Arthroscopic intra and extra articular ACL reconstruction with gracilis and semitendinosus tendons with early resumption of sport. Results at minimum two years follow-up
Introduction
The ultimate goal of ACL reconstruction is to produce a stable, strong and functional knee in the shortest time, especially for young athletes. Many factors can significantly influence the quality of the end result but graft selection, surgical technique and rehabilitation program certainly are the most important factors that can determine a satisfactory clinical and functional outcome. Bone-patellar tendon-bone is probably the most popular ACL graft and most series report 85–90% of good or excellent results 1, 2, 3, 4. However the problems related to this graft are numerous, necessitating sometimes a long rehabilitation phase and significantly affecting the final functional capacity of the knee. Many series have pointed out that the use of patellar tendon graft increases the incidence in knee stiffness, anterior knee pain and quadriceps weakness 5, 6, 7, 8, 9, 10. Moreover the harvesting time is longer relative to hamstring grafts and has a higher risk of iatrogenic damage to the patella and extensor apparatus 11, 12. The gracilis and semitendinosus tendons offer the advantages of strength when doubled, ease of harvesting, close biomechanical characteristics to ACL and low morbidity [13]. These tendons have been used in many different ways 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24and the results obtained are usually satisfactory and often comparable with patellar tendon graft 5, 16, 25, 26, 27, 28, 29, 30, 31. With the goal to reduce the recovery time of young sportsmen we have developed since 1993 an original hamstrings technique. This technique combines an intra and extra articular ACL plasty with a high graft strength, and avoids the morbidity connected with the use of patellar tendon graft. This technique is invented to provide firm graft fixation and allow immediate full motion and aggressive rehabilitation program with resumption of sport at 3–4 months. The purpose of this study was to evaluate the results of this technique with accelerated rehabilitation at minimum 2 years follow-up and analyze if this early resumption of sport could affect knee stability and function.
Section snippets
Materials and methods
From February 1993 an arthroscopic intra and extra-articular ACL reconstruction using gracilis and semitendinosus tendons was performed in prospectively selected patients. All young patients participating in sports at a high level that presented at first examination with a positive Lachman test and Pivot shift test were selected for our combined ACL reconstruction.
The first 40 patients who underwent this procedure were evaluated at minimum 2 years follow-up (average follow-up 36 months). The
Results
IKDC and Lysholm score demonstrated highly satisfactory results with 92.5% of normal or nearly normal knees and a mean value for Lysholm score of 95 points (Table 1Table 2).
Analysing in detail IKDC parameters: subjective knee evaluation had a mean value of 89.1% (min. 70%–max. 100%).
Pain was not reported at rest and only in two cases (5%) pain arose after maximum effort. All 40 patients did not report any knee swelling or giving way sensation.
Objectively knee effusion was never observed, thigh
Discussion
The results of our technique appeared highly satisfactory with a 92.5% of satisfactory results with IKDC score. Resumption of sport, activity level and subjective evaluation were also very high.
Certainly many factors have played an important role in obtaining this outcome. First of all graft selection. The arguments for using hamstring tendons include ease of harvesting tendons, ease of tunnel passage, less compromise in knee function by a graft sacrifice [13], and a lesser overall morbidity
Acknowledgements
We acknowledge Dott.ssa Elettra Pignotti for her fundamental support in statistical analysis.
References (61)
- et al.
A comparison of the doubled semitendinosus/gracilis and central third of the patellar tendon autografts in arthroscopic anterior cruciate ligament reconstruction
Arthroscopy
(1993) - et al.
Determination of graft tension before fixation in anterior cruciate ligament reconstruction
Arthroscopy
(1988) - et al.
The effects of graft tensioning on the laxity and kinematics of the anterior cruciate ligament reconstructed knee
Arthroscopy
(1991) - et al.
Anterior cruciate ligament reconstruction using one third of the patellar ligament augmented by extra articular tendon transfers
J Bone Joint Surg
(1982) - et al.
Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Long term follow up
Am J Sports Med
(1991) - et al.
Reconstruction of the chronically insufficient ACL with the central third of the patellar ligament
J Bone Joint Surg
(1991) Anterior cruciate ligament injury: evaluation of intra-articular reconstruction of acute tears without repair
Am J Sports Med
(1990)- et al.
Patellar tendon versus doubled semitendinosus and gracilis for anterior cruciate ligament reconstruction
Am J Sports Med
(1994) - Callaway GH, Nicholas SJ, Cavanaugh JT, et al. Hamstring augmentation versus patellar tendon reconstruction of the...
- et al.
Five to ten years follow up evaluation after reconstruction of the ACL
Clin Orthop
(1984)
Quadriceps strength and functional capacity following patellar tendon autograft and allograft ACL reconstruction
Am J Sports Med
Extensor mechanism function after patellar tendon graft harvest for ACL reconstruction
Am J Sports Med
Patellofemoral problems after anterior cruciate ligament reconstruction
Am J Sports Med
Rupture of the patellar ligament after use of its central third for anterior cruciate ligament reconstruction
J Bone Joint Surg
Fracture of the patella during a golf swing following reconstruction of the anterior cruciate ligament
Am J Sports Med
Reconstruction of the anterior cruciate ligament by semitendinosus tenodesis
J Bone Joint Surg
Anterior cruciate ligament reconstruction with a loop or double thickness of semitendinosus tendon
Am J Sports Med
Anterior cruciate ligament reconstruction using gracilis and semitendinosus tendons
Am J Sports Med
Uber den plastichen ersatz der creutzbander durch gestielte sehnenverpflanzung
Orthopadie
A new operative procedure for repair of ruptured cruciate ligaments of the knee joint
Surg Gin Ost
Diagnosis and management of isolated anterior cruciate ligament tears: a preliminary report on reconstruction with the gracilis tendon
J Trauma
Semitendinosus anatomic reconstruction for cruciate ligament insufficiency
Clin Orthop Rel Res
Method for reconstruction of the anterior cruciate ligament using the semitendinosus tendon
Am J Sports Med
Reconstruction of the anterior cruciate ligament of the knee using a doubled tendon graft
Clin Orthop Rel Res
Reconstruction of the anterior cruciate ligament using free tendon graft
Am J Sports Med
Combined anterior cruciate ligament reconstruction using semitendinosus tendon and iliotibial tract
J Bone Joint Surg
Anterior cruciate ligament reconstruction by semitendinosus and gracilis tendon autograft
Am J Knee Surg
Long term evaluation of knee stability and function following surgical reconstruction for anterior cruciate ligament insufficiency
Am J Sports Med
Evaluation of hamstring strength following use of semitendinosus and gracilis tendons to reconstruction the anterior cruciate ligament
Am J Sports Med
Cited by (4)
Patellar tendon autograft reconstruction of the anterior cruciate ligament with and without lateral plasty in advanced-stage chronic laxity. A clinical, prospective, randomized, single-blind study using passive dynamic X-rays
2014, KneeCitation Excerpt :In our series these pains were noted in 12% of cases, usually mild and without functional impairment. On the other hand, Lerat et al. [29,62], Noyes et al. [30], Aglietti et al. [34], Dejour et al. [27] and Marcacci et al. [63,64] found significant improvement in objective knee laxity when adding the extra-articular procedure to a single-bundle ACL reconstruction. To our knowledge, three randomized trials (except our study): Anderson [8], Ait Si Selmi [65] and Acquitter [22], concluded that there is a limited role for extra-articular procedures, but we propose that this thinking should be reconsidered.
Return to sport following anterior cruciate ligament reconstruction surgery: A systematic review and meta-analysis of the state of play
2011, British Journal of Sports Medicine