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Chalidis B, Pitsilos C, Pavlopoulos C, Papadopoulos P, Gigis I, Papadopoulos P. Comparison of Cross-Pin Versus Cortical Button Femoral Fixation in Anterior Cruciate Ligament Reconstruction With Hamstrings Autograft: A Long-Term Clinical Study and Review of the Literature. Cureus 2024; 16:e57928. [PMID: 38725740 PMCID: PMC11081715 DOI: 10.7759/cureus.57928] [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] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Background Anterior cruciate ligament reconstruction (ACLR) is a common operative procedure and many options regarding the type of the selected graft and fixation technique have been described to date. Although many studies have addressed the issue of the optimal femoral fixation device during ACLR with a hamstring tendon (HT) autograft, no clear evidence to indicate one technique over another has been found. Objective The purpose of this study was to compare the long-term postoperative outcomes and complication rates between transfemoral Cross-pin (CP) and Endobutton-Cortical Button (CB) fixation techniques in patients undergoing ACLR with an HT autograft. Methods One hundred and seven consecutive patients underwent ACLR by using a quadruple HT autograft that was stabilized with either a CP (CP Group: 52 patients) or a CB (CB Group: 55 patients) fixation technique. The Lachman test (LT), the Pivot-shift test (PST), the side-to-side difference in anterior translation of the tibia, the International Knee Documentation Committee (IKDC), and the Lysholm knee scoring systems were evaluated before surgery and during long-term follow up. The femoral and tibial tunnel diameter was measured in the anteroposterior (AP) and lateral radiographs after surgery and at the final follow-up. A review of the literature was also carried out to identify any differences between both techniques. Results Study groups were comparable in terms of patient demographics. The mean follow-up was 10.4 ± 1.3 and 10.6 ± 1.3 years in the CP and CB Groups, respectively (p = 0.47). In the CP Group, improvements after surgery in LT and PST from grade 2 (n=34) or 3 (n=18) to grade 0 (n = 41) or 1 (n = 11) and from grade 2 (n=36) or 3 (n = 16) to grade 0 (n = 44) or 1 (n = 8), respectively, were observed. In the CB Group, similar improvements in LT and PST scores from grade 2 (n = 40) or 3 (n = 15) to grade 0 (n = 46) or 1 (n = 9) and from grade 2 (n = 41) or 3 (n = 14) to grade 0 (n = 47) or 1 (n = 8), respectively, were observed. However, no differences between the groups (p = 0.53 for LT and p = 0.90 for PST) were noted. The mean Lysholm scores were 89.7 ± 6.8 and 90.2 ± 7.2 in the CP and CB groups, respectively (p = 0.59). Side-to-side difference improved from 9.1 ± 2.8 to 1.7 ± 1.5 mm and from 8.6 ± 2.5 to 1.6 ± 1.4 mm in the CP and CB groups, respectively (p = 0.89 between groups). According to IKDC grades, 92.1% and 91.4% of knees in the CP and CB groups, respectively were reported to be Grade A (Normal) or B (Nearly Normal) with a p = 0.7. Femoral and tibial tunnel widening was found in the last follow-up in both groups. However, there was no difference in the degree of tunnel widening among the two techniques. With respect to LT, PST, anterior drawer test, and IKDC score, none of the 15 published comparative studies demonstrated any significant differences between the two techniques and only one study detected a difference regarding the Lysholm score in favor of CP fixation. Conclusion In the long term, both CB and CP femoral stabilization techniques were shown to be associated with similar functional outcomes and low complication rates. Further large multicenter random clinical trials are still required to identify the most effective method of femoral fixation for HT autograft during ACLR surgery.
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Affiliation(s)
- Byron Chalidis
- 1st Orthopaedic Department, Papanikolaou Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Charalampos Pitsilos
- 2nd Orthopaedic Department, Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Charalampos Pavlopoulos
- 2nd Orthopaedic Department, Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Polychronis Papadopoulos
- 2nd Orthopaedic Department, Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Ioannis Gigis
- 2nd Orthopaedic Department, Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Periklis Papadopoulos
- 2nd Orthopaedic Department, Gennimatas Hospital, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Zainal Abidin NA, Ramlee MH, Ab Rashid AM, Ng BW, Gan HS, Abdul Kadir MR. Biomechanical effects of cross-pin's diameter in reconstruction of anterior cruciate ligament - A specific case study via finite element analysis. Injury 2022; 53:2424-2436. [PMID: 35641332 DOI: 10.1016/j.injury.2022.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/09/2022] [Accepted: 05/17/2022] [Indexed: 02/02/2023]
Abstract
For anterior cruciate ligament reconstruction (ACL-R), one of the crucial aspects of treatment is the fixator selection that could provide initial graft fixation post-operatively. Literature on biomechanical stabilities of different sizes of fixators as femoral graft fixation is limited. Therefore, this study aims to analyse the influence of different diameters of cross-pins on the stability of graft fixations after ACL-R via finite element analysis (FEA). In the methodology, three-dimensional (3D) models of three different diameters of cross-pins were developed, of which anterior tibial loads (ATL) were applied onto the tibia. From the findings, the cross-pin with a smaller diameter (4 mm) provided optimum stability than larger diameter cross-pins, whereby it demonstrated acceptable stresses at the fixators (both cross-pin and interference screw) with a different percentage of 28%, while the stresses at the corresponding bones were favourable for osseointegration to occur. Besides, the strains of the knee joint with 4 mm diameter cross-pin were also superior in providing a good biomechanical environment for bone healing, while the recorded strain values at fixators were comparable with a larger diameter of cross-pins without being inferior in terms of deformation. To conclude, the cross-pin with 4 mm diameter depicted the best biomechanical aspects in graft fixation for ACL-R since it allows better assistance for the osseointegration process and can minimise the possibility of the breakage and migration of fixators. This study is not only useful for medical surgeons to justify their choices of pin diameter to treat patients, but also for researchers to conduct future studies.
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Affiliation(s)
- Nur Afikah Zainal Abidin
- Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia; Department of Orthopaedics, Hospital Pakar Kanak-Kanak, Universiti Kebangsaan Malaysia, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Muhammad Hanif Ramlee
- Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia; Department of Orthopaedics, Hospital Pakar Kanak-Kanak, Universiti Kebangsaan Malaysia, Cheras, 56000 Kuala Lumpur, Malaysia.
| | - Amir Mustakim Ab Rashid
- Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia; Department of Orthopaedics, Hospital Pakar Kanak-Kanak, Universiti Kebangsaan Malaysia, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Bing Wui Ng
- Department of Orthopaedics, Hospital Pakar Kanak-Kanak, Universiti Kebangsaan Malaysia, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Hong Seng Gan
- Department of Data Science, Universiti Malaysia Kelantan, 16100 UMK City Campus, Pengkalan Chepa, Kelantan, Malaysia
| | - Mohammed Rafiq Abdul Kadir
- Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Research Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia; Sports Innovation and Technology Centre (SITC), Institute of Human Centered Engineering (iHumEn), Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia
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Zainal Abidin NA, Abdul Wahab AH, Abdul Rahim RA, Abdul Kadir MR, Ramlee MH. Biomechanical analysis of three different types of fixators for anterior cruciate ligament reconstruction via finite element method: a patient-specific study. Med Biol Eng Comput 2021; 59:1945-1960. [PMID: 34392448 DOI: 10.1007/s11517-021-02419-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/26/2021] [Indexed: 01/11/2023]
Abstract
Complication rates of anterior cruciate ligament reconstruction (ACL-R) were reported to be around 15% although it is a common arthroscopic procedure with good outcomes. Breakage and migration of fixators are still possible even months after surgery. A fixator with optimum stability can minimise those two complications. Factors that affect the stability of a fixator are its configuration, material, and design. Thus, this paper aims to analyse the biomechanical effects of different types of fixators (cross-pin, interference screw, and cortical button) towards the stability of the knee joint after ACL-R. In this study, finite element modelling and analyses of a knee joint attached with double semitendinosus graft and fixators were carried out. Mimics and 3-Matic softwares were used in the development of the knee joint models. Meanwhile, the graft and fixators were designed by using SolidWorks software. Once the meshes of all models were finished in 3-Matic, simulation of the configurations was done using MSC Marc Mentat software. A 100-N anterior tibial load was applied onto the tibia to simulate the anterior drawer test. Based on the findings, cross-pin was found to have optimum stability in terms of stress and strain at the femoral fixation site for better treatment of ACL-R.
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Affiliation(s)
- Nur Afikah Zainal Abidin
- Medical Devices & Technology Centre (MEDiTEC), Institute of Human Centered Engineering (iHumEn), Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia.,Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia
| | - Abdul Hadi Abdul Wahab
- Centre for Multimodal Signal Processing, Faculty of Engineering and Technology, Tunku Abdul Rahman Universiti College, Jalan Genting Kelang, 53300, Setapak, Kuala Lumpur, Malaysia.,Department of Electrical and Electronics Engineering, Faculty of Engineering and Technology, Tunku Abdul Rahman Universiti College, Jalan Genting Kelang, 53300, Setapak, Kuala Lumpur, Malaysia
| | - Rabiatul Adibah Abdul Rahim
- Medical Devices & Technology Centre (MEDiTEC), Institute of Human Centered Engineering (iHumEn), Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia
| | - Mohammed Rafiq Abdul Kadir
- Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia.,Sports Innovation and Technology Centre (SITC), Institute of Human Centered Engineering (iHumEn), Universiti Teknologi Malaysia, UTM, 81310, Johor Bahru, Johor, Malaysia
| | - Muhammad Hanif Ramlee
- Medical Devices & Technology Centre (MEDiTEC), Institute of Human Centered Engineering (iHumEn), Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia. .,Bioinspired Devices and Tissue Engineering (BIOINSPIRA) Group, School of Biomedical Engineering and Health Sciences, Faculty of Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia.
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Peloquin JM, Santare MH, Elliott DM. Short cracks in knee meniscus tissue cause strain concentrations, but do not reduce ultimate stress, in single-cycle uniaxial tension. ROYAL SOCIETY OPEN SCIENCE 2018; 5:181166. [PMID: 30564409 PMCID: PMC6281910 DOI: 10.1098/rsos.181166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/19/2018] [Indexed: 05/15/2023]
Abstract
Tears are central to knee meniscus pathology and, from a mechanical perspective, are crack-like defects (cracks). In many materials, cracks create stress concentrations that cause progressive local rupture and reduce effective strength. It is currently unknown if cracks in meniscus have these consequences; if they do, this would have repercussions for management of meniscus pathology. The objective of this study was to determine if a short crack in meniscus tissue, which mimics a preclinical meniscus tear, (a) causes crack growth and reduces effective strength, (b) creates a near-tip strain concentration and (c) creates unloaded regions on either side of the crack. Specimens with and without cracks were tested in uniaxial tension and compared in terms of macroscopic stress-strain curves and digital image correlation strain fields. The strain fields were used as an indicator of stress concentrations and unloaded regions. Effective strength was found to be insensitive to the presence of a crack (potential effect < 0.86 s.d.; β = 0.2), but significant strain concentrations, which have the potential to lead to long-term accumulation of tissue or cell damage, were observed near the crack tip.
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Affiliation(s)
- John M. Peloquin
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
| | - Michael H. Santare
- Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Dawn M. Elliott
- Department of Biomedical Engineering, University of Delaware, Newark, DE, USA
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Hu B, Shen W, Zhou C, Meng J, Wu H, Yan S. Cross Pin Versus Interference Screw for Femoral Graft Fixation in Hamstring Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Clinical Outcomes. Arthroscopy 2018; 34:615-623. [PMID: 29066266 DOI: 10.1016/j.arthro.2017.07.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the effectiveness of a cross pin and interference screw for femoral graft fixation in primary anterior cruciate ligament reconstruction (ACLR) and provide an appropriate reference for orthopaedic surgeons. METHODS The Medline, Cochrane Library, Web of Science, Scopus, and PubMed databases were searched in March 2016, and comparative trials using cross-pin and interference screw devices for femoral graft fixation in primary hamstring ACLR with clinical outcome measurements were included in the review. Trials with no controlled groups, hybrid fixation, no clinical outcomes, or follow-up of less than 1 year were excluded. The quality of the included studies was assessed with the Cochrane Back Review Group 12-item scale. Abstracted data were pooled with fixed or random effects depending on the detected heterogeneity. The outcome measures were the scoring system and physical examination findings, including the Lysholm score, International Knee Documentation Committee score or grade, Tegner score, negative Lachman test, negative pivot-shift test, and instrumented side-to-side anterior-posterior laxity difference. RESULTS All the studies reviewed were of prospective design. Within the cross-pin group, patients who underwent hamstring ACLR showed a significantly smaller instrumented side-to-side anterior-posterior laxity difference when compared with interference screw fixation (weighted mean difference, 0.38 mm [95% confidence interval, 0.08-0.67 mm]; P = .01), whereas the results of a negative Lachman test and negative pivot-shift test were comparable. Outcomes regarding the scoring system did not reach a significant difference between the 2 groups. CONCLUSIONS The statistically decreased instrumented side-to-side anterior-posterior laxity difference achieved by cross-pin transfixation appears to be of limited clinical significance when compared with interference screw fixation in primary hamstring ACLR. Clinically, the performance of cross-pin devices did not show a significant advantage over that of the interference screw for femoral graft fixation in hamstring ACLR. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Bin Hu
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, and Orthopedics Research Institute, Zhejiang University, Hangzhou, China
| | - Weiliang Shen
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, and Orthopedics Research Institute, Zhejiang University, Hangzhou, China
| | - Chenhe Zhou
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, and Orthopedics Research Institute, Zhejiang University, Hangzhou, China
| | - Jiahong Meng
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, and Orthopedics Research Institute, Zhejiang University, Hangzhou, China
| | - Haobo Wu
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, and Orthopedics Research Institute, Zhejiang University, Hangzhou, China
| | - Shigui Yan
- Department of Orthopedic Surgery, Second Affiliated Hospital, School of Medicine, and Orthopedics Research Institute, Zhejiang University, Hangzhou, China.
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Nishizawa Y, Hoshino Y, Nagamune K, Araki D, Nagai K, Kurosaka M, Kuroda R. Comparison Between Intra- and Extra-articular Tension of the Graft During Fixation in Anterior Cruciate Ligament Reconstruction. Arthroscopy 2017; 33:1204-1210. [PMID: 28130031 DOI: 10.1016/j.arthro.2016.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 11/16/2016] [Accepted: 11/28/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the tension deprivation through the tunnels with and without preconditioning at the time of fixation, and the influences of cyclic loading and pretensioning on graft tension in anatomic single bundle anterior cruciate ligament (ACL) reconstruction using a hamstring tendon. METHODS Nine fresh-frozen cadaveric knees underwent anatomic ACL reconstruction using hamstring grafts. Each specimen was examined to ensure that there was no severe osteoarthritic change, ligament insufficiency, or torn menisci by manual and arthroscopic evaluation. Applied graft tension was measured at the tibial tunnel outlet using a graft tensor with a load cell. Intra-articular graft tension was evaluated by using an originally developed microforce sensor, which was sutured into the graft. Both tensions were simultaneously measured just after initial tensioning under 3 different conditions: condition 1, just after initial tensioning of 20 N at 20° of knee flexion without preconditioning; condition 2, after the same initial tensioning following 5 rounds of passive cyclic flexion-extension movement; and condition 3, after the same initial tensioning following 5 minutes of static pretensioning of 20 N. RESULTS The intra-articular tension was 12.7 ± 5.3 N in condition 1, 12.0 ± 4.8 N in condition 2, and 13.5 ± 4.8 N in condition 3. In these 3 conditions, intra-articular graft tension was significantly lower than the applied tension of around 20 N (no pretension: P = .009, cyclic pretension: P = .004, static pretension: P = .008), with no difference among the 3 conditions (P = .82). CONCLUSIONS The intra-articular graft tension was significantly lower than the applied tension from the outside of the joint, even after cyclic loading and pretensioning. CLINICAL RELEVANCE It is difficult to evaluate the intra-articular graft tension precisely on the basis of the extra-articular tension at time zero in ACL reconstruction.
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Affiliation(s)
- Yuichiro Nishizawa
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Hoshino
- Department of Orthopaedic Surgery, Kobe Kaisei Hospital, Kobe, Japan.
| | - Kouki Nagamune
- Department of Human and Artificial Intelligent Systems, Graduate School of Engineering, University of Fukui, Fukui, Japan
| | - Daisuke Araki
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kanto Nagai
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Kurosaka
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Martel O, Garcés GL, Yánez A, Cuadrado A, Cárdenes JF. Can an expansion device be used in anterior cruciate ligament reconstruction? An in vitro study of soft tissue graft tibial fixation. Knee 2016; 23:1049-1054. [PMID: 27802926 DOI: 10.1016/j.knee.2016.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 04/20/2016] [Accepted: 06/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study was to compare the mechanical properties of an interference screw with an expansion device in anterior cruciate ligament (ACL) reconstruction. METHODS A total of 52 porcine tibia and 20 polyurethane foam blocks (0.16g/cm3) were used. Forty pullout tests were carried out to combine the two types of bones - surrogate and porcine - with the two fixation systems: interference screw and expansion device (n=10 per group). Thirty-two cyclic tests (n=8 per group) were carried out with both fixation devices in porcine bone at two different force amplitudes (100N and 200N). RESULTS Stiffness and load values (mean±SD) at six millimeters of displacement for the expansion device and the interference screw were 74±33N/mm, 318±135N, and 52±28N/mm, 205±70N, respectively, showing a difference in stiffness (P=0.016) and load at six millimeters of displacement (P=0.001). No correlation between insertion torque and the ultimate failure load was found for both fixation devices tested. In cyclic tests, significantly higher (P<0.001) numbers of cycles (mean±SD) were reached with the expansion device (81,014±30,291 at 100N; 13,462±11,351 at 200N) than with the interference screw (15,100±8623 at 100N; 343±113 at 200N) at six millimeters of displacement. CONCLUSION The use of an expansion device for ACL reconstructions seemed to be a promising alternative to an interference screw. Insertion torque alone was not a useful predictor of graft fixation strength in ACL reconstructions.
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Affiliation(s)
- Oscar Martel
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain.
| | - Gerardo L Garcés
- Department of Medical and Surgical Science, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Alejandro Yánez
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Alberto Cuadrado
- Department of Mathematics, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Juan F Cárdenes
- Department of Mechanical Engineering, University of Las Palmas de Gran Canaria, Las Palmas, Spain
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Peloquin JM, Santare MH, Elliott DM. Advances in Quantification of Meniscus Tensile Mechanics Including Nonlinearity, Yield, and Failure. J Biomech Eng 2016; 138:021002. [PMID: 26720401 DOI: 10.1115/1.4032354] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Indexed: 11/08/2022]
Abstract
The meniscus provides crucial knee function and damage to it leads to osteoarthritis of the articular cartilage. Accurate measurement of its mechanical properties is therefore important, but there is uncertainty about how the test procedure affects the results, and some key mechanical properties are reported using ad hoc criteria (modulus) or not reported at all (yield). This study quantifies the meniscus' stress-strain curve in circumferential and radial uniaxial tension. A fiber recruitment model was used to represent the toe region of the stress-strain curve, and new reproducible and objective procedures were implemented for identifying the yield point and measuring the elastic modulus. Patterns of strain heterogeneity were identified using strain field measurements. To resolve uncertainty regarding whether rupture location (i.e., midsubstance rupture versus at-grip rupture) influences the measured mechanical properties, types of rupture were classified in detail and compared. Dogbone (DB)-shaped specimens are often used to promote midsubstance rupture; to determine if this is effective, we compared DB and rectangle (R) specimens in both the radial and circumferential directions. In circumferential testing, we also compared expanded tab (ET) specimens under the hypothesis that this shape would more effectively secure the meniscus' curved fibers and thus produce a stiffer response. The fiber recruitment model produced excellent fits to the data. Full fiber recruitment occurred approximately at the yield point, strongly supporting the model's physical interpretation. The strain fields, especially shear and transverse strain, were extremely heterogeneous. The shear strain field was arranged in pronounced bands of alternating positive and negative strain in a pattern similar to the fascicle structure. The site and extent of failure showed great variation, but did not affect the measured mechanical properties. In circumferential tension, ET specimens underwent earlier and more rapid fiber recruitment, had less stretch at yield, and had greater elastic modulus and peak stress. No significant differences were observed between R and DB specimens in either circumferential or radial tension. Based on these results, ET specimens are recommended for circumferential tests and R specimens for radial tests. In addition to the data obtained, the procedural and modeling advances made in this study are a significant step forward for meniscus research and are applicable to other fibrous soft tissues.
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Barbier O, Guérard S, Boisrenoult P, Thoreux P. Biomechanical evaluation of four femoral fixation configurations in a simulated anterior cruciate ligament replacement using a new generation of Ligament Advanced Reinforcement System (LARS™ AC). EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:905-11. [DOI: 10.1007/s00590-015-1598-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 12/29/2014] [Indexed: 01/10/2023]
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Rylander L, Brunelli J, Taylor M, Baldini T, Ellis B, Hawkins M, McCarty E. A biomechanical comparison of anterior cruciate ligament suspensory fixation devices in a porcine cadaver model. Clin Biomech (Bristol, Avon) 2014; 29:230-4. [PMID: 24321231 DOI: 10.1016/j.clinbiomech.2013.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 10/31/2013] [Accepted: 11/01/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Suspensory fixation use during anterior cruciate ligament reconstruction has increased due to ease of use and high pullout strength. We hypothesize that there are no significant differences in biomechanical performance among four types of suspensory fixation devices: Stryker VersiTomic G-Lok, Smith & Nephew Endobutton, Biomet ToggleLoc, and Arthrex RetroButton. METHODS Forty fresh frozen porcine femurs and flexor digitorum profundus tendons were obtained. Each tendon graft was sized to 8.5mm or 9.0mm. Ten of each device were used to fix the grafts in the femur at the 2 o'clock (left) or 10 o'clock (right) position. The graft-femur complex was secured to a servohydraulic test machine in line with the femoral tunnel. The graft was cyclically loaded from 50 to 250 N for 1000 cycles at 1 Hz then loaded to failure at 20mm/min. Actuator load and displacement were recorded. Data were analyzed with multiple one-way ANOVA and Tukey HSD post-hoc tests. Bonferroni correction was applied resulting in P ≤ 0.005 considered statistically significant for ANOVA, P ≤ 0.05 for Tukey. FINDINGS There were no significant differences in cyclic displacement among any of the groups (P=0.43). The only significant difference in failure properties is the Endobutton exhibited at least 50% greater displacement at failure than the other three devices. INTERPRETATION Suspensory femoral soft tissue fixation devices are biomechanically similar with respect to failure load but differ in failure displacement. However, there was no significant difference in displacement after cyclic loading. All four fixation devices should withstand the forces associated with daily activities without failure.
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Affiliation(s)
| | | | | | | | - Byron Ellis
- University of Colorado-Denver, Aurora, CO, USA
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Challa S, Satyaprasad J. Hamstring graft size and anthropometry in south Indian population. J Clin Orthop Trauma 2013; 4:135-8. [PMID: 26403553 PMCID: PMC3880434 DOI: 10.1016/j.jcot.2013.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 09/10/2013] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND AIM The role of anthropometric measurements in the prediction of hamstring autograft size in Indian population remains unclear. Till now, no studies have been done on Indian population. METHODS We evaluated 41 consecutive patients (34 males, 7 females) prospectively with anterior cruciate ligament deficiency scheduled for reconstruction using hamstring autograft at our institution between June 2011 and June 2013. Preoperatively we recorded age, gender, height, weight, body mass index, and activity level. Intraoperative measurements of semitendinosus tendon like absolute length, diameter before fashioning the graft and final diameter of the tripled graft using sizing tubes calibrated to 1 mm. Correlation coefficient (Pearson's r) analysis was used. RESULTS As per study there is no correlation between graft diameter, age, sex, weight, activity, and body mass index, of patients. Height of patients correlated to graft diameter in both Indian men and women (p < 0.001). CONCLUSION Anthropometric measurements such as weight, gender, activity level cannot be used as definitive predictors for the hamstring graft diameter during harvest but height of the patients can be taken as good predictor in Indian population.
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Affiliation(s)
- Supradeeptha Challa
- Assistant Professor, Department of Orthopaedics, G.S.L. Medical College, Rajahmundry, Andhrapradesh 533296, India,Corresponding author. Tel.: +91 9941528076.
| | - Jonnalagedda Satyaprasad
- Professor, Department of Orthopaedics, G.S.L. Medical College, Rajahmundry, Andhrapradesh 533296, India
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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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Close-looped graft suturing improves mechanical properties of interference screw fixation in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2013; 21:476-84. [PMID: 22461016 DOI: 10.1007/s00167-012-1975-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE In anterior cruciate ligament reconstruction with looped soft-tissue grafts, an interference screw is frequently used for tibial fixation. This study compared three alternatives thought to improve the initial mechanical properties of direct bioabsorbable interference screw fixation: suturing the graft to close the loop, adding a supplementary staple, or increasing the oversize of the screw diameter relative to the bone tunnel from 1 to 2 mm. METHODS Twenty-eight porcine tibiae and porcine flexor digitorum profundus tendons were randomized into four testing groups: a base fixation using 10-mm-diameter screw with open-looped graft, base fixation supplemented by an extracortical staple, base fixation but closing the looped graft by suturing its ends, and base fixation but using an 11-mm screw. Graft and bone tunnel diameters were 9 mm in all specimens. Constructs were subjected to cyclic tensile load and finally pulled to failure to determine their structural properties. RESULTS The main mode of failure in all groups was pull-out of tendon strands after slippage past the screw. The sutured graft group displayed significantly lower residual displacement (mean value reduction: 47-67 %) and higher yield load (mean value increase: 38-54 %) than any alternative tested. No other statistical differences were found. CONCLUSIONS Suturing a soft-tissue graft to form a closed loop enhanced the initial mechanical properties of tibial fixation with a bioabsorbable interference screw in anterior cruciate ligament reconstructions using a porcine model, and thus, this may be an efficient means to help in reducing post-operative laxity and early clinical failure. No mechanical improvement was observed for an open-looped tendon graft by adding an extracortical staple to supplement the screw fixation or by increasing the oversize of the screw to tunnel diameter from 1 to 2 mm.
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Lee YS, Han SH, Kim JH. A biomechanical comparison of tibial back side fixation between suspensory and expansion mechanisms in trans-tibial posterior cruciate ligament reconstruction. Knee 2012; 19:55-9. [PMID: 21232962 DOI: 10.1016/j.knee.2010.11.012] [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: 06/22/2010] [Revised: 11/24/2010] [Accepted: 11/27/2010] [Indexed: 02/02/2023]
Abstract
Soft tissue grafts have attracted increasing attention in anterior cruciate ligament (ACL) reconstruction and offer a number of advantages Therefore, it can also be attractive for trans-tibial PCL reconstruction, if four-strand hamstring or two-strand tibialis grafts could be converted for this use. We intended to investigate the biomechanical properties of fixation devices that are frequently used for the soft tissue graft in the trans-tibial PCL reconstruction.Thirty-six fresh adult porcine knees were used in this study. Porcine digital extensor tendons were used as two-stranded soft tissue grafts. The tibial side of the PCL was fixed using a bio-TransFix of suspensory mechanism (TransFix system®: Arthrex, Naples, FL, USA) device (group I) or a RIGIDFIX of expansion mechanism (RIGIDFIX system®: Mitek, Johnson & Johnson, USA) device (group II). We performed biomechanical testing to identify maximum failure load, stiffness, and displacement for both devices.Maximum mean failure loads in groups I and II were 907.3±142.2 and 701.9±101.5N, respectively (p=0.03). Stiffness was 65.6±16.8 and 63.1±15.1N/mm, respectively (p=0.85). Mean displacements were 23.9±6.0 and 19.8±7.9mm, respectively (p=0.37).Suspensory and expansion mechanisms used for tibial back side fixation in the trans-tibial PCL reconstruction using soft tissue grafts showed acceptable biomechanical properties and could be a good choice in case of short multi-stranded soft tissue graft.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic Surgery, Gachon University Dongincheon Gil Hospital, Republic of Korea.
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Rodríguez C, Maestro A, García T, Rodríguez L. Comportamiento biomecánico bajo carga estática de diferentes sistemas de fijación femoral para la reconstrucción del ligamento cruzado anterior. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Static load biomechanical behaviour of different femoral fixation systems for anterior cruciate ligament reconstruction. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recote.2011.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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In vitro biomechanical testing of anterior cruciate ligament reconstruction: traditional versus physiologically relevant load analysis. Knee 2011; 18:193-201. [PMID: 20570155 DOI: 10.1016/j.knee.2010.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 04/26/2010] [Accepted: 04/29/2010] [Indexed: 02/02/2023]
Abstract
Various anterior cruciate ligament (ACL) graft-fixation devices exist. In this in vitro study a comparison of biomechanical characteristics of the cross-pin and button type fixation devices under practical rehabilitation loads was done. Forty bovine knees and hoof extensor tendons were harvested. After disarticulation, the femoral end of an ACL was prepared with either fixation, using the extensor tendon as graft. The mechanical test was either a single load to failure or load to failure after cycling loads. Twenty specimens were loaded to failure at a rate of 1mm/s, remaining specimens were cycled between 50 and 250 N for 1000 cycles then failure tested in a similar manner. Results show that both forms of fixation are able to withstand loads that exceed those observed in performing functional activities. Activity-specific stiffness (loads comparable to walking, jogging and stair descent) was lower than linear stiffness for both endobutton and cross-pin, without prior cycling. After cycling, activity-specific stiffness increased to linear stiffness values for the cross-pin for all activities. Thus, suggesting that the cross-pin provides a more rigid fixation after initial implantation over a wider range of activities, which would theoretically permit a more aggressive rehabilitation protocol and possibly an earlier return to regular activity. In contrast, activity-specific stiffness increased above linear stiffness values for the endobutton only under heavier loads (jogging and stair descent). Dynamic stiffness was higher and displacement lower for cross-pin throughout the cycle test. These results indicate, in ACL reconstruction, that graft complex stiffness should be considered at relevant loads only.
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Danieli MV, Padovani CR. Comparação entre parafuso de interferência e transcondilar na reconstrução do LCA. ACTA ORTOPEDICA BRASILEIRA 2011. [DOI: 10.1590/s1413-78522011000600003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJETIVO: A fixação femoral na reconstrução do Ligamento Cruzado Anterior (LCA) com enxerto de tendões flexores pode variar muito de acordo com a disposição dos materiais e a experiência do cirurgião. Porém os trabalhos que comparam os sistemas de fixação são efetuados na maioria das vezes em cadáveres ou em animais, sem avaliar os resultados clínicos, prejudicando sua comparação com pacientes humanos vivos. Neste artigo avaliamos o resultado clínico de dois métodos de fixação do enxerto ao fêmur (parafuso de interferência de titânio e parafuso transcondilar de titânio) para saber se, do ponto de vista clinico e subjetivo, há diferença entre estes métodos. MÉTODOS: Foram selecionados 40 pacientes com lesão do LCA sendo que 20 pacientes tiveram seu enxerto fixado ao fêmur com parafuso de interferência e 20 com parafuso transcondilar. Todos foram reavaliados com no mínimo dois anos de pós operatório para medição da gaveta anterior, Pivot Shift e teste de Lachman, além da obtenção dos questionário de Lysholm e IKDC (International Knee Documentation Committee). RESULTADOS: Os resultados não foram estatisticamente diferentes para os critérios avaliados. CONCLUSÃO: As duas formas de fixação são eficientes para esta técnica dentro dos parâmetros estabelecidos. Nível de Evidência II, Estudo Prospectivo Comparativo.
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Complications using bioabsorbable cross-pin femoral fixation: a case report and review of the literature. Case Rep Radiol 2011; 2011:349230. [PMID: 22606541 PMCID: PMC3350046 DOI: 10.1155/2011/349230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 07/19/2011] [Indexed: 01/10/2023] Open
Abstract
The use of bioabsorbable cross-pin transcondylar fixation has remained a viable option for femoral fixation in anterior cruciate ligament reconstruction. Although numerous biomechanical studies have demonstrated high fixation strength and minimal slippage with use of this method of fixation, there have been increasing reports of a variety of clinical complications associated with these implants. We reviewed the literature for all complications associated with the Bio-TransFix implant and present a case report of a patient status after ACL reconstruction using Bio-TransFix cross-pin femoral fixation with iliotibial band friction syndrome from a broken cross-pin four month post-operatively.
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Bellisari GE, Kaeding CC, Litsky AS. Mechanical evaluation of cross pins used for femoral fixation of hamstring grafts in ACL reconstructions. Orthopedics 2010; 33:722. [PMID: 20954667 DOI: 10.3928/01477447-20100826-08] [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] [Indexed: 02/03/2023]
Abstract
The goal of this study was to test the mechanical strength of 4 different cross pins currently available for femoral fixation by loading each cross pin to failure as received and determine the effect of 1 million cycles of fatigue loading. Additionally, the strength of resorbable pins was tested after prolonged exposure to biologic conditions. Six implants each of the Arthrotek LactoSorb (Biomet, Warsaw, Indiana), Mitek RigidFix (DePuy Mitek Inc, Raynham, Massachusetts), Arthrotek Bone Mulch Screw (Biomet), cortical allograft, and control were tested for 3-point failure without prior loading and after cyclic loading between 50 to 200 N at 10 Hz for 1 million cycles. The bioabsorbable pins were placed in sterile water at 37°C and tested after 2, 4, and 6 months for 3-point failure strength. All implants tested without antecedent loading demonstrated adequate strength for initial fixation for hamstring grafts. During fatigue testing, RigidFix implants (n=6) failed at 18,893±8365 cycles (with a central deformation of 0.48±0.11 mm prior to fracture). All of the other implants tested endured 1 million cycles of loading (50-200 N) without fracture or 1.5 mm central deformation. Neither of the bioabsorbable pins demonstrated a significant change in yield strength after prolonged exposure to water. All implants tested demonstrated adequate strength for initial fixation of hamstring grafts. The metal and bone implants far exceed the strength required to sustain mechanical fixation until biological fixation occurs; both polymeric implants demonstrated that they maintained enough mechanical strength to achieve this goal.
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Affiliation(s)
- Gregory E Bellisari
- Orthopaedic BioMaterials Laboratory, The Ohio State University, Columbus, Ohio, USA
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Meuffels DE, Docter PT, van Dongen RA, Kleinrensink GJ, Verhaar JAN, Reijman M. Stiffer fixation of the tibial double-tunnel anterior cruciate ligament complex versus the single tunnel: a biomechanical study. Arthroscopy 2010; 26:S35-40. [PMID: 20615655 DOI: 10.1016/j.arthro.2010.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 01/03/2010] [Accepted: 01/19/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The primary objective of this study was to evaluate the difference in graft pullout forces, stiffness, and failure mode of double-bundle anterior cruciate ligament (ACL) reconstruction of the tibial insertion by use of a single tunnel compared with a double-tunnel technique with interference screw fixation. METHODS ACL reconstruction on the tibial side was performed on 40 fresh-frozen porcine knees (mean bone mineral density of 0.64 g/cm(2) measured by dual-energy x-ray absorptiometry scan), randomly assigned to the single- or double-tunnel group. Interference screw fixation of the soft-tissue graft was used for both types of tibial reconstruction. Maximum failure load, stiffness, and failure mode were recorded. RESULTS There was no significant difference in maximum failure load between the single-tunnel group (400 +/- 26 N) and double-tunnel group (440 +/- 20 N). Stiffness of the tibial tunnel complex was significantly higher in the double-tunnel group (76 +/- 3 N/mm) than in the single-tunnel group (62 +/- 4 N/mm) (P = .013). All but 2 grafts (38 of 40) failed by slippage of the tendon past the interference screw. CONCLUSIONS There was significantly stiffer fixation of the tibial double-tunnel ACL complex when compared with the single tunnel. Our study did not show a different failure mode for the double-tunnel reconstruction compared with the single-tunnel reconstruction. CLINICAL RELEVANCE This study shows a biomechanical advantage with no potential deleterious side effects for fixation of the ACL with a double-tunnel technique on the tibial side.
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Affiliation(s)
- Duncan E Meuffels
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
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Biomechanical Comparison of Cross-Pin and Endobutton-CL Femoral Fixation of a Flexor Tendon Graft for Anterior Cruciate Ligament Reconstruction—A Porcine Femur-Graft-Tibia Complex Study. J Surg Res 2010; 161:282-7. [DOI: 10.1016/j.jss.2009.01.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 01/08/2009] [Accepted: 01/13/2009] [Indexed: 12/17/2022]
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Kokkinakis M, Ashmore A, El-Guindi M. Intraoperative complications using the Bio-Transfix femoral fixation implant in anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2010; 130:375-9. [PMID: 19787359 DOI: 10.1007/s00402-009-0976-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Indexed: 01/10/2023]
Abstract
The use of biodegradable Transfix femoral fixation technique is a safe and well-accepted method when performing anterior cruciate ligament reconstruction. We report on three cases of deformation and back out of the Bio-Transfix implant over the lateral, distal femoral cortex, with failure of the passing wire when advancing the graft into the femoral tunnel in one of these patients. Two of the patients presented with symptoms of iliotibial band friction syndrome, while the third patient was asymptomatic. The graft had clinically integrated demonstrating AP and rotational stability. The symptoms relieved after removal of the failed Bio-Transfix implants in the symptomatic patients. The aetiology of the implant failure and the alternative methods to avoid such complications are discussed.
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Affiliation(s)
- Michail Kokkinakis
- Stoke Mandeville Hospital, 43 Aston House, Mandeville Road, Aylesbury, Buckinghamshire, UK.
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Shen PH, Lien SB, Shen HC, Wang CC, Huang GS, Chao KH, Lee CH, Lin LC. Comparison of different sizes of bioabsorbable interference screws for anterior cruciate ligament reconstruction using bioabsorbable bead augmentation in a porcine model. Arthroscopy 2009; 25:1101-7. [PMID: 19801288 DOI: 10.1016/j.arthro.2009.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Revised: 04/28/2009] [Accepted: 05/22/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare the initial fixation strength of tendon grafts between different sizes of bioabsorbable interference screws (BioScrew; Linvatec, Largo, FL) with bioabsorbable bead (EndoPearl; Linvatec) augmentation through biomechanical analysis of a porcine femoral bone model. METHODS Forty pairs of porcine femurs and porcine flexor digitorum profundus tendons were divided into control and study groups. In the control group 8 x 30-mm BioScrews alone (n = 10) were inserted, whereas different sizes of BioScrews, measuring 7 x 30 mm (n = 10), 8 x 30 mm (n = 10), and 9 x 30 mm (n = 10), with 8-mm EndoPearl augmentation were inserted individually for fixation of tendon grafts in the study groups. All specimens were cyclically loaded with axial forces between 50 and 250 N at 1 Hz for 3,000 cycles and then incrementally loaded to failure at a rate of 150 mm/min. RESULTS BioScrews with EndoPearl augmentation had a significantly higher failure load than BioScrews alone (8-mm BioScrew alone v 8-mm BioScrew and EndoPearl, P < .05). There were no significant differences in the ultimate failure load (8 mm v 7 mm and 9 mm, P = .201 and P = .871, respectively), stiffness (8 mm v 7 mm and 9 mm, P = .789 and P = .823, respectively), displacement (8 mm v 7 mm and 9 mm, P = .695 and P = .781, respectively), and bone mineral density (P = .728 for all comparisons) except insertion torque (8 mm v 7 mm and 9 mm, P = .045 and P = .518, respectively) between study groups. Less tendon laceration by the screw thread was noted in the group in which smaller-sized BioScrews were used. CONCLUSIONS When EndoPearl augmentation was used, smaller-sized BioScrews (BioScrew size 1 mm smaller than bone tunnel) offered equivalent graft fixation strength to BioScrews of similar or larger sizes. CLINICAL RELEVANCE Smaller-sized BioScrews can be chosen if EndoPearl augmentation has been used, and EndoPearl augmentation may reduce the risk of tendon rupture while BioScrews are inserted.
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Affiliation(s)
- Pei-Hung Shen
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Biomechanical evaluation of cross-pin versus interference screw tibial fixation using a soft-tissue graft during transtibial posterior cruciate ligament reconstruction. Arthroscopy 2009; 25:989-95. [PMID: 19732637 DOI: 10.1016/j.arthro.2009.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Revised: 01/09/2009] [Accepted: 02/11/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE This article reports the biomechanical demonstration of a technique for transtibial posterior cruciate ligament (PCL) reconstruction using a soft-tissue graft with cross-pin fixation in the tibia and compares this with the biomechanical properties achieved with other methods. METHODS We used 5 paired cadaveric knees and another 10 tibias. Soft-tissue grafts were randomized. The femoral side of the anterior cruciate ligament was fixed with a Bio-TransFix device (Arthrex, Naples, FL) (group I), and the tibial side of the PCL was fixed with a Bio-TransFix device (group II). In another 10 tibias, tibial fixations were performed by use of a bio-interference screw (group III). Biomechanical testing was carried out on a testing machine, and maximal failure load, stiffness, and displacement were analyzed. The lengths of the slots of the TransFix device (Arthrex) from the near cortex were measured to compare the proper length of the device. RESULTS Maximal mean failure loads in groups I, II, and III were 549.3 +/- 55.4 N, 570.8 +/- 96.9 N, and 371.3 +/- 106.2 N, respectively, showing a significant difference (P = .0003). Stiffnesses were 47.52 +/- 16.84 N/mm, 59.14 +/- 17.09 N/mm, and 27.60 +/- 16.73 N/mm, respectively, showing a significant difference (P = .01). Mean displacements were 19.99 +/- 5.79 mm, 19.09 +/- 8.51 mm, and 17.58 +/- 7.10 mm, respectively, showing no significant difference (P = .7535). The mean lengths of the slots of the TransFix device of the femurs and tibias were similar at 20.3 +/- 1.25 mm and 20.2 +/- 1.32 mm, respectively, showing no significant difference (P = .8637). CONCLUSIONS The transtibial technique by use of cross-pin tibial fixation with a Bio-TransFix device in PCL reconstruction provides stable fixation that is comparable to that achieved by use of conventional bio-interference screw fixation and femoral fixation in an anterior cruciate ligament reconstruction, an already well-established technique. CLINICAL RELEVANCE Biomechanically, tibial cross-pin fixation compares favorably with interference screw fixation and is useful when a graft is short. However, safety issues have not yet been resolved.
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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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Lee YS, Ahn JH, Kim JG, Park JH, Park JW, Kim CB, Lee SW. Analysis and prevention of intra-operative complications of TransFix fixation in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2008; 16:639-44. [PMID: 18385979 DOI: 10.1007/s00167-008-0521-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 03/03/2008] [Indexed: 01/10/2023]
Abstract
We encountered some complications during the graft passage and fixation using a TransFix implant. Despite the large number of cases and publications related to the ligament surgery, few papers have reported intra-operative complications. We report our experience of such complications and prevention methods. From June 2005 to October 2007, anterior cruciate ligament reconstructions were performed in 128 patients using the TransFix devices. From the surgical records, the opinions of the assistant during the graft passage were divided into three subsets: tight, modest, and loose. The results were also analyzed according to the use of the routine procedure, vertical traction, and thigh portal. Complications during the graft passage and fixation were encountered in 13 patients. These complications occurred when the femoral tunnels were tight during the graft passage (P < 0.0001). The addition of vertical traction or a thigh portal decreased the number of complications significantly (P < 0.0001). The main cause of such complications was the lack of full proximal migration of the graft, which can cause tendon and wire breakage. This study introduces some methods to prevent such complications.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 516 Gozan-dong, Danwon-gu, Ansan 425-707, Republic of Korea.
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Pérez-Blanca A, Prado M, Ezquerro F, Montañéz E, Espejo A. Addition of a short central extension to surface cemented tibial trays in primary TKA: an in vitro study of the effect on initial fixation stability and its relationship to supporting bone density. Clin Biomech (Bristol, Avon) 2008; 23:483-92. [PMID: 18171597 DOI: 10.1016/j.clinbiomech.2007.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2007] [Revised: 09/26/2007] [Accepted: 11/20/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Short central extensions which do not enter the tibial medullary canal are incorporated to cemented tibial components to increase initial stability in primary total knee arthroplasty. Their role in tibiae of differing preoperative mechanical quality has been little studied. METHODS Twelve embalmed cadaveric tibiae were paired and divided into two groups, receiving a similar cemented tibial component with or without a non-cemented short central extension (10 mm diameter, 35 mm length). The specimens were subjected to 6000 cycles of a medially applied 1350 N load. Relative bone-tray displacements were measured and the evolution of inducible and permanent micromotions were computed. The apparent density of the cancellous bone under the tibial tray and at the area to support the extension was computed from computed tomography images of each specimen. FINDINGS No significant differences between groups were detected for any parameters. For the group with extension, a significant negative linear correlation (P = 0.009, r(2) = 0.849) was found between the inducible tilt of the tray and the bone density at the zone of the extension. Also a trend towards a negative linear relation (P = 0.07, r(2) = 0.59) was observed for the same group between maximum subsidence and apparent density at the zone of the extension. INTERPRETATION The study did not find that the addition of a non-cemented short central extension provides any overall improvement of the initial fixation stability. However, it was found that short extensions may enhance tilting stiffness of the bone-implant construct if bone of sufficient mechanical quality is located around its supporting area.
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Affiliation(s)
- A Pérez-Blanca
- Department of Mechanical Engineering, Campus El Ejido, University of Málaga, 29013 Málaga, Spain
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Dargel J, Schmidt-Wiethoff R, Heck M, Brüggemann GP, Koebke J. Comparison of initial fixation properties of sutured and nonsutured soft tissue anterior cruciate ligament grafts with femoral cross-pin fixation. Arthroscopy 2008; 24:96-105. [PMID: 18182209 DOI: 10.1016/j.arthro.2007.07.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Revised: 06/29/2007] [Accepted: 07/30/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether or not suturing a soft tissue graft in a whipstitch fashion is an essential procedure in order to ensure sufficient initial fixation strength of the cross-pin fixation technique in anterior cruciate ligament reconstruction. METHODS Porcine digital extensor tendons were used as 4-stranded soft tissue grafts. Specimens were fixated within 52 porcine femoral bone tunnels using a cross-pin fixation technique (RigidFix; Ethicon, Norderstedt, Germany). In group I (n = 28), the looped-over part of the grafts was sutured using a whipstitch technique; in group II (n = 28) the grafts were not sutured. Initial fixation properties were determined using either a single cycle load to failure protocol or a dynamic loading protocol, submitting the graft to 1,000 cycles of flexion-extension loading between 0 degrees and 90 degrees , followed by ultimate loading to failure. The graft-pin interaction and the graft-tunnel interface was histomorphologically visualized in unloaded and dynamically loaded grafts. RESULTS After dynamic loading, the residual displacement in sutured grafts was lower when compared to nonsutured grafts. The ultimate failure loads were significantly lower in nonsutured grafts when compared to sutured grafts after dynamic loading. The histomorphologic analysis demonstrated intratunnel displacement of nonsutured grafts after dynamic loading, while sutured grafts remained in situ. In cases where the cross-pins had not threaded the tendon loops, sutured grafts provided higher fixation strength and less graft displacement. CONCLUSIONS The results of the present study suggest that suturing the looped-over portion of a quadruple tendon graft provides superior biomechanical graft fixation properties when compared to nonsutured grafts when using the femoral cross-pin fixation technique. CLINICAL RELEVANCE Suturing the hamstring tendon graft in a whipstitch fashion is recommended for the femoral cross-pin fixation of an anterior cruciate ligament graft.
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Affiliation(s)
- Jens Dargel
- Department for Biomechanics and Orthopaedics, German Sport University Cologne, Cologne, Germany.
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Lee YS, Kim SK, Park JH, Park JW, Wang JH, Jung YB, Ahn JH. Double-bundle anterior cruciate ligament reconstruction using two different suspensory femoral fixation: a technical note. Knee Surg Sports Traumatol Arthrosc 2007; 15:1023-7. [PMID: 17497131 DOI: 10.1007/s00167-007-0336-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Accepted: 03/12/2007] [Indexed: 01/10/2023]
Abstract
We describe a novel double-bundle reconstruction method for ACL deficient knee. Grafts are tibialis allograft for AMB (anteromedial bundle) and semitendinosus autograft for PLB (posterolateral bundle). Femoral fixations are done by Bio-TransFix for AMB and EndoButton for PLB. Tibial fixations are done by Bio-interference screw for AMB at 60-70 degrees knee flexion and secure the PLB and remnant AMB graft simultaneously onto anteromedial aspect of tibia at 10-20 degrees knee flexion with spiked washer and screw. With our technique, graft lengths are not restricted and we provide strong femoral and tibial fixation if it is compared with previous techniques.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, 516 Gozan-dong, Danwon-gu, Ansan, 425-707, South Korea.
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Lee YS, Ahn JH, Jung YB, Wang JH, Yoo JC, Jung HJ, Kang BJ. Transtibial double bundle posterior cruciate ligament reconstruction using TransFix tibial fixation. Knee Surg Sports Traumatol Arthrosc 2007; 15:973-7. [PMID: 17356820 DOI: 10.1007/s00167-007-0300-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2006] [Accepted: 01/23/2007] [Indexed: 01/25/2023]
Abstract
Previous transtibial double bundle posterior cruciate ligament (PCL) reconstruction methods have several problems in graft length and tibial fixation. We introduce new surgical method that is less restrictive by graft length and is more stable with single tibial fixation. After diagnostic arthroscopy, we prepare the graft, ream the tibial tunnel, and perform the procedure for TransFix tibial fixation. Femoral 2 tunnel is made and graft is passed via anteromedial (AM) portal. Tibial fixation is done and femoral 2 graft is fixed sequentially at each knee position. TransFix tibial single fixation method in double bundle PCL reconstruction provides more stable fixation, more free graft selection, and prevents graft damage by passing the graft via AM portal.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic surgery, The Armed Forces Yangju Hospital, YongAm-ri 49-1, EunHyun-myun, YangJu-si, KyungGi-Province, and Chung-Ang University Medical Center, Seoul, South Korea.
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