RESEARCH ARTICLE Open Access

Effect of haemarthrosis on the rehabilitation ofanterior cruciate ligament reconstruction- singlebundle versus double bundleVibhu Bahl*, Ankit Goyal, Vineet Jain, Deepak Joshi and Deepak Chaudhary

Abstract

Background: Haemarthrosis and pain adversely affects the functional outcome of ACL reconstruction, especially incase of DB ACL reconstruction due to more extensive procedure. The purpose of the study was to evaluate theeffect of haemarthrosis on the rehabilitation of DB ACL reconstruction versus SB ACL reconstruction.

Methods: 100 patients were divided into two groups, of SB ACL and DB ACL reconstruction consisting of 50patients each. An intra-articular drain was put in every patient. The pain was evaluated till week 8 using VAS (VisualAnalog Scale). The Functional outcomes were evaluated using the Isokinetic Dynamometer at 3 and 6 months inboth the groups. Muscle bulk and Range of motion were also noted in each group.

Results: The results showed that there was statistically significant difference between the drain amount (n = 60.3 mlin SB ACL group vs. n = 94.2 ml in the DB ACL group) and haemarthrosis (n = 0.7 in SB ACL vs n = 1.5 in DB ACL) atweek 1 post-operatively. Also the pain outcome improved on SB ACL after day 3 (VAS, n = 1.8) as compared to theDB ACL group (VAS, n = 3.7). The isokinetic muscle strength was found to be statistically significantly (p value < 0.05)better in the SB ACL group in the quadriceps muscle (both concentric and eccentric) at the end of the 3rd month.In the SB ACL group the Quadriceps Concentric strength deficit was 22.32% as compared to 34.12% in the DB ACLgroup. Both the groups had comparable flexor muscle strength at end of 3rd month. Both the groups hadcomparable muscle strength after 6 months of post-operative rehabilitation in both quadriceps and Hamstringmuscle group.

Conclusion: We noted that rehabilitation of DB ACL reconstruction group lags behind that of SB ACLreconstruction during the first 3 months due to post-operative haemarthrosis & its effects, but show comparableresults after 6 months. The muscle strength measured isokinetically and the muscle bulk were found to be greaterin the SB ACL group initially after 3 months but was found to be similar after 6 months.

Keywords: Haemarthrosis, Drain, Double bundle ACL, Isokinetic, Muscle strength

IntroductionSeveral studies have evaluated the role of haemarthrosisand intra-articular drains in Anterior Cruciate Ligament(ACL) reconstructive procedures, with most of themdocumenting the fact that intra-articular drains are notnecessary in them as it doesn’t affect functional outcome[1-3]. These studies had incorporated only Single BundleACL (SB ACL) reconstruction procedures. There hasbeen no study comparing the blood loss in SB ACL

versus Double Bundle (DB ACL) reconstruction and itseffect on the functional outcome.The present study was undertaken to assess the blood

loss and incidence of haemarthrosis in SB ACL recon-struction vis-a-vis DB ACL reconstruction and its effecton functional outcome. This study also aimed to evalu-ate the role of other variables like notchplasty, durationof surgery and associated meniscal procedures contribut-ing to incidence of increased blood loss post-operatively.

* Correspondence: drvibhubahl@yahoo.co.inSports Injury Centre, Safdarjang Hospital, Delhi 110092, India

© 2013 Bahl et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

Bahl et al. Journal of Orthopaedic Surgery and Research 2013, 8:5http://www.josr-online.com/content/8/1/5

Materials & methodsThis was a prospective trial conducted between January2010 and January 2011, in which 100 male patients whounderwent either Single Bundle or Double Bundle ACLreconstruction and available for follow up for 6 monthswere included in the study. There were 50 patientsin each group. Ethical approval was obtained fromthe Ethical Committee/Institutional Review Board ofSafdarjang Hospital.Exclusion criteria included significant pain preoperatively

(VAS > 5), a large swelling preoperatively (grade 3 or 4effusion), revision cases, and patients with a known risk ofbleeding (bleeding diathesis or prescribed anticoagulationmedication). Female patients were not taken up for thestudy since invariably they have smaller knees and wouldrequire SB ACL reconstruction and thus could induce abias in the results.All the patients were informed about their surgery and

explained in detail regarding the procedure and post-operative rehabilitation protocol. All surgeries wereperformed by the senior author at least 4 weeks aftertrauma, when the patients had regained at least 120 de-grees of ROM (range of motion), knee had become non-tender and effusion had subsided.

Surgical techniqueSpinal anaesthesia was given in all patients and a pneu-matic tourniquet was used routinely. All patients receivedprophylactic intravenous antibiotics preoperatively (Ceftri-axone, 1gm).Surgery was performed using standard 3 portal tech-

nique using Antero lateral (AL), Anteromedial (AM) andAccessory Anteromedial (AAM) portals. Semitendinosusand Gracilis tendon were harvested using a standardtechnique. The Semitendinosus (for the AM bundle) wasdoubled and gracilis tendon (for the PL Bundle) was tri-pled. The distal free ends of the tendon were stitchedwith Ethibond and the grafts were pretensioned. Eitherthe soft tissue remnants of the ACL were identified ontibia and femur as a guide for the insertion sites of AMand PL bundles or the bony landmarks (lateral inter-condylar ridge and lateral bifurcate ridge) were visual-ized to delineate the bundles attachment on the femoralside in chronic cases. Arthrex tibial ACL guide was usedfor making the tibial tunnels. The AM tibial tunnel wasdrilled first followed by PL tibial tunnel with a 2.4 mmdrill bit. AM followed by PL tibial tunnel was reamedaccording to graft size. The AM femoral tunnel wasdrilled next using the trans-tibial approach. The depthof the femoral tunnel was kept at 35 mm. The PL fem-oral tunnel was drilled and reamed next using theaccessory anteromedial (AAM) portal and visualizing thePL bundle footprint. The tunnel reamed up to 30 mmwith a cannulated reamer which was matched to the

graft diameter. This tunnel was extended to the lateralfemoral cortex with the 4.0 mm cannulated reamer. Thegracilis graft for the PL bundle is fixed at the femoralside using a Bioscrew. AM graft is then fixed on thefemoral side using cross pin femoral instrumentation.The knee was then cycled several times through therange of motion and the PL graft is fixed at 0- 15 degreeof knee flexion whereas AM graft is fixed at 45 degree ofknee flexion using bioscrews of appropriate size.Notchplasty was performed only if there was signifi-

cant notch stenosis or when graft impingement waspresent. Full Range of Motion was confirmed intra-operatively and stability checked with Lachman Test.The intra-articular fluid was drained with a cannula afterthe procedure was over. An 18 G disposable suctiondrain was used in all cases and was put in an inside outmethod to confirm intra-articular placement of thedrain. Compression dressing with ice-pack was appliedbefore deflation of the tourniquet. Time taken for sur-gery, notchplasty and menisectomy if done were notedfor each case.All patients were put through a standardized rehabili-

tation protocol supervised by a physiotherapist with em-phasis on achievement of early Range of Motion andweight bearing as tolerated. Axillary crutches were usedtill there was adequate quadriceps control and minimallimp. The drain was removed by a member of the studygroup on first post-operative day and drainage recorded.The patients recorded their pain on a visual analogue

scale (VAS) [4] at a consistent time in the evening onpostoperative day 1, 2, and 3. They were reviewed in theclinic at 1, 4 weeks and then on monthly interval till6 months. Pain (VAS), grade of haemarthrosis, ROM,thigh circumference and muscle strength as well as thepresence of any complications was documented.Primary outcome measures included grade of haemar-

throsis, according to the classification of Coupens and Yates[3] (graded subjectively from 0 to 4) (Table 1) and painmeasured by VAS. Secondary outcome measures includedROM, measured by use of a standard handheld goniometer,loss of muscle bulk and muscle strength recovery.Thigh circumference was measured using an inch tape

kept 2.5 cm above the superior pole of patella, evaluating

Table 1 Clinical grading of haemarthroses (Coupens andYates)

Grade Description

0 No detectable fluid

1 Fluid present with fluid wave

2 Palpable fluid in suprapatellar space

3 Ballotable patella

4 Tense haemarthroses

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the quadriceps muscle bulk in both the thighs and thedifference calculated.Muscle strength (Quadriceps and Hamstrings) was

measured at the end of 12 weeks and 24 weeks with iso-kinetic muscle charting. Each subject underwent test tomeasure the isokinetic muscle strength (HUMAC/NORM Isokinetic muscle testing at 60/60 deg. /sec 3Reps.) while performing flexion-extension movementswith both involved and uninvolved knee joint. Isokineticdynamometer measured two types of muscular contrac-tions – eccentric isokinetic and concentric isokineticcontractions [5].All the tests were evaluated statistically using unpaired

t- tests and the p- value set at 0.05.

ResultsThe amount of blood drained varied from a mean of60.3 ml (range 40 ml to 120 ml) in SB ACL study groupto a mean of 94.2 ml (range 50 ml to 150 ml) in theDB ACL group (Table 2). The subjective analysis ofhaemarthrosis, done after removal of drain, was statisti-cally significant between the two groups till the endof fourth week. The mean value of the grade at the endof 4th week was 0.6 (range 0-1) in the SB ACL groupcompared to a mean of 1.1 (range 0-2) in the DB ACLgroup.The mean value of Visual Analog Scale (VAS) de-

creased from a mean of 2.7 at day 1 to 1.8 in the SBACL group on day 3, while it came down from 4.2 to 3.7in the DB ACL group. The differences in the recordingsin both the groups remained statistically significant onlytill the end of 4th week (Table 3).The other major outcome which was noted was the

loss of Range of motion (ROM) calculated after the firstweek using the standard goniometer. There was statisti-cally significant restriction of terminal extension at theend of first week in DB ACL group (p value < 0.05). Theloss of extension was noted to be 4.1 degree in the SBACL group as compared to 8.3 degree in the DB ACLgroup at the end of first week. The patients followed thesame rehabilitation protocol and it was noted that theROM were comparable at the end of 8th week in boththe groups (Table 3). The loss of flexion was comparable

in both the groups during the whole rehabilitationperiod.The thigh circumference was measured at the end

of week 1, 4 and 8. There was statistically significant(p value < 0.05) difference between the SB ACL group(n = 0.3 cm) as compared to the DB ACL group till8 weeks (n = 1.1 cm) (Table 3).The muscle strength testing was also done Isokinetically

(measured by Torque in N/M2) at 12 and 24 weeks toevaluate the recovery of the muscle strength post ACL re-construction. The quadriceps strength on concentric andeccentric contraction was found to lag behind in DB ACLgroup (p value < 0.05) at 3 months but was comparable tothe SB ACL group at 6 months. The hamstrings (Concen-tric and Eccentric) power had statistically insignificant dif-ference in (p value = 0.43) in both the groups even at endof 3 months (Table 4).There were no infections in either group but 3 patients

had to be aspirated (mean value-120 ml, range- 75 ml-150 ml) in the DB ACL group at 3rd post-operative dayfor tense haemarthrosis whereas no patient in the SBACL group had their knee aspirated.There was no statistical difference in the number of

menisectomies in both the groups. There was statisti-cally significant difference in the number of patient re-quiring notchplasty and time taken for surgery, bothbeing higher in the DB ACL reconstruction group(Table 2).

DiscussionThe Complications Committee of the Arthroscopy Associ-ation of North America formulated a registry to investigatecomplications associated with arthroscopy [6]. The overallcomplication rate in this study was 1.68%. Of the complica-tions recorded, haemarthrosis occurred with a frequency of60.1%. The actual significance of haemarthrosis has beendebated [7]. Not only is there a toxic effect on the articularcartilage by the haemarthrosis but the susceptibility to in-fection is increased in its presence. In addition, it has beendocumented that in certain arthroscopic procedures theoccurrence of haemarthrosis results in the scar formation,decreased range of motion, subsequent synovitis and de-layed rehabilitation [8].

Table 2 Clinical comparison between SB ACL & DB ACL reconstruction group

SB ACL Group DB ACL Group p value

No. 50 50

Age (yr) 36 (Range 15-52) 28 (Range 21-38) >0.05

Time to surgery (weeks) 12.2 13.1 >0.05

Partial menisectomy 31 36 >0.05

Notchplasty 12 23 <0.05

Drain amount (ml) 60.3 ml (Range 40 ml-120 ml) 94.2 ml (Range 50 ml-150 ml) <0.05

Tourniquet time (min.) 42.1 min. (Range 34 min.-100 min.) 74.7 min.(range-50 min-150 min) <0.05

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In our study the grade of the haemarthrosis and post –operative pain was significantly higher in the double bun-dle ACL group than the SB ACL group. This differencecan be attributed to following factors associated with DBACL reconstruction group i.e. increased surgical time(n = 74.7 min.), the numbers of tunnels drilled are dou-bled, in 46% of cases notchplasty was done due to graftimpingement of the Antero Medial bundle (AM) on ex-tension, this is especially true as more area is taken up inthe intercondylar notch due to 2 grafts in the DB ACLreconstruction.The significant difference in the range of motion be-

tween DB and SB ACL groups noted in terms of loss ofterminal extension and difference in muscle bulk at theend of 4th week between the two groups can be attributedto the increased haemarthrosis and pain post – operativelyleading to delayed rehabilitation of quadriceps.Most of the studies which had compared difference in

ROM and / or thigh circumference between DB ACL andSB ACL didn’t report significant difference on a long termfollow-up, [9,10] but no study has compared the results inthe initial 6 months of rehabilitation. McCormack et al[11] measured ROM and or thigh circumference in cases

of SB ACL reconstruction only with and without drainand didn’t find any statistically significant difference at 1,4,8 weeks.The numbers of menisectomies done in both these

groups were statistically similar and thus did not influ-ence the result of our study.Muscular strength was evaluated using the isokinetic ma-

chine at 12 and 24 weeks and there was a statistically sig-nificant difference in muscle strength deficit in the SB ACLgroup as compared to the DB ACL group. The SB ACLgroup had statistically significant better muscle strength at3 months in the quadriceps muscle groups. This again canbe attributed to pain and haemarthrosis post operatively inthe DB ACL group delaying rehabilitation.The results for quadriceps weakness can be explained

due to relative inactivity and ineffective strengtheningexercises following surgery which leads to type II musclefibre atrophy [12-16]. Also the patients with ACL recon-struction demonstrate arthrogenic quadriceps inhibitionin order to minimise anterior tibial translation and ACLgraft strain [17]. During ACL reconstruction the gammaloop function could be attenuated in the quadriceps be-cause the mechanoreceptors in the ACL are not surgically

Table 3 Functional outcomes

Day 1 Day 2 Day 3 Week 1 Week 4 Week 8

Pain SB 2.7 2.2 1.8 1.6 1.2 0.5

VAS DB 4.2 3.9 3.7 2.7 2.3 0.8

Range of motion SB NA NA NA 4.1° 3.2° 0°

Loss of terminal extension DB NA NA NA 8.3o 6.7o 1.2o

Loss of terminal flexion SB NA NA NA 60.2° 32 ° 15°

DB NA NA NA 63.1o 34o 11o

*Thigh circumference deficit (cm) SB NA NA NA 2.2 0.8 0.3

DB NA NA NA 3.6 2.4 1.1

Haemarthrosis SB 1.2 1.1 0.9 0.7 0.6 0

(Grade) DB 2.3 2.2 1.8 1.5 1.1 0.3

SB = Single Bundle ACL group DB = Double bundle ACL group.

Table 4 Quadriceps and hamstring muscle strength comparison between SB ACL and DB ACL group

Muscle testing Normal knee Operated knee Deficit (%)

3 months 6 months 3 months 6 months 3 months 6 months

Quadriceps (Concentric) SB 38.26 40.36 29.73 35.24 22.32 12.7

DB 39.32 42.34 25.91 32.66 34.12 16.8

Quadriceps (Eccentric) SB 34.21 39.45 24.54 34.29 28.27 13.09

DB 36.27 40.10 22.01 32.66 39.34 18.56

Hamstrings (Concentric) SB 18.98 23.05 15.70 21.16 17.33 8.23

DB 21.23 25.42 17.07 22.55 19.64 11.32

Hamstrings (Eccentric) SB 15.1 19.63 13.08 18.35 13.4 6.56

DB 18.46 22.31 15.72 20.31 14.88 9.80

*HUMAC/NORM Isokinetic muscle testing (torque = N/m2) at 60/60 deg/sec 3 Reps.*In normal subjects, imbalances of 10% or less can be considered normal while differences of 10% to 20% possibly abnormal and those above 20%probably abnormal.

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reconstructed [5,18]. In contrast to the quadriceps, thehamstrings are less susceptible to strength deficits follow-ing an ACL injury. These deficits are thought to be due tobi-arthrodial nature of three of the four hamstring compo-nents such that even when knee mobility is impaired fol-lowing in ACL injury, hip extension continues to act asstimulus for the hamstrings [19-22]. Also the current re-habilitation protocols emphasis early and aggressive ham-string training following an ACL reconstruction [23-26]on the basis that hamstring contraction can produce pos-terior tibial translation to reduce the strain on the matur-ing ACL substitute [19]. While using semitendinosus andgracilis tendon autograft, recovery of hamstring strength isof some concern given that the semitendinosus tendon issacrificed during the procedure [24] but most of the inves-tigators have generally found non-significant hamstringdeficits between the operated and non-operated site in thepost-operative period [27-29].

ConclusionIn our study we noted that the rehabilitation of DB ACLreconstruction group lags behind the SB ACL recon-struction during the first 3 months due to post-operativehaemarthrosis and pain even after using drain but showscomparable results after 6 months. Further studies areneeded comparing the results in DB ACL reconstruc-tions, with or without intra-articular drain to further in-vestigate these findings.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionAll the surgical procedures were performed by the senior surgeons DC andDJ, data collection including clinical & functional parameters in the pre-operative and post-operative period was done by AG. The study wasdesigned and manuscript was drafted by VJ and data analysis was done byVB. All authors read and approved the manuscript.

AcknowledgementWe really appreciate the work of all the team members and the paramedicalstaff for showing all the patience and co-operation during the writing of thispaper. We also thank our all patients for their patience and faith theyshowed towards the whole team.

Received: 21 June 2011 Accepted: 12 March 2013Published: 19 March 2013

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doi:10.1186/1749-799X-8-5Cite this article as: Bahl et al.: Effect of haemarthrosis on therehabilitation of anterior cruciate ligament reconstruction- singlebundle versus double bundle. Journal of Orthopaedic Surgery and Research2013 8:5.

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