A Pilot Study of Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Ligament Remnant Tissue Preservation

doi:10.1016/j.arthro.2011.08.305

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 28, Issue 3, March 2012, Pages 343-353

https://doi.org/10.1016/j.arthro.2011.08.305 Get rights and content

Purpose

The purpose of this pilot study was to evaluate the preliminary results of an anatomic double-bundle anterior cruciate ligament (ACL) reconstruction procedure with ligament remnant tissue preservation.

Methods

By use of the transtibial technique, 2 doubled semitendinosus tendons were grafted into 4 tunnels created at the center of each bundle attachment, penetrating the ACL remnant tissue. In total, 44 patients (27 male and 17 female patients) with an isolated ACL injury underwent ACL reconstruction with this procedure. The mean age of the patients was 29 years (range, 17 to 58 years). Postoperative clinical evaluations were performed at 16.6 months on average (range, 12 to 23 months). Radiologic evaluations were also performed to evaluate the tunnel location in the femur and the tibia.

Results

The mean operation time was 86 minutes (range, 72 to 96 minutes) in the cases with ACL reconstruction only. Postoperatively, the mean anterior laxity was 0.7 mm. The postoperative pivot-shift test was negative in 81.8% of the patients, whereas there were no patients evaluated as ++. No patients showed any extension or flexion deficit. There were no patients evaluated as “nearly abnormal” or “abnormal” according to the International Knee Documentation Committee evaluation. The tunnel angles of the 4 tunnels were identical to those reported in a previous study.

Conclusions

The minimal 1-year clinical results of anatomic double-bundle ACL reconstruction with ligament remnant tissue preservation were comparable to previously reported results of anatomic double-bundle reconstruction without remnant tissue preservation.

Level of Evidence

Level IV, therapeutic case series.

Section snippets

Operative Procedure

This procedure was performed in patients who had an ACL remnant tissue of type I, II, or III, as reported by Crain et al.⁶ The surgical setup and the fundamental double-bundle reconstruction procedure were previously reported.25, 29 We used an air tourniquet in all cases. After harvesting the semitendinosus tendon, we inserted a guidewire for the tibial posterolateral (PL) tunnel using a Wire Navigator device (Smith & Nephew Japan, Tokyo, Japan), which was developed for the transtibial tunnel

Operation Time and Complications

We completed the remnant-preserving procedure in all 44 patients. Namely, there were no patients requiring resection of the remnant tissue during surgery such that we had to change from this procedure to the conventional remnant-resecting procedure. The total operation time between skin incision and skin closure, including ACL reconstruction and additional meniscus surgeries, was 101 ± 19 minutes (mean ± SD), with a range between 81 and 115 minutes. In the cases with only ACL reconstruction,

Discussion

Although we should note that the clinical utility of the anatomic double-bundle ACL reconstruction has not been established in comparison with single-bundle reconstruction as of yet, we believe that it is of value to conduct a clinical study that clarifies the effect of the ACL remnant tissue preservation in anatomic double-bundle reconstruction. We compared our clinical results (Table 1) with the previously reported results of anatomic double-bundle reconstruction using hamstring tendons (

Conclusions

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Cited by (52)

Femoral tunnel placement in single-bundle, remnant-preserving anterior cruciate ligament reconstruction using a posterior trans-septal portal
2019, Knee
Anatomic tunnel formation and remnant preservation are valuable aspects of anterior cruciate ligament (ACL) reconstruction. However, anatomic landmarks are difficult to observe during remnant-preserving ACL reconstruction (ACLR). The aims of this study were to evaluate the: 1) femoral tunnel location created with guidance from the apex of the deep cartilage margin (ADC) and footprint compared to anatomical reference; and 2) relationship between femoral tunnel location and outcomes of ACLR.
A total of 109 ACLR patients without revision ACLR, multi-ligament reconstruction, peri-knee fracture, and osteotomy were included. The femoral tunnel was formed at the most proximal corner of the femoral footprint using a posterior trans-septal portal as the viewing portal. The distance from the tunnel center to ADC was measured by computed tomography and arthroscopy. The two measurements were then compared. Finally, femoral tunnel location was compared to the anatomic reference and correlated with the outcomes.
The average distance from ADC to the femoral tunnel center was 7.0 ± 1.4 mm as measured by arthroscopy, and 7.2 ± 2.0 mm using three-dimensional computed tomography. There was no statistically significant difference between the two methods (P = 0.420). Clinical and stability outcomes were significantly improved postoperatively. Clinical outcome was not related to femoral tunnel location; however, stability outcome was related to femoral tunnel location: the more proximally located femoral tunnels showed better stability.
The ADC can be a possible landmark in remnant-preserving ACLR using a trans-septal portal. A more proximal femoral tunnel, which is located at the proximal corner of the ACL remnant, can provide stability advantage during remnant-preserving ACLR.
Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction Procedure Using the Semitendinosus Tendon
2018, The Anterior Cruciate Ligament: Reconstruction and Basic Science: Second Edition
Graft-Tunnel Healing
2018, The Anterior Cruciate Ligament: Reconstruction and Basic Science: Second Edition
Clinical and arthroscopic outcome of single bundle anterior cruciate ligament reconstruction: Comparison of remnant preservation versus conventional technique
2017, Knee
The purpose of this study was to compare the clinical outcomes and second-look arthroscopic findings of remnant preservation technique with those of conventional anterior cruciate ligament (ACL) reconstruction in single bundle ACL reconstructions.
One hundred sixty two consecutive patients underwent ACL reconstruction by one surgeon, with 93 patients receiving remnant preservation technique (Group A) and 69 patients receiving conventional ACL reconstruction (Group B). The mean follow-up was 15 months. Clinical outcomes were assessed using Lysholm scores and the International Knee Documentation Committee form (IKDC form) evaluation. Post-operative knee stability was evaluated through manual knee laxity evaluation, pivot-shift test, and a Telos device.
Differences in post-operative stability (manual knee laxity, pivot shift test and Telos device) were not significant between the groups (p = 0.681, p = 0.610, p = 0.696). And also no significant differences were noted with respect to the IKDC form and the latest Lysholm scores. But in the second-look arthroscopic findings, synovial coverage was confirmed to be excellent in 36% (22/61) of Group A patients and 23% (7/30) of Group B patients.
ACL reconstruction with both techniques was found to result in acceptable stability, clinical outcomes and second-look arthroscopic findings. With regard to synovial coverage, the remnant reservation techniques were found to be superior to conventional ACL reconstruction.
Level III, retrospective comparative study.
Double-bundle anterior cruciate ligament reconstruction with and without remnant preservation — Comparison of early postoperative outcomes and complications
2017, Knee
To compare the early postoperative outcomes and complications of double-bundle anterior cruciate ligament (ACL) reconstruction with and without remnant preservation.
The study population comprised 125 consecutive knees that underwent double-bundle ACL reconstruction using hamstring autograft. Among the 125 knees, remnant preservation was indicated for 50 knees, while standard double-bundle reconstruction was performed in the remaining 75 knees. Postoperative evaluations included heel-height difference (HHD) at periodical follow-ups, number of knees requiring arthroscopic debridement due to problematic extension loss within six months, re-injury within one year, graft status upon second-look arthroscopy, and clinical examinations by Lysholm score and KT measurement at one year.
All patients could be followed up for a minimum of one year after surgery. When the results obtained from both groups were compared, HHD values were significantly larger in the preservation group at three and six months, and the rate of knees requiring arthroscopic debridement was also higher in this group (12% versus 4.0%). Graft status on second-look arthroscopy was considered to be good for 92% of the knees in the preservation group versus 59% in the non-preservation group. Re-injury rates within one year were 2.0% in the preservation group and 5.3% in the non-preservation group. No significant differences in clinical examinations were found between the groups at one year.
Remnant preservation in double-bundle hamstring autograft ACL reconstruction may enhance tissue healing; however, retention of the remnant with its full volume resulted in an increased incidence of postoperative problematic extension loss.
Femoral attachment of anterior cruciate ligament remnant tissue influences the stability of the anterior cruciate ligament-injured knee in patients over 40 years old
2017, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology

View all citing articles on Scopus

Note: To access the video accompanying this report, visit the March issue of Arthroscopy at www.arthroscopyjournal.org.

: The authors report no conflict of interest.

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Original Article With Video IllustrationA Pilot Study of Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Ligament Remnant Tissue Preservation

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Operative Procedure

Operation Time and Complications

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Orthop Traumatol Surg Res

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

J Orthop Sci

Arthroscopy

The sensory function of knee ligaments

Articular contributions to limb muscle reflexesThe effects of partial neurectomy of the knee-joint on postural reflexes

Br J Surg

Mechanoreceptors in joint function

J Bone Joint Surg Am

Proprioception and function after anterior cruciate reconstruction

J Bone Joint Surg Br

Original Article With Video Illustration
A Pilot Study of Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Ligament Remnant Tissue Preservation