Effect of Remnant Tissues on Outcomes of Anterior Cruciate Ligament Reconstruction at Follow-up Arthroscopy

Comparative efficacy and safety of different surgical approaches for the treatment of anterior cruciate ligament injury: a Bayesian network meta-analysis protocol

INTRODUCTION

Anterior cruciate ligament (ACL) rupture can be treated surgically or non-surgically, with several surgical interventions available at present. However, the comparatively effective surgical intervention with relatively fewer side effects remains unknown. This study aims to fill in this gap by conducting a Bayesian network meta-analysis (NMA) and provide a theoretical basis for the clinical application.

METHOD AND ANALYSIS

We will perform a Bayesian NMA and will include randomised controlled trials (RCTs) published in English or Chinese that compare surgical intervention (ie, standard ACL reconstruction, ACL remnant-preserving reconstruction and ACL repair with suture augmentation to conservative therapy or studies that compare one surgical intervention to another for the symptom relief and function recovery of patients with ACL rupture. Primary outcome will be the proportion of patients with symptomatic and functional improvement measured by the Knee Injury and Osteoarthritis Outcome Score before and 6 months after treatment, with scores ranging from 0 (worst) to 100 (best). Secondary outcomes will be knee-specific quality of life (ACL QoL), return to activity and level of sport participation (Tegner or modified Tegner score), health-related QoL (EuroQol Group 5-Dimension 5-Level, EQ-5D-5L), resource use, intervention-related complications and patient satisfaction. We have developed search strategies for PubMed, Embase, the Cochrane Library and Web of Science, retrieving RCTs that meet the inclusion criteria from database inception to 1 December 2023. The methodological quality of the included RCTs will be assessed based on the Cochrane risk of bias table. The relative ranking probability of the best intervention will be estimated using the surface under the cumulative ranking curve. The Bayesian NMA will be conducted by using WinBUGS V.1.4.3. The Grading of Recommendations Assessment, Development and Evaluation approach will be applied to determine our confidence in an overall treatment ranking from the NMA.

ETHICS AND DISSEMINATION

Ethical approval for this study is not required because no private or confidential patient data will be used in this study. Findings of this study would be disseminated through the publication in a peer-reviewed medical journal.

PROSPERO REGISTRATION NUMBER

CRD42023437115.

Reliability of the Tibial Spine Versus ACL Stump in Assisting Tibial Tunnel Positioning During ACL Reconstruction: Analysis Based on 3-Dimensional Computed Tomography Modeling

Background

Several techniques have been used by surgeons for anatomic tibial tunnel placement in anterior cruciate ligament (ACL) reconstruction, including the ACL stump positioning (ASP) technique and the tibial spine positioning (TSP) technique.

Purpose/Hypothesis

The purpose of this study was to evaluate whether bony landmarks (medial and lateral tibial spine [MLTS]) can be a reliable reference for improving the accuracy of tibial tunnel placement in anatomic single-bundle ACL reconstruction compared with the ACL stump. It was hypothesized that the MLTS would not be a reliable bony landmark for tibial tunnel placement.

Study Design

Cohort study; Level of evidence, 3.

Methods

The 3-dimensional computed tomography images of 111 patients who underwent ACL reconstruction between 2020 and 2021 were included in this study. For tibial tunnel placement, the ASP technique was used in 49 patients, and the TSP technique was used in 62 patients. The 3-dimensional computed tomography images were reconstructed to enable measurements of the locations of the MLTS and tunnel center based on a grid method. Statistical analysis was conducted to compare the MLTS location and tibial tunnel position as well as the accuracy (mean distance of each actual location from the anatomic center) and precision (standard deviation of the accuracy, indicating the reproducibility of the tunnel position) of the tunnel position between the ASP and TSP groups.

Results

Significant differences were observed between the ASP and TSP groups in terms of the tibial tunnel position on the mediolateral axis (46.7% ± 2.0% vs 45.9% ± 2.2%, respectively; P = .034), while no significant differences were found in terms of the accuracy (4.1% vs 4.6%, respectively; P = .259) or precision (2.1% vs 2.1%, respectively; P = .259) of tibial tunnel positioning between the 2 groups.

Conclusion

In anatomic single-bundle ACL reconstruction, the use of the MLTS for tibial tunnel placement achieved comparable accuracy and precision compared with the use of ACL remnants, supporting its role as a reliable bony landmark in tibial tunnel positioning.

Clinical application of modified Crain classification in the Design of Anterior Cruciate Ligament Reconstruction with remnant preservation

BACKGROUND

To investigate the clinical application of modified Crain classification in anterior cruciate ligament (ACL) reconstruction (ACLR) with remnant preservation.

METHODS

The subjects were 70 patients with ACL injury who underwent ACLR from May 2016 to June 2018, and their general data were recorded. They were randomly divided into modified remnant-preserved ACLR group (group M, n = 35) and non remnant-preserved ACLR group (group N, n = 35). ACLR program with remnant preservation was designed based on modified Crain classification in group M, while ACL remnants were completely cleaned during ACLR in group N. Subsequently, the two groups were compared in terms of operation time, complications, as well as Lysholm score, international knee documentation committee (IKDC) score and positive rate of Lachman test of knee joint before operation and at 3, 6 and 12 months after operation.

RESULTS

Both the groups showed good postoperative efficacy, and none had complications like limited knee extension or cyclops lesion. The comparison results found that group M (72.49 ± 7.64 min) required longer operation time than group N (66.06 ± 6.37 min) (P < 0.05). Lysholm score and IKDC score at 3, 6 and 12 months after operation in the two groups were significantly higher than those before operation (P < 0.05); group M had higher Lysholm score and IKDC score at 3 months and 6 months after operation compared with group N (P < 0.05). Additionally, the positive rate of Lachman test at 3, 6 and 12 months after operation in both groups was significantly lower than that before operation (P < 0.05), but there was no significant difference between group M and group N.

CONCLUSION

With the modified Crain classification, many remnant-preserved reconstruction techniques can be rationally used to completely preserve the remnant ligament tissue during operation and improve knee joint function and joint stability with few complications.

Effect of a new remnant-preserving technique with anatomical double-bundle anterior cruciate ligament reconstruction on MRI-based graft maturity: a comparison cohort study

PURPOSE

To investigate the effects of a new remnant-preserving double-bundle anterior cruciate ligament reconstruction (ACLR) technique, focused on avoiding remnant damage and preserving continuity of remnants, on graft maturity using magnetic resonance imaging (MRI).

METHODS

A total of 169 patients were divided into three groups: 41 in the preservation group, 70 in the resection group, and 58 in the absent group. In the preservation group, rather than passing the graft through the remnant tissue, the graft was reconstructed such that the anteromedial and posterolateral bundles sandwiched the remnant to avoid damage to the remnant and maintain its continuity. Based on 1-year postoperative MRI, the grafts were divided into three regions: distal, middle, and proximal. The signal/noise quotient (SNQ) of each region of interest was calculated to evaluate the signal intensity of the graft and was compared among the three groups. Additionally, to identify factors influencing graft maturity, a multiple regression analysis was performed with SNQ as the dependent variable and patient demographics, bone morphology, and surgical factors as independent variables.

RESULTS

In a three-group comparison of mean SNQs, the distal region was 3.3 ± 3.4, 8.9 ± 8.3, and 9.0 ± 8.6 (p < 0.001), the middle region was 5.3 ± 3.7, 10.9 ± 11.1, and 11.3 ± 10.2 (p < 0.001), and the proximal region was 6.8 ± 4.5, 11.1 ± 8.8, and 11.7 ± 10.8 (p = 0.017), in order of the preservation, resection, and absent groups, respectively. That indicated that the remnant-preserving ACLR was more hypointense than ACLR with remnant resection or absent in all three regions. Multiple regression analysis showed that remnant preservation remained the relevant factor affecting SNQ of the graft at the distal and middle levels.

CONCLUSION

The new remnant-preserving anatomic double-bundle ACLR had significantly better graft maturity, measured by SNQ on MRI, than the remnant resection and absent groups. The remnant procedure was the relevant factor affecting graft maturity.

LEVEL OF EVIDENCE

Level III.