| Abstract|| |
The results for the first 50 patients who had arthroscopically assisted reconstruction of anterior cruciate ligament (ACL) with autogenous patellar tendon graft were reviewed retrospectively. Forty one patients were available for evaluation after a minimum period of 5 years follow up. All patients had been managed with a standard programme of physical therapy. Subjective, objective, clinical and functional tests were performed according to the International Knee Documentation Commiftee scoring form (IKDC). Early results demonstrate excellent stability, preservation of motion and encouraging evaluation by the IKDC form.
Keywords: Arthroscopy- Anterior cruciate ligament (ACL)- Reconstruction- IKDC
|How to cite this article:|
Bhat N S, Rao S K, Rao P S. Arthroscopically assisted reconstruction of ACL using B-PT-B graft - Results after 5 years. Indian J Orthop 2003;37:3-10
|How to cite this URL:|
Bhat N S, Rao S K, Rao P S. Arthroscopically assisted reconstruction of ACL using B-PT-B graft - Results after 5 years. Indian J Orthop [serial online] 2003 [cited 2019 Dec 14];37:3-10. Available from: http://www.ijoonline.com/text.asp?2003/37/3/3/48537
| Introduction|| |
Anterior cruciate ligament (ACL) reconstruction for chronic insufficiency using the central one-third of the patellar tendon as a free autologous graft is considered the gold standard and has been used widely with success rates of around 90%. , Although the operation is successful in restoring stability, post-operative complications like loss of motion of the knee and pain in the patellofemoral joint do exist.  This is a long term follow up report of the first 50 patients who underwent ACL reconstruction at Kasturba Hospital, Manipal.
| Material and Methods|| |
Between October 1992 and December 1996, 50 patients underwent ACL reconstruction using bonepatellar tendon-bone (B-PT-B) graft by a single surgeon. A personal follow up evaluation was obtained from 41 of them by a single observer. Nine patients were not included in the study as they were from far off places and objective evaluation could not be done. All patients were males. The mean age was 29.7 (Range 19-39) years. Previous surgeries included 6 medial menisectomies and 4 lateral menisectomies and routine diagnostic arthroscopy.
Surgical technique: The operation was done under tourniquet control using a leg holder and normal saline for distension. Standard portals were used for arthroscopy. After careful inspection of the knee, minimum notchplasty was carried out using a rasp. After identifying the tibial insertion of ACL with arthroscope, a tibial guide was placed and K wire introduced from the anteromedial metaphysis. A cannulated 10 mm reamer was used to drill the tibial tunnel. The isometric point for femoral insertion of ACL was visualised and the same K wire from the tibial tunnel was drilled inside out to come out through the lateral femoral metaphysis through a short incision. Once again the 10 mm reamer was used to drill the femoral tunnel. Bone debris was removed from the joint and the sharp edges of the tunnels were beveled with a rasp. The central 9 mm portion of the patellar tendon was removed with the bone blocks at each end-, the graft was introduced in the knee from tibial to the femoral tunnel and inspected for satisfactory positioning, avoidance of impingement and tensioning. The graft was fixed securely at both ends using interference screws.
Post operative care: The knees were immobilised in a compression bandage and electrical stimulation of quadriceps was started from day 1. Active mobilisation exercises were started on day 7. Partial weight bearing was allowed on day 10 and full weight bearing by the end of 6 weeks. By this time a nearly full range of movement (0-130 0 ) was obtained. Patients were allowed to run at 6 months. After 9 months, the patients were permitted sports activities.
Methods: The patients were evaluated using the International Knee Documentation Commiftee (IKDC) form at the end of 5 years after surgery. It is a one page form consisting of documentation section, a qualification section and an evaluation section.
The pre-injury, pre-treatment and present activity levels were then recorded, using the four defined activity levels. The four problem areas viz. subjective assessment, symptoms, range of motion and ligament examination were evaluated for group qualification. The worst qualification within the group, allocated the group qualification. The worst group qualification defined the final evaluation. The other four problem areas viz., compartmental finding, harvest site pathology, X-ray findings and functional test do not affect the final qualification.
| Results|| |
The study group included 41 patients, all men, whose average age was 29.7 years (range 1939) at the time of the surgery. There were 27 right knees and 14 left knees. Duration in all cases was more than 4 weeks. Twenty nine patients indicated that their injury was sports related with cricket being the culprit in 13 cases followed by football (8), Kabaddi (3), sprinting (3) and tug of war (2). The remaining 12 patients had injuries due to road traffic accidents or fall from a height.
Subjective assessment & symptoms: All 41 patients reported for subjective assessment. None of the patients felt that their knees were normal following surgery. However 39 patients felt the operated knee was nearly normal. Only one patient had an abnormal knee and one more patient had a severely abnormal knee. The patient who qualified as severely abnormal had a fall prior to final review. Symptomatically 10 patients had their operated knees in the normal group, 20 patients were nearly normal, 8 patients were abnormal and 3 patients were severely abnormal.
Objective follow-up: Range of motion: According to IKDC parameters 35 knees qualified as normal, 5 knees as nearly normal and 1 knee as severely abnormal. The five patients who qualified as nearly normal had 10 o loss of terminal flexion. No patient had extension loss. The results of Lachman, pivot shift and anterior drawer tests were as follows: 18 knees qualified as normal and 23 knees qualified as nearly normal. Twenty six patients had no harvest site pathology, while 10 patients had numbness over the harvest site.
Functional follow-up: Sixteen patients returned to the pre-injury activity levels and 15 patients returned to participation at a lower activity level. The remainder settled for a sedentary lifestyle. The one legged hop test was normal in 21 patients and nearly normal in 16 patients. One patient who had a fall was unable to perfortn the test.
Radiographic analysis: Except one patient with medial compartment narrowing who qualified as nearly normal, all other patients showed no degenerative changes radiologically.
Final evaluation: Using the IKDC guidelines the final overall evaluation profile was calculated for this study group. Since no patient faired 'normal' in the subjective follow-up, there was no reconstructed knee which could be qualified as normal. Twenty nine patients qualified as nearly normal and 9 had abnormal knees. Three persons had severely abnormal reconstructed knees.
| Discussion|| |
The central one third of the patellar tendon was chosen as the graft because of its excellent biomechanical properties  the fact that it can be secured rigidly in position with the help of interference screws, and the previous results after open reconstruction using the patellar tendon.
On subjective assessment none of the patients felt that their knees were back to normal. This is consistent with the philosophy of the International Knee Documentation Commiftee (IKDC) that no knee and no knee function can be better than normal, and it is rather doubtful whether any operated knee can ever be "normal" again.  However a major percentage of patients felt it was nearly normal. Symptomatically about one fourth of the patients fell in the normal category and about one half in the nearly normal category. Pain was the predominant complaint followed by partial giving way. None of the patients had swelling of the operated knee (except for one patient who had a reinjury) or episodes of complete giving way.
On ligament examination nearly half the patients qualified as normal comparable to the other knee and the rest had nearly normal ligament tests. Buss et al reported 88% of patients in the normal or nearly normal category.  Only four patients needed interference screw removal because of either screw migration into the joint or bursitis due to backing out of the screw.
About 40% of patients went back to their pre-injury level of activity and another 37% were able to participate at a lower level of activity. This may be due to the fact that the majority of the patients were not professional sports persons. However, the two professionals in our study returned to their pre-injury activity levels. The most common reason for not participating in a particular sport was a change in lifestyle or fear of reinjury. Finally 70% of patients in this senes qualified for a nearly normal knee, encouraging us to state that this technique produces good results.
| References|| |
|1.||Clancy WG, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one third of patellar tendon augmented by extra articular tendon transfers. J Bone Joint Surg [Am] 1982- 64-A- 352-359. |
|2.||O'Brien SJ, Warren RF, Pavlov H, Panrielio R, Wickiewicz TL. Reconstruction of chronically insufficient anterior cruciate ligament with the central one third of the patellar ligament. J Bone Joint Surg [Am] 1991; 73-A: 278-286. |
|3.||Noyes FR, Butler DL, Grood ES et al. Biomechanical analysis of human ligament grafts used in knee ligament repair and reconstruction. J Bone Joint Surg [Am] 1984; 66-A- 344-352. |
|4.||Staubli HU, Jakob RP. The Knee and the cruciate ligaments. New York: SpringerVerlag. 1992; 134-139. |
|5.||Buss DD, Warren RF, Wickiewicz TL, et al. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autologous pattellar ligament grafts. J Bone Joint Surg [Am] 1993; 75-A: 1346-1355. |
S K Rao
Department of Orthopaedics, Kasturba Medical College, Manipal - 576 119
Source of Support: None, Conflict of Interest: None