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Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hamstring Graft – A Prospective Medium Term Study

Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hamstring Graft – A Prospective Medium Term Study

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Page 1: Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hamstring Graft – A Prospective Medium Term Study

Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hamstring Graft – A Prospective Medium Term Study

Page 2: Arthroscopic Anterior Cruciate Ligament Reconstruction Using Four-Strand Hamstring Graft – A Prospective Medium Term Study

Original Article

ARTHROSCOPIC ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING FOUR-STRAND HAMSTRING GRAFT – A PROSPECTIVE MEDIUM TERM STUDY+

KJ Reddy*, P Sunil Reddy#,Aashay L Kekatpure@ and Ajay Tiwari@

* Senior Consultant, # Consultant, @DNB Orthopaedics Resident,Department of Orthopaedics, Apollo Hospitals,Jubilee Hills, Hyderabad 500 033, India.

Correpondence to: Dr K J Reddy, Senior Consultant, Department of Orthopaedics, Apollo Hospitals,Jubilee Hills, Hyderabad 500 033, India.

Background: In this study, we analyzed the clinical outcomes at two years following reconstruction of theanterior cruciate ligament with use of a four-strand hamstring tendon autograft in patients who had presentedwith a symptomatic torn anterior cruciate ligament. Methods: Twenty four consecutive patients who had anisolated, symptomatic anterior tibial subluxation associated with rupture of the anterior cruciate ligament weretreated with reconstruction of the anterior cruciate ligament with a four-strand autologous semitendinosus-gracilis tendon graft. One surgeon performed all of the operations. Prior to surgery and at the follow-upexamination, physical findings and functional scores were recorded and knee radiographs were analyzed.Following surgery, a six-month rehabilitation regimen was implemented. Results: Of the 41 patients operated24 were available for follow-up. Twenty three of the patients had stable pain free knee negative Lachman andpivot shift tests. The mean IKDC score improved from an average preoperative from 38.62 point to average atfinal follow up 89.11 points at the time of follow-up (p < 0.01). One patient (5.5%) had a positive Lachmann’stest at final follow up. One patient had a traumatic rupture of the graft, occurring at a 16 monthspostoperatively. Conclusions: Reconstruction of the anterior cruciate ligament with use of a four-strandhamstring tendon autograft eliminated anterior tibial subluxation in 94.5% of patients who were examined at aminimum of two years postoperatively. The functional knee scores were significantly increased at the time offollow-up. Objective: A prospective study of 24 patients of Arthroscopic ACL reconstruction, all operated on bya Single Surgeon followed up for 24 months.All the patients were operated between January and December2005. Of the 41 patients operated, 24 were available for regular followup till 2 years. The study assessed theClinical outcome at various intervals during the study period.

Key words: Anterior cruciate ligament reconstruction, Hamstring tendon autograft.

INTRODUCTION

IN patients with symptomatic ACL deficient knees, ligamentreconstruction is the means of stabilizing and restoring highlevel function of the knee joint. The ‘ideal’ graft for use inACL reconstruction is still a matter of debate. Both BPTBgraft and Hamstring graft have comparable results in termsof stabilizing the knee and provide 90-95% good to excellentresults functionally as well as on clinical and KT-1000instrumented testing.

Recent surge of interest in Quadrupled Hamstringtendon graft is due partly to (i) considerable improvementsin soft tissue graft fixation techniques (especially theendobutton and transcondylar fixation devices) that haveresulted in reliable fixation with pull out strengths averaging1345 N vs 710 N for BPTB graft fixed with interferencescrews, (ii) increased concerns with anterior knee pain andproblems with knee extensor mechanism with Patellartendon graft.

Ultimately the choice of graft in ACL reconstructiondepends on the Surgeons experience and preference. Tissueavailability, patient preference and activity level, priorsurgeries and presence of chronic patello femoral paininfluence the choice in some patients. In this study weanalyzed the clinical outcomes of Arthroscopic ACLreconstruction with Four strand Hamstring graft (Quad-rupled Semitendinosus and Gracilis) in symptomatic,posttraumatic, isolated ACL deficient knees at a two year followup (all patients with positive Lachmann and Pivot shifttests).

METHOD OF STUDY

All twenty four patients in the age group 18- 40 yearswith symptomatic ACL rupture treated by ArthroscopicACL reconstruction with Four strand Hamstring graft, andavailable for regular followup till 24 months were includedin the study.All patients falling within the inclusion criteriawere evaluated by a detailed history and clinicalexamination. Preoperative assessment included+ Presented at IOACON

Apollo Medicine, Vol. 6, No. 1, March 2009 16

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assessment of Duration of injury; Mechanism of injury;Clinical examination of knee; International KneeDocumentation committee 2000 (IKDC) Subjective KneeEvaluation Score. IKDC Score is a reliable andreproducible indicator of knee function and correlates wellwith the KT-1000 Arthrometric testing. It is scored bysumming the responses to 18 factors assessing kneefunction and activity and transforming the score to a scaleof 0-100. Arthroscopy was done on all patients to treatassociated meniscal injury and confirm the diagnosis,followed by Quadriceps and Hamstring strengtheningexercises and ACL Reconstruction after 4-6 weeks.

The surgical procedures are listed below:

1. Positioning and graft harvesting (Fig.1) through a 2cm incision.

2. Whip suturing the graft to make it into a four-strandgraft.

3. Arthroscopic preparation of femoral and tibial (Figs.2 -4) graft fixation sites.

4. Arthroscopic placement of tibial tunnel.

5. Femoral tunnel placement and drilling using guide forarthroscopic tunnel placement.

6. Drilling for Endobutton .

7. Graft passage (Fig. 5) through both tunnels.

8. Femoral fixation using Endobutton (Fig. 6) and tibialfixation using interference screw.

9. Post operative AP and lateral radiographs are shown inFig.7.

Post operative protocol

1. Full weight bearing mobilisation on day 1.

2. Graduated exercise programme progressing to levelIII – IV at 12 weeks.

3. Full ROM at 6 weeks.

4. Return to unrestricted activity/sports after 5-6 months.

Post operative evaluation

(a) IKDC scores at 3 wks, 6 wks, 12 wks, 6 months, 12months and 2 yrs

(b) Range of motion

(c) Quadriceps power and extension deficit

(d) Laxity

(e) Anterior knee pain.

Fig.1 Hamstring graft harvested with tendin stripper; Thephoto shows the tendons (Semitendonosis & Gracilis)attached to their tibial insertion at Pes Anserinus.

Fig.2 Arthroscopic view of tibial guide wire.

RESULTS

The mode of injury in the patients was: vehicularinjuries - 50%; sports-46%; others-4%. Associated meniscalinjury was found in 60% of patients (Medical meniscus -40%; Lat. Meniscus-15%; both-5%). The preoperativeIKDC scores were: Mean Score-38.62%; Range-16.09 to51.72. The mean score were: pre-operative 38.62; 3 months65.67; 1 year 84.30; 2 years 89.11. Flexion dificit of 5-10deg. in 2 patients (9%) was found at 1 yr follow up. Noextension deficit was detected in any patient.

Laxity. One patient (5.5%) had a significant positivelachman test at final follow up. One patient had posttraumatic rupture of ACL graft at 16 months post op. 89%patients had a stable, pain free, functional knee joint. Nopatient had anterior knee pain at 3 months follow up.Diameter of Graft Harvested in patients was: 8 mm-85%and 9 mm-15%.

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Fig.3 Arthroscopic view femoral jig at the medial aspect ofthe lateral femoral condyle.

Fig.4 Arthroscopic view of femoral tunnel.

Fig.5 Hamstring graft in place at the end of the surgery.

Fig. 6 ENDOBUTTON: Ensures reliable and responsiblefemoral anchorage of the graft.

Fig.7 Post operative (a) anteroposterior and (b) lateralradiographs.

(a) (b)

Problems with graft harvesting

Difficulty in harvesting Hamstring graft wasencouxntered in 2 patients (8%), graft harvested from C/Lthigh in one patient, and superficial infection in one patient,which responded well to early exploration, debridement andantibiotics. No patient had deep or knee joint infection.

DISCUSSION

Successful clinical outcomes following anteriorcruciate reconstruction with a hamstring graft have beenreported by many authors [1-14]. In our study, anteriorcruciate reconstruction with a four-strand hamstring graftresulted in a successful clinical outcome in 94.5% ofpatients who were available for follow-up. Marder, et al.

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utilized a two-bundle semitendinosus construct and twofemoral Endobuttons in sixty-two patients and reportedimproved anterior stability compared with that in patientwho had been treated with a single semitendinosus bundle[5]. Hoffmann, et al. reported in the results sixty-fivepatients of anterior cruciate reconstruction with a doubled-semitendinosus-and-Endo-button construct that wasaugmented with an extra-articular lateral repair [15].

Nebelung, et al. reviewed the results of twenty-nineanterior cruciate reconstructions with a doubled autogenoussemitendinosus tendon and a femoral Endobutton [9]. Theygraded 66% of the results as normal or nearly normal usingthe criteria of the International Knee DocumentationCommittee. In the present study, we analyzed theeffectiveness of a double-loop (four-strand) semitendi-nosus- gracilis graft in eliminating symptomatic anteriortibial subluxation caused by a torn anterior cruciateligament. Anterior tibial subluxation was eliminated in94.5% of the patients who were examined at a mean of 2years postoperatively. The remaining 5.5% of the patientshad a positive lachmanns and pivot shift at the follow-upexamination. Bach et al. reported a reoperation rate of 15%in a series of 103 patients evaluated two years after anteriorcruciate reconstruction with a patellar tendon autograft[16].

With the rehabilitation protocol used in our study, themajority of patients returned to a high functional status in sixmonths. No motion deficits or clinically important kneepain was noted at the follow-up examination. Other authorshave reported success with similar rehabilitation protocolsfollowing anterior cruciate reconstruction [7,17-19]. Weallow full weight-bearing with the knee in terminalextension in a brace in the immediate limited active andemploy immediate passive range of motion following thereconstruction.

In their study of 2500 consecutive arthroscopicallyassisted anterior cruciate reconstructions performedWilliams, et al. reported an infection rate of 0.03% [20].One patient had a superficial infection of the knee followingthe anterior cruciate reconstruction. The patients who had apostoperative infection in our study were treated effectivelyby a combination of parenteral and oral antibiotics for a totalof six weeks.

Clinically relevant patellofemoral pain or loss of kneemotion has been reported following anterior cruciatereconstruction with the patellar tendon [16,20,21], butneither was observed in our study. The elimination of kneeinstability and the functional scores in our series wereconsistently good, but the rate of traumatic rupture of thegraft (5.5%) may be a cause for concern. The prevalence of

traumatic rupture of bone-patellar tendon bone grafts usedfor anterior cruciate reconstruction has been reported to be0% to 2% [16,21,22] where as those for Hamstring graft isabout 5%.

We did not observe any clinically relevant knee pain ormotion loss at the time of follow-up. The absence of suchmorbid findings following anterior cruciate reconstructionwith a hamstring graft may make this method ofreconstruction more desirable for certain patients (i.e., thosewith chronic patellofemoral pain or patellofemoral cartilagedisorder) over the BPTB graft.

CONCLUSION

We found that a four-strand semitendinosus-gracilisautograft with a torn anterior cruciate ligament in 94.5% ofthe patients who were available for follow-up. Significantimprovements in functional scores were noted. Four strandhamstring graft is an effective treatment option for patientswith symptomatic ACL tears without any concernsregarding knee extensor mechanisms or anterior knee pain.

REFERENCES

1. Aglietti P, Buzzi R, Zaccherotti G, De Biase P. Patellartendon versus doubled semitendinosus and gracilistendons for anterior cruciate ligament reconstruction. Am JSports Med. 1994; 22: 211-218.

2. Aglietti P, Buzzi R, Menchetti PM, Giron F. Arthroscopicallyassisted semitendinosus and gracilis tendon graft inreconstruction for acute anterior cruciate ligament injuriesin athletes. Am J Sports Med. 1996; 24: 726-731.

3. Barber FA. Tripled semitendinosus-cancellous boneanterior cruciate ligament reconstruction with bioscrewfixation. Arthroscopy. 1999;15: 360-367.

4. Maeda A, Shino K, Horibe S, Nakata K, Buccafusca G.Anterior cruciate ligament reconstruction withmultistranded autogenous semitendinosus tendon. Am JSports Med. 1996; 24: 504-509.

5. Marder RA, Raskind JR, Carroll M. Prospective evaluationof arthroscopically assisted anterior cruciate ligamentreconstruction. Patellar tendon versus semitendinosusand gracilis tendons. Am J Sports Med. 1991;19: 478-484.

6. Meystre JL, Vallotton J, Benvenuti JF. Doublesemitendinosus anterior cruciate ligament reconstruction:10-year results. Knee Surg Sports Traumatol Arthrosc.1998; 6: 76-81.

7. Muneta T, Sekiya I, Ogiuchi T, Yagishita K, Yamamoto H,Shinomiya K. Effects of aggressive early rehabilitation onthe outcome of anterior cruciate ligament reconstructionwith multi-strand semitendinosus tendon. Int Orthop.1998; 22: 352-356.

8. Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H,Shinomiya K. Two bundle reconstruction of the anterior

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Apollo Medicine, Vol. 6, No. 1, March 2009 20

cruciate ligament using semitendinosus tendon withendobuttons: operative technique and preliminary results.Arthroscopy. 1999;15: 618-624.

9. Nebelung W, Becker R, Merkel M, Ropke M. Bone tunnelenlargement after anterior cruciate ligamentreconstruction with semitendinosus tendon usingEndobutton fixation on the femoral side. Arthroscopy.1998;14: 810-815.

10. Noojin FK, Barrett GR, Hartzog CW, Nash CR. Clinicalcomparison of intraarticular anterior cruciate ligamentreconstruction using autogenous semitendinosus andgracilis tendons in men versus women. Am J Sports Med.2000; 28: 783-789.

11. Otero AL, Hutcheson L. A comparison of the doubledsemitendinosus/gracilis and central third of the patellartendon autografts in arthroscopic anterior cruciateligament reconstruction. Arthroscopy. 1993; 9:143-148.

12. Siegel MG, Barber-Westin SD. Arthroscopic-assistedoutpatient anterior cruciate ligament reconstruction usingthe semitendinosus and gracilis tendons. Arthroscopy.1998;14: 268-277.

13. Spicer DD, Blagg SE, Unwin AJ, Allum RL. Anterior kneesymptoms after four-strand hamstring tendon anteriorcruciate ligament reconstruction. Knee Surg SportsTraumatol Arthrosc. 2000; 8: 286-289.

14. Zysk SP, Kruger A, Baur A, Veihelmann A, Refior HJ.Tripled semitendinosus anterior cruciate ligamentreconstruction with Endobutton fixation: a 2-3-year follow-up study of 35 patients. Acta Orthop Scand. 2000; 71: 381-386.

15. Hoffmann F, Friebel H, Schiller M. The semitendinosustendon as replacement for the anterior cruciate ligament.Zentralbl Chir. 1998;123: 994-1001. German.

16. Bach BR Jr, Levy ME, Bojchuk J, Tradonsky S, Bush-Joseph CA, Khan NH. Single-incision endoscopic anteriorcruciate ligament reconstruction using patellar tendonautograft. Minimum two-year follow-up evaluation. Am JSports Med. 1998; 26: 30-40.

17. Howell SM, Taylor MA. Brace-free rehabilitation, with earlyreturn to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone JointSurg Am. 1996;78: 814-825.

18. MacDonald PB, Hedden D, Pacin O, Huebert D. Effects ofan accelerated rehabilitation program after anteriorcruciate ligament reconstruction with combinedsemitendinosus-gracilis autograft and a ligamentaugmentation device. Am J Sports Med. 1995; 23: 588-592.

19. Shelbourne KD, Nitz P. Accelerated rehabilitation afteranterior cruciate ligament reconstruction. Am J SportsMed. 1990;18: 292-299.

20. Williams RJ 3rd, Laurencin CT, Warren RF, Speciale AC,Brause BD, O’Brien S. Septic arthritis after arthroscopicanterior cruciate ligament reconstruction. Diagnosis andmanagement. Am J Sports Med. 1997; 25: 261-267.

21. Bach BR Jr, Tradonsky S, Bojchuk J, Levy ME, Bush-Joseph CA, Khan NH. Arthroscopically assisted anteriorcruciate ligament reconstruction using patellar tendonautograft. Five- to nine-year follow-up evaluation. Am JSports Med. 1998; 26: 20-29.

22. O’Brien SJ, Warren RF, Pavlov H, Panariello R,Wickiewicz TL. Reconstruction of the chronicallyinsufficient anterior cruciate ligament with the central thirdof the patellar ligament. J Bone Joint Surg Am. 1991;73:278-286.

23. Buss DD, Warren RF, Wickiewicz TL, Galinat BJ,Panariello R. Arthroscopically assisted reconstruction ofthe anterior cruciate ligament with use of autogenouspatellar-ligament grafts. Results after twenty-four to forty-two months. J Bone Joint Surg Am. 1993;75:1346-1355.

24. Deehan DJ, Salmon LJ, Webb VJ, Davies A, PinczewskiLA. Endoscopic reconstruction of the anterior cruciateligament with an ipsilateral patellar tendon autograft. Aprospective longitudinal five-year study. J Bone Joint SurgBr. 2000;82:984-991.

25. Shelbourne KD, Gray T. Anterior cruciate ligamentreconstruction with autogenous patellar tendon graftfollowed by accelerated rehabilitation. A two- to nine-yearfollowup. Am J Sports Med. 1997;25:786-795.

26. Goradia VK, Grana WA. A comparison of outcomes at 2 to 6years after acute and chronic anterior cruciate ligamentreconstructions using hamstring tendon grafts.Arthroscopy. 2001;17:383-392.

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