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J Knee Surg 2019; 32(09): 847-859
DOI: 10.1055/s-0038-1669902
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft with Remnant Preservation: Comparison of Outcomes According to the Amount of Remnant Tissue

Sung-Jae Kim
1   The Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Korea
,
Chong Hyuk Choi
2   The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Korea
,
Yong-Min Chun
2   The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Korea
,
Sung-Hwan Kim
2   The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Korea
,
Su-Keon Lee
3   The Department of Orthopaedic Surgery, Gwangmyung Sungae Hospital, Gyeonggi, Korea
,
Woo Seok Jung
4   The Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
,
Min Jung
2   The Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Seoul, Korea
› Author Affiliations
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Publication History

27 June 2017

23 July 2018

Publication Date:
07 September 2018 (online)

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Abstract

There has been controversy about whether remnant tissue of anterior cruciate ligament (ACL) has to be preserved in ACL reconstruction. The purpose of the study was to compare clinical outcomes between groups of patients who underwent ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft divided according to amount of ACL remnant and investigate effect of remnant preservation on outcomes of ACL reconstruction. A total of 185 patients who underwent ACL reconstruction with BPTB autograft were retrospectively reviewed. Patients were divided into four groups according to proportion of length of remnant tissue of injured ACL covering part of reconstructed ACL to total length of reconstructed ACL: group A included 83 patients with no remnant, group B consisted of 38 patients with remnant of < 1/3, group C consisted of 35 patients with remnant of 1/3 to2/3, and group D consisted of 29 patients with remnant of > 2/3. Primary outcome was International Knee Documentation Committee (IKDC) subjective score. Secondary outcomes were stability, range of motion, patient-reported outcomes determined by Lysholm knee scoring scale and Tegner activity scale, IKDC objective grade, and single hop for distance. Return to activity and near-return to activity were investigated. A minimum follow-up duration was 24 months. There was no statistically significant difference between four groups regarding postoperative anterior translation (p = 0.731), Lysholm knee score (p = 0.599), IKDC objective grade (p > 0.999), hop test (p = 0.878), and near-return to activity (p = 0.193). However, patients of group D had significantly better outcomes in IKDC subjective score (group A = 85.0 ± 5.9, group B = 84.9 ± 8.1, group C = 87.4 ± 6.4, group D = 89.2 ± 8.1, p = 0.017), Tegner activity scale (group A = 5.0 ± 1.1, group B = 5.2 ± 1.0, group C = 5.7 ± 1.3, group D = 5.9 ± 1.0, p = 0.001), and return to activity (group A = 25.3%, group B = 31.6%, group C = 45.7%, group D = 55.2%, p = 0.014). ACL reconstruction using BPTB autograft with remnant preservation did not provide better anterior stability compared with conventional ACL reconstruction. However, preservation of remnant of > 2/3 led to more improved activity-related clinical outcomes than no remnant preservation. In cases with substantial remnant tissue of injured ACL remaining, reconstruction of ACL while preserving as much remnant tissue as possible is recommended. This is a Level III, retrospective comparative therapeutic study.

Keywords

arthroscopy - anterior cruciate ligament - reconstruction - remnant preservation
 

  • References

  • 1 Yeow CH, Rubab SK, Lee PV, Goh JC. Inhibition of anterior tibial translation or axial tibial rotation prevents anterior cruciate ligament failure during impact compression. Am J Sports Med 2009; 37 (04) 813-821
    CrossrefPubMedSearch in Google Scholar
  • 2 Yasuda K, Kondo E, Ichiyama H. , et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy 2004; 20 (10) 1015-1025
    CrossrefPubMedSearch in Google Scholar
  • 3 Zelle BA, Brucker PU, Feng MT, Fu FH. Anatomical double-bundle anterior cruciate ligament reconstruction. Sports Med 2006; 36 (02) 99-108
    CrossrefPubMedSearch in Google Scholar
  • 4 Johansson H, Sjölander P, Sojka P. A sensory role for the cruciate ligaments. Clin Orthop Relat Res 1991; (268) 161-178
    PubMedSearch in Google Scholar
  • 5 Schultz RA, Miller DC, Kerr CS, Micheli L. Mechanoreceptors in human cruciate ligaments. A histological study. J Bone Joint Surg Am 1984; 66 (07) 1072-1076
    CrossrefPubMedSearch in Google Scholar
  • 6 Lee BI, Min KD, Choi HS. , et al. Immunohistochemical study of mechanoreceptors in the tibial remnant of the ruptured anterior cruciate ligament in human knees. Knee Surg Sports Traumatol Arthrosc 2009; 17 (09) 1095-1101
    CrossrefPubMedSearch in Google Scholar
  • 7 Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med 1982; 10 (06) 329-335
    CrossrefPubMedSearch in Google Scholar
  • 8 Barrett DS. Proprioception and function after anterior cruciate reconstruction. J Bone Joint Surg Br 1991; 73 (05) 833-837
    PubMedSearch in Google Scholar
  • 9 Ahn JH, Wang JH, Lee YS, Kim JG, Kang JH, Koh KH. Anterior cruciate ligament reconstruction using remnant preservation and a femoral tensioning technique: clinical and magnetic resonance imaging results. Arthroscopy 2011; 27 (08) 1079-1089
    CrossrefPubMedSearch in Google Scholar
  • 10 Lee BI, Kwon SW, Kim JB, Choi HS, Min KD. Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. Arthroscopy 2008; 24 (05) 560-568
    CrossrefPubMedSearch in Google Scholar
  • 11 Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V. Sparing the anterior cruciate ligament remnant: is it worth the hassle?. Br Med Bull 2012; 104: 91-111
    CrossrefPubMedSearch in Google Scholar
  • 12 Tonin M, Saciri V, Veselko M, Rotter A. Progressive loss of knee extension after injury. Cyclops syndrome due to a lesion of the anterior cruciate ligament. Am J Sports Med 2001; 29 (05) 545-549
    CrossrefPubMedSearch in Google Scholar
  • 13 Kim MK, Lee SR, Ha JK, Ra HJ, Kim SB, Kim JG. Comparison of second-look arthroscopic findings and clinical results according to the amount of preserved remnant in anterior cruciate ligament reconstruction. Knee 2014; 21 (03) 774-778
    CrossrefPubMedSearch in Google Scholar
  • 14 Kondo E, Yasuda K, Onodera J, Kawaguchi Y, Kitamura N. Effects of remnant tissue preservation on clinical and arthroscopic results after anatomic double-bundle anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43 (08) 1882-1892
    CrossrefPubMedSearch in Google Scholar
  • 15 Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br 1961; 43-B: 752-757
    CrossrefPubMedSearch in Google Scholar
  • 16 Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 1994; 25 (03) 425-465
    CrossrefPubMedSearch in Google Scholar
  • 17 Irrgang JJ, Anderson AF, Boland AL. , et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med 2001; 29 (05) 600-613
    CrossrefPubMedSearch in Google Scholar
  • 18 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10 (03) 150-154
    CrossrefPubMedSearch in Google Scholar
  • 19 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985; (198) 43-49
    PubMedSearch in Google Scholar
  • 20 Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993; 1 (3-4): 226-234
    CrossrefPubMedSearch in Google Scholar
  • 21 Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther 2007; 87 (03) 337-349
    CrossrefPubMedSearch in Google Scholar
  • 22 Kim SJ, Kim SH, Chun YM, Hwang BY, Choi DH, Yoon JY. Clinical comparison of conventional and remnant-preserving transtibial single-bundle posterior cruciate ligament reconstruction combined with posterolateral corner reconstruction. Am J Sports Med 2012; 40 (03) 640-649
    CrossrefPubMedSearch in Google Scholar
  • 23 Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods 2009; 41 (04) 1149-1160
    CrossrefPubMedSearch in Google Scholar
  • 24 Denti M, Monteleone M, Berardi A, Panni AS. Anterior cruciate ligament mechanoreceptors. Histologic studies on lesions and reconstruction. Clin Orthop Relat Res 1994; (308) 29-32
    PubMedSearch in Google Scholar
  • 25 Ochi M, Iwasa J, Uchio Y, Adachi N, Sumen Y. The regeneration of sensory neurones in the reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br 1999; 81 (05) 902-906
    CrossrefPubMedSearch in Google Scholar
  • 26 Dhillon MS, Bali K, Vasistha RK. Immunohistological evaluation of proprioceptive potential of the residual stump of injured anterior cruciate ligaments (ACL). Int Orthop 2010; 34 (05) 737-741
    CrossrefPubMedSearch in Google Scholar
  • 27 Papageorgiou CD, Ma CB, Abramowitch SD, Clineff TD, Woo SL. A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med 2001; 29 (05) 620-626
    CrossrefPubMedSearch in Google Scholar
  • 28 Muneta T, Koga H, Ju YJ, Horie M, Nakamura T, Sekiya I. Remnant volume of anterior cruciate ligament correlates preoperative patients' status and postoperative outcome. Knee Surg Sports Traumatol Arthrosc 2013; 21 (04) 906-913
    CrossrefPubMedSearch in Google Scholar
  • 29 Takazawa Y, Ikeda H, Kawasaki T. , et al. ACL reconstruction preserving the ACL remnant achieves good clinical outcomes and can reduce subsequent graft rupture. Orthop J Sports Med 2013; 1 (04) 2325967113505076
    Search in Google Scholar
  • 30 Fremerey RW, Lobenhoffer P, Zeichen J, Skutek M, Bosch U, Tscherne H. Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament: a prospective, longitudinal study. J Bone Joint Surg Br 2000; 82 (06) 801-806
    CrossrefPubMedSearch in Google Scholar
  • 31 Adachi N, Ochi M, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M. Mechanoreceptors in the anterior cruciate ligament contribute to the joint position sense. Acta Orthop Scand 2002; 73 (03) 330-334
    CrossrefPubMedSearch in Google Scholar
  • 32 Ahn JH, Lee SH, Choi SH, Lim TK. Magnetic resonance imaging evaluation of anterior cruciate ligament reconstruction using quadrupled hamstring tendon autografts: comparison of remnant bundle preservation and standard technique. Am J Sports Med 2010; 38 (09) 1768-1777
    CrossrefPubMedSearch in Google Scholar
  • 33 Cha J, Choi SH, Kwon JW, Lee SH, Ahn JH. Analysis of cyclops lesions after different anterior cruciate ligament reconstructions: a comparison of the single-bundle and remnant bundle preservation techniques. Skeletal Radiol 2012; 41 (08) 997-1002
    CrossrefPubMedSearch in Google Scholar
  • 34 Irrgang JJ, Anderson AF, Boland AL. , et al; International Knee Documentation Committee. Responsiveness of the International Knee Documentation Committee Subjective Knee Form. Am J Sports Med 2006; 34 (10) 1567-1573
    CrossrefPubMedSearch in Google Scholar