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PURPOSE: To determine if there is a correlation between lateral tibial slope and long-term clinical results in patients who underwent double-bundle ACL reconstruction. METHODS: We retrospectively reviewed patients that received double-bundle ACL reconstruction at a single institution by a single surgeon from January 2011 to December 2014. All the magnetic resonance imaging were reviewed and lateral tibial slopes (LTS) were recorded by an experienced surgeon and rechecked by the other two authors of this study that specialized in orthopedic knee surgery. The relationship between PROMs measurement and lateral tibial slope were analyzed. The patients were then separated into two groups (LTS > 7.4° and < 7.4°) according to the previous study. RESULTS: A total of 119 patients were enrolled in this study. All enrolled patients were followed for at least 8 years. The PROMS result were negatively correlated with the lateral tibial slope (p values all < 0.001). The patients with high lateral tibial slope had significantly lower PROMS values (Lysholm 94.26 ± 5.61 vs 80.15 ± 8.28, p = 0.013; IKDC 82.99 ± 4.55 vs 70.09 ± 7.15, p = 0.003; Tegner 9.32 ± 0.95 vs 6.85 ± 1.99, p < 0.001). Finally, the LTS cutoff value between patients with "Good" and "Fair" Lysholm score in our study was 7.55 degrees. CONCLUSIONS: Patients with high lateral tibial slope may result in inferior long-term subjective outcomes. The using of double-bundle ACL reconstruction along cannot overcome the negative impact caused by steep lateral tibial slope. A lateral tibial slope of 7.55° may be used as a cut-off for a good clinical outcome. LEVEL OF EVIDENCE: III retrospective comparative prognostic trial.
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Lesões do Ligamento Cruzado Anterior , Reconstrução do Ligamento Cruzado Anterior , Humanos , Estudos Retrospectivos , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Articulação do Joelho/cirurgia , Tíbia/cirurgiaRESUMO
PURPOSE: There is paucity in studies regarding double-bundle anterior cruciate ligament reconstruction (DB-ACLR) in teenagers. The purpose of this study is to investigate clinical outcome after DB-ACLR and analyze whether any differences exist between teenagers and young adults. METHODS: A retrospective study was performed between 2009 and 2017. Teenagers were defined as patients between 15 and 19 years and young adults between 20 and 25 years old. Isolated anterior cruciate ligament (ACL) injuries with DB-ACLR with minimum two-year follow up were included. Pre and post-operative Lysholm score, Tegner activity scale, KT-2000 arthrometer, manual pivot-shift grade, were assessed with post-operative one-leg hop test, isokinetic knee extensor strength test at 60°/sec, International Knee Documentation Committee Score (IKDC score), and re-injury rate. RESULTS: One-hundred and thirty-one patients, 75 patients in the teenage group (Group A) and 56 patients in the young adult group (Group B), were enrolled. Lysholm score was significantly lower in Group A (89.6 ± 21.1) compared to Group B (95.9 ± 4.6) (p = 0.04). Side to side difference in KT-2000 arthrometer (2.3 ± 2.2 mm vs 1.0 ± 2.3 mm, Group A vs Group B, respectively, p < 0.01) and ratio of post-operative positive pivot shift was significantly greater in Group A (30.7%) compared to Group B (7.1%) (p < 0.01). No significant difference was seen in re-injury rate (n.s.). CONCLUSION: Teenage patients have a greater tendency for residual knee joint laxity after DB-ACLR. Although teenagers and patients in the early twenties are close in age, characteristic in knee joint laxity may be different and, therefore, may require attention upon surgery and post-operative follow-up. LEVEL OF EVIDENCE: III.
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Lesões do Ligamento Cruzado Anterior/complicações , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Instabilidade Articular/etiologia , Adolescente , Adulto , Ligamento Cruzado Anterior/cirurgia , Feminino , Seguimentos , Humanos , Escore de Lysholm para Joelho , Masculino , Complicações Pós-Operatórias , Relesões , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To examine the clinical and biomechanical results of posterolateral (PL) augmentation to reconstruct damaged PL bundle while preserving the less-damaged anteromedial bundle for partial anterior cruciate ligament (ACL) tears in comparison with double-bundle ACL reconstruction. METHODS: Sixteen patients who underwent PL augmentation for partial ACL tears (Group P) and 37 patients who underwent double-bundle ACL reconstructions for complete ACL tears were examined (Group D). Anterior tibial translation (ATT) was evaluated using the KT-1000 arthrometer. ATT during the Lachman test and acceleration of posterior tibial translation (APT) during the pivot shift test were evaluated using an electromagnetic measurement system (EMS). Clinical outcomes were evaluated using the Lysholm score. Second-look arthroscopy was performed 1 year after surgery. RESULTS: The mean postoperative Lysholm scores were 91.7 ± 12.2 and 94.6 ± 7.2 in Groups P and D, respectively, and there was no statistically significant difference between the two groups. The mean side-to-side difference of ATT on the KT-1000 was significantly improved in both Groups P and D. In the EMS analysis, the mean side-to-side difference of ATT and the mean APT were significantly improved in both Groups P and D. There was no significant difference in the second-look evaluation between the two groups. CONCLUSIONS: The clinical and biomechanical outcomes of PL augmentation were satisfactorily comparable to those of double-bundle ACL reconstruction. PL augmentation could be a useful treatment option for patients with partial ACL tears. LEVEL OF EVIDENCE: IV.
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Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Adulto , Artroscopia , Fenômenos Eletromagnéticos , Feminino , Humanos , Instabilidade Articular/prevenção & controle , Instabilidade Articular/cirurgia , Masculino , Cirurgia de Second-Look , Tíbia/cirurgia , Resultado do TratamentoRESUMO
Introduction: ACL rupture is the most common type of knee injury. The All-inside ACL reconstruction procedure features some distinguished components including closed-socket tunnels with less bone expulsion, double suspensory fixation, and smaller incisions. We aimed to compare the outcomes between the All-inside Single-bundle and the Double-bundle ACL reconstruction techniques. Materials and methods: This study was a retrospective study which analysed the patient-reported and the clinical outcomes on patients who underwent ACL reconstruction between January and December 2020 at Dr Kariadi General Hospital Semarang, Indonesia. We compared the patient-reported and the clinical outcomes at 6- and 12-month follow-ups between the All-inside Single-bundle and the Double-bundle groups. The patient-reported outcomes were determined using the IKDC and Tegner-Lysholm scores while the clinical outcomes included the measurement of Thigh Circumference, Single Hop test, Anterior Drawer test, Lachman test, Range of motion, and the patient's level of return to sport. Results: A total of 24 subjects were divided into two groups, namely the All-inside Single-bundle and the Double-bundle groups, consisting of 12 subjects in each group. Most of the subjects were male in both groups, including 9 (75%) subjects in the All-inside Single-bundle group, and 11 (91.67%) subjects in the Double-bundle group. The mean age of the subjects were 25.75±7.57 years old in the All-inside Single-bundle group, and 24.5±6.87 years old in the Double-bundle group. In terms of the side of the knee that suffered the most injuries in both groups were the right knees. The result of the patient-reported outcomes using IKDC and Tegner-Lysholm scores showed no statistically significant differences in both groups at 6- and 12-month follow-ups (p=0.864; p=0.293 and p=0.589; p=0.233, respectively). The results of clinical assessments at 6- and 12-month follow-ups also showed no statistically significant differences in both groups. Conclusion: Our study showed no significant differences in the patient-reported and the clinical outcomes between the All-inside Single-bundle and the Double-bundle ACL reconstruction techniques at 6- and 12-month follow-ups.
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Background: The occurrence rate of cyclops lesion after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with remnant tissue preservation remains unclear. Hypothesis: The study hypotheses were as follows: (1) the occurrence rate of cyclops lesion will be comparable between the remnant-preserving and remnant-resecting ACL reconstruction methods, and (2) there will be no significant differences in clinical outcomes between the remnant-preserving and remnant-resecting procedures. Methods: This retrospective comparative study involved 177 patients who underwent unilateral anatomic double-bundle ACL reconstruction using hamstring tendon autografts from 2014 to 2018 at our hospital. According to the Crain classification of ACL remnant tissue, 98 patients with remnant types I, II, or III underwent the remnant-preserving procedure (group A), and the remaining 79 patients with remnant type IV underwent the remnant-resecting procedure (group B). All patients underwent second-look arthroscopy. Patients were evaluated according to arthroscopic and clinical results at postoperative 15.2 ± 8.4 months (mean ± SD). Statistical comparisons between groups were made using the paired Student t test, chi-square test, and Fisher exact test. Study Design: Cohort study; Level of evidence, 3. Results: At second-look arthroscopy, the incidence of cyclops lesions was significantly higher in group B than in group A (29.1% vs 13.3%; P = .0139). Cyclops lesions were divided into 4 locations: femoral side (type 1), midsubstance (type 2), tibial side (type 3), and anterior (type 4) of the ACL graft. The ratio of the tibial-side cyclops lesion (type 3) was significantly higher in group B than in group A (P = .0354). There were no significant differences in the clinical evaluation scores between the procedures. Side-to-side anterior laxity was significantly less in group A than in group B (0.7 vs 1.6 mm; P = .0035). Concerning postoperative laceration and synovium coverage of the grafts, group A was significantly better than group B (P < .0001). Conclusion: In this cohort of patients undergoing double-bundle ACL reconstruction, resection of the ACL remnant was associated with a significantly higher rate of cyclops lesion formation when compared with preservation of the remnant.
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BACKGROUND: There have been conflicting results about the theoretical advantages of anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. PURPOSE: To evaluate the clinical and functional outcomes comparing anatomic single- versus double-bundle techniques, anatomic versus nonanatomic techniques, and transportal versus outside-in tunnel drilling for ACL reconstruction. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A search was performed in the MEDLINE and EMBASE databases up to August 2018 for clinical trials comparing anatomic ACL reconstruction (with tunnel positioning demonstrated using gold standard radiologic techniques) with another technique, with a minimum functional and biomechanical follow-up of 6 months. A meta-analysis was performed to compare clinical and functional outcomes between anatomic single- versus double-bundle reconstruction and between anatomic versus nonanatomic techniques, using the risk difference or the mean difference. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale for cohort and case-control studies and the Cochrane Risk of Bias tool and Jadad Score for randomized controlled trials. RESULTS: Included were 15 studies comprising 1290 patients (follow-up, 12-36 months). No significant differences favoring anatomic double-bundle over anatomic single-bundle reconstruction or outside-in over transportal techniques were found. The meta-analyses showed significant differences in the International Knee Documentation Committee (IKDC) objective score (risk difference, -0.14; 95% confidence interval, -0.27 to -0.01) favoring anatomic over nonanatomic reconstruction. No statistically significant differences were found between anatomic and nonanatomic surgical techniques on other functional scores or clinical examination outcomes, including the IKDC subjective score, Lysholm score, Tegner score, KT-1000 arthrometer test, or pivot-shift test. CONCLUSION: Double-bundle reconstruction was not superior to the single-bundle technique in clinical and functional outcomes. Anatomic ACL reconstruction shows significantly superior results over nonanatomic ACL reconstruction, reinforcing the anatomic technique as the gold standard choice for clinical practice.
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BACKGROUND: Previous studies have suggested that increased mechanical stress due to acute graft bending angle (GBA) is associated with tunnel widening and graft failure after anterior cruciate ligament (ACL) reconstruction. Few studies have compared the GBA between the outside-in (OI) and the transportal (TP) techniques. PURPOSE: To evaluate the influence of GBA on clinical outcomes and tunnel widening after ACL reconstruction with OI versus TP technique. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included in the study were 56 patients who underwent double-bundle ACL reconstruction (n = 28 in the OI group and n = 28 in the TP group). Clinical outcomes (Lysholm, International Knee Documentation Committee, Tegner score, and knee laxity) 1 year postoperatively were evaluated. Computed tomography scans at 5 days and 1 year postoperatively were used for imaging measurements, and the femoral tunnel was divided into the proximal third, middle, and aperture sections. The GBA and cross-sectional area (CSA) were measured using image analysis software and were compared between groups. A correlation analysis was performed to determine if the GBA affected clinical outcomes or tunnel widening. RESULTS: No significant difference was observed in clinical outcomes between the groups. The GBA of both the anteromedial (AM) and posterolateral bundles were more acute in the OI group compared with the TP group (P < .05). The CSA at the AM tunnel aperture increased significantly in the OI group (84.2% ± 64.3%) compared with the TP group (51.4% ± 36.7%) (P = .04). However, there were no differences in the other sections. In the Pearson correlation test, GBA was not correlated with tunnel widening or clinical outcomes. CONCLUSION: Regardless of technique, the GBA did not have a significant influence on tunnel widening or clinical outcomes. Considering a wider AM tunnel aperture, a more proximal and posterior AM tunnel position might be appropriate with the OI technique.
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BACKGROUND: The posterolateral (PL) graft experiences a high failure rate in anterior cruciate ligament double-bundle (DB) reconstruction. It is hypothesized that tunnel positions could dramatically affect the graft forces. METHODS: A validated computational model was used to simulate DB reconstruction with various femoral PL tunnel locations (8-11 mm center-center tunnel spacing). Graft fixation was simulated at both 0° and 30°. Knee biomechanics were examined with the knee under a 134 N anterior load and 400 N quadriceps load at 0°, 30°, 60°, and 90° of flexion. Graft forces, tibial translation, and tibial rotation were calculated. RESULTS: PL graft forces at full extension increased with increasing tunnel spacing under both fixation settings, but the knee kinematics was not dramatically affected. CONCLUSION: Small changes in the femoral PL tunnel position could result in large changes in graft forces, implying that precise PL tunnel position is an important factor in a successful DB reconstruction.
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Reconstrução do Ligamento Cruzado Anterior/instrumentação , Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Cruzado Anterior/cirurgia , Fenômenos Biomecânicos , Simulação por Computador , Fêmur/cirurgia , Humanos , Imageamento Tridimensional , Instabilidade Articular , Joelho/cirurgia , Articulação do Joelho/cirurgia , Modelos Anatômicos , Pressão , Amplitude de Movimento Articular , Estresse Mecânico , Tíbia/cirurgiaRESUMO
BACKGROUND: The purpose of this study was to evaluate bone tunnel changes following anterior cruciate ligament (ACL) reconstruction during the early postoperative period using computed tomography (CT), and to understand the impact of postoperative immobilization on these changes. METHODS: Twenty patients who underwent double-bundle ACL reconstruction using hamstring tendon autografts were included. We subcategorized patients into two groups: patients who underwent isolated ACL reconstruction and had three days of knee immobilization (Group A, n=10); and patients with concomitant meniscus injuries who underwent ACL reconstruction and meniscus repair simultaneously (Group B, n=10) had their knees immobilized for two weeks after surgery. Bone tunnel enlargement was evaluated using CT imaging at one to three days, two weeks, one month, three months and six months after surgery. The cross-sectional area of the femoral and tibial tunnels was measured, and enlargement rate was calculated. The tunnel center location at two weeks after surgery was also evaluated. RESULTS: The mean cross-sectional area adjacent to the joint space of the femoral and tibial tunnels significantly increased immediately after surgery, especially in the first month (P<0.01). However, after one to six months they were not increased (P>0.01). There was no significant difference in tunnel enlargement rate between group A and B. Tunnel center location changed even in the first two weeks. CONCLUSIONS: Bone tunnel enlargement following double-bundle ACL reconstruction occurred at an earlier time point after surgery than anticipated. Postoperative immobilization could not prevent bone tunnel enlargement, but might prevent tunnel migration.
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Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Fêmur/diagnóstico por imagem , Imobilização/métodos , Tíbia/diagnóstico por imagem , Adulto , Anatomia Transversal , Feminino , Fêmur/cirurgia , Tendões dos Músculos Isquiotibiais/transplante , Humanos , Masculino , Cuidados Pós-Operatórios , Tíbia/cirurgia , Fatores de Tempo , Tomografia Computadorizada por Raios X , Transplante Autólogo , Adulto JovemRESUMO
BACKGROUND: Calcium phosphate (CaP)-hybridized tendon grafts improved biomechanical function compared with untreated grafts after single-bundle (SB) anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the biomechanical function between anatomic double-bundle (DB) and single-bundle (SB) ACL reconstructions using CaP-hybridized tendon grafts at 6 months postoperatively in goats. HYPOTHESIS: We hypothesized that the postoperative biomechanical function in the DB group will be better than that in the SB group. MATERIALS AND METHODS: Knee kinematics and in situ forces in the grafts under applied anterior tibial load (ATL) of 50N and internal tibial torque (ITT) of 2.0 Nm at full extension, and 60° and 90° of knee flexion, and the histology of the tendon-bone interface were compared between the DB group (n=6) and SB group (n=6). RESULTS: The in situ forces under ATL in the DB group at full extension and 90°of knee flexion were greater than those in the SB group. The in situ forces under ITT in the DB group at full extension and 60°of knee flexion were greater than those in the SB group. The in situ forces on the posterolateral bundle of the grafts under ATL and ITT in the DB group at full knee extension were greater than those on the posterior half of the grafts in the SB group. The histology did not differ significantly between the groups. CONCLUSIONS: Although CaP-hybridized tendon grafts were used in both groups, the in situ forces under ATL and ITT in the DB group were greater than those in the SB group at 6 months postoperatively. The posterolateral bundle of the grafts in the DB group acted effectively against both ATL and ITT at full extension. The tendon-to-bone healing was similar in both groups. STUDY DESIGN: Controlled laboratory study. Level 2.
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Reconstrução do Ligamento Cruzado Anterior/métodos , Ligamento Cruzado Anterior/cirurgia , Fosfatos de Cálcio , Tendões dos Músculos Isquiotibiais/transplante , Articulação do Joelho/cirurgia , Animais , Ligamento Cruzado Anterior/fisiopatologia , Fenômenos Biomecânicos , Feminino , Cabras , Articulação do Joelho/fisiopatologia , Período Pós-Operatório , Tíbia/cirurgiaRESUMO
BACKGROUND: The posterolateral graft has been reported to fail more frequently than the anteromedial graft in double-bundle ACL reconstructions. This study investigated the graft kinematics using a 3D modelling technique. METHODS: Twenty subjects performed a stair-ascending activity under dual fluoroscopy surveillance. A double-bundle ACL reconstruction was simulated on those healthy knees using an anteromedial portal technique. The graft-tunnel interaction was described using the graft-tunnel angle and the range of the graft-tunnel edge contact (GTEC). RESULTS: The femoral graft-tunnel angle of the anteromedial/posterolateral graft was 97.6 ± 7.5/100.7 ± 7.7° and the tibial graft-tunnel angle was 158.8 ± 6.5/146.5 ± 8.9° at knee extension. The femoral GTEC ranges were 23.2 ± 5.3-28.1 ± 7.6° for both grafts and the tibial GTEC ranges were 27.3 ± 2.2-34.5 ± 2.1° during stair-ascending. CONCLUSION: The femoral graft-tunnel angle was larger than on the tibial side and the GTEC angles influenced the PL graft more, implying that grafts may experience a less optimal biomechanical environment at the femoral tunnels.
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Reconstrução do Ligamento Cruzado Anterior , Simulação por Computador , Articulação do Joelho/fisiopatologia , Adulto , Fenômenos Biomecânicos , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Anterior cruciate ligament (ACL) reconstruction aims to restore the translational and rotational motion to the knee joint that is lost after injury. However, despite technical advancements, clinical outcomes are less than ideal, particularly in return to previous activity level. A major issue is the inability to standardize treatment protocols due to variations in materials and approaches used to accomplish ACL reconstruction. These include surgical techniques such as the transtibial and anteromedial portal methods that are currently under use and the wide availability of graft types that will be used to reconstruct the ACL. In addition, concomitant soft tissue injuries to the menisci and capsule are frequently present after ACL injury and, if left unaddressed, can lead to persistent instability even after the ACL has been reconstructed. Advances in the field of biomechanics that help to objectively measure motion of the knee joint may provide more precise data than current subjective clinical measurements. These technologies include extra-articular motion capture systems that measure the movement of the tibia in relation to the femur. With data gathered from these devices, a threshold for satisfactory knee stability may be established in order to correctly identify a successful reconstruction following ACL injury.
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BACKGROUND: Single-tunnel double-bundle (STDB) anterior cruciate ligament (ACL) reconstruction can restore biomechanical function and anatomic structure, but existing methods of graft fixation are not adequate. The aims of this study are to examine knee biomechanics after STDB reconstruction using a unique expandable interference screw for fixation. METHODS: The biomechanical parameters of six pairs of human cadaveric knee specimens were measured with the ACL intact, after ACL removal, and after STDB reconstruction using the interference screw or single-tunnel single-bundle (STSB) reconstruction. Anterior tibial translation under 134 N anterior tibial load in a neutral position as well as in 15° and 30° internal and external knee rotation and the internal tibial rotation angle under the rotatory load (5 N·m internal tibial rotation) were measured. RESULTS: Anterior tibial translations at each degree of knee flexion in the STDB group were significantly less than in the STSB group (all, P<0.05). The internal rotation angles in the STSB group at five flexion angles were significantly higher than in the ACL intact group, whereas there were significantly less than those of the ACL absent group (P<0.05). Under rotatory loads in the neutral position, the tibial internal rotation angles of the STDB group were significantly lower than in the STSB group at all flexion angles (all, P<0.05). CONCLUSIONS: STDB ACL reconstruction with the expandable interference screw provides better anteroposterior and rotational stability than STSB reconstruction. CLINICAL RELEVANCE: The technique provides the advantages of double-bundle reconstruction using a single-tunnel technique.