RESUMO
Introduction: The agenesis of the anterior cruciate ligament (ACL) is a rare condition infrequently diagnosed as an isolated malformation. Still, it is linked to systemic disorders such as Ehlers-Danlos syndrome (EDS), an inheritable connective tissue disorder characterized by joint hyperlaxity and increased risk of dislocations and subluxations. The literature on ACL reconstruction in EDS patients is minimal, and ours is the second case report describing the surgical management of an ACL agenesis in a patient with this pathology. Case Presentation: The present case report describes the surgical management of an 11-year-old patient affected by EDS. The particularity of this case is that the young patient presented with complete agenesis of the ACL in the right knee resulting in severe joint instability needing surgical reconstruction. This case represented a challenge for the orthopedic surgeon due to the need to improve joint stability without compromising the bone growth of a young patient with open physes while also dealing with tissues that have reduced mechanical properties due to the patient's disease. The patient was therefore treated with an Achilles tendon allograft through a modified version of the typical ACL reconstructive surgery that excluded the classical tunnel drilling in the tibia and femur. Conclusion: At a 2-year follow-up, this technique proved to be an effective treatment for ACL agenesis in an EDS patient. It could provide a reference for surgeons facing similar cases. The proposed surgical technique, completely extra-epiphyseal, could also be applied to healthy young patients with open physes to avoid future growth disturbances.
RESUMO
INTRODUCTION: Conservative treatment of partial ACL ruptures is associated with a high failure rate, and often patients undergo ACL reconstruction. ACL preservation by trephination of the ACL origin and application of Autologous Conditioned Plasma (ACP) seems to be an intriguing new treatment option to favour ACL tissue healing and avoid traditional reconstruction. The aim of this study was to describe the mid-term outcomes of this new ACL preserving technique. MATERIALS AND METHODS: Twenty-four patients (mean age 41.8 years) affected by partial rupture of one or both ACL bundles were included in the present trial. The partial ACL tears were arthroscopically assessed and classified according to a new five step grading system. All patients were treated by trephination of the femoral ACL stump and intra-ligamentary application of ACP. The postoperative outcome was evaluated by both subjective scores and stability testing up to a mean of 25.1 months' follow-up. Adverse events and failure rate were also documented. RESULTS: Clinical outcome was good to excellent with IKDC subjective 82.7 (SD 11.8), Lysholm 87.6 (SD 8.1), Tegner 5.3 (SD 2.1), Cincinnati 88.7 (SD 14.8). The failure rate (i.e. persisting knee instability assessed clinically or by rolimeter) was 12.5%. At objective measurements, knee joints showed a firm endpoint in Lachman test, negative pivot shift phenomenon and a significant reduction in AP-laxity compared to pre-operative status by rolimeter testing (p = 0.002). Return to sport practice was achieved after mean 4.8 months (SD 4.1). CONCLUSIONS: ACL stump trephination and concomitant intra-ligamentary application of ACP revealed promising results at mid-term follow-up to treat partial ACL lesions.