Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone autograft: experience of the first 100 cases

Anticoagulant Usage After Anterior Cruciate Ligament Reconstruction Is Associated With Increased Rate of Manipulation Under Anesthesia

BACKGROUND

Arthrofibrosis after anterior cruciate ligament reconstruction (ACLR) is a notable but uncommon complication of ACLR. To improve range of motion after ACLR, aggressive physical therapy, arthroscopic/open lysis of adhesions, and revision surgery are currently used. Manipulation under anesthesia (MUA) is also a reasonable choice for an appropriate subset of patients with inadequate range of motion after ACLR. Recently, the correlation between anticoagulant usage and arthrofibrosis after total knee arthroplasty has become an area of interest. The purpose of this study was to determine whether anticoagulant use has a similar effect on the incidence of MUA after ACLR.

METHODS

The Mariner data set of the PearlDiver database was used to conduct this retrospective cohort study. Patients with an isolated ACLR were identified by using Current Procedural Terminology codes. Patients were then stratified by MUA within 2 years of ACLR, and the use of postoperative anticoagulation was identified. In addition, patient demographics, medical comorbidities, and timing of ACLR were recorded. Univariate and multivariable analyses were used to model independent risk factors for MUA.

RESULTS

We identified 216,147 patients who underwent isolated ACLR. Of these patients, 3,494 (1.62%) underwent MUA within 2 years. Patients who were on anticoagulants after ACLR were more likely to require an MUA (odds ratio [OR]: 2.181; P < 0.001), specifically low-molecular-weight heparin (OR: 2.651; P < 0.001), warfarin (OR: 1.529; P < 0.001), and direct factor Xa inhibitors (OR: 1.957; P < 0.001).

DISCUSSION

In conclusion, arthrofibrosis after ACLR is associated with the use of preoperative or postoperative thromboprophylaxis. Healthcare providers should be aware of increased stiffness among these patients and treat them aggressively.

A Study of the Functional Outcome of Supplementation of Hamstring Graft With Anterior Half of the Peroneus Longus Tendon in Arthroscopic Anterior Cruciate Ligament Reconstruction

INTRODUCTION

The present study was done to analyze the functional outcome, donor site morbidities, and associated parameters when using the anterior half of the peroneus longus for augmentation of an inadequate hamstring graft when performing arthroscopic anterior cruciate ligament (ACL) reconstruction.

METHODS

Thirty patients with complete ACL tears were operated on. In all these patients, the thickness or length of the hamstring graft taken was found to be inadequate (less than 8 mm and 7.5 cm, respectively). So, additionally, the anterior half of the peroneus longus tendon (AHPLT) graft was harvested to reach an optimum size of the final graft. Functional outcome was assessed using the International Knee Documentation Committee (IKDC) score at six weeks, three months, and six months. The Foot and Ankle Disability Index (FADI) score at six months was used to assess ankle stability.

RESULTS

The mean age in our study was 28.8 years with male predominance (73.33%). The mean operative time was 86.4 minutes. The mean hamstring graft thickness in our study was 6.5 mm, which improved to 9.12 mm after augmentation. The mean graft length after AHPLT augmentation was 9.38 cm. The mean IKDC score at six months was 87.35. At the end of six months, FADI scores were found within normal limits (range: 135-136) in all the patients. No complications were noted in any of the patients.

CONCLUSION

The AHPLT graft was always found to be sufficient enough for augmenting the hamstring graft to reach an acceptable thickness and length. There was no graft site morbidity and the ankle functional levels remained the same as preoperative levels, making it an excellent choice for augmentation of inadequate hamstring grafts.

Usage of Accessory Anteromedial Portal for Anatomical Placement of Femoral Tunnel in Transportal Anterior Cruciate Ligament Reconstruction: A Prospective Study

Background and objective

The anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM).

Materials and methods

This prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system.

Results

The analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up.

Conclusion

Anatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

Arthrofibrosis after ACL reconstruction is best treated in a step-wise approach with early recognition and intervention: a systematic review

PURPOSE

Arthrofibrosis is the most common post-operative complication of anterior cruciate ligament (ACL) reconstruction. Risk factors and management strategies for arthrofibrosis remain unclear. The purpose of this review was to: (a) describe existing definitions of arthrofibrosis, and (b) characterize the management strategies and outcomes of arthrofibrosis treatment.

METHODS

MEDLINE, EMBASE, and PubMed were searched from database inception to search date (March 21, 2016) and screened in duplicate for relevant studies. Data regarding patient demographics, indications, index surgery, management strategy, and outcomes were collected.

RESULTS

Twenty-five studies of primarily level IV evidence (88%) were included. A total of 647 patients (648 knees) with a mean age of 28.2 ± 1.8 years (range 14-62 years) were treated for arthrofibrosis following ACL reconstruction and followed for a mean 30.1 ± 16.9 months (range 2 months-9.6 years). Definitions of arthrofibrosis varied widely and included subjective definitions and the Shelbourne classification system. Patients were treated by one or more of: arthroscopic arthrolysis (570 patients), manipulation under anaesthesia (MUA) (153 patients), oral corticosteroids (31 patients), physiotherapy (81 patients), drop-casting (17 patients), epidural therapy combined with inpatient physiotherapy (six patients), and intra-articular interleukin-1 antagonist injection (four patients). All studies reported improvement in range of motion post-operatively, with statistically significant improvement reported for 306 patients (six studies, p range <0.001 to =0.05), and one study (18 patients) reporting significantly better results if arthrofibrosis was treated within 8 months of reconstruction (p < 0.03). The greatest improvements for extension loss were seen with drop-casting (mean 6.2° ± 0.6° improvement), whereas MUA produced the greatest improvement for flexion deficit (mean 47.8° ± 3.3° improvement).

CONCLUSIONS

Arthrofibrosis is poorly defined and outcome measures range varies widely. Amongst the studies included in this review, arthrofibrosis was most commonly managed surgically by arthroscopic arthrolysis, and most patients showed at least some improvement, including six studies that reported statistically significant change in ROM. In studies that used a step-wise approach to treating arthrofibrosis, more than half of patients were successfully treated without an operation. A more well-defined concept of arthrofibrosis, along with large, prospective studies will provide a clearer understanding of how to describe and manage this complication. The issue of arthrofibrosis following ACL reconstruction is clinically relevant as it represents a common complication of a commonly performed operation that nonetheless remains poorly defined and without clear treatment guidelines.

LEVEL OF EVIDENCE

Systematic Review of Level III and IV Studies, Level IV.

The surgical treatment of knee stiffness following anterior cruciate ligament reconstruction

Knee stiffness following anterior cruciate ligament (ACL) reconstruction remains a common complication, which can substantially impair knee function. The aim of this study was to assess the effectiveness of arthroscopic arthrolysis, in conjunction with manipulation under anaesthetic (MUA), in treating stiffness post-ACL reconstruction. We reviewed the records of 18 patients who underwent arthroscopic arthrolysis to treat established stiffness following primary isolated ACL reconstruction. Eight of these patients underwent concomitant MUA at time of arthrolysis. The median time between reconstruction and arthrolysis was nine months. Seven patients had arthrolysis performed within eight months of reconstruction, while 11 patients underwent arthrolysis greater than eight months postreconstruction. Following arthrolysis, the mean extension loss improved from 7° to 1°. In patients with mild extension stiffness (prearthrolysis extension deficits <10°), the mean improvement to extension was 3°. In patients with severe extension stiffness (prearthrolysis extension deficit ≥10°), the mean improvement to extension was 10°. Arthroscopic arthrolysis was significantly more effective in restoring extension loss if carried out within eight months of the primary reconstruction (P < 0.03). In the patients who underwent MUA at time of arthrolysis, the mean flexion loss improved from 16° to 4°. In conclusion, arthroscopic arthrolysis, in conjunction with MUA, is an effective treatment for knee stiffness post-ACL reconstruction but ideally should be carried out within eight months.

Knee stiffness following anterior cruciate ligament reconstruction: the incidence and associated factors of knee stiffness following anterior cruciate ligament reconstruction

We reviewed 100 patients retrospectively following primary ACL reconstruction with quadruple hamstring autografts to evaluate the incidence and factors associated with postoperative stiffness. Stiffness was defined as any loss of motion using the contra-lateral leg as a control. The median delay between injury and operation was 15 months. The incidence of stiffness was 12% at 6 months post-reconstruction. Both incomplete attendance at physiotherapy (p<0.005) and previous knee surgery (p<0.005) were the strongest predictors of the stiffness. Anterior knee pain was also associated with the stiffness (p<0.029). Factors that failed to show a significant association with the stiffness included associated MCL sprain at injury (p=0.32), post-injury stiffness (p=1.00) and concomitant menisectomy at reconstruction (p=0.54). Timing of surgery also did not appear to influence the onset of stiffness (median delays: 29 months for stiff patients; 14 months for non-stiff patients). The rate of stiffness fell to 5% at 12 months postreconstruction, without operative intervention.

Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction

The anterior cruciate ligament (ACL) serves an important stabilizing and biomechanical function for the knee. Reconstruction of the ACL remains one of the most commonly performed procedures in the field of sports medicine. Reconstruction of the ACL with bone-patella tendon-bone (BPTB) autograft secured with interference screw fixation has been the historical reference standard and remains the benchmark against which other methods are gauged. This article reviews the reconstruction of the ACL with BPTB autograft including the surgical technique, rationale for BTPB use, and outcomes.