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Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Autograft
Original Article
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING PATELLAR TENDON AUTOGRAFT M.N. Sehar*, Sohail Ahmad** and R.M.Davies# From the: Senior Consultant Orthopaedic Surgeon*, Registrar, Orthopaedics**, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India and Senior Consultant Orthopaedics Surgeon#, Neath General Hospital, Neath, UK. Correspondence to: Dr. M.N. Sehar, Senior Consultant Orthopaedic Surgeon, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India. The purpose of this study was to present our clinical experience in terms of regained joint stability and its functional benefit following anterior cruciate ligament (ACL) reconstruction using the central third of patellar tendon. Forty nine patients with persistent clinical and functional instability of the knee due to ACL insufficiency underwent ligament reconstruction by patellar tendon autograft. They were followed-up for 18 to 24 months until functionally rehabilitated and 43 patients were recalled for this review, an average of 30 months after operation (range 12 months to 9 years). There were 42 male patients and one female .The average age was 27 years and the average interval from initial injury to index operation was 2 years and 3 months. Associated pathology was noted in many patients. Twenty eight patients had torn menisci; these lesions were treated either at previous arthroscopy or at the time of ACL reconstruction; three had osteochondritic lesions and ten had osteoarthritic change of varying degrees. At review, post -recostruction stability was assessed clinically; Lysholm Knee scores and Activity scores were recorded for knee pre-and post reconstruction. On overall IKDC rating based on subjective assessment, symptoms, range of movement and ligament stability 41 patients were graded as nearly normal (B), 2 were graded abnormal (C) and none were graded as abnormal.
INTRODUCTION During the last two decades, clinical and laboratory research has shown the functional importance of the anterior cruciate ligament. Several authors [1,2] have described the anterolateral instability associated with ACL rupture. ACL rupture typically leading to episodes of giving way [2] which may cause meniscal injury [2,3] and premature degenerative changes.[3,6]. The fact that ACL insufficiency may result in significant disability has led to numerous attempts at surgical reconstruction of the ligament. These may be extra articular, intra-articular, or a combination of both. Direct repair [7], extra-articular procedures [8,9] and intraarticular prostheses [10-12] have produced poor long-term results. Several types of auto grafts including iliotibial band, tendo-achilles, meniscus, patellar and hamstring tendons have been used for intra-articular reconstruction of the ACL.Initially, Jones [13] used the medial third of the patellar tendon with its tibial attachment intact; Clancy [14] later modified the technique using the central third of patellar tendon. At present the two most commonly used autografts for reconstruction of the ACL are central third of the patellar tendon or the combined semitendinosus [15,16] and gracilis tendons. Theoretical advantages of using the Apollo Medicine, Vol. 2, No. 2, June 2005
patellar tendon are that it is the strongest of all structures, that it has been shown to revascularise and regain sufficient tensile strength and that its use does not sacrifice entirely and essential stabilizer of the knee. When the graft is harvested with its bone insertions attached, union of bone to bone achieves fixation ultimately. The use of interference screws in securing the fixation of bone block gives adequate security to allow intensive rehabilitation. Several techniques have been used over the years for insertion of patellar tendon grafts. Initially an open procedure was employed but lately a miniarthrotomy with arthroscopic assistance or a fully endoscopic technique are also being used. PATIENTS AND METHODS Forty-nine patients underwent this operation at Neath General Hospital, Neath (UK) and Apollo Hospital, New Delhi. The indication for reconstructing the ACL was the presence of functional stability during normal activities, and we also required a positive pivot shift test that replicated the sensation the patient experienced when the knee was giving way. All patients with ACL instability were offered surgical reconstruction. Our primary goal in undertaking the procedure was to restore functional stability to the knee joint so as to allow normal activities of
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Original Article
daily living. Secondary aims were possibly to allow a return to some recreational activities; we also hoped to prevent or delay the onset of degenerative arthritis in the knee. The patients were cautioned that they should not necessarily expect to return to highly competitive sports, particularly contact sports. Of forty-nine patients, forty three returned to a personal follow up evaluation. There were forty two males and one female with a mean age of 27 years (20 to 42 years). All but six patients had sustained the initial injury to the knee while engaged in sports activities viz., soccer 25, rugby 11, karate 1. Domestic injury accounted for five cases and industrial accidents 1. Twenty six patients were injured in recreational sports and 11 while engaged in competitive sports. Pre-operatively none of patients could return to sports because of instability of the knee. All 43 patients had, as their main complaint, multiple episodes of giving way of the knee. This was occasionally associated with pain and effusion. Only 3 patients remembered hearing a “pop” in the knee at the time of initial injury, and all three had a significant swelling developing within two hours of injury. Five patients had a menisectomy after the initial injury and before the index reconstructive procedure. None of these had any decrease in the episodes of instability after the menisectomy. All the patients had a positive Lachman, positive anterior drawer tests and a markedly positive pivot shift test.
Table 1: Nature of Injury • • • • •
Football Rugby Karate Domestic Industrial accident
The ACL was reconstructed in the chronic phase (>12 weeks from injury) in all cases. The interval between injury and index operation was 6 months -5 years, with an average time of 27 month.
• 20-25 years
16
• 25-30 years
18
• 30-35 years
06
• >35 years
03
Operative technique All the operations were carried out by the senior author (MNS) under general anaesthesia and tourniquet.
Table 3: Associated injuries • • • • •
Medial meniscus Lateral meniscus Osteochondritic lesion Fissuring of medial femoral condyle Osteoarthritic changes
20 8 3 1 10
METHODS Via a short midline vertical incision from upper patella to just below the tibial tubercle, a graft 9 or 10 mm wide was fashioned from the central third of the patellar tendon. Parallel bone blocks were taken in continuity from the tibial tubercle, 30 mm long, and the patella 25 mm long. An arthrotomy was made via the graft site with resection of the fat pad. Notchplasty was undertaken if required. A graft width hole was drilled over a guide wire from just medial to the tibial tubercle, emerging in the centre of the site of the tibial ACL attachment.
25 11 1 5 1
Table 2: Age
Immediately preceding the main reconstructive procedures, all patients had an examination under anaesthesia and arthroscopy. The medial meniscus was found torn in 20 patients and 8 patients had a torn lateral meniscus. Three patients had osteochondritic lesions over the lateral femoral condyle and one patient had fissuring of the lateral edge of the medial femoral condyle. Ten patients showed some degenerative changes localized mainly to patella and medial femoral condyle. Three patients had more than one associated pathology.
The isometric point was determined on the upper medial wall of the LFC in the intercondylar notch. From this, a blind tunnel of graft width was drilled to a depth equal to the length of patellar bone over a guide wire in the LFC. The graft was pulled upwards through the tibial tunnel and patellar block pulled snug in the blind ended femoral tunnel. The patellar block was secured by a 7 mm diameter interference screw. Following 90 degrees medial rotation of tibial block of the graft, it was secured using a 9 mm diameter interference screw. The joint was drained and closed. An accelerated rehabilitation programme has been adopted with continuous passive motion commenced on the first postoperative day, without plaster splintage but allowing protected movement with a simple hinged brace only for 6 weeks.
125
Apollo Medicine, Vol. 2, No. 2, June 2005
Original Article
Evaluation All patients were assessed by one examiner (MNS) using the evaluation of internal knee documentation committee. Anterior cruciate stability was assessed on an exclusively clinical basis using Lachman, anterior drawer and a pivot shifts tests. No arthometric testing or radiographic imaging was carried out.
indicating its site as patellar. Two patients had mild effusion and another 2 (those with grade 2 Lachman and anterior drawer tests) experienced episodes of partial giving way when turning suddenly. On subjective assessment by the patient, 41 knees were nearly normal (B) and another 2 were graded abnormal (C); none was graded grossly abnormal (D). Crepitus
Table 4: Clinical Graft Stability Grade
Lachman
Anterior drawer
Pivot shift
0 (<3mm)
10
10
40
1 (3-5mm)
31
31
02
2 (>5mm)
02
02
01
Thirteen patients were noted to have crepitus, 11 in the patello-femoral compartment and 2 medially. Table 5: Knee Score of Patients Score
The Lachman and anterior drawer tests were graded as 0 (<3mm laxity), 1 (3-5mm laxity) and 2 (>5mm laxity) and the pivot shift test as 0 (negative), 1 (glide), 2 (clunck) and 3 gross. Thigh atrophy and knee effusion were noted. In order to assess function, every patient had a Lysholm knee score calculated and activity scores before injury and at the time of evaluation were compared. RESULTS Knee stability: Ten patients showed grade zero laxity on Lachman and anterior drawer tests, while 31 patients showed grade 1. Further 2 patients showed grade 2 laxity, although the pivot shift test was positive grade 2 in only 1 of these. Activity score
•
91-100
22
•
81-90
11
•
71-80
7
•
70 or above
3
Graft site tenderness Eight patients had mild to moderate tenderness at the graft site. Quadriceps wasting Twenty nine patients had regained quadriceps bulk to within 2 cm, while 2 patients had wasting of 5 cm or more, while other 12 patients had equal bulk as compared to normal site. Knee test
Pre injury 31 patients had activity score of 5, 7 had a score of 7, while 5 patients achieved a pre-injury activity score of 9. Only 7 patients went back to same level of activity score while 36 patients had a reduction of activity score by 1. It is to be noted that the majority of these patients expressed a fear of re-injuring the knee again if they attempt a resumption of the same activity level; they nevertheless had demonstrably stable knees. Lysholm knee score: Scores varied from 70-95 with a mean of 80. Twenty seven patients score more than 84 indicating a good or excellent rating. Pain and difficulty on stair climbing and squatting were main reason for the drop in score. Range of movement Three patients had a 5 degree lack of full extension while all 43 patients had full flexion. Symptoms Nine patients complained of anterior knee pain, Apollo Medicine, Vol. 2, No. 2, June 2005
No. of patients
Twelve patients complaint of pain at the tibial tubercle on kneeling while 6 of these were also tender over the lingamentum patellae. COMPLICATIONS Three patients has superficial infections which resolved after oral antibiotics.Six patients had effusions, presumable haemarthroses,but none needed drainage.One patient had urinary retention in the post-operative period.One patient’s knee gave way 3 months after surgery in a fall while farming and an MRI scan confirmed disruption of the graft. DISCUSSION Patients with a functionally unstable knee due to anterior cruciate ligament deficiency have a high incidence of meniscal tears and degenerative changes.In our study the majority of ACL ruptures occurred in sports injuries, but a significant number also occurred in domestic and other accidents. We included only those patients who had functional instability during normal activity and not
126
Original Article
improving following a muscle and proprioceptive rehabilitation programme.
4. Noyes FR, Mooar PA, Mathews DS, Butler DL. The symptomatic anterior cruciate deficient knee. Part I. The long term functional disability in athletically active individuals. J Bone Joint Surg (Am) 1983; 65-A: 154-162.
Intra-articular reconstruction of the ACL was performed with the intention of eliminating the functional instability and also of preventing the onset or retarding the progression of degenerative osteoarthritis although recent studies cast doubt on latter. It is doubtful whether a truly isolated rupture of ACL exists. In our study 28 patients had meniscal injuries, 4 had chondral lesions while 10 showed some degenerative changes. Associated injuries of this nature have also been reported by Finsterbush, et al [20] and Daniel & Fithian [21] . The availability of magnetic resonance scanning in recent years has demonstrated extensive bone bruising as a frequent occurrence undetectable clinically and arthroscopically. In our study 41 patients had stable knee following reconstructive surgery with a grade 0 or 1 laxity on Lachman or anterior drawer tests. One patient with a grade 2 pivot-shift test and 1 of the 2 patients with a grade 1 experienced episodes of giving way; the second patient with the grade 1 pivot shift abnormality denied subjective instability of this nature. On assessment of activity scores, 36 patients (84%) had a drop of 1 level as compared to their pre injury estimates and only 7 (16%) return to their pre injury levels. Anterior knee pain and pain on kneeling were the main complaints among patients in our study. Nine had anterior knee pain and three others were unable to kneel. It is interesting to note that all 9 patients with knees in the most stable categories with negative Lachman, anterior drawer and pivot shift tests.
5. Kannus P, Jarvinen M. Conservatively treated tears of anterior cruciate ligament: long term results. J Bone Joint Surg (Am) 1987; 69-A: 1007-1012. 6. Hawkings RJ, Misamore GW, Merritt TR. Follow-up of the acute nonoperated isolated anterior cruciate ligament tears. Am J Sports Med 1986; 14: 205-210. 7. Engerbresten L, Benum P, Sundalsvol S. Primary suture of the anterior cruciate ligament: A 6-year follow-up of 74 cases. Acta Orthop Scand 1989; 60: 561-564. 8. Chick RP, Collins HR, Rubin BD, et al. The pes anserinus transfer: a long-term follow-up. J Bone Joint Surg (Am) 1981; 63-A: 1449-1452. 9. Bray RC, Flanagan JP, Dandy DJ. Reconstruction for chronic anterior cruciate instability: a comparison of two methods after six years. J Bone Joint Surg (Br) 1988; 70B: 100-105. 10. Olson EJ, Kang JD, Fu FH, et al. The biochemical and histological effects of artificial ligament were particles: in vitro and in vivo studies. Am J Sports Med 1988; 16: 558570. 11. Woods GA, Indelicato PA, Prevot TJ. The Goretex anterior ligament prosthesis: two versus three year results. Am J Sports Med 1991; 19: 48-55. 12. Grotvedt T, Engerbrestsen L, Benum P, et al. A prospective, randomised study of three operations for acute rupture of the anterior cruciate ligament: 5 year follow-up of 131 patients. J Bone Joint Surg (Am) 1996; 78: 159-168.
In conclusion, our results show that all but two patients had stable knee during both normal and recreational activities. Despite the achievement of stability there was a drop of 1 level in activity as compared to pre injury level. No patient had a significant loss of range of motion and 41 patients out of 43 patients were satisfied with the result. Anterior knee pain and inability to kneel were the main concerns in 28% of patients; the cause seems to relate to the patellar tendon graft site.
13. Jones KG. Use of the central one-third of the patellar ligament to compensate for anterior cruciate ligament deficiency. Clin Orthop 1980; 147: 37.
REFERENCES
16. Johnson RJ, et al. Current concepts reviews: The treatment of injuries of anterior cruciate ligament. J Bone Joint Surg (Am) 1992; 74-A: 140-151.
1. Solcum DB, Larson RL. Rotatory Instability of the knee, its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg (Am) 1968; 50-A: 211. 2. McDaniel WJ, Damoron TB. Untreated ruptures of the anterior cruciate ligament. J Bone Joint Surg (Am) 1980; 62-A: 696-705. 3. Arnold JAA, Coker TP, Heaton LM, Park JP, Harris WD. Natural history of anterior cruciate tears. Am J Sports Med 1979; 7: 305-313.
14. Clancy WG, Nelson DA, Reider B, et al. Anterior cruciate ligament reconstruction using one third of patellar ligament, augmented by extra-articular tendon transfer. J Bone Joint Surg 1982; 64-A: 352. 15. Amiel D, Klenier JB, Akeson WH. The natural history of the anterior cruciate ligament autograft of patellar tendon origin. Am J Sports Med 1986; 14: 449-462.
17. Torg J, Conrad W, Kalen V. Clinical diagnosis of anterior cruciate ligament instability in the athlete. Am J Sports Med 1976; 4: 84-93. 18. Galway RD, Beaupre A, MacIntosh DL. Pivot shift: a clinical sign of symptomatic anterior cruciate ligament insufficiency. J Bone Joint Surg (Br) 1972; 54B: 763-764.
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Apollo Medicine, Vol. 2, No. 2, June 2005
Original Article 19. Tenger Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop 1985; 198: 43-49.
21. Daniel DM, Fithian DC. Indications for ACL surgery. Arthroscopy 1994; 10: 434-441.
20. Finsterbush A, Franki U, Matan Y, Mann G. Secondary damage to the knee after isolated injury of the anterior cruciate ligament. Am J Sports Med 1990; 18: 475-479.
22. Dye SF, Wojtys EM, Fu FH, Fithian DC, Gilquist J. Factors contributing to function of the knee joint after injury or reconstruction of anterior cruciate ligament. J Bone Joint Surg (Am) 1998; 80A: 1380-1393.
Apollo Medicine, Vol. 2, No. 2, June 2005
128
ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING PATELLAR TENDON AUTOGRAFT M.N. Sehar*, Sohail Ahmad** and R.M.Davies# From the: Senior Consultant Orthopaedic Surgeon*, Registrar, Orthopaedics**, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India and Senior Consultant Orthopaedics Surgeon#, Neath General Hospital, Neath, UK. Correspondence to: Dr. M.N. Sehar, Senior Consultant Orthopaedic Surgeon, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 044, India. The purpose of this study was to present our clinical experience in terms of regained joint stability and its functional benefit following anterior cruciate ligament (ACL) reconstruction using the central third of patellar tendon. Forty nine patients with persistent clinical and functional instability of the knee due to ACL insufficiency underwent ligament reconstruction by patellar tendon autograft. They were followed-up for 18 to 24 months until functionally rehabilitated and 43 patients were recalled for this review, an average of 30 months after operation (range 12 months to 9 years). There were 42 male patients and one female .The average age was 27 years and the average interval from initial injury to index operation was 2 years and 3 months. Associated pathology was noted in many patients. Twenty eight patients had torn menisci; these lesions were treated either at previous arthroscopy or at the time of ACL reconstruction; three had osteochondritic lesions and ten had osteoarthritic change of varying degrees. At review, post -recostruction stability was assessed clinically; Lysholm Knee scores and Activity scores were recorded for knee pre-and post reconstruction. On overall IKDC rating based on subjective assessment, symptoms, range of movement and ligament stability 41 patients were graded as nearly normal (B), 2 were graded abnormal (C) and none were graded as abnormal.
INTRODUCTION During the last two decades, clinical and laboratory research has shown the functional importance of the anterior cruciate ligament. Several authors [1,2] have described the anterolateral instability associated with ACL rupture. ACL rupture typically leading to episodes of giving way [2] which may cause meniscal injury [2,3] and premature degenerative changes.[3,6]. The fact that ACL insufficiency may result in significant disability has led to numerous attempts at surgical reconstruction of the ligament. These may be extra articular, intra-articular, or a combination of both. Direct repair [7], extra-articular procedures [8,9] and intraarticular prostheses [10-12] have produced poor long-term results. Several types of auto grafts including iliotibial band, tendo-achilles, meniscus, patellar and hamstring tendons have been used for intra-articular reconstruction of the ACL.Initially, Jones [13] used the medial third of the patellar tendon with its tibial attachment intact; Clancy [14] later modified the technique using the central third of patellar tendon. At present the two most commonly used autografts for reconstruction of the ACL are central third of the patellar tendon or the combined semitendinosus [15,16] and gracilis tendons. Theoretical advantages of using the Apollo Medicine, Vol. 2, No. 2, June 2005
patellar tendon are that it is the strongest of all structures, that it has been shown to revascularise and regain sufficient tensile strength and that its use does not sacrifice entirely and essential stabilizer of the knee. When the graft is harvested with its bone insertions attached, union of bone to bone achieves fixation ultimately. The use of interference screws in securing the fixation of bone block gives adequate security to allow intensive rehabilitation. Several techniques have been used over the years for insertion of patellar tendon grafts. Initially an open procedure was employed but lately a miniarthrotomy with arthroscopic assistance or a fully endoscopic technique are also being used. PATIENTS AND METHODS Forty-nine patients underwent this operation at Neath General Hospital, Neath (UK) and Apollo Hospital, New Delhi. The indication for reconstructing the ACL was the presence of functional stability during normal activities, and we also required a positive pivot shift test that replicated the sensation the patient experienced when the knee was giving way. All patients with ACL instability were offered surgical reconstruction. Our primary goal in undertaking the procedure was to restore functional stability to the knee joint so as to allow normal activities of
124
Original Article
daily living. Secondary aims were possibly to allow a return to some recreational activities; we also hoped to prevent or delay the onset of degenerative arthritis in the knee. The patients were cautioned that they should not necessarily expect to return to highly competitive sports, particularly contact sports. Of forty-nine patients, forty three returned to a personal follow up evaluation. There were forty two males and one female with a mean age of 27 years (20 to 42 years). All but six patients had sustained the initial injury to the knee while engaged in sports activities viz., soccer 25, rugby 11, karate 1. Domestic injury accounted for five cases and industrial accidents 1. Twenty six patients were injured in recreational sports and 11 while engaged in competitive sports. Pre-operatively none of patients could return to sports because of instability of the knee. All 43 patients had, as their main complaint, multiple episodes of giving way of the knee. This was occasionally associated with pain and effusion. Only 3 patients remembered hearing a “pop” in the knee at the time of initial injury, and all three had a significant swelling developing within two hours of injury. Five patients had a menisectomy after the initial injury and before the index reconstructive procedure. None of these had any decrease in the episodes of instability after the menisectomy. All the patients had a positive Lachman, positive anterior drawer tests and a markedly positive pivot shift test.
Table 1: Nature of Injury • • • • •
Football Rugby Karate Domestic Industrial accident
The ACL was reconstructed in the chronic phase (>12 weeks from injury) in all cases. The interval between injury and index operation was 6 months -5 years, with an average time of 27 month.
• 20-25 years
16
• 25-30 years
18
• 30-35 years
06
• >35 years
03
Operative technique All the operations were carried out by the senior author (MNS) under general anaesthesia and tourniquet.
Table 3: Associated injuries • • • • •
Medial meniscus Lateral meniscus Osteochondritic lesion Fissuring of medial femoral condyle Osteoarthritic changes
20 8 3 1 10
METHODS Via a short midline vertical incision from upper patella to just below the tibial tubercle, a graft 9 or 10 mm wide was fashioned from the central third of the patellar tendon. Parallel bone blocks were taken in continuity from the tibial tubercle, 30 mm long, and the patella 25 mm long. An arthrotomy was made via the graft site with resection of the fat pad. Notchplasty was undertaken if required. A graft width hole was drilled over a guide wire from just medial to the tibial tubercle, emerging in the centre of the site of the tibial ACL attachment.
25 11 1 5 1
Table 2: Age
Immediately preceding the main reconstructive procedures, all patients had an examination under anaesthesia and arthroscopy. The medial meniscus was found torn in 20 patients and 8 patients had a torn lateral meniscus. Three patients had osteochondritic lesions over the lateral femoral condyle and one patient had fissuring of the lateral edge of the medial femoral condyle. Ten patients showed some degenerative changes localized mainly to patella and medial femoral condyle. Three patients had more than one associated pathology.
The isometric point was determined on the upper medial wall of the LFC in the intercondylar notch. From this, a blind tunnel of graft width was drilled to a depth equal to the length of patellar bone over a guide wire in the LFC. The graft was pulled upwards through the tibial tunnel and patellar block pulled snug in the blind ended femoral tunnel. The patellar block was secured by a 7 mm diameter interference screw. Following 90 degrees medial rotation of tibial block of the graft, it was secured using a 9 mm diameter interference screw. The joint was drained and closed. An accelerated rehabilitation programme has been adopted with continuous passive motion commenced on the first postoperative day, without plaster splintage but allowing protected movement with a simple hinged brace only for 6 weeks.
125
Apollo Medicine, Vol. 2, No. 2, June 2005
Original Article
Evaluation All patients were assessed by one examiner (MNS) using the evaluation of internal knee documentation committee. Anterior cruciate stability was assessed on an exclusively clinical basis using Lachman, anterior drawer and a pivot shifts tests. No arthometric testing or radiographic imaging was carried out.
indicating its site as patellar. Two patients had mild effusion and another 2 (those with grade 2 Lachman and anterior drawer tests) experienced episodes of partial giving way when turning suddenly. On subjective assessment by the patient, 41 knees were nearly normal (B) and another 2 were graded abnormal (C); none was graded grossly abnormal (D). Crepitus
Table 4: Clinical Graft Stability Grade
Lachman
Anterior drawer
Pivot shift
0 (<3mm)
10
10
40
1 (3-5mm)
31
31
02
2 (>5mm)
02
02
01
Thirteen patients were noted to have crepitus, 11 in the patello-femoral compartment and 2 medially. Table 5: Knee Score of Patients Score
The Lachman and anterior drawer tests were graded as 0 (<3mm laxity), 1 (3-5mm laxity) and 2 (>5mm laxity) and the pivot shift test as 0 (negative), 1 (glide), 2 (clunck) and 3 gross. Thigh atrophy and knee effusion were noted. In order to assess function, every patient had a Lysholm knee score calculated and activity scores before injury and at the time of evaluation were compared. RESULTS Knee stability: Ten patients showed grade zero laxity on Lachman and anterior drawer tests, while 31 patients showed grade 1. Further 2 patients showed grade 2 laxity, although the pivot shift test was positive grade 2 in only 1 of these. Activity score
•
91-100
22
•
81-90
11
•
71-80
7
•
70 or above
3
Graft site tenderness Eight patients had mild to moderate tenderness at the graft site. Quadriceps wasting Twenty nine patients had regained quadriceps bulk to within 2 cm, while 2 patients had wasting of 5 cm or more, while other 12 patients had equal bulk as compared to normal site. Knee test
Pre injury 31 patients had activity score of 5, 7 had a score of 7, while 5 patients achieved a pre-injury activity score of 9. Only 7 patients went back to same level of activity score while 36 patients had a reduction of activity score by 1. It is to be noted that the majority of these patients expressed a fear of re-injuring the knee again if they attempt a resumption of the same activity level; they nevertheless had demonstrably stable knees. Lysholm knee score: Scores varied from 70-95 with a mean of 80. Twenty seven patients score more than 84 indicating a good or excellent rating. Pain and difficulty on stair climbing and squatting were main reason for the drop in score. Range of movement Three patients had a 5 degree lack of full extension while all 43 patients had full flexion. Symptoms Nine patients complained of anterior knee pain, Apollo Medicine, Vol. 2, No. 2, June 2005
No. of patients
Twelve patients complaint of pain at the tibial tubercle on kneeling while 6 of these were also tender over the lingamentum patellae. COMPLICATIONS Three patients has superficial infections which resolved after oral antibiotics.Six patients had effusions, presumable haemarthroses,but none needed drainage.One patient had urinary retention in the post-operative period.One patient’s knee gave way 3 months after surgery in a fall while farming and an MRI scan confirmed disruption of the graft. DISCUSSION Patients with a functionally unstable knee due to anterior cruciate ligament deficiency have a high incidence of meniscal tears and degenerative changes.In our study the majority of ACL ruptures occurred in sports injuries, but a significant number also occurred in domestic and other accidents. We included only those patients who had functional instability during normal activity and not
126
Original Article
improving following a muscle and proprioceptive rehabilitation programme.
4. Noyes FR, Mooar PA, Mathews DS, Butler DL. The symptomatic anterior cruciate deficient knee. Part I. The long term functional disability in athletically active individuals. J Bone Joint Surg (Am) 1983; 65-A: 154-162.
Intra-articular reconstruction of the ACL was performed with the intention of eliminating the functional instability and also of preventing the onset or retarding the progression of degenerative osteoarthritis although recent studies cast doubt on latter. It is doubtful whether a truly isolated rupture of ACL exists. In our study 28 patients had meniscal injuries, 4 had chondral lesions while 10 showed some degenerative changes. Associated injuries of this nature have also been reported by Finsterbush, et al [20] and Daniel & Fithian [21] . The availability of magnetic resonance scanning in recent years has demonstrated extensive bone bruising as a frequent occurrence undetectable clinically and arthroscopically. In our study 41 patients had stable knee following reconstructive surgery with a grade 0 or 1 laxity on Lachman or anterior drawer tests. One patient with a grade 2 pivot-shift test and 1 of the 2 patients with a grade 1 experienced episodes of giving way; the second patient with the grade 1 pivot shift abnormality denied subjective instability of this nature. On assessment of activity scores, 36 patients (84%) had a drop of 1 level as compared to their pre injury estimates and only 7 (16%) return to their pre injury levels. Anterior knee pain and pain on kneeling were the main complaints among patients in our study. Nine had anterior knee pain and three others were unable to kneel. It is interesting to note that all 9 patients with knees in the most stable categories with negative Lachman, anterior drawer and pivot shift tests.
5. Kannus P, Jarvinen M. Conservatively treated tears of anterior cruciate ligament: long term results. J Bone Joint Surg (Am) 1987; 69-A: 1007-1012. 6. Hawkings RJ, Misamore GW, Merritt TR. Follow-up of the acute nonoperated isolated anterior cruciate ligament tears. Am J Sports Med 1986; 14: 205-210. 7. Engerbresten L, Benum P, Sundalsvol S. Primary suture of the anterior cruciate ligament: A 6-year follow-up of 74 cases. Acta Orthop Scand 1989; 60: 561-564. 8. Chick RP, Collins HR, Rubin BD, et al. The pes anserinus transfer: a long-term follow-up. J Bone Joint Surg (Am) 1981; 63-A: 1449-1452. 9. Bray RC, Flanagan JP, Dandy DJ. Reconstruction for chronic anterior cruciate instability: a comparison of two methods after six years. J Bone Joint Surg (Br) 1988; 70B: 100-105. 10. Olson EJ, Kang JD, Fu FH, et al. The biochemical and histological effects of artificial ligament were particles: in vitro and in vivo studies. Am J Sports Med 1988; 16: 558570. 11. Woods GA, Indelicato PA, Prevot TJ. The Goretex anterior ligament prosthesis: two versus three year results. Am J Sports Med 1991; 19: 48-55. 12. Grotvedt T, Engerbrestsen L, Benum P, et al. A prospective, randomised study of three operations for acute rupture of the anterior cruciate ligament: 5 year follow-up of 131 patients. J Bone Joint Surg (Am) 1996; 78: 159-168.
In conclusion, our results show that all but two patients had stable knee during both normal and recreational activities. Despite the achievement of stability there was a drop of 1 level in activity as compared to pre injury level. No patient had a significant loss of range of motion and 41 patients out of 43 patients were satisfied with the result. Anterior knee pain and inability to kneel were the main concerns in 28% of patients; the cause seems to relate to the patellar tendon graft site.
13. Jones KG. Use of the central one-third of the patellar ligament to compensate for anterior cruciate ligament deficiency. Clin Orthop 1980; 147: 37.
REFERENCES
16. Johnson RJ, et al. Current concepts reviews: The treatment of injuries of anterior cruciate ligament. J Bone Joint Surg (Am) 1992; 74-A: 140-151.
1. Solcum DB, Larson RL. Rotatory Instability of the knee, its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg (Am) 1968; 50-A: 211. 2. McDaniel WJ, Damoron TB. Untreated ruptures of the anterior cruciate ligament. J Bone Joint Surg (Am) 1980; 62-A: 696-705. 3. Arnold JAA, Coker TP, Heaton LM, Park JP, Harris WD. Natural history of anterior cruciate tears. Am J Sports Med 1979; 7: 305-313.
14. Clancy WG, Nelson DA, Reider B, et al. Anterior cruciate ligament reconstruction using one third of patellar ligament, augmented by extra-articular tendon transfer. J Bone Joint Surg 1982; 64-A: 352. 15. Amiel D, Klenier JB, Akeson WH. The natural history of the anterior cruciate ligament autograft of patellar tendon origin. Am J Sports Med 1986; 14: 449-462.
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