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Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute.

ABSTRACT: Revision anterior cruciate ligament (ACL) reconstruction is a technically demanding procedure, and the surgeon should be prepared to address bone tunnel osteolysis, concurrent meniscal, ligamentous, or cartilage lesions, and limb malalignment. ACL revision can typically be done in one procedure, but it may need to be staged if there is poor previous tunnel positioning or excessive tunnel osteolysis. Bone grafting of the tunnels can be accomplished in several ways, including autograft, allograft, or bone substitutes. Currently, no consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision ACL reconstruction. Bone graft substitute for tunnel augmentation has been showed to have good histologic, radiographic, and intraoperative integration, comparable to that of autologous bone. In this Technical Note, the technical details of arthroscopic treatment of attenuated anterior cruciate ligament graft with enlarged bone tunnels are described. The tunnels are debrided arthroscopically and filled up with PRO-DENSE injectable regenerative graft.

SUBMITTER: Mak CY

PROVIDER: S-EPMC9243602 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Arthroscopic Delivery of Injectable Bone Graft for Staged Revision Anterior Cruciate Ligament Reconstruction.

Project description:Bone defects caused by femoral and tibial tunnel enlargement can pose a significant technical challenge when planning to perform revision anterior cruciate ligament reconstruction. A number of options have been described for managing osseous deficiencies, including the use of large autograft or allograft bone dowels to provide sufficient tunnel fill and subsequent structural support for revision surgery. These techniques can be time-consuming and technically demanding to ensure proper tunnel fill and press-fit stability of the bone graft. We describe our preferred technique for arthroscopic bone grafting using a mixture of demineralized cortical bone graft augmented with platelet-rich plasma delivered through a simple delivery system.

| S-EPMC5765773 | biostudies-literature

Minimally Invasive Quadriceps Tendon Single-Bundle, Arthroscopic, Anatomic Anterior Cruciate Ligament Reconstruction With Rectangular Bone Tunnels.

Project description:Many surgeons use quadriceps tendon (QT) graft for anterior cruciate ligament (ACL) revision surgery; however, despite excellent clinical results, the QT has not achieved universal acceptance for primary ACL reconstruction. One of the reasons for this may be that the QT is technically demanding to harvest and the scar from open harvesting techniques is less cosmetically favorable than that from hamstring tendon techniques. Recent evidence has suggested that broad flat QT grafts may more closely mimic native ACL "ribbon-like" morphology than hamstring tendon grafts. Furthermore, rectangular bone tunnels may more accurately re-create native ACL attachments, allowing grafts to simulate native ACL rotation during knee flexion and potentially improving biomechanics. Rectangular tunnels have further advantages in revision cases, in which-in comparison with round tunnels-they have reduced overlap with pre-existing transtibial tunnels, increasing the chance of bypassing primary tunnels during revision surgery. Finally, instrumentation for minimally invasive QT harvesting has reduced technical difficulty and improved cosmetic results. Hence, technical and cosmetic concerns are no longer barriers to QT use. These anatomic and biomechanical advantages and technical developments make the QT an increasingly attractive option for both primary and revision ACL reconstruction.

| S-EPMC6203691 | biostudies-literature

Anterior to Posterior Bone Plug Suture Tunnels Provide Optimal Biomechanics for Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Graft.

Project description:PurposeTo evaluate different bone-patellar tendon-bone (BPTB) plug suture configurations for pull through strength, stiffness, and elongation at failure in a biomechanical model of suspensory fixation.MethodsForty nonpaired, fresh-frozen human cadaveric BPTB allografts with an average age of 65.6 years were tested. Tensile testing was performed with the use of a custom-designed fixture mounted in a dynamic tensile testing machine. A preload of 90 N was applied to the graft and held for 5 minutes. Following this, a tensile load-to-failure test was performed. The ultimate failure load, elongation at failure, and mode of failure were recorded, and the resulting load-elongation curve was documented.ResultsThe drill tunnel through the cortical surface (anterior to posterior) was found to be significantly stronger than the drill tunnel through the cancellous surface (medial to lateral). There were no significant differences found when comparing the strength of the suture augmentation through the tendon and the drill tunnel alone (P = .13 among cancellous groups, P = .09 among cortical groups). The cortical drill tunnel with suture augmentation through the tendon showed significantly greater elongation values (13.7 ± 3.2) at failure when compared with either the cancellous or cortical drill tunnel only test groups (P = .0003 compared with cancellous alone, P = .009 when compared with cortical alone). Conclusions: The BPTB suture configuration with an anterior to posterior-directed suture tunnel without a suture through tendon augmentation provides the optimal strength and stiffness while minimizing graft elongation after fixation in a biomechanical model. This configuration is best for preventing suture pull through and failure when passing sutures through the BPTB plug.Clinical relevanceThis study biomechanically evaluates the optimal suture configuration in the proximal bone plug for suspensory fixation in the setting of BPTB grafts.

| S-EPMC9402455 | biostudies-literature

Single-Stage Revision Anterior Cruciate Ligament Reconstruction Using Fast-Setting Bone Graft Substitutes.

Project description:Revision anterior cruciate ligament reconstructions can be performed using either a single-stage or 2-stage technique. There are several benefits to using a single-stage approach when technically possible. Although not always feasible, eliminating the necessity of a 2-stage approach for certain indications is clearly preferable because it requires fewer operative procedures, leads to a more rapid recovery, and is cost effective. Here, we describe the use of fast-setting bone graft substitutes in the setting of single-stage revision anterior cruciate ligament reconstruction. The authors have found this technique useful in converting what would sometimes otherwise be approached using 2 stages into a single-stage procedure.

| S-EPMC7029178 | biostudies-literature

Bone-Tendon-Autograft Anterior Cruciate Ligament Reconstruction: A New Anterior Cruciate Ligament Graft Option.

Project description:The bone-tendon-bone (BTB) autograft is widely used for anterior cruciate ligament (ACL) reconstruction. However, the primary disadvantages of this technique include postoperative kneeling pain, the risk of perioperative patellar fracture, and graft-tunnel mismatch. Therefore, a single bone plug technique for ACL reconstructions was developed to mitigate the disadvantages of the BTB technique. To differentiate this graft, we have coined the term BTA, for bone-tendon-autograft. The middle third of the patellar tendon is used with a typical width of 10 to 11 mm. A standard tibial tubercle bone plug is harvested. The length of the patellar tendon and graft construct is then measured. If the tendon is >45 mm and the construct at least 70 mm, then we proceed with the BTA technique. At the inferior pole of the patella, electrocautery is used to harvest the tendon from the patella. The advantages of this technique include faster graft harvest and preparation. Obviating the patellar bone plug harvest should eliminate the risk of perioperative patellar fracture and theoretically will mitigate donor site morbidity and kneeling pain, 2 of the most commonly cited complications of the use of BTB autografts for ACL reconstruction. In conclusion, the BTA technique is a reliable technique for ACL reconstruction.

| S-EPMC7587499 | biostudies-literature

Revision Anterior Cruciate Ligament Reconstruction: Tibial Tunnel-First Graft-Sizing Technique.

Project description:Revision anterior cruciate ligament reconstruction (R-ACLR) has become more common as the number of failed primary ACLRs increase. Although increasingly common, R-ACLR has a greater failure rate than a primary reconstruction. Technical errors, particularly in tunnel placement, account for a large proportion of graft failure in R-ACLR as well as re-revision cases. Tunnel placement and trajectory is particularly important in R-ACLR and becomes more challenging with each additional revision attempt. This is in part because any tunnels created for revision may converge with formerly drilled tunnels or face interference hardware creating, complicating proper graft fixation. While there are many approaches to revision ACL surgery, our technique describes a simple, tibial tunnel-first graft-sizing method initially reaming tunnels with very small diameters and sequentially working your way up to more anatomic diameters.

| S-EPMC8719212 | biostudies-literature

Anatomic double-bundle anterior cruciate ligament reconstruction using in situ hamstring graft with 4 tunnels.

Project description:A careful review of the literature suggests that a significant number of patients undergoing anterior cruciate ligament (ACL) reconstruction have less-than-optimal results. Although overall outcomes of ACL reconstruction are favorable, there remains considerable room for improvement. Anatomically, the ACL consists of 2 major functional bundles, the anteromedial bundle and the posterolateral bundle. Biomechanically, both bundles contribute significantly to the anterior and rotational stability of the knee. Therefore anatomic double-bundle ACL reconstruction techniques may further improve the outcomes in ACL surgery. This article presents a technique for arthroscopic double-bundle ACL reconstruction that includes the use of 2 femoral and 2 tibial tunnels to restore both the anteromedial and posterolateral bundles of the ACL with minimal hardware for fixation.

| S-EPMC3986487 | biostudies-literature

A Bone-Hamstring Autograft for Arthroscopic Anterior Cruciate Ligament Reconstruction.

Project description:We describe a bone-hamstring autograft for anterior cruciate ligament reconstruction (ACLR). The semitendinosus and gracilis tendons are harvested using an open tendon stripper, keeping these distal tibial insertions intact. The bone-hamstring autograft is harvested using an oscillating saw. This modified autograft has the following advantages: (1) It possesses the potential for healing with the femur owing to its bone plug; (2) it is perfectly suited for various single-bundle reconstruction methods including oval-tunnel and rectangular-tunnel ACLR, as well as other flat ACLR methods; and (3) it is an attractive option for both primary ACLR and revision ACLR owing to its unique characteristics.

| S-EPMC8085407 | biostudies-literature

Arthroscopic Harvesting of Autologous Bone Graft for Use as a Mesenchymal Stem Cell Carrier in Anterior Cruciate Ligament Reconstruction.

Project description:Anterior cruciate ligament (ACL) tears are detrimental to knee stability and normal function. Although the standard of treatment is an ACL reconstruction, technical improvements are sought to enhance clinical outcomes due to the appreciable failure rate. The use of autologous biologic substances as carriers of stem cells are desirable because of their multipotent properties. Traditionally, the collection of autologous bone grafts is through an open incision of the iliac crest, which causes substantial morbidity to the patient. This Technical Note describes an arthroscopic, minimally invasive collection method of autologous tibial and femoral bone graft to use in backfilling the tunnels during an ACL reconstruction to improve graft incorporation and clinical outcomes.

| S-EPMC6993187 | biostudies-literature

Arthroscopic Primary Repair of the Anterior Cruciate Ligament With Single-Bundle Graft Augmentation.

Project description:Recently, there has been a resurgence of interest in ligament preservation of the anterior cruciate ligament (ACL) that has the advantage of preserving the native tissue and maintaining proprioceptive function. Studies reporting outcomes of remnant-preserving ACL surgery have shown encouraging results with a higher potential for early healing and better functional outcomes compared with remnant-resecting surgery. Over the past decade, several surgical techniques for remnant preservation of the ACL have been proposed. In this technical note, the technique of primary ACL repair with graft augmentation is described. The goal of this technique is to preserve and tension the native tissue, thereby restoring the anatomy as much as possible while avoiding cyclops lesions, whereas the additional graft provides strength to the repaired ligament.

| S-EPMC7093703 | biostudies-literature

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