|Year : 2022 | Volume
| Issue : 2 | Page : 154-159
Evaluation of functional outcome following transportal arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft
Harshal Suhas Sakale, Alok Chandra Agrawal, Martha Balakrishna, Bikram Keshari Kar, B Raj Kiran Moti
Department of Orthopaedics, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
|Date of Submission||17-Nov-2022|
|Date of Acceptance||29-Nov-2022|
|Date of Web Publication||30-Dec-2022|
Dr. Martha Balakrishna
Flat No. A2-502, Shree Ram Lotus Valley, Tatibandh, Raipur - 492 099, Chattisgarh
Source of Support: None, Conflict of Interest: None
Introduction: The anterior cruciate ligament (ACL) has an important role in preserving the function and stability of the knee joint, and it prevents anterior translation of the tibia. The ACL is the most commonly injured structure of the knee following posttraumatic and sports-related injuries. The treatment of modality for ACL insufficiency was arthroscopic ACL reconstruction. In this study, we followed the transportal approach for ACL reconstruction using a Quadrupled Hamstring graft, and we reported the functional outcome of ACL reconstruction at a minimum follow-up of 6 months. Materials and Methods: This was a prospective outcome study conducted on 32 patients who met the inclusion and exclusion criteria. All patients in this study underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft through transportal technique. The graft was fixed with an endobutton on the femoral side and an interference screw on the tibial side. Patients were assessed for the functional outcome for a minimum of 6 months using the Tegner-Lysholm knee scoring system. Results: The mean age of the patient was 27 years. The majority of involved patients were males. The left side (77.14%) was involved more than the right side (22.86%). The most common cause of ACL injury in this study was road traffic accidents. Preoperative Tegner-Lysholm scores were 20 (62.5%) patients had poor and 12 (37.5%) patients had fair scores. Post-operatively, at 6 months follow-up, 27 patients had excellent, four patients had good scores, and one patient had a fair score. There was a significant improvement in the Tenger-Lysholm scoring system after 6 months of follow-up when compared to preoperatively. Three patients had knee pain and thigh muscle wasting (2 – 3 cm) during follow-up. Conclusions: Transportal arthroscopic ACL reconstruction using Quadrupled Hamstring graft gives excellent functional outcome and knee kinematics.
Keywords: Anterior cruciate ligament reconstruction, arthroscopic, hamstring graft, transportal
|How to cite this article:|
Sakale HS, Agrawal AC, Balakrishna M, Kar BK, Moti B R. Evaluation of functional outcome following transportal arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. J Orthop Traumatol Rehabil 2022;14:154-9
|How to cite this URL:|
Sakale HS, Agrawal AC, Balakrishna M, Kar BK, Moti B R. Evaluation of functional outcome following transportal arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Apr 1];14:154-9. Available from: https://www.jotr.in/text.asp?2022/14/2/154/365822
| Introduction|| |
The anterior cruciate ligament (ACL) is the most commonly injured structure of the knee following posttraumatic and sports injuries. The ACL has an important role in preserving the function and stability of the knee joint. ACL injury alters the biomechanics of the knee and predisposes the joint to future degenerative changes.
Arthroscopic ACL reconstruction is the treatment modality for ACL injuries nowadays. There is a greater advantage with arthroscopic surgery, which includes minimal skin and capsular incisions, enhanced viewing of the intercondylar notch for tunnel making, less postoperative discomfort, fewer adhesions, earlier mobility, and rehabilitation.
There are different techniques for ACL reconstruction based on femoral tunnel placement, and there are two methods – transportal and transtibial techniques. The transtibial technique is an old and popular technique, but studies reported that it did not provide an anatomical placement of the tunnel resulting in rotational instability of the knee. The advantage of the transportal technique is the anatomical placement of the femoral tunnel, which preserves normal biomechanics of the knee and hence better functional outcomes.
Howell et al., working as a team, performed a comprehensive review of a large body of anatomic, histologic, biomechanical, and clinical data and recommended the use of the acronym “I. D. E. A. L.” as an abbreviated nomenclature for describing the guidelines for placing the femoral tunnel.
- ISOMETRIC: Graft will have a length-tension relationship that is similar to the native ACL
- DIRECT FIBERS: Fibers that have direct insertion on the footprint and fibers that are closest to the ridge
- ECCENTRIC: Anterior or higher in the footprint and the anterior-medial portion of the ACL
- EQUIDISTANT: Halfway between the top and the bottom of the notch, which is the inter-operative checkpoint
- ANATOMIC: Fibers within the bounds of the native ACL graft, which is anterior (higher) than the indirect fibers
- LOW TENSION: The tension of the native ACL should match the low tension-flexion pattern of the native ACL.
Various grafts used for ACL Reconstruction are autografts, allografts, and synthetic grafts. Bone-patellar tendon-bone (BPTB) and quadrupled hamstring (Semitendinosus) tendon are the most commonly used autografts. Allografts used are BPTB, hamstring tendons, Achilles tendon, and tibialis anterior or posterior tendons. The disadvantage of using allografts are a lower level of stability, higher failure rates, and a risk of infection. Gore-tex Ligament, Stryker Dacron Ligament, and Kennedy Ligament Augmentation Device are the synthetic grafts used. The disadvantage of synthetic grafts is the high rate of rupture and recurrent sterile knee effusions.
In this study, we followed the transportal approach for ACL reconstruction using a single-bundle quadrupled Hamstring graft and reported the functional outcome at a minimum follow-up of 6 months.
| Materials and Methods|| |
This was a prospective hospital-based study conducted in the Department of Orthopaedics, AIIMS Raipur, India, from December 2018 to December 2020. Inclusion criteria include patients in the age group of 18–45 years, with clinical and MRI evidence of ACL tear and excluded patients with grade 1 ACL injuries and those who have associated fractures and multi-ligament involvement, any prior surgery, and those with signs of infection, and those who lost to follow-up.
In this study, a total of 35 cases with symptomatic ACL insufficiency as a result of road traffic accidents (RTA) and sports-related activity were enrolled. Three patients were lost for follow-up, so a total of 32 cases were included in the study.
Patients with ACL insufficiency were clinically examined for anterior drawer test, posterior drawer test, Lachman's test and pivot shift test, and other associated tests. Radiographs and MRI of the knee were advised to accurately diagnose and assess the other soft-tissue structures.
All patients were operated on under regional (spinal or epidural) anesthesia. Standard arthroscopic portals, anteromedial and anterolateral, were established. Complete diagnostic arthroscopy was done. [Figure 1] shows the placement of standard arthroscopic portals, anteromedial and anterolateral, and [Figure 2] shows instrumentation through the anteromedial portal during ACL reconstruction. Diagnostic arthroscopy was performed to evaluate any associated injury.
|Figure 1: Standard knee arthroscopy portals, anterolateral and anteromedial portals|
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|Figure 2: Instrumentation through anteromedial portal during ACL reconstruction. ACL: Anterior cruciate ligament|
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A 5cm longitudinal incision was given over the anteromedial aspect of the tibia from tibial tuberosity directing downward. Using a tendon stripper, a semitendinosus tendon graft was harvested. The quadrupled graft was prepared and stitched to the end with ethibond sutures [Figure 3]. The length and diameter of the prepared graft were calculated. ACL remnant is preserved at the femoral end, which helps to identify the femoral footprint. Through an anteromedial portal, a guide pin for the femoral tunnel was passed over the center of the femoral footprint with the knee in 130° of flexion, and then drilling with a 4.5 mm endobutton reamer was done, and the size of the tunnel was calculated, then reaming with a proper size reamer equal to graft diameter was done [Figure 4]. The guide pin position was checked using a scope through an anterolateral portal. Reaming was done gently and with a proper size reamer so that the lateral femoral cortex was not compromised. The tibial tunnel for graft was drilled using a standard ACL tibial jig at an angle of 55° from the tibia such that the exit point is posterior and just lateral to the posterior border of the anterior horn of the lateral meniscus [Figure 5].
|Figure 4: Femoral tunnel guide pin placement through anteromedial portal|
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|Figure 5: Arthroscopic view showing tibial aimer over the center of the tibial footprint|
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For graft passage, proline sutures were used [Figure 6]. The graft was negotiated from the tibial tunnel to the femoral tunnel with the aid of shuttle sutures [Figure 7]. The endo-button flipped on the femoral side; thus, the graft was fixed on the femoral side with an endo-button and then a cycling maneuver was performed 20–25 times to tension the graft, on the tibial side aperture fixation was done with interference screw. Postoperative X-rays show proper placement of the femoral and tibial tunnel and endo-button [Figure 8].
|Figure 6: Arthoscopic view showing proline sutures helps to pass graft through portals|
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All the patients were advised to a functional knee range of motion (ROM) brace. Static quadriceps and hamstring exercises were started on the next day of the operation. Weight-bearing was introduced in patients after adequate quadriceps strength was achieved. Tegner-Lysholm scoring was done preoperatively and 1 month, 3 months, and 6 months postoperative follow-up.
All the statistical calculations were done using SPSS (version 16.0, Chicago, Illinois, SPSS Inc. USA). The Mean Tegner-Lysholm scores of preoperative and postoperative were compared using Wilcoxon signed-rank test.
| Results|| |
A total of 35 patients with ACL tears were operated on. Out of 35 patients, 3 patients were lost to follow-up and were excluded from the study. A total of 32 patients were included in the study and are at regular follow-up for a minimum of 6 months.
In our study, the mean age of patients was 27.81 years (ranging from 18 years to 45 years) [Graph 1]. Males (n = 23) are more involved than females (n = 9) [Graph 2]. In our study, the left side (n = 25) was involved more than the right [Graph 3].
68.75% of patients had a history of RTA that caused the ACL tear and 31.25% had a sports-related injury [Table 1]. Lateral meniscus injury was associated with 46.9% of our patients, medial meniscus in 18.7% of patients and 12.5% of patients had both [Table 2].
|Table 2: Frequency of meniscus injury along with anterior cruciate ligament tear in the study group|
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Tegner-Lysholm scores were compared before and after the operation in our study. Preoperative Tegner-Lysholm scores were 20 (62.5%) patients had poor and 12 (37.5%) patients had fair scores. Postoperatively, at 6 months follow-up, 27 (84.38%) patients had excellent, 4 (12.5%) patients had a good, and 1 (3.12%) patient had a poor score [Graph 4]. The mean scores preoperatively were 65.38 and postoperatively 93.36. The mean Tegner-Lysholm scores improved significantly (P < 0.0001) at the final follow-up compared to their preoperative value.
No major complications are seen in our study. Three patients had knee pain and thigh muscle wasting (2–3 cm).
| Discussion|| |
The primary goal of arthroscopic ACL reconstruction was to give a stable and good knee ROM so that patients get back to their preactivity level and avoid further injury to the knee.
Freedman et al., Goldblatt et al., Charlton et al., and Anderson et al. in their studies, have reported good functional outcomes after ACL reconstruction by quadrupled hamstring graft. The hamstring graft is commonly used for anatomical ACL reconstruction in the present time. Many studies have shown a good result with the least complications and excellent patient satisfaction both in terms of physical activity and on a pain scale.
In our study, the average age of individuals having ACL Reconstruction was 27.76 years which was comparable with other studies. In a study by Chaudhary et al., the average age was 26.8 years, and Jomha et al. were 26 years.
In our study, the majority of patients were males. This can be attributed to the fact that females are less involved in sports activities in rural settings and also the underreporting of injuries of females.
Our study showed that RTA were the predominant cause, followed by sports-related injuries. Patond et al. found that sporting practices were the primary cause of ACL. In a study by Chaudhary et al., Sports activities were responsible for 66.7% of injuries, while RTA was responsible for 30.8%. Most studies attribute sporting injury as the main cause of an ACL tear. However, our study shows a higher rate of RTA due to the careless attitude of driving by most of the young population and subsequent injuries.
None of the cases in our study with meniscus injury needed repair because of the late presentation to the hospital and central tears of the meniscus, which requires meniscus balancing, were done. Bucket handle tears and ramp lesions of the meniscus, which require repair, are not seen in our study.
In our study, the transportal technique was used, which gives the advantage of better rotational stability by placing the graft in a more horizontal position as against conventional transtibial reconstruction. Mardani-Kivi et al., in their study, concluded that using the transportal technique results in better clinical outcomes and greater patient satisfaction rates, as well as reducing the time of return to routine activities. Sarwar, et al. in their comparative study between transtibial and transportal for ACL reconstruction, the transportal technique gives superior patient-defined functional results in terms of Lysholm score (statistically significant).
In our study, Tegner-Lysholm knee scoring at 6 months follow-up was excellent in 27 (84.38%) patients. In our study, Tegner-Lysholm's knee score improved significantly from the preoperative value at the final follow-up (P < 0.0001). Our results also showed that 96.88% of patients had excellent to good results according to the Tegner-Lysholm score. In a study by Kumar et al. on the outcome of transportal ACL reconstruction, the mean Lysholm scores improved significantly (P < 0.0001) at the final follow-up when compared to their preoperative value.
Complication rates in our study were minimal, with knee pain and thigh muscle wasting in a few patients, which were not so significant [Table 3]. D. J. Deeham et al. also reported muscle wasting of <1 cm in 87%, 1–2 cm in 9%, and 3 cm in 4% in their study.
| Conclusions|| |
Transportal arthroscopic ACL reconstruction using a Quadrupled Hamstring graft is an effective modality of treatment in patients with ACL-deficient knees. In our study, functional results in terms of Tegner-Lysholm scoring are excellent and give a stable knee with a good range of movement.
The duration of the study and sample size were limitations for this study. A longer duration of the study and large samples helps for long-term complications and to understand of the results better.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Butler DL, Noyes FR, Grood ES. Ligamentous restraints to anterior-posterior drawer in the human knee. A biomechanical study. J Bone Joint Surg Am 1980;62:259-70.
Haimes JL, Wroble RR, Grood ES, Noyes FR. Role of the medial structures in the intact and anterior cruciate ligament-deficient knee. Limits of motion in the human knee. Am J Sports Med 1994;22:402-9.
Canale T, Beaty H. Arthroscopy of the lower extremity. In: Campbell's Operative Orthopaedics. 11th
ed. Philadelphia, PA: Mosby/Elsevier; 2008. p. 2855-6.
Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: A cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194-9.
Mahnik A, Mahnik S, Dimnjakovic D, Curic S, Smoljanovic T, Bojanic I. Current practice variations in the management of anterior cruciate ligament injuries in Croatia. World J Orthop 2013;4:309-15.
Available from: www.biomet.com/ideal/. [Last accessed on 2017 Dec 12].
Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2007;15:851-6.
Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: A metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31:2-11.
Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: Meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005;21:791-803.
Charlton WP, Randolph DA Jr., Lemos S, Shields CL Jr. Clinical outcome of anterior cruciate ligament reconstruction with quadrupled hamstring tendon graft and bioabsorbable interference screw fixation. Am J Sports Med 2003;31:518-21.
Anderson AF, Snyder RB, Lipscomb AB Jr. Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med 2001;29:272-9.
Chaudhary D, Monga P, Joshi D, Easwaran R, Bhatia N, Singh AK. Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone autograft: Experience of the first 100 cases. J Orthop Surg (Hong Kong) 2005;13:147-52.
Jomha NM, Pinczewski LA, Clingeleffer A, Otto DD. Arthroscopic reconstruction of the anterior cruciate ligament with patellar-tendon autograft and interference screw fixation. The results at seven years. J Bone Joint Surg Br 1999;81:775-9.
Patond KR, Chauhan VD, Kumar N. Semitendinosus transfer for anterior cruciate ligament insufficiency. Indian J Orthop 1992;26:1.
Mardani-Kivi M, Madadi F, Keyhani S, Karimi-Mobarake M, Hashemi-Motlagh K, Saheb-Ekhtiari K. Antero-medial portal versus transtibial techniques for drilling femoral tunnel in ACL reconstruction using 4-strand hamstring tendon: A cross-sectional study with 1-year follow-up. Med Sci Monit 2012;18:R674-9.
Sarwar S, Mushtaq M, Khan K, Khanday RI. Comparison of arthroscopic transtibial and transportal techniques of anterior cruciate ligament (ACL) reconstruction by a single bundle (SB) quadrupled hamstring graft. International Journal of Contemporary Medical Research 2018;5:B3-8.
Kumar C, Gupta AK, Singh SK, Jain R. Transportal anterior cruciate ligament reconstruction with quadrupled hamstring tendon graft: A prospective outcome study. Indian J Orthop 2017;51:600-5.
] [Full text]
Deehan DJ, Salmon LJ, Webb VJ, Davies A, Pinczewski LA. Endoscopic reconstruction of the anterior cruciate ligament with an ipsilateral patellar tendon autograft. A prospective longitudinal five-year study. J Bone Joint Surg Br 2000;82:984-91.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]