Printer Friendly

COMPLICATIONS OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTIONS/KOMPLIKACIJE REKONSTRUKCIJE PREDNJE UKRSTENE VEZE.

Introduction

Anterior cruciate ligament (ACL) injury was the main reason for ending a sport's career fourty years ago because it presents the beginning of the end of knee joint due to its instability [1, 2]. As arthroscopy and operative techniques developed ACL reconstructions provided excellent results without many complications of: bleeding, infection, scarf tissue, reduced operative time and allowed early rehabilitation [3]. The choice of graft for ACL substitution is also reduced into two most often used autografts: bone-pattelar tendon-bone (BTB) [4] and hamstring tendons [5]. Allografts are not abandoned but rarely used nowadays [6]. Drilling the femoral tunnel through anteromedial portal is substituting former transtibial way, which can not provide the anatomic position (footprint) and results with instability [7, 8]. Authors satisfied with a single-bundle technique [5, 9, 10] still want to achieve developement, expecially in the field of graft fixation. One of those attempts represents a hybrid fixation of bone-hamstring tendons-bone graft with additional screw in tibia [9, 10]. A few decades ago it seemed logical that ACL reconstructions can prevent degenerative changes in knee joint, but later studies did not comfirm it [2], althought they can: restore knee stability, reduce later meniscal injuries, provide return to sports activities and improve the life quality of patients [9, 11, 12]. Dilemma still preasent is does double-bundle technique provide rotatory stability [13] and significantly better results than single-bundle technique [14]. Some authors achieved better rotatory stability with additional reconstruction of antero-lateral ligament [5]. Questionable are also ideal timing for operation [15] and the choice of rehabilitation protocol [16].

Reconstruction of ACL is very popular procedure, because the success rates between 80 and 90% of all operations [1, 4, 8, 17], with small percents of complications [1, 4, 5, 8, 17]. The number of patients with complications increases as it increases the number of operations proportionally. Various factors have been associated with failure after a primary ACL surgery and are divided into [4]:

--preoperative [15, 16]: improper diagnosis, poor indications, improper preoperative range of motion, improper surgical timing, failure to prepare for concomitant procedures, failure to note concurrent diagnoses;

--intraoperative [8, 18]: improper graft choice, graft harvest errors, inadequate notchplasty, improper tunnel placement, femoral tunnel blowout, dropped graft, graft laceration, graft-construct mismatch, screw-tunnel divergence, improper tensioning, inadequate graft fixation;

--postoperative [8, 19]: infection, loss of motion/stiffness, extensor mechanism failure, graft failure, patellar pain, deep venous thrombosis/pulmonary embolus.

The aim of this study was to: compare the complications of ACL reconstructions between different grafts, analyse treatment and prevention possibilities, because those complications can compromise the final operative results and decrease the life quality of patients.

Material and Methods

We used a retrospective multicentric study to follow postoperative results and complications on 210 patients. BTB graft was used in 175 patients while 35 of them had reconstruction with bone-hamstring tendons-bone (BHB) graft. The same surgeons operated both groups of patients.

All reconstructions were performed through anteromedial portal with attention to achieve isometric characteristics of ACL and anatomic position on footprint. Single bundle autografts were fixed by interference screws and tensioned with force of 80 N. There was no significant difference between groups considering age, but there was resuming the level of sports activities. We reconstructed ACL with hamstring tendons in women and some recreative sportsmen, while BTB graft was used in all professional athletes.

The second generation of cephalosporins (or clindamycin in cases of panicillin allergy) was used as antibiotic profilaxis, preoperatively and two days postoperatively [20]. If infection occured the most often used antibiotic was vancomycin, according to bacteria cultures after the aspiration of knee joint. We did not use thromboprophylaxis as a routine. The hospitalization time of patients without complications lasted 5-7 days, while in cases of infections it was three weeks on average. Modified Shelbourn's rehabilitation protocol [16] was used in all of cases.

The average age was 27.4 years (15-54). We operated 7 times more often men than women (183:27). The follow up was 2.0-6.5 years (3.2 on average).

Sports activities caused 87% of all ACL ruptures (182 patients), while 28 (13%) were injured mostly during traffic accidents and other every day activities. Concidering level of sports activities, 103 athletes (56.6%) were recreational ones, while active in sports clubs were 79 (43.4%) of them. Soccer is sport that caused twoo thirds of all injuries - 120 (66%). The second is basketball 11 (6%), then volleyball 9 (5%), martial arts and skiing both 8 (4.4%), handball 6 (3.3%), american football 3 (1.7%) and others in minor percentage.

Right knee was operated in 106 patients, left in 101, while three patients had nonsimultaneously bilateral ACL reconstructions. Four years pasted on average between the first and the second ACL reconstructions.

Anterior cruciate ligament was the only injured structure of knee joint in 108 cases (51%), 53 (25%) had rupture of medial meniscus; 48 (24%) of medial colateral ligament; 38 (19%) had serious cartilage damage; 15 (7.5%) lateral meniscus; both menisci were ruptured in 7 (3.5%) of cases; lateral colateral ligament in 12 (6%). We also performed one posterior cruciate ligament reconstruction.

The average period that lasted from injury to operation was 9.5 months (3 weeks to 17 years), because patients spent too much time on: first examination, diagnostics, waitings lists and postponed operation. More than 60% of them (mostly active athletes) were operated within the first four months after injury.

Our study included subjective symptoms and clinical examination: range of motion and functional tests. The basic criteria for failure of operation were: postoperative instability (positive Lachman test over 6 mm in comparison to uninjured knee and positive pivot shift test) [21], or persistant swelling, pain and limited Range of motion (ROM) that unabled the patient to return to the level of activities he/she had before the injury.

We analyzed the position of bone tunnels and screws by X-rays with Staubli's and Rauschning's [22]. The best results were achieved if femoral tunnel was not vertical and placed as much posteriorly.

The results were showed by modified Knee Ostedoarthritis Outcome Scale questionnaire set (KOOS) and Lysholm scores [23]. Patients filled as questionnaire sets. The KOOS questionnaire is divided into five parts: the first involves the quality of life following ACL surgery; the second one related to pain in different activities; the third is related to daily activities performed by the patient; the fourth is related to the level of physical activity, (Lysholm score), the fifth focuses on the very consciousness of the patient's quality of life and how he perceives injury.

This study excluded those patients who did not fill the questionnaire and undergone rehabilitation protocol.

All of complications were devided [24] into: intraoperative (connected to surgical technique and instruments) and postoperative. During the first three postoperative days we also followed the complications connected to anesthesia. Later on connected to improper surgery, rehabilitation, new trauma etc. Complications are analyzed, compared between groups and showed by tables and figures. We also showed the our possibilities of prevention and treatment.

Results

We registered some of the complications in 19 patients (9%). There was no big difference between different graft groups (8.6% BTB vs. 11.4% BHB group) (Table 1).

Early postoperative complications are shown by Table 2. Patients with general anesthesia had significantly less complications, although they had severe pain in operated knee. Patients with spinal anesthesia more often had blader disfunction and headache.

We registered excellent position of bone tunnels in 151 case (71.9%), good in 57 (27.1%), while only in 2 cases (1%) intolerant (too anterior) .As we tried to achieve as much posterior position of femoral tunnel, we also had a complication of perforation of posterior femoral cortex (Figure 1).

Intraoperative complications where the choice of graft did not have influence are also presented (Figure 2). They were connected to breakage of instruments (one case of drill's and guide's breakage) and one case of dropping the graft on the floor of operation room (with no infection).

The criteria for postoperative contracture of knee joint was limited ROM: flexion more than 20 degrees and extension more than 5 degrees. Five patients had stiffness. This complications occurs if they delayed operation 17 years after the injury, so proper ROM could not be achieved.

The most common complications were infection (2.9%) and graft's rupture (2.4%). Infection happened in 6 cases. Staphylococcus aureus was isolated three times, Staphylococcus epidermidis or lungdunensis, Klebsiela and Enterococcus once. One patient had obvious infection although bacteria was not found. All of the infections had symptoms within the first 10 days after the reconstruction, with: increased laboratory values of C-reactive protein (over 150), severe knee pain and increased body temperature. We treated them with urgent aspiration, irrigation, drainage and three weeks with antibiotics, untill symptoms disappeared and CRP decreased to physiological values. Infections were managed by continuous irrigation and suction drainage in four cases. Five out of six (83%) of them were treated successfuly, but scores were lower (87 points on average).

We had to perform a revision surgery with graft substitution in 2.5% of cases. There were two cases of graft failure with unknown reasons among five patients. One of them did not want to be reoperated so he stopped with sports activities. The reasons for graft failure were: new trauma in two cases (although one patient participated a forbidden competition three months postoperatively) and too anterior femoral tunnel also in twoo cases (Figure 3). There was also a case of graft failure after treatment of infection. This resulted with instability so graft had to be removed and substituted with BTB graft from another knee. All of these patients had later return to sports activities (more than 9 months after revision).

Beside graft failure, the reasons for reoperations were: 6 mentioned infections, two arthroscopic treatment of cyclops lesions (Figure 4) and isolated cases of extraction of loose body (because of improper notch plasty) and open reduction and internal fixation of patellar fracture, one month after BTB reconstruction (Figure 5).

Our patients had no complications such as: graft's impigemente, patellar's tendon rupture, maior vascular injuries and compartment syndrome. The worst outcome was in case of algodystrophic syndrome.

The functional scales showed significantly less points in patients with complications (average Lysholm score 89.0, KOOS 88.2) in comparison to patients without them (Lysholm 93.8 points, KOOS 95.1).

Seventy three percent of patients (153) has returned to non-restricted (sports) activities, while 52 (27%) has not. The objective reasons were: five cases of postoperative instability, pain and swelling in 11, limited flexion in twoo, limited extension in three and muscular weekness in twoo cases. Other 29 patients were not unsatisfied with operation result but they chainged their life style or they are afraid of new injury and operation. Return to every-day activities happened 6.5 months on average (3-12).

Discussion

The basic aims of ACL reconstructions are restoring of knee stability and returning to life activities on the level as it was before injury [1, 3, 5, 11, 12, 25]. This operative procedure is unsuccessful if knee joint is postoperatively unstable or stable but with limited ROM, pain or swelling [25]. The main reasons for reccurent instability are: surgical technique, problems connected with graft and other complications, while some of them remain unknown [8].

All of our reconstructions were performed with single-bundle technique. Yagi et al. [13] concluded that advantage of double-bundle is in 97% of restauration of anterior tibial translation, versus 89% in single-bundle; with rotator stability even higher 91%:66%. Despite this study, others [5, 26] did not find statistic difference between those techniques. Drilling twoo tunnels in both bones, difficult operation, expecially revisions, can compromise theoretic advantages of double-bundle technique. A group of French authors [5] tried to achieve rotatory stability in another way. They performed a combination of ACL reconstruction with antero-lateral ligament (ALL) at 83 patients and concluded that additional ALL reconstruction two years after operation provided discrete positive pivot shift test only in 7 patients while 76 of them had negative test. These authors claim that this operation provides better rotatory stability than double-bundle operation which also has more complications of cyclops lesia [26]. So, the first promising experimental double-bundle results [13] are not varified in praxis. According to Swedish National Register, that included 16.791 operated patients, there was no statistic difference between single and double-bundle techniques concidering KOOS scale and revision rates [14].

Mid third of patellar tendon with bone plugs (BTB) for a long period of time happened to be the golden standard for ACL reconstuction, but nowadays semitendinosus et gracilis tendons are more often in use [5, 26]. Hamstring tendons are popular as graft because of lower morbidity in the place of harvesting, decreasing anterior knee pain and extensor apparatus rupture [27]. Experimental advantage of BTB graft in strenght is not present if tendons are quadrupled [26, 27]. Hamstring graft has also some disadvantages. Potential complications such as: bone tunnel enlargement [27], problems with graft fixation [9, 10] and weekness of posterior thigh muscle group are registered. Since 2007 it was developed a method of hybrid fixation of hamstring tendons with the attention to improve the results and reduce the complications of graft tensioning [9, 10]. That method was also used at some of our patients but we used more often BTB graft because of it's more uniformed results [17]. We indicate patellar tendon's graft in all sports active patients, while hamstring graft at women recreational patients and some professions with a lot of kneeling (automechanics, priests etc.).

The graft can be fixed with many invented devices, but we fixed it with domestic, titanium interference screws which caused no problems neither graft damage. Although they are the cheepest, there is no difference in knee stability between bioabsorbable and metallic screws [28]. Swelling and allergic reactions are less common after methal screws, while advantage of absorbable is easier postoperative MRI diagnostics [11, 36]. We did not register a signifficant difference between different graft's groups concidering complication rates (9:11%), neither in operative results (Lysholm scale BTB 93.9 points, BHB 93.1), which is similar to other results [1, 8, 17, 29].

Advantages of BTB graft are initial strenght and possibility of rigid fixation because of it's consistance of bone parts, why it is more often used in revision cases. We prevented potentional disadvantages of BTB graft in the following way:

--extensor mechanism's weakness was prevented with early mobilisation and passive extension during rehabilitation;

--patellar tendon's rupture did not happen in our study. Milankov et al. [30] had four cases among 2.215 BTB operations (0.18%). This complication can be prevented with adequate: harvesting of graft, sutures of tendon's sheath and avoiding local infiltrations of corticosteroids;

--patellar fracture had one of our patients (0.6%). It can be prevented with gentle harvesting with blade positioning 45 degrees over the patella. Other authors [31] had similar complication rate (0.45%) on much bigger specimen (10 cases out of 2.215 BTB operations).

--The advantages of STG graft are: less time needed for wound closure, small scarf, less painful place of harvesting tendons and possibility of use in doublebundle technique. We prevented potentional disadvantages of hamstring graft in the following way: - weak tibial fixation - with tendons harvesting with tibial periost and incorporation of cancellous bone [9];

--graft's strenght--with both tendons quadruppled and tensioning with the third screw (second in tibiahybrid fixation);

--weakness of knee flexor muscles--with rehabilitation. Within two years after the operation patients do not have limited flexion also because of MRI varified regenerative possibility of hamstring tendons [32].

All of the factors that cause complications of ACL reconstructions are also devided into [33]: nonspecific (general) and specific. Nonspecific are: temporary anesthesiological, vascular and nerve injuries, infection, trombosis, algodystrophic syndrome etc.

Postoperative complications connected to anesthesia, similar to ours were registered by some other authors [34]. General anesthesia cause less bladder disfunction, dizziness and haedache, so we prefer it during the ACL reconstructions.

Blood vessels injuries are very rare. Insall et al. [33] published two cases of popliteal artery injuries, because improper operative techniques. Milankov et al. [31] had a rare case of medial inferior genicular artery's false aneurism.

Nerve injuries (n. saphenus i n. peroneus) are also rare and often temporary. They are usually caused if reconstruction lasts more than twoo hours under a turnique. We did not have this complication.

Haemathoma occurs because of injury of geniculate artery or vein or as a consequence of bleeding from bone tunnels. Prevention is adequate hemostasis and placing the wax on bone harvested places. Amount of wax layer should be thin because of potential granulomatosis reaction. The blood in knee joint (haemarthros) is common but temporary complication prevented by intraoperative drains and treated with postoperative punctions.

Extravasation of solution for arthroscopy can lead to compartment syndrome because leeking a fluid through holes in bursa and injured capsula. Knee joint should be flexed during the operation because flexed knee receive less fluid than extended.

Increased pressure of arthro-pump can also cause extravasation. Swelling most often dissapears within 4 weeks. If synovitis persists more than 6 months it is the complication connected with cartilage and menisci damage.

Infection is a rare complication in ACL reconstructions with autografts. The prevalence of septic arthritis after those operations has been reported to range from 0.15% to 6%, mostly under 2% [19, 35-40]. Infection can be acute (most often caused by Staphylococcus) or chronic (after 6 weeks). Some authors [35, 36], also had 6 cases of infections (2%), that happened more often in hamstring group. Staphylococcus was bacteria that caused around twoo thirds of all infections [19, 35-40]. We were lucky because our patients did not have Methicillin Resistent Staphylococcus aureus (MRSA). We successfuly treated infections with: aspiration, continual irigation, drainage and antibiotics according to antibiogram, but some grafts must be removed because of impregnation with purulent exudation [35-40]. The same authors [35-40] suggest that graft's extraction should be in following cases: if therapy is delayed, when graft is infected and cartilage is seriously damaged, when therapy efect is not satisfied, when bacterial cultures are persistently positive or infection can be spread if graft is not removed. Infection can be very serious complication expecially if we do not know a proper antibiotic, when bacterial culture is sterile although clinical signs are evident.

Risk population groups for septic arthritis after ACL reconstructions are: professional athletes, allergic to penicillin with immunosuppressive diseases [19]. Some researches [39] showed that the prevalence of septic arthritis was 5.7% in the professional athlete population (88 of 1957 totally oparated). Our results also showed that active sportsmen are risk population for infection, by unknown reason. Preventive measures that should be performed are: aseptic preoperative treatment of operative field, aseptic conditions in operative rooms, irrigation of grafts before its placement in bone tunnels, experience of surgeon in early recognising and proper antibiotics. We registered more infections than it is expected (2.9%), similar to Yasen et al. [1], because we did not use all of mentioned measures. There are some evidences that 12% of microbiological examined grafts are initially contaminated, mostly with Staphylococcus [38], so we irrigated grafts before placement in bone tunnels. A group of Australian authors recently published no infections in 1300 ACL reconstructions with vancomycin pre-soaking of hamstring grafts [42]. There are also published incidents of dropping the graft during the operation [19, 38] and study [41] that surveyed leaders in sports medicine who perform ACL reconstructions to determine the preferred management when graft contamination occurs. Fortynine of 196 (25%) surgeons reported at least one contamination during their career. Forty-three of the 57 (75%) contaminated grafts were managed with cleaning of the graft and proceeding with reconstruction, like we did. Ten (18%) were managed by harvesting a different graft, and 4 (7%) were substituted with an allograft. No infections in any of the contaminated grafts were reported because cultures do not correlate with clinical infections. If operative time lasts longer than 90 minutes those patients had three times more risk for infection [19].

Algodystrophic syndrome is also rare (0-0.4%) [1, 8] but serious complication because these patients have severe pain, vascular, nerve, trophic changes and limited ROM. We registered an isolated case in hamstring group, treated with redressement force, drugs and rehabilitation procedures.

Deep vein thrombosis (DVT) happen to be rare complication because the majority of patients are young healthy athletes (with average age of 27 years). We used thromboprophylaxis only in risk patients and registered one isolated case of pulmonar thromboemboly one month after the reconstruction with good outcome. A group of researchers from India [43] had twoo similar cases out of 112 patients, while Cullison et al. [44] one among 67. The most of authors do not recommend routine thromboprophylaxis [8, 17, 18, 43, 44], but there are some who claim that even five days of intrahospital thromboprophylaxis is not enough and that extended duration postdischarge therapy for 20 days only significantly reduces the incidence of DVT [45]. We do not agree because of increasing bleeding in knee joint and delayed rehabilitation.

Limited Range of Motion (LROM) and Patellofemoral Pain

The incidence of stiffness and pain after ACL reconstruction are very different in literature. While Shelbourne and Urch [46] indicated reintervention because of limited knee extension only at 1% of patients, Kartus et al. [47] on similar specimen of 604 patients had 13% of reinterventions. The majority of modern studies [1, 8, 17, 18, 46] did not register significant postoperative anterior knee pain and LROM. Some thirty years ago [47] there were published even 34% cases of anterior pain in BTB groups. In our study there was 5 cases of stiffness (2.5%). Some other authors [48] registered in 19% correlation between pain and flexion contracture. However, the majority of studies demonstrated no significant difference in range of motion following either BTB or ST reconstruction [20, 37, 38, 45, 46]. Limitation of extension used to be a problem after ACL reconstruction, particularly when using the patella tendon, but now, with early mobilization and passive full extension, the problem is minimized [48]. If it occurs despite propriate rehabilitation, arthroscopic surgery should be performed. The area of the scar should be identified and resected with a motorized shaver. The scar is usually anterior; if necessary, a notchplasty is done to regain extension. After the procedure, manipulation should release any extra-articular adhesions. Finally, if the motion is not complete after manipulation, the ACL graft should be removed. It is important to achieve the full range of motion desired while on the table since range of motion will not significantly improve with postoperative therapy [8, 29, 35].

Arthrofibrosis is defined as the presence of scar tissue in at least one compartment of the knee joint, leading to a decreased range of motion. Localized anterior arthrofibrosis, called "cyclops" lesion ranges from 4 to 35%, mostly under 10% [49, 50], as we had (only 1%). The worst complication that we registered was in BHB group, where a patient had LROM after arthrofibrosis with the following Sudeck's syndrome. Redressement force under anesthesia and rehabilitation did not provide an adequate result. Shelbourne et al. [49, 50] noticed that arthrofibrosis happens more often at patients operated within the first three weeks after the injury, as it was in our mentioned case. That was the reason why we waited for ACL reconstruction at least three weeks after the injury. If we rush into surgery too quickly, before patients get their motion back in the knee and swelling is reduced, a stiff knee may result. Some authors agree with that [49, 50], some do not, expecially nowadays, when there are published excellent outomes even if reconstruction is performed in first week after ACL injury [1, 29]. We can not have influence on the timing of operation if some patients come to be operated 17 years after the injury, with: global instability, osteoarthritis, muscle weakness and meniscus injuries. So, preoperative condition of knee joint have more influence on this complication than timing of operation [15]. Former dilemma concidering too much stretching of graft and possible rerupture because of aggressive rehabilitation are not proved [49]. Although, rehabilitation can not compensate a poor operation, which can leed to graft's impigemente in femoral notch [49]. This happens if it is positioned too verticaly or anterior, after transtibial technique. The outcome is instability and rerupture. The prevention is femoral tunnel drilling through anteromedial portal, so we achieved anatomic position on footprint without such complication.

Reinterventions

Getelman et al. [6] concluded that the reason for 15% unsatisfied ACL reconstructions lies in: unrecognized colateral ligament injuries, development of rotatory instability, varus or valgus deformity or former meniscectomies. Early complications may occure within the first six months after the operation. They are mostly result of operation's techique, problems of graft's incorporation or too aggresive rehabilitation.

Late complications are caused by new trauma if a patients had full ROM and stabile knee. This happens at 5-10% of athletes [1, 25] and results with swelling and recurrent instability. Mistakes during the surgery are the most common cause of postoperative instability and non-anatomic position of graft in 70-80% of cases is the cause of bad outcome [8, 21, 50]. Improper tunnel position leeds to big changes of graft's tensioning during knee movements. The most common mistake is too anteriorly positioning a tunnel in femur. In that case, screw does not present too big problem during the revision, so it should not be extracted. There is enough space for a revisional screw (Figure 3). On the contrary, extraction of titanium screws can be a problem during the revisions when initial screw is good positioned. As we tried to achieve as much posterior position of femoral tunnel, sometimes without femoral guide (free hand), we had a complication of perforation of posterior cortex (Figure 1). Some other autors [51] think that in their 6 similar cases restricted rehabilitation protocol can be an alternative to revisional chirurgy. Although the returning to everyday activities is prolonged, they did not find the difference in functional recovery. Non-operative treatment was indicated in recreative athletes where time of returning is not crucial [51]. X-rays are good for the fast orientation for bune tunnels, but CT and MRI methods are more accurate, but more complicated [18, 52]. There is an agreement that improper position of graft can cause: complications, subjective symptoms, poor outcome and reintervention [8, 18, 51, 52]. We did not performed many revisions such Milankov et al. [8] did. They published 30 cases out of 2200 reconstructions (1.36%) and concluded that the reasons for ACL reoperations were: new trauma in 10 patients and improper tunnels in 15, while cause was unknown in 5 cases. Although they achieved very good results, the average Lysholm score was 85 points. Swedish National Register [14] contains 347 performed revisions in 16281 patients (2.1%) where ACL reconstruction was perfomed with single-bundle technique and 8 revisions among 510 patients (1.6%) in double-bundle group. We had 2.5% revisions, while a group of English authors [1] published 11.4% such of cases. These reoperations can be successfuly performed but with less excellent results than primar reconstructions [1, 8, 14].

If athletes return to sports activities without limitations, 2-10% of them have ACL injury of contralateral knee joint, most often within the first five years after initial reconstruction [11]. This may cause the end of a sport's carrer, because only 52% of them return to non-restricted sports activities after the both reconstructions [12]. ACL injury of contralateral knee is not a direct complication of the first operation, but it can happen because of sparing of the first operated knee.

Concidering returning to non-restricted activities, we achieved 73% of those cases. Results range between 40-88% in literature [5, 11, 12, 53]. According to average functional scales, we also achieved good average results among the patients without complications (Lysholm score-94 points, KOOS-95), comparable with others [1, 5, 8, 18], where Lysholm score ranges between 89 and 98 points, and KOOS from 88 to 95. The average values of the same scales are significanly lower in patients with complications (Lysholm-89, KOOS-88). The structure of complications (Table 1) is similar to some others [1], who had 9.2% of complications, with more common revisions (27 out of 237 operations -11.4%).

The limitations of this study are connected to not using arthrometer for evaluation of tests in all of cases, potential subjectivity of patients during filling the qustionnaires and usage of X-ray method to analyse bone tunnels, which is not precise enough.

Study opens possibilities in the field of prevention complications and achieving better outcomes of ACL reconstructions. It also opens many questions such as: which is better type of graft, which is the ideal method of fixation and its tension.

Dilemma is when it is needed to sacrifice the graft for revision after the complication; is it enough to drain infected knee or to place continual irrigation. The aim of similar studies in the future could be to give answers why contaminated graft on the floor does not result with infection while a professional athlete without risk factors gets a septic arthritis. There is no enough evidence if tibial osteotomy can reduce re(rupture), in according to reduce posterior tibial slope [54] or does the reconstruction of anterolateral ligament provide greater rotatory stability. In the future we should find the answers of unreasonable instabilities, expecially if graft is well positioned. We still do not have answers why allergic patients to penicillin are in risk population for infection or why is every eight graft contaminated before its placing in bone tunnels. Unknown is also why we operate more often men in Balkan countries than women, when women have greater risk for ACL injury. There would be a revolution in sports traumatology if there would be invented reconstruction and rehabilitation protocol which would reduce the period to return to unlimited sports activities in less than 6 months without risk for complications.

Conclusion

Complications can compromise the final results of anterior cruciate ligament reconstructions, because functional scales are much lower in patients with complications than in those without them.

Every eleventh patient had some of the complications and every eighteenth had new operation because of them.

Similar complication rates were registered between different types of grafts, with significant difference only in more common infections in hamstring group.

General anesthesia provides less nonspecific early complications than spinal.

Prevention of limited range of motion can be solved with proper position of bone tunnels and rehabilitation. Intraoperative complications are depending of surgen's experience. Postoperative infections can be reduced by: intraoperative irrigation of graft, aseptic conditions and antibiotics. Thromboprophylaxis as a routine is not recommended.

The most of complications can be prevented and treated successfuly althought many open questions are still present.

References

[1.] Yasen SK, Sabnis B, Lord B, Wandless F, Wilson A. Clinical outcomes using translateral all-inside ACL reconstruction. Revue de Chirurgie Orthopedique et Traumatologique. 2014;100(8 Suppl):e9.

[2.] Myklebust G, Holm I, Maehlum S, Engebretsen L, Bahr R. Clinical, functional, and radiologic outcome in team handball players 6 to 11 years after anterior cruciate ligament injury: a follow-up study. Am J Sports Med. 2003;31(6):981-9.

[3.] Milankov M, Jovanovic A, Milicic A, Savic D, Stankovic M, Kecojevic V, et al. Arthroscopy of the knee-"surgery without complications". Med Pregl. 2000;53(3-4):187-92.

[4.] Busam ML, Provencher MT, Bach BR. Complications of anterior cruciate ligament reconstruction with bone-patellar tendon-bone constructs. Am J Sports Med. 2008;36(2):379-94.

[5.] Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015;47(7):1598-605.

[6.] Getelman MH, Schepsis AA, Zimmer J. Revision ACL reconstruction: autograft versus allograft. Ar-throscopy. 1995;11:378.

[7.] Tudisco C, Bisicchia S. Drilling the femoral tunnel during ACL reconstruction: transtibial versus anteromedial portal techniques. Orthopedics. 2012;1;35(8):e1166-72.

[8.] Milankov M, Milicic A, Savic D, Stankovic M, Ninkovic S, Matijevic R, et al. Revision anterior cruciate ligament reconstruction due to knee instability. Med Pregl. 2007;60(11-12):587-92.

[9.] Milankov M, Miljkovic N, Savic D. Anterior cruciate ligament reconstruction using compressed bone-hamstring-bone graft. Arthroscopy. 2007;23(4):442.e1-3.

[10.] Yoo JC, Ahn JH, Kim JH, Kim BK, Choi KW, Bae TS, et al. Biomechanical testing of hybrid hamstring graft tibial fixation in anterior cruciate ligament reconstruction. Knee. 2006;13(6):455-9.

[11.] Ristic V, Ristic S, Maljanovic M, Dan V, Milankov V, Harhaji V. Risk factors for bilateral anterior cruciate ligament injuries. Med Pregl. 2015;68(5-6):192-7.

[12.] Ristic V, Ristic S, Maljanovic M, Milankov V, Harhaji V, Duricin A. Quality of life after bilateral anterior cruciate ligament reconstructions. Med Pregl. 2015;68(9-10);308-15.

[13.] Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SB. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002;30(5):660-6.

[14.] Bjornsson H, Andernord D, Desai N, Norrby O, Forssblad M, Petzold M, et al. No difference in revision rates between singleand double-bundle anterior cruciate ligament reconstruction: a comparative study of 16,791 patients from the Swedish national knee ligament register. Arthroscopy. 2015;31(4):659-64.

[15.] Evans S, Shaginaw J, Bartolozzi A. ACL reconstruction. It's all about timing. Int J Sports Phys Ther. 2014;9(2):268-73.

[16.] Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990;18(3):292-9.

[17.] Ristic V, Ninkovic S, Harhaji V, Stankovic M, Savic D, Milankov M. Reconstruction of anterior cruciate ligament by using two different techniques. Med Pregl. 2010;63(11-12):845-50.

[18.] Ninkovic S, Milicic A, Savic D, Stankovic M, Radic S, Milankov M. Uporedivanje klinickih i radiografskih rezultata rekonstrukcije prednjeg ukstenog ligamenta kolena. Med Pregl. 2006;59(9-10):421-5.

[19.] Ristic V, Maljanovic M, Harhaji V, Milankov M. Infections after reconstructions of anterior cruciate ligament. Med Pregl. 2014;67(1-2):11-5.

[20.] Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283.

[21.] Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament surgery. Experience from Cincinnati. Clin Orthop Relat Res. 1996;(325):116-29.

[22.] Staubli HU, Rauschning W. Tibial attachment area of the anterior cruciate ligament in the extended knee position. Knee Surg Sports Traumatol Arthrosc. 1994;2(3):138-46.

[23.] ASTAS.rs [homepage on the Internet]. Novi Sad: Association of Sport Traumatology and Arthroscopic Surgery in Serbia; [cited 2017 Oct 15]. Upitnik o Vasem zdravlju. Available from: http://www.astas.rs/dokumenti/upitnici/upitnik_o_kvalitetu_zivota_posle_rekonstrukcije_prednjeg_ukrstenog_ligamenta_kolena.pdf.

[24.] Milankov MZ, Miljkovic N, Ninkovic S. Femoral guide breakage during the anteromedial portal tehnique used for ACL reconstruction. Knee. 2009;16(2):165-7.

[25.] Johnson DL, Fu FH. Anterior cruciate ligament re-construction: why do failures occur? In: Jackson DW, editor. Instructional course lectures. Rosemont (IL): American Academy of Orthopaedic Surgeons; 1995. p. 391-406.

[26.] Sonnery-Cottet B, Lavoie F, Ogassawara R, Kasmaoui H, Scussiato RG, Kidder JF, et al. Clinical and operative characteristics of cyclops syndrome after double-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2010;26(11):1483-8.

[27.] Webster KE, Feller JA, Hameister K. Bone tunnel enlargement following anterior cruciate ligament reconstruction: a randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2001;9(2):86-91.

[28.] Shen C, Jiang SD, Jiang LS, Dai LY. Bioabsorbable versus metallic interference screw fixation in anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials. Arthroscopy. 2010;26(5):705-13.

[29.] Herrington L, Wrapson C, Matthews M, Matthews H. Anterior cruciate ligament reconstruction, hamstring versus bone--patella tendon--bone grafts: a systematic literature review of outcome from surgery. Knee. 2005;12(1):41-50.

[30.] Milankov MZ, Semnic R, Miljkovic N, Harhaji V. Reconstruction of patellar tendon rupture after anterior cruciate ligament reconstruction: a case report. Knee. 2008;15(5):419-22.

[31.] Milankov M, Kecojevic V, Ninkovic S, Gajdobranski D. Prelom patele posle rekonstrukcije prednjeg ukrstenog ligamenta kolena - prikaz slucaja. Med Pregl. 2003;56(11-12):574-6.

[32.] Rispoli DM, Sanders TG, Miller MD, Morrison WB. Magnetic resonance imaging at different time periods following hamstring harvest for anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(1):2-8.

[33.] Insall JN, Windsor RE, Scott WN, Kelly MA, Aglietti P. Surgery of the knee. 2nd ed. New York, Edinburgh, London: Churchill Livingstone; 1993.

[34.] Bozic T, Dolinaj V, Popovic R, Nikolic J, Harhaji V. Prednost tehnike anestezije u odnosu na nezeljene postoperativne pojave u rekonstrukciji LCA. In: IV Kongres Srpske ortopedsko traumatoloske asocijacije (SOTA): knjiga apstrakata; 2014 Oct 2-4; Beograd, Srbija. Beograd: Srpska ortopedsko traumatoloska asocijacija; 2014. p. 152.

[35.] Ejerhed L, Kartus J, Sernert N, Kohler K, Karlsson J. Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction? Am J Sports Med. 2003;31(1):19-25.

[36.] Eriksson K, Anderberg P, Hamberg P, Olerud P, Wredmark T. There are differences in early morbidity after ACL reconstruction when comparing patellar tendon and semitendinosus tendon graft. Scand J Med Sci Sports. 2001;11(3):170-7.

[37.] Kirchhoff C, Braunstein V, Paul J, Imhoff AB, Hinterwimmer S. Septic arthritis as a severe complication of elective arthroscopy: clinical management strategies. Patient Saf Surg. 2009;3(1):6.

[38.] Hantes ME, Basdekis GK, Varitimidis SE, Giotikas D, Petinaki E, Malizos KN. Autograft contamination during preparation for anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2008;90(4):760-4.

[39.] Sonnery-Cottet B, Archbold P, Zayni R, Bortolletto J, Thaunat M, Prost T, et al. Prevalence of septic arthritis after anterior cruciate ligament reconstruction among professional athletes. Am J Sports Med. 2011;39(11):2371-6.

[40.] Milankov M, Savic D. The importance of irrigation suction drainage in the treatment of septic arthritis after anterior cruciate ligament reconstruction. Arthroscopy. 2008;24(12):1434-5.

[41.] Izquierdo R Jr, Cadet ER, Bauer R, Stanwood W, Levine WN, Ahmad CS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21(11):1348-53.

[42.] Phegan M, Grayson JE, Vertullo CJ. No infections in 1300 anterior cruciate ligament reconstructions with vancomycin presoaking of hamstring grafts. Knee Surg Sports Traumatol Arthrosc. 2016;24(9):2729-35.

[43.] Adala R, Anand A, Kodikal G. Deep vein thrombosis and thromboprophylaxis in arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop. 2011;45(5):450-3.

[44.] Cullison TR, Muldoon MP, Gorman JD, Goff WB. The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction. Arthroscopy. 1996;12(6):657-9.

[45.] Marlovits S, Striessnig G, Schuster R, Stocker R, Luxl M, Trattnig S, et al. Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: a prospective, randomized, placebo-controlled study. Arthroscopy. 2007;23(7):696-702.

[46.] Shelbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med. 2000;28(5):651-8.

[47.] Kartus J, Stener S, Lindahl S, Ericksson BI, Karlsson J. Ipsi- or contralateral patellar tendon graft in anterior cruciate ligament revision surgery: a comparison of two methods. Am J Sports Med. 1998;26(4):499-504.

[48.] Aglietti P, Zaccherotti G, Menchetti PP, De Biase P. A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 1995;3(1):2-8.

[49.] Shelbourne KD, Wilckens JH, De Carlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991;19(4):322-6.

[50.] Lindenfeld T. Operative treatment of arthrofibrosis of the knee. Am J Sports Med. 2000;16(7):142-8.

[51.] Kadija M, Bumbasirevic M, Blagojevic Z, Dubljanin-Raspopovic E. Perforacija zadnjeg korteksa femura neprepoznata u toku artroskopske rekonstrukcije LCA. Acta Chir Iugosl. 2006;53(4):73-8.

[52.] Papakonstantinou O, Chung CB, Chanchairujira K, Resnick DL. Complications of anterior cruciate ligament reconstruction: MR imaging. Eur Radiol. 2003;13(5):1106-17.

[53.] Monaco E, Maestri B, Vadala A, Iorio R, Ferretti A. Return to sports activity after postoperative septic arthritis in ACL reconstruction. Phys Sportsmed. 2010;38(3):69-76.

[54.] Ristic V, Maljanovic MC, Pericin B, Harhaji V, Milankov. The relationship between posterior tibial slope and anterior cruciate ligament injury. Med Pregl. 2014;67(7-8):216-21.

Vladimir RISTIC (1), Miodrag VRANJES (2,3), Mirko OBRADOVIC (2,3), Mile BJELOBRK (2), Vladimir HARHAJI (2,3) and Miroslav MILANKOV (2,3)

General Hospital Subotica, Department of Orthopedics and Traumatology (1) Clinical Center of Vojvodina, Novi Sad, Department of Orthopedics and Traumatology (2) University of Novi Sad, Faculty of Medicine Novi Sad (3)

Corresponding Author: Prof. dr Miroslav Milankov, Klinicki centar Vojvodine, Klinika za ortopedsku hirurgiju i traumatologiju, 21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: miroslav.milankov@mf.uns.ac.rs

https://doi.org/10.2298/MPNS1712449R
Abbreviations

ACL   --anterior cruciate ligament
BTB   --bone-patellar tendon-bone
BHB   --bone-hamstring tendons- bone
KOOS  --Knee Osteoarthritis Outcome Scale
ROM   --Range of motion


Rad je primljen 1. X 2017.

Prihvacen za stampu 1. XI 2017.

BIBLID.0025-8105:(2017):LXX:11-12:465-471.
Table 1. ACL complications depending of graft
Tabela 1. Komplikacije u vezi sa kalemom

Complications/Komplikacije        175 - BTB/    35 - BHB/ ko-
                                  kost-casicna  st-tetiva ham-
                                  veza-kost     stringa-kost

Algodystrophic
syndrome/Algodistroficni sindrom   0            1
DVT, PTE/DVT, PTE                  1            0
Arthrofibrosis/Artrofibroza        2            0
Infection/Infekcija                4 (2.3%)     2 (5.7%)
Graft failure/Propadanje kalema    2            0
Loose body/Opusteno telo           1            0
Rerupture/Ponovno pucanje          4 (2.3%)     1 (2.9%)
Patellar fracture/Prelom casice    1            0
Total %/Ukupno %                  15 (8.6%)     4 (11.4%)

Complications/Komplikacije
                                  210 - Total/Ukupno


Algodystrophic
syndrome/Algodistroficni sindrom   1 (0.5%)
DVT, PTE/DVT, PTE                  1 (0.5%)
Arthrofibrosis/Artrofibroza        2 (1%)
Infection/Infekcija                6 (2.9%)
Graft failure/Propadanje kalema    2 (1%)
Loose body/Opusteno telo           1 (0.5%)
Rerupture/Ponovno pucanje          5 (2.4%)
Patellar fracture/Prelom casice    1 (0.6%)
Total %/Ukupno %                  19 (9%)

BTB - kost-casicna veza-kost, BHB - kost-tetiva hamstringa-kost, DVT -
deep vein thrombosis/tromboza dubokih vena, PTE - pulmonary
thromboembolism/plucna tromboembolija

Table 2. Complications connected to anesthesia
Tabela 2. Komplikacije u vezi sa anestezijom

Complication/Komplikacija              General/Opsta  Spinal/Kicmena

Blader disfunction/Disfunkcija besike   0%            18 (9%)
Severe knee pain/Jak bol u kolenu      66 (31%)       22 (10%)
Nausea/Mucnina                         20 (10%)       12 (6%)
Shivering/Drhtavica                    52 (25%)       26 (12%)
Dizziness and headache/Vrtoglavica
i glavobolja                           10 (5%)        46 (22%)
COPYRIGHT 2017 Drustvo Lekara Vojvodine
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2017 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Ristic, Vladimir; Vranjes, Miodrag; Obradovic, Mirko; Bjelobrk, Mile; Harhaji, Vladimir; Milankov, M
Publication:Medicinski Pregled
Article Type:Clinical report
Date:Nov 1, 2017
Words:7064
Previous Article:IN SITU ANALYSIS OF MITOCHONDRIAL RESPIRATORY CAPACITY --FOUNDATION FOR CELLULAR PHYSIOLOGY/IN SITU ANALIZA MITOHONDRIJALNOG RESPIRATORNOG KAPACITETA...
Next Article:CURRENT TREATMENT OF ACUTE ISCHEMIC STROKE IN VOJVODINA/AKTUELNO LECENJE AKUTNOG ISHEMIJSKOG UDARA U VOJVODINI.
Topics:

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters |