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Li X, Li H, Su J, Ding R. Anterior cruciate ligament femoral side retained stump technique reduces enlargement of the femoral bone tunnel after anterior cruciate ligament reconstruction. BMC Musculoskelet Disord 2024; 25:380. [PMID: 38745214 PMCID: PMC11092199 DOI: 10.1186/s12891-024-07464-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 04/22/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Enlargement of the bone tunnel has become an unavoidable early complication after anterior cruciate ligament (ACL) reconstruction, whether it is a single or double-bundle ACL reconstruction. Preservation of the ACL stump in ACL reconstruction reduces enlargement of the bone tunnel. The purpose of this study was to investigate the question of whether single-bundle ACL reconstruction using the ACL femoral side retained stump technique reduces enlargement of the femoral tunnel. METHODS Forty patients who underwent single-bundle reconstruction of the ACL were included in this study. The patients were categorized into a Remnant preservation group (Group R) and the Non-remnant preservation group (Group N). In the Remnant preservation group, a high-flexion femoral side retained stump technique was used intraoperatively for the establishment of the femoral side bone tunnel, and in the Non-remnant preservation group, the conventional femoral positioning method was used (we used a femoral positioning drill for localization and drilling of the femoral bone tunnel), and MRI of the operated knee joints was performed at 6 months postoperatively. We measured the internal diameter of the femoral bone tunnel at 5 mm from the intra-articular outlet of the femoral bone tunnel on an MRI scan image perpendicular to the femoral bone tunnel. The size of the tunnel was compared between the intraoperative drilling of the bone tunnel and the size of the bone tunnel at 6 months postoperatively. Postoperative clinical assessment was Lysholm score. RESULTS After a 6-month follow-up of 40 patients, the diameter of the femoral tunnel at a distance of 5 mm from the inner opening of the femoral tunnel was 10.96 ± 0.67 mm and 10.11 ± 0.62 mm in patients of group N and group R, respectively, and the difference was statistically significant (P < 0.05).The diameter of the femoral tunnel at 6 months postoperatively in group N and group R compared to the intraoperative bone tunnel increased by 2.58 ± 0.24 mm and 1.94 ± 0.31 mm, and the difference was statistically significant (P < 0.05).The femoral tunnel enlargement rates of group N and group R were 30.94 ± 3.00% and 24.02 ± 5.10%, respectively, and the differences were significant (P < 0.05). CONCLUSION ACL femoral side retained stump technique does not sacrifice the ideal location of the femoral tunnel and is able to preserve the possible benefits of the ACL stump: reduced femoral tunnel enlargement.
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Affiliation(s)
- Xiaobo Li
- Department of Orthopedics, General Hospital of Central Theater Command, 627 Wuluo Road, Wuchang District, Wuhan, Hubei Province, China
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Hanlin Li
- Department of Orthopedics, General Hospital of Central Theater Command, 627 Wuluo Road, Wuchang District, Wuhan, Hubei Province, China
- Clinical Medicine, Wuhan University of Science and Technology, 2 West Huangjiahu Road, Hongshan District, Wuhan, Hubei Province, China
| | - Jixian Su
- Department of Orthopedics, General Hospital of Central Theater Command, 627 Wuluo Road, Wuchang District, Wuhan, Hubei Province, China
- Clinical Medicine, Wuhan University of Science and Technology, 2 West Huangjiahu Road, Hongshan District, Wuhan, Hubei Province, China
| | - Ran Ding
- Department of Orthopedics, General Hospital of Central Theater Command, 627 Wuluo Road, Wuchang District, Wuhan, Hubei Province, China.
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McMellen CJ, Sinkler MA, Calcei JG, Hobson TE, Karns MR, Voos JE. Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction. J Bone Joint Surg Am 2023; 105:1458-1471. [PMID: 37506198 DOI: 10.2106/jbjs.22.01321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
➤ Both mechanical and biological factors can contribute to bone loss and tunnel widening following primary anterior cruciate ligament (ACL) reconstruction.➤ Revision ACL surgery success is dependent on graft position, fixation, and biological incorporation.➤ Both 1-stage and 2-stage revision ACL reconstructions can be successful in correctly indicated patients.➤ Potential future solutions may involve the incorporation of biological agents to enhance revision ACL surgery, including the use of bone marrow aspirate concentrate, platelet-rich plasma, and bone morphogenetic protein-2.
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Affiliation(s)
- Christopher J McMellen
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Margaret A Sinkler
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jacob G Calcei
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
| | - Taylor E Hobson
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
| | - Michael R Karns
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
| | - James E Voos
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
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Kanaya H, Enokida M, Ishida K, Yamashita T, Nagashima H. Factors associated with perioperative deep vein thrombosis in arthroscopic anterior cruciate ligament reconstruction. J Orthop Sci 2023; 28:1041-1045. [PMID: 35842268 DOI: 10.1016/j.jos.2022.06.003] [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: 06/01/2021] [Revised: 05/29/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is reportedly associated with a higher incidence of deep vein thrombosis (DVT) incidence than other arthroscopic surgical procedures. The aim of this study is to retrospectively investigate the incidence and type of DVT and evaluate the relationship between DVT and risk factors among all patients who underwent ACLR under uniform conditions consisting of mechanical prophylaxis, no medical prophylaxis, and preoperative and postoperative lower extremity venous ultrasonography. METHODS Of the 114 patients who underwent arthroscopic primary ACLR at our hospital who did not have a compound ligament injury or revision surgery, 112 patients were included. Two patients were not examined. DVT evaluation consisted of whole-leg ultrasonography at 1 week after surgery. We evaluated age, sex, body mass index, comorbidities, operative time, tourniquet time, presence of concurrent surgery (meniscus repair/resection or osteochondral column grafting), and non-weight-bearing status at 1 week after surgery as risk factors for DVT. RESULTS DVT was found in 33 (29.5%) of 112 patients. Of these, 22 (19.6%) had distal DVT and 11 (9.8%) had proximal DVT. Non-weight-bearing status at 1 week after surgery was a statistically significant risk factor for proximal DVT (P = .034). CONCLUSIONS Non-weight-bearing status is an independent risk factor for DVT, suggesting that early weight bearing may reduce the occurrence of DVT.
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Affiliation(s)
- Haruhisa Kanaya
- Department of Orthopedic Surgery, Tottori University, 36-1 Nishicho, Yonago City, Tottori, 683-8504, Japan.
| | - Makoto Enokida
- Sports Medical Center, Tottori University, 36-1 Nishicho, Yonago City, Tottori, 683-8504, Japan.
| | - Koji Ishida
- Department of Orthopedic Surgery, Tottori University, 36-1 Nishicho, Yonago City, Tottori, 683-8504, Japan.
| | - Takahiro Yamashita
- Department of Orthopedic Surgery, Tottori University, 36-1 Nishicho, Yonago City, Tottori, 683-8504, Japan.
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Tottori University, 36-1 Nishicho, Yonago City, Tottori, 683-8504, Japan.
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Mutsuzaki H, Kinugasa T. Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Using a Calcium Phosphate-Hybridized Tendon Graft with More than an Average of 5 Years of Follow-Up: A Follow-Up Study of a Randomized Controlled Trial. J Clin Med 2023; 12:4437. [PMID: 37445472 DOI: 10.3390/jcm12134437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
Calcium phosphate (CaP)-hybridized tendon grafting using an alternate soaking process improves tendon-to-bone healing in anterior cruciate ligament (ACL) reconstructions. This study aimed to compare bone tunnel enlargement, knee osteoarthritis, and clinical results between CaP-hybridized tendon grafting and conventional grafting in anatomical single-bundle ACL reconstruction. This study was a follow-up of a randomized controlled trial. Between July 2011 and December 2015, 90 patients underwent unilateral anatomical single-bundle ACL reconstructions and were randomly assigned to the CaP-hybridized tendon grafting (CaP group, n = 45; age, 27.1 [14-54] years; sex, 21 males and 24 females) or conventional grafting (control group, n = 45; age, 22.9 [13-58] years; sex, 26 males and 19 females). The randomization was performed according to the days of the week when the patients first visited the outpatient. The CaP-hybridized tendon grafting was created intraoperatively. The tendon grafts were soaked in a calcium solution for 30 s. After that, the tendon grafts were soaked in a NaHPO4 solution for 30 s. This soaking cycle between the calcium solution and the NaHPO4 solution was repeated 10 times. The bone tunnel enlargement, osteoarthritis grade, clinical score, and sports level were evaluated in patients who could be followed up for >3 years (CaP group, n = 20, average follow-up period 6.0 [5.1-6.9] years; control group, n = 15, average follow-up period 5.6 [4.3-6.9] years). Clinical scores, sports levels, and osteoarthritis grades were analyzed using a generalized linear mixed model (GLMM) based on repeated measurement data from preoperative and final observations, with time, group, sex, age, and BMI as fixed effects and the effect of individual differences as variable effects. In addition, bone-tunnel enlargements were analyzed using generalized linear models (GLM) with group, sex, age, and BMI as the main effects. Compared with the control group, the CaP group exhibited significantly reduced bone-tunnel enlargement on the femoral side (anteroposterior diameter; CaP group, 7.9% [-1.1-16.8] vs. control group, 29.2% [17.9-40.5], p = 0.004, MCID 16.05, proximal-distal diameter; CaP group, 7.9% [-1.9-17.8] vs. control group, 22.8% [10.9-34.7], p = 0.062, MCID 15.00). The osteoarthritis grades progressed in both groups (p < 0.001). The clinical scores and sports levels were not significantly different between the groups. This study suggests that the calcium phosphate-hybridized tendon graft reduces femoral bone-tunnel enlargement after anatomical single-bundle anterior cruciate ligament reconstruction in an average >5-year follow-up period. A longer follow-up period is necessary to reveal the clinical effects of the calcium phosphate-hybridized tendon grafts in anterior cruciate ligament reconstruction.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Center for Medical Science, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami, Ibaraki 300-0394, Japan
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences Hospital, 4773 Ami, Ibaraki 300-0331, Japan
| | - Tomonori Kinugasa
- Department of Orthopaedic Surgery, Ichihara Hospital, 3681 Oozone, Tsukuba 300-3295, Japan
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Kocabey Y, Yıldırım C, Erden T, Kaya A. Tibial Press-Fit Fixation Technique in Anterior Cruciate Ligament Reconstruction. Arthrosc Tech 2023; 12:e737-e743. [PMID: 37323777 PMCID: PMC10265682 DOI: 10.1016/j.eats.2023.02.001] [Citation(s) in RCA: 2] [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: 11/05/2022] [Accepted: 02/08/2023] [Indexed: 06/17/2023] Open
Abstract
Implant-free press-fit tibial fixation technique has gained popularity recently due to the problems in bone tunnel expansion, defect, and revision surgery due to the tibial fixation material preferred in anterior cruciate ligament surgery. Patellar tendon-tibial bone autograft offers several advantages in anterior cruciate ligament reconstruction. We describe a tibial tunnel preparation method and the use of patellar tendon-bone graft in the implant-free tibial press-fit technique. We call this the Kocabey press-fit technique.
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Affiliation(s)
- Yavuz Kocabey
- Acıbadem Kocaeli Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Cem Yıldırım
- Cam and Sakura City Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Tunay Erden
- Acıbadem Fulya Hospital Sports Medicine Center, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Alper Kaya
- Acıbadem University, Department of Orthopaedics and Traumatology, Istanbul, Turkey
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Wolfson TS, Mannino B, Owens BD, Waterman BR, Alaia MJ. Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts. Am J Sports Med 2023; 51:545-556. [PMID: 34766840 DOI: 10.1177/03635465211045705] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Bone tunnel-related complications are frequently encountered during revision anterior cruciate ligament reconstruction (ACLR). Issues with tunnel positioning, enlargement, containment, and hardware interference may complicate surgery and compromise outcomes. As a result, several strategies have emerged to address these issues and optimize results. However, a systematic, unified approach to tunnel pathology in revision ACLR is lacking. The purpose of this review is to highlight the current state of the literature on bone tunnel complications and, although extensive literature on the subject is lacking, present an updated approach to the evaluation and management of tunnel-related issues in revision ACLR.
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Affiliation(s)
| | | | - Brett D Owens
- Brown University Alpert Medical School, East Providence, Rhode Island, USA
| | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Effects of Platelet-Rich Osteoconductive-Osteoinductive Allograft Compound on Tunnel Widening of ACL Reconstruction: A Randomized Blind Analysis Study. PATHOPHYSIOLOGY 2022; 29:394-404. [PMID: 35893601 PMCID: PMC9394365 DOI: 10.3390/pathophysiology29030031] [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: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
Abstract
The anterior cruciate ligament (ACL) is a commonly injured ligament in the knee. Bone tunnel widening is a known phenomenon after soft-tissue ACL reconstruction and etiology and the clinical relevance has not been fully elucidated. Osteoconductive compounds are biomaterials providing an appropriate scaffold for bone formation such as a demineralized bone matrix. Osteoinductive materials contain growth factors stimulating bone lineage cells and bone growth. A possible application of osteoinductive/osteoconductive (OIC) material is in ACL surgery. We hypothesized that OIC placed in ACL bone tunnels: (1) reduces tunnel widening, (2) improves graft maturation, and (3) reduces tunnel ganglion cyst formation. To test this hypothesis, this study evaluated the osteogenic effects of demineralized bone matrix (DBM) and platelet-rich plasma (PRP) on tunnel widening, graft maturation, and ganglion cyst formation. This was a randomized controlled clinical trial pilot study. A total of 26 patients that elected to have ACL reconstruction surgery were randomized between the OIC and control group. Measurements of tunnel expansion and graft-tunnel incorporation were conducted via the quantitative image analysis of MRI scans performed at six months after surgery for both groups. No patients had adverse post-operative reactions or infections. The use of OIC significantly reduced tunnel widening (p < 0.05) and improved graft maturation (p < 0.05). Patients treated with OIC had a significantly lower prevalence of ganglion cyst compared to the control group (p < 0.05). The use of OIC has measurable effects on the reduction of tunnel widening, improved graft maturation, and decreased size of ganglion cyst after ACL reconstruction. This study explored the utilization of biologics to minimize bone tunnel widening in ACL reconstruction surgery.
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Leafblad ND, Maak TG. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick. Arthrosc Tech 2022; 11:e1367-e1372. [PMID: 35936861 PMCID: PMC9353587 DOI: 10.1016/j.eats.2022.03.024] [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: 12/13/2021] [Accepted: 03/11/2022] [Indexed: 02/03/2023] Open
Abstract
One- or two-staged bone grafting is sometimes required for tunnel malposition and/or tunnel widening in revision anterior cruciate ligament (ACL) reconstruction. The aim of this procedure is to restore the correct position of the ACL graft in the revision setting to provide a stable and functional ACL, thereby reproducing normal knee kinematics. We present a technique that allows for a cost-effective, convenient tunnel grafting of a femoral head allograft bone dowel into both femoral and tibial defects in revision ACL reconstruction.
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Affiliation(s)
- Nels D. Leafblad
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Travis G. Maak
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Kimura M, Nakase J, Asai K, Yoshimizu R, Kanayama T, Tsuchiya H. Tibial graft fixation methods and bone tunnel enlargement: A comparison between the TensionLoc implant system and the double-spike plate. Asia Pac J Sports Med Arthrosc Rehabil Technol 2022; 28:31-37. [PMID: 35465464 PMCID: PMC9019697 DOI: 10.1016/j.asmart.2022.03.003] [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: 01/17/2022] [Accepted: 03/14/2022] [Indexed: 11/15/2022] Open
Abstract
Background/objective TensionLoc (Arthrex, Naples, Florida, USA), a tibial graft fixation system for anterior cruciate ligament (ACL) reconstruction, is expected to apply the preoperatively determined level of graft tension and allow setting of lower initial tension. Considering its mechanism, we hypothesised that TensionLoc would prevent postoperative bone tunnel enlargement (TE) through fixation with lower initial tension. Therefore, the present study aimed to compare TE between ACL reconstructions using the double-spike plate (DSP; Smith and Nephew, Andover, Massachusetts) and TensionLoc implant system. Methods A total of 40 patients who underwent anatomical single-bundle ACL reconstruction with a hamstring tendon graft were retrospectively analysed. In the group in which DSP and screw were used, the initial graft tension was set to 40 N at 20° of knee flexion (group D). In the other group in which TensionLoc was used, the initial graft tension was set to 30 N at 20° of knee flexion (group T). Both groups included 20 patients each. Tunnel areas were measured using computed tomography images at one week and three months after surgery, and the TE ratio was calculated according to the following equation: TE ratio (%) = (tunnel area at three months after surgery - tunnel area at one week after surgery)/tunnel area at one week after surgery × 100. Results The femoral TE ratios were significantly higher in group T (80.5% ± 28.8%) than in group D (45.5% ± 34.6%) (p = 0.001). However, the tibial TE ratios did not significantly differ between the two groups. Conclusion Compared with ACL reconstruction using DSP and screw, ACL reconstruction using TensionLoc fixed the graft with lower initial tension but showed greater femoral TE and restricted knee extension in the early postoperative period.
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Affiliation(s)
- Mitsuhiro Kimura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuki Asai
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Tomoyuki Kanayama
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Weltsch D, Chan C, Dale KM, Koehler RJ, Talwar D, Ganley TJ, Lawrence JTR. Reduction in Diameter of Hamstring Autograft With Additional Circumferential Preconditioning During ACL Reconstruction in a Pediatric Population. Orthop J Sports Med 2021; 9:23259671211025497. [PMID: 34435070 PMCID: PMC8381437 DOI: 10.1177/23259671211025497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/25/2021] [Indexed: 01/15/2023] Open
Abstract
Background Over 130,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) are performed annually in the United States. Previous studies have shown that circumferential preconditioning reduces the diameter of fresh-frozen allografts, but no studies have described the effect in ACL autografts used during ACLR. Purpose To characterize the changes in the hamstring autograft diameter as a result of preparatory circumferential preconditioning. Study Design Case series; Level of evidence, 4. Methods A total of 135 patients with ACLR, with a median age of 15 years (interquartile range, 14-16 years; 50.4% boys), were identified in 2 pediatric hospitals. Three orthopaedic surgeons recorded hamstring autograft diameters at 2 time points during graft preparation. Hamstring tendons were prepared using a standardized procedure, tensioned to 15 to 20 lbs, and measured using cylindrical sizing guides. The graft was left with passive compression in the smallest initial rigid sizing guide for 10 minutes on both the tibial and femoral sides and then measured again immediately before implantation. Tunnels were drilled based on the second measurement of graft size. Comparisons were made between the graft diameter before and after circumferential preconditioning. A random-effects regression model and a linear regression model were performed to capture any unexplained variance on the linear predictor scale and determine correlations between demographics and graft characteristics. Results The median initial diameter for both femoral and tibial sides was 9.5 mm. After longitudinal tension and circumferential preconditioning, the median autograft diameter of both sides decreased by 1 mm (P < .001) to 8.5 mm. In the random-effects model, decreased patient height was a significant predictor of greater reduction in graft diameter. Increased height was a significant predictor for greater initial graft diameter (average beta coefficient = 3.08; P < .01). No intraoperative complications were noted with implantation of the preconditioned grafts in smaller diameter tunnels. Conclusion The median diameter of hamstring ACL autografts decreases by 1 mm after circumferential preconditioning within standard cylindrical sizing guides. This allowed for drilling of tunnels that were an average of 1 mm smaller without any noted intraoperative complications with graft insertion.
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Affiliation(s)
- Daniel Weltsch
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, Chaim Sheba Medical Center at Tel Hashomer, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Calvin Chan
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Kevin M Dale
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ryan J Koehler
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Divya Talwar
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Theodore J Ganley
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - J Todd R Lawrence
- Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
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A Prospective Observational Study on Short-Term Functional Outcome of Arthroscopic Anterior Cruciate Ligament Repair of Proximal Tears Using Knotless Single Suture Anchor Technique. Indian J Orthop 2021; 56:437-444. [PMID: 35251507 PMCID: PMC8854514 DOI: 10.1007/s43465-021-00487-2] [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: 03/15/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE To assess the clinical outcomes in patients with anterior cruciate ligament (ACL) proximal tears undergoing arthroscopic primary repair with knotless single suture anchor technique. METHODS The first twenty-two consecutive patients with proximal ACL tears (Sherman types I and II and high-grade partial tears) treated with arthroscopic primary repair with single suture anchor technique were evaluated until 6 months post-operatively. Patients were evaluated with validated functional outcome measures (IKDC and Lysholm scores) and clinical tests for ACL stability. RESULTS At 6-month follow-up, 91% of patients (n = 20) achieved excellent outcome measures for IKDC and Lysholm scores and had complete stability of the ACL to clinical testing. Two patients with poor outcomes at six weeks; one with subjective instability and the other underwent revision surgery represented a failure rate of 9%. The median Lysholm score was 96 (IQ range, 96-100) and median IKDC subjective score was 87.40 (IQ range, 78.20-88.50) at 6-month follow-up. The improvement in Lysholm and IKDC scores over a period of six months post-operatively was statistically significant when compared to preoperative scores (p ≪ 0.0001). Maximum improvement in clinical outcomes is achieved in the first 6 weeks post-surgery with a slower increase thereafter, a time interval which may be considered as a figurative yield point for future work in this field. CONCLUSION Arthroscopic ACL primary repair with knotless single suture anchor technique provides excellent short-term clinical outcomes in a carefully selected subset of patients with proximal ACL tears. More powered and longer duration studies are needed to understand longer term outcomes. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Baydoun H, Engler ID, Hosseini A, LeClere L, Zoon J, Zoon L, Li G, Salzler MJ, Gill TJ. Stacked Biocomposite Screws in a Single-Stage Revision Anterior Cruciate Ligament Reconstruction Has Acceptable Fixation Strength in a Porcine Cadaveric Model. Am J Sports Med 2021; 49:2144-2149. [PMID: 34048276 DOI: 10.1177/03635465211015192] [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 Stacked screws is a commonly used technique in single-stage revision anterior cruciate ligament (ACL) reconstruction in the setting of bone loss, but there are limited data to support its use. HYPOTHESIS Two configurations of a biocomposite stacked screws construct have similar fixation strength and linear stiffness as a primary ACL reconstruction construct in a biomechanical model. STUDY DESIGN Controlled laboratory study. METHODS A total of 30 porcine legs were divided into 3 groups. Group 1 underwent primary ACL reconstruction with a patellar tendon graft fixed into the femur, with an 8-mm biocomposite interference screw of beta-tricalcium phosphate and poly lactide-co-glycolide. For a revision ACL reconstruction model, groups 2 and 3 had bone tunnels created and subsequently filled with 12-mm biocomposite screws. New bone tunnels were drilled through the filler screw and the surrounding bone, and the patellar bone plug was inserted. Group 2 was fixed with 8-mm biocomposite screws on the side of the graft opposite the filler screw, while group 3 had the interference screw interposed between the graft and the filler screw. The construct was loaded at 1.5 mm/s in line with the tunnel until failure. Load to failure, linear stiffness, and mode of failure were recorded. RESULTS The mean pullout strength for groups 1, 2, and 3 was 626 ± 145 N, 653 ± 152 N, and 720 ± 125 N, respectively (P = .328). The mean linear stiffness of the construct in groups 1, 2, and 3 was 71.4 ± 9.9 N/mm, 84.1 ± 11.1 N/mm, and 82.0 ± 10.8 N/mm, respectively. Group 2 was significantly stiffer than group 1 (P = .037). CONCLUSION Two configurations of a biocomposite stacked screws construct for a single-stage revision ACL reconstruction in the setting of bone loss show a similar fixation strength and linear stiffness to a primary ACL reconstruction at time zero in a porcine model. CLINICAL RELEVANCE In the setting of bone loss from tunnel malpositioning, a single-stage revision ACL reconstruction using a stacked screws construct may provide adequate fixation strength and linear stiffness.
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Affiliation(s)
- Hasan Baydoun
- Department of Surgery, American University of Beirut, Beirut, Lebanon
| | - Ian D Engler
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ali Hosseini
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Lance LeClere
- United States Naval Academy, Naval Health Clinic Annapolis, Annapolis, Maryland, USA
| | - Joeri Zoon
- Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Luciano Zoon
- Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Guoan Li
- Orthopaedic Bioengineering Research Center, Newton-Wellesley Hospital, Newton Centre, Massachusetts, USA
| | - Matthew J Salzler
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Thomas J Gill
- Tufts University School of Medicine, Steward Healthcare System, and Boston Sports Medicine, Boston, Massachusetts, USA
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Ernat JJ, Rakowski DR, Millett PJ. Single-Stage Anterior Cruciate Ligament Revision Reconstruction Using an Allograft Bone Dowel for a Malpositioned and Widened Femoral Tunnel. Arthrosc Tech 2021; 10:e1793-e1797. [PMID: 34336577 PMCID: PMC8322569 DOI: 10.1016/j.eats.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/19/2021] [Indexed: 02/03/2023] Open
Abstract
Tunnel widening, osteolysis, and/or malposition can be a cause of anterior cruciate ligament (ACL) reconstruction failure and a challenging problem to treat when performing revision ACL reconstruction (RACLR). Traditionally, problematic tunnels that interfere with bony stability and incorporation of the new graft at the time of revision have been treated with staged procedures-bone grafting first, followed by a return several months later for the revision reconstruction after bony incorporation has occurred. Multiple staged procedures increase the level of risk the patient may encounter and increase cost and resource utilization. In addition, they prolong the recovery period for the patient. In recent years, several studies have evaluated the clinical outcomes of performing bone grafting of tunnels and concomitant RACLR in a single-stage setting in an effort to mitigate these issues. We describe a technique by which a malpositioned and widened femoral tunnel from a primary ACL failure is treated with bone grafting using an allograft dowel, as well as immediate RACLR using a bone-patellar tendon-bone allograft.
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Affiliation(s)
- Justin J. Ernat
- Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Peter J. Millett
- Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- Address correspondence to Peter J. Millett, M.D., M.Sc., Steadman Philippon Research Institute, The Steadman Clinic, 181 W Meadow Dr, Ste 400, Vail, CO 81657, U.S.A.
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14
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Bi F, Chen Y, Liu J, Wang Y, Xu D, Tian K. Anterior cruciate ligament reconstruction in a rabbit model using a silk-collagen scaffold modified by hydroxyapatite at both ends: a histological and biomechanical study. J Orthop Surg Res 2021; 16:139. [PMID: 33593365 PMCID: PMC7885370 DOI: 10.1186/s13018-021-02281-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Background To investigate osteointegration at the graft-bone interface and the prevention of osteoarthritis after anterior cruciate ligament (ACL) reconstruction using a silk-collagen scaffold with both ends modified by hydroxyapatite (HA) in a rabbit model. Methods The HA/silk-collagen scaffold was fabricated using a degummed, knitted silk scaffold, collagen I matrix, and simulated body fluid (SBF). The HA/silk-collagen scaffold was rolled up to make a graft for replacing the native ACL in the experimental group (HA group), and the silk-collagen scaffold was used in the control (S group). All specimens were harvested at 16 weeks postoperatively to evaluate graft-bone healing and osteoarthritis prevention. Results Histological staining revealed the massive formation of more mature bone at the tendon-bone interface, and immunohistochemistry staining revealed more collagen I and osteocalcin deposition in the HA group than in the S group. Higher signals indicating more bone mineral formation were detected in the HA group than in the S group, which was consistent with the results of biomechanical testing. Better osteoarthritis prevention was also observed in the HA group, indicating a more stable knee joint in the HA group than in the S group. Conclusion The HA/silk-collagen scaffold promotes osteointegration at the tendon-bone interface after ACL reconstruction and has great potential for clinical applications. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02281-0.
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Affiliation(s)
- Fanggang Bi
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, NO.1 Jianshe East Road, Zhengzhou, 450001, China.
| | - Yangdi Chen
- Henan University of Chinese Medicine, NO.156 Jinshui East Road, Zhengzhou, 450001, China
| | - Junqi Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, NO.1 Jianshe East Road, Zhengzhou, 450001, China
| | - Yafei Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, NO.1 Jianshe East Road, Zhengzhou, 450001, China
| | - Danfeng Xu
- Department of Orthopedic Surgery, Shaoxing Central Hospital, NO.1 Huayu Road, Shaoxing, 312000, China
| | - Ke Tian
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, NO.1 Jianshe East Road, Zhengzhou, 450001, China
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15
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Abstract
INTRODUCTION The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness. DISCUSSION Factors contributing to ACL failure may be classified as patient-related, surgeon-related, and biological factors. Of these, tunnel malposition and recurrent trauma are the most common causes. Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Infection has to be ruled out prior to planning any reconstructive surgical procedure. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. Autografts are preferred for revision ACL due their lesser re-tear rates and better outcomes. Associated meniscus tears and cartilage injuries are more common in revision than in primary surgery and need to be managed appropriately. Extra-articular reconstruction for controlling anterolateral instability is frequently required as well. CONCLUSION Revision ACL reconstruction is a complex undertaking due to limited graft options, compromised anatomy and high frequency of associated injuries. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery.
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16
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Devitt BM, Maes M, Feller JA, Webster KE. No long-term tunnel enlargement following anterior cruciate ligament reconstruction using autograft hamstring tendon with dual suspensory fixation. Knee Surg Sports Traumatol Arthrosc 2020; 28:2157-2162. [PMID: 31624903 DOI: 10.1007/s00167-019-05741-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/30/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Bone tunnel widening following anterior cruciate ligament reconstruction (ACLR) is well documented, although the aetiology and clinical significance of this phenomenon remain unclear. At mid-term follow-up, a greater prevalence of tunnel enlargement has been reported with the use of hamstring (HS) grafts. However, there are paucity of data on what happens in the longer term. The aim of this study was to assess the change in femoral and tibial tunnel dimensions 15 years after four-strand HS ACLR. METHODS This is a retrospective review of 15 patients who underwent arthroscopic ACLR using HS autograft tendon and were followed up radiographically at 4 months, 2 years and 15 years. Suspensory fixation was used for both ends of the graft. The diameters of the bone tunnels on posteroanterior (PA) and lateral radiographs were measured using digital callipers. Repeated measures analysis of variance (ANOVA) was used to examine change in tunnel width over time. RESULTS Radiographic tunnel width did not significantly change between 4 months and 2 years. However, a significant decrease in width was found for both the femoral and tibial tunnels between the 2- and 15-year follow-up (P < 0.01): the femoral tunnel decreased by 50% and 51% in the PA and lateral views, respectively; the tibial tunnel decreased by 77% and 91% in the PA and lateral views respectively. There was no significant correlation between femoral or tibial tunnel width and flexion and extension deficits or with side to side differences in anterior tibial laxity at 15 years. CONCLUSIONS This radiographic follow-up study of bone tunnel widening following HS ACLR with suspensory fixation demonstrated that tunnel width did not increase beyond 4 months and in fact had decreased significantly at long-term (15 years) follow-up. There was no correlation between tunnel width changes and clinical assessment of flexion and extension deficits or with side-to-side anterior knee laxity at 15-years. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- B M Devitt
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia.,School of Allied Health, La Trobe University, Melbourne, Australia
| | - M Maes
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia.,ZNA Hospitals, Antwerp, Belgium
| | - J A Feller
- OrthoSport Victoria, Epworth HealthCare, Melbourne, Australia.,School of Allied Health, La Trobe University, Melbourne, Australia
| | - K E Webster
- School of Allied Health, La Trobe University, Melbourne, Australia.
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17
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Su CA, Knapik DM, Trivedi NN, Megerian MF, Salata MJ, Voos JE. Femoral Interference Screw Fixation in ACL Reconstruction Using Bone-Patellar Tendon-Bone Grafts. JBJS Rev 2020; 8:e0066. [PMID: 32105240 DOI: 10.2106/jbjs.rvw.19.00066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Anterior cruciate ligament (ACL) reconstruction is a commonly performed orthopaedic procedure with numerous reconstructive graft and fixation options. Interference screws have become one of the most commonly utilized methods of securing ACL grafts such as bone-patellar tendon-bone (BPTB) autografts.
» The composition of interference screws has undergone substantial evolution over the past several decades, and numerous advantages and disadvantages are associated with each design.
» The composition, geometry, and insertional torque of interference screws have important implications for screw biomechanics and may ultimately influence the strength, stability of graft fixation, and biologic healing in ACL reconstruction.
» This article reviews the development and biomechanical properties of interference screws while examining outcomes, complications, and gaps in knowledge that are associated with the use of femoral interference screws during BPTB ACL reconstruction.
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Affiliation(s)
- Charles A Su
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Nikunj N Trivedi
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - Michael J Salata
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - James E Voos
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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18
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Dragoo JL, Kalisvaart M, Smith KM, Pappas G, Golish R. Single-stage revision anterior cruciate ligament reconstruction using bone grafting for posterior or widening tibial tunnels restores stability of the knee and improves clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2019; 27:3713-3721. [PMID: 30980118 DOI: 10.1007/s00167-019-05467-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 03/04/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Revision ACL surgery may be complicated by tunnel malposition and/or tunnel widening and often requires a staged treatment approach that includes bone grafting, a period of several months to allow bone graft incorporation and then definitive revision ACL reconstruction. The purpose of this study was to evaluate the results of a single-staged ACL revision reconstruction technique using a cylindrical dowel bone graft for patients who have existing posteriorly placed and/or widened tibial tunnels in the tibia at a minimum of 2 years follow-up. METHODS Between 2010 and 2014, patients undergoing single-stage revision ACL reconstruction with the described technique were prospectively enrolled and evaluated. At a minimum of 24 months, patients were evaluated by physical examination, multiple clinical outcome instruments including KOOS, Tegner and Lysholm, and preoperative and postoperative MRIs. RESULTS At a mean of 35.1 months, 18 consecutive patients had no revision surgery and no subjective knee instability. There were statistically significant improvements in the Tegner (median 2, interquartile range 2.25; p < 0.01), Lysholm (20.0 ± 15.0; p < 0.01), KOOS symptoms scale (12.9 ± 11.8; p < 0.01), KOOS pain scale (15.4 ± 18.7; p < 0.01), KOOS ADL scale (13.5 ± 19.0; p < 0.01), KOOS sports scale (32.8 ± 26.4; p < 0.01), and KOOS QoL scale (18.1 ± 16.9; p < 0.01). Postoperative MRI demonstrated statistically significant anteriorization of the tibial tunnel and a statistically significant decrease in tunnel widening. CONCLUSION Revision ACL reconstruction utilizing a single-staged tibial tunnel grafting technique resulted in improved knee pain, function, and stability at a minimum of 24-month follow-up. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jason L Dragoo
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.
| | - Michael Kalisvaart
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Kevin M Smith
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - George Pappas
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Ray Golish
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
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19
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Tajima T, Yamaguchi N, Nagasawa M, Morita Y, Nakamura Y, Chosa E. Early weight-bearing after anterior cruciate ligament reconstruction with hamstring grafts induce femoral bone tunnel enlargement: a prospective clinical and radiographic study. BMC Musculoskelet Disord 2019; 20:274. [PMID: 31159789 PMCID: PMC6547478 DOI: 10.1186/s12891-019-2653-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 05/23/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Bone tunnel enlargement following primary anterior cruciate ligament (ACL) reconstruction with soft tissue graft might be a severe disadvantage for revision surgery. The postoperative rehabilitation protocol including the non-weight-bearing periods were different depending on the surgeon or institute. To determine the relationship between femoral bone tunnel enlargement and the postoperative non-weight-bearing period after double-bundle ACL reconstruction with hamstring grafts. METHODS Forty-two patients who underwent primary double-bundle ACL reconstruction with hamstring grafts were divided into two postoperative non-weight-bearing protocol groups: 1-week non-weight-bearing postoperatively (group A, n = 19); and 2-week non-weight-bearing (group B, n = 18). Five cases were excluded due to additional knee injury, pregnancy, and lost to follow-up. Bone tunnel enlargement was evaluated by computed digital radiographs (anteroposterior (A-P) and lateral views) taken on the first postoperative day and at 12 months. Each tunnel diameter was shown as a percentage to the maximum joint width of the proximal tibia in the A-P view, or a percentage of the maximum diameter of the patella in the lateral view. To determine the incidence of tunnel enlargement, percentage diameter changes of more than 10% were defined as an enlarged tunnel. The magnitude of tunnel enlargement and the standard clinical evaluation were also evaluated. RESULTS There were no significant differences between groups in the incidences of anteromedial and posterolateral bone tunnel enlargement, both in the A-P and lateral views (2 × 2 Chi-squared test). The magnitude of femoral posterolateral bone tunnel enlargement was significantly greater in group A in the A-P view (p = 0.01) and lateral view (p = 0.03) (Mann Whitney U-test). Twelve months after surgery, the Lysholm score and Tegner activity level scale were not significantly different between the groups. CONCLUSIONS This prospective, clinical and radiographical study showed that early weight-bearing protocol after double-bundle ACL reconstruction with hamstring grafts might have the potential risk of significant postoperative femoral bone tunnel enlargement of the posterolateral bundle. There was no significant difference in clinical outcomes by postoperative non-weight-bearing period. To reduce and prevent the femoral bone tunnel enlargement, the comprehensive management could be considered and required to establish the suitable early stage rehabilitation protocol after surgery. TRIAL REGISTRATION Trial registration number; UMIN000036212 . Scientific title: Prospective comparisons of femoral tunnel enlargement with two different postoperative non weight bearing periods after double-bundle anterior cruciate ligament reconstruction with hamstring grafts. Registered date: 15 Mar 2019 (retrospectively registered).
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Affiliation(s)
- Takuya Tajima
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692 Japan
| | - Nami Yamaguchi
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692 Japan
| | - Makoto Nagasawa
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692 Japan
| | - Yudai Morita
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692 Japan
| | - Yoshihiro Nakamura
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692 Japan
| | - Etsuo Chosa
- Division of Orthopedic Surgery, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692 Japan
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Celik H, Lee DH. Comparison of the aperture and midportion femoral tunnel widening after anterior cruciate ligament reconstruction: A systematic review and meta-analyses. Medicine (Baltimore) 2019; 98:e16121. [PMID: 31261529 PMCID: PMC6616244 DOI: 10.1097/md.0000000000016121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To identify whether the aperture or the midportion of the femoral tunnel had a larger tunnel widening in patients who undergo ACL reconstruction. METHODS PubMed, EMBASE and Cochrane Library were searched for relative studies that evaluated tunnel widening in patients underwent arthroscopic ACL reconstruction. Two reviewers independently recorded data from each study, including the sample size and magnitude of tunnel widening. Random-effects meta-analyses were performed to pool the outcomes of tunnel widening by estimating the standardized mean differences in tunnel widening and their 95% confidence intervals (CIs), Publication bias was assessed using funnel plots and Egger test when the number of included studies was >10. RESULTS Eleven included studies compared tunnel widening between the aperture and the midportion. In these studies, 372 and 92 patients underwent single- and double-bundle ACL reconstructions, respectively. Subgroup analyses in terms of evaluation imaging tool for tunnel widening showed no significant differences in tunnel widening between the aperture and the midportion of the femoral tunnel regardless of plain radiograph (mean difference, 0.02 mm; P = .97), computed tomography (mean difference 0.08 mm; P = .55), and magnetic resonance imaging (mean difference, 0.13 mm; P = .78). Likewise, no significant difference in femoral tunnel widening was found between the aperture and the midportion, irrespective of transtibial (mean difference, 0.18 mm; P = .57), anteromedial (mean difference, 0.02 mm; P = .90), and outside-in techniques (mean difference, 0.01 mm; P = .98). CONCLUSION No significant difference in femoral tunnel widening was found between the aperture and the midportion in the patients who underwent ACL reconstruction.
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Affiliation(s)
- Haluk Celik
- Department of Orthopaedic Surgery, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Dae-Hee Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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21
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van der List JP, Vermeijden HD, O'brien R, Difelice GS. Anterior cruciate ligament reconstruction following failed primary repair: surgical technique and a report of three cases. ACTA ACUST UNITED AC 2019. [DOI: 10.23736/s0394-3410.19.03924-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Teuschl AH, Tangl S, Heimel P, Schwarze UY, Monforte X, Redl H, Nau T. Osteointegration of a Novel Silk Fiber-Based ACL Scaffold by Formation of a Ligament-Bone Interface. Am J Sports Med 2019; 47:620-627. [PMID: 30653344 DOI: 10.1177/0363546518818792] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Given the unsatisfactory results and reported drawbacks of anterior cruciate ligament (ACL) reconstruction, such as donor site morbidity and the limited choice of grafts in revision surgery, new regenerative approaches based on tissue-engineering strategies are currently under investigation. PURPOSES To determine (1) if a novel silk fiber-based ACL scaffold is able to initiate osteointegration in the femoral and tibial bone tunnels under in vivo conditions and (2) if the osteointegration process will be improved by intraoperatively seeding the scaffolds with the autologous stromal vascular fraction, an adipose-derived, stem cell-rich isolate from knee fat pads. STUDY DESIGN Controlled laboratory study. METHODS A total of 33 sheep underwent ACL resection and were then randomly assigned to 2 experimental groups: ACL reconstruction with a scaffold alone and ACL reconstruction with a cell-seeded scaffold. Half of the sheep in each group were randomly chosen and euthanized 6 months after surgery and the other half at 12 months. To analyze the integration of the silk-based scaffold in the femoral and tibial bone tunnels, hard tissue histology and micro-computed tomography measurements were performed. RESULTS Hard tissue histological workup showed that in all treatment groups, with or without the application of the autologous stromal vascular fraction, an interzone of collagen fibers had formed between bone and silk-based graft. This collagen-fiber continuity partly consisted of Sharpey fibers, comparable with tendon-bone healing known for autografts and allografts. Insertion sites were more broad based at 6 months and more concentrated on the slightly protruding, bony knoblike structures at 12 months. Histologically, no differences between the treatment groups were detectable. Analysis of micro-computed tomography measurements revealed a significantly higher tissue density for the cell-seeded scaffold group as compared with the scaffold-alone group in the tibial but not femoral bone tunnel after 12 months of implantation. CONCLUSION The novel silk fiber-based scaffold for ACL regeneration demonstrated integration into the bone tunnels via the formation of a fibrous interzone similar to allografts and autografts. Histologically, additional cell seeding did not enhance osteointegration. No significant differences between 6 and 12 months could be detected. After 12 months, there was still a considerable amount of silk present, and a longer observation period is necessary to see if a true ligament-bone enthesis will be formed. CLINICAL RELEVANCE ACL regeneration with a silk fiber-based scaffold with and without additional cell seeding may provide an alternative treatment option to current techniques of surgical reconstruction.
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Affiliation(s)
- Andreas Herbert Teuschl
- Department of Life Science Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Stefan Tangl
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Core Facility Hard Tissue and Biomaterial Research, Karl Donath Laboratory, School of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Patrick Heimel
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Uwe Yacine Schwarze
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Core Facility Hard Tissue and Biomaterial Research, Karl Donath Laboratory, School of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Xavier Monforte
- Department of Life Science Engineering, University of Applied Sciences Technikum Wien, Vienna, Austria
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Heinz Redl
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
| | - Thomas Nau
- Austrian Cluster for Tissue Regeneration, Vienna, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, Vienna, Austria
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Demyttenaere J, Claes S, Bellemans J. One-stage revision anterior cruciate ligament reconstruction in cases with excessive tunnel osteolysis. Results of a new technique using impaction bone grafting. Knee 2018; 25:1308-1317. [PMID: 30196983 DOI: 10.1016/j.knee.2018.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 07/17/2018] [Accepted: 08/23/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND This level IV study describes a new one-stage procedure for revision ACL reconstruction in cases with extreme tunnel widening. METHODS Eight consecutively treated subjects requiring ACL revision and presenting with excessive tunnel widening (87.5% to 250% tunnel enlargement) were included in this study. The graft-tunnel mismatch was resolved in this one-stage revision procedure by the use of custom-made eight to 10 mm cylindrical shaped bone allografts in a press-fit construct with the ACL-graft in combination with the usual fixation devices for ACL-reconstruction. All subjects were evaluated pre-operatively and at a minimum follow-up of one year by the IKDC objective and subjective scores, KOOS, and Tegner activity scale. RESULTS Mean improvement was 24.8 ± 16.1 on the KOOS evaluation (P-value 0,006) and 38.1 ± 16.8 on the IKDC subjective score (P-value 0,001). The objective IKDC scores improved significantly with an average of one grade (P-value 0,038). Anterior laxity as determined on the KT-1000 arthrometer improved with an average of 3.63 mm compared to the situation before primary reconstruction, and the Pivot-shift test was negative in all but one patient after the revision procedure while positive in all patients before primary reconstruction. CONCLUSION This new surgical technique using eight to 10 mm allograft bone cylinders for the management of excessive tunnel enlargement at single stage revision ACL reconstruction delivers excellent results after minimum one year of follow-up. The results of this study have the potential to lower the threshold for one-stage surgery in ACL revision complicated by extreme tunnel widening.
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Affiliation(s)
- Joachim Demyttenaere
- Leuven University Hospitals, Department of orthopaedic surgery, Campus Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium.
| | - Steven Claes
- Leuven University Hospitals, Department of orthopaedic surgery, Campus Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium; Algemeen Ziekenhuis Sint-Elisabeth Herentals, Department of orthopaedic surgery, Nederrij 133, 2200 Herentals, Belgium
| | - Johan Bellemans
- Leuven University Hospitals, Department of orthopaedic surgery, Campus Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium; Ziekenhuis Oost-Limburg, Department of orthopaedic surgery, Schiepse Bos 6, 3600 Genk, Belgium
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Malahias MA, Chytas D, Nakamura K, Raoulis V, Yokota M, Nikolaou VS. A Narrative Review of Four Different New Techniques in Primary Anterior Cruciate Ligament Repair: "Back to the Future" or Another Trend? SPORTS MEDICINE-OPEN 2018; 4:37. [PMID: 30094753 PMCID: PMC6085215 DOI: 10.1186/s40798-018-0145-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/02/2018] [Indexed: 01/28/2023]
Abstract
Recently, four different operative techniques, referring to the primary anterior cruciate ligament (ACL) repair, were described. These are the dynamic intraligamentary stabilization (DIS) with Ligamys™, the Bridge-enhanced repair (BEAR), the use of internal brace, and the refixation with suture anchors. The purpose of this study was to assess the already-published, clinical, and pre-clinical results of those techniques. A literature review was conducted and implemented by three independent researchers. Inclusion criteria were clinical or cadaveric or animal studies about patients suffering from ACL rupture, who were treated with one of those four different arthroscopic techniques of primary ACL repair. There were 10 clinical trials dealing with the different techniques of primary ACL repair and 12 cadaveric or animal studies. The majority of the published clinical trials investigated the dynamic intraligamentary stabilization (DIS), while only four studies referred to the three other surgical techniques. Most of the clinical trials suggested that primary ACL repair should be done during the first 14–21 days after a proximal ACL rupture and not later. Further clinical evidence is needed for the techniques of bridge-enhanced ACL repair, internal brace, and suture anchors ACL refixation in order to support the animal and cadaveric biomechanical studies. Till now, the existing clinical trials were not enough to establish the use of those techniques in the ACL-ruptured patients. On the contrary, the Dynamic intraligamentary stabilization with Ligamys™ device demonstrated very promising results in different types of clinical studies.
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Affiliation(s)
- Michael-Alexander Malahias
- 2nd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. .,ATOS Hospital, Heidelberg, Germany. .,Orthopaedic Surgeon, ATOS Klinik, Schlossberg 21, 69117, Heidelberg, Germany.
| | - Dimitrios Chytas
- 2nd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kaori Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,ATOS Hospital, Heidelberg, Germany
| | - Vasileios Raoulis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.,ATOS Hospital, Heidelberg, Germany
| | - Masashi Yokota
- Department of Sports Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Vasileios S Nikolaou
- 2nd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Daniels SP, van der List JP, Kazam JJ, DiFelice GS. Arthroscopic primary repair of the anterior cruciate ligament: what the radiologist needs to know. Skeletal Radiol 2018; 47:619-629. [PMID: 29285553 DOI: 10.1007/s00256-017-2857-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/18/2017] [Accepted: 12/12/2017] [Indexed: 02/02/2023]
Abstract
Recently, there has been a renewed interest in primary repair of proximal anterior cruciate ligament (ACL) tears. Magnetic resonance imaging (MRI) plays an important role in preoperative patient selection and in postoperative ligament assessment. Knowledge of the imaging factors that make patients candidates for primary ACL repair, namely proximal tear location and good tissue quality, can help radiologists provide information that is meaningful for surgical decision making. Furthermore, an understanding of the surgical techniques can prevent misinterpretation of the postoperative MRI. This article reviews preoperative MRI characterization of ACL injuries, techniques of arthroscopic primary ACL repair surgery and examples of postoperative MRI findings.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 East 68th Street, Box 141, New York, NY, 10065, USA.
| | - Jelle P van der List
- Orthopedic Trauma and Sports Medicine Services, Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA
| | - J Jacob Kazam
- Department of Radiology, New York Presbyterian Hospital-Weill Cornell Medical Center, 525 East 68th Street, Box 141, New York, NY, 10065, USA
| | - Gregory S DiFelice
- Orthopedic Trauma and Sports Medicine Services, Hospital for Special Surgery, 535 E. 70th St, New York, NY, 10021, USA
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Bez M, Kremen TJ, Tawackoli W, Avalos P, Sheyn D, Shapiro G, Giaconi JC, Ben David S, Snedeker JG, Gazit Z, Ferrara KW, Gazit D, Pelled G. Ultrasound-Mediated Gene Delivery Enhances Tendon Allograft Integration in Mini-Pig Ligament Reconstruction. Mol Ther 2018; 26:1746-1755. [PMID: 29784586 DOI: 10.1016/j.ymthe.2018.04.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 02/01/2023] Open
Abstract
Ligament injuries occur frequently, substantially hindering routine daily activities and sports participation in patients. Surgical reconstruction using autogenous or allogeneic tissues is the gold standard treatment for ligament injuries. Although surgeons routinely perform ligament reconstructions, the integrity of these reconstructions largely depends on adequate biological healing of the interface between the ligament graft and the bone. We hypothesized that localized ultrasound-mediated, microbubble-enhanced therapeutic gene delivery to endogenous stem cells would lead to significantly improved ligament graft integration. To test this hypothesis, an anterior cruciate ligament reconstruction procedure was performed in Yucatan mini-pigs. A collagen scaffold was implanted in the reconstruction sites to facilitate recruitment of endogenous mesenchymal stem cells. Ultrasound-mediated reporter gene delivery successfully transfected 40% of cells recruited to the reconstruction sites. When BMP-6 encoding DNA was delivered, BMP-6 expression in the reconstruction sites was significantly enhanced. Micro-computed tomography and biomechanical analyses showed that ultrasound-mediated BMP-6 gene delivery led to significantly enhanced osteointegration in all animals 8 weeks after surgery. Collectively, these findings demonstrate that ultrasound-mediated gene delivery to endogenous mesenchymal progenitor cells can effectively improve ligament reconstruction in large animals, thereby addressing a major unmet orthopedic need and offering new possibilities for translation to the clinical setting.
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Affiliation(s)
- Maxim Bez
- Skeletal Biotech Laboratory, The Hebrew University-Hadassah Faculty of Dental Medicine, Ein Kerem, Jerusalem 91120, Israel; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Thomas J Kremen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Wafa Tawackoli
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Pablo Avalos
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dmitriy Sheyn
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Galina Shapiro
- Skeletal Biotech Laboratory, The Hebrew University-Hadassah Faculty of Dental Medicine, Ein Kerem, Jerusalem 91120, Israel
| | - Joseph C Giaconi
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Shiran Ben David
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Jess G Snedeker
- Department of Orthopedics, University of Zurich, Zurich 8008, Switzerland
| | - Zulma Gazit
- Skeletal Biotech Laboratory, The Hebrew University-Hadassah Faculty of Dental Medicine, Ein Kerem, Jerusalem 91120, Israel; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Katherine W Ferrara
- Department of Biomedical Engineering, University of California, Davis, Davis, CA 95616, USA
| | - Dan Gazit
- Skeletal Biotech Laboratory, The Hebrew University-Hadassah Faculty of Dental Medicine, Ein Kerem, Jerusalem 91120, Israel; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Gadi Pelled
- Skeletal Biotech Laboratory, The Hebrew University-Hadassah Faculty of Dental Medicine, Ein Kerem, Jerusalem 91120, Israel; Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Woodmass JM, O'Malley MP, Krych AJ, Reardon PJ, Johnson NR, Stuart MJ, Levy BA. Revision Multiligament Knee Reconstruction: Clinical Outcomes and Proposed Treatment Algorithm. Arthroscopy 2018; 34:736-744.e3. [PMID: 29273255 DOI: 10.1016/j.arthro.2017.09.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 08/25/2017] [Accepted: 09/05/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To (1) assess clinical outcomes of revision multiligament knee injury (MLKI) reconstruction at a minimum of 2 years' follow-up and (2) present a standardized treatment algorithm used in treating revision MLKI patients. METHODS A retrospective review of our institution's MLKI database was performed to identify all patients who underwent revision MLKI reconstructions (≥2 ligaments reconstructed) after implementation of a standardized treatment algorithm in 2000 and had a minimum of 2 years' follow-up. Patient demographic information, injury description (mechanism of injury, neurovascular status, knee dislocation grade, associated chondral or meniscal injury), surgical technique (repair vs reconstruction, staged vs nonstaged, concomitant procedures), mechanism of failure, knee stability, and range of motion, as well as International Knee Documentation Committee and Lysholm scores, were obtained. RESULTS We assessed 23 patients (8 female and 15 male patients), with an average age of 26.7 ± 11.5 years at primary surgery and 30.8 ± 11.0 years at revision surgery. The mean follow-up period was 7.5 ± 5.3 years. Of the 23 patients, 10 (43.4%) underwent staged revision procedures: isolated bone grafting in 3, osteotomy in 4, hardware removal with osteochondral allograft in 1, hardware removal with bone grafting in 1, and meniscus repair for a locked knee in 1. The average International Knee Documentation Committee and Lysholm scores were 74.5 ± 22.3 and 79.4 ± 20.2, respectively. High-energy injury and increasing age at revision surgery were the only risk factors found to be associated with significantly worse outcomes (P < .05). CONCLUSIONS Patients with recurrent instability after MLKI reconstruction present with many concomitant pathologies, including limb malalignment, bone tunnel widening, retained hardware, meniscal incompetence, and cartilage defects. Revision MLKI reconstruction can provide these patients with modest functional outcomes when a standardized treatment algorithm is used focusing on identification and treatment of the concomitant pathology, often in a staged manner. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Jarret M Woodmass
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael P O'Malley
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J Krych
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Patrick J Reardon
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nick R Johnson
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Stuart
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A Levy
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A..
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Sabzevari S, Rahnemai-Azar AA, Shaikh HS, Arner JW, Irrgang JJ, Fu FH. Increased lateral tibial posterior slope is related to tibial tunnel widening after primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:3906-3913. [PMID: 28260200 DOI: 10.1007/s00167-017-4435-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/16/2017] [Indexed: 01/11/2023]
Abstract
PURPOSE The purpose of the study was to determine the influence of femoral and tibial bone morphology on the amount of femoral and tibial tunnel widening after primary anatomic ACL reconstruction. It was hypothesized that tibial and femoral bone morphology would be significantly correlated with tunnel widening after anatomic ACL reconstruction. METHODS Forty-nine consecutive patients (mean age 21.8 ± 8.1 years) who underwent primary single-bundle anatomic ACL reconstruction with hamstring autograft were enrolled. Two blinded observers measured the bone morphology of tibia and femur including, medial and lateral tibial posterior slope, medial and lateral tibial plateau width, medial and lateral femoral condyle width, femoral notch width, and bicondylar width on preoperative magnetic resonance imaging (MRI) scans. Tibial and femoral tunnel width at three points (aperture, mid-section, and exit) were measured on standard anteroposterior radiograph from 1 week and 1 year postoperatively (mean 12.5 ± 2 months). Tunnel width measurements at each point were compared between 1 week and 1 year to calculate percent of tunnel widening over time. Multivariable linear regression was used to analyze correlations between bone morphology and tunnel widening. RESULT Increase in lateral tibial posterior slope was the only independent bony morphology characteristics that was significantly correlated with an increased tibial tunnel exit widening (R = 0.58). For every degree increase in lateral tibial posterior slope, a 3.2% increase in tibial tunnel exit width was predicted (p = 0.003). Excellent inter-observer and intra-observer reliability were determined for the measurements (ICC = 0.91 and 0.88, respectively). CONCLUSION Increased lateral tibial posterior slope is an important preoperative anatomic factor that may predict tunnel widening at the tibial tunnel exit. In regard to clinical relevance, the results of this study suggest that lateral tibial posterior slope be measured preoperatively. In patients with increased lateral tibial posterior slope, more rigid graft fixation and a more conservative physical therapy regiment may be preferred. Level of evidence IV.
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Affiliation(s)
- Soheil Sabzevari
- Department of Orthopedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
- Department of Orthopedic Surgery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Ata Rahnemai-Azar
- Department of Orthopedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Humza S Shaikh
- Department of Orthopedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Justin W Arner
- Department of Orthopedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - James J Irrgang
- Department of Orthopedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Freddie H Fu
- Department of Orthopedic Surgery, University of Pittsburgh, Kaufman Building Suite 1011, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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Miller TK. The Role of an Extra-Articular Tenodesis in Revision of Anterior Cruciate Ligament Reconstruction. Clin Sports Med 2017; 37:101-113. [PMID: 29173550 DOI: 10.1016/j.csm.2017.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Patients who present for anterior cruciate ligament (ACL) revision with a high-grade pivot shift at the time of an index ACL revision procedure and subsequent reconstruction failure or a high-grade pivot shift at revision surgery, patients with generalized joint laxity, and those requiring softs tissue grafts should be considered candidates for lateral tenodesis to supplement intraarticular graft revision. Although there is no consensus regarding the optimal lateral tenodesis technique, due to the tibial positioning associated with tensioning and fixation of extra-articular procedures, a lateral tenodesis should not be used in patients with posterolateral corner injuries or lateral compartment articular disease.
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Affiliation(s)
- Thomas K Miller
- Department of Orthopaedic Surgery, Virginia Tech/Carilion School of Medicine, Institute for Orthopaedics and Neurosciences, 2331 Franklin Road, Roanoke, VA 24018, USA.
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Niu Y, Duan G, Wang F, Tang S, Li Y, Lu J, Yang X. Better 4-year outcomes for anterior cruciate ligament reconstruction with double-layer versus single-layer bone-patellar tendon-bone allografts. Knee Surg Sports Traumatol Arthrosc 2017; 25:1443-1448. [PMID: 26704799 DOI: 10.1007/s00167-015-3936-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 12/09/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the results of anterior cruciate ligament reconstruction using a double-layer bone-patellar tendon-bone (DBPTB) graft. METHODS Between 2010 and 2011, 98 patients underwent anterior cruciate ligament reconstruction with an allograft. Forty-seven of these patients received a DBPTB allograft and 51 received a traditional monolayer BPTB graft. Outcomes were evaluated at the end of a minimum 4-year follow-up in both groups using KT 1000 arthrometer measurements, Lachman and pivot-shift tests, the International Knee Documentation Committee form, and Lysholm scores. RESULTS One patient (1/47, 2 %) in the DBPTB allograft group and six patients (6/51, 12 %) in the traditional monolayer BPTB graft were lost during follow-up because of graft rupture (n.s.). The mean side-to-side differences in the DBPTB and monolayer BPTB graft groups 4 years post-operatively were significantly different at 1.4 ± 1.3 and 1.7 ± 1.6 mm, respectively (p < 0.05). The DBPTB group performed significantly better than the BPTB group on the Lachman test, International Knee Documentation Committee knee score, and Lysholm scores (p < 0.05). CONCLUSIONS The DBPTB allograft group achieved better outcomes than the traditional BPTB allograft group regarding success rate, anterior stability, and knee function. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Yingzhen Niu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Guman Duan
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Fei Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
| | - Shiyu Tang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Yao Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Jiangfeng Lu
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Xu Yang
- Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, USA
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Karaaslan F, Karaoğlu S. Fatigue Behavior of Nitinol Anterior Cruciate Ligament Graft and Inappropriate Femoral Tunnel Placement: Single-Stage Revision Anterior Cruciate Ligament Reconstruction Surgery. Arthrosc Tech 2017; 6:e455-e459. [PMID: 28580267 PMCID: PMC5443615 DOI: 10.1016/j.eats.2016.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/22/2016] [Indexed: 02/03/2023] Open
Abstract
Anterior cruciate ligament (ACL) injury is the most common ligament injury in the knee, and progressive instability and disability may develop in a significant number of patients. The incidence of ACL reconstruction is rapidly increasing, as is the number of failures. Although ACL reconstruction is a common procedure, less than satisfactory outcomes have been reported to occur in up to 25% of patients. The reasons for clinical failure after ACL reconstruction are numerous but can be broadly separated into 3 categories: technical, biological, and mechanical failures. It is generally thought that poor tunnel positioning (especially the femoral tunnel) is the most common technical error. Revision ACL reconstruction can be performed in 1 or 2 stages. The decision to perform a multistage approach is based on the position and size of the original tunnels. The varied success rates and associated advantages and disadvantages of each method have resulted in controversy as to the best treatment for revision ACL surgery. We describe our preferred operative technique to remove a fractured nitinol synthetic ACL graft and manage single-stage revision ACL reconstruction without bone grafting.
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Affiliation(s)
- Fatih Karaaslan
- Department of Orthopaedics and Traumatology, Bozok University Faculty of Medicine, Yozgat, Turkey,Address correspondence to Fatih Karaaslan, M.D., Bozok Universitesi Tip Fakultesi, Ortopedi ve Travmatoloji Bolumu, Yozgat, Turkey.Bozok Universitesi Tip FakultesiOrtopedi ve Travmatoloji BolumuYozgatTurkey
| | - Sinan Karaoğlu
- Department of Orthopaedics and Traumatology, Acıbadem Kayseri Hospital, Kayseri, Turkey
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Burnham JM, Herbst E, Pauyo T, Pfeiffer T, Johnson DL, Fu FH, Musahl V. Technical Considerations in Revision Anterior Cruciate Ligament (ACL) Reconstruction for Operative Techniques in Orthopaedics. ACTA ACUST UNITED AC 2017; 27:63-69. [PMID: 28989265 DOI: 10.1053/j.oto.2017.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
As the incidence of anterior cruciate ligament (ACL) reconstruction continues to increase, the rate of revision surgery continues to climb. Revision surgery has inherent challenges that must be addressed in order to achieve successful results. The cause of the primary ACL reconstruction failure should be determined, and careful preoperative planning should be performed to address the cause(s) of failure. Each patient undergoing revision surgery should undergo a thorough history and physical examination, receive full length alignment radiographs, lateral radiographs, 45-degree flexion weight-bearing postero-anterior radiographs, and patellofemoral radiographs. 3-dimensional computed topography (CT) scan should be performed to assess tunnel position and widening. Magnetic resonance imaging (MRI) should be used to assess for intra-articular soft tissue pathology. Meniscal tears, meniscal deficiency, anterolateral capsule injuries, bony morphology, age, activity level, connective tissue diseases, infection, graft choice, and tunnel position can all impact the success of ACL reconstruction surgery. Meniscal lesions should be repaired, and in cases of persistent rotatory instability, extra-articular procedures may be indicated. Furthermore, osteotomies may be needed to correct malalignment or excess posterior tibial slope. Depending on the placement and condition of the original femoral and tibial tunnels, revision surgery may be performed in a single procedure or in a staged manner. In most cases, the surgery can be performed in one procedure. Regardless, the surgeon must communicate with the patient openly regarding the implications of revision ACL surgery and the treatment plan should be developed in a shared fashion between the surgeon and the patient.
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Affiliation(s)
- Jeremy M Burnham
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Elmar Herbst
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Thierry Pauyo
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Thomas Pfeiffer
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Darren L Johnson
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky Medical Center, 740 S. Limestone, K401, Lexington, KY 40536 USA
| | - Freddie H Fu
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Center for Sports Medicine, University of Pittsburgh, 3200 S Water Street, Pittsburgh, PA 15203, USA
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Stolarz M, Ficek K, Binkowski M, Wróbel Z. Bone tunnel enlargement following hamstring anterior cruciate ligament reconstruction: a comprehensive review. PHYSICIAN SPORTSMED 2017; 45:31-40. [PMID: 27788037 DOI: 10.1080/00913847.2017.1253429] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nowadays, bone tunnel enlargement (BTE) after anterior cruciate ligament reconstruction is a well-known phenomenon. It has been identified, investigated and described by many authors during the last thirty years. Nevertheless, the etiology of bone tunnel enlargement still remains unclear. It is known that the causes are multifactorial and may include the surgical technique, the method of fixation, materials used, type of graft as well as biological factors. Due to the recent popularization of the use of hamstring grafts in anterior cruciate ligament reconstruction, the bone tunnel enlargement phenomenon is becoming increasingly common. In this review article, the authors focus on compiling current knowledge about the etiology, diagnosis, and the possibility of reducing the occurrence of this phenomenon by using the latest methods of supporting reconstruction surgery.
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Affiliation(s)
- Mateusz Stolarz
- a X-ray Microtomography Lab, Department of Computer Biomedical Systems , Institute of Computer Science, University of Silesia , Sosnowiec , Poland.,b Department of Orthopedics and Traumatology , City Hospital in Zabrze , Zabrze , Poland.,c Galen-Orthopaedics , Bieruń , Poland
| | - Krzysztof Ficek
- c Galen-Orthopaedics , Bieruń , Poland.,d Department of Physiotherapy Basics , Academy of Physical Education in Katowice , Katowice , Poland
| | - Marcin Binkowski
- a X-ray Microtomography Lab, Department of Computer Biomedical Systems , Institute of Computer Science, University of Silesia , Sosnowiec , Poland
| | - Zygmunt Wróbel
- a X-ray Microtomography Lab, Department of Computer Biomedical Systems , Institute of Computer Science, University of Silesia , Sosnowiec , Poland
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Colombet P, Graveleau N, Jambou S. Incorporation of Hamstring Grafts Within the Tibial Tunnel After Anterior Cruciate Ligament Reconstruction: Magnetic Resonance Imaging of Suspensory Fixation Versus Interference Screws. Am J Sports Med 2016; 44:2838-2845. [PMID: 27474387 DOI: 10.1177/0363546516656181] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The success of anterior cruciate ligament (ACL) reconstruction requires solid graft incorporation within the tunnels to enable graft remodeling. Resorbable interference screws (RIS) provide limited tendon-bone contact because much of the tunnel circumference is occupied by the screw itself, while adjustable suspensory fixation (ASF) systems provide larger contact zones, which favor ligamentization. PURPOSE To evaluate ligamentization of a 4-strand semitendinosus (4ST) graft fixed with ASF compared with RIS within the tibial bone tunnel at 6 months postoperatively using magnetic resonance imaging (MRI). STUDY DESIGN Cohort study; Level of evidence, 2. METHODS We prospectively enrolled 121 consecutive patients undergoing primary ACL reconstruction using a single-bundle 4ST graft. The femoral end of the graft was fixed using suspensory fixation in all knees. The tibial end of the graft was fixed using ASF in 67 knees and RIS in 54 knees. Six months postoperatively, knee laxity measurements were taken, and MRI was performed to assess graft incorporation within the tibial tunnel. RESULTS At 6-month follow-up, MRI scans of 109 knees were available for analysis. The mean tibial tunnel enlargement in the ASF group was 2.3 ± 1.1 mm (range, 0.5-6.0 mm), while in the RIS group, it was 4.7 ± 2.8 mm (range, 0.5-19.0 mm) (P < .001). The Howell graft signal assessment findings were excellent in 97% of knees in the ASF group and in 25% of knees in the RIS group (P < .001). The mean signal-to-noise quotient (SNQ) was 0.078 ± 0.62 in the ASF group and 0.671 ± 0.83 in the RIS group (P < .001). CONCLUSION ASF provides more favorable conditions than RIS for the incorporation and ligamentization of 4ST grafts within the tibial tunnel. The ASF system used showed very little tunnel widening, which suggests that it grants stabilization. The SNQ was also considerably better in the ASF group.
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Affiliation(s)
- Philippe Colombet
- Department of Orthopaedic Surgery and Sports Medicine, Clinique du Sport Bordeaux-Mérignac, Mérignac, France
| | - Nicolas Graveleau
- Department of Orthopaedic Surgery and Sports Medicine, Clinique du Sport Bordeaux-Mérignac, Mérignac, France
| | - Stephane Jambou
- Department of Orthopaedic Surgery and Sports Medicine, Clinique du Sport Bordeaux-Mérignac, Mérignac, France
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RETRACTED ARTICLE: Comparison of double-bundle anterior cruciate ligament reconstruction with and without autologous conditioned serum application. Knee Surg Sports Traumatol Arthrosc 2016; 24:3377. [PMID: 25448137 DOI: 10.1007/s00167-014-3457-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 11/19/2014] [Indexed: 01/15/2023]
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Cruz AI, Fabricant PD, Seeley MA, Ganley TJ, Lawrence JTR. Change in Size of Hamstring Grafts During Preparation for ACL Reconstruction: Effect of Tension and Circumferential Compression on Graft Diameter. J Bone Joint Surg Am 2016; 98:484-9. [PMID: 26984916 DOI: 10.2106/jbjs.15.00802] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove creep prior to implantation, but the literature contains little information on the influence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation. METHODS Twenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft preparation step. Interrater reliability was assessed using the intraclass correlation coefficient ICC(2,1). The mean allograft diameter at each time point was calculated and compared across all time points using repeated-measures analysis of variance (ANOVA). RESULTS Subjecting the grafts to both tension and circumferential compression significantly decreased their mean diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961. CONCLUSIONS The average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both tension and circumferential compression within a standard cylindrical sizing block. CLINICAL RELEVANCE Because ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.
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Affiliation(s)
- Aristides I Cruz
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island
| | - Peter D Fabricant
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark A Seeley
- Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, Pennsylvania
| | - Theodore J Ganley
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J Todd R Lawrence
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Giorgio N, Moretti L, Pignataro P, Carrozzo M, Vicenti G, Moretti B. Correlation between fixation systems elasticity and bone tunnel widening after ACL reconstruction. Muscles Ligaments Tendons J 2016; 6:467-472. [PMID: 28217568 DOI: 10.11138/mltj/2016.6.4.467] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Femoral and tibial tunnel widening (TW) after ACL reconstruction is a phenomenon increasing talk in the literature. It is underlying biological and mechanical causes. OBJECTIVE The aim of this study was to evaluate the relationship between bone tunnel enlargement and two different ACL fixation systems. PATIENTS AND METHODS 40 patient underwent ACL reconstruction with hamstring; randomly divided into group A with 20 patients treated with stiff systems (femoral Rigidfix and tibial interference screw), and into group B, with 20 patients treated with morel elastic system (femoral and tibial Tight-rope). Evaluated postoperatively with knee MRI at 40 days, 3 months, 6 months to measure bone tunnel diameters widening. RESULTS At 40 days tunnel widening between two groups shows no statistically difference. At 3 months postoperatively, femoral bone tunnel widening amounted on average to 1.84 mm in middle of tunnel and 1 mm at the mouth in joint in group A, and respectively 3.2 mm and 2.5 mm in group B (p<0.05). Tibial tunnel widening was 1.24 mm at the mouth in joint and 1.3 mm in middle in group A and respectively 2.26 mm and 2.43 mm in group B (p<0.05). At 6 months femoral tunnel widening amounted on average to 2.45 mm in middle and 1.35 mm at the mouth in joint in group A and respectively 3.5 mm and 2.7 mm in group B (p<0.01). Tibial tunnel widening amounted on average to 1.27 at mouth in joint and 1 mm in middle of tunnel in group A and respectively 2.6 mm and 2.3 mm in group B (p<0.01). CONCLUSIONS This study results suggest elastic fixation system increases bone tunnel enlargement after ACL reconstruction with hamstring without correlation with worse clinical performance. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nicola Giorgio
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Lorenzo Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Paolo Pignataro
- UO University Diagnostic Radiology, Azienda Ospedaliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Massimiliano Carrozzo
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Giovanni Vicenti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
| | - Biagio Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, UO Orthopaedics and Traumatology, Azienda Ospe - daliero Universitaria "Policlinico di Bari", Bari, Italy
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Burrus MT, Werner BC, Crow AJ, Brockmeier SF, Carson EW, Miller MD, Diduch DR. Increased Failure Rates After Anterior Cruciate Ligament Reconstruction With Soft-Tissue Autograft-Allograft Hybrid Grafts. Arthroscopy 2015; 31:2342-51. [PMID: 26276093 DOI: 10.1016/j.arthro.2015.06.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 06/02/2015] [Accepted: 06/17/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the rate of failure between a group of patients who underwent anterior cruciate ligament (ACL) reconstruction with an autograft-allograft hybrid soft-tissue graft and a matched group of patients who underwent ACL reconstruction with hamstring autograft. METHODS From 2007 to 2012, 29 patients underwent hybrid ACL reconstruction performed by 4 fellowship-trained sports medicine surgeons at a single institution. Patients who underwent ACL reconstruction with hamstring autograft comprised the control group and were matched to patients in the hybrid group by sex, age, date of surgery, reconstruction technique, and method of femoral fixation. Graft failure was defined as revision ACL reconstruction or complete graft rupture on magnetic resonance imaging. Graft compromise was defined as magnetic resonance imaging evidence of partial graft rupture or arthroscopically identified partial graft rupture. Lysholm Knee Scoring Scale and International Knee Documentation Committee scores were obtained. RESULTS Both groups included 10 men and 19 women, with a mean postoperative follow-up period of 44.4 ± 16.9 months in the hybrid group and 48.0 ± 15.2 months in the control group. Follow-up was obtained in 25 of 29 patients (86.2%) in the hybrid group, and each was matched to 1 patient who received hamstring autograft. The failure rate was 13.8% (4 of 29 patients) in the hybrid group compared with 3.4% (1 of 29) in the control group (P = .160). An additional 27.6% of hybrid group patients (7 of 29) had compromised grafts as defined earlier, as compared with 1 (3.4%) of the control patients (P = .022). Thus the overall hybrid graft failure/compromise rate was 37.9% (11 of 29) compared with 6.9% (2 of 29) for the hamstring autograft group (P = .005). In the hybrid group, the Lysholm score (80.2 ± 12.1) was significantly lower than that in the control autograft ACL group (89.9 ± 11.8) (P = .030). The International Knee Documentation Committee score for the hybrid ACL group (71.26 ± 19.5) was significantly worse than that for the autograft ACL group (85.7 ± 13.0) (P = .012). CONCLUSIONS Allograft-autograft hybrid hamstring ACL grafts fail or become structurally compromised at a higher rate than matched autograft hamstring controls. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Austin J Crow
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Eric W Carson
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Akoto R, Müller-Hübenthal J, Balke M, Albers M, Bouillon B, Helm P, Banerjee M, Höher J. Press-fit fixation using autologous bone in the tibial canal causes less enlargement of bone tunnel diameter in ACL reconstruction--a CT scan analysis three months postoperatively. BMC Musculoskelet Disord 2015; 16:200. [PMID: 26285568 PMCID: PMC4545716 DOI: 10.1186/s12891-015-0656-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 07/31/2015] [Indexed: 11/28/2022] Open
Abstract
Background Bone tunnel enlargement is a phenomenon present in all anterior cruciate ligament (ACL)- reconstruction techniques. It was hypothesized that press-fit fixation using a free autograft bone plug reduces the overall tunnel size in the tibial tunnel. Methods In a prospective cohort study twelve patients who underwent primary ACL reconstruction using an autologous quadriceps tendon graft and adding a free bone block for press-fit fixation (PF) in the tibial tunnel were matched to twelve patients who underwent ACL reconstruction with a hamstring graft and interference screw fixation (IF). The diameters of the bone tunnels were analysed by a multiplanar reconstruction technique (MPR) in a CT scan three months postoperatively. Manual and instrumental laxity (Lachman test, Pivot-shift test, Rolimeter) and functional outcome scores (International Knee Documentation Committee sore, Tegner activity level) were measured after one year follow up. Results In the PF group the mean bone tunnel diameter at the level of the joint entrance was not significantly enlarged. One and two centimeter distal to the bone tunnel diameter was reduced by 15 % (p = .001). In the IF group the bone tunnel at the level of the joint entrance was enlarged by 14 % (p = .001). One and two centimeter distal to the joint line the IF group showed a widening of the bone tunnel by 21 % (p < .001) One and two centimeter below the joint line the bone tunnel was smaller in the PF group when compared to the IF group (p < .001). No significant difference for laxity test and functional outcome scores could be shown. Conclusion This study demonstrates that press-fit fixation with free autologous bone plugs in the tibial tunnel results in significantly smaller diameter of the tibial tunnel compared to interference screw fixation.
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Affiliation(s)
- Ralph Akoto
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany. .,Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.
| | - Jonas Müller-Hübenthal
- Clinic for diagnostic Radiology and Nuclear medicine, Cologne-Triangle, Cologne, Germany.
| | - Maurice Balke
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.
| | - Malte Albers
- Clinic for Sports Traumatology at Cologne Merheim Medical Center, Cologne, Germany.
| | - Bertil Bouillon
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.
| | - Philip Helm
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.
| | - Marc Banerjee
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany.
| | - Jürgen Höher
- Clinic for Sports Traumatology at Cologne Merheim Medical Center, Cologne, Germany.
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Mahalingam VD, Behbahani-Nejad N, Horine SV, Olsen TJ, Smietana MJ, Wojtys EM, Wellik DM, Arruda EM, Larkin LM. Allogeneic versus autologous derived cell sources for use in engineered bone-ligament-bone grafts in sheep anterior cruciate ligament repair. Tissue Eng Part A 2015; 21:1047-54. [PMID: 25397361 DOI: 10.1089/ten.tea.2014.0422] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
The use of autografts versus allografts for anterior cruciate ligament (ACL) reconstruction is controversial. The current popular options for ACL reconstruction are patellar tendon or hamstring autografts, yet advances in allograft technologies have made allogeneic grafts a favorable option for repair tissue. Despite this, the mismatched biomechanical properties and risk of osteoarthritis resulting from the current graft technologies have prompted the investigation of new tissue sources for ACL reconstruction. Previous work by our lab has demonstrated that tissue-engineered bone-ligament-bone (BLB) constructs generated from an allogeneic cell source develop structural and functional properties similar to those of native ACL and vascular and neural structures that exceed those of autologous patellar tendon grafts. In this study, we investigated the effectiveness of our tissue-engineered ligament constructs fabricated from autologous versus allogeneic cell sources. Our preliminary results demonstrate that 6 months postimplantation, our tissue-engineered auto- and allogeneic BLB grafts show similar histological and mechanical outcomes indicating that the autologous grafts are a viable option for ACL reconstruction. These data indicate that our tissue-engineered autologous ligament graft could be used in clinical situations where immune rejection and disease transmission may preclude allograft use.
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Affiliation(s)
- Vasudevan D Mahalingam
- 1 Department of Molecular and Integrative Physiology, University of Michigan , Ann Arbor, Michigan
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Robbrecht C, Claes S, Cromheecke M, Mahieu P, Kakavelakis K, Victor J, Bellemans J, Verdonk P. Reliability of a semi-automated 3D-CT measuring method for tunnel diameters after anterior cruciate ligament reconstruction: A comparison between soft-tissue single-bundle allograft vs. autograft. Knee 2014; 21:926-31. [PMID: 25022839 DOI: 10.1016/j.knee.2014.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 04/01/2014] [Accepted: 05/13/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Post-operative widening of tibial and/or femoral bone tunnels is a common observation after ACL reconstruction, especially with soft-tissue grafts. There are no studies comparing tunnel widening in hamstring autografts versus tibialis anterior allografts. The goal of this study was to observe the difference in tunnel widening after the use of allograft vs. autograft for ACL reconstruction, by measuring it with a novel 3-D computed tomography based method. METHODS Thirty-five ACL-deficient subjects were included, underwent anatomic single-bundle ACL reconstruction and were evaluated at one year after surgery with the use of 3-D CT imaging. Three independent observers semi-automatically delineated femoral and tibial tunnel outlines, after which a best-fit cylinder was derived and the tunnel diameter was determined. Finally, intra- and inter-observer reliability of this novel measurement protocol was defined. RESULTS In femoral tunnels, the intra-observer ICC was 0.973 (95% CI: 0.922-0.991) and the inter-observer ICC was 0.992 (95% CI: 0.982-0.996). In tibial tunnels, the intra-observer ICC was 0.955 (95% CI: 0.875-0.985). The combined inter-observer ICC was 0.970 (95% CI: 0.987-0.917). Tunnel widening was significantly higher in allografts compared to autografts, in the tibial tunnels (p=0.013) as well as in the femoral tunnels (p=0.007). CONCLUSIONS To our knowledge, this novel, semi-automated 3D-computed tomography image processing method has shown to yield highly reproducible results for the measurement of bone tunnel diameter and area. This series showed a significantly higher amount of tunnel widening observed in the allograft group at one-year follow-up. LEVEL OF EVIDENCE Level II, Prospective comparative study.
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Affiliation(s)
- Cedric Robbrecht
- Department of Orthopedic Surgery and Traumatology, Ghent University, Ghent, Belgium.
| | - Steven Claes
- Division of Orthopedics, Department of Musculoskeletal Sciences, University Hospital Leuven, Pellenberg, Belgium
| | - Michiel Cromheecke
- Department of Orthopedic Surgery and Traumatology, Ghent University, Ghent, Belgium
| | - Peter Mahieu
- Department of Orthopedic Surgery and Traumatology, Ghent University, Ghent, Belgium
| | | | - Jan Victor
- Department of Orthopedic Surgery and Traumatology, Ghent University, Ghent, Belgium
| | - Johan Bellemans
- Division of Orthopedics, Department of Musculoskeletal Sciences, University Hospital Leuven, Pellenberg, Belgium
| | - Peter Verdonk
- Department of Orthopedic Surgery, Monica Hospitals, Antwerp, Belgium; Department of Physiotherapy and Orthopedic Surgery, Faculty of Medicine, Ghent University, Belgium
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Reverte-Vinaixa MM, Minguell J, Joshi N, Diaz-Ferreiro EW, Duarri G, Carrera L, Castellet E. Revision anterior cruciate ligament reconstruction using tibial or hamstring tendon allografts. J Orthop Surg (Hong Kong) 2014; 22:60-4. [PMID: 24781616 DOI: 10.1177/230949901402200116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To report outcomes of revision anterior cruciate ligament (ACL) reconstruction using tibial or hamstring tendon allografts and to compare with another study using non-irradiated fresh-frozen bone-patellar tendon-bone allografts. METHODS Records of 12 men and 7 women aged 18 to 53 (mean, 33) years who underwent revision ACL reconstructions using tibial tendon (n=17) or hamstring tendon (n=2) allografts were retrospectively reviewed. At the time of primary ACL reconstruction, hamstring autografts (n=8) and bonepatellar tendon-bone allografts (n=11) were used. The mean time interval between surgeries was 93 (range, 11-225) months. The causes of failure were traumatic injury (n=7) and technical or biological reasons (n=12). The physical activity level was high in 2 patients, medium in 10, and low in 7. For clinical assessment, the Lysholm test, International Knee Documentation Committee (IKDC) scale, and visual analogue scale (VAS) for pain were used. Patient satisfaction was also assessed. RESULTS Four of the patients had laxity and were dissatisfied or very dissatisfied with the outcome; the failure rate was 21%. The mean IKDC score was 63% (range, 25-100%), and the mean Lysholm score was 74% (range, 30-100%). Comparing our patients with those in another study using bone-patellar-bone allografts, there was no significant difference in terms of the VAS for pain, IKDC score, and Lysholm score. Comparing our patients with and without chondral and/or meniscal lesions, there was significant difference in terms of the Lysholm score only (86±11 vs. 57±28, p=0.043). Comparing patients who had used hamstring tendon autografts at the primary ACL reconstruction with those who had used bonepatellar tendon-bone autografts, there was significant difference in terms of the VAS for pain only (4.4±3.1 vs. 1.6±1.0, p=0.020). CONCLUSION Revision ACL reconstruction using tibial or hamstring tendon allografts provided acceptable results, similar to those using the bone-patellar tendon-bone allografts.
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Affiliation(s)
- Maria Mercedes Reverte-Vinaixa
- Department of Trauma and Orthopaedic Surgery, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
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Zaffagnini S, Marcheggiani Muccioli GM, Signorelli C, Lopomo N, Grassi A, Bonanzinga T, Nitri M, Marcacci M. Anatomic and nonanatomic double-bundle anterior cruciate ligament reconstruction: an in vivo kinematic analysis. Am J Sports Med 2014; 42:708-15. [PMID: 24519185 DOI: 10.1177/0363546513519070] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There have been no direct in vivo biomechanical comparisons performed between an anatomic double-bundle (ADB) and a nonanatomic double-bundle (NADB) anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS There are differences in kinematic outcomes between ADB and NADB ACL reconstruction techniques. STUDY DESIGN Controlled laboratory study. METHODS Twenty-six consecutive patients (mean age, 30 years; range, 18-32 years; 23 men, 3 women; 17 right knees, 9 left knees) with an isolated ACL injury were included in the study. The first 13 consecutive patients underwent NADB reconstruction (combination of a single-bundle and an over-the-top reconstruction), and the following 13 consecutive patients were treated with an ADB approach (using 2 tibial tunnels and 2 femoral tunnels placed in the center of the native femoral and tibial insertion sites). Grafts were pretensioned at 80 N and secured with cortical fixation systems under manual maximum force tension. Standard clinical laxity and pivot-shift tests were quantified at time zero before and after ACL reconstruction by means of a surgical navigation system dedicated to kinematic assessment; displacement of the medial and lateral compartments during the tests was also analyzed. RESULTS The ADB-reconstructed knees showed a larger preoperative-to-postoperative difference in anterior-posterior tibial plateau displacement of the medial and lateral compartments when compared with the NADB-reconstructed knees during the internal-external rotation test at 30° of flexion (P < .050). No other significant differences in laxity or pivot-shift values were noted. The mean surgical time for ADB reconstruction was significantly higher than that for NABD reconstruction (62 ± 13 and 43 ± 10 minutes, respectively; P < .0001). CONCLUSION Results showed a greater anterior-posterior translation of both compartments during the rotational passive laxity test in the ADB reconstruction group or overconstraint caused by the NADB technique. The 2 analyzed double-bundle ACL reconstructions did not show any significant quantitative difference in isolated anterior-posterior laxity and pivot-shift phenomenon at time zero. CLINICAL RELEVANCE Nonanatomic double-bundle ACL reconstruction can control anterior-posterior laxity and the pivot-shift phenomenon as well as ABD ACL reconstruction.
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Affiliation(s)
- Stefano Zaffagnini
- Giulio Maria Marcheggiani Muccioli, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, Bologna, Italy 40136.
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Yao J, Wen CY, Zhang M, Cheung JTM, Yan C, Chiu KY, Lu WW, Fan Y. Effect of tibial drill-guide angle on the mechanical environment at bone tunnel aperture after anatomic single-bundle anterior cruciate ligament reconstruction. INTERNATIONAL ORTHOPAEDICS 2014; 38:973-81. [PMID: 24566992 DOI: 10.1007/s00264-014-2290-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 01/16/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE The tibial drill-guide angle in anterior cruciate ligament (ACL) reconstruction influences the tunnel placement and graft-tunnel force, and is potentially associated with post-operative tunnel widening. This study aimed to examine the effect of the drill-guide angle on the stress redistribution at the tibial tunnel aperture after anatomic single-bundle ACL reconstruction. METHODS A validated finite element model of human knee joint was used. The tibial tunnel with drill-guide angle ranging from 30° to 75° was investigated. The post-operative stress redistribution in tibia under the compressive, valgus, rotational and complex loadings was analysed. RESULTS Compressive loading played a leading role on the stress redistribution at intra-articular tibial tunnel aperture. After ACL reconstruction, stress concentration occurred in the anterior and posterior regions of tunnel aperture while stress reduction occurred in the lateral and posteromedial regions under the compressive loading. Stress redistribution was partially alleviated by using the drill-guide angle ranging from 55° to 65°. CONCLUSIONS The present study quantified the effect of bone tunnel drill-guide angle on the post-operative stress redistribution. This phenomenon potentially contributed to tunnel widening. A tunnel drill-guide angle ranging from 55° to 65° was proposed based on the biomechanical rationale. It could serve as a helpful surgical guide for ACL reconstruction.
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Affiliation(s)
- Jie Yao
- National Key Lab of Virtual Reality Technology, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, 37 Xueyuan Road, Haidian District, Beijing, China
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Laupattarakasem P, Laopaiboon M, Kosuwon W, Laupattarakasem W. Meta-analysis comparing bioabsorbable versus metal interference screw for adverse and clinical outcomes in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014; 22:142-53. [PMID: 23238925 DOI: 10.1007/s00167-012-2340-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 12/04/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE To compare bioabsorbable screw (BS) against metal screw (MS) primarily on adverse effects and secondarily on clinical outcomes after single-bundle primary anterior cruciate ligament reconstruction. METHODS Electronic searches were performed using search strategies meeting the mentioned purposes. Retrieved articles were selected for randomised controlled trials (RCTs) reporting at least 1-year follow-up. Potential studies were selected under inclusion and exclusion criteria. Risk of biases and data extraction was completed by two review authors. Discrepancies were resolved through discussion. Mean difference and risk ratio with 95 % confidence interval (CI) were used for continuous and binary outcomes, respectively. Heterogeneity was assessed using I (2). Pooled treatment effects with 95 % CI were estimated using the fixed- or random-effect model where appropriate. RESULTS Eleven RCTs with 878 randomly allocated patients were included, and 711 patients (81 %) with eligible follow-up time up to 8 years were analysed. Comparing with the MS group, BS group using medial hamstring graft showed evidence of larger tunnel widening on the femoral side measured from radiographs or magnetic resonance imaging, though data could not be pooled because diverse measurement methods had been used. Significantly higher rates of effusion and screw breakage, and fewer cases of complete tunnel healing were reported in the BS group. Nevertheless, functional and clinical results were not deteriorated by the presence of these adverse effects for both short- and longer-term follow-ups. CONCLUSION This is the first systematic review focusing on adverse effects of the BS, such as larger tunnel widening and higher rates of other complications. With these effects, routine use of the BS should be balanced with the advantages claimed. Cost-effectiveness is another issue, and well-designed RCTs are needed to better validate the implication.
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Affiliation(s)
- Pat Laupattarakasem
- Department of Orthopaedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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Shi P, Teh TK, Toh SL, Goh JC. Variation of the effect of calcium phosphate enhancement of implanted silk fibroin ligament bone integration. Biomaterials 2013; 34:5947-57. [DOI: 10.1016/j.biomaterials.2013.04.046] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 04/23/2013] [Indexed: 01/12/2023]
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Mutsuzaki H, Sakane M, Nakajima H, Ochiai N. Calcium phosphate-hybridised tendon graft to reduce bone-tunnel enlargement after ACL reconstruction in goats. Knee 2012; 19:455-60. [PMID: 21514829 DOI: 10.1016/j.knee.2011.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 03/09/2011] [Accepted: 03/24/2011] [Indexed: 02/02/2023]
Abstract
Bone-tunnel enlargement can have a negative impact on long-term clinical success. To solve the problem, we developed a novel technique to improve tendon-bone healing by hybridising calcium phosphate (CaP) with a tendon graft using an alternate soaking process. The objective of this study was to analyse bone-tunnel enlargement, mechanical properties and histological features, especially the number of osteoclasts at the tendon-bone interface using a CaP-hybridised tendon graft and an untreated tendon graft 6 months after anterior cruciate ligament (ACL) reconstruction in goats. The percentage of bone-tunnel enlargement for the CaP group was decreased compared with that for the control group for the femoral side (p<0.05). The failure load was not statistically different between the CaP group and the control group, and was all midsubstance rupture for both groups. In the CaP group, cartilage layer was more observed at the tendon-bone interface of the joint aperture site than in the control group (p<0.05). Many osteoclasts on the femoral side of the tendon-bone interface in the control were observed compared with that in the CaP group (p<0.05). At the femoral side, the CaP-hybridised tendon graft reduced bone-tunnel enlargement associated with tendon-bone healing 6 months after ACL reconstruction in goats. Clinically, the CaP-hybridised tendon graft for ACL reconstruction can reduce bone-tunnel enlargement.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami Ami-machi, Inashiki-gun, Ibaraki 300-0394, Japan
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Mutsuzaki H, Kanamori A, Ikeda K, Hioki S, Kinugasa T, Sakane M. Effect of calcium phosphate-hybridized tendon graft in anterior cruciate ligament reconstruction: a randomized controlled trial. Am J Sports Med 2012; 40:1772-80. [PMID: 22713551 DOI: 10.1177/0363546512449618] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The authors developed a novel technique to improve tendon-bone healing by hybridizing calcium phosphate (CaP) with a tendon graft using an alternating soaking process. HYPOTHESIS Anterior cruciate ligament (ACL) reconstruction using the CaP-hybridized tendon graft would have a better clinical outcome and reduce the percentage of bone tunnel enlargement compared with a conventional method because of the enhanced anchoring between the tendon graft and the bone. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Patients (N = 64) with unilateral ACL rupture underwent arthroscopically assisted single-bundle ACL reconstruction using a 4-strand semitendinosus tendon or 4-strand semitendinosus and gracilis tendons with EndoButton femoral fixation and screw washer tibial fixation. These patients were equally randomized to undergo the CaP (n = 32) or conventional (n = 32) method using a transtibial tunnel approach according to the closed envelope method. In the CaP group, the tendon graft was hybridized with the CaP at both ends of the graft. One surgeon performed all reconstructions without knowing which graft was prepared. Patients' backgrounds regarding age at surgery, gender, period before surgery, and associated meniscal injuries were similar in the 2 groups. All patients followed the same postoperative protocol. At 1 and 2 years after surgery, they were evaluated with the manual knee laxity test, KT-1000 arthrometry, International Knee Documentation Committee (IKDC) examination form, Tegner scale, and Lysholm scale. Also, 1 year postoperatively, bone tunnel enlargement was analyzed using computed tomography, intensity of the tendon graft by magnetic resonance imaging (MRI), and tendon graft appearance by arthroscopic examination. All the examinations were performed blindly. RESULTS All patients underwent a minimum 2-year follow-up. KT-1000 arthrometry data indicated statistically significant decreased average anterior tibial translation in the CaP group compared with the conventional method group: 1.0 ± 2.0 mm versus 1.9 ± 1.6 mm (P < .05), respectively, at 1 year; 1.6 ± 2.1 mm versus 2.6 ± 2.4 mm (P < .05), respectively, at 2 years. The Lysholm score was higher in the CaP group than in the conventional method group at 2 years (96.9 ± 4.3 vs 91.7 ± 13.3, P < .05). The CaP-hybridized tendon graft reduced the percentage of bone tunnel enlargement of the anteroposterior diameter at the main joint aperture site 1 year postoperatively (femoral side: 15.5% ± 13.4% vs 22.1% ± 16.4%, P < .05; tibial side: 19.3% ± 17.1% vs 26.1% ± 13.7%, P < .05). The results of the pivot-shift test, IKDC grade, and Tegner score; the intensity of the tendon graft (MRI); and arthroscopic appearance were not significantly different at both follow-up periods in the 2 groups. CONCLUSION The CaP-hybridized tendon graft improved anterior knee stability and Lysholm scores at the 2-year follow-up and improved anterior knee stability and reduced the percentage of bone tunnel enlargement in both tunnels at the 1-year follow-up compared with the conventional method for single-bundle ACL reconstruction. However, longer follow-up is needed to investigate the appearance of any increased instability.
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Affiliation(s)
- Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences, Ami-machi, Inashiki-gun, Japan
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