Medicine of Peking University, Beijing,
China
| | - Cheng Wang
- Department of Sports Medicine, Peking University Third Hospital,
Beijing, China.,Institute of Sports Medicine of Peking University, Beijing,
China
| | - Dai Li
- Department of Sports Medicine, Peking University Third Hospital,
Beijing, China.,Institute of Sports Medicine of Peking University, Beijing,
China
| | - Yanfang Jiang
- Department of Sports Medicine, Peking University Third Hospital,
Beijing, China.,Institute of Sports Medicine of Peking University, Beijing,
China
| | - Yingfang Ao
- Department of Sports Medicine, Peking University Third Hospital,
Beijing, China.,Institute of Sports Medicine of Peking University, Beijing,
China.,Yingfang Ao, MD, Institute of Sports Medicine of Peking
University, 49 North Garden Road, Haidian District, Beijing 100191, China
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Saito M, Morikawa T, Iwasaki J, Hosokawa H, Sakamoto T, Nakagawa K, Sasho T. Influence of Age on Signal Intensity of Magnetic Resonance Imaging and Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction: Comparisons Among Different Age Groups. Am J Sports Med 2022; 50:93-102. [PMID: 34825843 DOI: 10.1177/03635465211059158] [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 Thus far, the clinical results of anterior cruciate ligament (ACL) reconstruction have been observed to be comparable between young and older patients. In contrast, age-related changes in the structural and mechanical properties of tendons used for autografts have been described. However, age-related changes associated with graft maturation remain poorly understood. HYPOTHESES The hypotheses of this study were that (1) clinical outcomes after ACL reconstruction would be comparable between younger and relatively older patients and (2) younger patients would show lower signal intensity changes on magnetic resonance imaging scans indicative of graft maturation that would be better than that in relatively older patients. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS We retrospectively evaluated 236 patients who underwent double-bundle ACL reconstruction via the outside-in technique using hamstring autograft between January 2012 and December 2015. The patients were categorized by age into 3 groups: <20 years old, 20 to 39 years old, and ≥40 years old. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) score, Tegner activity scale, Lysholm score, and objective assessment of joint laxity 24 months after surgery. In addition, graft maturation was evaluated using magnetic resonance imaging-derived measures of the signal intensity ratio (SIR) at 3, 6, 12, and 24 months postoperatively. Clinical outcomes and graft maturation were compared among the 3 groups. RESULTS The SIR of both bundles increased from 3 months to 12 months and decreased by 24 months, showing the same tendency in all groups. No significant difference was found in the SIR among the 3 groups at any time point (P > .05). The IKDC score was significantly lower in the ≥40-year group than in the <20-year group (P < .01). In contrast, no significant differences were noted in other clinical outcomes. CONCLUSION Patients aged ≥40 years exhibited lower IKDC scores compared with younger patients, although the results of graft maturation were comparable.
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Affiliation(s)
- Masahiko Saito
- Department of Orthopaedic Surgery, Chiba Medical Center, Chiba, Japan
| | - Tsuguo Morikawa
- Department of Orthopaedic Surgery, Chiba Medical Center, Chiba, Japan
| | - Junichi Iwasaki
- Department of Orthopaedic Surgery, Chiba Medical Center, Chiba, Japan
| | - Hiroaki Hosokawa
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takuya Sakamoto
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Chiba, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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Zhang J, Ma Y, Pang C, Wang H, Jiang Y, Ao Y. No differences in clinical outcomes and graft healing between anteromedial and central femoral tunnel placement after single bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1734-1741. [PMID: 32772135 DOI: 10.1007/s00167-020-06206-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/03/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to compare clinical outcomes and graft healing after anterior cruciate ligament (ACL) reconstruction with anteromedial and central femoral tunnel placement. METHODS During 2016 and 2018, 110 consecutive patients underwent single bundle ACL reconstruction; 85 patients met the inclusion criteria, and each patient underwent 3D-CT within 1 week and MRI 1.5 years after the operation. The central point of the femoral tunnel and signal/noise quotient (SNQ) of three regions of interest (ROI) in the intra-articular graft were measured to analyse the tunnel position and graft healing extent. Clinical assessments, including functional scores, KT-2000 arthrometer measurements and pivot-shift tests, were evaluated at the 2-year follow-up. Patients were divided into two groups depending on the femoral tunnel position: the anteromedial position group (Group A) and the centre position group (Group B). RESULTS Seventy-one patients were available for the 2-year follow-up and MRI examination: 34 patients in Group A and 35 patients in Group B, and 2 patients were excluded for an eccentric tunnel position. No graft failure occurred, and compared with the preoperative assessment outcomes, the outcomes of both groups improved at the final follow-up. Group A was significantly better than Group B regarding the KT-2000 arthrometer measurements (P = 0.031). No significant differences were observed in terms of functional scores, pivot-shift test results, or the SNQ between groups. CONCLUSIONS No differences in clinical outcomes or graft healing were found between AM and central femoral tunnel placements in single bundle ACL reconstruction. Therefore, satisfactory clinical outcomes, knee stability and graft healing can be obtained for both femoral tunnel placements. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jiahao Zhang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yong Ma
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Chaonan Pang
- Department of Radiology, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Haijun Wang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yanfang Jiang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yingfang Ao
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, NO. 49 North Garden Road, Haidian District, Beijing, 100191, People's Republic of China.
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黄 碧, 邓 文, 李 韬, 李 棋. [Progress of different methods for femoral tunnel positioning in anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:118-123. [PMID: 33448209 PMCID: PMC8171607 DOI: 10.7507/1002-1892.202005003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/31/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To systematically review the progress of different methods for femoral tunnel positioning in anterior cruciate ligament (ACL) reconstruction and provide a clinical reference for treatment of ACL rupture. METHODS The literature about the femoral tunnel positioning in ACL reconstruction was widely reviewed. The advantages and disadvantages and the clinical results of each method were summarized. RESULTS Currently in ACL reconstruction, methods for femoral tunnel positioning include transtibial technique (TT), anteromedial technique (AM), outside-in (OI), modified TT (mTT), and computer assisted surgery. There is no significant difference in the postoperative effectiveness between TT technique and AM technique. Compared with the TT technique, the OI technique has higher rotational stability of knee, but there is no significant difference in clinical results. The femoral tunnel located by mTT technique is closer to the anatomical placement than that of TT technique, but mTT technique is not effective for systematically anatomic femoral tunnel positioning, and further research is needed to prove its advantages. CONCLUSION Different femoral tunnel positioning methods have their own advantages and disadvantages, and there is no definite evidence that one is superior than the rest.
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Affiliation(s)
- 碧滢 黄
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 文宇 邓
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 韬 李
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 棋 李
- 四川大学华西临床医学院(成都 610041)West China School of Medicine, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Kim JH, Oh E, Yoon YC, Lee DK, Lee SS, Wang JH. Remnant-Tensioning Single-Bundle Anterior Cruciate Ligament Reconstruction Provides Comparable Stability to and Better Graft Vascularity Than Double-Bundle Anterior Cruciate Ligament Reconstruction in Acute or Subacute Injury: A Prospective Randomized Controlled Study Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging. Arthroscopy 2021; 37:209-221. [PMID: 33221428 DOI: 10.1016/j.arthro.2020.08.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical, second-look arthroscopic, magnetic resonance imaging (MRI), and dynamic-contrast-enhanced MRI (DCE-MRI) findings between remnant-tensioning single-bundle (RT-SB) and double-bundle (DB) anterior cruciate ligament reconstruction (ACLR). METHODS Sixty-seven patients with acute or subacute anterior cruciate ligament (ACL) injury were randomized to undergo RT-SB or DB ACLR. Twenty-six patients in the RT-SB group and 28 in the DB group were evaluated using stability tests (Lachman test, pivot-shift test, and KT-2000 arthrometer) and multiple clinical scores. One year postoperatively, all 54 patients underwent MRI for evaluation of graft continuity and graft signal/noise quotient and DCE-MRI for the calculation of normalized area under the curve (nAUC) as a marker of graft vascularity. Among them, 41 patients underwent second-look arthroscopy for the evaluation of graft continuity, graft tension, and synovialization. The results were compared between the 2 groups. RESULTS At the minimum 2-year follow-up (28.7 ± 6.4 months), the stability tests, clinical scores, second-look arthroscopic findings, and MRI findings were not significantly different between the groups. However, the mean nAUC values on DCE-MRI for the ACL graft were significantly higher in the RT-SB group than those in the DB group in all 3 zones (nAUCproximal, P = .005; nAUCmiddle, P = .021; nAUCdistal, P = .027; and nAUCaverage, P = .008). CONCLUSION For acute or subacute ACL injury, the RT-SB ACLR showed an outcome comparable to that of DB ACLR in terms of knee stability, clinical scores, MRI findings, and second-look arthroscopic findings. Moreover, RT-SB ACLR showed better graft vascularity 1 year postoperatively than DB ACLR using DCE-MRI. LEVEL OF EVIDENCE II, prospective randomized controlled trial.
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Affiliation(s)
- Jun Ho Kim
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, South Korea
| | - Eunsun Oh
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Young Cheol Yoon
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea; Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Do Kyung Lee
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Sung-Sahn Lee
- Department of Orthopedic Surgery, Ilsan Paik Hospital, Inje University School of Medicine, South Korea
| | - Joon Ho Wang
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea; Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Korea; Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Korea.
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Anterior cruciate ligament grafts display differential maturation patterns on magnetic resonance imaging following reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2020; 28:2124-2138. [PMID: 31520146 PMCID: PMC7067650 DOI: 10.1007/s00167-019-05685-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE The appearance of anterior cruciate ligament (ACL) grafts on magnetic resonance imaging (MRI) is related to graft maturity and mechanical strength after ACL reconstruction (ACLR). Accordingly, the purpose of this review was to quantitatively analyze reports of serial MRI of the ACL graft during the first year following ACLR; the hypothesis tested was that normalized MRI signal intensity would differ significantly by ACL graft type, graft source, and postoperative time. METHODS PubMed, Scopus, and CINAHL were searched for all studies published prior to June 2018 reporting MRI signal intensity of the ACL graft at multiple time points during the first postoperative year after ACLR. Signal intensity values at 6 and 12 months post-ACLR were normalized to initial measurements and analyzed using a least-squares regression model to study the independent variables of postoperative time, graft type, and graft source on the normalized MRI signal intensity. RESULTS An effect of graft type (P = 0.001) with interactions of graft type * time (P = 0.012) and graft source * time (P = 0.001) were observed. Post hoc analyses revealed greater predicted normalized MRI signal intensity of patellar tendon autografts than both hamstring (P = 0.008) and hamstring with remnant preservation (P = 0.001) autografts at postoperative month 12. CONCLUSION MRI signal varies with graft type, graft source, and time after ACLR. Enhanced graft maturity during the first postoperative year was associated with hamstring autografts, with and without remnant preservation. Serial MRI imaging during the first postoperative year may be clinically useful to identify biologically or mechanically deficient ACL grafts at risk for failure. LEVEL OF EVIDENCE IV.
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Yoon KH, Kim JH, Kwon YB, Kim EJ, Lee SH, Kim SG. A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2020; 140:383-390. [PMID: 31970504 DOI: 10.1007/s00402-020-03343-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry. METHODS This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2 days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes. RESULTS The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5 mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%). CONCLUSIONS The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR. LEVEL OF EVIDENCE Retrospective case series; level of evidence, 4.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Jae Ho Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Yoo Beom Kwon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Eung Ju Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang Hyeon Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, South Korea.
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Saito M, Nakajima A, Sonobe M, Takahashi H, Akatsu Y, Inaoka T, Iwasaki J, Morikawa T, Watanabe A, Aoki Y, Sasho T, Nakagawa K. Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique. Knee Surg Sports Traumatol Arthrosc 2019; 27:2468-2477. [PMID: 30374576 DOI: 10.1007/s00167-018-5240-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel. METHODS Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups. RESULTS There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004). CONCLUSION There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.
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Affiliation(s)
- Masahiko Saito
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan.
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Tsutomu Inaoka
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
| | - Junichi Iwasaki
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Tsuguo Morikawa
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba, 260-8670, Japan
| | - Koichi Nakagawa
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
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Van Dyck P, Zazulia K, Smekens C, Heusdens CHW, Janssens T, Sijbers J. Assessment of Anterior Cruciate Ligament Graft Maturity With Conventional Magnetic Resonance Imaging: A Systematic Literature Review. Orthop J Sports Med 2019; 7:2325967119849012. [PMID: 31211151 PMCID: PMC6547178 DOI: 10.1177/2325967119849012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) signal intensity (SI) measurements are being
used increasingly in both clinical and research studies to assess the
maturity of anterior cruciate ligament (ACL) grafts in humans. However, SI
in conventional MRI with weighted images is a nonquantitative measure
dependent on hardware and software. Purpose: To conduct a systematic review of studies that have used MRI SI as a proxy
for ACL graft maturity and to identify potential confounding factors in
assessing the ACL graft in conventional MRI studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was conducted by searching the MEDLINE/PubMed, Scopus,
and Cochrane Library electronic databases according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to
identify studies that examined the healing of the intra-articular portion of
the ACL graft by assessing SI on MRIs. Results: A total of 34 studies were selected for inclusion in this systematic review.
The MRI acquisition techniques and methods to evaluate the ACL graft SI
differed greatly across the studies. No agreement was found regarding the
time frames of SI changes in MRI reflecting normal healing of the ACL tendon
graft, and the graft SI and clinical outcomes after ACL reconstruction were
found to be poorly correlated. Conclusion: The MRI acquisition and evaluation methods used to assess ACL grafts are very
heterogeneous, impeding comparisons of SI between successive scans and
between independent studies. Therefore, quantitative MRI-based biomarkers of
ACL graft healing are greatly needed to guide the appropriate time of
returning to sports after ACL reconstruction.
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Affiliation(s)
- Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Katja Zazulia
- Department of Orthopedics, Antwerp University Hospital, Edegem, Belgium
| | | | | | | | - Jan Sijbers
- Imec/Vision Lab, Department of Physics, University of Antwerp, Wilrijk, Belgium
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Häberli J, Bieri KS, Aghayev E, Eggli S, Henle P. Dynamic intraligamentary stabilization of anterior cruciate ligament repair: hardware removal has no effect on knee laxity at 2-year follow-up. Arch Orthop Trauma Surg 2019; 139:639-644. [PMID: 30649589 DOI: 10.1007/s00402-019-03113-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Dynamic intraligamentary stabilization (DIS) stabilizes the knee joint during anterior cruciate ligament (ACL) healing. After 6 months, tibial hardware removal is offered to the patients if local discomfort at the implant site is present. AIM This study compared knee laxity and functional scores 2 years after DIS between patients with and without hardware removal. It is hypothesized that it does not affect ACL healing. MATERIALS AND METHODS The study retrospectively analyzed prospectively collected data from 173 patients with either hardware removal (n = 47) or no additional intervention (n = 126). Inverse probability of treatment weighting using the propensity score was applied to balance the groups for baseline characteristics. The primary outcome was the side-to-side difference in knee laxity measured with the rolimeter at manual maximum force (Δ-Lachman). Secondary outcomes were the pivot-shift test and subjective scores. RESULTS Mean age was 34 years in both groups, and female gender was 47% (hardware removal group) and 50% (control group), respectively. No significant differences were found for Δ-Lachman (p = 0.09), pivot-shift test (p = 0.41), and subjective scores (p > 0.10) two years after DIS. CONCLUSION Knee laxity 2 years after DIS in patients with tibial hardware removal and patients without hardware removal was not significantly different. The groups were also similar regarding all the assessed functional scores. This study confirms the hypothesis that the healing ACL resumes its stabilizing role, and the hardware can be removed beginning 6 months after surgery without adverse consequences for joint stability. LEVEL OF EVIDENCE Case-control study, Level III.
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Affiliation(s)
- Janosch Häberli
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
| | - Kathrin Susan Bieri
- Swiss RDL, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
| | - Emin Aghayev
- Swiss RDL, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.,Spine Center, Schulthess Klinik, Lennghalde 2, 8008, Zurich, Switzerland
| | - Stefan Eggli
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
| | - Philipp Henle
- Sonnenhof Orthopaedic Center, Buchserstrasse 30, 3006, Bern, Switzerland
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Ji G, Han A, Hao X, Li N, Xu R, Wang F. Better rotational control but similar outcomes with the outside-in versus the transtibial drilling technique for anterior cruciate ligament reconstruction: a systematic review of comparative trials. Arch Orthop Trauma Surg 2018; 138:1575-1581. [PMID: 29948227 DOI: 10.1007/s00402-018-2976-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Indexed: 12/23/2022]
Abstract
INTRODUCTION This study was a systematic review comparing the clinical outcomes of using the transtibial (TT) versus the outside-in (OI) technique for anterior cruciate ligament (ACL) reconstruction. MATERIALS AND METHODS A comprehensive literature search was conducted using multiple databases, including Medline, Embase, and Cochrane. All databases were searched from the earliest records through August 2017 using the following Boolean operators: transtibial AND (outside-in OR out-in OR two incisions) AND anterior cruciate ligament. All prospective and retrospective controlled trials were retrieved that directly compared physical examination and knee function scores and patient-rated outcomes between the TT and OI techniques. RESULTS Four prospective and three retrospective articles were identified by the search, and the findings suggested that the OI was superior to the TT technique for preparing the femoral tunnel based on the pivot shift test (p = 0.05). There was no statistically significant difference between the two treatment groups in International Knee Documentation Committee (IKDC) grades, IKDC scores, Lysholm scores, Tegner scores, or the Lachman test. CONCLUSIONS No statistically significant differences were found in clinical functional results when comparing patients who underwent ACL reconstruction with the TT or OI techniques. However, the OI technique was found to be advantageous in conferring increased rotational stability as revealed by the pivot shift test. Additional studies with larger sample sizes are needed to make more precise conclusions. LEVEL OF EVIDENCE Therapeutic study (systematic review), Level III.
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Affiliation(s)
- Gang Ji
- Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China
| | - Achao Han
- The Central Hospital of Wuhan, Wuhan, China
| | - Xuewei Hao
- The First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Na Li
- Weill Cornell Medical College, New York, USA
| | - Ren Xu
- Weill Cornell Medical College, New York, USA
| | - Fei Wang
- Third Hospital of Hebei Medical University, 139 Ziqiang Road, Shjiazhuang, 050051, Hebei, China.
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Subacute Clinical Features After Arthroscopy Surgical Reconstruction of Complete Anterior Cruciate Ligament Rupture: A Case-Control Study. J Manipulative Physiol Ther 2018; 41:596-601. [PMID: 30269932 DOI: 10.1016/j.jmpt.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the clinical features in the subacute phase after surgical reconstruction of complete anterior cruciate ligament rupture (ACLR) with respect to healthy participants. METHODS A case-control observational study was performed. A total sample of 80 participants was recruited from an outpatient clinic and divided into case (n = 40 patients after ACLR reconstruction in subacute phase) and control (n = 40 healthy participants) groups. Outcomes, including pain intensity, range of motion (ROM), stability, and functionality were assessed by the visual analogue scale, universal goniometer, the Star Excursion Balance Test, and the Western Ontario and McMaster Universities Osteoarthritis Index, respectively. RESULTS There were no statistically significant differences (P > .05) for sex, side, age, and body mass index between patients with ACLR after reconstruction surgery and healthy participants. Statistically significant differences (P < .001) with a large effect size (Rosenthal r) from -0.86 to -0.93 were shown for ROM (median ± interquartile range [IQR], -70.00° ± 10.00°) and Star Excursion Balance Test (mean ± standard deviation, -38.31 cm ± 4.52 cm) reduction, as well as higher visual analogue scale (median ± IQR, 7.00 ± 1.00) and Western Ontario and McMaster Universities Osteoarthritis Index (median ± IQR, 68.77 ± 6.29) scores in favor of the ACLR reconstructed group, with respect to the healthy control group. CONCLUSIONS Measurable clinical differences of functionality, stability, and ROM should be considered during the evaluation of patients at a subacute period after complete ACLR reconstruction surgery with respect to healthy matched controls.
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16
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Comparison of Modified Transtibial and Outside-In Techniques in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Arthroscopy 2018; 34:2857-2870. [PMID: 30197202 DOI: 10.1016/j.arthro.2018.05.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 05/20/2018] [Accepted: 05/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the bending angle of anterior cruciate ligament (ACL) graft at femoral tunnel, graft maturation, and tunnel positions and the clinical outcomes of the modified transtibial (mTT) and outside-in (OI) techniques. METHODS Patients who met the inclusion criteria were divided into the mTT group (n = 50) and the OI group (n = 50). Using 3-dimensional computed tomography (3-D CT), tunnel placement and femoral tunnel bending angle were analyzed. The 3.0-T magnetic resonance imaging (MRI) was used to assess the graft signal intensity (indicative of maturation) with signal/noise quotient (SNQ). Graft tension and synovialization were evaluated with second-look arthroscopy in all cases. Clinical and functional tests were completed at 36 months of follow-up. RESULTS When tunnel placements were analyzed using the quadrant method, no significant differences were found between the mTT group and the OI group. The femoral graft bending angle was reduced in the mTT group, and the total mean of SNQ values and mean SNQ values at the femoral intraosseous and proximal graft of the mTT group were significantly lower than in the OI group (P < .001), respectively. The femoral graft bending angle on the coronal and axial planes showed moderate-to-strong correlation with the SNQ values at the femoral intraosseous and proximal graft. Second-look arthroscopy revealed better synovialization in the mTT group than in the OI group (P = .040), with no significant difference in graft tension between the 2 groups (P = .328). CONCLUSIONS Anatomic tunnel placements did not vary between the mTT group and the OI group. However, the mTT group had more benefits in femoral graft bending angle and showed higher graft maturity and better synovial coverage than the OI group, although there were no significant differences in clinical outcomes. The acute femoral graft bending angle might negatively affect the maturation of proximal graft. LEVEL OF EVIDENCE: Level III, retrospective comparative study.
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17
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Jaecker V, Zapf T, Naendrup JH, Kanakamedala AC, Pfeiffer T, Shafizadeh S. Differences between traumatic and non-traumatic causes of ACL revision surgery. Arch Orthop Trauma Surg 2018; 138:1265-1272. [PMID: 29779039 DOI: 10.1007/s00402-018-2954-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Indexed: 02/09/2023]
Abstract
PURPOSE The purpose of this study was to evaluate and classify causes for anterior cruciate ligament (ACL) reconstruction failure. It was hypothesized that specific technical and biological reconstruction aspects would differ when comparing traumatic and non-traumatic ACL reconstruction failures. MATERIALS AND METHODS One hundred and forty-seven consecutive patients who experienced ACL reconstruction failure and underwent revision between 2009 and 2014 were analyzed. Based on a systematic failure analysis, including evaluation of technical information on primary ACL reconstruction and radiological assessment of tunnel positions, causes were classified into traumatic and non-traumatic mechanisms of failure; non-traumatic mechanisms were further sub-divided into technical and biologic causes. Spearman's rank correlation coefficient and chi-squared tests were performed to determine differences between groups based on various factors including graft choice, fixation technique, technique of femoral tunnel positioning, tunnel malpositioning, and time to revision. RESULTS Non-traumatic, i.e., technical, and traumatic mechanisms of ACL reconstruction failure were found in 64.5 and 29.1% of patients, respectively. Biological failure was found only in 6.4% of patients. Non-anatomical femoral tunnel positioning was found the most common cause (83.1%) for technical reconstruction failure followed by non-anatomical tibial tunnel positioning (45.1%). There were strong correlations between non-traumatic technical failure and femoral tunnel malpositioning, transtibial femoral tunnel drilling techniques, femoral transfixation techniques as well as earlier graft failure (p < 0.05). CONCLUSIONS Technical causes, particularly tunnel malpositioning, were significantly correlated with increased incidence of non-traumatic ACL reconstruction failure. Transtibial femoral tunnel positioning techniques and femoral transfixation techniques, showed an increased incidence of non-traumatic, earlier graft failure.
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Affiliation(s)
- Vera Jaecker
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Tabea Zapf
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Jan-Hendrik Naendrup
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Ajay C Kanakamedala
- University of Pittsburgh Medical Center, 3200 S Water Street, Pittsburgh, PA, 15203, USA
| | - Thomas Pfeiffer
- Department of Trauma and Orthopaedic Surgery, Cologne Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Sven Shafizadeh
- Department of Sports Traumatology and Trauma Surgery, Witten/Herdecke University, Sana Dreifaltigkeits-Krankenhaus, Aachener Straße 445-449, 50933, Cologne, Germany.
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Sim JA, Kim JM, Lee S, Song EK, Seon JK. No difference in graft healing or clinical outcome between trans-portal and outside-in techniques after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2018; 26:2338-2344. [PMID: 28756467 DOI: 10.1007/s00167-017-4655-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 07/19/2017] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of this study was to compare femoral tunnel geometry including tunnel position, length, and graft bending angle between trans-portal and outside-in techniques in anterior cruciate ligament (ACL) reconstruction and discover whether such differences in tunnel geometry could influence graft healing or clinical outcome. METHODS Sixty-four patients with anatomical single-bundle ACL reconstruction performed with either trans-portal technique (32 patients, one centre) or outside-in technique (32 patients, the other centre) were included in this retrospective study. Femoral tunnel location and length, and graft bending angle at the femoral tunnel were analysed on 3D CT knee model. The location and length of the femoral tunnel and graft bending angle were compared between the two techniques. All patients underwent MRI scans at around 1 year following ACL reconstruction. It was found that all patients had intact ACL graft on MRI images. On oblique axial image taken after ACL reconstruction to determine graft healing at femoral and tibial tunnels and the intra-articular portion, graft signal intensity ratio was calculated by dividing signal intensity (SI) of the reconstructed ACL by that of posterior cruciate ligament (PCL) in the region of interest selected with Marosis software. Clinical outcomes regarding Tegner activity scores, the International Knee Documentation Committee (IKDC) evaluation scores, Lachman test, and pivot shift test results were also compared between the two groups. RESULTS While the location of femoral tunnel was similar to each other in both groups, the femoral tunnel length was longer in the outside-in technique (37.0 vs. 32.4 mm, p = .02). Meanwhile, the outside-in technique showed significantly more acute graft tunnel angle than the trans-portal technique (106.7° vs. 113.8°, p = .01). However, signal intensity ratios of grafts (compared with SI of PCL) were similar in femoral and tibial tunnels and intra-articular portions. Moreover, there were no statistically significant differences in terms of IKDC scores (89.4 vs. 90.5, n.s.) or Tegner activity scores (6.2 vs. 6.4, n.s.) between the two groups. There was no significant difference in measurement of Lachman or Pivot shift test either between the two groups. CONCLUSION Even though the outside-in technique in ACL reconstruction created a more acute femoral graft bending angle and a longer femoral tunnel length than the trans-portal technique, these had no negative effect on graft healing. In addition, trans-portal and outside-in techniques in ACL reconstruction showed similar femoral tunnel positions and clinical outcomes. Acceptable graft healing and clinical outcomes can be obtained for both trans-portal and outside-in techniques in ACL reconstruction. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jae-Ang Sim
- Department of Orthopaedic Surgery, Gil Hospital, Gachon University of Medicine and Science, Inchon, Korea
| | - Jong-Min Kim
- Department of Orthopaedic Surgery, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - SahngHoon Lee
- Department of Orthopaedic Surgery, Seoul University Hospital, Seoul, Korea
| | - Eun-Kyoo Song
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 519-763, Korea
| | - Jong-Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Hwasun Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeonnam, 519-763, Korea.
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High non-anatomic tunnel position rates in ACL reconstruction failure using both transtibial and anteromedial tunnel drilling techniques. Arch Orthop Trauma Surg 2017; 137:1293-1299. [PMID: 28721590 DOI: 10.1007/s00402-017-2738-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Although it is well known from cadaveric and biomechanical studies that transtibial femoral tunnel (TT) positioning techniques are associated with non-anatomic tunnel positions, controversial data exist as so far no clinical differences could have been found, comparing transtibial with anteromedial techniques (AM). The purpose of the study was to analyze if graft failure following TT ACL reconstruction was more commonly associated with non-anatomic tunnel position in comparison with the AM technique. We hypothesized that, compared to AM techniques, non-anatomic tunnel positions correlate with TT tunnel positioning techniques. MATERIALS AND METHODS A total of 147 cases of ACL revision surgery were analyzed retrospectively. Primary ACL reconstructions were analyzed regarding the femoral tunnel drilling technique. Femoral and tibial tunnel positions were determined on CT scans using validated radiographic measurement methods. Correlation analysis was performed to determine differences between TT and AM techniques. RESULTS A total of 101 cases were included, of whom 64 (63.4%) underwent the TT technique and 37 (36.6%) the AM technique for primary ACL reconstruction. Non-anatomic femoral tunnel positions were found in 77.2% and non-anatomical tibial tunnel positions in 40.1%. No correlations were found comparing tunnel positions in TT and AM techniques, revealing non-anatomic femoral tunnel positions in 79.7 and 73% and non-anatomic tibial tunnel positions in 43.7 and 35.1%, respectively (p > 0.05). CONCLUSIONS Considerable rates of non-anatomic femoral and tibial tunnel positions were found in ACL revisions with both transtibial and anteromedial femoral drilling techniques. Despite the potential of placing tunnels more anatomically using an additional AM portal, this technique does not ensure anatomic tunnel positioning. Consequently, the data highlight the importance of anatomic tunnel positioning in primary ACL reconstruction, regardless of the applied drilling technique.
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