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
Section snippets
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In cooperation with A. Weiler, MD and F. Kandziora, MD (unpublished data, 1999) biomechanical pull-out tests on pig knees have shown that under cyclic loading (100 x 300 N, 100 x 400 N, 100 x 500 N, 100 x 600 N, and 100 x 700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
References (61)
- et al.
The natural history of the anterior cruciate ligament-deficient knee. A review
Clin Sports Med
(1993) - et al.
Primary bone grafting following graft procurement for anterior cruciate ligament insufficiency
Arthroscopy
(1990) - et al.
Graft failure in intra-articular anterior cruciate ligament reconstructions: a review of the literature
Arthroscopy
(1995) Arthroscopic anterior cruciate ligament reconstruction using a patellar tendon graft in press-fit technique: surgical technique and follow-up
Arthroscopy
(1997)- et al.
Primary stability with tibial press-fit fixation of patellar ligament graft: an experimental study in ovine knees
Arthroscopy
(2001) - et al.
Patellar versus hamstring tendons in anterior cruciate ligament reconstruction: a meta-analysis
Arthroscopy
(2001) - et al.
Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts
Arthroscopy
(2001) - et al.
Alterations of the extensor apparatus after anterior cruciate ligament reconstruction using the medial third of the patellar tendon
Arthroscopy
(2001) - et al.
An alternative cruciate reconstruction graft: the central quadriceps tendon
Arthroscopy
(1995) - et al.
Accuracy of femoral tunnel placement and resulting graft force using one- or two-incision drill guides. A cadaver study on ten paired knees
Arthroscopy
(1996)