|Year : 2021 | Volume
| Issue : 1 | Page : 9-11
Anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft through transtibial tunnel: Functional results after 7 years of follow-up
Riddhideb Barman, Sarkar Pushpal Pijush, Lawrence Kisku, Mohammad Nasim Akhtar, Sanjay Keshkar
Department of Orthopaedics, ESIC Medical College & Hospital Joka, Kolkata, West Bengal, India
|Date of Submission||10-Jul-2021|
|Date of Acceptance||12-Jul-2021|
|Date of Web Publication||21-Aug-2021|
Department of Orthopaedics, ESIC Medical College & Hospital Joka, Diamond Harbour Rd, Bratachari Gram, Joka, Kolkata 700104, West Bengal.
Source of Support: None, Conflict of Interest: None
Background: The anterior cruciate ligament (ACL) reconstruction is conducted to improve the stability and function of the knee. Bone-patellar tendon-bone (BPTB) graft is still considered as one of the best grafts for ACL reconstruction. The purpose of this paper was to assess outcomes of BPTB ACL reconstruction at 7 years of follow-up. Materials and Methods: This was a retrospective study in which records of 26 patients, who had ACL reconstruction using BPTB graft from 2013 to 2015, were done and the outcomes of results were analyzed by clinical Tegner activity levels and Lysholm score at 6–8 years of follow-up. Results: The follow-up study has revealed excellent long-term results. Approximately 87% of 26 patients had negative pivot shift examination with the remaining 13% having grade 1 ligament laxity. Tegner activity levels were similar to preinjury levels and Lysholm score was 91. All patients were satisfied with the procedure. Conclusion: BPTB ACL reconstruction using transtibial tunnel provides a satisfactory mid-term follow-up outcome.
Keywords: Anterior cruciate ligament (ACL) reconstruction, arthroscopy, mid-term follow-up, patellar tendon, transtibial tunnel
|How to cite this article:|
Barman R, Pijush SP, Kisku L, Akhtar MN, Keshkar S. Anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft through transtibial tunnel: Functional results after 7 years of follow-up. Int J Orthop Surg 2021;29:9-11
|How to cite this URL:|
Barman R, Pijush SP, Kisku L, Akhtar MN, Keshkar S. Anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft through transtibial tunnel: Functional results after 7 years of follow-up. Int J Orthop Surg [serial online] 2021 [cited 2021 Sep 25];29:9-11. Available from: https://www.ijos.in/text.asp?2021/29/1/9/324273
| Introduction|| |
The anterior cruciate ligament (ACL) reconstruction is performed to improve the stability and function of the knee. Bone-patellar tendon-bone (BPTB) graft is still considered as one of the best grafts for ACL reconstruction being inserted through a transtibial tunnel and fixing it by interference screws. There is limited study on the said subject showing such a long follow-up of 7 years. The purpose of this paper was to assess outcomes of BPTB ACL reconstruction at 7 years of follow-up.
| Materials and Methods|| |
This was a retrospective study in which records of 26 patients who had ACL reconstruction using BPTB graft through transtibial tunnel from 2013 to 2015 were done. The inclusion criteria for selection of cases for this procedure were isolated complete tear ACL (Grade III injury) in young active patients, evidenced by magnetic resonance imaging (MRI) and clinical examination (preoperative as well as per operative on the table after anesthesia). ACL injuries associated with other injuries (posterior cruciate ligament [PCL], lateral collateral ligament [LCL], medial collateral ligament [MCL], or meniscal injuries) were excluded and were reconstructed by other methods. All of them were kept under strict postoperative rehabilitation protocol and continued during follow-up. The outcome of results was analyzed by clinical Tegner activity levels and Lysholm score. They were followed up for 6–8 years.
Graft harvesting, tunnel preparation, and graft insertion
Under spinal/general anesthesia, the stability of the knee was evaluated followed by diagnostic arthroscopy to evaluate the ACL integrity. After confirmation of isolated ACL tear, the BPTB graft was harvested and given to assistant for preparation [Figure 1]A and B. In the meanwhile, ACL stump was removed with a mechanical shaver until the tibial and femoral footprints were well visualized, through AM and anterolateral (AL) portals. After this, transtibial tunnel was created [Figure 1]C and then prepared grafts were inserted [Figure 1]D by the usual standard technique.
|Figure 1: Steps of surgical procedure showing harvesting BPTB graft (A), harvested and prepared BPTB graft (B), and tunnel preparation and graft insertion (C and D)|
Click here to view
We used an interference screw for both sides. With the knee at 100–110° of flexion, a guidewire for the cannulated interference screw (titanium / bioabsorbable) was inserted through the stab made through an exposed patellar fat pad parallel to the tibial tunnel. Interference screw was inserted through it. Tibial fixation of graft was done by interference screw in the usual manner.
Closure, dressing, and rehabilitation
The longitudinal gap of the patellar tendon was approximated properly by absorbable suture. Paratenon was closed nicely and finally the skin was closed by nonabsorbable suture. Dressing and then compression bandage (Robert Jone’s Bandage) were applied. The patient shifted to the ward and an accelerated rehabilitation program was implemented on the day of surgery.
| Results|| |
In this study, 26 cases who had ACL reconstruction using BPTB graft through the transtibial tunnel were evaluated. There were 21 men and 3 women with male-to-female ratio 7:1. The mean age of patients was 35 years ranging from 20 to 45 years. A total of 18 patients had involvement of right knee and 8 had left side.
The follow-up study of 6–8 years has revealed excellent mid-term results as evident in radiograph [Figure 2]A and B] and clinical photograph of a patient [Figure 2]C and D. Approximately 87% of 26 patients had negative pivot shift examination with the remaining 13% having grade 1 ligament laxity. Tegner activity levels were similar to preinjury levels; Lysholm score was 91. No patients showed any long-term patellar tendinitis; however, low incidence of patellar pain (17%) was noted. All patients except one were satisfied with the procedure.
|Figure 2: Clinicoradiological result after follow-up of 6–8 years. Radiograph of knee showing implants (interference screws in situ and good graft take-up (A and B) and clinical photograph of a patient showing full range of motion of knee (C and D)|
Click here to view
| Discussion|| |
The ACL is the most commonly injured ligament in the knee and needs reconstruction if patient gets feeling of instability during everyday activities or when he wants to perform high-risk sports such as soccer or skiing, typically after decelerating/pivoting movements during sports., The procedure “ACL reconstruction” includes various steps starting from diagnostic arthroscopy to tunnel placement graft fixation and type of graft. The options regarding autograft choice include the autologous BPTB graft, the hamstring tendons (semitendinosus/gracilis), and the quadriceps tendon. Two recent long-term randomized controlled trials comparing hamstrings versus patellar tendon autograft revealed only minor and mostly insignificant differences between the two graft options with good long-term subjective and objective outcomes., However, the number of studies with patients evaluated at long term is still limited.
This study revealed that BPTB ACL reconstruction provides a satisfactory objective and subjective outcome with respect to the score evaluation at an average follow-up of 18 years.
In our study, the Lysholm knee scoring scale was good with an average of 91 and is comparable to 90 points, reported by Möller et al. after an average follow-up of 11.5 (11–12) years. Our result is also consistent with the results presented in the systematic review by Chalmers et al. with Lysholm scores of mean 84.4 for nonoperative compared with 88.7 for operative, independent of transplant, or surgical technique, with a mean follow-up of 10 years or longer., The Tegner activity level scale was similar to preinjury levels in our study, which is superior to other reports. , In lower Tegner activity score in these reports, could be related to the increase in age and changes in life style between the time of injury and the time of follow-up., The success of ACL reconstruction surgeries, especially in sportive active patients, subjective instability is regarded as crucial concern. In our study, all patients except one were satisfied with the procedure. The dissatisfaction of one patient was the stiffness of the knee, which was manipulated under anesthesia even then some degree of stiffness persisted.
| Conclusion|| |
In conclusion, BPTB ACL reconstruction through transtibial tunnel provides a satisfactory objective and subjective outcome with a good activity level in patients with graft survival at an average follow-up of 7 years.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
RB helped in study design, data collection, preoperative investigation, and surgical intervention. SPP contributed to the study design, analysis of data, preparation of manuscript, and reviewed the manuscript. LK helped in study design, surgical intervention, and follow-up of patients. MNA helped in study design, preoperative investigation, surgical intervention, data collection, and preparation of manuscript. SK contributed to the study design, analysis of data, surgical intervention, supervised the study, and reviewed the manuscript for final preparation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| References|| |
Neuman P, Kostogiannis I, Fridén T, Roos H, Dahlberg LE, Englund M Patellofemoral osteoarthritis 15 years after anterior cruciate ligament injury–a prospective cohort study. Osteoarthr Cartil 2009;17:284-90.
Kostogiannis I, Ageberg E, Neuman P, Dahlberg L, Fridén T, Roos H Activity level and subjective knee function 15 years after anterior cruciate ligament injury: A prospective, longitudinal study of nonreconstructed patients. Am J Sports Med 2007;35:1135-43.
Laupattarakasem P, Laopaiboon M, Kosuwon W, Laupattarakasem W Meta-analysis comparing bioabsorbable versus metal interference screw for adverse and clinical outcomes in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2014;22:142-53.
Leiter JR, Gourlay R, McRae S, de Korompay N, MacDonald PB Long-term follow-up of ACL reconstruction with hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2014;22:1061-9.
Bjornsson H A randomized controlled trial with mean 16-year follow-up comparing hamstring and patellar tendon autografts in anterior cruciate ligament reconstruction. Am J Sports Med2016;44:2304-13.
Webster KE, Feller JA, Hartnett N, Leigh WB, Richmond AK Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: A 15-year follow-up of a randomized controlled trial. Am J Sports Med 2016;44:83-90.
Möller E, Weidenhielm L, Werner S Outcome and knee-related quality of life after anterior cruciate ligament reconstruction: A long-term follow-up. Knee Surg Sports Traumatol Arthrosc 2009;17:786-94.
Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A Long-term results of anterior cruciate ligament reconstruction: A comparison with non-operative treatment with a follow-up of 17-20 years. Int Orthop 2011;35:1093-7.
Meuffels DE, Favejee MM, Vissers MM, Heijboer MP, Reijman M, Verhaar JA Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. Br J Sports Med 2009;43:347-51.
[Figure 1], [Figure 2]