Evaluation of Arthroscopic Anterior Cruciate Ligament Reconstruction using Hamstring Graft

Transcription

1 384 Clinicale Evaluation Evaluation of Arthroscopic Anterior Cruciate Ligament Reconstruction using Hamstring Graft Swaroop Patel, Resident, Vijendra D. Chauhan, Professor, Anil Juyal, Professor, Rajesh Maheshwari, Professor and Head, Atul Agrawal, Assistant Professor Department of Orthopaedics, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand. Abstract Purpose: To evaluate the results of quadrupled hamstring tendon autograft Anterior Cruciate Ligament (ACL) fixed with bioabsorbable interference screw fixation. Methods: Twenty-five patients underwent arthroscopic anterior cruciate ligament s using autogenous hamstring graft (semitendinosis and gracilis). All patients underwent through standard surgical procedure and rehabilitation protocol. Patients were assessed using International Knee Documentation Committee (IKDC) and Lysholm knee scoring scale at a minimum duration of six-month. Results: In all patients at 6 months post surgery. The mean Lysolm knee score was 91.2 (range, 63 to 99) and the mean IKDC score was 90.7 (range, 60 to 98). Conclusion: The short-term results were quite promising on evaluation with IKDC and Lysholm scale. Keywords hamstring, autograft, anterior cruciate ligament Introduction Anterior cruciate ligament is the most frequently disrupted ligament in the human knee, yet wide disagreement exists concerning the effect of its rupture and appropriate means of treatment 1. The untreated complete injuries of the ligament have been suggested to progress to symptomatic instability leading to recurrent injury, damage to menisci, articulating cartilage and osteoarthrosis of the knee joint 2. The long term excellent results of a well performed arthroscopic anterior cruciate ligament in terms of functional stability, relief of symptoms and return to pre-injury level of activity have been stated to be between 75 and 90 percent, however, leaving a substantial group of patients unsatisfied 3. We evaluated the effectiveness of anterior cruciate ligament, with a fourstranded semitendinosus and gracilis autograft fixed with bioabsorbable interferance screw. Material and Methods All patients above 18 years with anterior cruciate ligament tear visiting the hospital between were included in the study. Patients with previous anterior cruciate ligament surgery or any fracture of the condyles were excluded from the study. Under tourniquet with knee flexed down from operating table arthroscopy was performed. Standard anterolateral and anteromedial portals were used. The diagnosis of anterior cruciate ligament tear was confirmed Address for correspondence: Dr Swaroop Patel, Dept. of Orthopaedics, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, Uttarakhand

2 . 385 arthroscopically and associated lesions were diagnosed and treated concurrently. The gracilis and semitendinosis tendons were harvested and measured in dimensions after being doubled. Krackow sutures were placed on both ends of the quadrupled graft. The tibial tunnel was made using the Tibial guide (Acufex - Smith & Nephew) at an angle of 45 in all cases. The knee was flexed to more than 90 and the femoral tunnel was drilled through the transtibial approach. The femoral tunnel was positioned at 10 O clock for the right knee and 2 O clock for the left knee. Introperativelly the placement of the tunnels were confirmed by c-arm (Fig. 1 a-b). The graft was fixed with biodegradable interferance screw in all patients. Fig. 1 (a): showing intra-operative tibial tunnel placement. (b): showing intra-operative femoral tunnel placement -operatively Knee brace was applied to all the patients to protect the newly reconstructed ligament. The post-operative rehabilitation consisted of open and closed chain exercises. Quadriceps isometric exercise was started from day 01. Knee bending exercises were started by 7th day. By 6th week full range of motion was achieved. Each patient was followed at 3 weeks, 3 months and 6 months intervals and assessed six months post-operatively using the Lysholm Knee Scoring Scale and IKDC scoring scale. Results The study group consisted of Twenty-five cases. The mean age was 28.2 years. The male female ratio was 23:2. Right knee was involved in 16 (64%) cases and left knee was involved in 9 (36%) cases. Major mode of trauma was RTA in 10 cases (40%) followed by sports injury in 8 cases (32%) and 7 cases (28%) reported to have history of fall. All patients presented after 4 weeks of injury. Isolated anterior cruciate ligament tear was present in 15 cases (60%), anterior cruciate ligament with medial meniscus tear was present in 8 cases (32%) and anterior cruciate ligament with lateral meniscus was present in 2 cases (8%). In patients who had undergone surgery after 12 months, 5 had medial meniscus tear and 1 had lateral meniscus tear. Patients who underwent surgery within 7-12 months of injury 2 had medial meniscus tear and 1 had lateral meniscus tear. Patients who underwent surgery within 1-6 months of injury, only 1 had medial meniscus tear and none had injured lateral meniscus. The pre-operative and at six-month follow up evaluation of the patients using IKDC form is as shown in Table 1. Similarly, Table 2 depicts the IKDC scores. Table 2 and at six-month follow up IKDC scores Statistics IKDC score IKDC score at six-month follow up n Mean SD Max Min IKDC Grade Table 1 and at six-month follow up IKDC grades No. of patients % of patients No. of patients at six-months follow up % of patients at six-months follow up A Normal 0 0 % % B Near normal 0 0 % 9 36 % C Abnormal % 0 0 % D Severely abnormal 5 20 % 1 4 %

3 386 Grade No. of patients (n-25) Table 3 and at six-month follow up Lyshlom grades % of patients No. of patients at six-month follow up % of patients at six-month follow up Excellent 0 0% 12 48% Good 0 0% 9 36% Fair 15 60% 3 12% Poor 10 40% 1 4% Table 4 and at six-month follow up Lysholm scores Statistics Lysholm Score At six-month follow up Lysholm Score n Mean SD Max Min The pre-operative and at six-month follow up evaluation of the patients using Lyshlom knee scoring form the inferences are as shown in Table 3. Similarly, Table 4 depicts the Lyshlom scores of all patients at pre-operative and at six-month follow up. All patients were able to perform single leg hop test and had full range of motion at their last follow up. None of the patient complained of post-operative laxity and all had full range of motion (Fig. 2 a-c). Fig. 2 (a): Showing pre-operative laxity (b): no laxity post operatively (c): Patient performing single leg hop test post-operatively Discussion Reconstruction of the anterior cruciate ligament is an effective method of eliminating anterior tibial subluxation that is associated with rupture of anterior cruciate ligament 4. Anterior cruciate ligament using Bone Patellar Bone (BPB) graft is still considered as the gold standard 5,6. However, associated complications of BPB graft may lead to donor site morbidity causing patellofemoral joint problems, patellar fracture, quadriceps weakness and rupture of patellar tendon 9,5. The hamstring graft has lower harvest morbidity and preserves the extensor mechanism and has wider cross-sectional area. It has more consistent mechanical properties which is similar to that of the normal anterior cruciate ligament. The fact that the hamstring graft is not affected by age makes it the most appropriate choice 4,9. Harner et al 7 in a biomechanical study demonstrated that quadrupled hamstring graft has higher ultimate failure loads of 4140 N as compared to BPB graft, which has failure load of 2977 N 8. Hamstring graft fixation to host bone remained a cause of concern in the past but with recent advancements in the fixation techniques this dilemma is obscured. Steiner et al 10 were the first to demonstrate that a direct and strong fixation of hamstring graft to bone was the key to success. Presently endobutton or interferance screws are being used for soft tissue graft fixation, as both the fixation devices are competent and comparable in terms of functional outcome 11. In the present study we used biodegradable interferance screw for hamstring graft fixation in all cases and used two scales (Lysholm and IKDC) for the meticulous evaluation of the knee functions following anterior cruciate ligament.

4 387 Author Table 6 Comparison of IKDC and Lyshlom scores of present study with other similar studies Type of graft Mean Lysholm score Mean Lysholm score (Present study) Mean IKDC score Mean IKDC score (Present study) 4 strand HT graft Taylor et al 13 BPB Bach et al 12 BPB Charlton et al 16 4 strand HT graft Williams et al 4 4 strand HT graft Benjamin et al 11 4 strand HT graft (endobutton) 4 strand HT graft (interference screw) Benjamin et al 11 evaluated the hamstring anterior cruciate ligament technique, using bioabsorbable interference screw and by using endobutton fixation device respectively. Their results showed that using interferance screw had comparable clinical outcome at 24 to 40 months. The mean IKDC score at 2 years follow up was 85 for the interferance group and 81 for the endobutton group. In present study the post-operative IKDC score was 90.7 and 96% of the patients had normal or near normal knee at six month follow up. The IKDC scores of our study were comparable to other studies done in past (Table 6). Taylor et al 13 in their comparative study of 4 stranded hamstring graft and BPB graft observed no significant difference in clinical outcomes. The post-operative mean Lysholm scores were 90.3 for the hamstring and 90.4 for the patellar tendon groups. In present study the postoperative mean Lysholm score was 90.2 at six-month follow up and the results were comparable to other studies done in the past (Table 6). Although the hamstring weakness and post-operative laxity is common with hamstring graft 14,15, but in the present study none of our patients were found to have post laxity. All patients were able to perform single leg hop test and returned to his or her pre-injury status at their last follow-up. However, in one of our patient hamstring weakness was found on manual testing which improved to normal at his last follow up. One patient had extension lag with recurrent swelling at subsequent follow up. On evaluation roof graft impingement was found, notch plasty was performed for the same and patient showed improvement during his last follow-up At a short-term follow up the results of the hamstring graft fixed with bio-absorbable interferance screw are quite promissing. However, a large study with longer follow up duration is necessary to see the long-term results. References 1. Johnson R.J. The anterior cruciate ligament: A dilemma in sport medicine. Int J Sports Med. 3(2):71-79, Kennedy J., Jackson M.P., O Kelly P., Moran R. Timing of of the anterior cruciate ligament in athletes and the incidence of secondary pathology within the knee. J Bone Joint Surg Br. 92(3): , Mar Wong J.W., Yip D.K. The peashooter device: An invaluable tool for bone grafting during revision anterior cruciate ligament surgery. Arthroscopy. 21(8): , Aug Williams R.J. III, Petrigliano F., Rozental T., Hyman

5 388 J. Anterior cruciate ligament with a four-strand hamstring tendon autograft. J Bone Joint Surg Am. 86(2): , Feb Herrington L., Wrapson C., Matthews M., Matthews H. Anterior cruciate ligament, hamstring versus bone-patella tendon-bone grafts: A systematic literature review of outcome from surgery. Knee. 12(1):41-50, Jan Carmichael J.R., Cross M.J. Why bone-patella tendon-bone grafts should still be considered the gold standard for anterior cruciate ligament. Br J Sports Med. 43(5): , May Hamner D.L., Brown C.H., Steiner M.E., Hecker A.T., Hayes W.C. Hamstring tendon grafts for of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg. 81(4): , Apr Cooper D.E., Deng X.H., Burstein A.L., Warren R.F. The strength of the central third patellar tendon graft; A biomechanical study. Am J Sports Med. 21: , Nov.-Dec Stephen H., Liu J., Kabo M., Osti L. Biomechanics of two types of bone-tendon-bone graft for Anterior Cruciate Ligament. J Bone Joint Surg Br. 77(2): , Mar. l Steiner M.E., Hecker A.T., Brown C.H. Jr, Hayes W.C. Anterior cruciate ligament graft fixation. Comparison of hamstring and patellar tendon grafts. Am J Sports Med. 22(2): , Mar.-Apr Benjamin C., Kimberly F., Freddie H.F.U., Jeffery T., Harner C.D. Hamstring anterior cruciate ligament : A comparison of bioabsorbable interference screw and endobutton-post fixation. Arthroscopy. 20(2): , Feb Bach B.R., Tradonsky S., Levy M.E., Bush-Joseph C.A., Khan N.H., John B. Arthroscopically assisted anterior cruciate ligament using patellar tendon autograft five- to nine-year follow-up evaluation. Am J Sports Med. 26(1):20-29, Jan.-Feb Taylor D.C., DeBerardino T.M., Nelson B.J., Duffey M., Tenuta J., Stoneman P.D., Sturdivant R.X., Mountcastle S. Patellar tendon versus hamstring tendon autografts for anterior cruciate ligament : A randomized controlled trial using similar femoral and tibial fixation methods. Am J Sports Med. 37(10): , Oct Aune A.K., Holm I., Steen H. Four-strand hamstring tendon autograft; Compared with patellar tendon-bone autograft for anterior cruciate ligament : A randomized study with two-year follow-up. Am J Sports Med. 29(6): , Nov.- Dec Freedman K.B., Amato M.J.D., Nedeff D., Kaz A. and Bach B.R. Jr. Arthroscopic Anterior Cruciate Ligament Reconstruction A Meta analysis Comparing Patellar Tendon and Hamstring Tendon Autografts. Am J Sports Med. 31(1):2-11, Charlton W.P., Randolph D.A. Clinical outcome of anterior cruciate ligament with quadrupled hamstring tendon graft and bioabsorbable interference screw fixation. Am J Sports Med. 31(4): , 2003.