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Tabatabaei Irani P, Ayati Firoozabadi M, Toofan H, Seyedtabaei SMM, Poursalehian M, Ghasemian M, Mortazavi SMJ. Simultaneous Tunnel Grafting and Anterior Cruciate Ligament Reconstructions Revision Using Double Suspensory Fixation: A Single-Stage Solution. Arthrosc Tech 2024; 13:102806. [PMID: 38312866 PMCID: PMC10837771 DOI: 10.1016/j.eats.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/20/2023] [Indexed: 02/06/2024] Open
Abstract
The anterior cruciate ligament (ACL) is often vulnerable to sports-related injuries, leading to numerous ACL reconstructions (ACLRs) annually in the United States. Although largely successful, these procedures face the risk of recurrent instability due to graft failure. ACLR failures are typically attributed to technical errors and patient-related factors, with improper positioning of the tibial and femoral tunnels as the most common technical mistake. Current 2-stage revision techniques involve primary bone grafting followed by secondary tendon graft placement, resulting in increased costs and extended rehabilitation times. This article proposes a single-stage revision strategy involving simultaneous tunnel grafting and ACLR revision. The method employs double suspensory fixation by adjustable loop buttons, thereby eliminating the dependence on metaphyseal bone stock for stable graft fixation. This new procedure may offer a more efficient and cost-effective approach, reducing the need for a second surgery and potentially allowing patients to return to normal activities more quickly.
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Affiliation(s)
- Pouya Tabatabaei Irani
- Joint Reconstruction Research Center, Orthopedic Surgery Department, Imam Khomeini Hospital, Tehran, Iran
| | - Mohammad Ayati Firoozabadi
- Joint Reconstruction Research Center, Orthopedic Surgery Department, Imam Khomeini Hospital, Tehran, Iran
| | - Hesam Toofan
- Joint Reconstruction Research Center, Orthopedic Surgery Department, Imam Khomeini Hospital, Tehran, Iran
| | | | - Mohammad Poursalehian
- Joint Reconstruction Research Center, Orthopedic Surgery Department, Imam Khomeini Hospital, Tehran, Iran
| | - Mohammadmahdi Ghasemian
- Joint Reconstruction Research Center, Orthopedic Surgery Department, Imam Khomeini Hospital, Tehran, Iran
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de Geofroy B, Ghabi A, Jouvion AX, Limouzin J, de Landevoisin E. Return to duty in military personnel after ACL reconstruction: STG versus ST4 double adjustable-loop device. Orthop Traumatol Surg Res 2022; 108:103378. [PMID: 35907624 DOI: 10.1016/j.otsr.2022.103378] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION ACL ligamentoplasty with a quadruple semitindosus graft (ST4) and double adjustable endobutton (ST4E) allow the preservation of the gracilis, which should allow more rapid recovery of soldiers following ACL reconstruction. However, the literature does not report any superiority of this technique over others in terms of return to duty and sport. HYPOTHESIS The ST4E system allows a return to military duty at least equivalent to the semitendinosus and gracilis graft (STG) with screw fixation. MATERIAL AND METHOD A total of 133 soldiers operated on for ACL were included, 64 by the STG technique and 69 by ST4E, with an average follow-up of 4 years. The return to duty was assessed, with recovery of skills between the first and second postoperative year, as well as the medico-administrative status at the last follow-up, muscle recovery through isokinetic tests, the sports level before/after surgery, and the failure rate. RESULTS No difference was found in the return to the soldier's previous post between the STG (64%) and the ST4E (64%) (p=0.97). No difference was found for the medico-administrative status at the last follow-up, but the short-term muscle recovery, the return to sport, and the failure rate were in favor of the ST4E group. DISCUSSION The ST4E, adjustable double endobutton system, is comparable to the STG technique in terms of return to military duty. On the other hand, it offers faster muscle recovery with better sports results and fewer patients on prolonged sick leave (PSL). This study demonstrated that two-thirds of soldiers operated on for anterior cruciate ligamentoplasty regained their initial aptitude regardless of the technique used, which influences the army's operational capacity and on disability pension requests after service. LEVEL OF EVIDENCE III, single center retrospective comparative study.
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Affiliation(s)
- Bernard de Geofroy
- Department of Orthopaedic surgery and traumatology, Military teaching hospital Laveran, 34, boulevard Laveran, 13013 Marseille, France.
| | - Ammar Ghabi
- Department of Orthopaedic surgery and traumatology, Military teaching hospital Laveran, 34, boulevard Laveran, 13013 Marseille, France
| | - Arnaud-Xavier Jouvion
- Physical Medicine and Rehabilitation Department, Military teaching hospital Laveran, 34, boulevard Laveran, 13013 Marseille, France
| | - Jacques Limouzin
- Department of Orthopaedic surgery and traumatology, Military teaching hospital Laveran, 34, boulevard Laveran, 13013 Marseille, France
| | - Emmanuel de Landevoisin
- Department of Orthopaedic surgery and traumatology, Military teaching hospital Laveran, 34, boulevard Laveran, 13013 Marseille, France; Department of Orthopaedic surgery and traumatology, Hôpital Privé Toulon Hyères-Saint-Roch, 99, avenue Saint-Roch, 83000 Toulon, France
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Toofan H, Tabatabaei Irani P, Ghadimi E, Ayati Firoozabadi M, Mortazavi SMJ. Simultaneous Arthroscopic Anterior Cruciate Ligament Reconstruction Using Double Suspensory Technique and Medial Open-Wedge, High Tibial Osteotomy. Arthrosc Tech 2022; 11:e2357-e2364. [PMID: 36632396 PMCID: PMC9827118 DOI: 10.1016/j.eats.2022.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/24/2022] [Indexed: 11/19/2022] Open
Abstract
Anterior cruciate ligament reconstruction (ACLR) is generally performed regardless of knee malalignments. However, there are some indications for either staged or simultaneous ACL reconstruction and realignment procedures, such as high tibial osteotomy (HTO). Simultaneous HTO-ACL reconstruction has the apparent benefit of a single surgical procedure with a faster recovery than a staged procedure, and it produces good clinical outcomes. Several techniques have been described for simultaneous ACLR and medial open wedge HTO. The tibial tunnel preparation and graft fixation are the most challenging part of the procedure. Recent studies on comparison of fixation of tibial tunnel graft using suspensory fixation versus bioabsorbable screws have shown superior results of more bone preservation and less graft rupture. We assumed suspensory fixation on the tibial side with bone preservation might be more reliable in patients who received ACLR and open wedge HTO at the same time. Therefore, we described our technique of simultaneous open-wedge HTO and ACLR using double suspensory graft fixation.
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Affiliation(s)
- Hesam Toofan
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pouya Tabatabaei Irani
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Seyed Mohammad Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran,Address correspondence to Javad Mortazavi, M.D., Joint Reconstruction Research Center, Tehran University of Medical Sciences, 1419733141, Tehran, Iran.
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Graf-Alexiou L, Karpyshyn J, Baptiste JJ, Hui C, Sommerfeldt M, Westover L. Biomechanical Strength of All-Inside ACL Reconstruction Grafts Using Side-to-Side and Backup Fixation. Orthop J Sports Med 2021; 9:23259671211006521. [PMID: 34026917 PMCID: PMC8120549 DOI: 10.1177/23259671211006521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background: The all-inside anterior cruciate ligament reconstruction (ACLR) procedure uses a single hamstring tendon folded twice and secured to itself to form a 4-stranded graft. There are several possible configurations for preparing the graft. Purpose: To investigate the biomechanical properties of a new graft preparation technique in comparison with 2 commonly used configurations. Study Design: Controlled laboratory study. Methods: Five porcine flexor tendons were prepared into the test graft configuration: side-to-side fixation with a backup fixation at the button loop (graft M). The test configuration was compared with the results of a previous study that included grafts with simple interrupted sutures (graft A; n = 5) and end-to-end fixation (graft C; n = 5). All grafts were subjected to the same mechanical testing protocol to determine the mean failure load, stiffness, rate of elongation, and total elongation during both cyclic loading and pull to failure. Differences between groups were evaluated. Results: Graft A had a significantly lower failure load (637 ± 99 N) compared with graft M (883 ± 66 N; P = .002) and graft C (846 ± 26 N; P = .002). Graft A also had significantly lower stiffness (166 ± 12 N/mm) compared with graft M (215 ± 8 N/mm; P < .001) and graft C (212 ± 11 N/mm; P < .001). Graft C had a significantly lower elongation during cyclic loading (3.42 ± 0.24 mm) compared with graft M (4.37 ± 0.74 mm; P = .026) and graft A (4.90 ± 0.88 mm; P = .006). The unsecured fixation was the weakest graft, with the lowest failure load and stiffness. The new side-to-side configuration and end-to-end configuration were equally strong. Conclusion: The new side-to-side configuration was not biomechanically superior to the end-to-end configuration; however, they were both stronger than unsecured fixation. Clinical Relevance: As the all-inside ACLR is gaining popularity, this study provides surgeons with a new method of preparing grafts and evaluates the method with respect to currently used configurations.
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Affiliation(s)
- Lucas Graf-Alexiou
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Jillian Karpyshyn
- Division of Orthopaedics, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jonelle Jn Baptiste
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Hui
- Division of Orthopaedics, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
| | - Mark Sommerfeldt
- Division of Orthopaedics, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsey Westover
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
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Bowes J, Mohamed N, Baptiste JJ, Westover L, Hui C, Sommerfeldt M. Biomechanical Comparison of Graft Preparation Techniques for All-Inside Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2020; 8:2325967120938039. [PMID: 32782906 PMCID: PMC7383687 DOI: 10.1177/2325967120938039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/04/2020] [Indexed: 01/13/2023] Open
Abstract
Background: All-inside anterior cruciate ligament reconstruction (ACLR) is an emerging technique used to treat ACL injuries. The all-inside technique uses a 4-stranded graft made from a single tendon that is looped on itself. The 4 strands of the graft must be secured to each other to become a closed-loop structure. Various suture configurations exist to secure the graft to adjustable loop devices, and there is a lack of data to support one technique over another. In addition to the primary sutures used to fasten the graft together, accessory sutures can be tied over the button as secondary fixation. Purpose: To evaluate biomechanical properties of 4-stranded grafts prepared in 5 different configurations. Study Design: Controlled laboratory study. Methods: Porcine flexor tendons (N = 25) were prepared in 5 different configurations (n = 5 tendons per group): simple-interrupted sutures (unsecured fixation), side-to-side fixation with and without secondary fixation, and end-to-end fixation with and without secondary fixation. The grafts were put through the same mechanical testing protocol (cyclic loading, pull to failure) to measure average load at graft failure, average displacement at failure, average stiffness, and average elongation rate. Differences between graft preparation techniques were investigated using 1-way analyses of variance (ANOVAs) with post hoc t tests (P < .05). Results: Significant 1-way ANOVAs for each biomechanical property were found. Unsecured fixation was the weakest graft preparation with the lowest stiffness (167 ± 12 N/mm), lowest ultimate failure load (637 ± 99 N), and highest elongation rate (0.0033 ± 0.0007 mm/s). End-to-end fixation without secondary fixation showed the highest ultimate failure load (846 ± 26 N), highest stiffness (212 ± 10 N/mm), and lowest rate of elongation (0.0025 ± 0.0001 mm/s). End-to-end fixation, both with and without secondary fixation, as well as side-to-side fixation with secondary fixation showed significantly higher ultimate failure loads than grafts with unsecured fixation. End-to-end fixation performed better than side-to-side fixation; however, for most variables, the difference was not statistically significant. Secondary fixation did not provide significant improvement. Conclusion: The all-inside ACL graft with simple-interrupted sutures is biomechanically inferior to a graft that has its free ends secured to the adjustable tibial loop. Adding secondary fixation to the tibial button does not significantly change the biomechanical properties. Further clinical studies are required to determine whether these findings translate into differences in clinical outcome. Clinical Relevance: All-inside ACLR is gaining popularity in hamstring ACL reconstructive techniques. These results provide surgeons with guidance on the best graft preparation method when using a single quadrupled hamstring tendon graft.
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Affiliation(s)
- Julia Bowes
- Division of Orthopaedics, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nada Mohamed
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Jonelle Jn Baptiste
- Department of Civil and Environmental Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsey Westover
- Department of Mechanical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Hui
- Division of Orthopaedics, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
| | - Mark Sommerfeldt
- Division of Orthopaedics, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada
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Quadruple Semitendinosus Graft Construct With Double Cortical Suspensory Fixation for Anterior Cruciate Ligament Reconstruction: A Biomechanical Study. Sci Rep 2018; 8:12835. [PMID: 30150641 PMCID: PMC6110799 DOI: 10.1038/s41598-018-30931-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/26/2018] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to evaluate the biomechanical properties of a graft construct with quadrupled Semitendinosus and two cortical buttons with adjustable loops concerning elongation, stiffness and resistance. A total of 15 fresh human cadaveric semitendinosus tendons were quadrupled over the two adjustable loops and stitched at the tibial tip with a cerclage type suture. They underwent pre-tensioning at 300 N for 2 minutes followed by cyclic loading (1000 cycles between 50–250 N) and finally a load-to-failure test. Statistical analysis was performed using SPSS Statistics software and groups were compared using a paired t-test, with a significance level set at α = 0.05. Graft construct elongation after pre-tensioning at 300 N was 12.8 mm (9.3 mm–16.5 mm) and mean cyclic elongation 0.4 mm (0.2 mm–0.9 mm), considered significant (p < 0,001). The resistance and stiffness values were respectively 849.46 N (649.30 N-1027.90 N) and 221.49 N (178,30 N – 276.10 N). Quadruple ST graft construct using two cortical buttons and adjustable loops showed a high stiffness and resistance with a very low elongation after cycling.
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Noronha JC, Oliveira JP. Inside-out Tibial Tunnel Drilling Technique for All-inside Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2018; 7:e373-e377. [PMID: 29868407 PMCID: PMC5982608 DOI: 10.1016/j.eats.2017.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 10/15/2017] [Indexed: 02/03/2023] Open
Abstract
All-inside anterior cruciate ligament reconstruction passed through a series of modifications over the past 2 decades, maintaining 2 common factors: half tunnels in both the femur and tibia and introduction of the graft into the knee through an arthroscopic portal. One of the disadvantages noted with this technique is the excessive cost of the instrumentation needed to perform it and its economic impact on the health care system. We describe a modification of the original technique, both maintaining the cortical bone in an intact state and avoiding the retrograde drill aiming device.
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Affiliation(s)
| | - João Pedro Oliveira
- Address correspondence to João Pedro Oliveira, M.D., Ph.D., Trindade Hospital, Rua da Trindade 115, 4000-541 Porto, Portugal.
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Li T, Yang ZZ, Deng Y, Xiao M, Jiang C, Wang JW. Indirect transfer of the sternal head of the pectoralis major with autogenous semitendinosus augmentation to treat scapular winging secondary to long thoracic nerve palsy. J Shoulder Elbow Surg 2017; 26:1970-1977. [PMID: 28688935 DOI: 10.1016/j.jse.2017.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Scapular winging resulting from long thoracic nerve palsy is uncommon but debilitating, and the choice of surgical treatment is inconsistent. The autogenous semitendinosus tendon plays a key role as an interposed tendon graft, although its use in the indirect transfer of the sternal head of the pectoralis major during the treatment of scapular winging has rarely been reported. MATERIALS AND METHODS A retrospective review was performed during a 9-year period from the clinical data of 26 cases (28 shoulders) with indirect transfer of the sternal head of the pectoralis major with the interposition of an autogenous semitendinosus tendon graft for dynamic stabilization of the scapula. The range of active movement (forward elevation, abduction, and external rotation), American Shoulder and Elbow Surgeons score, visual analog scale score, and complications were evaluated with a mean of 47 months of clinical follow-up. RESULTS Patients' active shoulder movements (forward elevation, abduction, and external rotation), American Shoulder and Elbow Surgeons score, and visual analog scale score showed significant improvements (P < .01). One seroma developed and resolved with extraction. Four shoulders had adhesive capsulitis and recovered after physiotherapy. There was no recurrence of scapular winging in any patient. CONCLUSION Timely treatment, often surgical, is vital to the recovery of scapular winging secondary to long thoracic nerve palsy. Our results suggest that indirect transfer of the sternal head of the pectoralis major with interposition of the autogenous semitendinosus tendon can effectively treat scapular winging due to long thoracic nerve palsy with limited sequelae. Widespread use of this technique is recommended.
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Affiliation(s)
- Tao Li
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Ze Z Yang
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Deng
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Ming Xiao
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuan Jiang
- Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin W Wang
- Shanghai Key Laboratory of Orthopaedic Implant, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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