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A medium to long-term follow-up of ACL reconstruction using double gracilis and semitendinosus grafts

  • Andrea Ferretti
  • Edoardo Monaco
  • Silvio Giannetti
  • Ludovico Caperna
  • David Luzon
  • Fabio Conteduca
Knee

Abstract

This paper reports the results of our approach to ACL tears and knee laxity, based on 30 years of experience in ACL reconstruction with hamstrings and founded on the following cornerstones: the use of doubled semitendinosus and gracilis as a free graft; the use of an out-in technique for femoral drilling and of very strong and stiff fixation devices; the careful examination and repair or reconstruction of the lateral compartment in selected patients; and the use of unaggressive rehabilitation. We prospectively evaluated a series of 100 consecutive patients who underwent ACL reconstruction between 2001 and 2002. A clinical and radiological follow-up was performed at a minimum of 6 years. After 6 years, the International Knee Documentation Committee score demonstrated good-to-excellent results (A and B) in 98% of patients. However, arthrometric results using the KT-1000 demonstrated that 6/80 patients (7.5%) had >5 mm manual maximum side-to-side difference. The median Tegner activity score was 5 (range 1–9); the median Lysholm score was 96 (range 81–100); and the median subjective IKDC score was 94 (range 66–100). We reported 6/80 failures as revealed by a 2+ or 3+ pivot-shift test result and/or KT-1000 side-to-side difference of more than 5 mm. The IKDC score revealed excellent results in all women who underwent extra-articular tenodesis. Radiographic evaluation demonstrated early signs of osteoarthritis in 9% of patients.

Keywords

Anterior cruciate ligament (ACL) reconstruction Extra-articular tenodesis Hamstrings Tunnel widening 

References

  1. 1.
    Aglietti P, Buzzi R, D’Andria S, Zaccherotti G (1992) Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis. Am J Sports Med 20:38–45CrossRefPubMedGoogle Scholar
  2. 2.
    Asik M, Sen C, Tuncay I, Erdil M, Avci C, Taser OF (2007) The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique. Knee Surg Sports Traumatol Arthrosc 15:965–972CrossRefPubMedGoogle Scholar
  3. 3.
    Barrett GR, Noojin FK, Hartzog CW, Nash CR (2002) Reconstruction of the anterior cruciate ligament in females: a comparison of hamstring versus patellar tendon autograft. Arthroscopy 18:46–54CrossRefPubMedGoogle Scholar
  4. 4.
    Bunchner M, Schmeer T, Schmitt H (2007) Anterior cruciate ligament reconstruction with quadrupled semitendinosus tendon—minimum 6 year clinical and radiological follow-up. Knee 14:321–327CrossRefGoogle Scholar
  5. 5.
    Cinar BM, Akpinar S, Hersekli MA, Uysal M, Cesur N, Pourbagher A, Derincek A (2009) The effects of two different fixation methods on femoral bone tunnel enlargement and clinical results in anterior cruciate ligament reconstruction with hamstring tendon graft. Acta Orthop Traumatol Turc 43:515–521CrossRefPubMedGoogle Scholar
  6. 6.
    Clatworthy MG, Annear P, Bulow J-U, Bartlett RJ (1999) Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon graft. Knee Surg Sports Traumatol Arthrosc 7:138–145CrossRefPubMedGoogle Scholar
  7. 7.
    Draganich LF, Reider B, Ling M, Samuelson M (1990) An in vitro study of an intraarticular and extraarticular reconstruction in the anterior cruciate ligament deficient knee. Am J Sports Med 18:262–266CrossRefPubMedGoogle Scholar
  8. 8.
    Engebretsen L, Lew WD, Lewis JL, Hunter RE (1990) The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med 18:169–176CrossRefPubMedGoogle Scholar
  9. 9.
    Fairbank TJ (1948) Knee joint changes after meniscectomy. J Bone Joint Surg 30B:664–670Google Scholar
  10. 10.
    Ferretti A, Conteduca F, La Bianca L, Monaco E, De Carli A (2005) Evolgate fixation of doubled flexor graft in ACL reconstruction: biomechanical evaluation with cyclic loading. Am J Sports Med 33:574–582CrossRefPubMedGoogle Scholar
  11. 11.
    Ferretti A, Conteduca F, Morelli F, Ticca L, Monaco E (2003) The Evolgate: a method to improve the pullout strength of interference screws in tibial fixation of anterior cruciate ligament reconstruction with doubled gracilis and semitendinosus tendons. Arthroscopy 19:936–940CrossRefPubMedGoogle Scholar
  12. 12.
    Ferretti A, Monaco E, Labianca L, D’Angelo F, De Carli A, Conteduca F (2006) How four and twelve weeks of implantation affect the strength and stiffness of a tendon graft securely fixed in a bone tunnel: a study of Evolgate fixation in an extra-articular model bovine model. J Orthop Traumatol 7:136–141CrossRefGoogle Scholar
  13. 13.
    Ferretti A, Vadalà A, De Carli A, Argento G, Conteduca F, Severini G (2008) Minimizing internal rotation strength deficit after use of semitendinosus for anterior cruciate ligament reconstruction: a modified harvesting technique. Arthroscopy 24:786–795CrossRefPubMedGoogle Scholar
  14. 14.
    Giron F, Aglietti P, Cuomo P, Mondanelli N, Ciardullo A (2005) Anterior cruciate ligament reconstruction with double-looped semitendinosus and gracilis tendon graft directly fixed to cortical bone: 5-year results. Knee Surg Sports Traumatol Arthrosc 13:81–91CrossRefPubMedGoogle Scholar
  15. 15.
    Goertzen M, Schulitz KP (1993) Comparison of combined extra- and intra-articular stabilization versus isolated arthroscopic semitendinosus repair after rupture of the anterior cruciate ligament. Sportverletz Sportschaden 7:7–12CrossRefPubMedGoogle Scholar
  16. 16.
    Hefti F, Muller W, Jakob RP, Staubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234CrossRefPubMedGoogle Scholar
  17. 17.
    Hertel P, Behrend H, Cierpinski T, Musahl V, Widjaja G (2005) ACL reconstruction using bone-patellar tendon-bone press-fit fixation: 10-year clinical results. Knee Surg Sports Traumatol Arthrosc 13:248–255CrossRefPubMedGoogle Scholar
  18. 18.
    Horer J, Moller HD, Fu FH (1998) Bone enlargement after anterior cruciate ligament reconstruction: fact or fiction? Knee Surg Sports Traumatol Arthrosc 6:231–240CrossRefGoogle Scholar
  19. 19.
    Iorio R, Vadalà A, Argento G, Di Sanzo V, Ferretti A (2007) Bone tunnel enlargement after ACL reconstruction using autologous hamstring tendons: a CT study. Int Orthop 31:49–55CrossRefPubMedGoogle Scholar
  20. 20.
    Jonsson H, Riklund-Ahlstrom K, Lind J (2004) Positive pivot shift after ACL reconstruction predicts later osteoarthrosis. Acta Orthop Scand 75:594–599CrossRefPubMedGoogle Scholar
  21. 21.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502CrossRefPubMedGoogle Scholar
  22. 22.
    Kessler MA, Behrend H, Henz S, Stutz G, Rukavina A, Kuster MS (2008) Function, osteoarthritis and activity after ACL-rupture: 11 year follow-up results of conservative versus reconstructive treatment. Knee Surg Sports Traumatol Arthrosc 16:442–448CrossRefPubMedGoogle Scholar
  23. 23.
    L’Insalata JC, Klatt B, Fu FH et al (1997) Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc 5:234–238CrossRefPubMedGoogle Scholar
  24. 24.
    Labianca L, Monaco E, Speranza A, Camillieri G, Ferretti A (2006) A biomechanical evaluation of six femur-graft-tibia complex in ACL reconstruction. J Orthop Traumatol 7:131–135CrossRefGoogle Scholar
  25. 25.
    Lerat JL, Chotel F, Besse JL et al (1998) The results after 10–16 years of the treatment of chronic anterior laxity of the knee using reconstruction of the anterior cruciate ligament with a patellar tendon graft combined with an external extra-articular reconstruction. Rev Chir Orthop Reparatrice Appar Mot 84:712–727PubMedGoogle Scholar
  26. 26.
    MacIntosh DL, Darby JA (1976) Lateral substitution reconstruction. In: Proceedings of the Canadian Orthopaedic Association. J Bone Joint Surg Br 58:142Google Scholar
  27. 27.
    Marcacci M, Zaffagnini S, Giordano G, Iacono F, Presti ML (2009) Anterior cruciate ligament reconstruction associated with extra-articular tenodesis: a prospective clinical and radiographic evaluation with 10–13-year follow-up. Am J Sports Med 37:707–714CrossRefPubMedGoogle Scholar
  28. 28.
    Monaco E, Labianca L, Conteduca F, De Carli A, Ferretti A (2007) Double bundle or single bundle plus extraarticular tenodesis in ACL reconstruction? A CAOS study. Knee Surg Sports Traumatol Arthrosc 15:1168–1174CrossRefPubMedGoogle Scholar
  29. 29.
    Outerbridge RE (1961) The etiology of chondromalacia patellae. J Bone Joint Surg 43-B:752–757Google Scholar
  30. 30.
    Pearl AJ, Bergfeld JA (eds) (1992) Extraarticular reconstruction in the anterior cruciate ligament deficient knee. Human Kinetics, ChampaignGoogle Scholar
  31. 31.
    Sommer CH, Friederich NF, Muller W (2000) Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 8:207–213CrossRefPubMedGoogle Scholar
  32. 32.
    Tegner Y, Lysholm J (1985) Rating systems in evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–48PubMedGoogle Scholar
  33. 33.
    Vadalà A, Iorio R, De Carli A, Argento G, Di Sanzo V, Conteduca F, Ferretti A (2007) The effect of accelerated, brace free, rehabilitation on bone tunnel enlargement after ACL reconstruction using hamstring tendons: a CT study. Knee Surg Sports Traumatol Arthrosc 15:365–371CrossRefPubMedGoogle Scholar
  34. 34.
    Zaffagnini F, Marcacci M, Lo Presti M et al (2006) Prospective and randomized evaluation of ACL reconstruction with three techniques: a clinical and radiographic evaluation at 5 year follow-up. Knee Surg Sports Traumatol Arthrosc 14:1060–1069CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Andrea Ferretti
    • 1
  • Edoardo Monaco
    • 1
    • 2
  • Silvio Giannetti
    • 1
  • Ludovico Caperna
    • 1
  • David Luzon
    • 1
  • Fabio Conteduca
    • 1
  1. 1.Department of Orthopaedics and Traumatology, Kirk Kilgour Sports Injury Center, II School of Medicine, Sant’Andrea HospitalSapienza University of RomeRomeItaly
  2. 2.RomeItaly

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