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EVALUATION OF ARTHROSCOPIC ACL

RECONSTRUCTION BY 3 DIFFERENT TECHNIQUES

DISSERTATION SUBMITTED TO UNIVERSITY OF SEYCHELLES

AMERICAN INSTITUTE OF MEDICINE

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE

M.Ch (Orthopaedic Surgery)

By DR. AMIT AHLUWALIA

Orthopaedic Surgeon

2013 

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Special thanks to co-author and my colleague

Dr. Atul Mishra

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INTRODUCTION

• The goal of arthroscopic ACL reconstruction is to restore joint function by recreating as closely as possible normal knee kinematics.

• Biomechanical studies have demonstrated that single bundle ACL reconstruction is insuf ficient for controlling rotation in extension.

• Double bundle ACL reconstruction has been shown to provide more improvement in knee stability theoretically because it more closely mimics the anatomic structure of ACL.

Aim

• To analyze the clinical outcome of arthroscopic anterior cruciate ligament (ACL) reconstruction done in 58 patients over a period of 1 year by 3 different surgical techniques using hamstring autograft.

3 different surgical techniques:

1. Hamstrings [semitendinosis and gracilis (STG) combined] by Double Bundle anatomical reconstruction (DB)

2. Quadrupled Single Bundle reconstruction (SB)

3. Over the top with Lateral Plasty {OTLP (combined intra and extra-articular tenodesis technique)}

MATERIALS AND METHODS

• The records of 58 consecutive patients who underwent arthroscopic ACL reconstruction in the year 2007 were evaluated.

• The patients were selected if they met the following criteria:

1. Presence of unilateral isolated monoligamentous injury

2. No history of surgery on the contra lateral knee or extremity

3. No history of surgery on the ipsilateral extremity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Demog

Surgica

No of p

Mean a

Male/F

Mean t(month

                                            

 

The type osufficient limplants.

graphic da

al Group

patients

age in yrs

Female rati

time to surhs)

                                            

of reconstrength of h

ata of the

o

rgery

18

             Surg                    (

uction seleamstring g

patients

OTL

18

24.6

15/3

2.7

20

4 

gical Groups(n=58) 

ected was graft and af

LP

6

3

dictated byffordability

SB

20

25.6

15/5

2.6

20

y the needof the pat

DB

20

24.7

17/3

2.9

DSO

to obtain ient for the

DBSBOTLP

a e

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Radiological Evaluation Preoperative MRI   

    

           

 

           

 

SurgicOver th

•

•

 

             

 

Prepar

 

             

cal Technihe top wit

STG auto

The insert

ration of Ov

que th lateral p

graft was

tion of STG

ver the Top

plasty:

harvested

G over tibia

p position

6 

using an o

a was pres

open type t

erved

 

tendon striipper

 

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Surgical Technique Over the top with lateral plasty:

• Tibial tunnel was drilled using 6mm diameter cannulated reamer and was further dilated using a 7mm dilator.

• Over the top femoral position was prepared

• The STG auto graft was negotiated through the tibial tunnel and routed over the top of the lateral femoral condyle

 

                

• Fixation on the lateral femoral cortex was done by two 8mm ligament staples.

                

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• Prior to fixation manual tensioning of the graft was done by constantly pulling the graft and subjecting the knee through a full range of motion 10 times

 

                 

• Fixation was done keeping the knee in 900 flexed position while maintaining a posterior push on the tibia and externally rotating the tibia by 100.

• The remaining graft was negotiated distally beneath the facia lata and fixed on Gerdys tubercle with one ligament staple keeping the knee in the same position as above.

• Notchplasty was not done.

    

 

•

•

Postop X

SurgicalSingle B

GRAFT P

STG was

Gracilis &

X Ray AP

l TechniqBundle R

REPARAT

harvested

ST were s

P view 

que Reconstru

TION

and the in

stitched tog

9 

 

uction

sertion wa

gether and

as sacrifice

quadruple

ed

ed

 

 

•

Quadrup

A tibial tdiamete

pled graf

tunnel wr of quad

ft

was drilledrupled g

10 

d up to 7graft

7-8mm depending on the

e

 

•

•

•

•

•

A femoral 1.30 0’clocappropriat

An approp

Manual tesubjecting

Femoral fi

Tibial fixatinterferenc

guide pin wck on the lete offset de

priate size t

nsioning o the knee t

xation was

tion was doce screw.

was positioeft knee wevice inser

tunnel was

f the graft through a

s done usin

one keepin

11 

oned at 10ith 90-1100

rted throug

s prepared

was done full range o

ng endobu

ng the knee

0.30 0’clock0 flexion ath the AM p

d

by constanof motion 1

tton (CL, M

e in 300 fle

k on the rigt the knee,portal.

ntly pulling10 times.

Mersilene t

exion with m

ght knee a using an

g the graft a

tape)

metal/ bio

nd

and

 

Postop X

 

 

 

 

 

X-Ray APP and La

12 

ateral vie

 

 

ews

 

 

 

Postop X

 

 

 

 

 

X-Ray annd MRI

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Surgical Technique Double Bundle Reconstruction

GRAFT PREPARATION

• Semitendinosis and Gracilis tendons were separately prepared so as to obtain a minimum graft diameter of 7mm for anteriomedial (AM) bundle and 5-6mm for posterolateral (PL) bundle.

FEMORAL TUNNEL PREPARATION

• For AM femoral tunnel, a 4mm over the top guide was inserted through the AM portal keeping the knee in about 1000 of flexion and placed on the proximal cortex of the intercondylar notch at about 11 o’clock for the right knee and 1 o’clock for the left knee.

PL FEMORAL TUNNEL PREPARATION

• The 4mm offset guide hook was placed in the AM femoral tunnel and the knee was flexed further by 5-100 to get adequate divergence of the two tunnels.

PL TUNNEL ENTRY POINT IDENTIFICATION

1. The point lies roughly at the same level in horizontal plane in relation to AM tunnel in 900 knee flexion.

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2. The center of the PL bundle footprint is approximately located at the crossing point of the long axis line of the ACL attachment and a vertical line drawn through the contact point between the femoral condyle and tibial plateau at 900 of knee flexion

3. The socket was placed at 9 o’clock position for the right knee and 3 o’clock position for the left knee.

4. The position of the guide wire was rechecked by switching the arthroscope from anterolateral to anteromedial portal

TIBIAL AM & PL TUNNEL PREPARATION

• The tibial guide pin was inserted using a normal tibial guide tip aimer through the anterior part of ACL footprint

• With the guide pin in place the same tibial aimer was used to pass another guide pin in the posterior part of the ACL footprint.

• Two leading sutures were passed through the two femoral tunnels.

• The suture in the AM femoral tunnel was pulled out through the AM tibial tunnel

• The leading suture in the PL femoral tunnel was pulled out into the PL tibial tunnel.

• Care was taken that the PL leading suture remains posterior to the AM leading suture.

• The PL bundle was negotiated first through the tibial and femoral tunnels followed by the AM bundle.

TENSIONING & FIXATION

• The graft loops were secured on the femoral side with endobutton CL or endobutton with mersiliene tape loop and on the tibial side with bio interference screws.

• The AM bundle is isometric and the PL bundle is anisometric.

• Therefore the PL bundle is secured on the tibial side first keeping the knee in 100 flexion using bioabsorbable interference screw.

• The AM bundle is secured later with the knee in 300 flexion.

 

Posto

 

Follow

 

 

op X-Ray

w up X-ra

ys AP and

ay

d Latera

16 

l views

 

 

 

 

Postopeerative Re

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ehabilitaation Prootocol:

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Clinical Assessment:

• Recorded prior to surgery and at 1 year follow up.

• Ligament stability was assessed by the use of Lachmans and Anterior Drawer Test.

• Cincinnati Knee Score was used to evaluate the functional outcome.

• Pivot shift test was not used for clinical assessment as it is less reproducible and more subjective.

• The Cincinnati score includes hard shifts, cuts and pivots.

Preoperative findings on physical examination

Grade 0 1 2 3

Anterior Drawer test

OTLP (n=18) 0 0 11 7

SB (n=20) 0 1 13 6

DB (n=20) 0 0 12 8

Lachman’s test

OTLP (n=18) 0 1 10 7

SB (n=20) 0 0 14 6

DB (n=20) 0 0 13 7

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Cincinnati Knee Score

Measure Ability Points

Walking normal unlimited 40

some limitations 30

only 3-4 blocks possible 20

less than 1 block possible 0

stairs normal unlimited 40

some limitations 30

only 11 – 30 steps possible 20

only 1 – 10 steps possible 0

squatting and kneeling normal unlimited 40

some limitations 30

only 6 – 10 possible 20

only 0 – 5 possible 0

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Cincinnati Knee Score

Measure Ability Points

Straight running full competitive 100

some limitations guarding 80

half-speed definite limitations 60

not able 40

jumping and landing full competitive 100

some limitations guarding 80

half-speed definite limitations 60

not able 40

hard twists cuts pivots full competitive 100

some limitations guarding 80

half-speed definite limitations 60

not able 40

Cincinnati Knee Score

• Functional assessment score = SUM of points for all 6 activities

• Interpretation:

• minimum score: 120

• maximum score: 420

• The goal is to have the highest possible function in each of the 6 categories.

 

•

Mean A

Male: F

0

5

10

15

20

25

30

0

2

4

6

8

10

12

14

16

18

20

There wasat the time

Age at sur

Female ra

OT

1

3

s no signifie of surgery

rgery in ye

atio

24.6

LP

5

3

R

cant differey, sex and

ears

25

SB

15

5

21 

ESULTS

ence betw time to su

.6

B

5

5

S

een the 3 gurgery

24.7

DB

17

3

groups wit

B

7

3

th respect t

Fem

Ma

to age

male

le

 

Mean

RESU

•

0

1

2

time to

ULTS

The 3 grouand Subje

0

0.5

1

1.5

2

2.5

3

O

surgery

ups were cective evalu

OTLP

2.7

(in mont

compared wuation thro

SB

2

22 

ths)

with respeugh Cincin

B

2.6

ct to findinnnati Knee

DB

2.9

ngs of physscore.

sical exami

Time

ination

e to Surgeryy

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Preoperative findings on physical examination

Grade 0 1 2 3

Anterior Drawer test

OTLP (n=18) 0 0 11 7

SB (n=20) 0 1 13 6

DB (n=20) 0 0 12 8

Lachman’s test

OTLP (n=18) 0 1 10 7

SB (n=20) 0 0 14 6

DB (n=20) 0 0 13 7

Postoperative findings on physical examination at 1 year

Grade 0 1 2 3

Anterior Drawer test

OTLP (n=18) 15 3 0 0

SB (n=20) 14 4 2 0

DB (n=20) 16 4 0 0

Lachman’s test

OTLP (n=18) 14 4 0 0

SB (n=20) 15 3 2 0

DB (n=20) 16 4 0 0

 

Preope

Preope

0

50

100

150

200

250

300

350

400

450

0

50

100

150

200

250

300

350

400

450

erative an

erative an

OTLP

270.5

3

d postope

d postope

P

26

396

Preop

erative Cin

erative Cin

SB

65.5

380

24 

ncinnati S

ncinnati S

DB

256

3

Score

Score

97.2

1 yr po

Mean pre

mean po

ostop

eop Score

ostop scoree

SB

OTLP

DB

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Complications

• Infection (n=1 in SB group)

• Tunnel widening (n=1 in SB group)

• Heterotrophic calcification (n=1 in OTLP group)

• Restriction of terminal flexion (n=1 in DB group)

• Extension lag (n=1 in DB group)

Complications in the three surgical groups

n=58

OTLP (n=18)

Heterotropic Calcification

(n=1)

Underwent implant removal

DB (n=20)

Restriction of Terminal flexion

(n=1)

Extension lag(n=1)

SB (n=20)

Infection(n=1)

Tunnel widening(n=1)

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Tunnel widening after SB Reconstruction at 1 yr

           

 

Tunnel widening seen on MRI

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DISCUSSION

• The overall results were comparable in all 3 groups.

• The incidence of antero-posterior laxity was less in the DB and OTLP groups as compared to the SB group.

• There was no incidence of kneeling pain.

• Hypoesthesia around the graft harvest site was seen in few patients and can be attributed to the involvement of saphenous nerve

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Conclusions and recommendations

• The sample size was small and hence statistical analysis was difficult.

• The patients were not allotted to the 3 treatment groups in a randomized manner due to graft length issues and patients’ financial constraints.

• Since we did not evaluate pivot shift test preoperatively, we were unable to determine whether rotational laxity influenced patient satisfaction with regard to surgical outcome

• Biomechanical evaluation like KT-2000 arthrometer is needed to further quantify the results.

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REFRENCES

1. Yasuda et al, Arthroscopy. 2006 Mar;22(3):240‐51  

2. Fu F H et al Sports Med. 2006;36(2):99‐108  

3. Kurosaka et al, Clin Orthop Relat Res. 2007 Jan;454:100‐7.  

4. Noyes FR et al.Clin Orthopaedics and Related Research. 1989; 246: 238-249 

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