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Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 11, pp 3592–3598 | Cite as

Superior knee flexor strength at 2 years with all-inside short-graft anterior cruciate ligament reconstruction vs a conventional hamstring technique

  • Panagiotis KouloumentasEmail author
  • Efstratios Kavroudakis
  • Efstathios Charalampidis
  • Dimitris Kavroudakis
  • Georgios K. Triantafyllopoulos
KNEE
  • 199 Downloads

Abstract

Purpose

To compare the “all-inside technique” for anterior cruciate ligament (ACL) reconstruction using a short, quadrupled semitendinosus tendon (ST4) autograft and suspensory cortical fixation on both the femoral and tibial side vs the “conventional technique” using a semitendinosus/gracilis (ST/G) autograft fixed with a suspensory device on the femoral side and with an interference screw on the tibial side, in terms of clinical and functional outcomes.

Methods

A total of 90 patients were enrolled, randomised into two groups, and prospectively followed. Group A comprised 45 patients treated with the all-inside technique and Group B included 45 patients treated with the conventional ACL technique (55 males, 35 females; mean age 28.7 ± 11.3 years). Patients completed the Lysholm knee score, the International Knee Documentation Committee (IKDC) score, the Knee Injury and Osteoarthritis Score (KOOS), and the Knee Society Score (KSS) preoperatively and at 2 years postoperatively. Anterior tibial translation measurement (KT-1000 arthrometer) and isokinetic testing of the operative vs non-operative limb were also conducted and the limb symmetry index (LSI) was determined.

Results

At 24 months, the Lysholm, IKDC, KOOS, and KSS scores between the two groups were similar (n.s.). Anterior tibial translation between the operative and non-operative knee was also similar among the two groups (n.s.). Patients of Group A had significantly higher mean LSIs in terms of flexor peak torque (1.0 ± 0.1 vs 0.9 ± 0.1; p < 0.001), time-to-peak (0.9 ± 0.1 vs 0.8 ± 0.1; p < 0.001) and total work (0.9 ± 0.1 vs 0.8 ± 0.1; p < 0.001) at 180°/s, and significantly better mean LSI for isometric flexor/extensor ratio at 90° (1.1 ± 0.3 vs 0.8 ± 0.2; p < 0.001).

Conclusion

The all-inside ACL reconstruction with an ST4 autograft and cortical button fixation on both ends is a viable alternative to the conventional technique. It affords preservation of knee flexor strength, which is of advantage, especially when treating athletes with ACL injury.

Level of evidence

I.

Keywords

Anterior cruciate ligament reconstruction All-inside Cortical button fixation Short graft 

Notes

Author contributions

PK conceived and designed the study, performed all surgeries, and helped to draft the manuscript. EK and EC performed data collection. DK performed the statistical analysis. GT performed the randomisation and drafted the manuscript. All authors have read and approved the final manuscript.

Funding

No funding was received for the present study.

Compliance with ethical standards

Conflict of Interest

The authors have no conflicts of interest in relation with this study.

Ethical approval

The study was approved by the Institutional Ethics Committee, Metropolitan Hospital, ID number: 2501101214.

References

  1. 1.
    Aglietti P, Buzzi R, D’Andria S, Zaccherotti G (1993) Patellofemoral problems after intraarticular anterior cruciate ligament reconstruction. Clin Orthop Relat Res 288:195–204Google Scholar
  2. 2.
    Barenius B, Nordlander M, Ponzer S, Tidermark J, Eriksson K (2010) Quality of life and clinical outcome after anterior cruciate ligament reconstruction using patellar tendon graft or quadrupled semitendinosus graft: an 8-year follow-up of a randomized controlled trial. Am J Sports Med 38:1533–1541CrossRefGoogle Scholar
  3. 3.
    Benea H, d’Astorg H, Klouche S, Bauer T, Tomoaia G, Hardy P (2014) Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study. Knee 21:102–106CrossRefGoogle Scholar
  4. 4.
    Blackman AJ, Stuart MJ (2014) All-inside anterior cruciate ligament reconstruction. J Knee Surg 27:347–352CrossRefGoogle Scholar
  5. 5.
    Brandsson S, Faxen E, Eriksson BI, Sward L, Lundin O, Karlsson J (1999) Reconstruction of the anterior cruciate ligament: comparison of outside-in and all-inside techniques. Br J Sports Med 33:42–45CrossRefGoogle Scholar
  6. 6.
    Bressy G, Brun V, Ferrier A, Dujardin D, Oubaya N, Morel N et al (2016) Lack of stability at more than 12 months of follow-up after anterior cruciate ligament reconstruction using all-inside quadruple-stranded semitendinosus graft with adjustable cortical button fixation in both femoral and tibial sides. Orthop Traumatol Surg Res 102:867–872CrossRefGoogle Scholar
  7. 7.
    Buchner M, Schmeer T, Schmitt H (2007) Anterior cruciate ligament reconstruction with quadrupled semitendinosus tendon—minimum 6 year clinical and radiological follow-up. Knee 14:321–327CrossRefGoogle Scholar
  8. 8.
    Buller LT, Best MJ, Baraga MG, Kaplan LD (2015) Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med 3:2325967114563664CrossRefGoogle Scholar
  9. 9.
    Cooley VJ, Deffner KT, Rosenberg TD Quadrupled semitendinosus anterior cruciate ligament reconstruction: 5-year results in patients without meniscus loss. Arthroscopy 17:795–800CrossRefGoogle Scholar
  10. 10.
    Engebretsen L, Benum P, Fasting O, Molster A, Strand T (1990) A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate ligament. Am J Sports Med 18:585–590CrossRefGoogle Scholar
  11. 11.
    Eriksson K, Anderberg P, Hamberg P, Löfgren AC, Bredenberg M, Westman I et al (2001) A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. J Bone Jt Surg Br 83:348–354CrossRefGoogle Scholar
  12. 12.
    Goyal S, Matias N, Pandey V, Acharya K (2016) Are pre-operative anthropometric parameters helpful in predicting length and thickness of quadrupled hamstring graft for ACL reconstruction in adults? A prospective study and literature review. Int Orthop 40:173–181CrossRefGoogle Scholar
  13. 13.
    Hefti F, Muller W, Jakob RP, Staubli HU (1993) Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1:226–234CrossRefGoogle Scholar
  14. 14.
    Howe JG, Johnson RJ, Kaplan MJ, Fleming B, Jarvinen M (1991) Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term followup. Am J Sports Med 19:447–457CrossRefGoogle Scholar
  15. 15.
    Jessop DM, Pain MT (2016) Maximum velocities in flexion and extension actions for sport. J Hum Kinet 50:37–44CrossRefGoogle Scholar
  16. 16.
    Kern M, Love D, Cotter EJ, Postma W (2016) Quadruple-bundle semitendinosus-gracilis graft technique for all-inside anterior cruciate ligament reconstruction. Arthrosc Tech 5:e1317–e1320CrossRefGoogle Scholar
  17. 17.
    Kim JG, Yang SJ, Lee YS, Shim JC, Ra HJ, Choi JY (2011) The effects of hamstring harvesting on outcomes in anterior cruciate ligament-reconstructed patients: a comparative study between hamstring-harvested and -unharvested patients. Arthroscopy 27:1226–1234CrossRefGoogle Scholar
  18. 18.
    Ko MS, Yang SJ, Ha JK, Choi JY, Kim JG (2012) Correlation between hamstring flexor power restoration and functional performance test: 2-year follow-up after ACL reconstruction using hamstring autograft. Knee Surg Relat Res 24:113–119CrossRefGoogle Scholar
  19. 19.
    Kyung H-S, Lee H-J, Oh C-W, Hong H-P (2015) Comparison of results after anterior cruciate ligament reconstruction using a four-strand single semitendinosus or a semitendinosus and gracilis tendon. Knee Surg Sports Traumatol Arthrosc 23:3238–3243CrossRefGoogle Scholar
  20. 20.
    Liden M, Ejerhed L, Sernert N, Laxdal G, Kartus J (2007) Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-year follow-up. Am J Sports Med 35:740–748CrossRefGoogle Scholar
  21. 21.
    Lubowitz JH (2010) All-inside ACL: retroconstruction controversies. Sports Med Arthrosc Rev 18:20–26CrossRefGoogle Scholar
  22. 22.
    Lubowitz JH, Ahmad CS, Anderson K (2011) All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction. Arthroscopy 27:717–727CrossRefGoogle Scholar
  23. 23.
    Lubowitz JH, Schwartzberg R, Smith P (2015) Cortical suspensory button versus aperture interference screw fixation for knee anterior cruciate ligament soft-tissue allograft: a prospective, randomized controlled trial. Arthroscopy 31:1733–1739CrossRefGoogle Scholar
  24. 24.
    Lubowitz JH, Schwartzberg R, Smith P (2013) Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel. Arthroscopy 29:1195–1200CrossRefGoogle Scholar
  25. 25.
    Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr et al (2014) Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med 42:2363–2370CrossRefGoogle Scholar
  26. 26.
    Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT et al (2013) The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy 29:1948–1953CrossRefGoogle Scholar
  27. 27.
    Mohtadi N, Chan D, Barber R, Oddone Paolucci E (2015) A randomized clinical trial comparing patellar tendon, hamstring tendon, and double-bundle ACL reconstructions: patient-reported and clinical outcomes at a minimal 2-year follow-up. Clin J Sport Med 25:321–331CrossRefGoogle Scholar
  28. 28.
    O’Brien SJ, Warren RF, Pavlov H, Panariello R, Wickiewicz TL (1991) Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament. J Bone Jt Surg Am 73:278–286CrossRefGoogle Scholar
  29. 29.
    Rosenberg TD, Franklin JL, Baldwin GN, Nelson KA (1992) Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction. Am J Sports Med 20:519–525CrossRefGoogle Scholar
  30. 30.
    Sachs RA, Daniel DM, Stone ML, Garfein RF (1989) Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 17:760–765CrossRefGoogle Scholar
  31. 31.
    Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA (2016) Posteromedial meniscocapsular lesions increase tibiofemoral joint laxity with anterior cruciate ligament deficiency, and their repair reduces laxity. Am J Sports Med 44:400–408CrossRefGoogle Scholar
  32. 32.
    Streich NA, Reichenbacher S, Barié A, Buchner M, Schmitt H (2013) Long-term outcome of anterior cruciate ligament reconstruction with an autologous four-strand semitendinosus tendon autograft. Int Orthop 37:279–284CrossRefGoogle Scholar
  33. 33.
    Thomas S, Bhattacharya R, Saltikov JB, Kramer DJ (2013) Influence of anthropometric features on graft diameter in ACL reconstruction. Arch Orthop Trauma Surg 133:215–218CrossRefGoogle Scholar
  34. 34.
    Vairo GL (2014) Knee flexor strength and endurance profiles after ipsilateral hamstring tendons anterior cruciate ligament reconstruction. Arch Phys Med Rehabil 95:552–561CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Panagiotis Kouloumentas
    • 1
    Email author
  • Efstratios Kavroudakis
    • 1
  • Efstathios Charalampidis
    • 1
  • Dimitris Kavroudakis
    • 2
  • Georgios K. Triantafyllopoulos
    • 1
  1. 1.Orthopaedics and Sports Orthopaedics ClinicMetropolitan HospitalPiraeusGreece
  2. 2.Department of GeographyUniversity of the AegeanMytileneGreece

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