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Kemler B, Coladonato C, Sonnier JH, Campbell MP, Darius D, Erickson BJ, Tjoumakaris FP, Freedman KB. Evaluation of Failed ACL Reconstruction: An Updated Review. Open Access J Sports Med 2024; 15:29-39. [PMID: 38586217 PMCID: PMC10998505 DOI: 10.2147/oajsm.s427332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/23/2024] [Indexed: 04/09/2024] Open
Abstract
Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.
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Affiliation(s)
- Bryson Kemler
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Carlo Coladonato
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Michael P Campbell
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | - Danielle Darius
- Department of Education, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Brandon J Erickson
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
| | | | - Kevin B Freedman
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA, USA
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Lamplot JD, Smith BL, Slone HS, Hauck OL, Wijdicks CA. Tape-Reinforced Graft Suturing and Retensioning of Adjustable-Loop Cortical Buttons Improve Quadriceps Tendon Autograft Biomechanics in Anterior Cruciate Ligament Reconstruction: A Cadaveric Study. Arthroscopy 2024; 40:136-145. [PMID: 37355187 DOI: 10.1016/j.arthro.2023.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/13/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE To investigate the biomechanical effects of tape-reinforced graft suturing and graft retensioning for all-soft tissue quadriceps tendon (ASTQT) anterior cruciate ligament reconstruction (ACLR) in a full-construct human cadaveric model. METHODS Harvested cadaveric ASTQT grafts were assigned to either (1) double-suspensory adjustable-loop cortical button device (ALD) fixation in which both graft ends were fixed with a suspensory fixation device with (n = 5) or without (n = 5) tape-reinforced suturing or (2) single-suspensory distal tendon fixation in which only the patellar end was fixed with an ALD (n = 5) or fixed-loop cortical button device (FLD) (n = 5). All specimens were prepared using a No. 2 whipstitch technique, and tape-reinforced specimens had an integrated braided tape implant. Graft preparation time was recorded for double-suspensory constructs. Samples were tested on an electromechanical testing machine using a previously published protocol simulating rehabilitative kinematics and loading. RESULTS Tape-reinforced graft suturing resulted in greater graft load retention after cycling (11.9% difference, P = .021), less total elongation (mean [95% confidence interval (CI)], 5.57 mm [3.50-7.65 mm] vs 32.14 mm [25.38-38.90 mm]; P < .001), greater ultimate failure stiffness (mean [95% CI], 171.9 N/mm [158.8-185.0 N/mm] vs 119.4 N/mm [108.7-130.0 N/mm]; P < .001), and less graft preparation time (36.4% difference, P < .001) when compared with unreinforced specimens. Retensioned ALD constructs had less cyclic elongation compared with FLD constructs (mean total elongation [95% CI], 7.04 mm [5.47-8.61 mm] vs 12.96 mm [8.67-17.26 mm]; P = .004). CONCLUSIONS Tape-reinforced graft suturing improves time-zero ASTQT ACLR construct biomechanics in a cadaveric model with 83% less total elongation, 44% greater stiffness, and reduced preparation time compared with a whipstitched graft without tape reinforcement. ALD fixation improves construct mechanics when compared with FLD fixation as evidenced by 46% less total elongation. CLINICAL RELEVANCE Tape-reinforced implants and graft retensioning using ALDs improve time-zero ACLR graft construct biomechanics in a time-zero biomechanical model. Clinical studies will be necessary to determine whether these implants improve clinical outcomes including knee laxity and the incidence of graft rupture.
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Affiliation(s)
| | - Benjamin L Smith
- Department of Orthopedic Research, Arthrex, Naples, Florida, U.S.A
| | - Harris S Slone
- Department of Orthopedic Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Oliver L Hauck
- Department of Orthopedic Research, Arthrex, Naples, Florida, U.S.A
| | - Coen A Wijdicks
- Department of Orthopedic Research, Arthrex, Naples, Florida, U.S.A
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Marcaccio SE, Morrissey PJ, Testa EJ, Fadale PD. Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction. JBJS Rev 2023; 11:01874474-202310000-00002. [PMID: 37812667 PMCID: PMC10558152 DOI: 10.2106/jbjs.rvw.23.00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).» The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.» QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.» The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.» There are emerging data that the QT autograft is a viable option in revision ACLR.
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Affiliation(s)
- Stephen E. Marcaccio
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Patrick J. Morrissey
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Edward J. Testa
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul D. Fadale
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Gawish HM, Hashish MH, Elghaish MAE. Anterior Cruciate Ligament Reconstruction Using Fixed Loop All-Inside (FLAI) Technique. Arthrosc Tech 2023; 12:e1843-e1852. [PMID: 37942108 PMCID: PMC10628345 DOI: 10.1016/j.eats.2023.06.017] [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: 04/08/2023] [Accepted: 06/22/2023] [Indexed: 11/10/2023] Open
Abstract
The aim of this surgical technical note is to provide a more secure option to prevent possible graft loosening with all-inside anterior cruciate ligament (ACL) reconstruction. A triple strategy is used. First, a fixed loop cortical device is used on the femoral side. Second, an internal brace augmentation for ACL graft is employed to prevent graft loosening during early postoperative period. Lastly, tying off the sutures of tibial adjustable loop after retensioning to secure its locking mechanism from slippage.
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Affiliation(s)
| | - Mahmoud Hammam Hashish
- Department of Orthopedic Surgery and Traumatology, Ibrahim Obeid Specialized Hospital, Alexandria, Egypt
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Heng CHY, Wong JYS, Tan AHC. Both Adjustable and Fixed Loop Hamstring Tendon Graft Fixation Have Similar Clinical and Patient-Reported Outcomes in Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100775. [PMID: 37583621 PMCID: PMC10424139 DOI: 10.1016/j.asmr.2023.100775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/15/2023] [Indexed: 08/17/2023] Open
Abstract
Purpose This study aims to compare the outcomes of fixed-loop device (FLD) vs adjustable-loop device (ALD) graft fixation with up to 2-year follow-up in patients undergoing primary anterior cruciate ligament reconstruction (ACLR) in a predominantly Asian setting. Methods Prospectively collected outcome measures as well as clinical records of patients who underwent primary ACLR using either FLD or ALD fixation of hamstring tendon autograft performed by a single surgeon were reviewed. The surgeon in this study used a fixed-loop device from 2018 to 2019 and then changed to adjustable loop from 2019 to 2020. Suspensory fixation was performed on the femoral side, and aperture (interference screw) fixation was performed on the tibial side. Outcome measures included knee range of motion, KT-1000 arthrometer testing, Lysholm knee score, and Tegner activity scale. Patients were assessed preoperatively and postoperatively at regular intervals of 6, 12, and 24 months. Results A total of 105 patients were identified. Forty-six were excluded due to incomplete follow-up data, so 59 patients with full 2-year follow-up were included in the final study group. Both groups (FLD vs ALD) were similar in demographics except for age (P = .042). Out of 105, there were 59 patients remaining in the study group with 2-year follow-up data. No significant differences were observed between the 2 groups at all respective testing intervals. Conclusions FLDs and ALDs for suspensory fixation of hamstring tendon autograft in ACLR had similar clinical outcomes with a minimum of 2-year follow up. There is no evidence of graft loosening from loop lengthening. Level of Evidence Level III, retrospective comparative trial.
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Affiliation(s)
| | - Joel Yat Seng Wong
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Bachmaier S, Monaco E, Smith PA, Frank RM, Matzkin EG, Wijdicks CA. Biomechanical Comparison of 3 Adjustable-Loop Suspensory Devices for All-Inside ACL Reconstruction: A Time-Zero Full-Construct Model. Orthop J Sports Med 2023; 11:23259671231201461. [PMID: 37786476 PMCID: PMC10541758 DOI: 10.1177/23259671231201461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 10/04/2023] Open
Abstract
Background Little is known about the stability of adjustable-loop devices (ALDs) for anterior cruciate ligament (ACL) reconstruction (ACLR). Purpose To evaluate the stabilization behavior of 3 different types of ALDs for all-inside ACLR in a full-construct surgical technique-based manner. Study Design Controlled laboratory study. Methods The femoral and tibial devices of Ultrabutton (Smith & Nephew), Infinity (Conmed), and TightRope II (Arthrex) were applied to quadrupled bovine tendon grafts (n = 8 each) with tibial-sided traction applied (350 N) for graft tensioning in a simulated fully extended knee. Knotless femoral graft fixation was based on either a suture-locking device (SLD; Ultrabutton), button-locking device (BLD; Infinity), or dual-locking device (DLD; TightRope II). All constructs were progressively loaded (50 N/500 cycles) from 50 to 300 N for 3000 cycles (0.75 Hz), including complete unloading situations and pull to failure (50 mm/min). Construct elongation, stiffness, and ultimate load were analyzed. Results BLD showed significantly greater initial elongation (-2.69 ± 0.15 mm) than DLD (-3.19 ± 0.21 mm; P < .001) but behaved similarly to SLD (-2.93 ± 0.23 mm). While DLD and SLD had the smallest initial elongation at the same significance level, they behaved opposite to each other with gradually increasing peak loading. At the end of testing, DLD had the lowest (-0.64 ± 0.32 mm) and SLD the highest (3.41 ± 1.01 mm) total elongation (P < .003 for both). SLD displayed significantly higher dynamic elongation (6.34 ± 0.23 mm) than BLD (3.21 ± 0.61 mm) and DLD (2.56 ± 0.31 mm) (P < .001 for both). The failure load of BLD (865.0 ± 183.8 N) was significantly lower (P < .026) compared with SLD and DLD (>1000 N). The predominant failure mode was suture rupture and tibial bone breakage with button subsidence (SLD, n = 4). No significant difference in stiffness between constructs was found. Conclusion While DLD successfully restricted critical construct elongation, BLD partially and SLD completely exceeded the clinical failure threshold (>3 mm) of plastic elongation with loop lengthening during increasing cyclic peak loading with complete unloading. Higher failure loads of SLD and DLD implants (>1000 N) were achieved at similar construct stiffness to BLD. Clinical Relevance A detailed biomechanical understanding of the stabilization potential is pertinent to the continued evolution of ALDs to improve clinical outcomes.
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Affiliation(s)
| | - Edoardo Monaco
- Department of Orthopaedics and Traumatology Sant’Andrea Hospital, University of Rome La Sapienza, Rome, Italy
| | | | - Rachel M. Frank
- University of Colorado School of Medicine, Aurora, Colorado, USA
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Kocazeybek E, Meric E, Ersin M, Ekinci M, Kizilkurt T, Sahinkaya T, Polat G. Clinical outcomes of three different techniques using adjustable-loop fixation in arthroscopic single-bundle anterior cruciate ligament reconstruction: A prospective randomized clinical trial. Knee 2023; 43:208-216. [PMID: 37467701 DOI: 10.1016/j.knee.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 06/14/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Adjustable femoral suspensory fixation for anterior cruciate ligament reconstruction (ACLR) become popular in recent years. The purpose of this study is to evaluate and compare the clinical outcomes of three different techniques using an adjustable-loop fixation in ACRL. METHODS This study included 38 patients who underwent ACLR using the adjustable-loop device for femoral fixation between January 2018 and November 2021. All the participants were randomly assigned to a standard (group 1), retensioning (group 2), retensioning and knot tying (group 3). Clinical outcome parametres included Tegner - Lysholm Score, IKDC score, KT-1000 displacement and isokinetic muscle function tests. RESULTS Overall, 38 patients (group 1: n = 13 [mean ± SD age, 30.1 ± 9.40 years]; group 2: n = 12 [mean ± SD age, 24.5 ± 7.79 years]; group 3 = 13 [mean ± SD age, 27.8 ± 6.59 years]) were included in the final analysis. The follow-up period was 9.7 ± 1.2; 9.5 ± 1.7 and 10 ± 1.5 months for groups 1, 2 and 3 respectively. From preoperatively to postoperatively, the mean Tegner-Lysholm scores improved significantly in all three groups (group 1: from 63.5 to 95.6; group 2: from 61.58 to 98.5; group 3: from 66.6 to 95.9, P < 0.0001 for all), as did the mean IKDC score (group 1: 53.9-88.8; group 2: 61.3-94.9; group 3: 60.7-94.6 (P < 0.0001 for all). CONCLUSION The retensioning with or without knot-tying method is believed to increase stability in graft fixation. However, there were no significant differences in clinical outcomes in each technique.
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Affiliation(s)
- Emre Kocazeybek
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey.
| | - Emre Meric
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey
| | - Mehmet Ersin
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Ekinci
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Taha Kizilkurt
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey
| | - Turker Sahinkaya
- Istanbul Faculty of Medicine, Department Sports Medicine, İstanbul, Turkey
| | - Gokhan Polat
- Istanbul Faculty of Medicine, Department of Orthopedics and Traumatology, Istanbul University, İstanbul, Turkey
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Hyodo K, Kanamori A, Watanabe R, Ainoya T, Kikuchi N, Arai N, Yamazaki M. Does loop length change after anterior cruciate ligament reconstruction with adjustable loop cortical suspension device?: Observation of the hamstring graft completely filling the femoral tunnel. J Exp Orthop 2023; 10:67. [PMID: 37393331 DOI: 10.1186/s40634-023-00629-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/03/2023] Open
Abstract
PURPOSE The adjustable loop cortical suspension device (ALD) is a useful femoral fixation device in anterior cruciate ligament (ACL) reconstructions, but the possibility of loosening has been suggested. The purpose of this study was to evaluate the elongation of an adjustable loop and the position of the hamstring graft inside the femoral socket. METHODS The subjects were 33 patients who underwent ACL reconstruction with a hamstring tendon. The graft was fixed using ALD and completely filled the femoral socket. Magnetic resonance images were taken one week and one year after the operation. The loop length, femoral socket length, and graft length inside the socket were measured and statistically compared with the clinical outcomes. RESULTS The loop length one week after surgery was 18.9 ± 4.4 mm, and 1 year after surgery was 19.9 ± 4.5 mm (P < 0.001). The gap between the top of the graft and femoral socket was 0.9 ± 1.8 mm one week after surgery and 1.3 ± 1.7 mm one year after surgery (P = 0.259). At one week post-operation, a gap was found in nine patients (27.3%). The loop length and gap did not strongly correlate with clinical findings. CONCLUSION ACL reconstruction using ALD showed a gap between the graft and femoral socket at the one week post-operation mark in 27.3% of participants. One year after the surgery, there were cases where the gap increased and/or decreased, but the elongation of the loop was 1 mm on average. Our findings suggest that ALD is clinically safe to use; however, has the possibility of initial loop elongation and non-uniform changes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kojiro Hyodo
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
- Department of Orthopaedic Surgery, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, Ibaraki, 300-2622, Japan.
| | - Akihiro Kanamori
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Orthopaedic Surgery, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, Ibaraki, 300-2622, Japan
| | - Ryunosuke Watanabe
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Takeshi Ainoya
- Department of Orthopaedic Surgery, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, Ibaraki, 300-2622, Japan
| | - Naoya Kikuchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Norihito Arai
- Department of Orthopaedic Surgery, Tsukuba Memorial Hospital, 1187-299 Kaname, Tsukuba, Ibaraki, 300-2622, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Chapman G, Hannah J, Vij N, Liu JN, Morrison MJ, Amin N. Biomechanical Comparison of Adjustable-Loop Femoral Cortical Suspension Devices for Soft Tissue ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671221146788. [PMID: 36814772 PMCID: PMC9940176 DOI: 10.1177/23259671221146788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Background Several new adjustable-loop devices (ALDs) for anterior cruciate ligament reconstruction (ACLR) have not been tested in vitro. Purpose To compare the biomechanical performances of 5 ALDs under a high cyclic load and forces representative of the return-to-play conditions seen in the recovering athlete. Study Design Controlled laboratory study. Methods A total of 10 devices for each of 5 chosen ALDs (UltraButton [Smith & Nephew], RigidLoop [DePuy Mitek], ProCinch [Stryker], TightRope [Arthrex], and ToggleLoc [Biomet]) were tested in a device-only model. The devices were secured to a servohydraulic test machine and preconditioned from 10 to 75 N at a rate of 0.5 Hz for 20 cycles. They were then subjected to high cyclic forces (100-500 N for 4000 cycles) and subsequently pulled to failure at 50 mm/min. The preconditioning displacement, permanent deformation, cumulative peak displacement, stiffness coefficient, and load to failure data were collected. Results The UltraButton displayed the greatest preconditioning displacement (0.22 ± 0.20 mm), followed by the RigidLoop (0.11 ± 0.03 mm), ProCinch (0.07 ± 0.04 mm), TightRope (0.07 ± 0.02 mm), and ToggleLoc (0.02 ± 0.03 mm). The TightRope displayed the greatest permanent deformation (3.19 ± 1.03 mm) followed by the UltraButton (2.14 ± 0.92 mm), ToggleLoc (2.02 ± 1.09 mm), RigidLoop (1.67 ± 0.1 mm), and ProCinch (1.38 ± 0.18 mm). The TightRope displayed the greatest cumulative peak displacement (3.69 ± 1.03 mm) followed by the UltraButton (2.46 ± 0.92 mm), ToggleLoc (2.37 ± 1.08 mm), RigidLoop (2.01 ± 0.1 mm), and ProCinch (1.75 ± 0.19 mm). The UltraButton displayed the largest stiffness coefficient (1347.22 ± 136.33 N/mm) followed by the RigidLoop (1325.4 ± 116.37 N/mm), ToggleLoc (1216.62 ± 131.32 N/mm), ProCinch (1155.56 ± 88.04), and TightRope (848.48 ± 31.94). The ToggleLoc displayed the largest load to failure (1874.42 ± 101.08 N) followed by the RigidLoop (1614.12 ± 129.11 N), UltraButton (1391.69 ± 142.04 N), ProCinch (1384.85 ± 58.62 N), and TightRope (991.8 ± 51.1 N.). Conclusion The 5 ALDs exhibited different biomechanical properties. None of them had peak cumulative displacements for which the confidence interval lay above 3 mm, thus no single device was determined to have a higher rate of clinical failure compared with the others. Clinical Relevance ALD choice may affect biomechanics after ACLR.
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Affiliation(s)
- Garrett Chapman
- Spine and Joint Institute, Redlands Community Hospital, Redlands, California, USA
| | - John Hannah
- Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Neeraj Vij
- University of Arizona College of Medicine–Phoenix, Phoenix, Arizona, USA.,Neeraj Vij, BS, University of Arizona College of Medicine–Phoenix, 475 N. 5th Street, Phoenix, AZ 85004, USA ()
| | - Joseph N. Liu
- Loma Linda University School of Medicine, Loma Linda, California, USA.,Department of Orthopedic Surgery, Keck Hospital of University of Southern California, Los Angeles, California, USA
| | - Martin J. Morrison
- Renown Pediatric Orthopedics and Scoliosis, University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | - Nirav Amin
- Jerry L. Pettis Memorial Veterans Hospital, Loma Linda Healthcare System, Loma Linda, California, USA
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Horstmann H, Karkosch R, Plagge J, Smith T, Petri M. All-Arthroscopic Refixation of an Osteochondral Femoral Avulsion of the Anterior Cruciate Ligament with a Laxity-Minimizing Suture. Open Access J Sports Med 2023; 14:21-27. [PMID: 37163159 PMCID: PMC10164377 DOI: 10.2147/oajsm.s397512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/14/2023] [Indexed: 05/11/2023] Open
Abstract
Purpose Torn anterior cruciate ligaments in children are rare injuries. The incidence of concomitant avulsion fracture in the skeletally immature patient is high. Reports of arthroscopic reconstruction in the literature are sparse. Case Presentation We present the case of a femoral avulsion fracture of the anterior cruciate ligament in a seven-year-old girl. The patient underwent arthroscopic refixation with DynacordTM Suture and Suture Button. At a follow-up of 8 weeks, the patient had free range of motion and a stable knee, with a negative Lachman- and Pivot-Shift-test in particular. Conclusion Refixation of femoral avulsion fracture can lead to good results. Open physes and size of the knee should be taken into account. Anatomic reconstruction is compulsory to receive bone on bone healing.
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Affiliation(s)
- Hauke Horstmann
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
- Correspondence: Hauke Horstmann, Anna-von-Borries-Straße 1-7, Hannover, 30625, Germany, Tel +49 511 5354 568, Fax +49 511 5354 685, Email
| | - Roman Karkosch
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Jochen Plagge
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Tomas Smith
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
| | - Maximilian Petri
- Department of Orthopedic Surgery, Hannover Medical School, Hannover, Germany
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11
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Benca E, van Knegsel KP, Zderic I, Caspar J, Strassl A, Hirtler L, Fuchssteiner C, Gueorguiev B, Windhager R, Widhalm H, Varga P. Biomechanical evaluation of an allograft fixation system for ACL reconstruction. Front Bioeng Biotechnol 2022; 10:1000624. [PMID: 36406221 PMCID: PMC9670106 DOI: 10.3389/fbioe.2022.1000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
The purpose of this study was to compare the biomechanical stability, especially graft slippage of an allograft screw and a conventional interference screw for tibial implant fixation in ACL reconstruction. Twenty-four paired human proximal tibia specimens underwent ACL reconstruction, with the graft in one specimen of each pair fixed using the allograft screw and the other using the conventional interference screw. Specimens were subjected to cyclic tensile loading until failure. The two fixation methods did not show any statistical difference in load at graft slippage (p = 0.241) or estimated mean survival until slippage onset (p = 0.061). The ultimate load and the estimated mean survival until failure were higher for the interference screw (p = 0.04, and p = 0.018, respectively). Graft displacement at ultimate load reached values of up to 7.2 (interference screw) and 11.3 mm (allograft screw). The allograft screw for implant fixation in ACL reconstruction demonstrated comparable behavior in terms of graft slippage to the interference screw but underperformed in terms of ultimate load. However, the ultimate load, occurring at progressive graft slippage, may not be considered a direct indicator of clinical failure.
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Affiliation(s)
- Emir Benca
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
- AO Research Institute Davos, Davos Platz, Switzerland
- *Correspondence: Emir Benca,
| | - Kenneth P. van Knegsel
- AO Research Institute Davos, Davos Platz, Switzerland
- Department of Orthopedics and Trauma Surgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Davos Platz, Switzerland
| | - Jan Caspar
- AO Research Institute Davos, Davos Platz, Switzerland
| | - Andreas Strassl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Christoph Fuchssteiner
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | | | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Harald Widhalm
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Varga
- AO Research Institute Davos, Davos Platz, Switzerland
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Additional tying on the adjustable-loop device improves the outcomes of anterior cruciate ligament reconstruction using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2022; 30:3673-3680. [PMID: 35445328 DOI: 10.1007/s00167-022-06936-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to verify the efficacy of a novel technique for additional tying on the adjustable-loop device to prevent stress concentration on the graft loop end and gradual loop lengthening. METHODS A total of 124 patients who underwent anterior cruciate ligament reconstruction using hamstring autografts from 2014 to 2017 were included in this retrospective study. After 1:1 propensity score matching, two groups were formed (group I: 50 patients without tying vs. group II: 50 patients with tying). Anterior laxity was evaluated using side-to-side differences. Tunnel length, loop length, and graft-tunnel gap were measured using follow-up magnetic resonance imaging. The signal-to-noise ratio was calculated at the loop end, loop inner side, tunnel entrance, and graft mid-substance. The clinical outcomes were assessed using the International Knee Documentation Committee score, Lysholm score, pivot shift test, and Lachman test. RESULTS The average follow-up period was 63.2 ± 4.8 and 53.8 ± 11.9 months in groups I and II, respectively. Anterior laxity showed that side-to-side differences improved significantly 6 months postoperatively in both the groups. Although the anterior laxity improved in group II (2.9 ± 1.0 to 1.6 ± 0.8, p < 0.001), it deteriorated in group I (2.5 ± 1.5 to 3.3 ± 1.3 mm, p < 0.001) at the final follow-up. The graft-tunnel gap was significantly larger in group I (p < 0.001). The signal-to-noise ratios of the loop end and loop inner side were significantly higher in group I (p < 0.001 and p = 0.020, respectively). The clinical outcomes at the final follow-up were not significantly different between the groups. CONCLUSION The additional tying on the adjustable-loop device was not superior to the control group in clinical stability examination or outcome. However, it was effective in anterior laxity measured by stress radiographs, preventing stress on the adjustable-loop device, and gradual graft loop lengthening. LEVEL OF EVIDENCE Level III.
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Comparison of biomechanical analysis of four different tibial tunnel fixations in a bovine model. Knee 2022; 38:193-200. [PMID: 36095927 DOI: 10.1016/j.knee.2022.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 06/16/2022] [Accepted: 08/24/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND To determine the ideal fixation technique for an ACL reconstruction with a hamstring graft, multiple studies have been undertaken to define the initial biomechanical properties of tibial fixation. PURPOSE The aim of this study was to compare the biomechanical properties of tibial fixation methods by creating single or hybrid systems. METHODS Bovine tibias and forefoot digital extensor tendons were prepared with four different tibial anterior cruciate ligament fixation methods and compared biomechanically. Fixation materials included polyethylene Ultrabraid high-strength sutures, Biosure interference screws (Smith and Nephew, Memphis, TN, USA), staples (Smith and Nephew, Richards Regular Fixation Staples without Spikes, Memphis, TN, USA), and knotless suture anchors (Multifix-S PEEK) (Smith and Nephew, Memphis, TN, USA). Four groups (n = 5 specimens) were established - group I: single fixation with interference screws; group II: single fixation with knotless anchors; group III: hybrid fixation with interference screws and staples; group IV: hybrid fixation with interference screws and knotless anchors. Each specimen underwent evaluations for cyclic displacement, cyclic stiffness, initial loading strength, ultimate failure load, pull-out displacement, and pull-out stiffness. RESULTS All specimens completed cyclic loading and load-to-failure. The cyclic displacement in group II, which had a single fixation, indicated significantly greater elongation compared with the other groups (P = 0.002). The hybrid systems were more rigid than the single systems in terms of cyclic stiffness, and no statistically significant difference was observed between the hybrid systems (P = 0.461). Group IV was significantly superior in terms of the ultimate failure load (P = 0.004). No statistically significant differences were noted between the groups for pull-out displacement or pull-out stiffness. CONCLUSION Single fixation with bioscrews as an in-tunnel tibia fixation method was as successful as hybrid systems. Multifix-S PEEK knotless suture anchors, which can be combined with bioscrews, can be a superior fixation alternative due to its flexibility and ultimate failure load values.
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Comparison of the mechanical properties and mechanical damages to tendon tissue in three suspensory fixation techniques. Asia Pac J Sports Med Arthrosc Rehabil Technol 2022; 30:1-8. [PMID: 35949263 PMCID: PMC9343929 DOI: 10.1016/j.asmart.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 03/26/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022] Open
Abstract
Background Anterior cruciate ligament (ACL) injury is the most common traumatic injury to the knee joint. Suspensory fixation has become popular in ACL reconstruction because of its high primary stability, less invasiveness, and surgical convenience. There are two common types of suspensory fixation devices: those with fixed-length and those with adjustable-length loops. Owing to structural differences and differences in initial tensioning techniques, it is expected that mechanical property and damage to the tendons will vary from device to device; however, no literature has examined this so far. The main purpose of this study was to evaluate the damage caused to the tendon by three different suspensory fixation devices. An effective mechanical test was carried out as a prerequisite. Methods First, the mechanical properties of simple loop device (SLD) as fixed-length loop device, first-generation, and second-generation adjustable devices (AD1 and AD2) as adjustable-length loop devices were tested (isolated device testing). Second, each device was tested using bovine extensor tendons (specimen testing). Cyclic testing included 2000 cycles; the devices were subsequently displaced until failure, and the ultimate tensile strength was determined using isolated device testing. Six samples of 3 devices were used in each testing experiment. After specimen testing, the surface structure of the tendon was evaluated quantitatively using optical coherence tomography (OCT) and our original histological scoring system. Results During isolated device testing, SLD demonstrated the least cyclic displacement, followed by AD1 and AD2. The highest ultimate tensile strength was observed in AD2, followed by SLD and AD1. In specimen testing, the least cyclic displacement was observed in SLD, followed by AD1 and AD2. Histologically, AD1 demonstrated a significantly lower score, with damaged surface morphology, than SLD and AD2. OCT values were significantly higher, with a more disturbing tendon surface structure, in AD1 than in SLD and AD2. Conclusions The first-generation adjustable loop device exhibited greatest graft tissue damage at the suspensory site in a clinically relevant setting. The thinner adjustable loop mechanism may have elevated graft damage by frictional stresses during loop adjustment or by repetitive tensioning stresses.
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Anterior cruciate ligament reconstruction with short hamstring grafts: the choice of femoral fixation device matters in controlling overall lengthening. Knee Surg Sports Traumatol Arthrosc 2022; 30:2215-2226. [PMID: 34796366 DOI: 10.1007/s00167-021-06783-6] [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: 05/04/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose was to conduct an independent biomechanical study comparing the main types of femoral fixation adapted to short hamstring grafts in anterior cruciate ligament (ACL) reconstruction surgery and to validate their performance. METHODS The ACLip® Femoral, ToggleLoc™ Ziploop (TLZ), and Tape Locking Screw (TLS®) implants were tested in tension in the following three different configurations: implant alone, implant fixed on the femur without graft, and implant fixed on the femur with graft. Grafts alone were also tested. The femurs and the 4-strand semi-tendinosus grafts were derived from porcine and human models, respectively. Each set-up was subjected to the same protocol of creep (50 N for 30 s), cycling (1000 cycles between 50 and 250 N, 1 Hz), and load to failure (50 mm/min). RESULTS A total of 93 tests were performed (30 ACLip®, 30 TLZ, 20 TLS®, and 13 ST4 alone). For the implants tested with femur and graft, the mean ± standard deviation (SD) overall elongation at 250 N after cycling was 5.2 ± 0.2 mm, 8.4 ± 2.1 mm, and 5.3 ± 0.8 mm, the mean ± SD ultimate load to failure was 736 ± 116 N, 830 ± 204 N, and 640 ± 242 N, and the mean ± SD stiffness at the 1000th cycle was 185 ± 15 N/mm, 172 ± 19 N/mm, and 178 ± 21 N/mm for ACLip®, ToggleLoc™, and TLS® devices, respectively. There was no significant difference between the implants except for post-cycling elongation between TLZ and the other two implants (p < 0.05). CONCLUSION The choice of femoral fixation device plays a decisive role in controlling the overall lengthening of an ACL reconstruction using a short hamstring graft. All implants validated the specifications in terms of ultimate load to failure, the TLS® system had, however, a low performance limit. ToggleLoc™ with adjustable loop should no longer be used on the femur side; instead the other types of fixation should be used to improve the overall elongation control.
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Khan MJ, Asif N, Aziz MH, Raza A, Anwar S, Nuhmani S, Alghadir AH, Khan M. Does an Adjustable-Loop Device Loosen following ACL Reconstruction with a Hamstring Graft? A Retrospective Study with a Follow-Up of Two Years. J Clin Med 2022; 11:jcm11133648. [PMID: 35806933 PMCID: PMC9267585 DOI: 10.3390/jcm11133648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
Arthroscopic anatomic anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for an ACL tear and requires the use of fixed or adjustable-loop devices to fix a femoral-side graft. Although the adjustable mechanism is designed to provide one-way tensioning, there is a concern that the adjustable loop will loosen and lengthen during cyclic loads, creating graft laxity. The present paper is a retrospective study of patients who underwent ACLR with the fixation of a hamstring graft with an adjustable loop on the femoral side from November 2016 to October 2018. The knee’s functional outcome was evaluated using an International Knee Documentation Committee (IKDC) score, Lysholm score, Lachman test, and pivot shift test. The patients were assessed preoperatively and finally postoperatively after two years of surgery. Thirty-two patients were analyzed. Significant improvement was obtained in the final clinical outcome of the patients. Twenty-seven patients (84.4%) were Lachman negative, and twenty-eight patients (87.5%) were pivot shift test negative, the mean Lysholm score was 96.91, and the IKDC score was 91.47 (p < 0.001). There was no infection, graft failure, or flexion restriction. Arthroscopic ACLR with an adjustable-loop suspensory device is a successful fixation method for femoral-side graft fixation and offers a similar functional outcome as with fixed-loop devices.
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Affiliation(s)
- Mohammad Jesan Khan
- Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh 202002, Uttar Pradesh, India; (M.J.K.); (N.A.); (M.H.A.); (A.R.)
| | - Naiyer Asif
- Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh 202002, Uttar Pradesh, India; (M.J.K.); (N.A.); (M.H.A.); (A.R.)
| | - Mohd Hadi Aziz
- Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh 202002, Uttar Pradesh, India; (M.J.K.); (N.A.); (M.H.A.); (A.R.)
| | - Ariz Raza
- Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh 202002, Uttar Pradesh, India; (M.J.K.); (N.A.); (M.H.A.); (A.R.)
| | - Shahzad Anwar
- Department of TB and Chest, Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh 202002, Uttar Pradesh, India;
| | - Shibili Nuhmani
- Department of Physical Therapy, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Dammam 34221, Saudi Arabia;
| | - Ahmad H. Alghadir
- Rehabilitation Research Chair, Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, Saudi Arabia;
| | - Masood Khan
- Rehabilitation Research Chair, Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh 11433, Saudi Arabia;
- Correspondence: or ; Tel.: +966-11-469-8544
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Adjustable-loop implants are non-inferior to fixed-loop implants for femoral fixation in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 31:1723-1732. [PMID: 35737010 DOI: 10.1007/s00167-022-07034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Button implants with an adjustable-loop device (ALD) are often used in anterior cruciate ligament reconstruction (ACLR). Clinical research comparing ALDs with fixed-loop devices (FLD) has mainly been conducted in small patient populations with short follow-up times. To determine whether ALDs are safe to use in ACLR, a non-inferiority study with a large sample population and a long follow-up period would be beneficial. This study compared ALDs with FLDs to determine non-inferior revision surgery rates, knee stability, and patient-reported outcomes (PROM) in ACLRs. METHODS This non-inferiority register-based cohort study was conducted using data from the Danish Knee Ligament Reconstruction Registry (DKRR). A total of 12,723 patients > 15 years of age with primary ACLR using hamstring tendon autografts and either an FLD or ALD for femoral fixation were included: 9719 patients were in the FLD group, and 3014 patients were in the ALD group. The primary outcome was revision ACLR with a non-inferiority margin for ALDs at 4% at the 2-year follow-up. The secondary outcomes were anterior and rotatory knee stability and PROMs based on the Knee Injury and Osteoarthritis Outcome Score (KOOS) at the 1-year follow-up. RESULTS The crude cumulative revision rates in ALD implants at 2 and 5 years were 2.1% (95% CI 1.62-2.68) and 5.0% (95% CI 4.22-5.96), respectively. In the FLD group, the rates were 2.2% (95% CI 1.89-2.48) at 2 years and 4.7% (95% CI 4.31-5.20) at 5 years. The 1-year side-to-side differences were 0.97 mm (95% CI 0.90-1.03) in the ALD group and 1.45 mm (95% CI 1.41-1.49) in the FLD group. In the FLD group, 13% had a positive pivot shift, and in the ALD group, 6% had a positive pivot shift. There were no differences in KOOS. CONCLUSION ALDs were non-inferior to FLDs regarding revision rates, knee stability, and patient-reported outcomes. Based on this conclusion, ALDs are safe to use for femoral fixation in ACLR. LEVEL OF EVIDENCE III.
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Arakgi ME, Burkhart TA, Hoshino T, Degen R, Getgood A. Biomechanical Comparison of Three Suspensory Techniques for all Soft Tissue Central Quadriceps Tendon Graft Fixation. Arthrosc Sports Med Rehabil 2022; 4:e843-e851. [PMID: 35747631 PMCID: PMC9210367 DOI: 10.1016/j.asmr.2021.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 12/01/2021] [Indexed: 10/27/2022] Open
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Wicks ED, Stack J, Rezaie N, Zeini IM, Osbahr DC. Biomechanical Evaluation of Suture Tape Internal Brace Reinforcement of Soft Tissue Allografts for ACL Reconstruction Using a Porcine Model. Orthop J Sports Med 2022; 10:23259671221091252. [PMID: 35547611 PMCID: PMC9083057 DOI: 10.1177/23259671221091252] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Internal bracing of anterior cruciate ligament (ACL) surgery is a newer concept gaining popularity. Purpose/Hypothesis: To assess the biomechanical performance of soft tissue ACL reconstruction allografts reinforced with suture tape. It was hypothesized that load to failure would increase and cyclic displacement would decrease at time zero in the constructs reinforced with internal brace suture tape compared with those without suture tape augmentation. Study Design: Controlled laboratory study. Methods: We performed ACL reconstruction on porcine knees using bovine extensor tendon soft tissue allografts: 10 knees without (control) and 10 knees with (reinforced) suture tape reinforcement. An all-inside reconstruction technique was utilized with retrograde tunnel creation. An adjustable-loop device was used for femoral and tibial fixation of all grafts. The suture tape was placed through the tension loop in the femoral fixation construct and independently fixed in the tibia with an interference screw anchor. For each specimen, the authors recorded ultimate load, yield load, stiffness, cyclic displacement, and mode of failure. Outcomes between groups were compared using the Student t test. Results: There was a 33% decrease in mean cyclic displacement in the specimens with reinforced grafts (reinforced vs control: 3.9 ± 0.7 vs 5.8 ± 1.5 mm; P = .001). The reinforced grafts also had a 22% higher mean ultimate load (921 ± 180 vs 717 ± 122 N; P = .008) and a 25% higher mean yield load (808 ± 201 vs 602 ± 155 N; P = .020). There was no significant difference in stiffness between the reinforced versus nonreinforced grafts (136 ± 16 vs 132 ± 18 N/mm; P = .617). Three of the 10 control specimens failed at the graft, compared with 1 of 10 reinforced grafts. All other constructs in both groups failed at the tibial fixation site. Conclusion: Suture tape reinforcement of soft tissue grafts significantly decreased cyclic displacement while significantly increasing ultimate and yield loads without increasing graft construct stiffness during biomechanical testing at time zero in a porcine animal model. Clinical Relevance: The improved biomechanical performance of suture tape–reinforced graft constructs could allow patients to participate in earlier advancement of aggressive rehabilitation and potentially reduce failure rates as graft remodeling progresses.
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Affiliation(s)
- Eric D. Wicks
- Orlando Health Orthopedics and Sports Medicine, Orlando, Florida, USA
| | - Jason Stack
- Orlando Health Orthopedics and Sports Medicine, Orlando, Florida, USA
| | - Nima Rezaie
- Orlando Health Orthopedics and Sports Medicine, Orlando, Florida, USA
| | | | - Daryl C. Osbahr
- Orlando Health Orthopedics and Sports Medicine, Orlando, Florida, USA
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Chandru V, M.S. S, J.S. ST, Nair RR. Comparison of Fixed- and Variable-Loop Button Fixation in Arthroscopic Anterior Cruciate Ligament Reconstruction. Cureus 2022; 14:e24218. [PMID: 35602836 PMCID: PMC9117830 DOI: 10.7759/cureus.24218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction With the advent of fixed- and variable-loop suspensory fixation devices for arthroscopic anterior cruciate ligament (ACL) reconstruction, a maximum number of grafts can be placed within the femoral tunnel. Although several biomechanical studies have been conducted comparing these two devices, only a few comparative clinical studies are available. This study was conducted to compare the functional outcomes of arthroscopic ACL reconstruction using fixed-loop devices with those of variable-loop devices by determining their effect on graft laxity clinical assessment and patient-reported outcome scores. Methodology Out of 32 patients (27 males and five females) who underwent primary ACL reconstruction using tripled hamstring autograft, fixed- and variable-loop devices were used for 13 and 19 patients, respectively. Thirteen patients in each group were evaluated over a period of one year using the Lysholm knee score. Six patients in the variable-loop group had only six months of follow-up. Anterior drawer and Lachman tests were performed at six-month and one-year follow-ups, respectively. Results The mean ages of patients in the fixed- and variable-loop groups were 34.5\begin{document}\pm\end{document}11 and 34.1\begin{document}\pm\end{document}9.1 years, respectively. The Lysholm knee score at six weeks was fair in 7.7% of the patients in the fixed-loop group when compared to 52.6% of those in the variable-loop group (p<0.05). All the other parameters were comparable between the two groups. One patient in each group had ligament laxity at six-month and one-year follow-up, respectively. Conclusion This study showed no statistically significant difference in graft laxity or functional outcomes of arthroscopic ACL reconstruction with fixed- and variable-loop devices, except for a better patient-reported outcome score in the variable-loop group at six weeks of follow-up. Hence, there is a need for more comparative studies in this direction.
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Matsuo T, Kusano M, Uchida R, Tsuda T, Toritsuka Y. Anatomical rectangular tunnel anterior cruciate ligament reconstruction provides excellent clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2022; 30:1396-1403. [PMID: 34014338 DOI: 10.1007/s00167-021-06609-5] [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: 01/22/2021] [Accepted: 05/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to prospectively evaluate the clinical outcomes following anatomical rectangular tunnel anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone (BTB) graft using an adjustable-length femoral cortical fixation device with enough patients and a high follow-up rate. METHODS This study included 125 patients who underwent anatomical rectangular tunnel ACL reconstruction with a BTB graft. A BTB TightRope® was used for femoral graft fixation. Clinical evaluations were performed more than 2 years after surgery using the International Knee Documentation Committee (IKDC) Form. Patients interviewed by telephone were only subjectively evaluated. The side-to-side difference in anterior laxity at a manual maximum force was measured using the KT-2000 Arthrometer®. RESULTS Among the 125 patients, 99 were ultimately included and 26 were lost to follow-up (follow-up rate: 79%). Eight patients had re-tear (re-tear rate: 8%) and six patients had ACL injuries to the contralateral knee. Three patients did not follow our rehabilitation programme. One patient suffered septic arthritis. These 18 patients were considered ineligible for clinical evaluations. Therefore, clinical evaluations were performed in 81 of the 99 patients (64 were available for direct follow-up and 17 were available for a telephone interview). The follow-up period was 30 ± 10 months (range 24-68 months). According to the IKDC subjective assessment, 48 (59%) and 33 (41%) knees were graded as normal and nearly normal, respectively. A loss of extension (3°-5°) was observed in five patients (8%), whereas one patient (2%) exhibited a loss of flexion (3°-5°). The Lachman test was negative in 63 patients (98%). The pivot shift test was negative in 59 patients (92%). The side-to-side difference in KT value was 0.4 ± 0.7 mm (range - 1-4 mm). CONCLUSION Anatomical rectangular tunnel ACL reconstruction with a BTB graft using an adjustable-length femoral cortical fixation device provided excellent clinical outcomes both subjectively and objectively more than 2 years after surgery, whereas 8 of the 99 patients had re-tear of the graft. The adjustable-length femoral cortical fixation device could be safely used in anatomical rectangular tunnel ACL reconstruction with a BTB graft. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tomohiko Matsuo
- Department of Orthopedic Sports Medicine, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki, Hyogo, 660-0064, Japan
| | - Masashi Kusano
- Department of Orthopedics, Japan Community Healthcare Organization Osaka Hospital, 4-2-78, Fukushima, Osaka, 553-0003, Japan
| | - Ryohei Uchida
- Department of Orthopedic Sports Medicine, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki, Hyogo, 660-0064, Japan
| | - Takayuki Tsuda
- Department of Orthopedic Sports Medicine, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki, Hyogo, 660-0064, Japan
| | - Yukiyoshi Toritsuka
- School of Health and Sports Sciences, Mukogawa Women's University, 6-46, Ikebirakicho, Nishinomiya, Hyogo, 663-8558, Japan.
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22
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Kehribar L, Yılmaz AK, Karaduman E, Kabadayı M, Bostancı Ö, Sürücü S, Aydın M, Mahiroğulları M. Post-Operative Results of ACL Reconstruction Techniques on Single-Leg Hop Tests in Athletes: Hamstring Autograft vs. Hamstring Grafts Fixed Using Adjustable Cortical Suspension in Both the Femur and Tibia. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58030435. [PMID: 35334611 PMCID: PMC8950666 DOI: 10.3390/medicina58030435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 01/13/2023]
Abstract
Background and Objectives: Anterior cruciate ligament (ACL) tears are common injuries in the athletic population, and accordingly, ACL reconstruction (ACLR) is among the most common orthopedic surgical procedures performed in sports medicine. This study aims to compare the semitendinosus/gracilis (ST/G) and ACL hamstring grafts fixed using adjustable cortical suspension in both the femur and tibia (MAI) ACLR techniques. We aimed to compare the results of single-leg hop tests (SLHT) applied in different directions and limb symmetry indices (LSI) in athletes with a 6-month post-operative ACLR history. Materials and Methods: A retrospective cohort of 39 athletes from various sports branches who underwent MAI (n = 16) and ST/G (n = 23) ACLR techniques by the same surgeon were evaluated. The knee strength of the participants on the operated and non-operated sides was evaluated with five different SLHTs. The SLHT included the single hop for distance (SH), triple hop for distance (TH), crossover triple hop for distance (CH), medial side triple hop for distance (MSTH), and medial rotation (90°) hop for distance (MRH). Results: There was a significant improvement in the mean Lysholm, Tegner, and IKDC scores in the post-operative leg for both techniques (p < 0.05) compared to the pre-operative levels. When there was a difference between the SH of the operative and the non-operative legs in the ST/G technique (p < 0.05), there was no significant difference in the other hop distance for both ST/G and MAI (p > 0.05). There was no difference between the techniques regarding the LSI scores. Conclusions: The fact that our research revealed similar LSI rates of the SLHTs applied in different directions in the ST/G and MAI techniques assumes that the MAI technique can be an ACLR technique which can be functionally used in athletes.
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Affiliation(s)
- Lokman Kehribar
- Department of Orthopaedics and Traumatology, Samsun University, Samsun 55090, Turkey;
| | - Ali Kerim Yılmaz
- Faculty of Yaşar Doğu Sport Sciences, Ondokuz Mayıs University, Samsun 55270, Turkey; (E.K.); (M.K.); (Ö.B.)
- Correspondence: or ; Tel.: +90-542-495-3737
| | - Emre Karaduman
- Faculty of Yaşar Doğu Sport Sciences, Ondokuz Mayıs University, Samsun 55270, Turkey; (E.K.); (M.K.); (Ö.B.)
| | - Menderes Kabadayı
- Faculty of Yaşar Doğu Sport Sciences, Ondokuz Mayıs University, Samsun 55270, Turkey; (E.K.); (M.K.); (Ö.B.)
| | - Özgür Bostancı
- Faculty of Yaşar Doğu Sport Sciences, Ondokuz Mayıs University, Samsun 55270, Turkey; (E.K.); (M.K.); (Ö.B.)
| | - Serkan Sürücü
- Department of Orthopaedics, University of Missouri, Kansas City, MO 64108, USA;
| | - Mahmud Aydın
- Haseki Training and Research Hospital, Orthopaedics and Traumatology, Istanbul 34096, Turkey;
| | - Mahir Mahiroğulları
- Memorial Sisli Hospital, Orthopaedics and Traumatology, Istanbul 34384, Turkey;
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Comparison of fixed versus adjustable-loop device for femoral graft fixation in anterior cruciate ligament reconstruction. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Asif N, Khan MJ, Haris KP, Waliullah S, Sharma A, Firoz D. A prospective randomized study of arthroscopic ACL reconstruction with adjustable- versus fixed-loop device for femoral side fixation. Knee Surg Relat Res 2021; 33:42. [PMID: 34863318 PMCID: PMC8642980 DOI: 10.1186/s43019-021-00124-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 11/07/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Suspensory devices are extensively used in the management of anterior cruciate ligament (ACL) tear. They include fixed- and adjustable-loop devices. There are only a few studies comparing the efficacy of these two devices in the available literature. Therefore, the aim of this study is to compare clinical outcomes between the adjustable-loop device (group I) and fixed-loop device (group II). Materials and methods This was a prospective randomized study. Both groups were equivalent in demographic, preoperative, and intraoperative variables. Twenty-three patients underwent femoral side graft fixation with adjustable-loop and 20 with fixed-loop devices. Four patients were lost to follow-up. Assessment of clinical outcome was done with International Knee Documentation Committee (IKDC) score, Lysholm score, and knee stability tests (Lachman test and pivot shift test). Patient evaluation was performed preoperatively and finally postoperatively 2 years after surgery. Results Postoperative IKDC scores of group I and II were 91.9 ± 3.6 and 91.5 ± 3.6, respectively, and Lysholm scores were 91.0 ± 3.6 and 91.4 ± 3.5, respectively, after 2 years; however, the difference in the outcomes was statistically insignificant (p > 0.05). Twenty patients (87%) in group I and 17 patients (85%) in group II had a negative Lachman test (p = 0.8). Twenty-two patients (95.7%) in group I and 19 patients (95%) in group II had a negative pivot shift test (p = 0.9). Conclusion ACL reconstruction with fixed- and adjustable-loop suspensory devices for graft fixation gives equivalent and satisfactory clinical results. Level of evidence 1.
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Affiliation(s)
- Naiyer Asif
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| | - Mohammad Jesan Khan
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India.
| | - K P Haris
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| | - Shah Waliullah
- Department of Orthopaedics, KGMU, Lucknow, Uttar Pradesh, India
| | - Anubhav Sharma
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| | - Danish Firoz
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
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25
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Kayaalp ME, Collette R, Kruppa P, Flies A, Schaser KD, Wulsten D, Duda GN, Becker R, Kopf S. A Higher Initial Tensioning Force of an ACL Graft Results in a Higher Graft Force After Screw Fixation Irrespective of the Screw Diameter: A Biomechanical Study. Am J Sports Med 2021; 49:3825-3832. [PMID: 34672786 DOI: 10.1177/03635465211047861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The intra-articular graft force (IAGF) in anterior cruciate ligament reconstruction decreases quickly over the first hours after surgery. Nevertheless, little is known about whether the initial extra-articular tensioning force (EATF) and screw diameter affect the graft force after fixation. PURPOSE To investigate the effects of different EATFs on the IAGF of a soft tissue graft fixated via a bioabsorbable interference screw over 100 minutes after fixation and to evaluate the effects of different screw diameters within 1 mm of the tunnel width during this process. STUDY DESIGN Controlled laboratory study. METHODS In this biomechanical study, a porcine quadruple-strand soft tissue graft was inserted into the tibial anterior cruciate ligament tunnel. On the extra-articular side, 3 loads were applied during retrograde insertion of the bioabsorbable interference screw (6, 7, and 8 mm): 20 N, 80 N, and maximum manual EATF (Nmax). Nine study groups consisting of 10 tibiae each were created to test the effects of different EATFs and screw sizes. The IAGF was measured up to 100 minutes after the EATF was released. RESULTS An EATF ≥80 N resulted in a larger IAGF for all screw sizes at 100 minutes. There were no significant associations between the IAGF at 100 minutes and different screw diameters. Inserting the tibial screw significantly increased the IAGF in all groups, with the exception of Nmax applied in groups with 7- or 8-mm screws. When compared with the end of screw insertion, after the release of the EATF, the IAGF dropped by 55% to 77 % at 100 minutes. CONCLUSION An initial EATF ≥80 N is associated with a significantly larger IAGF at 100 minutes in this cadaveric simulation. The IAGF in soft tissue grafts decreased substantially after the retrograde placement of an interference screw. A recommendation regarding screw diameter with respect to the IAGF cannot be given. CLINICAL RELEVANCE To obtain a higher residual graft force after bioabsorbable interference screw fixation, an initial EATF ≥80 N should be applied according to this model. The significant decrease in graft force after the release of the EATF indicates that the reconstructed knee cannot be mechanically stabilized after the surgery.
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Affiliation(s)
- M Enes Kayaalp
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School Theodor Fontane, Germany.,Istanbul Kartal Training and Research Hospital, Orthopaedics and Traumatology, Istanbul, Turkey
| | - Robert Collette
- Department of Anesthesiology and Intensive Care, University Medical Centre Schleswig-Holstein, Lübeck, Germany.,Julius-Wolff-Institute, Berlin Institute of Health and Charité-University Medicine Berlin, Berlin, Germany
| | - Philipp Kruppa
- Julius-Wolff-Institute, Berlin Institute of Health and Charité-University Medicine Berlin, Berlin, Germany.,Department of Plastic and Reconstructive Microsurgery / Handsurgery, Ernst von Bergmann Clinic, Potsdam, Germany
| | - Anne Flies
- Julius-Wolff-Institute, Berlin Institute of Health and Charité-University Medicine Berlin, Berlin, Germany
| | - Klaus-Dieter Schaser
- Department of Orthopaedic and Trauma Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Dag Wulsten
- Julius-Wolff-Institute, Berlin Institute of Health and Charité-University Medicine Berlin, Berlin, Germany
| | - Georg N Duda
- Julius-Wolff-Institute, Berlin Institute of Health and Charité-University Medicine Berlin, Berlin, Germany
| | - Roland Becker
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School Theodor Fontane, Germany
| | - Sebastian Kopf
- Center of Orthopaedics and Traumatology, University Hospital Brandenburg an der Havel, Brandenburg Medical School Theodor Fontane, Germany
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26
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Gibbs CM, Winkler PW, Tisherman RT, Chan CK, Diermeier TA, Debski RE, Musahl V. Continuous-Loop Tape Technique Has Greater Stiffness and Less Elongation Compared With Tied-Suture Fixation of Full-Thickness All-Soft Tissue Quadriceps Tendon Autografts. Orthop J Sports Med 2021; 9:23259671211054108. [PMID: 34790834 PMCID: PMC8591645 DOI: 10.1177/23259671211054108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background Many graft fixation techniques are utilized for full-thickness soft tissue quadriceps tendon autografts during anterior cruciate ligament reconstruction (ACLR). Purpose To determine the tensile properties of all-soft tissue quadriceps tendon graft fixation using a tied-suture versus continuous-loop tape technique. It was hypothesized that the continuous-loop tape technique would have less cyclic elongation and greater ultimate load to failure and stiffness compared with a commonly used tied-suture technique. Study Design Controlled laboratory study. Methods Sixteen fresh-frozen human knee specimens were used to harvest a full-thickness all-soft tissue quadriceps tendon graft; half were secured using a Krackow suture technique with 2 braided sutures, and half were secured using a continuous-loop tape suspensory fixation button with a rip-stop stitch. Cyclic and permanent elongation, toe- and linear-region stiffness, and ultimate load were determined. Statistical analysis was performed at P <.05. Results The tied-suture fixation group demonstrated significantly higher permanent elongation (11.7 ± 3.6 vs 4.2 ± 1.0 mm, P < .001) and cyclic elongation (5.9 ± 1.3 vs 2.0 ± 0.4 mm, P < .001) compared with the continuous-loop tape fixation group. There was a significantly higher linear-region stiffness with continuous-loop tape fixation compared with tied-suture fixation (98.8 ± 12.7 vs 85.5 ± 7.5 N/mm, P = .022). No significant difference in ultimate load between groups (517.1 ± 149.2 vs 465.6 ± 64.6 N) was found. The mode of failure was tendon pull-through for the continuous-loop tape group and suture breakage in the tied-suture group (P < .001). Conclusion Continuous-loop tape fixation is superior to tied-suture fixation in regard to elongation and stiffness for all-soft tissue quadriceps tendon grafts, but there was no significant difference in ultimate load. Clinical Relevance Continuous-loop tape fixation of all-soft tissue quadriceps tendon grafts for ACLR is a valid technique with superior tensile properties.
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Affiliation(s)
- Christopher M Gibbs
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philipp W Winkler
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Robert T Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Calvin K Chan
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Theresa A Diermeier
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Orthopaedic Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Richard E Debski
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Massey PA, Caldwell C, Vauclin CP, Hoefler AK, Berken D, Barton RS, Solitro GF. The Ideal Cortical Button Location on the Lateral Femur for Anterior Cruciate Ligament Suspensory Fixation is 30 mm Proximal to the Lateral Epicondyle. Arthrosc Sports Med Rehabil 2021; 3:e1255-e1262. [PMID: 34712961 PMCID: PMC8527268 DOI: 10.1016/j.asmr.2021.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/31/2021] [Indexed: 11/08/2022] Open
Abstract
Purpose To determine the ideal location for anterior cruciate ligament (ACL) suspensory cortical button placement on the lateral femur with the highest failure load and to establish the relationship of tunnel diameter and cortical thickness on load to failure. Methods Computed tomography (CT) data were obtained from 45 cadaveric distal femurs. A Cartesian coordinate system was established along the lateral femur with the lateral epicondyle (LE) as a reference point. Locations 0, 20 and 30 mm from the LE along lines 0°, 25°, 50°, and 75° posterioproximal from the axial plane were created. Tunnels connecting from each location to the center of the ACL footprint were simulated. Cortical thickness and long axis diameter of the oval cortical holes were determined for each location. Based on the CT data, custom drill guides were created and used to drill 4.5 mm tunnels at each lateral femur location to the ACL footprint on the cadaver femurs. Cortical buttons were placed at each location and pulled using a servohydraulic testing system. The correlation of tunnel diameter and cortical thickness to button failure load were analyzed using a regression analysis. Results Significant differences were found for failure load (P<.0001) and cortical thickness between the locations tested (P<.0001). The location 30 mm proximal from the LE and 75⁰ from the axial plane had the highest failure load of 573 N. A regression analysis (R2 = .15) indicated that the cortical thickness was significantly correlated with load to failure (P <.0001), whereas the long-axis diameter was not (P = .33). Conclusion The ideal cortical button location on the lateral femur for ACL suspensory fixation was located 30 mm proximal from the lateral epicondyle, based on this area’s high failure load. Oblique tunnel drilling of this proximal location may cause a larger long-axis diameter cortical hole, but the cortex is also thicker, which is more closely correlated with failure load. Clinical Relevance Different ACL suspensory cortical button locations on the lateral femur have different failure loads based on the cortical thickness of the bone supporting the button. It is important for surgeons to understand which drilling techniques place the button in a proximal and posterior location, especially if the bone quality of the patient is of concern.
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Affiliation(s)
- Patrick A Massey
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Christopher Caldwell
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Cameron P Vauclin
- School of Medicine, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Anna K Hoefler
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - David Berken
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - R Shane Barton
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Giovanni F Solitro
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
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Takahashi T, Watanabe S, Ito T. Current and future of anterior cruciate ligament reconstruction techniques. World J Meta-Anal 2021; 9:411-437. [DOI: 10.13105/wjma.v9.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.
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Affiliation(s)
- Toshiaki Takahashi
- Department of Sports and Health Science, Ehime University, Matsuyama 790-8577, Ehime, Japan
| | - Seiji Watanabe
- Department of Orthopedic Surgery, Ehime University Graduate School of Medicine, Toon 791-0295, Ehime, Japan
| | - Toshio Ito
- Department of Orthopaedic Surgery, Murakami Memorial Hospital, Saijo 793-0030, Ehime, Japan
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29
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印 钰, 梅 宇, 王 泽, 宋 首, 刘 鹏, 何 鹏, 武 文, 谢 兴. [Lengths of the fixed loop and the adjustable loop in the coarse bone tunnel were compared to influence the widening of the femoral bone tunnel and the function of the knee joint]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:883-890. [PMID: 34650289 PMCID: PMC8517680 DOI: 10.19723/j.issn.1671-167x.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the effects of two different femoral cortical suspension devices (fixation loop and adjustable loop) on tunnel widening and knee function in patients following anterior cruciate ligament reconstruction for 12 months. METHODS A total of 60 patients who had undergone anterior cruciate ligament reconstruction were included in this study. According to the length of the loop(n)[n= total length of loop-(total length of femoral tunnel-total length of coarse tunnel)] in the rough bone tunnel, the patients were divided into A (adjustable loop was 0 mm in the coarse bone tunnel), B (fixation loop was greater than 0 mm and less than or equal to 10 mm in the coarse bone tunnel) and C (fixation loop was greater than 10 mm in the coarse bone tunnel) groups, of which 11 cases were in group A, 27 cases in group B and 22 cases in group C. In the three-dimensional reconstruction of the knee joint with multi-slice spiral CT, the widening of the bone tunnel in the three groups was compared. At the same time, IKDC, Lysholm and Tegner scores of the patients in the three groups were compared. RESULTS There were differences in the widening degree of the femoral canal among groups A, B and C, and the median difference of the widening degree of the femoral tunnel 12 months and immediately after the surgery was A < B < C. The difference of femoral canal widening in group A was significantly different from that in groups B and C (P < 0.05).According to the linear regression the relationship between the difference of the width of the femoral canal and the change of the length (n) of the loop in the coarse canal, it was found that there was a linear relationship between the value of n and the difference of the width of the bone canal. With the increase of the value of n, the difference of the width of the bone canal gradually became larger. The median difference of the width of the middle and superior tunnel was negative, while the median difference of the width of the middle and inferior tunnel was positive. During the follow-up, we found that there were no statistical differences in IKDC, Lysholm and Tegner scores among the three groups one year after surgery (P > 0.05). CONCLUSION Twelve months after surgery, compared with group B (fixed loop group) and group C (fixed loop group), group A (adjustable loop group) had less bone tunnel widening.In groups A, B and C, as the length of the loop in coarse bone tunnel gradually increased, the width of bone tunnel became more significant. At the end of 12 months follow-up after anterior cruciate ligament reconstruction, the medial and inferior femoral tunnel was significantly wider than immediately after surgery, and the medial and superior femoral tunnel had gradually begun to undergo tendon-bone healing. There was no significant difference in knee function scores among groups A, B, and C in the follow-up 12 months after surgery.
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Affiliation(s)
- 钰 印
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 宇 梅
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 泽刚 王
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 首一 宋
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 鹏飞 刘
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 鹏峰 何
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 文杰 武
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
| | - 兴 谢
- />北京大学第三医院运动医学科, 北京大学运动医学研究所, 运动医学关节伤病北京市重点实验室, 北京 100191Department of Sports Medicine, Peking University Third Hospital; Institute of Sports Medicine of Peking University; Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
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30
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On Measuring Implant Fixation Stability in ACL Reconstruction. SENSORS 2021; 21:s21196632. [PMID: 34640951 PMCID: PMC8513052 DOI: 10.3390/s21196632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/29/2021] [Accepted: 10/02/2021] [Indexed: 11/17/2022]
Abstract
Numerous methods and devices are available for implant fixation in anterior cruciate ligament (ACL) reconstruction. Biomechanical data indicate high variability in fixation stability across different devices. This study aims to provide a better insight into measuring the structural characteristics and mechanical behavior of ACL implant fixations. Fourteen human tibial specimens with reconstructed ACLs were subjected to progressively increasing dynamic loading until failure. The motions of the tibia, the proximal and distal graft ends, as well as the testing frame and actuator, were continuously recorded via a motion tracking system. Significantly higher displacements of the machine actuator (1.0 mm at graft slippage onset, and 12.2 mm at ultimate load) were measured compared to the displacements of the proximal (0.8 and 4.3 mm, respectively) and distal graft (0.1 and 3.4 mm, respectively) ends. The displacements measured at different sites showed significant correlations. The provided data suggest significant and systematic inaccuracies in the stiffness and slippage of the fixation when using machine displacement, as commonly reported in the literature. The assessment of the distal graft displacement excludes the artifactual graft elongation, and most accurately reflects the graft slippage onset indicating clinical failure. Considering the high displacement at the ultimate load, the ultimate load could be used as a standardized variable to compare different fixation methods. However, the ultimate load alone is not sufficient to qualitatively describe fixation stability.
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31
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Choi NH, Yang BS, Kang HK, Kim KW, Kim HB, Victoroff BN. Comparison Between Early and Late Retensioning of an Adjustable-Loop Cortical Suspension Device During Hamstring ACL Reconstruction. Orthop J Sports Med 2021; 9:23259671211042334. [PMID: 34541018 PMCID: PMC8445536 DOI: 10.1177/23259671211042334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Biomechanical studies have demonstrated significant loosening of the adjustable-loop device as compared with the fixed-loop device used in anterior cruciate ligament reconstruction. Retensioning of the adjustable loop has been recommended; however, the timing of the retensioning is unknown. Hypothesis: Early (ER) and late retensioning (LR) will show similar gapping between the femoral tunnel and graft on follow-up magnetic resonance imaging (MRI) and similar clinical outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 101 patients who underwent hamstring anterior cruciate ligament reconstruction using the adjustable-loop device for femoral fixation between June 2016 and January 2018. All patients a had follow-up MRI on postoperative day 1. Patients with revision surgery and those with reinjury after reconstruction were excluded. In the ER group, retensioning and knot tying of the initially tightened adjustable loop were performed after the flip of the button and before the graft was fixed at the tibia. In the LR group, retensioning and knot tying were performed after initial tightening of the adjustable loop and graft fixation at the tibial side. The tunnel-graft gap measured on multiplanar reformatted images of MRI scans was compared between the groups, as were clinical outcomes. Results: The mean age of the patients at the time of surgery was 30.3 years (range, 14-61 years). ER and knot tying were performed in 56 patients and LR and knot tying in 45. Preoperative characteristics of the 2 groups showed no significant differences. The mean ± SD tunnel-graft gap was 1.5 ± 2.0 mm in the ER group and 5.4 ± 4.0 mm in the LR group (P < .001). There were no significant differences in clinical outcomes between the groups. Conclusion: ER and knot tying demonstrated less tunnel-graft gap than that of LR. However, there were no differences in clinical outcomes according to the timing of retensioning.
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Affiliation(s)
- Nam-Hong Choi
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, Republic of Korea
| | - Bong-Seok Yang
- Department of Orthopaedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
| | - Hang-Ki Kang
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, Republic of Korea
| | - Kyu-Wan Kim
- Department of Orthopaedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
| | - Han-Bit Kim
- Department of Orthopaedic Surgery, Gwangmyeong Sungae Hospital, Gwangmyeong, Republic of Korea
| | - Brian N Victoroff
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio, USA
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32
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Garcés GL, Martel O, Yánez A, Manchado-Herrera I, Motta LM. In Vitro Testing of 2 Adjustable-Loop Cortical Suspensory Fixation Systems Versus Interference Screw for Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211031652. [PMID: 35146030 PMCID: PMC8821986 DOI: 10.1177/23259671211031652] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background: It is not clear whether the mechanical strength of adjustable-loop suspension devices (ALDs) in anterior cruciate ligament (ACL) reconstruction is device dependent and if these constructs are different from those of an interference screw. Purpose: To compare the biomechanical differences of 2 types of ALDs versus an interference screw. Study Design: Controlled laboratory study. Methods: ACL reconstruction was performed on porcine femurs and bovine extensor tendons with 3 types of fixation devices: interference screw, UltraButton (UB) ALD, and TightRope (TR) ALD (n = 10 for each). In addition to specimen testing, isolated testing of the 2 ALDs was performed. The loading protocol consisted of 3 stages: preload (static 150 N load for 5 minutes), cyclic load (50-250 N at 1 Hz for 1000 cycles), and load to failure (crosshead speed 50 mm/min). Displacement at different cycles, ultimate failure load, yield load, stiffness, and failure mode were recorded. Results: In specimen testing, displacement of the ALDs at the 1000th cycle was similar (3.42 ± 1.34 mm for TR and 3.39 ± 0.92 mm for UB), but both were significantly lower than that of the interference screw (7.54 ± 3.18 mm) (P < .001 for both). The yield load of the UB (547 ± 173 N) was higher than that of the TR (420 ± 72 N) (P = .033) or the interference screw (386 ± 51 N; P = .013), with no significant difference between the latter 2. In isolated device testing, the ultimate failure load of the TR (862 ± 64 N) was significantly lower than that of the UB (1879 ± 126 N) (P < .001). Conclusion: Both ALDs showed significantly less displacement in cyclic loading at ultimate failure than the interference screw. The yield load of the UB was significantly higher than that of the other 2. The ultimate failure occurred at a significantly higher load for UB than it did for TR in isolated device testing. Clinical Relevance: Both UB and TR provided stronger fixation than an interference screw. Although difficult to assess, intrinsic differences in the mechanical properties of these ALDs may affect clinical outcomes.
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Affiliation(s)
- Gerardo L. Garcés
- Department of Medical and Surgical Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Oscar Martel
- Department of Mechanical Engineering, 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
| | | | - Luci M. Motta
- University of Las Palmas de Gran Canaria, Las Palmas, Spain
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The Graft Insertion Length in the Femoral Tunnel During Anterior Cruciate Ligament Reconstruction With Suspensory Fixation and Tibialis Anterior Allograft Does Not Affect Surgical Outcomes but Is Negatively Correlated With Tunnel Widening. Arthroscopy 2021; 37:2903-2914.e1. [PMID: 33887417 DOI: 10.1016/j.arthro.2021.03.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using a low-dose irradiated tibialis anterior allograft with a fixed-loop cortical suspension device for the femur based on the graft insertion length (GIL) in the femoral tunnel. METHODS Between January 2010 and January 2018, the medical records of consecutive patients who underwent arthroscopic ACL reconstruction with a tibialis anterior allograft fixed with the EndoButton CL for the femur and who had at least 2 years of follow-up were retrospectively evaluated. Patients were classified into 3 groups based on the GIL in the femoral tunnel (group 1, GIL < 15 mm; group 2, GIL of 15-20 mm; and group 3, GIL > 20 mm), and their functional scores, knee laxity, and radiographic parameters were evaluated. RESULTS A total of 91 patients were analyzed. There were no statistically significant differences in the functional scores and knee laxity between the 3 groups at 2 years postoperatively. However, significant differences were observed in tunnel widening at 1 year postoperatively in the femur (P = .045 for absolute value and P = .004 for relative value) and the tibia (P = .014 for absolute value and P = .012 for relative value), revealing that both the femoral and tibial tunnels widened as the GIL decreased. Additional linear regression analyses were performed to identify whether the GIL independently affects tunnel widening. Consequently, the femoral tunnel depth, tunnel diameter, and GIL were found to independently influence femoral tunnel widening (P = .008, P = .019, and P < .001, respectively), whereas the tunnel diameter and GIL affected tibial tunnel widening (P < .001 and P = .004, respectively). CONCLUSIONS The GIL in the femoral tunnel during ACL reconstruction using a tibialis anterior allograft with a fixed-loop cortical suspension device for the femur has no significant association with the postoperative functional outcomes and knee laxity, but it has a negative correlation with tunnel widening in the femur and the tibia. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Hoit G, Rubacha M, Chahal J, Khan R, Ravi B, Whelan DB. Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial. Clin Orthop Relat Res 2021; 479:1725-1736. [PMID: 33729214 PMCID: PMC8277250 DOI: 10.1097/corr.0000000000001729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion. QUESTIONS/PURPOSES (1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score? METHODS Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed. RESULTS With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year. CONCLUSION With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Graeme Hoit
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
| | | | - Jaskarndip Chahal
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Women’s College Hospital, Toronto, ON, Canada
| | - Ryan Khan
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bheeshma Ravi
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
| | - Daniel B. Whelan
- Department of Surgery, Division of Orthopaedics, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, St. Michael’s Hospital, Unity Health, Toronto ON, Canada
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Ono Y, Sato Y, Mukai H, Enomoto T, Kimura S, Nakagawa R, Akagi R, Inaba Y, Kawasaki Y, Ohtori S, Sasho T. Randomized comparative study of suspension femoral fixation device in graft position maintenance in anterior cruciate ligament reconstruction: EndoButton CL vs TightRope RT. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2021; 25:42-46. [PMID: 34141595 PMCID: PMC8184406 DOI: 10.1016/j.asmart.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/07/2021] [Accepted: 05/10/2021] [Indexed: 11/06/2022]
Abstract
Background In double-bundle anterior cruciate ligament reconstruction (ACLR), fixed-loop and adjustable-loop cortical suspensory devices are commonly used to fix the soft graft on the femoral side. However, few studies have compared in vivo elongation of the two devices. The purpose of this study was to determine whether EndoButton CL (EB) and TightRope RT (TR), the suspensory fixation devices used in ACLR, maintained their length in vivo from the time of surgery through the postoperative period in a randomized controlled trial. Methods This study prospectively incorporated 30 patients undergoing initial ACLR at a single center. Participants were divided into two groups using a stratified randomization method with age and sex as assignment adjustment factors. EB or TR was used for fixation of the soft graft on the femoral side. The primary endpoint was to compare the elongation distance of the suspensory device. MRIs were taken within seven days after ACLR and 3,6,12 months postoperatively and measured by a radiologist in a blinded fashion. Secondary endpoints included the side-to-side difference in anterior translation, one leg hop test (HOP index), Lachman test, lateral pivot shift test, and Lysholm score one year postoperatively. Results Twenty-eight patients (EB, n = 13; TR, n = 15) were followed for one year. There was no significant difference between EB and TR groups in elongation from the immediate postoperative period to 3, 6, 12 months after surgery. However, the non-inferiority of TR to EB (non-inferiority margin: 1.5 mm) was not proved by the difference in measured elongation between the two groups (TR – EB, lower 95% CI. AM: 1.80 mm; PL: 1.86 mm) at 6 months. There was no significant difference in anterior translation, HOP index, Lachman test, lateral pivot shift test, or Lysholm score. Conclusion EB and TR had similar graft retaining ability in vivo for 12 months, but the non-inferiority of TR against EB was not verified statistically.
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Affiliation(s)
- Yoshimasa Ono
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan.,Musculoskeletal Disease and Pain, Preventive Medical Sciences, Chiba University, Japan
| | - Yusuke Sato
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Hiroki Mukai
- Department of Diagnostic Radiology and Radiation Oncology, Chiba University, Japan
| | - Takahiro Enomoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Seiji Kimura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Ryosuke Nakagawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Ryuichiro Akagi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Yosuke Inaba
- Biostatistics Section, Clinical Research Center, Chiba University, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Japan.,Musculoskeletal Disease and Pain, Preventive Medical Sciences, Chiba University, Japan
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Kumar R, Kalra M, Garg AK, Choudhary R, Venishetty N, Verma S, Kumar A. Clinical Reliability of Adjustable Femoral Cortical Suspensory Fixation in Anterior Cruciate Ligament Reconstruction and Correlation of Clinical Outcomes With Demographic and Perioperative Factors. Cureus 2021; 13:e15345. [PMID: 34235023 PMCID: PMC8243633 DOI: 10.7759/cureus.15345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/16/2022] Open
Abstract
Background and objective The primary goal of anterior cruciate ligament reconstruction (ACLR) is to protect the initial graft fixation against heavy loads encountered during the rehabilitation phase. The purpose of this study was to evaluate the functional outcomes (Lysholm score) and laxity [anterior tibial translation (ATT), anterior drawer test, Lachman test, and pivot shift test] of ACLR with adjustable-loop femoral cortical suspensory fixation (CSF) and tibial interferences crew fixation. Methods This study included 100 patients who underwent primary ACL reconstruction using quadruple hamstring grafts secured with TightRope® (Arthrex Inc, Naples, FL) femoral fixation and an interference screw on the tibial end. Six patients were excluded from the final analysis (four lost to follow-up, one suffered re-injury, and one had septic arthritis). The remaining 94 patients were evaluated for laxity and functional outcomes preoperatively, as well as at one, six, and 12 months postoperatively. Regression analysis was performed to determine the association between outcomes and 11 independent variables. This was designed as a prospective cohort study (level of evidence: II). Results The mean age of the participants was 28.46 ± 7.01 years. The median preoperative Lysholm knee score of 49 (mean ± SD: 48.2 ± 5.42) improved to 93 (92.7 ± 2.1) at six months and 98 (97.6 ± 2.1) at the one-year follow-up. The improvement was found to be statistically significant (p<0.01). The median ATT was 10 mm preoperatively, which decreased to 2 mm at one month, remained the same at six months, and rose to 3 mm at the one-year follow-up. ATT was found significantly reduced at one month postoperatively (p<.001) and did not show any significant further changes at subsequent follow-ups (p>0.05). Multiple linear regression revealed that one-year postoperative ATT (Rolimeter, Aircast Europa, Stephanskirchen, Germany) was independent of all demographic and perioperative variables tested. Conclusion Quadrupled hamstring graft ACLR with adjustable-loop fixation showed excellent subjective and objective outcomes with no residual laxity or failure of graft over mid-term follow-up. Postoperative laxity was not correlated with graft and tunnel dimensions.
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Affiliation(s)
- Ramesh Kumar
- Orthopaedics and Trauma, Pushpawati Singhania Research Institute, New Delhi, IND
| | - Mukesh Kalra
- Orthopaedics, Lady Hardinge Medical College, New Delhi, IND
| | - Ankit Kumar Garg
- Orthopaedics, All India Institute of Medical Sciences, Raipur, IND
| | | | | | - Shilp Verma
- Orthopaedics, All India Institute of Medical Sciences, Raipur, IND
| | - Ankush Kumar
- Orthopaedics, Lady Hardinge Medical College, New Delhi, IND
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Outcomes of retro-drilled all-inside tibial tunnel vs complete tibial tunnel techniques in anterior cruciate ligament reconstruction-a comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:523-532. [PMID: 34028623 DOI: 10.1007/s00590-021-03011-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/18/2021] [Indexed: 09/29/2022]
Abstract
PURPOSE The all-inside tibial tunnel preparation technique of arthroscopic anterior cruciate ligament (ACL) reconstruction differs from traditional complete tibial tunnel technique in using closed tibial sockets, dual-cortical suspensory graft-fixation, quadrupled semitendinosus tendon graft and lesser bone removal. The study aims to find out if all-inside technique differs from complete tibial tunnel technique of single bundle ACL reconstruction in terms of graft dimensions, functional and clinical outcomes. METHODS A prospective comparative study was conducted including 80 patients with isolated ACL tears, divided into 2 groups of 40 patients each without any randomization. The two techniques differed in tibial tunnel preparation. Group 1 underwent ACL reconstruction with a complete tibial tunnel drilled from the anteromedial tibial cortex and group 2 underwent all-inside tibial socket preparation. Duration of the surgery, perioperative and midterm complications were noted. All patients had 24 month follow-up. Functional outcome scores (Tegner-Lysholm knee scoring scale and IKDC score) were assessed preoperatively and postoperatively at 6 months and 24 months. Hamstring and quadriceps muscle strength was assessed preoperatively and postoperatively at 6 months, 9 months and 24 months. Visual analogue score (VAS) for knee pain was assessed preoperatively and postoperatively at day 2, 2 weeks, 6 weeks, 6 months and 24 months. RESULTS Quadrupled semitendinosus tendon graft was significantly thicker than doubled semitendinosus and gracilis tendons graft (8.17 ± 0.58 vs 8.71 ± 0.4, p < 0.0001). The VAS score for knee pain at 2 and 6 weeks were lower in group 2 (5.75 ± 0.6 and 1.78 ± 1.0) as compared to group 1 (6.50 ± 0.5 and 2.5 ± 0.8) and the difference was statistically significant (P = 0.0007 and p = 0.002 respectively). There were no statistically significant differences in functional outcome scores and quadriceps muscle strength between the two groups. However, there were significant difference in hamstring power in two groups. CONCLUSION The all-inside technique has the advantages of using a single tendon graft, lesser early postoperative pain with similar clinical and functional outcomes compared to the complete tibial tunnel technique. Level of Evidence IIProspective comparative study.
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O'Brien DF, Fones L, Stoj V, Edgar C, Coyner K, Arciero RA. Confirming Proper Button Deployment of Suspensory Fixation During ACL Reconstruction. Orthop J Sports Med 2021; 9:2325967120974349. [PMID: 33521157 PMCID: PMC7817951 DOI: 10.1177/2325967120974349] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/14/2020] [Indexed: 11/15/2022] Open
Abstract
Background Suspensory fixation of anterior cruciate ligament (ACL) reconstruction (ACLR) grafts has emerged as a popular device for femoral graft fixation. However, improper deployment of the suspensory fixation can compromise proper graft tensioning, leading to failure and revision. Also, soft tissue interposition between the button and bone has been associated with graft migration and pain, occasionally requiring revision surgery. Many surgeons rely on manual testing and application of distal tension to the graft to confirm proper button deployment on the lateral cortex of the femur for ACL graft fixation. Purpose To determine the reliability of the manual resistance maneuver when applying distal tension to deploy the suspensory device along the lateral cortex of the femur. Study Design Case series; Level of evidence, 4. Methods All patients undergoing ACLR with a suture button suspensory device for femoral fixation were eligible for enrollment in the study. The surgeries were performed by 3 board-certified, sports medicine fellowship-trained orthopaedic surgeons at a single outpatient surgical center between May 2018 and June 2019. All grafts were passed in a retrograde manner into the femoral tunnel, and a vigorous manual tensioning maneuver in a distal direction was placed on the graft to deploy and secure along the lateral cortex of the femur. Intraoperative mini c-arm fluoroscopy was obtained to demonstrate proper suture button positioning. If interposing tissue or an improperly flipped button was identified, rectifying steps were undertaken and recorded. Results A total of 51 patients with a mean age of 33.3 years were included in the study. Of these patients, 74.5% had normal suture button positioning identified via intraoperative fluoroscopic imaging, while 15.7% had interposed soft tissue and 9.8% had an improperly flipped button. In all cases, the surgeon was able to rectify the malpositioning intraoperatively. Conclusion Despite the manual sensation of proper suspensory button positioning, intraoperative fluoroscopy identified suture button deployment errors in ACLR 25% of the time. Correcting the malpositioning is not technically demanding. These findings advocate for routine intraoperative surveillance to confirm appropriate suture button seating during ACLR.
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Affiliation(s)
- Daniel F O'Brien
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Lilah Fones
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Victoria Stoj
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Cory Edgar
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Katherine Coyner
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Robert A Arciero
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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Adjustable suspension versus hybrid fixation in hamstring autograft anterior cruciate ligament reconstruction. Knee 2021; 28:1-8. [PMID: 33278738 DOI: 10.1016/j.knee.2020.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/25/2020] [Accepted: 10/17/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND There has been increased use of adjustable suspensory fixation (ASF) for anterior cruciate ligament reconstruction (ACLR). Potential benefits are the ability to use a shorter graft and to prevent graft displacement and damage. The purpose of this study was to establish the efficacy of this fixation method and assess whether it leads to less tunnel widening, and avoids known complications of screw fixation. METHODS Thirty-eight patients who underwent ACLR with ASF on both the femoral and tibial sides met the inclusion criteria and were propensity matched demographically with 38 patients who underwent hybrid fixation with femoral suspensory and tibial screw and sheath. At one-year, KT-1000 knee laxity measurements were recorded and detailed MRI analysis looking at tunnel aperture widening, tunnel appearance, graft integration within the tunnels, and graft healing. RESULTS MRI comparison between ASF and hybrid cohorts revealed no significant differences in graft signal or integration, and clinically there were no differences in knee laxity between cohorts (mean 1.5 mm ± 2.0 and 1.5 mm ± 2.3 (n.s.) in the ASF and hybrid fixation respectively). Significantly less aperture tibial tunnel widening (2.2 mm versus 4.4 mm, p < 0.0001) and tibial cysts (2 versus 9, p = 0.047) were observed in the ASF cohort, whilst mean femoral tunnel widening was comparable between both cohorts (ASF 2.8 mm, hybrid 3.2 mm; n.s.). CONCLUSIONS Hamstring autografts for ACLR fixed using either ASF or a hybrid fixation technique provided comparable knee stability and MRI graft signal intensity. Tibial ASF demonstrated significantly less tibial aperture widening and tunnel cyst formation when compared to screw and sheath fixation.
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Abstract
Background Anchors are frequently used in reconstructive orthopedic surgery to achieve fixation of soft tissue to bone. Anchors vary with respect to material composition, configuration, and methods of fixation at the site of attachment. The fixation component of anchoring devices has generally evolved from metal-fabricated implants to various types of bioresorbable anchors. The SonicAnchorTM (Stryker, Kalamazoo, MI USA) polymer implant provides a unique form of anchor fixation using SonicFusionTM technology to achieve interdigitation within cancellous bone while being radiolucent and providing a small footprint. Methods During a four-year period, 116 patients underwent a reconstructive orthopedic foot and ankle surgical procedure with the use of at least one bioresorbable polymer anchor (SonicAnchor implant). There were 59 males and 57 females, with an average age of 42 years (range: 12-83 years). Results A total of 233 bioresorbable anchor (SonicAnchor) implants were used in 116 patients. Of the 116 patients, 108 (93.1%) achieved successful clinical healing of their surgery at their most recent follow-up. The average follow-up duration was 309 days (range: 14-1,429 days). Eight (6.9%) patients were lost to follow-up prior to clinical healing. Two (1.7%) patients underwent reoperation. Also, 65 (56%) patients had at least six months of follow-up and 36 (31%) had at least one year of follow-up. Conclusions This preliminary clinical trial of patients undergoing soft tissue repair or reconstruction with a bioresorbable polymer appears to perform comparably to other commercially available devices. The lack of adverse events, mechanical failures, or infections further supports the safety of this device.
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Affiliation(s)
- Robert R Burnham
- Orthopaedic Surgery, Loyola University Medical Center, Maywood, USA
| | - Jayanth Kumar
- Orthopaedic Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - Michael Pinzur
- Orthopaedic Surgery, Loyola University Medical Center, Maywood, USA
| | - Adam Schiff
- Orthopaedic Surgery, Loyola University Medical Center, Maywood, USA
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Gürpınar T, Polat B, Eren M, Çarkçı E, Özyalvaç ON, Erdoğan S. The effect of soft tissue interposition of the Endobutton on clinical results and on its postoperative migration after single-bundle anterior cruciate ligament reconstruction. Knee 2020; 27:1980-1987. [PMID: 33248352 DOI: 10.1016/j.knee.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 08/29/2020] [Accepted: 10/17/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to investigate the possible consequences of soft tissue interposition of Endobutton on clinical outcomes and reoperation rates after anterior cruciate ligament reconstruction. METHODS We measured the distance between the centre of the Endobutton and the lateral femoral cortex on the postoperative first day anteroposterior X-rays of the 156 knees that underwent anterior cruciate ligament reconstruction. Those with a distance less than 1 mm were regarded as Group 1 (118 patients), the ones between 1 mm and 2 mm were regarded as Group 2 (30 patients) and the ones more than 2 mm were regarded as Group 3 (8 patients). The movement of the Endobutton of more than 1 mm along the femoral tunnel axis on anteroposterior X-rays or its rotation by more than 5° on lateral X-rays during follow-up were considered migration. Clinical assessment scores (Lysholm, Tegner Activity Scale), clinical examination tests, and rates of Endobutton migration in the groups were analysed. RESULTS Eleven Endobuttons (9.3%) in Group 1, 26 Endobuttons (86.7%) in Group 2 and all of the 8 Endobuttons (100%) in Group 3 were observed to have migrated. Clinical results and examination tests showed no significant difference between Groups 1 and 2, whereas a significant difference was detected in Group 3 compared to Groups 1 and 2 (p < 0.05). CONCLUSION Soft tissue interposition is a major cause of Endobutton migration, and an interposition over 2 mm between the Endobutton and the lateral femoral cortex can negatively affect the outcomes after an anterior cruciate ligament surgery.
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Affiliation(s)
- Tahsin Gürpınar
- Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey.
| | - Barış Polat
- Department of Orthopaedics and Traumatology, Faculty of Medicine, University of Kyrenia, Kyrenia, Cyprus.
| | - Murat Eren
- Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey.
| | - Engin Çarkçı
- Department of Orthopaedics and Traumatology, Istanbul Training and Research Hospital, Istanbul, Turkey.
| | - Osman Nuri Özyalvaç
- Department of Orthopaedics and Traumatology, Baltalimanı Bone and Joint Diseases Training and Research Hospital, Istanbul, Turkey.
| | - Sinan Erdoğan
- Department of Orthopaedics and Traumatology, Baltalimanı Bone and Joint Diseases Training and Research Hospital, Istanbul, Turkey.
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Choi NH, Lee SJ, Oh WK, Victoroff BN. Hamstring Anterior Cruciate Ligament Reconstruction Using an Adjustable-Loop Cortical Suspension Device: Immediate Postoperative Magnetic Resonance Imaging. J Knee Surg 2020; 33:1147-1151. [PMID: 31269522 DOI: 10.1055/s-0039-1692648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to determine whether the hamstring grafts are fully inserted into the femoral tunnel with the adjustable loop using immediate postoperative magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) reconstructions. A total of 62 consecutive patients underwent hamstring ACL reconstruction using an adjustable-loop cortical suspension device for the femoral fixation and the Intrafix sheath and screw for the tibial fixation. Multiplanar reformatted images of 3-T MRI scans were obtained at the 1st postoperative day before weight bearing is initiated in all patients to evaluate the gap (the tunnel-graft gap) between the top of the hamstring graft and top of the femoral tunnel. Postoperative MRI scans showed that the tunnel-graft gap was 1.5 ± 2.7 mm (range, 0-12 mm). In 43 (69.4%) patients, there was no gap between the top of the femoral tunnel and hamstring graft. In 19 (30.6%) patients, there was a gap between the tunnel and graft, and nine patients demonstrated a tunnel-graft gap greater than 5 mm. Immediate postoperative MRI scans demonstrated that an adjustable-loop cortical suspension device may not pull the hamstring graft completely into the femoral tunnel.
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Affiliation(s)
- Nam-Hong Choi
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, Korea
| | - Seung-Joo Lee
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, Korea
| | - Whang-Kyun Oh
- Department of Orthopaedic Surgery, Eulji Medical Center, Seoul, Korea
| | - Brian N Victoroff
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
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Smith PA, Bradley JP, Konicek J, Bley JA, Wijdicks CA. Independent Suture Tape Internal Brace Reinforcement of Bone-Patellar Tendon-Bone Allografts: Biomechanical Assessment in a Full-ACL Reconstruction Laboratory Model. J Knee Surg 2020; 33:1047-1054. [PMID: 31269528 DOI: 10.1055/s-0039-1692649] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Internal bracing for anterior cruciate ligament (ACL) surgery is a relatively new concept. The purpose of this study was to evaluate the effects of an "independent" button-fixed internal brace on the biomechanical properties of ACL reconstruction in a full-construct experimental model. Three groups (n = 10 each) were tested in a full-construct porcine-bone model with human bone-patellar tendon-bone allografts using different reconstruction techniques: interference screw fixation on femur and tibia (S-S group), adjustable-loop device (ALD) fixation on the femur with tibial interference screw without suture tape (ALD-S group), and with internal brace (ALD-S-IB group). Measured outcomes included cyclic displacement, stiffness, and ultimate load to failure. The ALD-S-IB group (2.9 ± 0.8 mm) displaced significantly less than the ALD-S (4.2 ± 0.9 mm; p = 0.015) and S-S group (4.3 ± 1.1 mm; p = 0.017). No significant difference was found between the ALD-S and the S-S group. Construct stiffness was significantly higher for the ALD-S-IB group (156 ± 23 N/mm) and the ALD-S group (122 ± 28 N/mm) than for the S-S group (104 ± 40 N/mm; p = 0.003 and p = 0.0042), but there was no significant difference between both ALD groups. Similarly, ultimate loads in the ALD-S-IB (758 ± 128 N) and the ALD-S groups (628 ± 223 N) were significantly greater than in the S-S group (416 ± 167 N; p < 0.001 and p = 0.025), but there was no significant difference between ALD groups. Adding an internal brace reinforcement to an ALD in a full-construct experimental model significantly decreased cyclic displacement by 31% without increasing construct stiffness or ultimate load significantly. These results indicate that suture tape internal bracing of bone-patellar tendon-bone allograft ACL reconstruction decreases cyclic displacement during experimental testing, which has clinical implications regarding initial construct stability.
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Affiliation(s)
- Patrick A Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James P Bradley
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Konicek
- Department of Research and Development, Arthrex Inc., Naples, Florida
| | - Jordan A Bley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Coen A Wijdicks
- Department of Research and Development, Arthrex Inc., Naples, Florida
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Sohn S, Koh IJ, Kim MS, In Y. Confirmation of Femoral Button Deployment Under Direct Visualization During ACL Reconstruction Is Not Beneficial. Orthopedics 2020; 43:270-276. [PMID: 32745225 DOI: 10.3928/01477447-20200721-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 03/31/2020] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to determine whether direct visualization of adjustable-loop cortical suspensory button deployment onto the lateral femur increases the cortical contact rate of the button, thereby improving clinical outcomes after anterior cruciate ligament (ACL) reconstruction. Sixty-five single-bundle anteromedial portal ACL reconstructions using an adjustable-loop button were retrospectively divided into 2 groups according to use of the blind pulling technique (control group; 32 patients) or the direct visualization technique (visualization group; 33 patients) when confirming deployment of the button. Cortical contact rate of the button on immediate and 2-year postoperative radiographs, knee stability measured using a KT-1000 arthrometer, and functional scores (Lysholm score and International Knee Documentation Committee score) at 2 years postoperative were compared between the groups. There was no significant difference in femoral cortical contact rate between the groups immediately (56% control group vs 55% visualization group; P=1.000) and at 2 years postoperative (78% control group vs 82% visualization group; P=.764). At 2 years postoperative, there was no difference between the groups regarding knee stability (1.3±0.9 mm vs 1.5±0.8 mm, respectively; P=.404), Lysholm score (P=.436), and International Knee Documentation Committee score (P=.507). Confirmation of adjustable-loop button deployment under direct visualization during anteromedial portal ACL reconstruction neither increased cortical contact rate nor improved clinical outcomes. [Orthopedics. 2020;43(5);270-276.].
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Roessler PP, Burkhart TA, Getgood A, Degen RM. Suture Tape Reduces Quadriceps Tendon Repair Gap Formation Compared With High-Strength Suture: A Cadaveric Biomechanical Analysis. Arthroscopy 2020; 36:2260-2267. [PMID: 32353619 DOI: 10.1016/j.arthro.2020.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical differences between quadriceps tendon (QT) repair with high-strength suture (HSS) versus suture tape (ST) with varying number of suture passes. METHODS In total, 28 fresh-frozen QTs were randomized into 2 groups: (1) HSS; or (2) ST; specimens were then further randomized into subgroups of either 4 or 6 suture passes. Specimens were secured within a materials testing system and a 150-N preload was applied for 10 seconds followed by a cyclic loading protocol between 50 N and 250 N for 1000 cycles. Video was used to follow tracking markers used to calculate the magnitude of tendon displacement. Two-way univariate analysis of variance was used to determine the effect of suture type and passes on the displacement after preloading and mixed repeated-measures analysis of variance was used to determine the effect of suture type and passes on displacement following cyclic loading. RESULTS There were large increases in displacement following the preload across all conditions (7.82 ± 3.64 mm), with no statistically significant differences between groups. There was a significant difference in the mean (± standard deviation) displacement between the ST (5.24 ± 2.82 mm) and HSS (7.93 ± 2.91 mm) starting at 200 cycles, which became more pronounced with successive testing out to 1000 cycles (P = .021). There were no significant difference with respect to the number of suture or tape passes. CONCLUSIONS Following preloading at 150 N, significant displacement occurred in both QT repair groups. ST demonstrated significantly less displacement than HSS under cyclic loading and had greater ultimate failure loads. CLINICAL RELEVANCE When performing QT repair, emphasis should be placed on appropriate pretensioning of sutures to at least 150 N before knot-tying. In addition, where available, ST should be used over HSS to reduce further cyclic elongation and improve ultimate failure loads.
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Affiliation(s)
- Philip P Roessler
- Fowler Kennedy Sports Medicine Clinic, 3M Center, Western University, London Ontario, Canada
| | - Timothy A Burkhart
- Lawson Health Research Institute, Mechanical and Materials Engineering, Western University, London Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, 3M Center, Western University, London Ontario, Canada
| | - Ryan M Degen
- Fowler Kennedy Sports Medicine Clinic, 3M Center, Western University, London Ontario, Canada.
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Roger J, Bertani A, Vigouroux F, Mottier F, Gaillard R, Have L, Rongièras F. ACL reconstruction using a quadruple semitendinosus graft with cortical fixations gives suitable isokinetic and clinical outcomes after 2 years. Knee Surg Sports Traumatol Arthrosc 2020; 28:2468-2477. [PMID: 32699919 DOI: 10.1007/s00167-020-06121-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/24/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE The objective of this single-center randomized single-blinded trial was to assess the hypothesis that anterior cruciate ligament reconstruction (ACLR) using a four-strand semitendinosus (ST) graft with adjustable femoral and tibial cortical fixation produced good outcomes compared to an ST/gracilis (ST/G) graft with femoral pin transfixation and tibial bioscrew fixation. Follow-up was 2 years. METHODS Patients older than 16 years who underwent primary isolated ACLR included for 1 year until August 2017 were eligible. The primary outcome measures were the subjective International Knee Documentation Committee (IKDC) score, isokinetic muscle strength recovery, and return to work within 2 years. The study was approved by the ethics committee. RESULTS Of 66 eligible patients, 60 completed the study and were included, 33 in the 4ST group and 27 in the ST/G group. Mean age was 30.5 ± 8.9 years in the 4ST group and 30.3 ± 8.5 in the ST/G group (n.s.). No significant between-group differences were found for mean postoperative subjective IKDC (4ST group, 80.2 ± 12.5; ST/G group, 83.6 ± 13.6; n.s.), side-to-side percentage deficits in isokinetic hamstring strength (at 60°/s: ST group, 17% ± 16%; ST/G group, 14% ± 11%; n.s.) or quadriceps strength (at 60°/s: ST group, 14% ± 12%; ST/G group, 19% ± 17%; n.s.), return to work, pain during physical activities, side-to-side differential laxity, balance, loss of flexion/extension, or surgical complications. CONCLUSION This trial demonstrates that functional outcomes after 4ST for ACLR with cortical fixations could be as good, although not better, than those obtained using ST/G. The 4ST technique spares the gracilis tendon, which thus preserves the medial sided muscle and thereby could improve function and limit donor-side morbidity. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Julien Roger
- Division of Orthopaedic Surgery, Department of Surgery, Hôpital de La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.
| | - Antoine Bertani
- Division of Orthopaedic Surgery, Department of Surgery, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France.
| | - Florence Vigouroux
- Division of Orthopaedic Surgery, Department of Surgery, Hôpital d'Instruction des Armées Bégin, Service de Santé des Armées, Saint-Mandé, France
| | - Franck Mottier
- Division of Orthopaedic Surgery, Department of Surgery, Centre Hospitalier Pierre Oudot, Bourgoin-Jallieu, France
| | - Romain Gaillard
- Division of Orthopaedic Surgery, Department of Surgery, Hôpital de La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Laurence Have
- Department of Physical and Medical Rehabilitation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Rongièras
- Division of Orthopaedic Surgery, Department of Surgery, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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Loop changes after knee flexion-extension movement in a cadaveric anterior cruciate reconstruction model. Chin Med J (Engl) 2020; 133:1676-1679. [PMID: 32530878 PMCID: PMC7401748 DOI: 10.1097/cm9.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Recently, adjustable-loop devices (ALDs) have been widely used, and their reliability has always been the focus of attention. This study compared loop length changes under pull stress caused by flexion and extension of the cadaver knee between ALDs and fixed-loop devices (FLDs) in terms of femoral fixation after anterior cruciate ligament (ACL) reconstruction. Methods ACL reconstruction in cadaveric knee joints was performed under arthroscopy with femoral suspension devices and tibial fixation by tying sutures on staples. The knee joint was repeatedly flexed and extended 30 times after fixation. According to the femoral fixation device used (Endobutton or Ultrabutton), the knee joints were divided into two groups: the ALD group (12 specimens) and the FLD group (ten specimens). The length of the loop before and after fixation was measured, and the loop length of the ALD group was re-measured 1 day after reconstruction. Results There was no significant difference in the length of the loop between the two groups (t = 0.579, P = 0.569). One day later, the loop length of the ALDs retracted by 0.29 ± 0.33 (0–1.1) mm, and there was no retraction in three specimens. Conclusion There was no significant difference in the loop length under flexion and extension stress after ACL reconstruction between ALDs and FLDs.
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Smith PA, Cook CS, Bley JA. All-Inside Quadrupled Semitendinosus Autograft Shows Stability Equivalent to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial in Athletes 24 Years or Younger. Arthroscopy 2020; 36:1629-1646. [PMID: 32059954 DOI: 10.1016/j.arthro.2020.01.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 12/20/2019] [Accepted: 01/18/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare clinical outcomes of knee anterior cruciate ligament (ACL) autograft reconstruction using all-inside quadrupled semitendinosus (AIST) versus bone-patellar tendon-bone (BPTB) in a high-risk athletic population 24 years or younger. METHODS Skeletally mature candidates younger than 24 years old with an ACL tear were randomized into either the AIST (n = 32) or BPTB (n = 32) group and were followed for 2 years. Magnetic resonance imaging scans were obtained at 1-year follow-up, and radiographs were obtained at 2-year follow-up. All surgeries were performed by a single surgeon using an anteromedial portal to establish the femoral tunnel. The primary outcome measure was KT-1000 stability testing. Secondary outcome measures included International Knee Documentation Committee (IKDC) Knee Evaluation Form, IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx Activity Scale, visual analog pain scale, and SF-12 (Mental and Physical). RESULTS At 2-year follow-up, no statistical difference existed with KT-1000-measured side-to-side laxity between AIST (0.3 ± 0.7 mm, 95% confidence interval 0.0-1.0 mm) and BPTB (0.0 ± 0.8 mm, confidence interval CI -0.3 to 1.1 mm) (P = .197). In addition, no statistical differences between the groups were found for IKDC Subjective Form, Knee Injury and Osteoarthritis Outcome Score, Marx, SF-12 Mental, SF-12 Physical, or with regards to imaging findings. Patients with BPTB reported significantly greater postoperative pain scores at days 2 (P = .049), 3 (P = .004), and 7 (P = .015) and had significantly greater kneeling pain at 2 years (P < .019). A return to sport questionnaire at 2 years revealed no significant difference between the groups for returning to preoperative level of sport activity (83% AIST, 74% BPTB; P = .415). Two graft retears (7%; P = .222) occurred in the AIST group. Three patients in the BPTB group experienced ACL tears in the contralateral knee (9%; P = .239). CONCLUSIONS ACL reconstruction with an all-inside quadrupled semitendinosus autograft construct is equivalent to patellar BPTB autograft based on KT-1000 stability testing in athletes 24 years or younger. LEVEL OF EVIDENCE randomized controlled trial with 92% 2-year follow-up, Level I.
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Affiliation(s)
- Patrick A Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.; Columbia Orthopaedic Group, Columbia, Missouri, U.S.A..
| | - Corey S Cook
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A
| | - Jordan A Bley
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A
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Prado-Nóvoa M, Pérez-Blanca A, Espejo-Reina A, Lombardo-Torre M, Ezquerro-Juanco F, Espejo-Baena A. Assessment of fixation for anterior cruciate ligament reconstruction using oversized suspensory devices on full-length femoral tunnels. Clin Biomech (Bristol, Avon) 2020; 76:105008. [PMID: 32413774 DOI: 10.1016/j.clinbiomech.2020.105008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 02/13/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In ACL repair, full-length single-diameter tunnels facilitate anatomic femoral fixation with suspensory devices, especially with outside-in techniques, and are required after accidental cortical perforation. With tunnel diameters over 6 mm, fixation resistance using regular suspensory devices may not suffice. Oversized cortical footprint devices could be a solution to guarantee fixation performance in larger tunnel diameters. This study aims to assess the biomechanical properties of ACL femoral fixation provided by two enlarged suspensory devices of similar characteristics, a fixed loop (G-Lok™ with G-Lok-XL™) and an adjustable loop (ProCinch™ with G-Lok-XL™), resting on a full-length 9 mm diameter tunnel compared to the widely accepted regular fixed-loop device (G-Lok™) on a socket tunnel. METHODS Twenty-seven fresh frozen porcine femurs and flexor digitorum profundus tendons were randomly assigned to a study group depending on the fixation method used (N = 9). Graft-femur constructs were subjected to a traction cyclic test (5000 cycles, [50-250]N load, 1 Hz) followed by a load-to-failure test (v = 1 mm/s). Residual displacement during the cyclic test and stiffness, displacements at physiological loads, ultimate load and corresponding displacement during the load-to-failure test were determined. FINDINGS No significant differences could be established for any parameter measured in the comparison between the control with the socket tunnel and the oversized fixations with full-length tunnels. INTERPRETATION ACL femoral fixation achieved in full-length single diameter tunnels by using an enlarged suspension device, both with a fixed or an adjustable loop, provide similar biomechanical properties to the gold-standard fixed-loop device in a socket tunnel. Therefore, its clinical use may be safe.
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Affiliation(s)
- María Prado-Nóvoa
- Escuela de Ingenierías Industriales, Laboratorio de Biomecánica, C/Dr. Ortíz Ramos s/n., 29071 Málaga, Spain
| | - Ana Pérez-Blanca
- Escuela de Ingenierías Industriales, Laboratorio de Biomecánica, C/Dr. Ortíz Ramos s/n., 29071 Málaga, Spain.
| | | | - Maximiano Lombardo-Torre
- Hospital Vithas Parque San Antonio, Avda Pintor Joaquin Sorolla, 2, 29016 Malaga, Spain; Hospital Universitario Virgen de la Victoria, Servicio de Traumatología y Cirugía Ortopédica, Campus de Teatinos s/n., 29010 Málaga, Spain
| | - Francisco Ezquerro-Juanco
- Escuela de Ingenierías Industriales, Laboratorio de Biomecánica, C/Dr. Ortíz Ramos s/n., 29071 Málaga, Spain
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Hagemans FJA, van Overvest KLJ, Zijl JAC, Meuffels DE. Four-strand hamstring graft is stiffer than a tripled semitendinosus graft in anterior cruciate ligament reconstruction: a cadaveric study. J Exp Orthop 2020; 7:37. [PMID: 32462522 PMCID: PMC7253562 DOI: 10.1186/s40634-020-00254-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/13/2020] [Indexed: 01/11/2023] Open
Abstract
Purpose The aim of this study was to compare the biomechanics of a four-strand hamstring graft with a tripled semitendinosus graft, with and without adjustable extra-cortical button fixation, in a cadaveric model. Methods Four groups of 10 cadaveric hamstrings were tested: In group A, a tripled semitendinosus graft fixated with two adjustable extra-cortical buttons; in Group B, a four-strand semitendinosus and gracilis graft fixated with an adjustable extra-cortical button and a clamp; in group C, a tripled semitendinosus graft fixated to a steel hook and a clamp; in group D, a four-strand semitendinosus and gracilis graft fixated to a steel hook and a clamp. Each group was submitted to a cyclic loading test (1000 cycles between 50 and 250 Newton at a frequency of 0.5 hertz) and a load-to-failure test. Primary outcomes were ultimate failure load and stiffness. Secondary outcomes were graft elongation and graft diameter. Results There was no difference in ultimate failure load among groups. Group B achieved a median stiffness of 171 N/mm (interquartile range [IQR] 139–204) which was significantly higher than Group A (median 103 N/mm (74–119), p < 0.01). Group B showed more cyclic elongation (4.1 mm (3.4–5.7)) compared to group D (2.3 mm (1.9–3.0)), and also lower stiffness was noted (171 N/mm (139–204) vs 265 N/mm (227–305)). There was no difference in graft diameter among groups. Conclusions The results of this study indicate that higher stiffness can be achieved using four-strand hamstring tendon grafts compared to tripled semitendinosus grafts when using femoral extra-cortical buttons, despite comparable graft diameters. Thereby, the use of adjustable extra-cortical fixation devices may result in more cyclic elongation and lower stiffness of the graft.
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Affiliation(s)
- Frans J A Hagemans
- Department of Orthopaedics and Centre for Orthopaedic Research Alkmaar (CORAL), Northwest clinics, Wilhelminalaan 12, NL - 1815 JD, Alkmaar, The Netherlands. .,Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, the Netherlands, Doctor Molewaterplein 40, NL- 3015 GD, Rotterdam, The Netherlands.
| | - Karlijn L J van Overvest
- Department of Orthopaedic Surgery, Antonius Hospital, Nieuwegein Koekoekslaan 1, NL - 3435 CM, Nieuwegein, The Netherlands
| | - Jacco A C Zijl
- Department of Orthopaedic Surgery, Antonius Hospital, Nieuwegein Koekoekslaan 1, NL - 3435 CM, Nieuwegein, The Netherlands
| | - Duncan E Meuffels
- Department of Orthopaedic Surgery, Erasmus MC, University Medical Centre Rotterdam, the Netherlands, Doctor Molewaterplein 40, NL- 3015 GD, Rotterdam, The Netherlands
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