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Functional outcome of arthroscopic reconstruction of anterior cruciate ligament tears.

INTRODUCTION

Anterior Cruciate Ligament (ACL) tear is the most common serious ligamentous injury to the knee joint. (1) Anterior Cruciate Ligament (ACL) injury is quite common among young active population, athletes and contact sports. (2) The exact incidence of anterior cruciate ligament tears is not known as the cases are being under-reported. The goals of reconstruction are to restore stability to the knee, allow the patient to return to normal activities including sports and to delay the onset of osteoarthritis with associated recurrent injuries to the articular cartilage and loss of meniscal functions. (3)

The ACL is the primary stabilizer against anterior translation of the tibia on the femur and is important in counteracting rotation and valgus stress. Anterior cruciate ligament deficiency leads to knee instability. (4) this results in recurrent injuries and increased risk of intra-articular damage, especially the meniscus. During the past decade, arthroscopically assisted techniques have been an accepted method of reconstructing the ACL. (5,6,7) There is little or no difference between bone-patellar tendon-bone and combined semitendinosus and gracilis tendon grafts in terms of the functional outcome after ACL reconstruction despite greater laxity measurements in the hamstring tendon group patients. (8) Graft choice, surgeon experience, correct graft position, choice of graft fixation and postoperative rehabilitation confound the results of comparison of ACL reconstruction. (9,10,11) Stiffness and strength tend to be slightly better with bone-patellar tendon-bone, but overall results are comparable.

The advantages of arthroscopically assisted anterior cruciate ligament reconstruction include elimination of capsular incisions, decrease in trauma to the fat pad, avoidance of desiccation of the articular cartilage, better visualization of the femoral attachment and a lower incidence of postoperative patello-femoral pain than with open reconstruction. (11) Similar to all arthroscopic techniques, the primary disadvantage of arthroscopically assisted ACL reconstruction is that the technique has a long learning curve and is a technically demanding procedure. (9)

The bone-patellar tendon-bone and the hamstring tendon are the two most commonly used autografts for reconstruction. (12,13,14,15,16) The bone-patellar tendon-bone graft has been widely accepted as gold standard for ACL reconstruction with high success rate. (17,18,19) However, donor site morbidities and extensor mechanism problems associated with bone-patellar tendon-bone graft have led to increasing popularity of hamstring tendon graft, which also had better cosmoses. (20)

In our study, we have analyzed the results of Arthroscopic ACL Reconstruction using autologous ipsilateral bone patellar tendon bone graft and quadrupled hamstring graft.

AIMS AND OBJECTIVES THE AIM OF THE STUDY

Evaluation of the results of arthroscopic guided anterior cruciate ligament reconstruction.

OBJECTIVES

To know the functional outcome of arthroscopic guided anterior cruciate ligament reconstruction using Lysholm knee score and IKDC score.

To list and evaluate the complications encountered with anterior cruciate ligament reconstruction. To analyze the results and compare the same with standard published data in literature.

We want to analyze the results of arthroscopic ACL reconstruction using autologous ipsilateral bone patellar tendon bone graft and quadrupled hamstring graft.

MATERIALS AND METHODS

Between November 2012 to October 2014, 34 consecutive patients who underwent arthroscopic assisted ACL reconstructions in the Department of Orthopedics and Traumatology, King George Hospital, Visakhapatnam, were the material in our study.

No. of Cases: 34 cases Duration of Study: November 2012 to October 2014

Inclusion Criteria

All patients with ACL Tear ...

Who are in the age groups between 18 to 45 years? With history of repeated and episodic knee instability (ACL Tear).

With no evidence of clinical and radiological degenerative change in the knee.

Exclusion Criteria Included

Patients with ACL tear in age groups less than 18 and greater than 45 years.

Patients with ACL tears with associated injuries of tibial or femoral condyles.

Patients with ACL tears with tri-compartmental osteoarthritis of knee joint.

Contralateral ACL deficiency.

Bilateral ACL reconstruction.

Revision ACL surgery.

Previous knee surgeries.

Concomitant extra-articular reconstruction.

Comorbid conditions.

METHODS

After the patients are clinically and radiologically diagnosed to have ACL tear and after meeting inclusion criteria, the patients were taken up for arthroscopic ACL reconstruction. All the patients followed standard physiotherapy protocol.

We utilised both BPTB and Quadrupled hamstring graft at random depending on the patient's age, physical activity, occupation. Standardised postoperative rehabilitation protocol were followed for 6 months. The outcome testing in all cases were performed at the latest follow-up (at least 6 months]. In all the patients, graft was fixed with titanium interference screws on femoral and tibial side.

OBSERVATIONS AND RESULTS

In our study of Arthroscopic Anterior Cruciate Ligament reconstruction, a total of 34 cases were operated and followed up. Minimum followup period was six months and maximum followup period was twenty four months, average being 14 months.

SEX DISTRIBUTION. (17)

Male predominance was found in our study; 34 (97.1%] patients were males and one (2.9%] female patient was present. This probably because males are more frequently involved in sports and road traffic accidents.

LATERALITY

Left knee was affected in 13 (33.33%] patients and right knee was affected in 17 (66.66%] patients. There was not much difference in lateralization of the injury.

ASSOCIATED INJURIES

Nineteen patients in our study had isolated ACL tears. Two patients had associated lateral meniscal tears, eleven patients had medial meniscal tears and one patient had both medial and lateral meniscus tear. All 14 patients had undergone arthroscopic meniscectomy at the time of reconstruction. Patients with isolated ACL injuries had better post-operative knee functional score compared to those with associated injuries.

AVERAGE LYSHOLM SCORE

We have used the Lysholm score and IKDC score for subjective evaluation of all our patients at each followup. The following are the parameters and the maximum points given for each.
Parameters        (100 points).
Limp              (5 points)
Support           (5 points)
Stair climbing    (10 points)
Squatting         (5 points)
Instability       (30 points)
Pain              (30 points)
Swelling          (10 points)
Locking           (5 points)


In our study Lysholm score was done at preop, 3 months, 6 months, 1 year, 18 months and 2 years. Average Lysholm score at preop 56.44, at 3 months 79.9, at 6 months 88.17, at 1 year 92.92, 18 months 94.73 and at 2 years 94.0. There was clinically significant improvement in Lysholm score preoperative period (56.44) to 6 months post-operative period (88.17).

GRADING OF LYSHOLM SCORE
Poor                 <65 points
Fair                 66 to 81 points
Fair-to-good         82 to 92 points
Good-to-excellent    93 to 97 points
Excellent            98 to 100 points


Anterior drawer test was negative in 33 (97.0%) patients. These patients had no instability at 1 year followup during activities like running or climbing up and down stairs; 1 patient (2.9%) had 1+ laxity. This patient had no instability while walking. None of the patients had pivot shift test positive.

RANGE OF MOTION OF OPERATED KNEE

In our study of 34 patients at 3 months followup, 29 (85.2%) patients had normal range of motion of the operated knee at 6 months followup; 31 (91.17%) patients had equal range of motion compared to normal contralateral side at 1 year followup; 32 (94.11%) patients had equal range of motion compared to contralateral side; 1 patient had deep infection with loss of range of motion.

QUADRICEPS POWER

At 3 months followup, 29 patients (85.29%) had grade of 5/5 power in Quadriceps. At 6 months, 30 patients (88.23%) had grade 5/5 power. At 1 year followup, 18 patients (90.0%) out of 20 had grade 5/5 power.

This shows that there was significant improvement in Quadriceps muscle strength at long-term followup with good rehabilitation program; 2 patients (6.7%) had grade 3/5 power, one patient had deep infection which was treated and power improved to 4/5 at latest followup.

DISCUSSION

The present study of Arthroscopic guided Anterior Cruciate Ligament Reconstruction using BPTB graft and Quadrupled hamstring graft was done during the period of November 2012 to October 2014, at Andhra Medical College and King George Hospital, Visakhapatnam. Outcome was measured using Lysholm knee score, IKDC Score, Anterior drawer test, Range of motion of the knee joint and Quadriceps power of ipsilateral knee. And result of the present study was compared with the studies of D Choudhary et al. 2005, Jomha et al. 1999, Riley et al. 2004 and Mahir et al. 2005.

Average age at surgery in the present study group was 27 years and that of D Choudhary et al. was 27 years and that of Jomha et al. was 26 years and Railey et al. was 33 years and Mahir et al. was 24 yrs.

Average duration of follow-up of the present study was 14 months with a minimum follow-up period 6 months and maximum follow-up period was 24 months. Average duration of follow-up of D Choudhary et al. was 12 months and that of Jomha et al. was 84 months, Railey et al. was 24 months, Mahir et al. was 18 months.

The measured Lysholm score of D Choudhary et al. at the end of the study was 92, Jomha et al. at the end of the study was 94, Railey et al. at the end of the study was 91, Mahir et al. was 93.5 and in our study average Lysholm score at last followup was 90.

In the present study, no patient had Pivot Shift test positive postoperatively.

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COMPLICATIONS AND REOPERATION

Jomha et al. 1999 reported six patients with graft failure, screw removal in seven patients. Manipulation under anesthesia in three patients. Arthroscopic division of adhesions in two patients. One patient with deep infection was treated with lavage and screw removal.

Railey et al. 2004 reported six patients with traumatic rupture of graft, five of which were revised arthroscopically and one was treated with knee stabilization brace. Two patients with deep infection were treated with arthroscopic irrigation and debridement, intravenous and oral antibiotics and rehabilitation.

D Choudhary et al. 2005 had not reported any graft failure or deep infection. They reported most common complication as anterior knee pain and most common immediate complication as screw divergence.

Mahir et al. 2005 have not reported any complications in their study.

In the present study, we had a patient with deep infection who was treated with arthroscopic screw removal, joint lavage and debridement, IV antibiotics and prolonged oral antibiotics and rehabilitation. Two patients developed superficial infection, which was treated by oral antibiotics and regular dressings. Three patients developed anterior knee pain.

CONCLUSIONS

Majority of study subjects were males, i.e. 33 out of 34. Mean age was 27 years.

Only nineteen patients had isolated ACL injury, remaining fifteen patients had ACL associated injuries.

Patients with isolated ACL injury had better outcome compared to patients who underwent associated meniscectomy.

Right side was affected in 22 patients and left side in 9 patients.

Most common mechanism of injury was activity of sports in 20 patients, injuries during RTA in 10 patients and others (work related, daily activities] injuries in 4 patients. There is significant pre-operative to post-operative improvement in knee functional scores both Lysholm and IKDC.

Postoperatively at 3 months anterior drawers was 1+ in 6 (17.64%) patients, which improved with rehabilitation in all patients.

Postoperatively at 3 months 29 (85.2%) patients had normal range of motion.

Postoperatively at 3 months, 29 (85.29%) patients had 5/5 quadriceps power (MRC grading), 94% of them had 5/5 power at latest followup.

In our study, we had complications like Anterior Knee Pain, Superficial infection and Deep infection which were treated accordingly.

Autologous ipsilateral bone patellar tendon bone graft and quadrupled hamstring graft have produced good-to-excellent post-operative functional scores which were clinically significant.

There is no significant difference between outcomes of BPTB and Hamstrings graft.

Functional outcome of our study were similar to the previously published studies.

Financial or Other, Competing Interest: None. Submission 18-11-2015, Peer Review 23-11-2015, Acceptance 26-11-2015, Published 04-02-2016.

Corresponding Author: Dr. P. Ashok Kumar, # B-98, Dayal Nagar, Visakhapatnam-530043, Andhra Pradesh. E-mail: ashok_ortho59@rediffmail.com DOI: 10.14260/jemds/2016/98

REFERENCES

(1.) Miyasaka KC, Daniel DM, Stone ML. The incidence of knee ligament injuries in the general population. Am J Knee Surg 1991;4:3-8.

(2.) Jorgensen U, Sonne-Holm, Lauridsen F, et al. Long-term follow-up of meniscectomy in athletes. J Bone Joint Surg (Br] 1987;69:80-3.

(3.) Rangger C, Klestil T, Gloetzer W, et al. Osteoarthritis after arthroscopic partial meniscectomy. Am J Sports Med 1995;23:240-4.

(4.) Dye SF, Wojtys EM, Fu FH, et al. Factors contributing to function of the knee joint after injury and reconstruction of the anterior cruciate ligament. In Zuckerman JD. Ed. Instructional Course Lecture. Rosemont, American Academy of Orthopedic Surgery 1999;48:185-98.

(5.) Jomha NM, Pinczewski LA, Clingeleffer A, et al. Arthroscopic reconstruction of anterior cruciate ligament with patellar-tendon autograft and interference screw fixation. The results at seven years. J Bone Joint Surg (Br] 1999;81:775.

(6.) Barrack RL, Bruckner JD, Knist J, et al. The outcome of non-operatively treated complete tears of the anterior cruciate ligament in active young adults. Clin Orthop 1990;259:192-9.

(7.) Single versus two incision arthroscopic anterior cruciate ligament reconstruction. J Arthroscopy 1996;12:462-9.10.

(8.) Buss DD, Warren RF, Wickiewicz TJ, et al. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar ligament grafts. Results after twenty-four to forty-two months. J Bone Joint Surg (Am) 1993;75:1346-5.

(9.) Barry B Phillips, Campbell's operative orthopedics, tenth edition, ch: 48.

(10.) Fu FH, Schulte KR. Anterior cruciate ligament surgery 1996. State of the art. Clin Orthop 1996;325:19-24.

(11.) Meade TD, Dickson TB. Technical pitfalls of a single incision arthroscopic ACL reconstruction. Am J Arthroscopy 1992;2:15-9.

(12.) Shaieb MD, Kan DM, Chang SK, et al. A prospective randomized comparison of patellar versus semitendinosus and Gracilis tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2002;30:214-20.

(13.) Barrett GR, Noojin FK, Hartzog CW, et al. Reconstruction of the anterior cruciate ligament in females. A comparison of hamstring versus patellar tendon autograft. Arthroscopy 2002;18:46-54.

(14.) Ejerhed L, Kartus J, Sernert N, et al. Patellar tendon or semitendinosus tendon autografts for ACLR: a prospective randomized study with a two-year followup. Am J Sports Med 2003;31:19-25.

(15.) Jansson KA, Linko E, Sandelin J, et al. A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 2003;31:12-8.

(16.) Pinczewski LA, Deehan DJ, Salmon LJ, et al. A five-year comparison of patellar tendon versus four-strand hamstring tendon autograft for arthroscopic reconstruction of the ACL. Am J Sports Med 2002;30:523-36.

(17.) Beynnon BD, Johnson RJ, Fleming, et al. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two strand hamstring grafts. J Bone Joint Surg (Am) 2002;84:1503-13.

(18.) Aglietti P, Buzzi R, Zaccherotti G, et al. Patellar tendon versus doubled semitendinosus and Gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med 1994;22:211-8.

(19.) Marder RA, Raskind JR, Carroll M. Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and Gracilis tendons. Am J Sports Med 1991;19:478-84.

(20.) Romano VM, Graf BK, et al. (1993), "Anterior cruciate ligament reconstruction. The effect of tibial tunnel placement on range of motion." American Journal of Sports Medicine 21(3):415-8,1993 May 21(3):415-8.

P. Ashok Kumar [1], P. Rambabu [2], K. Srinivasarao [3], K. Vamsi Krishna [4], CH. V. Murali Krishna [5], S. Chandra Sekhar [6], V. Krishna Swamy [7], Jameer Shaik [8], K. Ramakrishna [9]

[1] Professor I/c, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[2] Assistant Professor, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[3] Assistant Professor, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[4] Assistant Professor, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[5] Assistant Professor, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[6] Assistant Professor, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[7] Junior Resident, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[8] Junior Resident, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.

[9] Junior Resident, Department of Orthopaedics, King George Hospital, Andhra Medical College, Visakhapatnam, Andhra Pradesh.
Table 1: Age Group (n=34)

AGE GROUP   NO. OF PATIENTS   PERCENTAGE
(YRS)         (BPTB; STG)

18-24          14(05;10)        44.11%
25-31          09(02;07)        26.41%
32-38          05(03;02)        14.7%
39-45          05(02;03)        14.7%

Table 2: Average Lysholm Score (n=34)

                     AVERAGE LYSHOLM
DURATION                  SCORE
                       (BPTB;STG)

Preop (n=34)        56.44 (54.1;57.6)
3 months (n=34)     79.9 (78.5;80.7)
6 months (n=34)     88.1 (86.5;89.0)
1 year (n=26)       92.92 (93.5;92.4)
18 months (n=19)    94.73 (95.8;93.7)
2 years (n=4)       94.0 (97.5;90.5)

Table 3: Average IKDC Score

DURATION            AVERAGE IKDC SCORE

Preop (n=34)        54.94 (53.6;55.63)
3 months (n=30)     75.5 (73.0;76.18)
6 months (n=30)     85.5 (83.9;86.36)
1 year (n=21)       89.38 (90.3;88.54)
18 months (n=20)     95 (95.44;94.0)
2 years                 94 (98,93)

Table 4: Anterior Drawer Test at 3 Months
Follow-up (n=34)

TEST RESULT    NO. OF PATIENTS
                 (BPTB;STG)

NEGATIVE         28 (10;18)
1+                6 (02;04)

Table 5: Anterior Drawer Test at
6 Months Follow-up (n=34)

TEST RESULT    NO. OF PATIENTS
                 (BPTB;STG)

NEGATIVE         30 (11;19)

1+                4 (02;02)

Table 6: Anterior Drawer Test at 1 Year Follow-up (n=30)

TEST RESULT    NO. OF PATIENTS
                 (BPTB;STG)

NEGATIVE         33 (12;21)

1+                 1 (0;1)

Table 7: Surgical Protocol

Author & Year      Graft Used         Technique
of Publisher

D Choudhary        Ipsilateral      Arthroscopic
et al. 2005      autogenous BPTB   single incision

Jomha 1999         Ipsilateral      Arthroscopic
                 autogenous BPTB   single incision

Railey et al.     Four stranded     Arthroscopic
2004             Hamstring graft   single incision

Mahir et al.      Four stranded     Arthroscopic
2005             hamstring graft   single incision

Our Study          Ipsilateral      Arthroscopic
                 autogenous BPTB   single incision
                 four stranded
                 hamstring graft

Author & Year     Femoral Fixation     Tibial Fixation
of Publisher

D Choudhary      Interference screw   Interference screw
et al. 2005

Jomha 1999       Interference screw   Interference screw

Railey et al.        Endobutton        Staples, washer
2004                                      and screw

Mahir et al.         Cross pin        Interference screw
2005

Our Study        Interference screw   Interference screw

Table 8: Patient Variables

Author & Year of             No. of     Followup      Mean age at
Publisher                   Patients                    Surgery

Jomha 1999                     59         74%          26 Years
D Choudhary et al. 2005       100         78%          27 Years
Railey et al. 2004             85         70%          33 Years
Mahir et al. 2005              62         100%         24 Years
Our Study (BPTB;STG)       34 (12;22)     76%            27yrs
                                                   (28.6yrs;26.5yrs)

Author & Year of           Mean Followup     Gender
Publisher                  Interval (mo)

Jomha 1999                      84          73% Male
D Choudhary et al. 2005         12          93% Male
Railey et al. 2004              24          59% Male
Mahir et al. 2005               18         100% Male
Our Study (BPTB;STG)            14         97.1% Male

Table 9: Lysholm Knee Score

Author & Year of Publisher    Average Lysholm Score

D Choudhary et al. 2005                92
Jomha 1999                             94
Railey et al. 2004                     91
Mahir et al. 2005                     93.5
Our Study (BPTB;STG)              90 (90;90.3)

Table 10: Pivot Shift Examination

                             Postoperative Grade (%)
Author and
Year Published               0    1+   2+   3+ or 4+

D Choudhary et al. 2005     95    4    1       0
Jomha 1999                  76    22   1       0
Railey et al. 2004          89    7    4       0
Mahir et al. 2005           100   0    0       0
Our Study                   100   0    0       0

Fig. 1: Pie Diagram showing
the Age Groups

18-24 yrs    44%

25-31 yrs    26%

Note: Table made from pie chart.
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Title Annotation:Original Article
Author:Kumar, P. Ashok; Rambabu, P.; Srinivasarao, K.; Krishna, K. Vamsi; Krishna, CH. V. Murali; Sekhar, S
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Feb 4, 2016
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