Abstract
We propose a new technique, with double bundle, double tibial tunnels with a bridge between them, using the hamstrings as auto-grafts, retaining either their central or peripheral attachment. A prospective series of 41 patients underwent primary reconstruction of the anterior cruciate ligament by one surgeon, arthroscopically and electronically assisted; 37 were men and 4 were women with a mean age of 24.7 years. The mean follow-up was19.05 (12–30) months. Normal function and joint stability was achieved. The patients returned to full occupational activities within 3–6 months after the operation. The function of hamstrings was not disturbed. Two patients have sustained a new injury without rupture of the grafts. The Noulis-Lachman test was negative in 35 knees. Positive Pivot shift, post-operatively, was present in 15.45% of patients. The IKDC score was 84.55. In the proposed ACL reconstruction technique, the two tendons are transferred and used as grafts, with gracillis and semitendinosus retaining their distal and central attachment, respectively; the former superimposed upon the latter while entering the femoral tunnel. The tibial tunnels leave a bone bridge ranging between 12 and 15 mm within the footprints of ACL. The two bundles are tensioned, each at different angle. This configuration imitates both the anatomy and the function of ACL and controls not only the anterior translation, but also the rotatory stability. With this innovative technique, the final outcome is improved, thus being closer to normal, as evidenced from previous experiments and the present prospective series.
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References
Arnoczky SP (1983) Anatomy of the anterior cruciate ligament. Clin Orthop 172:19–25
Bellier G, Christel P, Colombet P, Djian P, Francheschi JP, Sbihi A (2004) Double-stranded hamstring graft for anterior cruciate ligament reconstruction. Arthroscopy 20(8):890–894
Brown GH Jr., Wilson DR, Hecker AT, Ferragamo M (2004) Graft-bone motion and tensile properties of hamstring and patellar tendon anterior cruciate ligament femoral graft fixation under cyclic loading. Arthroscopy 20(9):922–935
Cha PS, Brucker PU, Weat RV, Zelle BA, Yagi M, Kurosaka M, Fu FH (2005) Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy 21:1275.e1–1275.e8
Clancy WR Jr, Rajesh GN, Rosemberg TD (1981) Anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J Bone Joint Surg 63A:1270–1284
Fetto JF, Marshall JL (1980) The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 147:29–38
Frank CB, Jackson DW (1997) The science of reconstruction of the anterior cruciate ligament. J Bone Joint Surg 79-A:1556–1576
Gabriel MT, Wong EK, Woo SL, Yagi M, Debski RE (2004) Distribution of in situ forces in the anterior cruciate ligament in response to rotatory loads. J Orthop Res 22:85–89
Girgis FG, Marshall JL, Al Monajem ARS (1975) The cruciate ligaments of the knee joint: anatomical, functional and experimental analysis. Clin Orthop 106:216–321
Hollis JM, Takai S, Adams DJ, Horibe S, Woo SL (1991) The effects of knee motion and external loading on the length of the anterior cruciate ligament (ACL): a kinematic study. J Biomech Eng 113(2):208–214
Howell SM, Knox KE, Farley TE, Taylor MA (1995) Revascularization of a human anterior cruciate ligament graft during the first two years of implantation. Am J Sports Med 23:42–49
Ishibashi Y, Tsuda E, Tazwa K, Sato H, Toh S (2005) Intraoperative evaluation of the anatomical double-bundle anterior cruciate ligament reconstruction with the OrthoPilot navigation system. Orthopedics 28:1277–1282
Kartus J, Ejerhed L, Sernert N, Brandsson S, Karlsson J (2000) Comparison of traditional and subcutaneous patellar tendon harvest. A prospective study of donor site-related problems after anterior cruciate ligament reconstruction using different graft harvesting techniques. Am J Sports Med 28:328–335
Kapandji IA (1976) The physiology of the joints, vol 2, 2nd edn. Churchill Livingstone, London (Reprint)
Miyasaka KC, Daniel DM, Stones ML, Hirschman P (1991) The incidence of knee ligaments in the general population. Am J Knee Surg 4:43–48
Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K (1999) Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with endo-buttons: operative technique and preliminary results. Arthroscopy 15:618–624
O´Brien SJ, Warren RF, Pavlof H, Panariello R, Wickiewikz TL (1991) Reconstruction of the chronically insufficient anterior cruciate ligament whith the central third of the patellar ligament. J Bone Joint Surg (Am) 73:258–286
Papachristou G, Priftis G, Efstathopoulos N, Levidiotis C (1993) Acute rupture and chronic insufficiency of anterior cruciate ligament. Acta Orthop Hellenica 44:49–52
Papachristou G, Tilentzoglou A, Efstathopoulos N, Khaldi L (1998) Reconstruction of anterior cruciate ligament using the doubled tendon technique: an experimental study in rabbits. Knee Surg Sports Traumatol Arthrosc 6:246–252
Papachristou G, Sourlas J, Magnissalis EA (2003) Biomechanical evaluation of a double- bundle technique for the recostruction of ACL. In: Proceedings of International Association of Science and Technology for Development IASTED. Biomechanics. ACTA Press, Calgary, pp 12–17
Papachristou G, Nikolaou V, Frangia K, Sourlas J, Lazarettos J, Efstathopoulos N (2005) ACL reconstruction using autologous semitendinosus tendon graft retaining the tibial insertion. Histologic study in rabbit model. In: Proceedings, 3rd Biomechanic Congress, IASTED, Spain
Papachristou G, Sourlas J, Magnissalis EA, Plessas S, Papachristou K (2006) ACL reconstruction and the implication of its tibial attachment for the stability of the joint: anthropometric and biomechanical study. Int Orthop 31(4):465–470
Papachristou G, Kalliakmanis A, Papachristou K, Magnissalis E, Sourlas J, Plessas S (2007) Comparison of fixation methods of double-bundle double-tibial tunnel ACL reconstruction and double-bundle single tunnel technique. Int Orthop (in press)
Papachristou G, Nikolaou V, Efstathopoulos N, Sourlas J, Lazarettos J, Frangia K, Papalois A (2007) ACL reconstruction with semitendinosus tendon autograft without detachment of its tibial insertion: a histologic study in a rabbit model. Knee Surg Sports Traumatol Arthrosc 15(10):1175–1180
Papageorgiou CD, Ma CB, Abramowitch SD, Clineff TD, Woo SL (2001) A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med 29(5):620–626
Papastergiou SG, Voulgaropoulos H, Mikalef P, Ziogas E, Pappis G, Giannakopoulos I (2006) Injuries to the infrapatellar branch(es) of the saphenous nerve in anterior cruciate ligament reconstruction with four-strand hamstring tendon autograft: vertical versus horizontal incision for harvest. Knee Surg Sports Traumatol Arthrosc 14(8):789–793
Park MJ, Lee MC, Seong SC (2001) A comparative study of the healing of tendon autograft and tendon-bone autograft using patellar tendon in rabbits. Int Orthop 25(1):35–39
Pederzini L, Adriani E, Botticella C, Tosi M (2000) Double tibial tunnel using quadriceps tendon in anterior cruciate ligament reconstruction. Arthroscopy 16(5):9e
Petersen W, Tillmann B (2002) Anatomy and function of the anterior cruciate ligament. Orthopade 31:710–718 (in German)
Petersen W, Tretow H, Weimann A, Herbort M, Fu FH, Raschke M, Zantop T (2007) Biomechanical evaluation of two techniques for double-bundle anterior cruciate ligament reconstruction. One tibial tunnel versus two tibial tunnels. Am J Sports Med 35:228–234
Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J (2007) A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med
Rougraff BT, Shelbourne KD (1999) Early histologic appearance of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 7(1):9–14
Yasuda K, Kondo E, Tchiyama H, Tanabe Y, Toyama H (2006) Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures. Arthroscopy 22(3):240–251
Weiler A, Scheffler SU, Sudcamp NP (2000) Current aspects of anchoring hamstring tendon transplants in cruciate ligament surgery. Chirurg 71(9):1034–1044
Woo SL, Wu C, Dede O, Vercillo F, Noorani S (2006) Biomechanis of anterior cruciate ligament reconstruction. J Orthop Surg 1:2
Zarins B, Rowe CR (1986) Combined anterior cruciate ligament reconstruction using semitendinosus tendon and iliotibial tract. J Bone Joint Surg 68A(2):160–177
Zantop T, Petersen W, Sekiya JK, Mushal V, Fu FH (2006) Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc 14(10):982–992
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Papachristou, G., Sourlas, J., Plessas, S. et al. Arthroscopic ACL reconstruction with Δ plasty: an innovative approach with hamstrings’ transfer and double tibial tunnel. Knee Surg Sports Traumatol Arthr 16, 420–426 (2008). https://doi.org/10.1007/s00167-007-0426-5
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DOI: https://doi.org/10.1007/s00167-007-0426-5