Anterior cruciate ligament reconstruction using the medial third of the patellar tendon

Knee Extensor Mechanism Complications After Autograft Harvest in ACL Reconstruction: A Systematic Review and Meta-analysis

Background

Existing systematic reviews have sought to characterize the relative donor-site morbidity of bone-patellar tendon-bone (BTB) and quadriceps tendon (QT) grafts after anterior cruciate ligament reconstruction (ACLR). However, no studies have reported the pooled proportions of patellar fractures and donor tendon ruptures across the body of literature.

Purpose

To estimate the proportion of patellar fractures, patellar tendon ruptures, and QT ruptures associated with BTB or QT autograft harvest during ACLR using published data.

Study Design

Systematic review; Level of evidence, 4.

Methods

A meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using 3 online databases (PubMed, Scopus, and Web of Science). A total of 800 manuscripts were included in the initial research of peer-reviewed articles in English that reported extensor mechanism complications associated with graft harvest in patients after ACLR. Pooled proportions of patellar fractures, patellar tendon ruptures, and QT ruptures were calculated for each graft type (BTB, QT) using a random-effects model for meta-analysis.

Results

A total of 28 studies were analyzed. The pooled proportion of patellar fractures was 0.57% (95% CI, 0.34%-0.91%) for the BTB harvest and 2.03% (95% CI, 0.78%-3.89%) for the QT harvest. The proportion of patellar tendon ruptures was 0.22% (95% CI, 0.14%-0.33%) after the BTB harvest, and the proportion of QT ruptures was 0.52% (95% CI, 0.06%-1.91%) after the QT harvest. The majority of included studies (16/28 [57.1%]) had an evidence level of 4.

Conclusion

Based on the current literature, the proportion of extensor mechanism complications after ACLR using either a BTB or a QT autograft is low, indicating that the extensor mechanism harvest remains a safe option. A higher proportion of patellar fractures was noted for QT grafts and a higher proportion of donor tendon ruptures was noted for QT grafts compared with BTB grafts.

A cadaveric study of the location and morphology of the central patellar ridge for bone-patellar tendon-bone graft

Introduction

The central ridge of the patella is the thickest area of patella and varies among patients. This cadaveric study identified the location and thickness of the bone at the central patella ridge for bone-patellar tendon-bone (BPTB) harvesting.

Materials and methods

Fifty cadaveric knees were assessed. First, the morphology, length, width, and location of the central patellar ridge were recorded. Then, we transversely cut the patella 25 mm from the lower pole and measured the thickness of the anterior cortex, cancellous bone, and cartilage from both the mid-patella and the central ridge location. Finally, the depth of the remaining cancellous bone at the mid-patella was compared to the bone at the central ridge.

Results

The location of the central-patellar ridge deviated medially from the mid-patella in 46 samples with an average distance of 4.36 ± 1 mm. Only 4 samples deviated laterally. The mean patella length was 41.19 ± 4.73 mm, and the width was 42.8 ± 5.25 mm. After a transverse cut, the remaining cancellous bone was significantly thicker at the central ridge compared to the bone at the mid-patella.

Conclusions

Most of the central patellar ridge deviated medially, approximately 4 mm from the mid-patella. Harvesting the graft from the central ridge would have more remaining bone compared to the mid-patella.

Contribution of Additional Anterolateral Structure Augmentation to Controlling Pivot Shift in Anterior Cruciate Ligament Reconstruction

BACKGROUND

Several types of anterolateral structure (ALS) augmentation procedures in anterior cruciate ligament (ACL) reconstruction have been reported. However, information is limited regarding the effect of additional ALS augmentation on rotatory stability in a clinical setting.

PURPOSE/HYPOTHESIS

This study aimed to investigate the contribution of additional ALS augmentation in ACL reconstruction in cases with a high risk of residual pivot shift. The 2 hypotheses were as follows. First, additional ALS augmentation would improve rotatory stability as compared with solely reconstructing the ACL. Second, graft tension changes would be different between the ACL and ALS during knee range of motion and against anterior or rotatory loads.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifteen patients who met at least 1 of the following criteria were included: (1) revision ACL reconstruction, (2) preoperative high-grade pivot shift, or (3) hyperextended knee. The pivot-shift test was performed preoperatively and during surgery after ACL reconstruction and after additional ALS augmentation with acceleration measurements from a triaxial accelerometer. The tension changes of the ACL and ALS grafts were also measured during knee range of motion and against manual maximum anterior tibial translation, internal rotation, and external rotation.

RESULTS

After ACL reconstruction, the pivot-shift acceleration was still greater than that of the uninjured knee. However, additional ALS augmentation further reduced acceleration when compared with ACL reconstruction alone in both primary and revision cases (P < .05 vs preoperative, P < .05 vs ACL). During knee flexion-extension, the tension of the ACL increased as the knee was extended, whereas that of the ALS did not change. Graft tension of the ACL and ALS became higher with internal rotation and lower with external rotation as compared with the neutral position. Tension of the ACL was significantly increased against anterior tibial translational loads, whereas that of the ALS was not.

CONCLUSION

Additional ALS augmentation further improved the rotatory stability during ACL reconstruction in patients with a high risk of residual pivot shift at the time of surgery. Significant differences in graft tension changes were also observed between the ACL and ALS against different loads. Additional ALS augmentation may be considered to eliminate the pivot shift in patients with a high risk of residual pivot shift.

Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons

PURPOSE

To compare the results of bone-patellar tendon-bone graft (BPTB), semitendinosus-gracilis graft with preserved insertions (STGPI) and semitendinosus-gracilis-free graft (STGF) in terms of graft failure, objective mechanical stability, functional outcome, and return to sports in elite and recreational sports persons. It was hypothesized that the STGPI graft provided superior outcome as compared to the other two grafts.

METHODS

Two hundred and forty-nine elite and recreational players who underwent ACL reconstruction surgery, with BPTB graft (N = 80), STGPI graft (N = 85), and STGF graft (N = 84) with a minimum follow-up of 2 years, were assessed using clinical tests, knee arthrometer (KT 1000™), single-leg hop test, Lysholm knee score, Tegner's activity scale, and return to sports. Groups were matched in terms of age, gender, mode of injury, side involved, the level of sports, associated injuries, and mean follow-up.

RESULTS

The median age of the patients was 24 years (range 16-46 years), with 227 males and 22 females, with a mean follow-up of 61.8 ± 25.9 months. At the final follow-up, the mean side-to-side difference by KT 1000™ was significantly superior in BPTB group (1.4 ± 2.1 mm) as compared to STGPI (1.9 ± 2.0 mm) and STGF group (2.5 ± 2.0 mm) (p = 0.002). The mean Lysholm knee score, Limb symmetry index (LSI) using single-leg hop test and the mean difference in pre-injury and post-surgery level of Tegner's activity scale were not significantly different. The rate of graft failure was significantly higher in STGF group (7.1%) as compared to BPTB (1.2%) and STGPI (1.2%) groups (p = 0.043).

CONCLUSION

BPTB graft is a better graft in terms of mechanical stability than STGPI and STGF grafts. STGPI graft and BPTB graft are superior to STGF graft in terms of graft failure rate. However, there is no statistically significant difference amongst the three grafts in terms of return to sports and clinical tests of instability. STGPI graft is another option in the clinical setting with low graft failure rate like that of BPTB graft and with the added advantage of not having significant donor site morbidity.

LEVEL OF EVIDENCE

III.

Can we use peroneus longus in addition to hamstring tendons for anterior cruciate ligament reconstruction?

Background:

The aim of this study is to evaluate the possible effects of removing the peroneus longus on the ankle and gait parameters, in order to add insufficient hamstring tendons for anterior cruciate ligament (ACL) reconstruction.

Materials and Methods:

In this controlled clinical trial, 375 patients with ACL rupture who underwent ACL reconstruction arthroscopically using hamstring tendons in the orthopedic clinics of Isfahan University of Medical Sciences in 2010 and 2011 were selected. Fifteen patients were included because their hamstring tendon diameter was lower than 8 mm and peroneus longus was added. After 6 months, the patients were followed using “Kistler force plate” to detect 3D kinematics and kinetics of the ankles and spatiotemporal walking parameters.

Results:

There was a significant difference between both operated and non-operated ankles in flexion/extension range of motion (P < 0.05). There was no significant difference between the moments of both ankles in sagittal and coronal planes (P > 0.05), but there was a significant difference between the moments of both ankles in the transverse plane (P = 0.006). There was a significant difference in the force of operated and non-operated ankles in all three planes (P < 0.05). There was no significant difference in the mean values of spatiotemporal gait parameters between operated and non-operated sides (P > 0.05).

Conclusion:

Removing the peroneus longus tendon has no effect on gait parameters and does not lead to instability of the ankle. So, it can be used as an autogenous graft in orthopedic surgeries.