Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon–graft with press-fit fixation without hardware: A new and innovative procedure

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Bone—patellar tendon

Currently, the most frequently used autograft material for ACL reconstruction is the middle one third of the patellar tendon [5], [6], [7]; the bone blocks at either end are fixed with interference screws. Problems such as patellofemoral pain [8], [9], patellar fractures [10], [11], [12], bone resorption around the implants [13], tunnel widening—especially of the tibial tunnel [14], [15], and difficulties with hardware removal at revision surgery have, however, been reported.

Semitendinosus—gracilis

Over the past few years, there has been increasing interest in the use of the semitendinosus tendon for ACL reconstruction because of the comparatively low postoperative morbidity. Pinczewski et al (2002) [39] recently reported 5-year results in a prospective study, comparing patellar tendon and 4-strand hamstring tendon graft for ACL reconstruction. Patellar tendon grafts appeared tighter clinically, and with lower KT 1000 measurements, up to 3 years postoperatively, compared with hamstring

Biomechanical testing

In cooperation with A. Weiler, MD and F. Kandziora, MD (unpublished data, 1999) biomechanical pull-out tests on pig knees have shown that under cyclic loading (100 x 300 N, 100 x 400 N, 100 x 500 N, 100 x 600 N, and 100 x 700 N) this technique was demonstrated to be twofold stronger than the “Gold Standard” BTB fixed with interference screws.

In this article, two new techniques for ACL reconstruction with press-fit fixation are presented: (1) a BPT without a bone block from the patella or a

Setup

We use the same setup for all three grafts. The operation may be performed under either general or regional anesthesia. A pneumatic tourniquet is placed on the proximal thigh of the injured leg, but generally not inflated. An infusion pump allows the procedure to be performed without tourniquet control. The operating table is angled at knee level, to allow the injured leg to hang over the edge of the table. A lateral post is used for applying a valgus force. The opposite leg is abducted and

Graft harvesting

Kartus et al [43] recommend avoidance of intraoperative injury of the infrapatellar nerve because this fact and the harvesting of one block from the tibial tuberosity might be reasons of donor site morbidity. Therefore, we prefer a subcutaneous graft-harvesting technique with a double incision that avoids injury to the infrapatellar nerve.

With the knee flexed to 90°, a 25-mm vertical incision is made just above the tibial tubercle. The medial and lateral borders of the patellar tendon are

Graft harvesting

With the knee flexed to 90°, a 2-cm incision is used 3 cm medial and distal to the tibial tuberosity, parallel to the lines of the skin, to avoid damage to the inferior branch of the saphenous nerve, and for cosmesis (Fig. 15). The bursa of the pes is incised and split proximally.

Both the tendons are visualized and mobilized. First the gracilis tendon is grasped using a curved clamp. Maximal traction is applied, which releases the “web-like” fascia slips. The gracilis tendon is inserted into an

Bone—patellar tendon

The “no hardware” technique for ACL reconstruction is a new method that offers many advantages and is straightforward to perform. Its main innovative feature is that it does not require bone-block harvesting from the patella. This reduces donor site morbidity and prevents patellar fractures. The bone tunnels are made using tube harvesters and compaction drilling. This minimizes trauma and obviates the risk of bone necrosis. The articular entrance of the tibial tunnel is completely occupied by

Semitendinosus—gracilis

This technique, which was used with 915 patients from June 1998 to February 2002, shows a particularly low rate of postoperative morbidity. The reason is probably to be found in the “waterproofing” of the bone tunnels, which lead to less postoperative bleeding and swelling. No drains were used. Rehabilitation follows the same protocol as used for the reconstruction using patellar tendon grafts (accelerated/functional). As expected, there was no widening of the femoral tunnels and little

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References (61)

  • S.P. Arnoczky et al.

    Microvasculature of the cruciate ligaments and its response to injury. An experimental study in dogs

    J Bone Joint Surg Am

    (1979)
  • S.P. Arnoczky et al.

    The microvasculature of the meniscus and its response to injury. An experimental study in the dog

    Am J Sports Med

    (1983)
  • R.M. Lyon et al.

    Ultrastructural differences between the cells of the medical collateral and the anterior cruciate ligaments

    Clin Orthop

    (1991)
  • W.G. Clancy et al.

    Acute tears of the anterior cruciate ligament. Surgical versus conservative treatment

    J Bone Joint Surg Am

    (1988)
  • R.J. Johnson et al.

    The treatment of injuries of the anterior cruciate ligament

    J Bone Joint Surg Am

    (1992)
  • P. Lobenhoffer et al.

    Indications for anterior cruciate ligament reconstruction–current surgical techniques, choice of transplant

    Orthopade

    (1993)
  • P. Aglietti et al.

    Patellofemoral problems after intra-articular anterior cruciate ligament reconstruction

    Clin Orthop

    (1993)
  • B.R. Bach et al.

    Arthroscopy-assisted anterior cruciate ligament reconstruction using patellar tendon substitution. Two- to four-year follow-up results

    Am J Sports Med

    (1994)
  • B. Christen et al.

    Fractures associated with patellar ligament grafts in cruciate ligament surgery

    J Bone Joint Surg Br

    (1992)
  • A.D. Georgoulis et al.

    The presence of proprioceptive mechanoreceptors in the remnants of the ruptured ACL as a possible source of re-innervation of the ACL autograft

    Knee Surg Sports Traumatol Arthrosc

    (2001)
  • P.T. Simonian et al.

    Indirect forces and patella fracture after anterior cruciate ligament reconstruction with the patellar ligament. Case report

    Am J Knee Surg

    (1995)
  • J. Höher et al.

    Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction?

    Knee Surg Sports Traumatol Arthrosc

    (1998)
  • M.G. Clatworthy et al.

    Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts

    Knee Surg Sports Traumatol Arthrosc

    (1999)
  • J.C. L'Insalata et al.

    Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts

    Knee Surg Sports Traumatol Arthrosc

    (1997)
  • H. Breitfuss et al.

    The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon–a problem for the patellofemoral joint?

    Knee Surg Sports Traumatol Arthrosc

    (1996)
  • D.D. Buss et al.

    Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months

    J Bone Joint Surg Am

    (1993)
  • S.M. Howell et al.

    Evaluation of the single-incision arthroscopic technique for anterior cruciate ligament replacement. A study of tibial tunnel placement, intraoperative graft tension, and stability

    Am J Sports Med

    (1999)
  • S. Brandsson et al.

    Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit

    Knee Surg Sports Traumatol Arthrosc

    (1998)
  • H. Staeubli
  • H.U. Staubli et al.

    Mechanical tensile properties of the quadriceps tendon and patellar ligament in young adults

    Am J Sports Med

    (1999)
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