Original Article

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING PATELLARTENDON AUTOGRAFT

M.N. Sehar*, Sohail Ahmad** and R.M.Davies#

From the: Senior Consultant Orthopaedic Surgeon*, Registrar, Orthopaedics**, Indraprastha ApolloHospitals, Sarita Vihar, New Delhi 110 044, India and Senior Consultant Orthopaedics Surgeon#,

Neath General Hospital, Neath, UK.

Correspondence to: Dr. M.N. Sehar, Senior Consultant Orthopaedic Surgeon, Indraprastha ApolloHospitals, Sarita Vihar, New Delhi 110 044, India.

The purpose of this study was to present our clinical experience in terms of regained joint stability and itsfunctional benefit following anterior cruciate ligament (ACL) reconstruction using the central third of patellartendon.Forty nine patients with persistent clinical and functional instability of the knee due to ACL insufficiencyunderwent ligament reconstruction by patellar tendon autograft. They were followed-up for 18 to 24 monthsuntil functionally rehabilitated and 43 patients were recalled for this review, an average of 30 months afteroperation (range 12 months to 9 years).There were 42 male patients and one female .The average age was 27 years and the average interval frominitial injury to index operation was 2 years and 3 months. Associated pathology was noted in many patients.Twenty eight patients had torn menisci; these lesions were treated either at previous arthroscopy or at the timeof ACL reconstruction; three had osteochondritic lesions and ten had osteoarthritic change of varying degrees.At review, post -recostruction stability was assessed clinically; Lysholm Knee scores and Activity scores wererecorded for knee pre-and post reconstruction. On overall IKDC rating based on subjective assessment,symptoms, range of movement and ligament stability 41 patients were graded as nearly normal (B), 2 weregraded abnormal (C) and none were graded as abnormal.

INTRODUCTION

During the last two decades, clinical and laboratoryresearch has shown the functional importance of theanterior cruciate ligament. Several authors [1,2] havedescribed the anterolateral instability associated with ACLrupture. ACL rupture typically leading to episodes ofgiving way [2] which may cause meniscal injury [2,3] andpremature degenerative changes.[3,6].

The fact that ACL insufficiency may result insignificant disability has led to numerous attempts atsurgical reconstruction of the ligament. These may be extraarticular, intra-articular, or a combination of both. Directrepair [7], extra-articular procedures [8,9] and intra-articular prostheses [10-12] have produced poor long-termresults. Several types of auto grafts including iliotibialband, tendo-achilles, meniscus, patellar and hamstringtendons have been used for intra-articular reconstruction ofthe ACL.Initially, Jones [13] used the medial third of thepatellar tendon with its tibial attachment intact; Clancy [14]later modified the technique using the central third ofpatellar tendon. At present the two most commonly usedautografts for reconstruction of the ACL are central third ofthe patellar tendon or the combined semitendinosus [15,16]and gracilis tendons. Theoretical advantages of using the

patellar tendon are that it is the strongest of all structures,that it has been shown to revascularise and regain sufficienttensile strength and that its use does not sacrifice entirelyand essential stabilizer of the knee. When the graft isharvested with its bone insertions attached, union of bone tobone achieves fixation ultimately. The use of interferencescrews in securing the fixation of bone block givesadequate security to allow intensive rehabilitation.

Several techniques have been used over the years forinsertion of patellar tendon grafts. Initially an openprocedure was employed but lately a miniarthrotomy witharthroscopic assistance or a fully endoscopic technique arealso being used.

PATIENTS AND METHODS Forty-nine patients underwent this operation at Neath

General Hospital, Neath (UK) and Apollo Hospital, NewDelhi. The indication for reconstructing the ACL was thepresence of functional stability during normal activities,and we also required a positive pivot shift test thatreplicated the sensation the patient experienced when theknee was giving way. All patients with ACL instabilitywere offered surgical reconstruction. Our primary goal inundertaking the procedure was to restore functionalstability to the knee joint so as to allow normal activities of

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daily living. Secondary aims were possibly to allow a returnto some recreational activities; we also hoped to prevent ordelay the onset of degenerative arthritis in the knee. Thepatients were cautioned that they should not necessarilyexpect to return to highly competitive sports, particularlycontact sports.

Of forty-nine patients, forty three returned to a personalfollow up evaluation. There were forty two males and onefemale with a mean age of 27 years (20 to 42 years). All butsix patients had sustained the initial injury to the kneewhile engaged in sports activities viz., soccer 25, rugby 11,karate 1. Domestic injury accounted for five cases andindustrial accidents 1. Twenty six patients were injured inrecreational sports and 11 while engaged in competitivesports. Pre-operatively none of patients could return tosports because of instability of the knee. All 43 patients had,as their main complaint, multiple episodes of giving way ofthe knee. This was occasionally associated with pain andeffusion.

Only 3 patients remembered hearing a “pop” in the kneeat the time of initial injury, and all three had a significantswelling developing within two hours of injury. Fivepatients had a menisectomy after the initial injury andbefore the index reconstructive procedure. None of thesehad any decrease in the episodes of instability after themenisectomy. All the patients had a positive Lachman,positive anterior drawer tests and a markedly positive pivotshift test.

Immediately preceding the main reconstructiveprocedures, all patients had an examination underanaesthesia and arthroscopy. The medial meniscus wasfound torn in 20 patients and 8 patients had a torn lateralmeniscus. Three patients had osteochondritic lesions overthe lateral femoral condyle and one patient had fissuring ofthe lateral edge of the medial femoral condyle. Ten patientsshowed some degenerative changes localized mainly topatella and medial femoral condyle. Three patients hadmore than one associated pathology.

Operative technique

All the operations were carried out by the senior author(MNS) under general anaesthesia and tourniquet.

Table 2: Age

• 20-25 years 16• 25-30 years 18• 30-35 years 06

• >35 years 03

The ACL was reconstructed in the chronic phase (>12weeks from injury) in all cases. The interval between injuryand index operation was 6 months -5 years, with an averagetime of 27 month.

METHODS

Via a short midline vertical incision from upper patellato just below the tibial tubercle, a graft 9 or 10 mm wide wasfashioned from the central third of the patellar tendon.Parallel bone blocks were taken in continuity from the tibialtubercle, 30 mm long, and the patella 25 mm long.

An arthrotomy was made via the graft site withresection of the fat pad. Notchplasty was undertaken ifrequired. A graft width hole was drilled over a guide wirefrom just medial to the tibial tubercle, emerging in thecentre of the site of the tibial ACL attachment.

The isometric point was determined on the uppermedial wall of the LFC in the intercondylar notch. Fromthis, a blind tunnel of graft width was drilled to a depthequal to the length of patellar bone over a guide wire in theLFC. The graft was pulled upwards through the tibialtunnel and patellar block pulled snug in the blind endedfemoral tunnel. The patellar block was secured by a 7 mmdiameter interference screw. Following 90 degrees medialrotation of tibial block of the graft, it was secured using a9 mm diameter interference screw.

The joint was drained and closed. An accelerated re-habilitation programme has been adopted with continuouspassive motion commenced on the first postoperative day,without plaster splintage but allowing protected movementwith a simple hinged brace only for 6 weeks.

Table 3: Associated injuries

• Medial meniscus 20• Lateral meniscus 8• Osteochondritic lesion 3• Fissuring of medial femoral condyle 1• Osteoarthritic changes 10

Table 1: Nature of Injury

• Football 25• Rugby 11• Karate 1• Domestic 5• Industrial accident 1

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Evaluation

All patients were assessed by one examiner (MNS)using the evaluation of internal knee documentationcommittee. Anterior cruciate stability was assessed on anexclusively clinical basis using Lachman, anterior drawerand a pivot shifts tests. No arthometric testing orradiographic imaging was carried out.

The Lachman and anterior drawer tests were graded as0 (<3mm laxity), 1 (3-5mm laxity) and 2 (>5mm laxity) andthe pivot shift test as 0 (negative), 1 (glide), 2 (clunck) and3 gross. Thigh atrophy and knee effusion were noted.

In order to assess function, every patient had a Lysholmknee score calculated and activity scores before injury andat the time of evaluation were compared.

RESULTS

Knee stability: Ten patients showed grade zero laxity onLachman and anterior drawer tests, while 31 patientsshowed grade 1. Further 2 patients showed grade 2 laxity,although the pivot shift test was positive grade 2 in only 1 ofthese.

Activity score

Pre injury 31 patients had activity score of 5, 7 had ascore of 7, while 5 patients achieved a pre-injury activityscore of 9. Only 7 patients went back to same level ofactivity score while 36 patients had a reduction of activityscore by 1. It is to be noted that the majority of these patientsexpressed a fear of re-injuring the knee again if they attempta resumption of the same activity level; they neverthelesshad demonstrably stable knees.

Lysholm knee score: Scores varied from 70-95 with a meanof 80. Twenty seven patients score more than 84 indicatinga good or excellent rating. Pain and difficulty on stairclimbing and squatting were main reason for the drop inscore.

Range of movement

Three patients had a 5 degree lack of full extensionwhile all 43 patients had full flexion.

Symptoms

Nine patients complained of anterior knee pain,

Table 4: Clinical Graft Stability

Grade Lachman Anterior drawer Pivot shift

0 (<3mm) 10 10 401 (3-5mm) 31 31 022 (>5mm) 02 02 01

indicating its site as patellar. Two patients had mildeffusion and another 2 (those with grade 2 Lachman andanterior drawer tests) experienced episodes of partialgiving way when turning suddenly. On subjectiveassessment by the patient, 41 knees were nearly normal (B)and another 2 were graded abnormal (C); none was gradedgrossly abnormal (D).

Crepitus

Thirteen patients were noted to have crepitus, 11 in thepatello-femoral compartment and 2 medially.

Graft site tenderness

Eight patients had mild to moderate tenderness at thegraft site.

Quadriceps wasting

Twenty nine patients had regained quadriceps bulk towithin 2 cm, while 2 patients had wasting of 5 cm or more,while other 12 patients had equal bulk as compared tonormal site.

Knee test

Twelve patients complaint of pain at the tibial tubercleon kneeling while 6 of these were also tender over thelingamentum patellae.

COMPLICATIONS

Three patients has superficial infections which resolvedafter oral antibiotics.Six patients had effusions, presumablehaemarthroses,but none needed drainage.One patient hadurinary retention in the post-operative period.One patient’sknee gave way 3 months after surgery in a fall whilefarming and an MRI scan confirmed disruption of the graft.

DISCUSSION

Patients with a functionally unstable knee due toanterior cruciate ligament deficiency have a high incidenceof meniscal tears and degenerative changes.In our study themajority of ACL ruptures occurred in sports injuries, but asignificant number also occurred in domestic and otheraccidents. We included only those patients who hadfunctional instability during normal activity and not

Table 5: Knee Score of Patients

Score No. of patients

• 91-100 22• 81-90 11• 71-80 7• 70 or above 3

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improving following a muscle and proprioceptiverehabilitation programme.

Intra-articular reconstruction of the ACL wasperformed with the intention of eliminating the functionalinstability and also of preventing the onset or retarding theprogression of degenerative osteoarthritis although recentstudies cast doubt on latter. It is doubtful whether a trulyisolated rupture of ACL exists. In our study 28 patients hadmeniscal injuries, 4 had chondral lesions while 10 showedsome degenerative changes. Associated injuries of thisnature have also been reported by Finsterbush, et al [20]and Daniel & Fithian [21] . The availability of magneticresonance scanning in recent years has demonstratedextensive bone bruising as a frequent occurrenceundetectable clinically and arthroscopically.

In our study 41 patients had stable knee followingreconstructive surgery with a grade 0 or 1 laxity onLachman or anterior drawer tests. One patient with a grade2 pivot-shift test and 1 of the 2 patients with a grade 1experienced episodes of giving way; the second patientwith the grade 1 pivot shift abnormality denied subjectiveinstability of this nature.

On assessment of activity scores, 36 patients (84%) hada drop of 1 level as compared to their pre injury estimatesand only 7 (16%) return to their pre injury levels.

Anterior knee pain and pain on kneeling were the maincomplaints among patients in our study. Nine had anteriorknee pain and three others were unable to kneel. It isinteresting to note that all 9 patients with knees in the moststable categories with negative Lachman, anterior drawerand pivot shift tests.

In conclusion, our results show that all but two patientshad stable knee during both normal and recreationalactivities. Despite the achievement of stability there was adrop of 1 level in activity as compared to pre injury level.No patient had a significant loss of range of motion and41 patients out of 43 patients were satisfied with the result.Anterior knee pain and inability to kneel were the mainconcerns in 28% of patients; the cause seems to relate to thepatellar tendon graft site.

REFERENCES

1. Solcum DB, Larson RL. Rotatory Instability of the knee, itspathogenesis and a clinical test to demonstrate itspresence. J Bone Joint Surg (Am) 1968; 50-A: 211.

2. McDaniel WJ, Damoron TB. Untreated ruptures of theanterior cruciate ligament. J Bone Joint Surg (Am) 1980;62-A: 696-705.

3. Arnold JAA, Coker TP, Heaton LM, Park JP, Harris WD.Natural history of anterior cruciate tears. Am J Sports Med1979; 7: 305-313.

4. Noyes FR, Mooar PA, Mathews DS, Butler DL. Thesymptomatic anterior cruciate deficient knee. Part I. Thelong term functional disability in athletically activeindividuals. J Bone Joint Surg (Am) 1983; 65-A:154-162.

5. Kannus P, Jarvinen M. Conservatively treated tears ofanterior cruciate ligament: long term results. J Bone JointSurg (Am) 1987; 69-A: 1007-1012.

6. Hawkings RJ, Misamore GW, Merritt TR. Follow-up of theacute nonoperated isolated anterior cruciate ligamenttears. Am J Sports Med 1986; 14: 205-210.

7. Engerbresten L, Benum P, Sundalsvol S. Primary sutureof the anterior cruciate ligament: A 6-year follow-up of 74cases. Acta Orthop Scand 1989; 60: 561-564.

8. Chick RP, Collins HR, Rubin BD, et al. The pes anserinustransfer: a long-term follow-up. J Bone Joint Surg (Am)1981; 63-A: 1449-1452.

9. Bray RC, Flanagan JP, Dandy DJ. Reconstruction forchronic anterior cruciate instability: a comparison of twomethods after six years. J Bone Joint Surg (Br) 1988; 70-B: 100-105.

10. Olson EJ, Kang JD, Fu FH, et al. The biochemical andhistological effects of artificial ligament were particles: invitro and in vivo studies. Am J Sports Med 1988; 16: 558-570.

11. Woods GA, Indelicato PA, Prevot TJ. The Goretex anteriorligament prosthesis: two versus three year results. Am JSports Med 1991; 19: 48-55.

12. Grotvedt T, Engerbrestsen L, Benum P, et al. Aprospective, randomised study of three operations foracute rupture of the anterior cruciate ligament: 5 yearfollow-up of 131 patients. J Bone Joint Surg (Am) 1996;78: 159-168.

13. Jones KG. Use of the central one-third of the patellarligament to compensate for anterior cruciate ligamentdeficiency. Clin Orthop 1980; 147: 37.

14. Clancy WG, Nelson DA, Reider B, et al. Anterior cruciateligament reconstruction using one third of patellarligament, augmented by extra-articular tendon transfer. JBone Joint Surg 1982; 64-A: 352.

15. Amiel D, Klenier JB, Akeson WH. The natural history of theanterior cruciate ligament autograft of patellar tendonorigin. Am J Sports Med 1986; 14: 449-462.

16. Johnson RJ, et al. Current concepts reviews: Thetreatment of injuries of anterior cruciate ligament. J BoneJoint Surg (Am) 1992; 74-A: 140-151.

17. Torg J, Conrad W, Kalen V. Clinical diagnosis of anteriorcruciate ligament instability in the athlete. Am J SportsMed 1976; 4: 84-93.

18. Galway RD, Beaupre A, MacIntosh DL. Pivot shift: aclinical sign of symptomatic anterior cruciate ligamentinsufficiency. J Bone Joint Surg (Br) 1972; 54B:763-764.

Apollo Medicine, Vol. 2, No. 2, June 2005 128

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19. Tenger Y, Lysholm J. Rating systems in the evaluation ofknee ligament injuries. Clin Orthop 1985; 198: 43-49.

20. Finsterbush A, Franki U, Matan Y, Mann G. Secondarydamage to the knee after isolated injury of the anteriorcruciate ligament. Am J Sports Med 1990; 18: 475-479.

21. Daniel DM, Fithian DC. Indications for ACL surgery.Arthroscopy 1994; 10: 434-441.

22. Dye SF, Wojtys EM, Fu FH, Fithian DC, Gilquist J. Factorscontributing to function of the knee joint after injury orreconstruction of anterior cruciate ligament. J Bone JointSurg (Am) 1998; 80A: 1380-1393.