|Year : 2018 | Volume
| Issue : 1 | Page : 38-41
Arthroscopic reconstruction of Anterior Cruciate Ligament (ACL) in IGIMS: One year follow up
Abhijeet Subhash, Manish Kumar, Santosh Kumar, Rajesh Kumar Ranjan
Department of orthopaedics, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
|Date of Web Publication||10-Dec-2020|
Associate professor, Department of Orthopaedics, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar
Source of Support: None, Conflict of Interest: None
Purpose : To review the results of patients who underwent arthroscopic reconstruction of the anterior cruciate ligament (ACL) done in IGIMS.
Methods : Patients having symptomatic ACL-deficient knees and who wanted to continue an active lifestyle or maintain sporting activities were included. ACL reconstruction using the quadrupled hamstring autografts in more than 100 patients were done . One-year follow up was completed in 56 patients who were then reviewed. The mean age of patients reviewed was 26.8 years (range, 21-39 years), of whom 35 (62.5%) were aged between 26 and 30 years. There were 52 male and 4 female patients (ratio, 13:1). Injuries on the left side was greater than right (32 versus 24).Both motor vehicle accidents as well as Sports injuries accounted for 46.4% (n=26) of patients, while household injuries accounted for 7.2% (n=4).
Results : Excellent and good-to-excellent results were achieved in 6 (10.7%) and 40 (71.4%) of patients respectively. Residual knee swelling (n=13) was the most common complication, followed by difficulty in regaining full range of motion (n=9) and divergence of femoral screw (n=6).
Conclusion : This procedure at IGIMS provided consistent and reproducible results and allowed patients, an early return to daily activities with minimal morbidity.
Keywords: Anterior cruciate ligament , Arthroscopy, Quadrupled hamstring autograft
|How to cite this article:|
Subhash A, Kumar M, Kumar S, Ranjan RK. Arthroscopic reconstruction of Anterior Cruciate Ligament (ACL) in IGIMS: One year follow up. J Indira Gandhi Inst Med Sci 2018;4:38-41
|How to cite this URL:|
Subhash A, Kumar M, Kumar S, Ranjan RK. Arthroscopic reconstruction of Anterior Cruciate Ligament (ACL) in IGIMS: One year follow up. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2022 Jan 20];4:38-41. Available from: http://www.jigims.co.in/text.asp?2018/4/1/38/302982
| Introduction :|| |
ACL rupture deprives the knee of a major stabilizer as well as a proprioceptive structure. Mensci becomes more prone to injury and early degeneration of knee occurs. ACL reconstruction is one of the common procedures done by an orthopaedic surgeon. In recent past ACL surgery has tremendously evolved from open surgery to arthroscopic reconstruction using variety of graft choice and fixation techniques. Single bundle ACL reconstruction that is focused mainly on the AM bundle remains the “gold standard” and quadrupled hamstring autograft are the strongest available graft,,,. We represent our experience of first 56 cases of arthoscopically assisted single bundle ACL reconstruction using quadrupled hamstring autografts done in IGIMS, Patna.
| Materials and Methods :|| |
This is a prospective study was conducted at the Indira Gandhi Institute of Medical Sciences, Patna between September 2016 and October 2017. Patients with symptomatic ACL deficient knees who wished to return to active lifestyle and sporting activities were included. Patients were excluded if there was fracture around the knee, posterior cruciate ligament injury or age below 18 years. The study was approved by departmental and institutional ethical committee, and informed consent was obtained from all patients. ACL reconstruction using the hamstring autograft was performed in more than 100 patients during the study period. One-year follow-up was completed in 56 patients. The mean age of patients reviewed was 28.7 years (range, 21-46years), of whom 35 (62.5%) were aged between 26 and 30 years. There were 52 male and 4 female (ratio, 13:1) patients. Injury on the left side was greater than right (32 versus 24). Sports injuries accounted for 46.4% (n=26) of patients, while motor vehicle accidents and household injuries accounted for 46.4% (n=26) and 7.2% (n=4) respectively.
Majority of diagnosis was done by clinical examination and confirmed by magnetic resonance imaging (MRI). Radiographs were obtained in two planes to rule out any fracture and deformity around knee. Acute ACL ruptures were treated conservatively for three weeks prior to surgery. Surgery was performed after subsidence of acute inflammatory response. Preoperatively full range of motion and absence of extension lag was achieved in all patients by intense physiotherapy. All patients were operated under spinal or combined spinal-epidural anaesthesia with prophylactic antibiotic coverage. Graft was harvested before pneumatic tourniquet was inflated to reduce the overall tourniquet time.
A three cm skin incision was made 3 finger breaths distal to the joint line and 2 finger breaths medial to the tibial tubercle. Sartorial fascia was identified and pes tendons palpated deep to it. Sartorial fascia was elevated with blunt object and incised longitudinally exposing gracillis and the semitendinosus tendons. Semitendenosous tendon was released and harvested by tendon stripper.
The edges of the graft were trimmed and remaining muscle fibers removed. The graft was then mounted on the graft workstation. The length of the graft was measured accurately and doubled over fixation device. The open end were sutured with No.5 ethibond and covered with a moist sponge.
All soft tissues along with ligamentum mucosum were excised from lateral wall of the intercondylar notch. Except tibial stump most of the remaining ACL tissue was excised.
In cases of stenotic notches of less than 20 mm and difficult ‘over-the-top’ visualization notch plasty was performed.
Femoral tunnel placement
A femoral offset guide was used to position the guide pin 7 mm anterior to the ‘over-the-top’ position. A 4-mm reamer was used to create initial femoral tunnel. Final reaming was done in accordance with graft size. The opening of the tunnel was cleared of all soft tissue.
Tibial tunnel placement
ACL jig was introduced via anteromedial portal and positioned on the ACL footprint just lateral to medial tibial spine and medial to posterior border of anterior horn of lateral meniscus. The cannulated guide was then pressed against the tibial cortex 1.5 cm medial to the tubercle. A pin was drilled and observed arthroscopically as it entered the desired site on the intercondylar area. A cannulated reamer was used to prepare the tunnel over the guide pin.
Graft placement and fixation
Ethibond thread was placed across both the tibial and femoral tunnels to exit through the anterolateral aspect of the thigh. The ethibond threads attached to threads of endobutton were withdrawn from femoral side along with flipping of endobutton.The knee was cycled 25 times while applying tension over the holding sutures. Tibial fixation was performed at 20° flexion using interference screw.
A compression dressing and hinge knee brace were applied postoperatively. Partial weight bearing was encouraged and gradually increased. Full weight bearing was permitted 4 weeks postoperatively. An intensive rehabilitation programme was instituted to allow patients to resume sporting activities and to regain range of motion, muscle strength, and normal gait.
| Results :|| |
Evaluation was performed using lower extremity functional score (LEFS) proposed by Binkley et al [Table 1]. At one-year follow-up, knee function was considered excellent in 6 (10.7%) patients, good-to-excellent in 40 (71.4%) patients, and fair-to-good in 6 (10.7%) patients, based on the LEFS. Results were poor in 4 (7.1%) patients with other associated injuries [Table 2].
|Table 2: Surgical outcome of patients at one-year follow- up according to LEFS|
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Most patients (n=48, 85.7%) achieved a good range of motion.Five (8.9%) patients had restriction of terminal extension, 2 (3.5%) had more than 15° loss of terminal flexion, and one (1.7%) had 10° to 90° flexion. Only one fourth (25%) of patients had isolated ACL injury as rest of them had associated injuries of the knee [Table 3].
During arthroscopic ACL reconstruction, meniscal tears were treated either by partial meniscectomy or meniscal repair. Medial Collateral ligament tears were reconstructed and lateral collateral ligament tears managed conservatively. Instability was assessed at the final follow-up using the anterior drawer and Lachman test. The knee joint was found to be unstable in 9 (16.07%) patients. Further one (1.7%) patient had clinically significant instability that interfered with his activities of daily living.
The most common complication was knee swelling which gradually subsided with time [Table 4]. Poor hold of tibial screw was the most common intra operative complication managed by additional fixation implants. Posterior blow out of the femur was managed by a second interference screw to provide additional stability. Loss of full range of motion was present in 9 (16.07%) patients.
| Discussion :|| |
Rupture of the ACL causes instability of the knee and episodes of giving way, leading to repeated injury to the menisci, and early degenerative changes,. Arthroscopic ACL reconstruction facilitates easy rehabilitation, less morbidity, early recovery and improves patient satisfaction, and allows an early return to daily activity. Associated injuries can be managed simultaneously.
The hamstring tendon autograft for ACL reconstruction can be readily procured and firmly fixed. It can tolerate the loads produced by an intensive rehabilitation programme. Fixation of graft using endobutton (suspensory fixation) and interference screw provides sufficient stability to meet the demand of a vigorous postoperative rehabilitation programme.
42 patients had associated injuries out of 56. Among them most common was medial meniscal injury, followed by medial collateral ligament tear (n=16, 24.2%)[Table 3]. Presence of associated injury is not only an indicator of damage occurring at the time of initial trauma but also secondary damage in the ACL deficient knee. Extensive bone bruises are evident on late MRI that could not be detected clinically or arthroscopically in initial phase. Results of ACL reconstruction can be compromised due to these associated injuries.
Based on the lower extremity functional scoring system (LEFS) proposed by Binkley et al5 [Table 1]. 82.1% of the patients achieved excellent and good-to-excellent results At one-year follow-up.These results were comparable with those achieved following similar reconstruction procedures,,. The scoring system assigns 80 points under 20 headings of pain and instability during walking, running, or jumping and other parameters. It correlates well with patients’ return to pre-injury level of activity. Results obtained using this technique was significantly better than conservative management, open ACL reconstruction, extra-articular procedure and intraarticular prosthesis.
Knee function was considered excellent in 6 (10.7%) patients, good-to-excellent in 40 (71.4%) patients, and fair-to-good in 6 (10.7%) patients based on the LEFS scoring. Results were poor in 4 (7.1%) patients with other associated injuries [Table 2].
Most patients (n=48, 85.7%) achieved a good range of motion. Five (8.9%) patients had restriction of terminal extension, 2 (3.5%) had more than 15° loss of terminal flexion, and one (1.7%) had 10° to 90° flexion. Only one fourth (25%) of patients had isolated ACL injury as rest of them had associated injuries of the knee [Table 3]. There was a single instance of postoperative infection which required joint lavage in this series. This signifies the advantage of this method over other methods as it does not require wide exposure which may lead to disastrous infective sequalae. A magnified view obtained during arthroscopy helps us for accurate tunnel and graft placement.
The advantages of the hamstring tendon as a graft source are less invasive while harvesting it, negligible immediate pain and no anterior knee pain, its strength and faster return of range of motion. Prosthetic materials are expensive, prohibitively so for most Indian patients. Bone patellar tendon bone graft as a source of graft have the disadvantages of being more invasive and source of anterior knee pain.
Residual anterior knee swelling (n=13, 23.2%) and loss of full range of motion (n=09, 16%) were 2 most common complications. Rehabilitation program starts day after surgery to avoid these complications. There were no disruptions of the extensor mechanism or non-traumatic graft failure. No incidence of extensor mechanism disruption or non traumatic graft failure occurred. In spite of risk of poor result in cases of ACL tear with associated injuries, result obtained from them was comparable to cases with isolated ACL tear. This validates the fact that ACL has major contribution in knee function.
In early stage when the procedure was first introduced at our institute frequency of complications was high but it decreased over time indicating improvement in surgical technique. No significant technical drawback detected so far.
| Conclusion :|| |
Patients with ACL-deficient knees and having rehabilitation potential undergoing arthroscopic ACL reconstruction using hamstring tendon autograft can expect consistent and reproducible surgical results. Early and intensive rehabilitation had major contribution for return to preoperative levels of daily activity. Residual knee swelling is a major complication.
- Contributors All authors contributed to the surgery. Author2 and author1 wrote the manuscript and analyzed the results with support from Author4. Author3 supervised the project.
- Data sharing statement I do not object to sharing our data for the original research article.
| References|| |
Yunes M, Richmond JC, Engels EA, Pinczewski. Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: A meta-analysis. Arthoscopy, 2001 Mar;17(3):248-257.
Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BRJr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003;31(1):2-11.
Cerulli G, Placella G, Sebastiani E, Tei MM, Speziali A, Manfreda F. ACL Reconstruction: Choosing the Graft. Joints. 2013;1:18-24.
Watanabe M. The development and present status of the arthroscope [in Japanese]. J Jpn Med Instr 1954;25:11.
Binkley JM, Stratford PW, Lott SA, Riddle DL. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties , and clinical application. North American Orthopaedic Rehabilitation Research Network. Phy ther.1999 apr;79(4):371-81.
Arnold JA, Coker TP, Heaton LM, Park JP, Harris WD. Natural history of anterior cruciate tears. Am J Sports Med 1979;7:305-13.
Fetto JF, Marshall JL. The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 1980;147:29-38.
Johnson RJ, Beynnon BD, Nichols CE, Renstrom PA. The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74:140-51.
Howell SM, Taylor MA. Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 1996;78:814- 25.
Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990; 18:292-9.
Stein LN, Fischer DA, Fritts HM, Quick DC. Occult osseous lesions associated with anterior cruciate ligament tears. Clin Orthop 1995;313:187-93.
Marquass B, Hepp P, Engel T, Düsing T, Lill H, Josten C. The use of hamstrings in anterior cruciate ligament reconstruction in patients over 40 years. Arch Orthop Trauma Surg. 2007;127:835-43.
Rob PA Janssen, Nicky van Melick, Jan BA van Mourik, Max Reijman, Lodewijk W van Rhijn Similar clinical outcome between patellar tendon and hamstring tendon autograft after anterior cruciate ligament reconstruction with accelerated, brace-free rehabilitation: a systematic review DOI: 10.1136/journal of international society of arthroscopy knee surgery and orthopedics sports medicine (ISAKOS)-2016-000110
Poolman RW, Abouali JAK, Conter HJ, et al. Overlapping systematic reviews of anterior Cruciate ligament reconstruction comparing hamstring autograft with bone-patellar tendon-bone autograft: why are they different?. J Bone Joint Surg Am 2007
Engebretsen L, Benum P, Sundalsvoll S. Primary suture of the anterior cruciate ligament. A 6-year follow-up of 74 cases.Acta Orthop Scand 1989;60:561-4.
Chick RP, Collins HR, Rubin BD, Kerlan RK, Jobe FW, Carter VS, et al. The pes anserinus transfer. A long-term follow-up. J Bone Joint Surg Am 1981;63:1449-52.
Olson EJ, Kang JD, Fu FH, Georgescu HI, Mason GC, Evans CH. The biochemical and histological effects of artificial ligament wear particles: in vitro and in vivo studies. Am J Sports Med 1988;16:558- 70.
[Table 1], [Table 2], [Table 3], [Table 4]