Arthroscopic double-bundle anterior cruciate ligament reconstruction using autogenous quadriceps tendon

Patellar Size Variation at the Quadriceps Tendon-Bone Block Harvest Site: A Magnetic Resonance Imaging Study to Evaluate the Safe Zone for Harvesting a Sufficient Bone Block

BACKGROUND

Quadriceps tendon (QT) autografts with and without a bone block are the least studied and least used options for anterior cruciate ligament reconstruction surgery. In particular, there is a lack of literature describing patellar anatomy. Until now, guidelines for patellar bone block harvesting have been based solely on personal experience. In this study, we intended to derive recommendations from physical regularities and objective criteria.

PURPOSE

To determine the maximal, individual-related length and depth of the bone block that can be safely harvested and to provide guidelines to help surgeons make decisions on graft choice.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The study group consisted of 50 male participants and 50 female participants (mean age, 29.4 ± 7.9 years) who underwent 3.0-T magnetic resonance imaging of their knee. Patellar height was determined at the center of the middle third of the QT insertion on the patella and the medial and lateral endpoints; the depth was measured at the midpoints of the respective heights.

RESULTS

The mean width of the QT and the mean thickness were 49.0 ± 7.6 and 7.3 ± 1.0 mm, respectively. The mean patellar thickness in reference to the medial endpoint, the center, and the lateral endpoint was 18.3 ± 2.4, 17.9 ± 2.3, and 15.1 ± 2.3 mm, respectively, whereas the mean patellar height was 35.1 ± 4.1, 36.7 ± 4.2, and 35.1 ± 3.9 mm. In general, the tendon and patellar dimensions were significantly larger in male participants than in female participants (P = .016).

CONCLUSION

Bone block harvesting, with its depth not exceeding 50% of the patellar thickness and its length accounting for <50% of the patellar height, poses the least risk for a patellar fracture when located medial to midline. If the bone block is excised from the medial half of the central area (the latter is defined by the middle third of the QT insertion), with the outer edge of the saw positioned at the medial border of the central area, a graft of 15 mm length, 10 mm width, and 8 mm depth can be safely harvested in all White male participants and almost all female participants taller than 165 cm, according to our findings.

CLINICAL RELEVANCE

This is the first study presenting recommendations for patellar bone block harvesting at the quadriceps tendon insertionbased on physical regularities and objective criteria and not on personal experience.

Reconsidering Reciprocal Length Patterns of the Anteromedial and Posterolateral Bundles of the Anterior Cruciate Ligament During In Vivo Gait

BACKGROUND

Some cadaveric studies have indicated that the anterior cruciate ligament (ACL) consists of anteromedial and posterolateral bundles that display reciprocal function with regard to knee flexion. However, several in vivo imaging studies have suggested that these bundles elongate in parallel with regard to flexion. Furthermore, the most appropriate description of the functional anatomy of the ACL is still debated, with the ACL being described as consisting of 2 or 3 bundles or as a continuum of fibers.

HYPOTHESIS

As long as their origination and termination locations are defined within the ACL attachment site footprints, ACL bundles elongate in parallel with knee extension during gait.

STUDY DESIGN

Descriptive laboratory study.

METHODS

High-speed biplanar radiographs of the right knee joint were obtained during gait in 6 healthy male participants (mean ± SD: body mass index, 25.5 ± 1.2 kg/m²; age, 29.2 ± 3.8 years) with no history of lower extremity injury or surgery. Three-dimensional models of the right femur, tibia, and ACL attachment sites were created from magnetic resonance images. The bone models were registered to the biplanar radiographs, thereby reproducing the in vivo positions of the knee joint. For each knee position, the distances between the centroids of the ACL attachment sites were used to represent ACL length. The lengths of 1000 virtual bundles were measured for each participant by randomly sampling locations on the attachment site surfaces and measuring the distances between each pair of locations. Spearman rho rank correlations were performed between the virtual bundle lengths and ACL length.

RESULTS

The virtual bundle lengths were highly correlated with the length of the ACL, defined as the distance between the centroids of the attachment sites (rho = 0.91 ± 0.1, across participants; P < 5 × 10^-5). The lengths of the bundles that originated and terminated in the anterior and medial aspects of the ACL were positively correlated (rho = 0.81 ± 0.1; P < 5 × 10^-5) with the lengths of the bundles that originated and terminated in the posterior and lateral aspects of the ACL.

CONCLUSION

As long as their origination and termination points are specified within the footprint of the attachment sites, ACL bundles elongate in parallel as the knee is extended.

CLINICAL RELEVANCE

These data elucidate ACL functional anatomy and may help guide ACL reconstruction techniques.

All inside full thickness quadriceps tendon ACL reconstruction: Long term follow up results

Purpose

The aim of this study is to evaluate results of anterior cruciate ligament reconstruction (ACL) using an All-Inside Full Thickness Quadriceps Reconstruction technique at 5 years follow up.

Methods

This is a Retrospective cohort study of patients undergoing ACL reconstruction. Inclusion criteria for this report were isolated primary ACL reconstructions without chondral lesions (Grade III/IV Outerbridge), using autologous full-thickness quadriceps tendon (FQT) graft with bone block, with an “all-inside” technique. Functional scales of Lysholm, IKDC, Tegner and objective results of side to side difference (KT1000) were used for this evaluation. Additionally, complications and comorbidities were also analyzed.

Results

Two hundred and ninety-one ACL reconstructions were retrospectively reviewed at 5 years postoperatively; 268 (92.1%) were men and 23 (7.90%) women. Lysholm Score improved from 64 (SD = 6.09) to 91 (SD = 6.05) points average. IKDC showed 59.79%, excellent and 3.4% good results. Arthrometric analysis showed that 259 knees (89%) had a difference of less than 3 mm. Median pre-injury Tegner score was 9 (Range 4–10), while final median Tegner activity level at 5 years was 8 (Range 4–10). Among comorbidities, 5.15% of the patients presented anterior knee pain. No visualization difficulties or significant hematomas were found.

Conclusion

Use of all inside FQT for ACL reconstruction in a young, high demand sports population, present at 5 years, good to excellent results, functionally and objectively, with low rates of complications and comorbidities.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autograft through Single Femoral Tunnel and Single Branched Tibial Tunnel

Conventional single-bundle anterior cruciate ligament (ACL) reconstruction cannot improve the rotational stability of the knee. Traditional double-bundle ACL reconstruction requires is demanding, complex, time- and implant consuming, and associated with a high incidence of complications. Double-bundle ACL reconstruction using a free quadriceps tendon autograft through 3 independent tunnels provides some advantage, but the antegrade graft passage, tibial tunnel confluence, and graft site morbidity represent disadvantages. This Technical Note describes a modification of double-bundle ACL reconstruction using the hamstring tendon autograft through a single branched tibial tunnel and a single femoral tunnel using 2 interference screws (Arthrex, Naples, FL). The gracilis tendon autograft is passed through tibial tunnel stem to the posterolateral tibial tunnel branch to the posterolateral position in the femoral tunnel. The semitendinosus tendon autograft is passed through the tibial tunnel stem to the anteromedial tibial tunnel branch to the anteromedial position in the femoral tunnel. Both grafts are fixed by 2 interference screws: 1 at the femoral tunnel and 1 at the tibial tunnel stem with the knee at 20° flexion.

RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT WITH THE CENTRAL THIRD OF THE QUADRICEPS MUSCLE TENDON: ANALYSIS OF 10-YEAR RESULTS

Objective: Assess clinical results using two different protocols, 10 years after ACL reconstruction surgery with the central third of quadriceps muscle tendon (QT). Method: Between November /1997 and April/1998, 25 patients were submitted to 25 ACL reconstructions with QT by transtibial technique. The bone portion of the graft was fixated on femoral tunnel with interference screw and the tendinous portion of tibial tunnel with screw with washer. Two patients injured the new when playing soccer. Six patients were not available for follow-up (24%). Seventeen patients were evaluated, 15 men and two women, with mean age at surgery time of 28.53 ± 6.64 years. All patients were examined at six months, one year, and ten years after surgery. Clinical evaluation was made by the Lysholm scale, and the knee evaluation, with the Hospital for Special Surgery scale. Results: The patients had their injuries operated after 9.87 ± 14.42 months of the accident. According to Lysholm scale, the results at the end of the first year were 98.71 ± 2.47 and, after 10 years, 97.35 ± 3.12. Using the Hospital for Special Surgery scale, the mean score was 95.07 ± 5.23 in one year, and 94.87 ± 4.16 in 10 years. All patients returned to their professional activities with the same previous status. Fifteen (88.24%) patients were able to return to their sports activities, one by modifying the practice, while another one switched to another sport. No patient complained of pain on the donor area in the medium and long term. The sports return rate was excellent, and no changes were found on the femoropatellar joint.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results

PURPOSE

The autograft of choice for anterior cruciate ligament (ACL) reconstruction remains controversial. Recently, there has been an increase in interest in the quadriceps tendon as an autologous graft option for ACL reconstruction. The purposes of this study were to provide an in-depth review of quadriceps tendon anatomy, histology, and biomechanics and to synthesize reported clinical outcomes of ACL reconstructions using quadriceps tendon autografts. We hypothesize that (1) published studies on the anatomic, histologic, and biomechanical data regarding the quadriceps tendon support its use as a graft option for ACL reconstruction and (2) clinical outcomes of ACL reconstruction using quadriceps tendon autograft have similar clinical outcomes to bone-patellar tendon-bone autografts with less donor-site morbidity.

METHODS

We performed a comprehensive review of the literature regarding the anatomy, histology, and biomechanical studies of the quadriceps tendon, as well as a systematic review of clinical studies (Level of Evidence I-III) evaluating outcomes after ACL reconstruction using quadriceps tendon autograft. Stability outcomes, functional outcomes, range of motion, patient satisfaction, morbidity, and complications were comprised.

RESULTS

Fourteen studies were included in the review of clinical results, including 1,154 ACL reconstructions with quadriceps tendon autograft. Six studies directly compared quadriceps tendon autografts (n = 383) with bone-patellar tendon-bone autografts (n = 484). Stability outcomes (Lachman, pivot-shift, and instrumented laxity testing), functional outcomes (International Knee Documentation Committee and Lysholm scores), overall patient satisfaction, range of motion, and complications were similar between quadriceps tendon and other graft options. Less donor-site morbidity was seen in patients who underwent quadriceps tendon ACL reconstructions.

CONCLUSIONS

Use of the quadriceps tendon autograft for ACL reconstruction is supported by current orthopaedic literature. It is a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction.

LEVEL OF EVIDENCE

Level III, systematic review of Level I, II, and III studies.

Anterior Cruciate Ligament Reconstruction with Quadriceps Tendon Autograft: A Minimally Invasive Harvest Technique

Introduction

We describe a minimally invasive surgical technique for harvest of a quadriceps tendon autograft that reliably produces a graft suitable for anterior cruciate ligament (ACL) reconstruction while minimizing morbidity and complications classically associated with alternative autograft choices.

Step 1 Positioning

Position the patient supine on the operating room table.

Step 2 Marking of Landmarks

Palpate and mark soft-tissue and osseous landmarks on the involved extremity.

Step 3 Subcutaneous Dissection

Perform the incision and subcutaneous dissection.

Step 4 Graft Harvest

Harvest the graft.

Step 5 Graft Preparation

Prepare the graft.

Step 6 Closure

If a partial-thickness graft is harvested, no deep closure is needed.

Results

Since September of 2011, the quadriceps tendon has been our autograft of choice for ACL reconstruction.IndicationsContraindicationsPitfalls & Challenges.

A Brief History of Anterior Cruciate Ligament Reconstruction

Reconstructions of the anterior cruciate ligament (ACL) are among the most frequently performed procedures in knee surgery nowadays. The history of ACL surgery can be traced as far back as the Egyptian times. The early years reflect the efforts to establish a viable, consistently successful reconstruction technique while, during the early 20th century, we witness an increasing awareness of, and interest in, the ligament and its lesions. Finally, we highlight the most important steps in the evolution of the ACL reconstruction surgery by discussing the various techniques spanning the years using not only autologous grafts (fascia lata, meniscal, hamstring, patella tendon, bone-patella tendon-bone, and double bundle grafts) but also synthetic ones and allografts.

Anterior cruciate ligament reconstruction using bone plug-free quadriceps tendon autograft: intermediate-term clinical outcome after 24-36 months

Introduction

Although known as a possible graft option for decades, quadriceps tendon grafts have often been termed a second-line graft option. We report a consecutive case series using this method as the primary treatment line. The rationale for this study was to evaluate the midterm results of this method in a prospective and consecutive case series. The primary study question was to determine the clinical results 24–36 months after primary anterior cruciate ligament (ACL) reconstruction using a bone plug-free quadriceps tendon autograft fixed with bioabsorbable cross-pins.

Materials and methods

The study population included 55 patients, of whom 24 were female (43.6%). The mean age at the index procedure was 31.7 years (15–58 years). All patients received an ACL construction using a bone block-free quadriceps tendon graft fixed with resorbable cross-pins. The postoperative regimen included partial weight-bearing for 3 weeks and flexion limited to 90° for six weeks; an orthosis was not used. The mean follow-up duration was 29.5 months (24.3–38.5 months) after the index procedure. The International Knee Documentation Committee (IKDC) subjective score and examination form was assessed, as well as the Lysholm and Gillquist score and the Tegner activity index. The Rolimeter arthrometer was used to assess the anterior laxity of the knee.

Results

Graft harvesting was possible in all cases; a bony extension was never required. On average, graft length was measured at 8.8 cm (7.5–10 cm). The mean IKDC subjective score at follow-up was 80.44 points (55.17–100 points, standard deviation [SD] 12.05). The mean preinjury Tegner activity index was 4.98 (2–7) compared to a mean value of 4.16 (2–7, SD 0.8) at follow-up. There was a mean loss of 0.82 index points. The average Lysholm and Gillquist score was 89 points (65–100, SD 17.7). Of the results, 89.1% were in the good or very good groups; in one case (1.8%), the result was poor, while the rest were fair.

Conclusion

ACL reconstruction using a bone plug-free quadriceps tendon autograft achieved satisfactory results in a midterm review.

Intertunnel relationships in combined anterior cruciate ligament and posterolateral corner reconstruction: an in vivo 3-dimensional anatomic study

BACKGROUND

Combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries are relatively common, and tunnel convergence could occur in combined ACL and PLC reconstruction.

PURPOSE

This study sought to elucidate the ranges of angles and distances of lateral collateral ligament (LCL) and popliteus tendon (PT) femoral tunnels that do not violate the intercondylar notch distally and ACL tunnels proximally during combined ACL and PLC reconstruction.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Three-dimensional anatomic knee models were developed using customized software from computed tomography images of 14 patients at 0°, 90°, and 120° of flexion. Single-bundle (SB) and double-bundle (DB) ACL tunnels using the transtibial method for anteromedial bundles and the anteromedial portal method for posterolateral bundles were created. The ranges of safe angles and distances were measured at 10° and 20° posterior, neutral (0°), and 10° and 20° anterior on the horizontal plane relative to the transepicondylar axis from the isometric LCL and PT femoral insertions. The SB ACL reconstruction using the accessory medial portal and LCL reconstruction using the anatomic footprint were also analyzed.

RESULTS

Distal and proximal angles from insertions of the LCL and PT, not violating the intercondylar notch or the ACL tunnels, increased as the LCL or PT headed from a posterior to anterior direction. Safe distances from the LCL and PT femoral insertions were approximately over 35 mm distally and 30 mm proximally. For SB ACL reconstruction using the accessory medial portal, safe angles were larger proximally than those of SB ACL reconstruction using the transtibial technique. For LCL reconstruction using the anatomic footprint, proximal angles were significantly smaller than those of the isometric LCL.

CONCLUSION

Considering the relationship between the LCL and PT tunnels and fixation strength, tunneling will be safe when the LCL and PT are positioned at an angle of approximately 20° anterior and 10° proximal to the transepicondylar axis.

CLINICAL RELEVANCE

These results will help to reduce the incidence of tunnel convergence in combined ACL and PLC reconstructions.

Clinical results of technique for double bundle anterior cruciate ligament reconstruction using hybrid femoral fixation and Retroscrew

Background

Anatomic anterior cruciate ligament (ACL) reconstruction has been presented as a means to more accurately restore the native anatomy of this ligament. This article describes a new method that uses a double bundle to perform ACL reconstruction and to evaluate the clinical outcome.

Methods

Grafts are tibialis anterior tendon allograft for anteromedial bundle (AMB) and hamstring tendon autograft without detachment of the tibial insertion for posterolateral bundle (PLB). This technique creates 2 tunnels in both the femur and tibia. Femoral fixation was done by hybrid fixation using Endobutton and Rigidfix for AMB and by biointerference screw for PLB. Tibial fixations are done by Retroscrew for AMB and by native insertion of hamstring tendon for PLB. Both bundles are independently and differently tensioned. We performed ACL reconstruction in 63 patients using our new technique. Among them, 47 participated in this study. The patients were followed up with clinical examination, Lysholm scales and International Knee Documentation Committee (IKDC) scoring system and radiological examination with a minimum 12 month follow-up duration.

Results

Significant improvement was seen on Lachman test and pivot-shift test between preoperative and last follow-up. Only one of participants had flexion contracture about 5 degrees at last follow-up. In anterior drawer test by KT-1000, authors found improvement from average 8.3 mm (range, 4 to 18 mm) preoperatively to average 1.4 mm (range, 0 to 6 mm) at last follow-up. Average Lysholm score of all patients was 72.7 ± 8.8 (range, 54 to 79) preoperatively and significant improvement was seen, score was 92.2 ± 5.3 (range, 74 to 97; p < 0.05) at last follow-up. Also IKDC score was normal in 35 cases, near normal in 11 cases, abnormal in 1 case at last follow-up.

Conclusions

Our new double bundle ACL reconstruction technique used hybrid fixation and Retroscrew had favorable outcomes.

Anatomic double-bundle anterior cruciate ligament reconstruction using bone-patellar tendon-bone and gracilis tendon graft: a comparative study with 2-year follow-up results of semitendinosus tendon grafts alone or semitendinosus-gracilis tendon grafts

PURPOSE

The purpose of this study was to assess the clinical results of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction by use of bone-patellar tendon-bone and gracilis tendon (BPTB-G) grafts and to compare them with the results of double-bundle ACL reconstruction by use of semitendinosus tendon (ST) or semitendinosus-gracilis tendon (ST-G) grafts, with particular emphasis on the postoperative incidence of anterior knee pain.

METHODS

The study comprised 144 patients who underwent unilateral anatomic double-bundle ACL reconstruction with 3 graft types, including 55 BPTB-G, 56 ST, and 33 ST-G grafts. A traumatic graft rupture occurred within 2 years postoperatively in 5 patients (1 BPTB-G, 3 ST, and 1 ST-G). Clinical results and incidence and severity of anterior knee pain were assessed and compared among the 3 different graft groups at 2 years postoperatively. Potential variables influencing postoperative anterior knee pain development were subjected to univariate analysis, followed by logistic regression analysis to identify risk factors for anterior knee pain.

RESULTS

Both subjective and objective clinical results in anatomic double-bundle ACL reconstruction with BPTB-G graft were similar to those using ST or ST-G graft at 2 years postoperatively. The incidences of anterior knee pain at 2 years' follow-up were 18.5%, 9.4%, and 9.3% in the BPTB-G, ST, and ST-G groups, respectively, indicating no statistically significant difference among the 3 groups. Multivariate logistic regression analyses showed that BPTB graft harvest and patellofemoral cartilage defect failed to be significant factors for anterior knee pain whereas quadriceps peak torque at 60°/s was the only significant factor for anterior knee pain at 2 years.

CONCLUSIONS

Clinical results including the incidence of anterior knee pain 2 years after anatomic double-bundle ACL reconstruction with BPTB-G grafts were comparable to those after ACL reconstruction with ST or ST-G grafts.

LEVEL OF EVIDENCE

Level III, therapeutic, retrospective comparative study.

Anatomical placement of double femoral tunnels in anterior cruciate ligament reconstruction: anteromedial tunnel first or posterolateral tunnel first?

PURPOSE

The purpose of this study was to know which tunnel--the anteromedial (AM) bundle or the posterolateral (PL) bundle--should be prepared first to create the 2 femoral tunnels accurately in anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction.

METHODS

Thirty-four patients were divided into 2 groups of 17 depending on the sequence of preparation of the 2 femoral tunnels. In group A, the AM tunnel was prepared first, whereas the PL tunnel was prepared first in group P. ACL reconstruction was performed using a three-dimensional (3-D) fluoroscopy-based navigation system to place the double femoral tunnels through an accessory medial portal. The double femoral socket positioning was evaluated by 3-D computed tomography (CT) scan image.

RESULTS

The non-anatomical placement of the femoral sockets occurred in 5 patients (29%) in group A, whereas the 2 sockets were placed anatomically in all patients in group P (P < 0.05). Evaluation of the AM and the PL socket location on the 3-D CT images using the quadrant method showed more similar values to the laboratory data in a literature in group P than in group A. No complication occurred in group A, whereas complications such as socket communications or back wall blowout occurred in 5 patients (29%) in group P (P < 0.05).

CONCLUSION

The sequence of creating 2 femoral tunnels through accessory medial portal affected the resultant location of the sockets and the rate of the complications. When femoral tunnels are prepared with a transportal technique, PL tunnel first technique seems to be superior to AM first technique regarding anatomic placement. However, PL tunnel first technique accompanies the risk of socket communication.

Anatomic double-bundle anterior cruciate ligament reconstruction

Several double-bundle anterior cruciate ligament (ACL) reconstruction procedures were reported in the 1980s and 1990s. However, no significant differences were found in the clinical results between these double-bundle procedures and single-bundle procedures because the double-bundle procedures appeared to reconstruct only the anteromedial bundle with 2 bundles. In the early 2000s, we proposed a new concept of anatomic reconstruction of the anteromedial and posterolateral bundles, in which 4 independent tunnels were created through the center of each anatomic attachment of the 2 bundles. We called it "anatomic" double-bundle ACL reconstruction. Biomechanical studies have shown that the anatomic double-bundle ACL reconstruction can restore knee stability significantly more closely to the normal level than the conventional single-bundle reconstruction. Recent intraoperative measurement studies have shown that the clinically available anatomic double-bundle procedures can reconstruct knee stability significantly better and improve knee function close to the normal level at the time immediately after surgery compared with the conventional single-bundle procedures. However, the greatest criticism of the anatomic double-bundle reconstruction is whether its clinical results are better than the results of single-bundle reconstruction. To date (January 2010), 10 prospective comparative clinical trials (Level I or II) and 1 meta-analysis have been reported comparing single-bundle and anatomic double-bundle reconstructions using hamstring tendons. In 8 of the 10 studies, the anterior and/or rotatory stability of the knee was significantly better with the anatomic double-bundle ACL reconstruction than with the conventional single-bundle reconstruction. However, 1 original trial and the meta-analysis found that there were no differences in the results between the 2 types of reconstructions. Thus the utility of the anatomic double-bundle reconstruction has not yet been established. Our review does show how much evidence exists as to the benefits of double-bundle ACL reconstruction at present.

Anterior cruciate ligament reconstruction in patients with generalized joint laxity

Generalized joint laxity is a genetically determined component of overall joint flexibility. The incidence of joint laxity in the overall population is approximately 5% to 20%, and its prevalence is higher in females. Recently it was noticed that individuals with generalized joint laxity are not only prone to anterior cruciate ligament injuries but also have inferior results after a reconstruction. Therefore, an anterior cruciate ligament reconstruction in patients with generalized laxity should be undertaken with caution due to the higher expected failure rate from the complexity of problems associated with this condition. It is also necessary to identify the risk factors for the injury as well as for the post operative outcome in this population. A criterion that includes all the associated components is necessary for the proper screening of individuals for generalized joint laxity. Graft selection for an anterior cruciate reconstruction in patients with ligament laxity is a challenge. According to the senior author, a hamstring autograft is an inferior choice and a double bundle reconstruction with a quadriceps tendon-bone autograft yields better results than a single bundle bone-patella tendon-bone autograft. Future studies comparing the different grafts available might be needed to determine the preferred graft for this subset of patients. Improved results after an anterior cruciate ligament reconstruction can be achieved by proper planning and careful attention to each step beginning from the clinical examination to the postoperative rehabilitation.

Anatomic double-bundle ACL reconstruction using a bone-patellar tendon-bone autograft: a technical note

This article describes an original arthroscopic double-bundle anterior cruciate ligament (ACL) reconstruction technique using a bone-patellar tendon-bone autograft. A rectangular patellar bone block, with a double strand patellar tendon, and a double tibial bone block is harvested. The femoral anteromedial tunnel is made using an all-inside technique by the anteromedial portal. The femoral posterolateral (PL) tunnel is created with an outside-in technique, with a 30 degrees divergence between both tunnels. A single tibial tunnel is drilled, the graft is then passed through the tibial tunnel, and the bundles are separately tensioned and fixed with three bioabsorbable interference screws. The femoral AM bone block is fixed by the anteromedial portal, the tibial bone block is then fixed in an oblique manner in order to mimic the ACL orientation with the knee at 30 degrees of flexion. The femoral PL bone block is fixed at the end with the knee in full extension.

The effect of intra-operative knee flexion angle on determination of graft location in the anatomic double-bundle anterior cruciate ligament reconstruction

Graft tunnel placement is the factor with most influence on the outcome of double-bundle anterior cruciate ligament (ACL) reconstruction. However the final decision for the graft location has to be decided subjectively under arthroscopy, and can be misplaced due to the effect of the knee flexion angle. The displacement of the estimated placement by surgeons from the ACL anatomical attachment is due to the knee's differing knee flexion angle. Eight cadaveric knees and an electromagnetic position recording system were employed. After digitizing the anatomical location of AM and PL bundle center, four experienced surgeons estimated the graft placement repeatedly at 70 degrees , 90 degrees and 110 degrees of knee flexion. The displacements between these two positions were calculated and analyzed separately in antero-posterior and disto-proximal directions. The displacements of the estimated AM bundle placements were 4.7 +/- 3.4 mm at 70 degrees , 4.3 +/- 2.2 mm at 90 degrees , and 6.0 +/- 2.6 mm at 110 degrees , while those of the PL bundle were 4.0 +/- 2.2 mm at 70 degrees , 3.4 +/- 1.9 mm at 90 degrees , and 4.2 +/- 2.5 mm at 110 degrees . The best results were obtained at 90 degrees of knee flexion. Additionally, the estimated placements for both AM and PL bundle were located more distally as the flexion angle increased. Our results imply that the knee should be set at 90 degrees when determining the graft placement in double-bundle reconstruction to prevent misplacement of the graft usually in a disto-proximal direction.

Outcome of double-bundle ACL reconstruction using hamstring tendons

The objective of this article is to describe the clinical outcome of the transitional double-bundle procedure for anatomical ACL reconstruction. Subjects included 78 patients (average age 25 years) who had undergone ACL reconstruction with the transitional double-bundle procedure with multi-stranded hamstring tendons. The femoral socket for the anteromedial (AM) graft was created at 5-6 mm from the mid-sagittal line of the intercondylar notch at 2:00 or 10:00, and that for the posterolateral (PL) graft was drilled adjacent to the AM socket at 3:00 or 9:00. For the tibial side, two tunnels were made at the center of the footprint of the AM and PL bundles of the normal ACL. Patients were evaluated at 24 months or longer postoperatively based on the IKDC Knee Examination Form. Subjectively, 32 knees (41%) were graded as normal; 41 (53%), as nearly normal; 4 (5%), as abnormal; and 1 (1%) as graft rupture by re-injury. The average side-to-side difference in anterior laxity at manual maximum force with the KT-2000 arthrometer was 0.9 mm +/- 1.2. Seventy patients (93%) had a range between -1 mm and 2 mm. In conclusion the transitional double-bundle ACL reconstruction provided a satisfactory outcome after a short-term follow-up.

Comparison of single- and double-bundle anterior cruciate ligament reconstruction using quadriceps tendon-bone autografts

PURPOSE

The purpose of this study was to evaluate and compare postoperative knee stability and functional scores between single- and double- bundle anterior cruciate ligament (ACL) reconstruction with the use of quadriceps tendon-bone autografts at a 2-year follow-up.

METHODS

The records of 59 patients who had ACL reconstruction between January 2005 and April 2006 were analyzed retrospectively. Twenty-eight patients had single-bundle reconstruction (group S) and 31 received double-bundle reconstruction (group D). Ligament stability was assessed with the Lachman and pivot-shift tests and a KT-2000 arthrometer. International Knee Documentation Committee (IKDC) and Lysholm scores were employed to evaluate the functional outcomes.

RESULTS

The postoperative mean side-to-side difference for group S was 2.64 mm and 1.79 mm for group D, a difference that was found to be statistically significant (P = .020). Regarding the pivot-shift test, 3 patients had grade 1+ and 1 patient had grade 2+ pivot-shift in group S, while no patients had abnormal pivot-shift in group D (P = .093). The patients who reported grade A or B on IKDC scores were 24 and 28 in group S and D, respectively (P > .1). On the questionnaire of the twisting activity, although statistical difference was not found between the groups, there was a trend toward more restriction in twisting activity in group S (P = .096). We found significant correlation between the twisting activity and instability questionnaire of the Lysholm score (Spearman coefficient, 0.737; P < .001).

CONCLUSIONS

Double-bundle ACL reconstruction using quadriceps tendon-bone autografts provide less laxity (1.79 mm) than single-bundle ACL reconstruction (2.64 mm) as measured by the KT-2000. However, we could not find any significant differences in the functional measurements between the 2 groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anteromedial portal technique for the anterior cruciate ligament femoral socket: pitfalls and solutions

Creating the anterior cruciate ligament (ACL) femoral socket using the anteromedial (AM) portal technique has advantages. Furthermore, the technique is ideal for anatomic double-bundle (particularly posterolateral bundle) and all-inside ACL techniques. However, although the AM portal technique has advantages, the learning curve is steep when making the transition from familiar, transtibial reaming to the AM portal technique for ACL femoral tunnel creation. Complications and challenges are many when learning the AM portal technique. The purpose of this technical note is to describe tips and pearls for surgeons contemplating the transition to the AM portal technique for the ACL femoral socket.

Anatomic double-bundle anterior cruciate ligament reconstruction with anatomic aimers

Graft positioning is a key issue in anterior cruciate ligament (ACL) reconstruction and even more sensitive in double-bundle reconstruction, where 2 tunnels have to be drilled within the ACL footprints at both the femoral and tibial insertion sites. Specific ancillary instruments have been developed to facilitate the positioning of the 4 sockets necessary when performing anatomic double-bundle ACL reconstruction. This technical note describes the rationale and the step-by-step method of using the specific aimers developed for this purpose. However, a prerequisite for successful double-bundle ACL reconstruction is a good knowledge of ACL footprint anatomy.

Arthroscopic double bundle ACL reconstruction using a bone patellar tendon bone-gracilis tendon composite autograft: a technical note

The authors devised an alternative arthroscopic double bundle ACL reconstruction technique using a bone patellar tendon bone (BPTB)-gracilis tendon composite autograft. One tibial and two femoral tunnels were used to reconstruct two bundles of anterior cruciate ligaments (ACL) [an anteromedial bundle (AM) and a post-erolateral bundle (PL)]. BTBB was fixed in the tunnels produced on the isometric points of the tibia and femur using the conventional technique. The gracilis tendon was then fixed in a PL tunnel produced using the outside-in technique. The authors consider that the devised technique based on a combination of autogenous bone patellar bone graft and gracilis tendon, can minimize tunnel widening post-operatively, allow easier revision should the reconstructed ACL fail, and also provides an alternative means of restoring rotation stability.

Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction

PURPOSE

Biomechanical studies show increased anterior and rotational stability with double-bundle (DB) compared to single-bundle (SB) anterior cruciate ligament (ACL) reconstruction. The aim of this study was to evaluate the clinical results of four-tunnel DB ACL reconstruction.

METHODS

Seventy patients undergoing arthroscopic hamstring ACL reconstruction were prospectively randomized to DB (n = 35) or SB (n = 35) groups. Each bundle fixation was by means of a femoral EndoButton CL and a tibial biodegradable interference screw. Demographic data were comparable between groups, and the average age of all patients was 29 years. The average follow-up was 19 months for both groups and included a history, clinical evaluation with knee scores, and radiographs.

RESULTS

The subjective results were similar in groups. The subjective International Knee Documentation Committee (IKDC) 2000 score was 88 P for DB versus 90 P for SB; the Lysholm score was 90 P for DB versus 93 P for SB; and the Cincinnati knee score was 91 P for DB versus 92 P for SB. The objective IKDC was significantly higher for DB: 78% "A" (P < .000) and 19% "B" compared to 24% "A" and 68% "B" for SB. The average KT-1000 side-to-side difference was 1.0 mm for DB and 1.6 mm for SB (P = .054) and the pivot shift test was negative in 97% for DB (P = .01) and 71% for SB. The range of motion was comparable for both groups.

CONCLUSIONS

Our study shows a significant advantage in anterior and rotational stability as well as objective IKDC for four-tunnel DB ACL reconstruction compared to SB ACL reconstruction. The subjective Cincinnati knee score, the Lysholm score, and the subjective IKDC 2000 did not show any statistical difference for one or the other technique.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

KIN-Nav navigation system for kinematic assessment in anterior cruciate ligament reconstruction: features, use, and perspectives

In this paper a new navigation system, KIN-Nav, developed for research and used during 80 anterior cruciate ligament (ACL) reconstructions is described. KIN-Nav is a user-friendly navigation system for flexible intraoperative acquisitions of anatomical and kinematic data, suitable for validation of biomechanical hypotheses. It performs real-time quantitative evaluation of antero-posterior, internal-external, and varus-valgus knee laxity at any degree of flexion and provides a new interface for this task, suitable also for comparison of pre-operative and post-operative knee laxity and surgical documentation. In this paper the concept and features of KIN-Nav, which represents a new approach to navigation and allows the investigation of new quantitative measurements in ACL reconstruction, are described. Two clinical studies are reported, as examples of clinical potentiality and correct use of this methodology. In this paper a preliminary analysis of KIN-Nav's reliability and clinical efficacy, performed during blinded repeated measures by three independent examiners, is also given. This analysis is the first assessment of the potential of navigation systems for evaluating knee kinematics.

Second-look arthroscopic evaluations of anatomic double-bundle anterior cruciate ligament reconstruction: relation with postoperative knee stability

PURPOSE

The purpose of this study was to test the hypothesis that both the anteromedial and posterolateral bundles may be clearly visible after anatomic double-bundle reconstruction, as well as that a strong relation may exist between the appearance of the 2 bundles and the clinical evaluation.

METHODS

A prospective study was performed based on 178 consecutive patients who underwent anatomic double-bundle anterior cruciate ligament reconstruction with 2 hamstring tendon autografts in the unilateral knee. To develop arthroscopic diagnostic criteria, clinical evaluations were carried out at 1 to 2 years concerning the anterior laxity, the pivot-shift test, the Lysholm knee score, and the International Knee Documentation Committee evaluation, and 136 of the 178 patients underwent second-look arthroscopy shortly before or after the clinical examinations that are the basis of this study. The focus of the second-look arthroscopy was on graft thickness, apparent tension, and synovium coverage of the bundle.

RESULTS

Second-look arthroscopy showed that the anteromedial bundle was evaluated as excellent in 79.5% of the knees, fair in 16.7%, and poor in 3.8% and the posterolateral bundle was evaluated as excellent in 75.8%, fair in 21.2%, and poor in 3.0%. There was a significant difference in the anterior laxity and the pivot-shift test among the arthroscopically observed categories. Between the knees with second-look arthroscopy and those without it, there were no significant differences in all clinical evaluations.

CONCLUSIONS

Both the anteromedial and posterolateral bundles were clearly visible after the anatomic double-bundle anterior cruciate ligament reconstruction at 1 to 2 years after surgery. There was a significant difference in the anterior laxity and pivot-shift test in patients in category I, which comprised those who had excellent anteromedial and posterolateral bundles, compared with those in category II or III, which comprised those in whom either 1 or both of the bundles was scored as less than excellent.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria on the basis of consecutive patients with universally applied reference gold standard.

Double-bundle anterior cruciate ligament reconstruction using two different suspensory femoral fixation: a technical note

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.

Radiologic evaluation of femoral and tibial tunnels created with the transtibial tunnel technique for anatomic double-bundle anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to clarify femoral and tibial tunnel angles in anatomic double-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

A prospective study was performed in 50 consecutive patients who underwent anatomic double-bundle ACL reconstruction via hamstring tendon grafts for chronic ACL deficiency in the unilateral knee. For this procedure, 2 hamstring tendon grafts were secured with EndoButtons (Smith & Nephew Endoscopy, Andover, MA) on the femur and with 2 staples on the tibia. Each patient underwent radiologic examination 1 year after surgery.

RESULTS

The tibial tunnel angles of the posterolateral bundle averaged 40.7 degrees in the anteroposterior view and 35.4 degrees in the lateral view. The tibial tunnel angles of the anteromedial bundle averaged 15.6 degrees in the anteroposterior view and 41.4 degrees in the lateral view. The femoral tunnel angles of the posterolateral bundle averaged 44.0 degrees in the anteroposterior view and 52.0 degrees in the lateral view. The femoral tunnel angles of the anteromedial bundle averaged 18.0 degrees in the anteroposterior view and 49.8 degrees in the lateral view.

CONCLUSIONS

The given data will be useful for surgeons to evaluate the tunnel positions and standardization postoperatively in anatomic double-bundle reconstruction.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria on the basis of consecutive patients with universally applied reference gold standard.

Anatomic double bundle ACL reconstruction: a literature review

With the abundance of anatomic double bundle ACL reconstruction techniques that currently exist and limited patient outcome data, one has to ask whether or not they should be used and if so, which one, and what is the learning curve for the average knee surgeon to become competent with the technique that they select? The purpose of this literature review is to summarize existing anatomic double bundle ACL reconstruction surgical and rehabilitation techniques and the clinical and biomechanical study evidence that currently exists. In choosing to perform anatomic double bundle ACL reconstruction we suggest that the knee surgeon should look for evidence of: (1) control of the pivot shift phenomenon, (2) improved transverse plane rotatory knee control during the performance of sports type movements, (3) a decreased likelihood of revision procedures either for ACL reconstruction or for treatment of associated primary or recurrent meniscal injuries, (4) improved patient self-reports of perceived function, satisfaction, and quality of life, and (5) radiographic evidence of a lower incidence and/or magnitude of osteoarthritic changes compared to conventional single bundle ACL reconstruction.

Bilok interference screws for anterior cruciate ligament reconstruction: clinical and radiographic outcomes

PURPOSE

The purpose of this study was to evaluate the clinical effectiveness and radiographic response of a poly-L-lactide (PLLA)/beta-tricalcium phosphate (TCP) interference screw for anterior cruciate ligament (ACL) reconstruction.

METHODS

In a consecutive series of patellar tendon autograft ACL reconstructions, all patients had both ends fixed with PLLA/beta-TCP screws. Inclusion criteria were positive Lachman and pivot-shift tests and closed or nearly closed growth plates. Exclusionary criteria were posterior cruciate ligament tears and bilateral ACL or multiple ligament injuries. Tegner, Lysholm, Cincinnati, and International Knee Documentation Committee activity scores; Lachman and pivot-shift data; radiographic examinations; and KT measurements (MEDmetric, San Diego, CA) were obtained.

RESULTS

In this study 41 patients met the criteria (31 male and 10 female patients), at a mean follow-up of 34 months (range, 24 to 44 months). Of these patients, 40 were available for follow-up (1 had died). Postoperatively, the mean Cincinnati score was 83 (64 preoperatively), the mean Tegner score was 5.5 (3.2 preoperatively), the mean Lysholm score was 88 (59 preoperatively), and the mean International Knee Documentation Committee activity score was 3.0 out of 4 (1.8 preoperatively). No patients had positive postoperative Lachman or pivot-shift tests. The maximum difference based on KT manual examinations 3 mm or less. Adverse events included screw breakage during insertion. Postoperative radiographs showed rapid bone plug incorporation. Radiographic tunnel obliteration with bony ingrowth was shown at 2 and 3 years' follow-up.

CONCLUSIONS

The PLLA/beta-TCP interference screw performed well clinically based on both subjective and objective results. Radiographic screw incorporation into the adjacent bone was apparent at 3 years.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The in vivo kinematics of the anteromedial and posterolateral bundles of the anterior cruciate ligament during weightbearing knee flexion

BACKGROUND

Recently, double-bundle anterior cruciate ligament reconstruction has been advocated. However, there are little data on the in vivo biomechanics of the anteromedial and posterolateral bundles of the anterior cruciate ligament. Our objective was to measure the kinematics of the 2 bundles during weightbearing flexion.

STUDY DESIGN

Descriptive laboratory study.

HYPOTHESIS

The bundles of the anterior cruciate ligament are longest at low flexion angles during in vivo weightbearing flexion.

METHODS

Magnetic resonance images from 7 healthy subjects were used to create 3-dimensional models of the knee. The attachments of the anteromedial and posterolateral bundles were outlined on each model. Next, the subjects performed a quasi-static lunge from full extension to 135 degrees while being imaged using a dual orthogonal fluoroscopic system. The models and fluoroscopic images were used to reproduce the motion of the knee. The length, elevation, deviation, and twist of the functional bundles were measured.

RESULTS

The anteromedial and posterolateral bundles were longest at low flexion angles and shortened significantly with increasing flexion. The elevation and deviation angles of both bundles were similar at low flexion angles ( < 45 degrees ). The twist of the bundles was minimal ( < 5 degrees ) at low flexion.

CONCLUSION

With in vivo flexion, the anteromedial and posterolateral bundles did not demonstrate the reciprocal behavior noted in previous cadaveric studies. Both bundles were parallel and maximally elongated at low flexion angles. Our data suggest that if a double-bundle reconstruction is performed, 2 tunnels might need to be drilled in the femur and tibia to reproduce the orientation of the anterior cruciate ligament. Both anteromedial and posterolateral grafts should be fixed at low flexion angles to prevent over-constraint.