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Primary Proximal ACL Repair: A Biomechanical Evaluation of Different Arthroscopic Suture Configurations. J Clin Med 2023; 12:jcm12062340. [PMID: 36983341 PMCID: PMC10059937 DOI: 10.3390/jcm12062340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 03/19/2023] Open
Abstract
Purpose: Several suture techniques have been described in the past for direct ACL repair with poor healing capacity and a high re-rupture rate. Therefore, we investigated a refixation technique for acute primary proximal ACL repair. The purpose of this study is to compare the biomechanical properties of different suture configurations using a knotless anchor. Methods: In this study, 35 fresh-frozen porcine knees underwent proximal ACL refixation. First, in 10 porcine femora, the biomechanical properties of the knotless anchor, without the ligament attached, were tested. Then, three different suture configurations were evaluated to reattach the remaining ACL. Using a material testing machine, the structural properties were evaluated for cyclic loading followed by loading to failure. Results: The ultimate failure load of the knotless anchor was 198, 76 N ± 23, 4 N significantly higher than all of the tested ACL suture configurations. Comparing the different configurations, the modified Kessler–Bunnell suture showed significant superior ultimate failure load, with 81, 2 N ± 15, 6 N compared to the twofold and single sutures (50, 5 N ± 14 N and 37, 5 ± 3, 8 N). In cyclic loading, there was no significant difference noted for the different configurations in terms of stiffness and elongation. Conclusions: The results of this in vitro study show that when performing ACL suture using a knotless anchor, a modified Kessler–Bunnell suture provides superior biomechanical properties than a single and a twofold suture. Within this construct, no failure at the bone–anchor interface was seen. Clinical relevance: Since primary suture repair techniques of ACL tears have been abandoned because of inconsistent results, ACL reconstruction remains the gold standard of treating ACL tears. However, with the latest improvements in surgical techniques, instrumentation, hardware and imaging, primary ACL suture repair might be a treatment option for a select group of patients. By establishing an arthroscopic technique in which proximal ACL avulsion can be reattached, the original ACL can be preserved by using a knotless anchor and a threefold suture configuration. Nevertheless, this technique provides an inferior ultimate failure load compared to graft techniques, so a careful rehabilitation program must be followed if using this technique in vivo.
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Gibbs CM, Winkler PW, Tisherman RT, Chan CK, Diermeier TA, Debski RE, Musahl V. Continuous-Loop Tape Technique Has Greater Stiffness and Less Elongation Compared With Tied-Suture Fixation of Full-Thickness All-Soft Tissue Quadriceps Tendon Autografts. Orthop J Sports Med 2021; 9:23259671211054108. [PMID: 34790834 PMCID: PMC8591645 DOI: 10.1177/23259671211054108] [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: 07/12/2021] [Accepted: 08/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background Many graft fixation techniques are utilized for full-thickness soft tissue quadriceps tendon autografts during anterior cruciate ligament reconstruction (ACLR). Purpose To determine the tensile properties of all-soft tissue quadriceps tendon graft fixation using a tied-suture versus continuous-loop tape technique. It was hypothesized that the continuous-loop tape technique would have less cyclic elongation and greater ultimate load to failure and stiffness compared with a commonly used tied-suture technique. Study Design Controlled laboratory study. Methods Sixteen fresh-frozen human knee specimens were used to harvest a full-thickness all-soft tissue quadriceps tendon graft; half were secured using a Krackow suture technique with 2 braided sutures, and half were secured using a continuous-loop tape suspensory fixation button with a rip-stop stitch. Cyclic and permanent elongation, toe- and linear-region stiffness, and ultimate load were determined. Statistical analysis was performed at P <.05. Results The tied-suture fixation group demonstrated significantly higher permanent elongation (11.7 ± 3.6 vs 4.2 ± 1.0 mm, P < .001) and cyclic elongation (5.9 ± 1.3 vs 2.0 ± 0.4 mm, P < .001) compared with the continuous-loop tape fixation group. There was a significantly higher linear-region stiffness with continuous-loop tape fixation compared with tied-suture fixation (98.8 ± 12.7 vs 85.5 ± 7.5 N/mm, P = .022). No significant difference in ultimate load between groups (517.1 ± 149.2 vs 465.6 ± 64.6 N) was found. The mode of failure was tendon pull-through for the continuous-loop tape group and suture breakage in the tied-suture group (P < .001). Conclusion Continuous-loop tape fixation is superior to tied-suture fixation in regard to elongation and stiffness for all-soft tissue quadriceps tendon grafts, but there was no significant difference in ultimate load. Clinical Relevance Continuous-loop tape fixation of all-soft tissue quadriceps tendon grafts for ACLR is a valid technique with superior tensile properties.
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Affiliation(s)
- Christopher M Gibbs
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philipp W Winkler
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Robert T Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Calvin K Chan
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Theresa A Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Richard E Debski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Matthews JR, Wang J, Zhao J, Kluczynski MA, Bisson LJ. The influence of suture materials on the biomechanical behavior of suture-meniscal specimens: a comparative study in a porcine model. Knee Surg Relat Res 2020; 32:42. [PMID: 32859270 PMCID: PMC7453549 DOI: 10.1186/s43019-020-00053-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background Repair of a meniscal tear is indicated in certain conditions. Despite extensive research on the biomechanics of various repair methods, there has been minimal investigation of whether the suture material influences the meniscal-suture construct. The purpose of this study was to compare the biomechanical properties of nine different suture materials under cyclic and load-to-failure conditions. Methods Ninety porcine menisci were randomly allocated to simple suture placement using either Ultrabraid®, Ultratape®, Magnum Wire®, TigerWire®, TigerTape®, LabralTape®, Orthocord®, 0 FiberWire®, or 2-0 FiberWire®. Each suture-meniscus specimen underwent cyclic loading followed by load-to-failure testing. Elongation, maximum load to failure, stiffness, and mode of failure were recorded and compared between each suture type using non-parametric testing. Mean ± standard deviation was reported and the statistical significance was p < 0.05. Results Elongation during cyclic loading was lowest with 2-0 FiberWire (0.95 ± 0.17 mm); this value was statistically significantly different than the results for all other sutures except 0 FiberWire® (1.09 ± 0.17 mm, p = 0.79), TigerWire® (1.09 ± 0.29 mm, p = 0.85), TigerTape® (1.39 ± 0.29 mm, p = 0.08), and LabralTape® (1.20 ± 0.33 mm, p = 0.41). The highest elongation was seen with Ultrabraid® (1.91 ± 0.34 mm); this value was statistically significantly greater than the results for all other suture materials except Orthocord® (1.59 mm ± 0.31 mm, p = 0.46) and Magnum Wire® (1.43 ± 0.25 mm, p = 0.14). Load to failure was highest for TigerTape® (287.43 ± 41.15 N), and this result was statistically significantly different than the results for all other sutures except LabralTape® (271.34 ± 48.48 N, p = 0.99) and TigerWire® (251.03 ± 25.8 N, p = 0.51). Stiffness was highest for LabralTape® (195.77 ± 49.06 N/mm), and this result was statistically significantly different than the results for all other sutures except TigerWire® (186.49 ± 19.83 N/mm, p = 0.45) and TigerTape® (173.35 ± 15.60 N/mm, p = 0.19). The majority of sutures failed by pullout (n = 46, 51%) or tearing (n = 40, 45%). Conclusion Suture design and material affect the biomechanical behavior of porcine meniscal-suture specimens. LabralTape®, TigerWire®, and TigerTape® demonstrated better overall combinations of low elongation, high maximum load to failure, and high stiffness.
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Affiliation(s)
- John Reza Matthews
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Jiefei Wang
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Jiwei Zhao
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Melissa A Kluczynski
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Leslie J Bisson
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Comparison of the outcomes of anterior cruciate ligament reconstruction by using patellar tendon or hamstring tendon autografts that have been fixed with cross-pin system at femoral side. ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2020. [DOI: 10.21673/anadoluklin.735533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Noh JH, Lee JW. One-Year Serial Follow-up Magnetic Resonance Imaging Study of RigidFix for Femoral Fixation in Anterior Cruciate Ligament Reconstruction. Knee Surg Relat Res 2017; 29:203-209. [PMID: 28854766 PMCID: PMC5596400 DOI: 10.5792/ksrr.16.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 06/02/2017] [Accepted: 06/09/2017] [Indexed: 01/10/2023] Open
Abstract
Purpose To assess graft slippage at the site of femoral fixation by follow-up magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) reconstruction with a four-strand autogenous hamstring tendon using RigidFix (DePuy Mitek). Materials and Methods Twenty-one subjects diagnosed with ACL rupture underwent ACL reconstruction using hamstring autograft with the transtibial technique. RigidFix was used for femoral fixation and Intrafix and washer screw were used for tibial fixation. Follow-up MRIs were taken immediately after surgery and at 1, 3, 6, and 12 months after surgery. Slippage of the graft and breakage of the RigidFix cross-pin were assessed. Side-to-side difference (SSD) on stress radiographs was measured to assess residual laxity. Results Mean slippage of the graft was 0.21±0.31 mm at one year after surgery. Cross-pin breakage was noted in two subjects: in one subject, immediately after surgery and in the other subject, at 6 months after surgery. Mean SSD was 1.32±1.07 mm at the last follow-up. The correlation coefficient between graft slippage and SSD was 0.131 (p=0.571). Conclusions RigidFix is a stable fixation device for hamstring autograft with minimally statistically significant but clinically insignificant graft slippage. Cross-pin breakage did not affect the clinical outcomes. Careful preparation of the graft is needed for performing the technique correctly.
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Affiliation(s)
- Jung Ho Noh
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jae Woo Lee
- Department of Orthopaedic Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
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The biomechanical strength of a hardware-free femoral press-fit method for ACL bone-tendon-bone graft fixation. Knee Surg Sports Traumatol Arthrosc 2017; 25:1234-1240. [PMID: 26744280 DOI: 10.1007/s00167-015-3960-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose was to investigate graft slippage and ultimate load to failure of a femoral press-fit fixation technique for anterior cruciate ligament (ACL) reconstruction. METHODS Nine fresh-frozen knees were used. Standardized harvesting of the B-PT-B graft was performed. The femora were cemented into steel rods, and a tunnel was drilled outside-in into the native ACL footprint and expanded using a manual mill bit. The femoral bone block was fixed press-fit. To pull the free end of the graft, it was fixed to a mechanical testing machine using a deep-freezing technique. A motion capture system was used to assess three-dimensional micro-motion. After preconditioning of the graft, 1000 cycles of tensile loading were applied. Finally, an ultimate load to failure test was performed. Graft slippage in mm ultimate load to failure as well as type of failure was noted. RESULTS In six of the nine measured specimens, a typical pattern of graft slippage was observed during cyclic loading. For technical reasons, the results of three knees had to be discarded. 78.6 % of total graft slippage occurred in the first 100 cycles. Once the block had settled, graft slippage converged to zero, highlighting the importance of initial preconditioning of the graft in the clinical setting. Graft slippage after 1000 cycles varied around 3.4 ± 3.2 mm (R = 1.3-9.8 mm) between the specimens. Ultimate loading (n = 9) revealed two characteristic patterns of failure. In four knees, the tendon ruptured, while in five knees the bone block was pulled out of the femoral tunnel. The median ultimate load to failure was 852 N (R = 448-1349 N). CONCLUSION The implant-free femoral press-fit fixation provided adequate primary stability with ultimate load to failure pull forces at least equal to published results for interference screws; hence, its clinical application is shown to be safe.
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Gaines EB, Lau D, Naziri Q, Hayes W, Jauregui JJ, Kapadia BH, Urban WP, Zikria BA. A biomechanical analysis of tibial ACL reconstruction with graft length mismatch. J Orthop Surg (Hong Kong) 2017; 25:2309499017690983. [PMID: 28211291 DOI: 10.1177/2309499017690983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The incidence of graft length mismatch (GLM) during anterior cruciate ligament (ACL) reconstruction is reported to be up to 13%, with a rate of 20% when using bone-patellar tendon-bone (BPTB) allografts. Multiple techniques have been described to accommodate for the longer BPTB graft. As no study has compared the biomechanical properties of these methods (with cyclic loading), we evaluated the strength of four different surgical techniques used to accommodate for GLM during ACL reconstruction. METHODS A total of 32 fresh-frozen bovine tibiae and patellar tendons were divided into four groups based on the method of tibial graft fixation: (1) sutures tied over a post, (2) bone staples, (3) screws and washers, and (4) soft-tissue conversion with interference screw. Biomechanical testing was performed comparing the tensile properties of graft fixation techniques under cyclic loading. Ability to withstand 1500 cycles of load, the maximum tensile strength at load-to-failure, and the mode-of-failure were evaluated. RESULTS Only group 4 had all grafts intact after 1500 loading cycles, while the other groups had one graft failure at 338 (group 1), 240 (group 2), and 309 (group 3) cycles. The highest mean load-to-failure was observed in group 3 at 762 ± 173 N, which was found to be significantly higher than the other groups. The mean loads to failure in groups 1-4 were 453 ± 86 N, 485 ± 246 N, 762 ± 173 N, and 458 ± 128 N. CONCLUSION While there are multiple viable techniques for fixation of a BPTB graft in the case of GLM, this study demonstrated that direct screw fixation offers the strongest construct.
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Affiliation(s)
- Evan B Gaines
- 1 Department of Orthopaedic Surgery, POWR Premier Orthopaedics of Westchester and Rockland, NY, USA
| | - Diana Lau
- 2 Department of Orthopaedic Surgery, Sports Clinic Orthopaedic Medical Associates, CA, USA
| | - Qais Naziri
- 3 Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, NY, USA
| | - Westley Hayes
- 3 Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, NY, USA
| | - Julio J Jauregui
- 4 Department of Orthopaedics, University of Maryland Medical Center, MD USA
| | - Bhaveen H Kapadia
- 3 Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, NY, USA
| | - William P Urban
- 3 Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, NY, USA
| | - Bashir A Zikria
- 5 Department of Orthopaedic Surgery, Johns Hopkins University, MD USA
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Herbort M, Hoser C, Domnick C, Raschke MJ, Lenschow S, Weimann A, Kösters C, Fink C. MPFL reconstruction using a quadriceps tendon graft: part 1: biomechanical properties of quadriceps tendon MPFL reconstruction in comparison to the Intact MPFL. A human cadaveric study. Knee 2014; 21:1169-74. [PMID: 25178693 DOI: 10.1016/j.knee.2014.07.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 07/18/2014] [Accepted: 07/21/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to analyze the structural properties of the original MPFL and to compare it to a MPFL-reconstruction-technique using a strip of quadriceps tendon. METHODS In 13 human cadaver knees the MPFLs were dissected protecting their insertion at the patellar border. The MPFL was loaded to failure after preconditioning with 10 cycles in a uniaxial testing machine evaluating stiffness, yield load and maximum load to failure. In the second part Quadriceps-MPFL-reconstruction was performed and tested in a uniaxial testing machine. Following preconditioning, the constructs were cyclically loaded 1000 times between 5 and 50 N measuring the maximum elongation. After cyclic testing, the constructs have been loaded to failure measuring stiffness, yield load and maximum load. For statistical analysis a repeated measures (RM) one-way ANOVA for multiple comparisons was used. The significance was set at P<0.05. RESULTS During the load to failure tests of the original MPFL the following results were measured: stiffness 29.4 N/mm (+9.8), yield load 167.8 N (+80) and maximum load to failure 190.7 N (+82.8). The results in the QT-technique group were as follows: maximum elongation after 1000 cycles 2.1 mm (+0.8), stiffness 33.6 N/mm (+6.8), yield load 147.1 N (+65.1) and maximum load to failure 205 N (+77.8). There were no significant differences in all tested parameters. CONCLUSIONS In a human cadaveric model using a strip of quadriceps-tendon 10 mm wide and 3mm deep, the biomechanical properties match those of the original MPFL when tested as a reconstruction. CLINICAL RELEVANCE The tested QT-technique shows sufficient primary stability with comparable biomechanical parameters to the intact MPFL.
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Affiliation(s)
- Mirco Herbort
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany.
| | | | - Christoph Domnick
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany
| | - Simon Lenschow
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany
| | - Andre Weimann
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany
| | - Clemens Kösters
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelian-Wilhelms University of Muenster, Muenster, Germany
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The primary stability of pelvic reconstruction after partial supraacetabular pelvic resection due to malignant tumours of the human pelvis: A biomechanical in vitro study. Med Eng Phys 2013; 35:1731-5. [DOI: 10.1016/j.medengphy.2013.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/08/2013] [Accepted: 07/19/2013] [Indexed: 11/21/2022]
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Graft failure versus graft fixation in ACL reconstruction: histological and immunohistochemical studies in rabbits. Arch Orthop Trauma Surg 2013; 133:1197-202. [PMID: 23793478 DOI: 10.1007/s00402-013-1790-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Indexed: 02/09/2023]
Abstract
The causes of graft failure after anterior cruciate ligament (ACL) reconstruction are multifactorial including the methods of graft fixation. The purpose of this study was to examine the ACL graft failure in three different methods of graft fixations including interference screw fixation, suture-post fixation and combined interference screw and suture-post fixation. We hypothesized that the fixation method after ACL reconstruction can affect the graft healing in tibial tunnel. Eighteen New Zealand white rabbits were categorized into three groups according to the method of fixation in unilateral ACL reconstruction with long digital extensor autograft. Histological examination demonstrated that the combined fixation and suture-post fixation groups showed significantly better integration between tendon and bone (P = 0.04). In immunohistochemical analysis, the combined fixation and suture-post fixation groups showed significantly higher BMP-2 and VEGF expressions than interference screw (P < 0.01). The tendon-bone healing after ACL reconstruction was affected by the method of graft fixation. Combined fixation with interference screw and suture-post reduced graft-tunnel micromotion and improved the graft healing in tibial tunnel.
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von der Heide N, Ebneter L, Behrend H, Stutz G, Kuster MS. Improvement of primary stability in ACL reconstruction by mesh augmentation of an established method of free tendon graft fixation. A biomechanical study on a porcine model. Knee 2013; 20:79-84. [PMID: 23114263 DOI: 10.1016/j.knee.2012.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 09/04/2012] [Accepted: 09/14/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of the present study was to compare primary stability in ACL reconstruction and ultimate load to failure of a mesh augmented hamstring tendon graft fixed with two cross pins to established hamstrings and bone-patellar-tendon-bone (BTB) graft fixation methods. METHODS Forty fresh porcine femora were divided into four groups: (A): BTB graft fixed with two RigidFix® pins, (B): hamstring tendon graft fixed with a Milagro® interference screw, (C): hamstring tendon graft fixed with two RigidFix® pins, and (D): hamstring tendon graft augmented with Ultrapro® mesh fixed with two RigidFix® pins. Each graft underwent cyclic loading in tension and load to failure. Elastic and plastic displacements were measured by 3-dimensional digital image correlation. Groups were compared by one-way ANOVA and Tukey-Kramer post-hoc tests. RESULTS After 1000 cycles, the mean plastic displacement was lowest in the BTB graft (p < 0.001). Plastic displacement was significantly lower in the mesh augmented group compared to the plain hamstring graft and the Milagro screw group (p < 0.05). Load to failure was highest in the mesh-augmented group; significant to the hamstring tendon (p = 0.023). CONCLUSION Although the BTB-graft represented the most stable construct against plastic displacement in our study, mesh augmentation of free tendon grafts significantly increased primary stability and reduced plastic displacement of femoral cross pin fixation. This new augmentation device may better protect the hamstrings graft from secondary elongation during postoperative rehabilitation. CLINICAL RELEVANCE Mesh augmentation seems to be an effective technique to stabilise free hamstring tendon autografts during postoperative rehabilitation with significant reduction of graft slippage.
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Choi NH, Yoo SY, Victoroff BN. Tibial tunnel widening after hamstring anterior cruciate ligament reconstructions: comparison between Rigidfix and Bio-TransFix. Knee 2013; 20:31-5. [PMID: 22743062 DOI: 10.1016/j.knee.2012.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 04/17/2012] [Accepted: 05/24/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is no study comparing tibial tunnel widening after hamstring anterior cruciate ligament (ACL) reconstructions between RigidFix(r) and Bio-TransFix(r). METHODS Hamstring ACL reconstructions using RigidFix(r) in 56 patients and Bio-TransFix(r) in 41 with a minimum of 2years postoperative evaluation were reviewed. Tibial fixation was performed using Intrafix in both groups. On the anterior-posterior (AP) and lateral radiographs, the diameter of the tibial tunnel was measured at proximal, middle, and distal positions. Postoperative laxity evaluations were performed using Lachman test, pivot-shift test, and instrumented laxity testing using the KT-1000 arthrometer. RESULTS On the AP and lateral radiographs, the average diameter of the tibial tunnel in the Bio-TransFix(r) group significantly increased after 6months compared to the immediate postoperative measurement (p=0.002 and p=0.002, respectively). However, the average diameter of the tibial tunnel in the RigidFix(r) group did not increase after 6months compared to the immediate postoperative measurement. Tunnel widening at 12months postoperatively in the Bio-TransFix(r) group was significantly more than that of the RigidFix(r) group on AP and lateral radiographs (p=0.012 and 0.016, respectively). Tunnel widening at 24months postoperatively showed a significant difference between the two groups (p=0.000 and 0.000, respectively). Fifteen patients (36.6%) in the Bio-TransFix(r) group and 15 patients (26.8%) in the RigidFix(r) group showed tunnel widening. There were no significant differences in results of the Lachman and pivot-shift tests, and mean KT-1000 measurement between the two groups. CONCLUSION The Bio-TransFix(r) group showed progressive tibial tunnel widening after 6months postoperatively but no clinical signs of instability. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nam-Hong Choi
- Department of Orthopaedic Surgery, Eulji Medical Center, 280-1, Hagye-1-dong, Nowon-gu, Seoul, 139-231, Republic of Korea.
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Tse BK, Vaughn ZD, Lindsey DP, Dragoo JL. Evaluation of a one-stage ACL revision technique using bone void filler after cyclic loading. Knee 2012; 19:477-81. [PMID: 21775147 DOI: 10.1016/j.knee.2011.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 06/10/2011] [Accepted: 06/22/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Revision anterior cruciate ligament (ACL) reconstruction often requires a two-stage approach. This study analyzes the biomechanical properties after cyclic loading of a one-stage ACL revision technique using a calcium phosphate bone cement. METHODS Arthroscopic reconstruction of the ACL was performed in 5 matched pairs of fresh-frozen cadaveric knees separated into two groups. The control group underwent a standard reconstruction with a bone-patellar tendon-bone autograft with bioabsorbable interference screw fixation. The experimental group simulated a failed reconstruction by drilling a 12 mm hole and underwent a revision after filling it with a bioabsorbable calcium phosphate bone cement. The specimens were dissected, scanned for bone mineral density, and cyclically loaded on a mechanical testing system (preload of 250 cycles of 5-75 N at 0.5 Hz followed by 10,000 cycles of 20-150 N at 1 Hz). Intact specifmens underwent a load-to-failure protocol of 50mm/min. Ultimate load, stiffness, and modes of failure were recorded. Data was analyzed using paired t-tests. FINDINGS All specimens completed the mechanical testing protocol. The control group had a mean maximum load of 471.33 N (SD 220.73 N) and the experimental group had 453.54 N (SD 152.36; p=0.84). There were no statistically significant differences in maximum load or stiffness. No correlation between bone mineral density (BMD) and maximum load was found. INTERPRETATION Using calcium phosphate filler in a single-stage ACL revision is biomechanically viable. Further testing of long-term incorporation of the ACL graft in an animal model, along with human clinical trials, should be performed before there is clinical acceptance of this technique.
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Affiliation(s)
- Brian K Tse
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, CA 94063-6342, USA
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Noyes FR, Barber-Westin SD. Management of meniscus tears that extend into the avascular region. Clin Sports Med 2012; 31:65-90. [PMID: 22108660 DOI: 10.1016/j.csm.2011.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Frank R Noyes
- Cincinnati Sportsmedicine Research and Education Foundation, Cincinnati, OH 45242, USA
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Abstract
Preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following repair of meniscus tears for both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. This operation is usually indicated in active patients who have tibiofemoral joint line pain and are less than 50 years of age. However, not all meniscus tears are repairable, especially if considerable damage has occurred. In select patients, meniscus transplantation may restore partial load-bearing meniscus function, decrease symptoms, and provide chondroprotective effects. The initial postoperative goal after both meniscus repair and transplantation is to prevent excessive weight bearing, as high compressive and shear forces can disrupt healing meniscus repair sites and transplants. Immediate knee motion and muscle strengthening are initiated the day after surgery. Variations are built into the rehabilitation protocol according to the type, location, and size of the meniscus repair, if concomitant procedures are performed, and if articular cartilage damage is present. Meniscus repairs located in the periphery heal rapidly, whereas complex multiplanar repairs tend to heal more slowly and require greater caution. The authors have reported the efficacy of the rehabilitation programs and the results of meniscus repair and transplantation in many studies.
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Accidental perforation of the lateral femoral cortex in ACL reconstruction: an investigation of mechanical properties of different fixation techniques. Arthroscopy 2012; 28:382-9. [PMID: 22305326 DOI: 10.1016/j.arthro.2011.10.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 10/23/2011] [Accepted: 10/25/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to evaluate the mechanical properties of anterior cruciate ligament (ACL) reconstruction using the medial portal technique with cortical fixation and hybrid fixation after penetration of the lateral cortex by use of different drill sizes. METHODS In this biomechanical study a porcine in vitro model was used. The testing protocol consisted of a cyclic loading protocol (1,000 cycles, 50 and 250 N) and subsequent ultimate failure testing. Number of cyclic loadings survived, stiffness, yield load, maximum load, and graft elongation, as well as failure mode, were analyzed after ACL reconstruction with 5- to 9-mm soft-tissue grafts. In the control group, conventional penetration of the lateral cortex with a 4.5-mm drill and cortical fixation were performed. In the tested groups, the lateral cortex was penetrated with a drill matching the graft size. In the first part of the study, we used cortical fixation. In the second part, we used hybrid fixation with an interference screw. RESULTS In the first part of the study, ACL reconstruction with 5- to 6-mm perforation of the lateral cortex showed no significant differences in ultimate failure load after cyclic loading compared with the control group (P > .05). Specimens with reconstruction with 7- to 9-mm perforation of the lateral cortex and cortical fixation did not survive the cyclic loading protocol. In the second part of the study, with a hybrid fixation technique, ultimate failure testing after cyclic loading of specimens with 7- to 9-mm penetration showed no significant differences in tested parameters compared with the control group (P > .05). CONCLUSIONS After penetration of the lateral cortex with a drill size of more than 6 mm, cortical ACL fixation results in poor mechanical properties. Hybrid fixation increases the mechanical properties significantly after penetration with a 7- to 9-mm drill. CLINICAL RELEVANCE We advise caution to avoid penetration of the lateral femoral cortex when using cortical flip-button fixation. In case of accidental perforation of the lateral cortex with a diameter greater than 6 mm, we recommend performing hybrid fixation.
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Albano MB, Borges PC, Namba MM, da Silva JLV, de Assis Pereira Filho F, Filho ES, Matias JEF. BIOMECHANICAL STUDY OF TRANSCORTICAL OR TRANSTRABECULAR BONE FIXATION OF PATELLAR TENDON GRAFT WITH BIOABSORBABLE PINS IN ACL RECONSTRUCTION IN SHEEP. Rev Bras Ortop 2012; 47:43-9. [PMID: 27027081 PMCID: PMC4799357 DOI: 10.1016/s2255-4971(15)30344-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 10/25/2011] [Indexed: 12/02/2022] Open
Abstract
Objective: To determine the initial resistance of fixation using the Rigid Fix® system, and compare it with traditional fixation methods using metal interference screws; and to evaluate the resistance of the fixation with the rigid fix system when the rotational position of the bone block is altered in the interior of the femoral tunnel. Methods: forty ovine knee specimens (stifle joints) were submitted to anterior cruciate ligament reconstruction (ACL) using a bone-tendon-bone graft. In twenty specimens, the Rigid Fix method was used; this group was subdivided into two groups: ten knees the pins transfixed only the spongious area of the bone block, and ten for fixation passing through the layer of cortical bone. In the twenty remaining specimens, the graft was fixed with 9mm metal interference screws. Results: comparison of the RIGIDFIX® method with the metal interference screw fixation method did not show any statistically significant differences in terms of maximum load and rigidity; also, there were no statistically significant differences when the rotational position of the bone block was altered inside the femoral tunnel. For these evaluations, a level of significance of p < 0.017 was considered. Conclusion: fixation of the bone-tendon-bone graft with 2 bioabsorbable pines, regardless of the rotational position inside the femoral tunnel, gave a comparable fixation in terms of initial resistance to the metal interference screw, in this experimental model.
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Affiliation(s)
- Mauro Batista Albano
- MSc in Surgical Clinical Medicine from the Federal University of Paraná (UFPR); Professor in the Specialization Course on Sports Traumatology and Arthroscopy,UFPR; Member of the Orthopedics and Traumatology Service, Hospital do Trabalhador, UFPR, Curitiba, PR, Brazil
| | - Paulo César Borges
- PhD in Mechanical Engineering; Professor in the Academic Department of Mechanics, Federal Technological University of Paraná (UTFPR), Curitiba, PR, Brazil
| | - Mario Massatomo Namba
- MSc in Surgical Clinical Medicine from UFPR; Professor and Coordinator of the Specialization Course on Sports Traumatology,UFPR; Member of the Orthopedics and Traumatology Service, UFPR, Curitiba, PR, Brazil
| | - João Luiz Vieira da Silva
- PhD in Surgical Clinical Medicine from UFPR; Professor in the Specialization Course on Sports Traumatology and Arthroscopy,UFPR; Member of the Orthopedics and Traumatology Service,UFPR, Curitiba, PR, Brazil
| | - Francisco de Assis Pereira Filho
- Physician and Professor in the Specialization Course on Sports Traumatology and Arthroscopy,UFPR; Member of the Orthopedics and Traumatology Service,UFPR, Curitiba, PR, Brazil
| | - Edmar Stieven Filho
- Physician andProfessor in the Specialization Course on Sports Traumatology and Arthroscopy,UFPR, Curitiba, PR, Brazil
| | - Jorge Eduardo Fouto Matias
- PhD in Surgical Clinical Medicine. Adjunct Professor in the Department of Surgery, UFPR, Curitiba, PR, Brazil
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Abstract
The anterior cruciate ligament (ACL) has been the focus of a substantial amount of research. Thousands of studies have evaluated the structure and function of the intact ACL, as well as the best reconstruction techniques. Despite the amount of literature, many controversies remain regarding the ACL and its surgical reconstruction. This article reviews the anatomy and function of the native ACL, the nature of injury, and aspects of ACL reconstruction, including surgical approach, tunnel positioning, graft choice, and graft fixation.
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Willis-Owen CA, Hearn TC, Keene GC, Costi JJ. Biomechanical testing of implant free wedge shaped bone block fixation for bone patellar tendon bone anterior cruciate ligament reconstruction in a bovine model. J Orthop Surg Res 2010; 5:66. [PMID: 20813059 PMCID: PMC2939630 DOI: 10.1186/1749-799x-5-66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 09/02/2010] [Indexed: 12/14/2022] Open
Abstract
Background The use of an interference fit wedged bone plug to provide fixation in the tibial tunnel when using bone-patellar tendon-bone autograft for anterior cruciate ligament reconstruction offers many theoretic advantages including the potential to offer a more economical and biological alternative to screw fixation. This technique has not been subjected to biomechanical testing. We hypothesised that a wedged bone plug fixation technique provides equivalent tensile load to failure as titanium interference screw fixation. Methods In a controlled laboratory setting, anterior cruciate ligament reconstruction was performed in 36 bovine knees using bone-patella-bone autograft. In 20 knees tibial fixation relied upon a standard cuboid bone block and interference screw. In eight knees a wedge shaped bone block with an 11 mm by 10 mm base without a screw was used. In a further eight knees a similar wedge with a 13 mm by 10 mm base was used. Each specimen used a standard 10 mm tibial tunnel. The reconstructions were tested biomechanically in a physiological environment using an Instron machine to compare ultimate failure loads and modes of failure. Results Statistical analysis revealed no significant difference between wedge fixation and screw fixation (p = 0.16), or between individual groups (interference screw versus 11 mm versus 13 mm wedge fixation) (P = 0.35). Conclusions Tibial tunnel fixation using an impacted wedge shaped bone block in anterior cruciate ligament reconstruction has comparable ultimate tensile strength to titanium interference screw fixation.
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Efe T, Bauer J, Herdrich S, Gotzen L, El-Zayat BF, Schmitt J, Schofer MD. Comparison between bovine bone and titanium interference screws for implant fixation in ACL reconstruction: a biomechanical study. Arch Orthop Trauma Surg 2010; 130:993-9. [PMID: 20066430 DOI: 10.1007/s00402-010-1052-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The application of interference screws for the fixation of bone-patellar tendon-bone (BPTB) grafts is a well-established technique in anterior-cruciate ligament reconstruction. Interference screws derived from bovine compact bone are a biological alternative to metallic or biodegradable polymer interference screws. MATERIALS AND METHODS In 60 porcine specimens, the tibial part of an anterior-cruciate ligament reconstruction was performed using a BPTB graft. To secure the graft, either an 8-mm titanium interference screw or a self-made bovine interference screw (BC), or a commercial bovine compact bone screw (Tutofix) was used. The maximum failure load was determined by means of a universal testing machine with computer interface at a testing speed of 50 mm/min. In a second test series, cyclic sub-maximal load was applied to the test specimen from 40 to 400 N with a number of 1,000 load cycles and a frequency of 1 Hz. Subsequently, the maximum failure load was determined. The stiffness of the test specimen was investigated in both test series. Each type of interference screw was tested 10 times. RESULTS A secure fixation of the grafts was achieved with all interference screws. In the experiments on the maximum load to failures, the titanium screws showed significantly higher failure loads than the Tutofix screws (P = 0.005). The stiffness of the grafts fixed with BC screws was significantly higher as compared to the fixation with Tutofix screws (P = 0.005). After cyclic sub-maximal loading, the maximum failure load of the titanium screws was significantly higher than that of the Tutofix screws (P = 0.033). The fixation of the BC screws showed a significantly higher failure load (P = 0.021) and stiffness (P = 0.032) than the Tutofix screw fixation. Except for two screw head fractures and two intra-tendinous graft ruptures, the failure mode was slippage in the interface between interference screw and bone plug. CONCLUSION Interference screws derived from bovine compact bone show similar good results as the titanium interference screws. Therefore, the safety and in vivo performance of products derived from xenogenic bone should be the focus of further investigations.
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Affiliation(s)
- Turgay Efe
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Germany.
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Bauer J, Efe T, Herdrich S, Gotzen L, El-Zayat BF, Schmitt J, Timmesfeld N, Schofer MD. Torsional stability of interference screws derived from bovine bone--a biomechanical study. BMC Musculoskelet Disord 2010; 11:82. [PMID: 20433761 PMCID: PMC2881015 DOI: 10.1186/1471-2474-11-82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 05/01/2010] [Indexed: 01/10/2023] Open
Abstract
Background In the present biomechanical study, the torsional stability of different interference screws, made of bovine bone, was tested. Interference screws derived from bovine bone are a possible biological alternative to conventional metallic or bioabsorbable polymer interference screws. Methods In the first part of the study we compared the torsional stability of self-made 8 mm Interference screws (BC) and a commercial 8 mm interference screw (Tutofix®). Furthermore, we compared the torsional strength of BC screws with different diameters. For screwing in, a hexagon head and an octagon head were tested. Maximum breaking torques in polymethyl methacrylate resin were recorded by means of an electronic torque screw driver. In the second part of the study the tibial part of a bone-patellar tendon-bone graft was fixed in porcine test specimens using an 8 mm BC screw and the maximum insertion torques were recorded. Each interference screw type was tested 5 times. Results There was no statistically significant difference between the different 8 mm interference screws (p = 0.121). Pairwise comparisons did not reveal statistically significant differences, either. It was demonstrated for the BC screws, that a larger screw diameter significantly leads to higher torsional stability (p = 9.779 × 10-5). Pairwise comparisons showed a significantly lower torsional stability for the 7 mm BC screw than for the 8 mm BC screw (p = 0.0079) and the 9 mm BC screw (p = 0.0079). Statistically significant differences between the 8 mm and the 9 mm BC screw could not be found (p = 0.15). During screwing into the tibial graft channel of the porcine specimens, insertion torques between 0.5 Nm and 3.2 Nm were recorded. In one case the hexagon head of a BC screw broke off during the last turn. Conclusions The BC screws show comparable torsional stability to Tutofix® interference screws. As expected the torsional strength of the screws increases significantly with the diameter. The safety and in vivo performance of products derived from xenogeneic bone should be the focus of further investigations.
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Affiliation(s)
- Joscha Bauer
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Baldingerstrasse, 35043 Marburg, Germany
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Julien TP, Ramappa AJ, Rodriguez EK. Femoral condylar fracture through a femoral tunnel eleven years after anterior cruciate ligament reconstruction: a case report. J Bone Joint Surg Am 2010; 92:963-7. [PMID: 20360522 DOI: 10.2106/jbjs.i.00408] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Terrill P Julien
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215, USA
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Abstract
Secure graft fixation for anterior cruciate ligament reconstruction is an important goal. Optimally, graft fixation allows for an aggressive postoperative rehabilitation program with the goals of immediate full range of motion, full weight bearing, and an early return to athletic activity. Current anterior cruciate ligament reconstruction techniques advance soft tissue grafts with or without bone plugs into the joint to replace the damaged ligament. Segments of these grafts are fixed within a bone tunnel or on the periosteum at a distance from the normal ligament attachment site. The graft fixation should be secure, allow normal tendon healing, and provide the graft construct with biomechanical properties, which approach that of the native ligament. Several different fixation devices are available for anterior cruciate ligament construction.
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Fracture of the tibial bone block after posterior cruciate ligament allograft reconstruction using double cross pins. Arch Orthop Trauma Surg 2010; 130:385-9. [PMID: 19921226 DOI: 10.1007/s00402-009-1005-7] [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: 03/15/2009] [Indexed: 10/20/2022]
Abstract
We report the fracture of the tibial bone block after posterior cruciate ligament reconstruction using double cross pins for bone block fixation in the postoperative period. The possible reasons include the size of bone block,direction of cross pin or the quality of bone block. This case emphasizes the biomechanical properties and failure of modes of double cross pin.
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Double-bundle PCL reconstruction using tibial double cross-pin fixation. Knee Surg Sports Traumatol Arthrosc 2010; 18:117-22. [PMID: 19399475 DOI: 10.1007/s00167-009-0812-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 04/08/2009] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to assess the clinical results of arthroscopic double-bundle posterior cruciate ligament (PCL) reconstruction using double cross-pin fixation on the tibial side. Twenty-two patients who underwent PCL reconstruction using an Achilles tendon allograft with double cross-pins for tibial fixation were evaluated. There were 19 men and 3 women with mean age 36 years (range 18-59), and the average follow-up period was 33 months (range 24-60). Preoperative and postoperative knee functions were evaluated in all patients using Lysholm knee scores, the 2000 International Knee Documentation Committee (IKDC) grades, and Tegner activity scores. Median Lysholm knee scores were 64 (50-75) preoperatively and 88 (82-96), 89.9 +/- 6.5 postoperatively (P < 0.001). Median side-to-side differences, determined using Telos stress radiographs, were 11 mm (8-14) preoperatively, and 3 mm (1-7) at final follow-up visits (P < 0.01). According to KT-2000 arthrometer measurements, mean side-to-side differences were 11 mm (8-13) preoperatively and 3 mm (1-6, P < 0.01) at final follow-up visits (P < 0.01). Preoperatively the 2000 IKDC evaluation system rated all patients as abnormal or severely abnormal (C or D), and at final follow-up visits, 20 patients (88%) were rated as normal or nearly normal (A or B) and 2 patients (12%) were rated as abnormal (C). Median preinjury and preoperative Tegner scores were 7 (range 5-9) and 3 (range 2-5), respectively, and the mean postoperative Tegner score was 6 (range 3-9). There were no intraoperative or postoperative complications. Our study shows that arthroscopic double-bundle PCL reconstruction using an Achilles allograft with double cross-pins for tibial fixation provides satisfactory clinical results given a mean follow-up of 33 months. We believe that this method provides a reliable alternative technique of PCL reconstruction.
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Kamelger FS, Onder U, Schmoelz W, Tecklenburg K, Arora R, Fink C. Suspensory fixation of grafts in anterior cruciate ligament reconstruction: a biomechanical comparison of 3 implants. Arthroscopy 2009; 25:767-76. [PMID: 19560641 DOI: 10.1016/j.arthro.2009.01.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 12/15/2008] [Accepted: 01/21/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE Our purpose was to evaluate the biomechanical difference between 2 new soft-tissue anterior cruciate ligament (ACL) fixation devices (RetroButton [Arthrex, Naples, FL] and ToggleLoc [Biomet, Warsaw, IN]) and a clinically established implant (EndoButton CL; Smith & Nephew, Andover, MA). METHODS In test session 1 biomechanical testing was performed by use of 48 porcine femora fixed to a material testing machine. In session 2 the implants were tested alone. Cyclic loading was carried out for 1,000 cycles, followed by a load-to-failure test. The tested devices were as follows: EndoButton CL, 20-mm and 40-mm loops; RetroButton, 12/20-mm and 12/40-mm loops; and ToggleLoc, 20-mm and 40-mm loops. RESULTS In test session 1 the EndoButton CL showed higher motion per cycle (0.30 +/- 0.09 mm for 20-mm loop and 0.43 +/- 0.03 mm for 40-mm loop) but lower plastic displacement values (0.66 +/- 0.19 mm for 20-mm loop and 0.50 +/- 0.13 mm for 40-mm loop) than the objects of comparison. The RetroButton devices were the stiffest (331.47 +/- 133.92 N/mm for 12/20-mm loop and 265.66 +/- 103.97 N/mm for 12/40-mm loop). The highest ultimate failure load, however, was shown by the EndoButton CL devices. In test session 2 the EndoButton CL oscillated the most. The ToggleLoc devices elongated more than the objects of comparison (0.66 +/- 0.12 mm for 20-mm loop and 0.76 +/- 0.06 mm for 40-mm loop). The RetroButton devices were both the stiffest among the respective implants (542.7 +/- 148.0 N/mm for 12/20-mm loop and 379.0 +/- 40.1 N/mm for 12/40-mm loop). The EndoButton CL showed the highest values for displacement to failure (3.6 +/- 0.4 mm for 20-mm loop and 6.4 +/- 0.4 mm for 40-mm loop). The ToggleLoc devices failed the latest on load-to-failure testing. CONCLUSIONS All tested implants could provide adequate fixation strength. Despite advantages in the design of the EndoButton CL regarding its handling, the 2 newly released products showed superior material properties. CLINICAL RELEVANCE Suspensory fixation of hamstring grafts in ACL reconstruction is frequently associated with bone tunnel enlargement. Material properties and implant design may limit graft-tunnel motion and result in enlargement of the femoral bone tunnel. With improved implant design, suspensory graft fixation may still be an attractive fixation technique in primary and revision ACL reconstruction.
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Affiliation(s)
- Florian S Kamelger
- Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Innsbruck, Austria.
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The biomechanical performance of bone block and soft-tissue posterior cruciate ligament graft fixation with interference screw and cross-pin techniques. Arthroscopy 2009; 25:250-6. [PMID: 19245986 DOI: 10.1016/j.arthro.2008.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 10/13/2008] [Accepted: 10/13/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the biomechanical properties of 4 different graft fixation constructs on the tibial side of the posterior cruciate ligament with reconstruction by use of an Achilles tendon graft. METHODS Biomechanical testing of 4 different fixation techniques was performed on 20 human cadaveric tibias and Achilles tendons. Cross-pin fixation with bone blocks (group A), interference screw fixation with bone blocks (group B), cross-pin fixation of soft tissue with backup fixation (group C), and interference screw fixation of soft tissue with backup fixation (group D) were tested. The tibia-graft fixation complex was cyclically loaded between 50 N and 250 N at 1 Hz for 1,000 cycles. After cycling, the amount of graft displacement was determined by measuring the change in grip-to-grip distance. The complex was then loaded to failure at 1 mm/s, and maximum failure load, stiffness, and mode of failure were determined. RESULTS Group C had a higher maximum failure load and stiffness than groups A and B (P < .05 and P < .001, respectively) but poor results for displacement (P < .05 and P < .05, respectively). The failure modes were bone block fracture, graft laceration, or cross-pin fracture in the cross-pin groups and graft pullout in the interference screw groups. CONCLUSIONS Our study suggests that maximum failure load and stiffness of hybrid fixation for Achilles tendon graft are comparable to those of both single calcaneal bone plug fixation methods that we studied. However, tendon graft displacement was significantly greater regardless of fixation method when compared with bone plug fixation. CLINICAL RELEVANCE Hybrid fixation for soft-tissue graft on the tibial fixation site provides comparable biomechanical properties of bone-to-bone fixation.
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Meuffels DE, Niggebrugge MJN, Verhaar JAN. Failure load of patellar tendon grafts at the femoral side: 10- versus 20-mm-bone blocks. Knee Surg Sports Traumatol Arthrosc 2009; 17:135-9. [PMID: 18839146 DOI: 10.1007/s00167-008-0631-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Accepted: 09/15/2008] [Indexed: 01/10/2023]
Abstract
The aim of the study was to investigate whether use of short bone blocks is safe in anterior cruciate ligament (ACL) reconstruction. Our hypothesis was that the smaller 10-mm-length bone blocks will fail at lower loads than 20-mm-bone blocks. Ten paired human cadaver knees were randomly assigned to the 10- or 20-mm group (group 1 and 2) and underwent bone-patellar tendon-bone femoral fixation with interference screw. Tensile tests were performed using a tensile testing machine (Instron). Stiffness, failure load and failure mode were recorded. Median stiffness was 72 N/mm (16-103) for 10-mm-bone blocks and 91 N/mm (40-130) for 20-mm-bone blocks. Median failure loads were 402 N (87-546) for 10-mm-long bone block and 456 N (163-636) for 20-mm-bone blocks. There was no statistically significant difference between groups (P = 0.35). All bone-patellar tendon-bone grafts were pulled out of the femoral tunnel with interference screw, due to slippage. We concluded that a 10-mm-long bone block was not significantly weaker than a 20-mm-long bone block. Failure loads of a 10-mm-bone block exceeded loading values at passive and active extension of the knee under normal conditions. Ten millimetre bone blocks offered sufficient fixation strength in ACL reconstruction.
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Affiliation(s)
- Duncan E Meuffels
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, P. O. Box 2040, Rotterdam 3000 CA, The Netherlands.
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Zheng N, Price CT, Indelicato PA, Gao B. Tibial fixation of bone-patellar tendon-bone grafts in anterior cruciate ligament reconstruction: a cadaveric study of bovine bone screw and biodegradable interference screw. Am J Sports Med 2008; 36:2322-7. [PMID: 18765676 DOI: 10.1177/0363546508322895] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of interference screw fixation for bone-patellar tendon-bone grafts in anterior cruciate ligament fixation is well established. No previous study has compared bovine bone screws and biodegradable interference screws or demonstrated their efficacy for requirements associated with early rehabilitation. HYPOTHESIS There is no difference in tension loss and pull-out strength between bovine bone screws and biodegradable interference screws. STUDY DESIGN Controlled laboratory study. METHODS Anterior cruciate ligament reconstructions with bone-patellar tendon-bone allografts were performed in 40 human tibiae from 20 donors. A bovine bone screw and a polylevolactide interference screw were used for tibial fixation in each pair. A cyclic testing protocol with varying magnitude and orientation of the graft loading was developed. Cyclic tests were performed at 1 Hz for 5000 cycles with a peak force of 200 N applied to the graft. Survival rate and postcyclic-test pull-out strength were compared. RESULTS Fifteen of 20 reconstructions fixed with bovine bone screws and 17 of 20 fixed with biodegradable screws reached 5000 cycles. Graft tension drop after the 5000 cycles averaged 19.7 N ( +/- 12.9) for bovine bone screws and 18.9 N ( +/- 16.3) for biodegradable screws. There were no significant differences in tension loss and pull-out strength between the 2 types of screws. CONCLUSION Bovine bone screws are comparable to biodegradable interference screws in providing stable tibial fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone allografts. CLINICAL RELEVANCE The use of bovine bone screws may be comparable to the popular biodegradable interference screws used for anterior cruciate ligament reconstruction in postsurgery rehabilitation.
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Affiliation(s)
- Naiquan Zheng
- Department of Mechanical Engineering and Engineering Science, University of North Carolina at Charlotte, Charlotte, NC 28223, USA.
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Gorschewsky O, Stapf R, Geiser L, Geitner U, Neumann W. Clinical comparison of fixation methods for patellar bone quadriceps tendon autografts in anterior cruciate ligament reconstruction: absorbable cross-pins versus absorbable screws. Am J Sports Med 2007; 35:2118-25. [PMID: 17932398 DOI: 10.1177/0363546507307390] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recently, the use of the quadriceps tendon transplant with bone block (patellar bone quadriceps tendon autografts) for anterior cruciate ligament reconstruction has increasingly been reported. HYPOTHESIS Clinical results after the implantation of a patellar bone quadriceps tendon autograft fixed with cross-pins or screws will show no significant difference between the 2 techniques with regard to stability, function, and subjective satisfaction. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Between 1998 and 2004, 193 patients with anterior cruciate ligament ruptures were implanted with a patellar bone quadriceps tendon autograft. For 100 of these patients, fixation was carried out using absorbable cross-pins, and for the remaining 93, fixation was carried out using absorbable screws. The results were evaluated by means of International Knee Documentation Committee, Noyes, and Lysholm scores, as well as KT-1000 arthrometer measurement and subjective satisfaction. RESULTS The mean follow-up postoperative control period was 29 months. In the International Knee Documentation Committee overall evaluation, the pin group showed a significantly better result (P =.03). The values of the Noyes score produced no significant differences. The mean value of the Lysholm score was 94 points in the screw group and 89 points in the pin group (P <.001). Overall, 90% of the patients subjectively judged their conditions as good or very good. CONCLUSION With both operating processes examined, 80% to 90% of the cases achieved good to very good results. The use of cross-pins can be recommended for fixing patellar bone quadriceps tendon autografts.
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Affiliation(s)
- Ottmar Gorschewsky
- Sportorthopädie Bern, Klinik Sonnenhof, Buchserstrasse 30, CH-3006 Bern, Switzerland.
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Schoderbek RJ, Treme GP, Miller MD. Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction. Clin Sports Med 2007; 26:525-47. [PMID: 17920951 DOI: 10.1016/j.csm.2007.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The anterior cruciate ligament (ACL) serves an important stabilizing and biomechanical function for the knee. Reconstruction of the ACL remains one of the most commonly performed procedures in the field of sports medicine. Reconstruction of the ACL with bone-patella tendon-bone (BPTB) autograft secured with interference screw fixation has been the historical reference standard and remains the benchmark against which other methods are gauged. This article reviews the reconstruction of the ACL with BPTB autograft including the surgical technique, rationale for BTPB use, and outcomes.
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Affiliation(s)
- Robert J Schoderbek
- Department of Orthopaedic Surgery, University of Virginia Health Systems, 400 Ray C. Hunt Drive, Third Floor, Charlottesville, VA 22903, USA
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Milano G, Mulas PD, Ziranu F, Deriu L, Fabbriciani C. Comparison of femoral fixation methods for anterior cruciate ligament reconstruction with patellar tendon graft: a mechanical analysis in porcine knees. Knee Surg Sports Traumatol Arthrosc 2007; 15:733-8. [PMID: 17295042 DOI: 10.1007/s00167-006-0269-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Accepted: 12/01/2006] [Indexed: 01/10/2023]
Abstract
The aim of the present study was to evaluate the structural properties of femur-patellar tendon graft complex in anterior cruciate ligament (ACL) reconstruction using different femoral fixation devices. Type of study is biomechanical testing. An ACL reconstruction was performed on 40 cadaver porcine knees, using patellar tendon (PT) graft. Specimens were divided into four groups according to the femoral fixation: interference absorbable screw (Group A), metallic setscrew (Group B), absorbable pins (Group C), and a combination of metallic setscrew and pin (Group D). Other ten knees were used as controls. On each sample, a cyclic loading test, then a load-to-failure test were performed. Elongation after 1,000 loading cycles, ultimate failure load, yield load, stiffness, deformation at the yield point, and mode of failure were recorded. Kruskal-Wallis test and Tukey test were used to compare the differences between groups. The lowest mean elongation after 1,000 load cycles was observed for Group B (1.7 +/- 1.4 mm) and D (1.2 +/- 0.3 mm). Ultimate failure load of Group D (1,021.8 +/- 199.4 N) was comparable with that of normal ACL (1,091.2 +/- 193.3 N) and PT graft (1,140.6 +/- 285.7 N). All other groups were lower than the controls. For mean stiffness, all the groups, excepting for Group D (172.8 +/- 40.4 N/mm), were significantly lower than PT control group (216 +/- 78.4 N/mm). Mode of failure was graft pullout for Groups A and B, distal pin breakage for Group C, and midsubstance graft rupture in 80% of the cases for Group D. Only combined compression and suspension fixation did not show significantly different structural properties in comparison with normal ACL and PT graft. Furthermore, it showed no risk of graft pullout or hardware breakdown in comparison with other fixation devices.
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Affiliation(s)
- Giuseppe Milano
- Department of Orthopaedics, Catholic University, Largo A. Gemelli 1, 00168 Rome (RM), Italy.
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