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Arthroscopic Reconstruction of the Anterior Cruciate Ligament
Arthroscopy Classics: Commentaries by Our Editors on Classic Articles From the Past
Arthroscopic Reconstruction of the Anterior Cruciate Ligament Jan Gillquist, M.D., Ph.D., and Magnus Odensten, M.D., Ph.D.
Summary: Arthroscopic reconstruction of the anterior cruciate ligament was compared with reconstruction through a miniarthrotomy. The operation time was significantly longer with arthroscopy, but the Lysholm scores and activity levels were the same in both groups before and 1 year after the operation. There was no difference in quadriceps torque between the groups before surgery and at 3, 6, and 12 months postoperatively. The measured stability in 20° of knee flexion was similar in both groups before, immediately after, and 3, 6, and 12 months after surgery. A slow increase in the laxity was noted. One of 20 ligaments ruptured in the arthrotomy group due to a new trauma. In the arthroscopy group, there was one rupture due to abrasion. During the follow-up, two cases in the arthroscopy group had synovitis, in one case leading to removal of the prosthesis. There seems to be no major benefit from arthroscopic reconstruction in terms of rehabilitation. The miniarthrotomy is preferred since the notch plasty is easier to perform adequately during it than during arthroscopy. Key Words: Arthroscopic reconstruction—Anterior cruciate ligament. Arthroscopy 1988;4:5-9.
Commentary by John C. Richmond, M.D., Associate Editor
W
ho now would ever believe that the conclusion of the first paper to report the results of an all-arthroscopic transtibial anterior cruciate ligament (ACL) reconstruction1 would have been prescient enough to recognize that it might just not be an advance in our treatment of an ACL injured patient? That was, however, the conclusion of Gillquist and Odensten in their ground-breaking report, published in the fourth volume of our Journal in 1988. At that time Jan Gillquist, from Linköping, Sweden, was one of the most respected thought leaders when it came to the ACL. He, along with Lysholm2 and Tegner,3 had developed the Lysholm and Tegner scales, which remain in widespread use today. Gillquist and Odensten developed the initial transtibial instrumentation to al-
© 2010 by the Arthroscopy Association of North America 0749-8063/10/2605-10129$36.00/0 doi:10.1016/j.arthro.2010.02.023
low ACL reconstruction to be performed without an arthrotomy. While their initial report on the transtibial ACL reconstruction failed to note any major benefit of this technique over the standard technique at that time of using a medial arthrotomy, Gillquist and Odensten’s rejection of the arthroscopic procedure was not based on recognition that the technique might be less than anatomic or have inferior outcomes. They rejected the arthroscopic technique because it took more time owing to difficulties performing a notchplasty arthroscopically. Little did they realize that a myriad of other arthroscopic surgeons would take their lead and refine the instrumentation and technique, such that by the end of the 20th century, the all-arthroscopic transtibial ACL reconstruction was widely performed with multiple graft sources. The goal of arthroscopic surgeons was then, and remains today, to improve our patients’ lives through minimally invasive techniques. Advances in arthroscopic techniques are also driven by the patients we serve in their desire to return to full function as quickly and painlessly as possible.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 5 (May), 2010: pp 675-676
675
676
ARTHROSCOPY CLASSICS
Freddie Fu recognized, in the middle of this past decade, that an intact graft following a transtibial ACL reconstruction might not control the rotational stability of the knee, and hence could lead to instability while the graft was present and appeared competent. Dr. Fu’s identification of this failing of some transtibial ACL reconstructions using soft-tissue grafts has lead to the debate over double-bundle versus singlebundle ACL reconstruction. Reproduction of anatomy, as opposed to the expediency of the technique, is the force now moving us away from transtibial ACL reconstruction.4 This debate will be settled on the merits of anatomic single- versus double-bundle reconstruction, as measured by patient-centric outcome instruments and patients’ return to function, through multiple publications of Level I randomized controlled trials that seek to identify which technique will best suit our patients’ needs. As both superb technical
innovators and students of the importance of functional measurement as the means to determine success of ACL reconstruction, Dr. Gillquist and his colleagues, I am confident, would demand that we abandon the transtibial technique, as they recommended 22 years ago, if more anatomic (e.g., medial portal or double-bundle) techniques better serve our patients’ needs to return to full functioning. REFERENCES 1. Gillquist J, Odensten M. Arthroscopic reconstruction of the anterior cruciate ligament. Arthroscopy 1988;4:5-9. 2. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150-154. 3. Tegner Y, Lysholm J, Gillquist J. Rating systems in the evaluation of knee surgery. Clin Orthop Relat Res 1985;198:43-49. 4. van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament flowchart. Arthroscopy 2010;26:258-268.
Arthroscopic Reconstruction of the Anterior Cruciate Ligament Jan Gillquist, M.D., Ph.D., and Magnus Odensten, M.D., Ph.D.
Summary: Arthroscopic reconstruction of the anterior cruciate ligament was compared with reconstruction through a miniarthrotomy. The operation time was significantly longer with arthroscopy, but the Lysholm scores and activity levels were the same in both groups before and 1 year after the operation. There was no difference in quadriceps torque between the groups before surgery and at 3, 6, and 12 months postoperatively. The measured stability in 20° of knee flexion was similar in both groups before, immediately after, and 3, 6, and 12 months after surgery. A slow increase in the laxity was noted. One of 20 ligaments ruptured in the arthrotomy group due to a new trauma. In the arthroscopy group, there was one rupture due to abrasion. During the follow-up, two cases in the arthroscopy group had synovitis, in one case leading to removal of the prosthesis. There seems to be no major benefit from arthroscopic reconstruction in terms of rehabilitation. The miniarthrotomy is preferred since the notch plasty is easier to perform adequately during it than during arthroscopy. Key Words: Arthroscopic reconstruction—Anterior cruciate ligament. Arthroscopy 1988;4:5-9.
Commentary by John C. Richmond, M.D., Associate Editor
W
ho now would ever believe that the conclusion of the first paper to report the results of an all-arthroscopic transtibial anterior cruciate ligament (ACL) reconstruction1 would have been prescient enough to recognize that it might just not be an advance in our treatment of an ACL injured patient? That was, however, the conclusion of Gillquist and Odensten in their ground-breaking report, published in the fourth volume of our Journal in 1988. At that time Jan Gillquist, from Linköping, Sweden, was one of the most respected thought leaders when it came to the ACL. He, along with Lysholm2 and Tegner,3 had developed the Lysholm and Tegner scales, which remain in widespread use today. Gillquist and Odensten developed the initial transtibial instrumentation to al-
© 2010 by the Arthroscopy Association of North America 0749-8063/10/2605-10129$36.00/0 doi:10.1016/j.arthro.2010.02.023
low ACL reconstruction to be performed without an arthrotomy. While their initial report on the transtibial ACL reconstruction failed to note any major benefit of this technique over the standard technique at that time of using a medial arthrotomy, Gillquist and Odensten’s rejection of the arthroscopic procedure was not based on recognition that the technique might be less than anatomic or have inferior outcomes. They rejected the arthroscopic technique because it took more time owing to difficulties performing a notchplasty arthroscopically. Little did they realize that a myriad of other arthroscopic surgeons would take their lead and refine the instrumentation and technique, such that by the end of the 20th century, the all-arthroscopic transtibial ACL reconstruction was widely performed with multiple graft sources. The goal of arthroscopic surgeons was then, and remains today, to improve our patients’ lives through minimally invasive techniques. Advances in arthroscopic techniques are also driven by the patients we serve in their desire to return to full function as quickly and painlessly as possible.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 5 (May), 2010: pp 675-676
675
676
ARTHROSCOPY CLASSICS
Freddie Fu recognized, in the middle of this past decade, that an intact graft following a transtibial ACL reconstruction might not control the rotational stability of the knee, and hence could lead to instability while the graft was present and appeared competent. Dr. Fu’s identification of this failing of some transtibial ACL reconstructions using soft-tissue grafts has lead to the debate over double-bundle versus singlebundle ACL reconstruction. Reproduction of anatomy, as opposed to the expediency of the technique, is the force now moving us away from transtibial ACL reconstruction.4 This debate will be settled on the merits of anatomic single- versus double-bundle reconstruction, as measured by patient-centric outcome instruments and patients’ return to function, through multiple publications of Level I randomized controlled trials that seek to identify which technique will best suit our patients’ needs. As both superb technical
innovators and students of the importance of functional measurement as the means to determine success of ACL reconstruction, Dr. Gillquist and his colleagues, I am confident, would demand that we abandon the transtibial technique, as they recommended 22 years ago, if more anatomic (e.g., medial portal or double-bundle) techniques better serve our patients’ needs to return to full functioning. REFERENCES 1. Gillquist J, Odensten M. Arthroscopic reconstruction of the anterior cruciate ligament. Arthroscopy 1988;4:5-9. 2. Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150-154. 3. Tegner Y, Lysholm J, Gillquist J. Rating systems in the evaluation of knee surgery. Clin Orthop Relat Res 1985;198:43-49. 4. van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament flowchart. Arthroscopy 2010;26:258-268.