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Anterior Cruciate Ligament Reconstruction Using Combined Graft of Hamstring and Fascia Lata With Extra-articular Tenodesis. A Technique in Case of Insufficient Hamstrings.

ABSTRACT: A technique for augmentation of the anterior cruciate ligament (ACL) with hamstring graft and lateral extra-articular tenodesis is presented. The patient is positioned supine with the knee flexed 90°. First, intra-articular injuries are addressed arthroscopically, and then autologous hamstring tendons are harvested and measured; the present technique is a resource for cases with a very small graft diameter (less than 8 mm), due to thin tendons or to tendon breakage, even after tripling the hamstring graft, which is prepared using a facia lata strip long enough to fit the lengths of the femoral tunnel, the anterior cruciate ligament graft, and the tibial tunnel. A single femoral tunnel is performed and only 2 interference screws are needed for fixation.

SUBMITTER: Espejo-Reina A

PROVIDER: S-EPMC7695551 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Anterior Cruciate Ligament Reconstruction Using Combined Graft of Hamstring and Fascia Lata With Extra-articular Tenodesis. A Technique in Case of Insufficient Hamstrings.

Espejo-Reina Alejandro A Espejo-Reina María Josefa MJ Lombardo-Torre Maximiano M Ruiz-Del Pino Joaquina J Espejo-Baena Alejandro A

Arthroscopy techniques 20201023 11

A technique for augmentation of the anterior cruciate ligament (ACL) with hamstring graft and lateral extra-articular tenodesis is presented. The patient is positioned supine with the knee flexed 90°. First, intra-articular injuries are addressed arthroscopically, and then autologous hamstring tendons are harvested and measured; the present technique is a resource for cases with a very small graft diameter (less than 8 mm), due to thin tendons or to tendon breakage, even after tripling the hamst ...[more]

PMID: 33294323

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Project description:PurposeTo identify the risk of anterior cruciate ligament (ACL) femoral tunnel penetration with the use of a staple for lateral extra-articular tenodesis (LET) graft fixation and to determine whether this varied between 2 different techniques for ACL femoral tunnel drilling.MethodsTwenty paired, fresh-frozen, cadaver knees underwent ACL reconstruction with a LET. Left and right knees were randomized to ACL reconstruction with femoral tunnel creation by use of either a rigid guide pin and reamer through the accessory anteromedial portal or by the use of a flexible guide pin and reamer through the anteromedial portal. Immediately after tunnel creation, the LET was performed and fixated with a small Richard's staple. Fluoroscopy was used to obtain a lateral view of the knee to determine staple position, and visualization of the ACL femoral tunnel was performed with the arthroscope to investigate penetration of the staple into the femoral tunnel. The Fisher exact test was conducted to determine whether there was any difference in tunnel penetration between tunnel creation techniques.ResultsThe staple was noted to penetrate the ACL femoral tunnel in 8 of 20 (40%) extremities. When stratified by tunnel creation technique, the Richards staple violated 5 of 10 (50%) of the tunnels made via the rigid reaming technique compared with 3 of 10 (30%) of those created with a flexible guide pin and reamer (P = .65).ConclusionsA high incidence of femoral tunnel violation is seen with lateral extra-articular tenodesis staple fixation.Level of evidenceLevel IV, controlled laboratory study.Clinical relevanceThe risk of penetrating the ACL femoral tunnel with a staple for LET graft fixation is not well understood. Yet, the integrity of the femoral tunnel is important for the success of ACL reconstruction. Surgeons can use the information in this study to consider adjustments to operative technique, sequence, or fixation devices used when performing ACL reconstruction with concomitant LET to avoid the potential for disruption of ACL graft fixation.

Project description:BackgroundAnterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined.Purpose/hypothesisThe purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture.Study designCase-control study; Level of evidence, 3.MethodsData were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level.ResultsOf the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture.ConclusionThe addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Project description:PurposeTo investigate the differences in maximal (isometric and concentric peak torque) and explosive (rate of torque development (RTD)) hamstring and quadriceps strength symmetry between males and females during early- and late-phase rehabilitation after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) autografts and to determine the interaction of time and sex on maximal and explosive strength symmetry.MethodsA total of 38 female and 51 male participants were assessed during early (3-6 months post-operative) and late (7-12 months post-operative) phases of rehabilitation following ACLR. Maximal (concentric and isometric peak torque) and explosive (isometric RTD) hamstring and quadriceps strength were assessed and presented as limb symmetry index (LSI).ResultsMaximal concentric hamstrings asymmetry (Early: 86 ± 14; Late 92 ± 13; p = 0.005) as well as maximal concentric (Early, 73 ± 15; Late 91 ± 12; p < 0.001) and explosive (Early: 82 ± 30; Late: 92 ± 25; p = 0.03) quadriceps asymmetry decreased from early to late rehabilitation. However, there were no significant changes in maximal isometric quadriceps strength and explosive isometric hamstring strength in the same time period. Females had a larger asymmetry in maximal concentric (Females: 75 ± 17; Males: 81 ± 15; p = 0.001) and explosive (Females: 81 ± 32; Males: 89 ± 25; p = 0.01) quadriceps strength than males throughout rehabilitation. There were no sex differences in maximal and explosive hamstring strength. There were no sex by time interactions for any variables.ConclusionExplosive hamstring strength asymmetry did not improve despite recovery of maximal hamstring strength during rehabilitation following ACLR with HT autografts. While sex did not influence strength recovery, females had larger maximal and explosive quadriceps strength asymmetry compared to males throughout rehabilitation following ACLR.Level of evidenceLevel III.

Project description:BackgroundIt is still controversial whether the combination of anterior cruciate ligament (ACL) reconstruction and extra-articular reconstruction (EAR) have good clinical efficacy. This meta-analysis aims systematically to compare the clinical effectiveness of ACL reconstruction and combined reconstruction.MethodsElectronic databases, including Medline/PubMed, Embase and the Cochrane Library, were systematically searched to identify targeted studies. A meta-analysis were performed to pool the outcome estimates of interest, such as the Lysholm, International Knee Documentation Committee (IKDC) and Tegner scores and the results from the KT-1000/2000 arthrometer test, the Lachman test and the pivot shift test.ResultsTwelve studies involving 1146 knees were identified. Compared with single ACL reconstruction, combined reconstruction had better results for a pivot shift of grade 1 (relative ratio [RR] = 0.88, 95% CI: 0.83-0.94) and grade 2 (RR = 0.95, 95% CI: 0.91-0.99) rather than grade 3 (RR = 0.98, 95% CI: 0.90-1.06) and no statistically significant difference for both Lachman grade 1 (RR = 0.96, 95% CI: 0.89-1.05) and grade 2 (RR = 0.96, 95% CI: 0.90-1.03). Combined reconstruction resulted in significant improvements on the instrumented joint laxity test when considering a failure standard of more than 5 mm (a side-to-side arthrometric difference) (RR = 0.94, 95% CI: 0.89-0.98) rather than 3 mm (RR = 0.94, 95% CI: 0.86-1.03). Moreover, combined reconstruction increased the IKDC score at the 12-month (weighted mean difference [WMD] = - 6.38, 95% CI: - 9.66 to - 3.10), 24-month (WMD = - 5.60, 95% CI: - 8.54 to - 2.66) and 36-month follow-ups (WMD = - 4.71, 95% CI: - 7.59 to - 1.83) and the Tegner score at the 36-month follow-up (WMD = - 0.53, 95% CI: - 0.97 to - 0.09), but it did not increase the Lysholm score at the 36-month follow-up (WMD = - 0.84, 95% CI: - 2.02 to 0.34).ConclusionWith the advances in reconstruction techniques, combined reconstructions were found to be effective in improving rotational stability and to lead to good functional scores. However, obviously, the combined reconstruction technique is more time-consuming and requires an additional incision, which is not suitable for all ACL-deficient patients. Therefore, programs should be personalized and customized for the specific situation of each patient.

Dataset Information

Anterior Cruciate Ligament Reconstruction Using Combined Graft of Hamstring and Fascia Lata With Extra-articular Tenodesis. A Technique in Case of Insufficient Hamstrings.

Publications

Anterior Cruciate Ligament Reconstruction Using Combined Graft of Hamstring and Fascia Lata With Extra-articular Tenodesis. A Technique in Case of Insufficient Hamstrings.

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