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Spontaneous rupture of the hamstring graft after anterior cruciate ligament reconstruction
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Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 9 (2017) 59e124
ACL patients had a malpositioned tibia tunnel. 43.1% had a malpositioned femoral tunnel, 31% had both malpositioned femur and tibia tunnels Given the high correlation between tibia tunnel placement and the ACL inclination angle, we believe that a good indicator for failure of ACL reconstruction surgery may also lie in the tibia tunnel positioning. Conclusion: Among the radiographic measurements available for tunnel placement after an Anterior Cruciate Ligament reconstruction surgery, the Amis and Jakob line has shown to be the most important assessment in determining graft inclination angle as well as potential for failure of surgery. Keywords: Revision, ACL, Amis Jakob, Radiographic, Anterior cruciate ligament, Failure
Knee - Ligament > ACL EP-072 SPONTANEOUS RUPTURE OF THE HAMSTRING GRAFT AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION Keisuke Kita 1, Hiroshi Amano 1, Ryohei Yoshinari Tanaka 1, Yoshiki Shiozaki 2, Yasukazu Yonetani 4, Shuji Uchida 2, Horibe 3. 1 Department of Sports Orthopedics, Osaka Rosai Hospital, Japan; 2 Department of Orthopedic Surgery, Seifu Hospital, Japan; 3 Department of Comprehensive Rehabilitation, Osaka Prefecture University, Japan; 4 Department of Orthopedic Surgery, Hoshigaoka Medical Center, Japan Objectives: A spontaneous ACL graft rupture without an apparent trauma has been seen in some clinical cases with long-lasting ACL deficiency. One possible cause of the graft rupture is preoperative anterior tibial subluxation. This study aimed to reveal the rate of spontaneous graft rupture on MR images according to preoperative time, as well as the effects of preoperative anterior tibial subluxation on the rupture. Our hypothesis was that cases with long-term ACL deficiency would have the highest rate of spontaneous graft rupture and that greater preoperative anterior tibial subluxation would affect the graft morphology on postoperative MR images. Methods: Three hundred and fifty-eight patients who underwent anatomic ACL reconstruction with the hamstring tendon graft were included in this study. All cases were divided into five groups according to their preoperative time from the primary injury (group A, 228 cases, 0-6 months; group B, 27 cases, 7-12 months; group C, 27 cases, 13-24 months; group D, 31 cases, 25-60 months; and group E, 45 cases, over 60 months). The ACL grafts in all cases were examined by MRI at 6 months and classified as ‘intact’ or ‘ruptured’ according to morphology on MR images, followed by assessment of rate of the graft rupture in each group. For evaluation of the tibiofemoral relationship, strictly lateral radiographs in the fully extended position were used. On lateral radiographs, the radiographic variables which included anterior tibial subluxation (ATS) and side-to-side difference of space for the ACL (sACL-SSD) were measured, before and immediately after reconstruction. The sACL was defined as the distance between the tip of the tibial eminence and the Blumensaat line. The Wilcoxon rank sum test was used to assess differences among groups with respect to continuous variables. The level of significance was set at P < 0.05. Results: Spontaneous graft rupture without an apparent trauma was seen in four (1.8%) in group A, zero (0%) in group B, one (3.7%) in group C, three (9.7%) in group D, and eight (17.8%) in group E. In cases with the spontaneously ruptured graft, preoperative ATS and sACL-SSD were significantly larger in group D (5.0 and 3.3 mm) and E (4.4 and 4.9 mm) than those in Group A (1.0 and 1.2 mm) while immediately postoperative ATS and sACLSSD were not different among the groups. And then, four cases who had rupture in group A had high Tegner activity scale and seemed to have poor compliance with rehabilitation program. Conclusion: The ACL-deficient knees for over 60 months had the highest rate of spontaneous graft rupture. The preoperative sACL-SSD and the ATS seemed to affect the morphology of the graft at 6 months postoperatively in cases with long-term ACL deficiency. Although the tibia might be posteriorly over-constrained immediately after ACL reconstruction with the hamstring graft, in cases of ACL-deficient knees for more than 24 months, ATS and sACL-SSD over 5 mm should be paid attention to consider the
modification of perioperative management of knees or graft source. Keywords: Long-lasting ACL deficiency, Spontaneous graft rupture, Anterior tibial subluxation, Space for the ACL
Knee - Ligament > ACL EP-073 COMPARTMENT SYNDROME AFTER ARTHROSCOPIC JOINT RELEASE FOR STIFFNESS FOLLOWING ACL RECONSTRUCTION INFECTION: A CASE REPORT Qingxiang Hu, Yaohua He, Qingxiang Hu, Weihan Yu. Department of Sports Medicine, Shanghai No. 6 Hospital, China Background: Arthroscopic joint release could be employed to improve range of motion (ROM) of patients suffered from joint stiffness after anterior cruciate ligament (ACL)-reconstruction-associated infection. Arthroscopic joint release, a relatively safe procedure, may present with various complications including bleeding, infection and even compartment syndrome. We present this case of a patient who developed compartment syndrome after arthroscopic joint release. Case Report: A 33-year-old female, complaining about pain and instability of the right knee following exercise, visited Shanghai No.6 Hospital in 2015. A physical examination showed positive anterior drawer and Lachman tests. Preoperative X-rays did not show any definite bony abnormalities. The magnetic resonance imaging (MRI) showed total rupture of ACL, medial meniscus tear, corpus liberum and intercondylar fracture. An arthroscopic surgery including anatomic single-bundle ACL reconstruction, meniscus repair and joint debridement was performed one month after her initial visit. Five days after the initial surgery, the patient complained about fever, pain, swelling in right knee, and restricted ROM. Erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count were elevated. MRI reported postoperative change with synovial fluid and surrounding tissue swelling. The patient was diagnosed with ACL reconstruction infection and prescribed with antibiotics. The patient’s knee pain and swelling unrelieved, an arthroscopic debridement surgery and an open debridement surgery were performed separately on the 11th day and 25th day after the initial ACL reconstruction. During the open debridement surgery, a distal extension of the incision was performed for another 4 cm and necrotic tissue was cleaned up. Compression screw for tibial tunnel was also removed and sent for microbe detection, which later reported a positive culture of methicillin-resistant Staphylococcus aureus. After the open debridement surgery, antibiotic use was adjusted according to microbe detection and rehabilitation program was started timely by professional physician. 33 days after the open debridement surgery, the patient was discharged and continued anti-infection treatment and rehabilitation at home. 8 months later, the patient paid another visit to us complaining about the restricted ROM and poor rehabilitation. A physical examination showed a ROM of 0-0-20. MRI showed postoperative change with bone marrow swelling and healed reconstructed ACL. After a thorough evaluation, an arthroscopic joint release and internal fixation removal was performed. On the first morning after the operation the patient complained about pain and swelling in the right foot. No abnormality in active flexion or sensation was discovered in the physical examination. The pulses were palpable around her right ankle. The physician thought that postoperative tissue swelling could account for the complaints and gave the prescription of Celecoxib. However, the pain and swelling of the right foot was not relieved that night. The third toe on the right foot turned purple and sensory deficit was present. Deep vein thrombosis was suspected. Fraxiparine was prescribed for anticoagulation and mannitol for the swelling. Ultra sound found no blood flow in anterior tibial artery, dorsalis pedis artery, dorsal metatarsal artery and arteria digitalis. In addition, fluid was found between subcutaneous soft tissue and hyperechoic muscles, indicating compartment syndrome. A decompression surgery was given the next day morning. Three 5 cm longitudinal incisions were made along the midline between fibula and tibial crest, exposing and decompressing the anterior and lateral compartment, and superficial peroneal nerve in the lower 1/3 of the limb. Another three 5 cm longitudinal incisions were
Abstracts / Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology 9 (2017) 59e124
ACL patients had a malpositioned tibia tunnel. 43.1% had a malpositioned femoral tunnel, 31% had both malpositioned femur and tibia tunnels Given the high correlation between tibia tunnel placement and the ACL inclination angle, we believe that a good indicator for failure of ACL reconstruction surgery may also lie in the tibia tunnel positioning. Conclusion: Among the radiographic measurements available for tunnel placement after an Anterior Cruciate Ligament reconstruction surgery, the Amis and Jakob line has shown to be the most important assessment in determining graft inclination angle as well as potential for failure of surgery. Keywords: Revision, ACL, Amis Jakob, Radiographic, Anterior cruciate ligament, Failure
Knee - Ligament > ACL EP-072 SPONTANEOUS RUPTURE OF THE HAMSTRING GRAFT AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION Keisuke Kita 1, Hiroshi Amano 1, Ryohei Yoshinari Tanaka 1, Yoshiki Shiozaki 2, Yasukazu Yonetani 4, Shuji Uchida 2, Horibe 3. 1 Department of Sports Orthopedics, Osaka Rosai Hospital, Japan; 2 Department of Orthopedic Surgery, Seifu Hospital, Japan; 3 Department of Comprehensive Rehabilitation, Osaka Prefecture University, Japan; 4 Department of Orthopedic Surgery, Hoshigaoka Medical Center, Japan Objectives: A spontaneous ACL graft rupture without an apparent trauma has been seen in some clinical cases with long-lasting ACL deficiency. One possible cause of the graft rupture is preoperative anterior tibial subluxation. This study aimed to reveal the rate of spontaneous graft rupture on MR images according to preoperative time, as well as the effects of preoperative anterior tibial subluxation on the rupture. Our hypothesis was that cases with long-term ACL deficiency would have the highest rate of spontaneous graft rupture and that greater preoperative anterior tibial subluxation would affect the graft morphology on postoperative MR images. Methods: Three hundred and fifty-eight patients who underwent anatomic ACL reconstruction with the hamstring tendon graft were included in this study. All cases were divided into five groups according to their preoperative time from the primary injury (group A, 228 cases, 0-6 months; group B, 27 cases, 7-12 months; group C, 27 cases, 13-24 months; group D, 31 cases, 25-60 months; and group E, 45 cases, over 60 months). The ACL grafts in all cases were examined by MRI at 6 months and classified as ‘intact’ or ‘ruptured’ according to morphology on MR images, followed by assessment of rate of the graft rupture in each group. For evaluation of the tibiofemoral relationship, strictly lateral radiographs in the fully extended position were used. On lateral radiographs, the radiographic variables which included anterior tibial subluxation (ATS) and side-to-side difference of space for the ACL (sACL-SSD) were measured, before and immediately after reconstruction. The sACL was defined as the distance between the tip of the tibial eminence and the Blumensaat line. The Wilcoxon rank sum test was used to assess differences among groups with respect to continuous variables. The level of significance was set at P < 0.05. Results: Spontaneous graft rupture without an apparent trauma was seen in four (1.8%) in group A, zero (0%) in group B, one (3.7%) in group C, three (9.7%) in group D, and eight (17.8%) in group E. In cases with the spontaneously ruptured graft, preoperative ATS and sACL-SSD were significantly larger in group D (5.0 and 3.3 mm) and E (4.4 and 4.9 mm) than those in Group A (1.0 and 1.2 mm) while immediately postoperative ATS and sACLSSD were not different among the groups. And then, four cases who had rupture in group A had high Tegner activity scale and seemed to have poor compliance with rehabilitation program. Conclusion: The ACL-deficient knees for over 60 months had the highest rate of spontaneous graft rupture. The preoperative sACL-SSD and the ATS seemed to affect the morphology of the graft at 6 months postoperatively in cases with long-term ACL deficiency. Although the tibia might be posteriorly over-constrained immediately after ACL reconstruction with the hamstring graft, in cases of ACL-deficient knees for more than 24 months, ATS and sACL-SSD over 5 mm should be paid attention to consider the
modification of perioperative management of knees or graft source. Keywords: Long-lasting ACL deficiency, Spontaneous graft rupture, Anterior tibial subluxation, Space for the ACL
Knee - Ligament > ACL EP-073 COMPARTMENT SYNDROME AFTER ARTHROSCOPIC JOINT RELEASE FOR STIFFNESS FOLLOWING ACL RECONSTRUCTION INFECTION: A CASE REPORT Qingxiang Hu, Yaohua He, Qingxiang Hu, Weihan Yu. Department of Sports Medicine, Shanghai No. 6 Hospital, China Background: Arthroscopic joint release could be employed to improve range of motion (ROM) of patients suffered from joint stiffness after anterior cruciate ligament (ACL)-reconstruction-associated infection. Arthroscopic joint release, a relatively safe procedure, may present with various complications including bleeding, infection and even compartment syndrome. We present this case of a patient who developed compartment syndrome after arthroscopic joint release. Case Report: A 33-year-old female, complaining about pain and instability of the right knee following exercise, visited Shanghai No.6 Hospital in 2015. A physical examination showed positive anterior drawer and Lachman tests. Preoperative X-rays did not show any definite bony abnormalities. The magnetic resonance imaging (MRI) showed total rupture of ACL, medial meniscus tear, corpus liberum and intercondylar fracture. An arthroscopic surgery including anatomic single-bundle ACL reconstruction, meniscus repair and joint debridement was performed one month after her initial visit. Five days after the initial surgery, the patient complained about fever, pain, swelling in right knee, and restricted ROM. Erythrocyte sedimentation rate (ESR) and white blood cell (WBC) count were elevated. MRI reported postoperative change with synovial fluid and surrounding tissue swelling. The patient was diagnosed with ACL reconstruction infection and prescribed with antibiotics. The patient’s knee pain and swelling unrelieved, an arthroscopic debridement surgery and an open debridement surgery were performed separately on the 11th day and 25th day after the initial ACL reconstruction. During the open debridement surgery, a distal extension of the incision was performed for another 4 cm and necrotic tissue was cleaned up. Compression screw for tibial tunnel was also removed and sent for microbe detection, which later reported a positive culture of methicillin-resistant Staphylococcus aureus. After the open debridement surgery, antibiotic use was adjusted according to microbe detection and rehabilitation program was started timely by professional physician. 33 days after the open debridement surgery, the patient was discharged and continued anti-infection treatment and rehabilitation at home. 8 months later, the patient paid another visit to us complaining about the restricted ROM and poor rehabilitation. A physical examination showed a ROM of 0-0-20. MRI showed postoperative change with bone marrow swelling and healed reconstructed ACL. After a thorough evaluation, an arthroscopic joint release and internal fixation removal was performed. On the first morning after the operation the patient complained about pain and swelling in the right foot. No abnormality in active flexion or sensation was discovered in the physical examination. The pulses were palpable around her right ankle. The physician thought that postoperative tissue swelling could account for the complaints and gave the prescription of Celecoxib. However, the pain and swelling of the right foot was not relieved that night. The third toe on the right foot turned purple and sensory deficit was present. Deep vein thrombosis was suspected. Fraxiparine was prescribed for anticoagulation and mannitol for the swelling. Ultra sound found no blood flow in anterior tibial artery, dorsalis pedis artery, dorsal metatarsal artery and arteria digitalis. In addition, fluid was found between subcutaneous soft tissue and hyperechoic muscles, indicating compartment syndrome. A decompression surgery was given the next day morning. Three 5 cm longitudinal incisions were made along the midline between fibula and tibial crest, exposing and decompressing the anterior and lateral compartment, and superficial peroneal nerve in the lower 1/3 of the limb. Another three 5 cm longitudinal incisions were