Abstract
Objective
The aim of this study is to determine the outcome of anterior cruciate ligament (ACL) reconstruction without foreign material with patellar tendon bone graft in the fixation with bone dowels near the native insertion.
Materials and methods
Between 1998 and 1999, 189 patients were operated with ACL reconstruction with BTB patellar tendon graft. In a prospective study, 148 (78%) (91M, 57F) patients could be seen for a mean follow-up of 10.3 years. All had foreign material-free press-fit and a bottom-to-top (BTT) fixation in 120° knee flexion. All patients were evaluated with detailed history, clinical examinations, radiographic examination with weight bearing which could be compared to the time of surgery in 64 (43%) patients. Laxity testing was performed in Lachman position with the Rolimeter and pivot shift. All patients were graded according to the IKDC and Tegner activity score.
Results
87% of the patients achieved an IKDC score of A/B. The subjective IKDC score was A/B in 94.6% of the subjects. The average side-to-side difference was 1.42 ± 0.88 mm for the Lachman test, 97% of the patients were rated between 0 and 2 mm. The pivot-shift test was negative in 90% and was observed with a glide in 7% of the patients. Radiological joint space narrowing was found in the medial compartment in 8 (12.4%) cases, and laterally in 9 (14.1%) cases. All these patients had partial or total meniscus resections. The patello-femoral joint space was reduced in 21 (23%) cases. The Tegner activity score changed from 6.9 pre-injury to 5.0 at the 10-year follow-up.
Conclusion
The implant-free fixation of the graft with bone dowels and BTT implantation has good and excellent results after 10 years in more than 80% of the patients. Loss of the meniscus is a main factor contributing to osteoarthritis. Advantages of patellar tendon bone press-fit fixation include anatomical positioning and fast bone-to-bone healing, ease for revision surgery and cost effectiveness.
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References
Aglietti P, Buzzi R, Giron F, Simeone AJ, Zaccherotti G (1997) Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5–8 year follow-up. Knee Surg Sports Traumatol Arthrosc 5:138–144
Al-Husssein M, Batterjee K (2004) Press fit fixation in reconstruction of anterior cruciate ligament, using bonepatellar tendon–bone graft. Knee Surg Sports Traumatol Arthrosc 12:104–109
Bonatus T, Alexander A (1991) Patellar fracture and avulsion of the patellar ligament complicating arthroscopic anterior cruciate ligament reconstruction. Orthopedics 20:770–774
Boszotta H (1997) Arthroscopic anterior cruciate ligament reconstruction using a patellar tendon graft in press-fit technique: surgical technique and follow-up. Arthroscopy 13:332–339
Boszotta H (2003) Arthroscopic reconstruction of anterior cruciate ligament using BTB patellar ligament in the press-fit technique. Surg Technol Int 11:249–253
Bouchard C, Theriault G, Gauthier J, Morin F, Simoneau J (1993) Fracture of the patella during rehabilitation of the knee extensor muscles following reconstruction of the anterior cruciate ligament: a brief report. Clin J Sports Med 3:118–122
Chatain F, Adeleine P, Chambat P, Neyret P (2003) A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10 years minimum follow-up. Arthroscopy 19:842–849
Christen B, Jakob R (1992) Fractures associated with patellar ligament grafts in cruciate ligament surgery. J Bone Joint Surg B 74:617–619
Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KB (1994) Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 22:632–644
Deehan DJ, Salmon LJ, Webb VJ, Davies A, Pinczewski LA (2000) Endoscopic reconstruction of the anterior cruciate ligament with an ipsilateral patellar tendon autograft. A prospective longitudinal five-year study. J Bone Joint Surg B 82:984–991
Eichhorn J, Strobel M (1997) Ersatz des vorderen Kreuzbands mit der Quadruppelsemitendinosussehne in der 2-Kanal-Technik mit der Dualbuttonfixation Arthroskopie, vol 10. Springer, Berlin, pp 246–249
Felmet G (1997) Vorderer Kreuzbandersatz mit dem mittleren Ligamentum Patellae Drittel und gleichzeitiger proximaler und distaler Press-Fit-Verankerung, ALL PRESS FIT, 14. Kongress der deutschsprachigen Arbeitsgemeinschaft für Arthroskopie AGA, 3. und 4. Oktober 1997, Berlin
Felmet G (1999) All-press-FIT, eine neue Operationsmethode zum vorderen Kreuzbandersatz mit gleichzeitiger femoraler und tibialer Press-Fit-Verankerung, Arthroskopie 12:299–304
Felmet G (2000) Vorderer Kreuzbandersatz in proximaler und distaler Pressfit-Verankerung (ALLPRESS-FIT) mit SDI (surgical diamond instrument)-Instrumentarium. Osteosynth Int 8(Suppl 1):173–174
Felmet G (2002) Rehabilitation nach Kreuzbandersatz, der Stellenwert des “Aquasprint” im frühfunktionellen Nachbehandlungsprogramm (Arthroskopische Gelenkchirurgie, Gestern-heute-morgen, Standortbestimmung; G. Frenzel, H. Wuschech Kongress CompactVerlag, Berlin, pp 188–196. ISBN 3-98008025-5-8
Fink C, Hoser C, Benedetto KP, Hackl W, Gabl M (1996) Langzeitergebnisse nach konservativer oder operativer Therapie der vorderen Kreuzbandruptur. Unfallchirurg 99:964–969
Halder AM (1997) Die implantatfreie arthroskopische Kreuzbandplastik in Double-Press-Fit—Technik-Operationstechnik und erste Ergebnisse. Arthroskopie 10(6):298–302
Harner CD, Fu FH, Irrgang JJ, Vogrin TM (2001) Anterior and posterior cruciate ligament reconstruction in the new millennium: a global perspective. Knee Surg Sports Traumatol Arthrosc 9:330–336
Hertel P (1990) Anatomic reconstruction of the ACL: a new technique for ACL replacement. Presented at the 4th ESSKA congress, Stockholm
Hertel P (1997) Technik der offenen Ersatzplastik des vorderen Kreuzbandes mit autologer Patellarsehne Anatomische Rekonstruktion in schraubenfreier Press-fit-Technik. Arthroskopie 10:240–245
Hertel P (2003) Specific techniques in recent knee ligament surgery. In: Surgical techniques in orthopaedics and traumatology, vol 7. Editiones Scientifiques et Médicales Elsevier, Paris
Hertel P, Behrend H, Cierpinski T, Musahl V, Widjaja G (2005) ACL reconstruction using bone–patellar tendon–bone press-fit fixation: 10-years clinical results. Knee Surg Sports Traumatol Arthrosc 13:248–255
Ishibashi Y, Rudy TW, Livesay GA, Stone JD, Fu FH (1997) The effect of anterior cruciate ligament fixation site at the tibia on knee stability. Evaluation using a robotic testing system. Arthroscopy 13(2):177–182
Irrgang JJ, Ho H, Harner CD, Fu FH (1998) Use of International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 6:107–114
Jäger A, Welsch F, Braune C, Eberhardt C, Kappler C (2003) 10-Jahreergebnisse nach arthroskopischer vorderer Kreuzbandrekonstruktion mit dem Patellarsehnentransplantat. Z Orthop Ihre Grenzgeb 141:42–47
Jagodzinski M, Scheunemann K, Knobloch K, Albrecht K, Krettek C, Hurschler C, Zeichen J (2006) Tibial press-fit fixation of the hamstring tendons for ACL-reconstruction. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-006-0105-y
Jarvela T, Kannus P, Jarvinen M (2001) Anterior cruciate ligament reconstruction in patients with or without accompanying injuries: a re-examination of subjects 5 to 9 years after reconstruction. Arthroscopy 17:818–825
Jomha NM, Pinczewski LA, Clingeleffer AJ (1999) Arthroscopic reconstruction of the anterior cruciate ligament with patellar-tendon autograft and interference screw fixation. The results at seven years. J Bone Joint Surg B 81:775–779
Kartus J, Ejerhed L, Sernert N, Brandsson S, Karlsson J (2000) Comparison of traditional and subcutaneous patellar tendon harvest. A prospective study of donor site-related problems after anterior cruciate ligament reconstruction using different graft harvesting techniques. Am J Sports Med 28:328–335
Kurosaka M, Yoshiya S, Andrisch JT (1987) A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction. Am J Sports Med 15:225–229
Loubignac F, Lequire F, Rubini J, Basso M (1998) Troublesome radiologic changes after reconstructive fixation of the anterior cruciate ligaments with resorbable interference screws. Acta Orthop Belg 64(1):47–51
Martinek V, Friederich NG (1999) Tibial and pretibial cyst formation after anterior cruciate ligament reconstruction with bioabsorbable interference screw fixation. Arthroscopy 15:317–320
Mayr HO, Hube R, Bernstein A, Seibt AB, Hein W, von Eisenhart-Rothe R (2007) Beta-tricalcium phosphate plugs for press-fit fixation in ACL reconstruction—a mechanical analysis in bovine bone. Knee 14(3):239–244
Mushal V, Abramowitch SC, Gabriel MT, Debski RE, Hertel P, Fu FH, Woo SL (2003) Tensile properties of an anterior cruciate ligament graft after bone–patellar tendon–bone press-fit fixation. Knee Surg Sports Traumatol Arthrosc 11:68–74
Mushal V, Hertel P, Fussan A, Stumpenhausen B, Cierpinski T, Hornung H (2001) Bone tunnel enlargement in B-PT-B press-fit ACL-reconstruction. ISAKOS Congress, Montreux
Müller B, Rupp S, Seil R, Kohn D (2000) Entnahmestellenmorbidität nach VKB-Ersatzplastik mit dem Ligamentum-patellae-Transplant. Unfallchirurg 103:662–667
Pässler H, Mastrokalos DS (2003) Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. A new and innovative procedure. Orthop Clin North Am 34:49–64
Pavlik A, Hidas P, Tallay A, Tomann J, Berkes I (2006) Femoral press-fit fixation technique in anterior cruciate ligament reconstruction using bone-patellar tendon–bone graft: a prospective clinical evaluation of 285 patients. Am J Sports Med 34:220
Pavlik A, Hidas P, Czigany T, Berkes I (2004) Biomechanical evaluation of press-fit femoral fixation technique in ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 6:528–533
Papageorgiou CD, Ma CB, Abramovic SD, Clineff TD, Woo SL (2001) A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goal model. Am J Sports Med 29:620–626
Pinczewski LA, Deehan DJ, Salmon LJ, Russel VJ, Clingeleffer A (2002) A five-year comparison of patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the anterior cruciate ligament. Am J Sports Med 30:523–536
Pokar S, Wißmeyer T, Krischak G, Kiefer H, Kinzl L, Hehl G (2001) Die arthroskopisch gestützte Rekonstruktion des vorderen Kreuzbandes mittels autologer Patellarsehnenersatzplastik. 5-Jahres-Ergebnisse. Unfallchirurg 104:317–324
Rupp S, Krauss PW, Fritsch EW (1997) Fixation strength of a biodegradable interference screw and a press-fit technique in anterior cruciate ligament reconstruction with a BPTB-graft. Arthroscopy 13:61–65
Said HG, Baloch K, Green M (2006) A new technique for femoral and tibial tunnel bone grafting using the OATS harvesters in revision anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg, 22(7):796.e1–796.e3
Schmidt-Wiethoff R, Dargel J, Gerstner M, Schneider T, Koebke J (2005) Bone plug length and loading angle determine the primary stability of patellar tendon–bone grafts in press-fit ACL reconstruction. Knee Surgery Sports Traumatol Arthrosc 108–111. doi:10.1007/s00167-005-0645-6
Shelbourne KD, Gray T (1991) Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year follow-up. Am J Sports Med 25:786–795
Tegner Y, Lysholm J (1985) Rating system in the evaluation of knee ligament injuries. Clin Orthop 198:43–49
Tomita F, Yasuda K, Mikami S, Sakai T, Yamazaki S, Tohyama H (2001) Comparison of intraosseous graft healing between the double flexor tendon graft and the bone–patellar tendon–bone graft in anterior cruciate ligament reconstruction. Arthroscopy 17:461–476
Viola R, Vianello R (1999) Three cases of patella fracture in 1320 anterior cruciate ligament reconstructions with bone-patellar tendon–bone autograft. Arthroscopy 15:93–97
Wuschech H (1989) Neue LCA-OP-Methode durch Einbringen des Transplantates in den lateralen Femurkondylus mit Verankerung des tibialen Knochenteils an der inneren femoralen Kortikalis. AGA, Luzern
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Felmet, G. Implant-free press-fit fixation for bone–patellar tendon–bone ACL reconstruction: 10-year results. Arch Orthop Trauma Surg 130, 985–992 (2010). https://doi.org/10.1007/s00402-010-1050-2
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DOI: https://doi.org/10.1007/s00402-010-1050-2