Re-tensioning technique to cover the graft with remnant in anterior cruciate ligament reconstruction

Remnant preservation with tensioning can improve the clinical outcome after anterior cruciate ligament reconstruction

BACKGROUND

Many studies exist about remnant preservation in anterior cruciate ligament (ACL) reconstruction. However, concern remains for development of a cyclops lesion during remnant preservation. To prevent this, a tensioning method has been suggested. Current study evaluated the clinical and radiologic results of remnant preservation in ACL reconstruction with tensioning compared to classical ACL reconstruction.

METHODS

From January 2016 to June 2017, ACL reconstruction patients who underwent magnetic resonance imaging (MRI) 2 years postoperatively were enrolled. For comparison, all participants were divided in two groups: remnant preservation with tensioning (group R) and controls (group C). Clinically, Hospital for Special Surgery (HSS), International Knee Documentation Committee (IKDC), Lysholm scores, and incidence of symptomatic cyclops lesions were evaluated. Radiologically, signal-to-noise quotient (SNQ) and size of the synovium on MRI as well as anterior instability in Telos stress radiographs were evaluated.

RESULTS

A total of 64 patients were enrolled (42 in group R and 22 in group C). The IKDC score in group R (70) was better than that in group C (62; p < 0.05). One patient in group R had a cyclops lesion with clinical symptoms and arthroscopic excision was recommended. Radiologically, the SNQ, synovium area, and anterior instability on Telos radiography showed no difference between the two groups.

CONCLUSION

Remnant preservation with tensioning is a good option for ACL reconstruction without the development of a cyclops lesion.

Anterior cruciate ligament remnant-preserving and re-tensioning reconstruction: a biomechanical comparison study of three different re-tensioning methods in a porcine model

BACKGROUND

With the developments in the arthroscopic technique, anterior cruciate ligament (ACL) remnant-preserving reconstruction is gradually gaining attention with respect to improving proprioception and enhancing early revascularization of the graft. To evaluate the mechanical pull-out strength of three different methods for remnant-preserving and re-tensioning reconstruction during ACL reconstruction.

METHODS

Twenty-seven fresh knees from mature pigs were used in this study. Each knee was dissected to isolate the femoral attachment of ACL and cut the attachment. An MTS tensile testing machine with dual-screw fixation clamp with 30° flexion angle was used. The 27 specimens were tested after applying re-tensioning sutures with No. 0 polydioxanone (PDS), using the single stitch (n = 9), loop stitch (n = 9), and triple stitch (n = 9) methods. We measured the mode of failure, defined as (1) ligament failure (longitudinal splitting of the remnant ACL) or (2) suture failure (tearing of the PDS stitch); load-to-failure strength; and stiffness for the three methods. Kruskal-Wallis test and Mann-Whitney U-test were used to compare the variance of load-to-failure strength and stiffness among the three groups.

RESULTS

Ligament failure occurred in all cases in the single stitch group and in all but one case in the triple stitch group. Suture failure occurred in all cases in the loop stitch group and in one case in the triple stitch group. The load-to-failure strength was significantly higher with loop stich (91.52 ± 8.19 N) and triple stitch (111.1 ± 18.15 N) than with single stitch (43.79 ± 11.54 N) (p = 0.002). With respect to stiffness, triple stitch (2.50 ± 0.37 N/mm) yielded significantly higher stiffness than the other methods (p = 0.001).

CONCLUSIONS

The results suggested that loop stitch or triple stitch would be a better option for increasing the mechanical strength when applying remnant-preserving and re-tensioning reconstruction during ACL reconstruction.

Anterior cruciate ligament reconstruction using an anterior cruciate ligament stump

Introduction

Anterior cruciate ligament (ACL) injury always leads to knee pain and dysfunction for which surgical reconstruction is recommended, with good clinical results, but decreased postoperative proprioception also tends to occur. ACL stump (ACLS)-retaining ACL reconstruction and non-ACLS-retaining ACL reconstruction are the two surgical options.

Aim

To investigate the efficacy of retaining the ACLS in allograft reconstruction.

Material and methods

Thirty patients were retrospectively assigned to group A, ACLS-retaining ACL reconstruction; and group B, non-ACLS-retaining ACL reconstruction, and their data were analyzed. The knee function (Lysholm score and Tegner motion score) and proprioceptive function of the two groups were assessed and compared by postoperative reconstruction angle.

Results

The 30 patients were followed up for a mean 20 months. The mean Lysholm score in group A increased from 55.7 ±11.6 points preoperatively to 95.2 ±5.7 points postoperatively; that in group B increased from 56.7 ±11.3 points preoperatively to 94.6 ±7.2 points postoperatively. The mean Tegner motion score in group A was increased from 2.4 ±0.7 points preoperatively to 6.0 ±0.7 points postoperatively; that in group B increased from 2.73 ±0.96 points preoperatively to 6.24 ±0.48 points postoperatively; the postoperative scores did not differ significantly between the two groups. The proprioception was better in group A than in group B at 3, 6, and 12 months postoperatively (p < 0.05).

Conclusions

ACLS-retaining ACL reconstruction has good efficacy and the retained ACLS can benefit postoperative proprioception recovery at an early stage.

Remnant-preserving and re-tensioning technique to cover the graft in anterior cruciate ligament reconstruction

PURPOSE

This study set out to assess the clinical and radiographic outcomes and the extent of synovial coverage on second-look arthroscopy of anterior cruciate ligament (ACL) reconstruction using a remnant-preserving and re-tensioning technique to easily cover the graft with a remnant.

METHODS

Forty-three subjects with ACL rupture underwent remnant-preserving and re-tensioning ACL reconstruction using a free tendon Achilles allograft between 2011 and 2013. The clinical outcomes were assessed by Lysholm knee score, Lachman stress test, pivot shift test, International Knee Documentation Committee (IKDC) classification, and Tegner Activity Scale score. Side-to-side difference (SSD) was assessed on stress radiographs. The extent of synovialization was evaluated on second-look arthroscopy.

RESULTS

The mean Lysholm score was 54 ± 11 before surgery and 94 ± 5 at the last follow-up (p < 0.001). On Lachman stress test, 42 subjects had grade 0 or 1 on the Lachman stress test, and 42 had grade 0 or 1 on the pivot shift test. Forty-one subjects had IKDC classification A or B; two were classified as C or D. The median Tegner Activity Scale score was 6.5 (range 5-9) before injury and 6 (range 4-8) at the last follow-up (p = 0.048). Mean SSD on stress radiographs was 9.9 ± 2.6 mm preoperatively and 1.0 ± 1.7 mm at the last follow-up (p < 0.001). In the assessment of the extent of synovial coverage of the graft, 39 subjects were in group 1 (>75 %) for synovial coverage of the graft, three were in group 2 (50-75 %), and one was in group 4 (≤25 %).

CONCLUSIONS

The remnant-preserving and re-tensioning technique resulted in satisfying short-term results clinically and radiologically and good synovial coverage on second-look arthroscopy.

LEVEL OF EVIDENCE

Case series, Level IV.