bundle anterior cruciate ligament reconstruction using ... - Springer Link

Knee Surg Sports Traumatol Arthrosc (2013) 21:957–964 DOI 10.1007/s00167-012-2001-y

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Long-term results of arthroscopically assisted anatomical singlebundle anterior cruciate ligament reconstruction using patellar tendon autograft: are there any predictors for the development of osteoarthritis? Pascal Gerhard • Robert Bolt • Klaus Du¨ck Ralph Mayer • Niklaus F. Friederich • Michael T. Hirschmann

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Received: 4 October 2011 / Accepted: 29 March 2012 / Published online: 10 April 2012 Ó Springer-Verlag 2012

Abstract Purpose The primary purpose of our study was to analyse the long-term outcome of patients treated for anterior cruciate ligament (ACL) tears by anatomical single-bundle ACL reconstruction with patellar tendon autograft. The secondary purpose was to identify predictive factors for good outcome and occurrence of osteoarthritis. Methods Sixty-three patients (m:f = 54:9; mean age at surgery, 27 ± 7 years) treated by ACL reconstruction were evaluated with a mean follow-up of 16 ± 1 years using IKDC2000, the SF36, Lysholm and Tegner score, Knee Society score, visual analogue scale for pain and satisfaction and KOOS. The femoral tunnel position was evaluated according to Sommer. It was also assessed in percentage of the Blumensaat line and the tibial tunnel position in P. Gerhard N. F. Friederich M. T. Hirschmann (&) Department of Orthopaedic Surgery and Traumatology, Kantonsspital Bruderholz, 4101 Bruderholz, Switzerland e-mail: [email protected] P. Gerhard e-mail: [email protected] N. F. Friederich e-mail: [email protected] R. Bolt Institute of Radiology and Nuclear Medicine, Kantonsspital Bruderholz, 4101 Bruderholz, Switzerland e-mail: [email protected] K. Du¨ck Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg e-mail: [email protected] R. Mayer Praxisklinik2000, Freiburg, Germany e-mail: [email protected]

percentage of the total anterior–posterior plateau length. The extent of osteoarthritis was graded according to the Kellgren–Lawrence score. Results The total IKDC2000 was normal in 20 (32 %), nearly normal in 29 (46 %), abnormal in 12 (19 %) and severely abnormal in 3 (5 %) of patients. The mean total SF-36 was 89 ± 13, the Lysholm score 95 ± 12, the Knee Society score 191 ± 16 and the total KOOS 84 ± 19. The Tegner score decreased from pre-injury 7(4–10) to 6 (2–10) at follow-up. The Kellgren–Lawrence score was normal in 17 (27 %), suspected osteoarthritis in 25 (40 %), minimal osteoarthritis in 5 (8 %), moderate osteoarthritis in 9 (14 %) and severe osteoarthritis in 3 patients (5 %). The femoral tunnel was in zone A in 43 patients (68 %), in zone B in 16 (25 %) and in zone C in 4 patients (7 %). The femoral tunnel position in percentage of the Blumensaat line was 49 ± 3 (range, 44–57), and the tibial tunnel position in percentage of the total anterior–posterior plateau length was 32 ± 6 (range, 21–46). Patients with meniscal lesion at the time of ACL tear showed significantly less favourable outcomes than those without. Conclusions Patients treated by the proposed ACL reconstruction technique showed on average good to excellent long-term results. A meniscal lesion at the time of ACL tear was highly predictive for less favourable outcome. Level of evidence IV. Keywords Anterior cruciate ligament reconstruction Osteoarthritis Patellar tendon autograft Single bundle Outcome Introduction Anterior cruciate ligament (ACL) reconstruction is a well-established procedure for treatment of patients with

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symptomatic ACL deficient knees [22, 26, 38, 42, 46, 48, 50]. A variety of surgical procedures, fixation methods and grafts has been used and advocated [4, 6, 7, 26, 37]. The main goal of ACL reconstruction is to restore the anterior– posterior and rotational stability of the knee as anatomical as possible. A stable knee joint is considered to lead to a lower risk for secondary injuries such as meniscal and chondral lesions compared to patients treated non-surgically [27]. However, whether an ACL reconstruction can reduce the degree and rate of osteoarthritis remains controversial [45]. Some studies even suggest that an ACL reconstruction leads to higher rates of osteoarthritis, which at least partly may be attributed to the higher activity level afterwards in the ACL reconstructed groups [2, 10, 11]. The primary purpose of our study was to analyse the clinical and radiological long-term outcome of patients treated for an ACL tear by anatomical single-bundle ACL reconstruction with patellar tendon autograft. The secondary purpose was to investigate whether the tunnel position correlates with the extent of osteoarthritis in these patients.

Materials and methods

Knee Surg Sports Traumatol Arthrosc (2013) 21:957–964

(PDS 0, Johnson & Johnson, Spreitenbach, Switzerland). Importantly, only the ventral layers were sutured in order to prevent post-operative excessive scarring and occurrence of a patella infera. A high anterolateral portal in the corner between the patella and the patella tendon was established with a vertical incision. A second, low anteromedial portal was performed under arthroscopic control. It was our aim to be as close as possible to the base of the anterior horn of the medial meniscus without harming it. A horizontal incision further helped to avoid lesions of the infrapatellar rami of the saphenous nerve. The intercondylar notch, tibial and femoral attachment areas were cleaned using a shaver blade. A burr was used to create a groove in the very posterior aspect of the lateral side wall of the notch from 1:30 to 3 o’clock for a left and from 9 to 10:30 for a right knee, respectively. After verification of the correct tunnel position via the medial portal, the groove was gradually deepened using 6- to 10-mm-wide surgical spoons. To achieve an adequate press-fit of the bone block into this groove, a 3.5-mm tunnel was drilled from the posterolateral bottom of this groove using the anteromedial portal. The femoral tunnel was established through the anteromedial

A review of the medical records in the hospital archives was conducted. All patients with an ACL tear who were treated by an arthroscopically assisted anatomical singlebundle ACL reconstruction with ipsilateral patellar tendon autograft with a minimum follow-up of 15 years (mean 16 ± 1 years) were included in our study. This yielded 70 patients, from which 63 patients (male:female = 54:9; mean age at surgery, 27 ± 7 years; weight, 80 ± 13 kg; height, 175 ± 9 cm) with 63 knees (n = 29 left, n = 34 right) were available for clinical and radiological follow-up (90 %). These patients were operated between March 1990 and February 1996 (mean, 11 ± 23 months from injury). Informed consent was obtained from all patients, and the study was approved by the local ethics committee of both Basel cantons (EK 181/09). Surgical technique (Figs. 1 and 2) In all patients, an arthroscopically assisted anatomical single-bundle ACL reconstruction using an ipsilateral patellar tendon autograft (BTB) in ‘Bruderholz’ technique was performed. Harvesting of the BTB graft was done using a lateral parapatellar skin incision, and a 10 9 10 9 5 mm bone block was prepared. The BTB graft, particularly the proximal bone block, was then reshaped to the size of a 10-mm spoon. The bone blocks were armed with two non-resorbable sutures (PremiCronÒ 3-0, Braun, Melsungen, Germany). The harvest site was closed by suturing of the medial and lateral remaining patellar tendon

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Fig. 1 Illustration demonstrating the fixation of the bone blocks of the patellar tendon single-bundle autograft using AO cortical long neck screws


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Fig. 2 Post-operative MRI of a patient showing the anatomical course and orientation of the fibres of the patellar tendon autograft after this ACL reconstruction technique

Fig. 3 KOOS profile at last follow-up divided in each subcategory

portal independent from the tibial tunnel. The BTB graft was inserted in retrograde direction, and the bone block was press-fit into the grove under arthroscopic control. The proximal and distal sutures were fixed to femoral or tibial post-screws (AO-modified cortical screw with long neck, Synthes, Oberdorf, Switzerland). Conditioning of the graft was done in 10–15° of knee flexion. Clinical follow-up The ability and time to return to sport were recorded. All patients were examined by one independent observer who had not been involved in the index surgery. For clinical outcome assessment, we used the International Knee Documentation Committee (IKDC2000) Standard Evaluation Form [3, 14, 18], the SF36 health survey [9, 20], the Lysholm score [49], the Tegner score [49], the Knee Society score [17] and the Knee Injury and Osteoarthritis Outcome Score (KOOS) [34]. The examination included assessment of ACL and PCL laxity with the KT-1000 arthrometer (Medmetric, San Diego, USA) in 25° flexion

with 67N, 89N and 134N and with the Rolimeter (Ormed, Freiburg, Germany) in 90° flexion. The patient’s subjective perceived impairment was evaluated by a visual analogue scale (0–10) to evaluate pain (0 = best value and 10 = poorest value) and satisfaction (10 = best value and 0 = poorest value). Weight-bearing radiographs of the injured knee (anteroposterior and lateral views), a skyline view of the patella and a Rosenberg view (45° flexion posterior–anterior weight bearing), were performed. The mechanical alignment of the leg was assessed on full-length weight-bearing radiographs. The extent of osteoarthritis of the knee was graded according to the Kellgren–Lawrence Osteoarthritis score (0, normal; grade 1, suspected osteoarthritis; grade 2, minimal osteoarthritis; grade 3, moderate osteoarthritis; and grade 4, severe osteoarthritis). The femoral tunnel position was noted by the use of an ACL ruler according to Sommer et al. [41]. The femoral tunnel position was assessed as percentage of the Blumensaat line and the tibial tunnel position in percentage of the total anterior–posterior plateau length. All measurements were made using the PACS (Picture Archiving Communication System, Phillips Easy Vision, Netherlands). Statistical analysis Data were analysed by a statistician using SPSS 16.0 (SPSS, Chicago, USA). Continuous variables were described using means, standard deviations and ranges. Categorical variables were tabulated as absolute and relative frequencies. A two-tailed Pearson’s correlation was used to compute associations between variables. For all analyses, p \ 0.05 was considered statistically significant and p \ 0.1 as a tendency.

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Results

Table 1 Subjective and objective outcome scoring of patients at final follow-up

Eighty-four per cent of patients (n = 53) returned to their previous sport (mean time to return to sport, 3.6 ± 2.4 months; range, 1–14) with 49 % (n = 31) returning to preinjury levels. The total IKDC2000, the IKDC2000 for the subcategories ligament and function, the SF-36 health survey, the Lysholm score, the Tegner score, the Knee Society score and the KOOS (Fig. 3) score are presented in Table 1. The mean VAS pain was 1.0 ± 1.4 (median, 1; range, 0–7), and satisfaction was 8.7 ± 2.0 (median, 10; range, 1–10). The assessment of ACL laxity in 25° flexion with 67N, 89N and 134N is shown in Table 2. In Table 3, we present valgus and varus stress testing in 30° flexion. Ten (16 %) patients presented with a flexion deficit (0–5°, n = 53; 6–15°, n = 6; 16–25°, n = 2; [ 25°, n = 2), and 7 patients (11 %) presented with an extension deficit (\ 3°, n = 56; 3–5°, n = 3; 6–10°, n = 4; [ 10° n = 0). The ipsilateral knee flexion was 142° ± 14° and contralateral 144° ± 9°. During Lachman’s manoeuver and anterior drawer testing, 62 patients (98 %) had a firm endpoint. The pivot and reverse pivot shift test were normal in 46 (73 %), nearly normal in 16 (25 %) and abnormal in 1 patient (2 %). The relative length of a one-leg hop in comparison with the uninjured side was [ 90 % (normal) in 58 (92 %), 76–89 % (nearly normal) in 3 (5 %), 50–75 % (abnormal) in 2 (3 %) patients. No patient suffered from a severely abnormal function loss (\ 50 %) by means of a one-leg hop comparison. At the final follow-up, three patients (5 %) had a VAS pain score [ 3. Two patients (3 %) were not able to flex their knee more than 120°. Only one patient underwent another ACL reconstruction due to a retear one year after the first ACL operation. Forty-two (67 %) patients did not have any other knee surgery, 17 (27 %) one and 4 (6 %) two secondary interventions. The secondary surgeries were mainly meniscectomies, arthroscopic debridements and arthrolyses (Table 4).

Outcome instrument

Mean ± SD (median, range)

IKDC score (range of motion)

n (%)

A (normal)

49 (78)

B (nearly normal)

8 (13)

C (abnormal)

4 (6)

D (severely abnormal)

2 (3)

IKDC score (ligament laxity) A (normal) B (nearly normal)

n (%) 39 (10) 20 (76)

C (abnormal)

3 (13)


1 (1)

Total IKDC score

n (%)

A (normal)

20 (32)

B (nearly normal)

29 (46)

C (abnormal)

12 (19)


3 (5)

SF-36 total

89 ± 13 (93, 30–100)

SF-36 somatic

56 ± 4 (57, 32–60)

SF-36 mental

54 ± 8 (57, 33–62)

Lysholm score

91 ± 13, 95, 28–100

Tegner score pre-injury

(7, 4–10)

Tegner score at follow-up

(6, 2–10)

Knee score Knee Function score

92 ± 11, 95, 26–100 99 ± 5, 100, 60–100

Knee Society score total

191 ± 16, 195, 86–200

Univariate correlations Patients who additionally had a meniscal lesion at the time of ACL tear showed less favourable outcomes (Tegner score, IKDC total, VAS pain, Lysholm score, KSS total, KOOS) than those having an isolated ACL tear (p \ 0.05).

Table 2 ACL laxity measurements using the KT-1000 arthrometer (a) and the Rolimeter (b) 0–2 mm

Radiological outcome

3–5 mm

6–10 mm [10 mm

(a) KT-1000 arthrometer in 25° knee flexion

The Kellgren–Lawrence score was normal in 8 (14 %), suspected osteoarthritis in 30 patients (54 %), minimal osteoarthritis in 5 patients (9 %), moderate osteoarthritis in 9 patients (16 %) and severe osteoarthritis in 4 patient (7 %). The femoral tunnel was in zone A in 41 patients (68 %), in zone B in 12 (25 %) and in zone D in 3 patients (7 %). The femoral tunnel position in percentage of the Blumensaat line was 49 ± 3 (range, 44–57), the tibial tunnel position in percentage of the total anterior–posterior plateau length was 32 ± 6 (range, 21–46).

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134N

n=3 (5 %)

n = 45 (71 %)

n = 14 (22 %)

n=1 (1 %)

Difference to contralateral knee at 134N

n = 52 (83 %)

n=9 (14 %)

n=2 (3 %)

–

(b) Rolimeter at 90° knee flexion Rolimeter (manuell)

n=7 (11 %)

n = 47 (75 %)

n=8 (13 %)

n=1 (1 %)

Difference to contralateral knee

n = 55 (87 %)

n=7 (11 %)

n=1 (2 %)

–


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Table 3 Valgus and varus stress testing in 30° flexion at final follow-up 0–2 mm

3–5 mm

6–10 mm [10 mm

Valgus stress test

n = 58 (92 %)

n=5 (8 %)

–

–

Varus stress test

n = 58 (92 %)

n=5 (8 %)

–

–

Table 4 Summary of all secondary surgeries Type of secondary surgery

Number of each intervention

Arthroscopic debridement

n = 17 (27 %)

Partial medial meniscectomy

n = 7 (11 %)

Partial lateral meniscectomy

n = 3 (5 %)

Meniscus suture

n = 1 (1.6 %)

Arthrolysis

n = 9 (14 %)

Notch plasty

n = 3 (5 %)

Screw removal

n = 4 (6.5 %)

ACL reconstruction with BPTB

n = 1 (1.6 %)

Other subsequent surgery (arthroscopic debridements, arthrolysis, screw removals)

n = 4 (6.5 %)

Patients who additionally underwent meniscus surgery at the time of initial ACL reconstruction significantly had a lower total SF36 score and less satisfaction measured by VAS (p \ 0.05). The KOOS subscore for pain correlated significantly with the femoral and tibial tunnel position measured in percentage of the Blumensaat line and the anterior–posterior tibial plateau length (p = 0.025 0.299; p = 0.042, -0.272). There was no significant correlation between tunnel positioning and radiological signs of osteoarthritis.

Discussion The most important findings of this long-term study were the following: Firstly, patients with ACL tears who were treated by anatomical single-bundle ACL reconstruction with patellar tendon autograft showed on average good to excellent subjective and objective clinical long-term results with stable knee joints and highly satisfied patients at minimum 15 years after surgery. With a mean Lysholm score of 91 ± 13, a mean Knee Society score of 191 ± 16 and a mean VAS pain score of 1.0 ± 1.4 the subjective, selfreported assessment results of our study were good to excellent when compared with other studies [5, 8, 16, 29, 30, 32, 47]. Nevertheless, there is still room for improvement.

As an orthopaedic surgeon, one cannot be satisfied if not even half of the patients could return to their pre-injury level of sports-activities and one-third showed radiological signs of osteoarthritis. For the last ten years, double-bundle ACL reconstruction was proposed by many authors as the one and only treatment option in patients with ACL deficient knees [12, 19, 35, 40, 51, 52]. Comparing our data with the results of recent review articles including many papers on the outcome of double-bundle ACL reconstruction, or with a review by Mohtadi et al. comparing 19 trials on different single-bundle techniques with comparable study settings as ours, our study shows at least similar or even superior clinical and subjective long-term outcomes [28, 39]. Secondly, only one patient had a retear of the reconstructed ACL (1.5 %) which is a low retear rate compared to recent published data that proposed a retear rate between three and six per cent [28, 36]. In total, 27 % of the patients needed to be re-operated, mostly as a consequence of meniscal lesion at the first trauma. The re-operation rate of 27 % is consistent with that from other reports of ACL reconstruction using bone-patellar tendon-bone graft. [5, 8, 16, 29, 30, 44, 47] Thirdly, there was no correlation between tunnel positioning and radiological signs of osteoarthritis. The results of the KOOS questionnaire showed that the mean value for pain, activity, sport and life quality are very close to values of a population without ACL rupture and without osteoarthritic changes [23, 29, 31]. Measured with the Kellgren– Lawrence score, less than 1/4 of the patients showed 15 years after ACL reconstruction radiologically signs of moderate or severe osteoarthritis, thus meaning that the osteoarthritis rate was in our study much lower than in many similar studies, in which mostly poorer radiological outcomes have been reported [15, 33, 47]. One could speculate if this is due to an examiner’s bias as recently described by Sutherland. He noted that the grading of osteoarthritis of the knee is very subjective, even when using an established scoring system, such as the Kellgren– Lawrence method. Intra-observer error rates for this system, in a review of several published studies, varied from 0.66 to 0.88 [47]. Questioning the comparability of these studies, Gossec et al. [13] criticized quantitative osteoarthritis scores in a similar way. However, even if the patients’ osteoarthritis scores were downgraded by one subcategory, the present study reveals good results. Comparing the currently available literature, it seems that the type of surgical technique if meticulously performed is not a factor significantly influencing the development of osteoarthritis [1, 21, 24, 37, 49]. Fourthly, patients with additional meniscal lesion at the time of ACL tear showed less favourable outcome than those having an isolated ACL tear. The same observation

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was described by Liden [24] and Maletius [25]. Clearly, the need for a secondary surgery and the clinical and subjective outcome is strongly related to associated meniscal injuries at the time of surgery. Hui et al. [16] recently highlighted that it is important to distinguish between the effects of recurrent instability due to ACL deficiency and the deterioration caused by the meniscal or chondral injury at the time of ACL tear. However, Oiestad found that even though the subjects with combined injury (i.e. ACL and meniscal tears) had significantly higher prevalence of radiographic knee osteoarthritis compared with those with isolated injury (80 and 62 %, p = .008), no significant differences in knee function over time were detected between the isolated and combined injury groups and no significant group differences were shown for symptomatic radiographic knee osteoarthritis (46 and 32 %, p = .053) [33]. Nevertheless, our study showed that meniscal tears at the time of ACL rupture have an influence not only on radiological but also on clinical outcomes. In conclusion, the presented ACL reconstruction technique using patellar tendon autograft showed good to excellent long-term outcome. In the time of diagnosis-related groups, use of tibial and femoral post-screw fixation might offer a good cost-benefit perspective. In addition, orthopaedic surgeons should inform their patients with additional meniscal lesion at the time of injury about the expected inferior outcome when compared to isolated ACL tears. It can be speculated that as in many other long-term follow-up studies a selection bias might have occurred. Interestingly, the presented study population predominantly consisted of more male than female patients, a fact that should be considered when compared to generally more female patient groups in other studies. It is also possible that patients with poor or excellent outcome have not agreed on participating in the study. Due to the retrospective and non-randomized study, a selection bias might have influenced the results. However, various studies with different trial settings (randomized and prospective) showed very similar and comparable outcome [43]—a fact that supports our data.

Conclusion Patients treated by anatomical single-bundle ACL reconstruction with patellar tendon autograft showed on average good to excellent subjective and objective clinical longterm results. There was no correlation between tunnel positioning and radiological signs of osteoarthritis. Patients with additional meniscal lesion at the time of ACL tear showed less favourable outcome than those having an isolated ACL tear.

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