w w w . r b o . o r g . b r
Original
article
Comparison
of
grafts
for
anatomical
reconstruction
of
the
ACL:
patellar
versus
semitendinosus/gracilis
夽
Patrícia
Barros
Bitun
∗,
Carlos
Roberto
Miranda,
Ricardo
Boso
Escudero,
Marcelo
Araf,
Daphnis
Gonc¸alves
de
Souza
Dr.CarminoCaricchioMunicipalHospital,MunicipalHospitalAdministrativeAuthorityofSãoPaulo,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
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n
f
o
Articlehistory:
Received7September2013 Accepted24October2013 Availableonline14February2015
Keywords:
Reconstructionoftheanterior cruciateligament
Transplants Tendons
a
b
s
t
r
a
c
t
Objective:Tocomparethefunctionalresultsfromsurgicaltreatmentforanatomical recon-structionoftheanteriorcruciateligament(ACL)withasingleband,usingtwotypesof autologousgrafts.
Methods:Twenty-sevenpatientswhounderwentanatomicalreconstructionoftheACLby meansoftheChambattechniquewereevaluatedprospectively.Theyweredividedintotwo groups:A,with14patients,usinggraftsfromflexortendons;andB,with13patients,using graftsfromthepatellartendon.Inbothgroups,fixationwasperformedusinganabsorbable interferencescrew.
Results:BasedontheLysholmscore,groupApresentedameanscoreof71.6inthefirst month,whileBpresented75.Attheendofthesixthmonth,bothgroupspresented96.6. EvaluationofthetotalIKDCshowedthatinthefirstmonth,themajorityofthepatients, bothingroupA(85.7%)andingroupB(76.9%),presentedakneeassessmentthatwasclose tonormal.Inthesixthmonth,92.9%ofgroupAhadnormalpresentations,and100%of groupB.
Conclusion:AccordingtotheLysholmfunctionalevaluationandtheIKDCsubjective assess-ment,therewasnostatisticallysignificantdifferenceintheresultsbetweenthegroups,and theresultswerebetterinthesixthmonth.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
夽
WorkdevelopedintheDr.CarminoCaricchioMunicipalHospital,MunicipalHospitalAdministrativeAuthorityofSãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](P.B.Bitun). http://dx.doi.org/10.1016/j.rboe.2015.02.004
Comparac¸ão
dos
enxertos
para
reconstruc¸ão
anatômica
do
LCA:
patelar
versus
semitendíneo/grácil
Palavras-chave:
Reconstruc¸ãodoligamento cruzadoanterior
Transplantes Tendões
r
e
s
u
m
o
Objetivo: Comparar o resultado funcional do tratamento cirúrgico da reconstruc¸ão anatômicadoligamentocruzadoanterior(LCA)combandaúnicacomousodedoistipos deenxertoautólogos.
Métodos: Foram avaliadosprospectivamente 27 pacientes, submetidos à reconstruc¸ão anatômicadoLCApelatécnicadeChambat,divididosemdoisgrupos:A,com14euso comoenxertodostendõesflexores;eB,com13eusocomoenxertodotendãopatelar.Em ambososgruposfoifeitafixac¸ãocomparafusodeinterferênciaabsorvível.
Resultados: CombasenoescoredeLysholm,ogrupoAapresentoupontuac¸ãomédiade71,6 noprimeiromês,enquantooBapresentou75.Jánofimdosextomêsambosapresentaram 96,6.Aavaliac¸ãodoIKDCtotalmostrouquenoprimeiromêsamaioriadospacientes,tanto nogrupoA(85,7%)nogrupoB(76,9%),apresentavaumaavaliac¸ãodojoelhopróximodo normalenosextomêsogrupoAapresentou92,9%comonormaleogrupoB,100%.
Conclusão: Osresultados,segundoavaliac¸ãofuncionaldeLysholmesubjetivadoIKDC,não apresentaramdiferenc¸asestatisticamentesignificantesentreosgruposeforammelhores nosextomês.
©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Surgerytoreconstructtheanteriorcruciateligament(ACL)is frequentlyperformedwithinorthopedicpractice.1
TheACLactsasanessentialstabilizerwithinthe biome-chanicsoftheknee.Inadditiontobeingconsideredtobethe primarystabilizeragainstanteriortranslationofthetibia,it actsasasecondarystabilizeragainstexcessiveinternal rota-tionandvalgusandvarusstress.1
Studieshavealsodemonstratedthatitdiminishesthe pos-sibilityofjointdegeneration,sinceitpromotesprotectionfor thecartilageandmenisci.2
Tearingof this importantligament is common in high-performancesports.Inmakingchangesindirectionorrapid decelerationwith the foot planted onthe ground, individ-ualsmaypromotevalgusstressandstressthroughinternalor externalrotation,therebyinjuringtheligamentwithoutdirect trauma.Oncetheinjuryhasbecomeestablished,thepatient willpresentfrequentepisodesofinstability,pain,edemaand diminishedfunction.Forthisreason,thepossibilityof retur-ningtosports activitieswiththesamevigor and thesame mobilityislow.3
ChoosingthebestautologousgraftforACLreconstruction, inkneeswithinsufficiencyofthisligament,isamatterfor discussion.Graftstakenfromthecentralthirdofthepatellar ligament,asdescribedbyCampbell,4werewidelyusedinthe
1980sand1990s.Attheendofthe1990s,useofthe semitendi-nosusandgracilisflexortendonswasdescribedbyMacey5and
thesegraftsstartedtobeusedmorefrequently.6
TheACLiscomposedoftwobands:posterolateral,which mainlystabilizes rotationalmovements;and anteromedial, which stabilizes movements of anteroposterior transla-tion. Through anatomical studies, a tendency toward ACL
reconstruction usingthe single-band anatomicaltechnique hasbeennoted.7,8
Today, with technological advances, arthroscopic intra-articularreconstructionmakesitpossibletoreduce postop-erative morbidity,9 but divergences between surgeons still
existregardingthebestgrafttouse.
Materials
and
methods
This was a blinded randomized controlled clinical trial. Twenty-seven patientsof bothsexes (25males,92.6%, and two females,7.4%)aged18–48years (mean:31.7)who pre-sented ACLinjurieswereprospectivelyevaluated.Theright sidewasaffectedin19(70.4%)andtheleftsideineight(29.6%). Twelve(44%)presentedlesionsofthemedialmeniscusand onepatient had lesionsofboththe medialand the lateral meniscus.
The inclusion criteriarequired that the patients should present a unilateral ACL tear and the absence of surgical antecedentsorpreviouspathologicalconditionsintheknee affected.
These patients were randomly divided into two groups, throughadrawthatdeterminedthetypeofgraft(patellaror flexor)tobeusedinACLreconstructionsurgery.
GroupA,composedof14patients,underwentACL recon-struction using autologous grafts from the flexor tendons, whilegroupB,with13patients,receivedagraftfromthe patel-lartendon.
Fig.1–(A)Flexortendon;(B)patellartendon.
Afterthereconstruction,bothgroupswerereferredtothe sameearlyrehabilitationprogram,whichwasconducted indi-viduallybytrainedprofessionals.
All the patients were evaluated atthe outpatient clinic bythesameresearcher,one,threeandsixmonthsafterthe operation.TheInternational KneeDocumentation Commit-tee(IKDC)200010andLysholmprotocolswerefollowed.11The
IKDCiscomposedof10objectivequestions,subdividedinto sevenonsymptoms,twoonsportsactivitiesandoneon func-tionalitybeforeand aftertheinjury. ThemodifiedLysholm scaleiscomposedofeightquestionsinwhichtheoptionsare closedresponses,suchthatthefinalresultisexpressedthus: from95to100pointsas“excellent”;from84to94as“good”; from 65 to83 as “fair”; and 64 orunder as “poor”.11 After
thedata-gathering,thesedataweresubjectedtodescriptive statisticalanalysisusingpercentagefrequencies.
Thestatisticalanalysiswasperformedusingthefollowing software:SPSS®V17,Minitab®16andExcelOffice®2010.The
confidenceinterval(p)of95%wasusedinparametric statis-ticaltests,sincethedatawerequantitativeandcontinuous, andthecentrallimittheoremwasused,whichensured nor-maldistribution.Thus,therewasnoneedtotestthenormality oftheresidualsandparametrictestswereuseddirectly,given thatthesearemorepowerfulthannonparametrictestssuch asANOVAandequalityoftwoproportions.
Surgical
technique
Thetwogroupsdifferedregardingthegrafttobeused(Fig.1), whichwasharvestedfromtherespectivedonorareasusing routineprocedures.Thereconstructionwasdoneusingthe Chambattechniqueandwasthesameforbothgroups.12
Afterarthroscopyandtreatmentofassociatedlesions,the tunnelswereconstructedindependently,frominsideto out-side. By means of a lateral access, 2cm above the lateral epicondyle,aguidewirewasintroducedusingatibialguide adapted for constructing a femoral tunnel, at an angle of 80–90◦ (Figs. 2 and 3), which emerged between the joints,
betweentheoriginsofthetwobands(thefootprints)ofthe lateralcondyleattheanatomicallocationoftheACLonthe femur. Using this guidewire, progressivedrilling witha bit correspondingtothethicknessofthegraftwasperformed.
Thetibialtunnelwasconstructedwiththeremainsofthe ACLonthetibiaasareferencepoint,orinparalleltothe pos-teriormarginoftheanteriorcornuofthe lateralmeniscus,
Fig.2–Guideadaptedforthefemur.
Fig.4–Graftfixationusingabsorbablescrew:(A)tibial fixation;(B)femoralfixation.
withprogressivedrilling.Thegraftwaspassedthroughfrom distallytoproximally,usingtwoEthibond2.0threads.After this,thegraftwasfixedusingabsorbableinterferencescrews inthefemurandtibia,respectively13(Fig.4).
Results
Toanalyzetheresultsfromthegroupsafterthesurgical treat-ment,theparametersfromtheIKDCindexandthefunctional parametersfromtheLysholmscalewereusedinthefirst,third andsixthmonthsaftertheoperation.
TheLysholmfunctionalscalepresentedameanscoreof 71.6outof100ingroupA,inthefirstmonth,whilegroupB
120 100 80 60 40 20 0
1m 3m 6m
96.6 96.6 75
71.6
Group A Group B
Group comparison using lysholm
86.5 89.1
Fig.5–Comparisonbetweenthegroupsaccordingtothe Lysholmscale.
Group comparison using distribution of total IKDC
150%
100%
50%
0%
Group A Group B
1m 3m 6m
A B C A B A B
14.3% 15.4% 85.7% 76.9%
0.0% 7.7%
50.0%
76.9%
50.0%
23.1%
92.9% 100.0%
7.1% 0.0%
Fig.6–Comparisonbetweenthegroupsaccordingtothe totalIKDCscale.
presentedmeanof75.Attheendofthesixthmonth,they presentedthesamemeanscoresof96.6(Fig.5).
TheevaluationusingtheIKDCscaleshowedthatinthefirst month,thekneeassessmentsonthemajorityofthepatients wereclosetonormal,bothingroupA(85.7%)andingroup B(76.9%).Inthesixthmonth,92.9%ofthepatientsingroup Awere assessedasnormaland100%ingroupB.However, statistically,neithertheLysholmnortheIKDCscalepresented anysignificantdifferences,withp>0.05(Fig.6).
Bothgroupspresentedlimitationsregardingtherangeof motioninthefirstmonthaftertheoperation.Inrelationto flexion,14.3%ofthepatientsingroupAand7.7%ingroup Bpresentedlimitations.Inrelationtoextensioninthefirst month,groupAwasalreadyfreefromlimitations,while15.4% of the patientsin groupB presentedlimitations.After the rehabilitationwithphysiotherapy,therewereimprovements among the patients in bothgroups and no joint range-of-motiondeficits were seen inthe sixth month.Statistically, therewerenosignificantdifferencesbetweenthegroups.
FromtheevaluationusingtheIKDCscale,thecriteriaof graftdonorareaandanteriorkneepaindidnotpresentany statistically significant differences at the end of the sixth month,inbothgroups(Figs.7and8).GroupBpresentedtwo casesofhealingthatwasdelayeduntilthethirdmonth.
Inthe evaluationusingtheLachman test,theresultsin groupBwerebetterinthethirdandsixthmonths,with trans-lation of1–2mm in 100%, while in group A, 42.9% of the patientspresentedtranslationof3–5mm(Table1).
Group comparison using distribution of alterations in the graft donor areas
100.0%
84.6%
0.0% 15.4%
92.3%
100.0% 100.0% 100.0%
A
B
A
B A
7.7%
0.0%
3m 6m
m 1
Group A Group B 100%
150%
50%
0%
Fig.7–Comparisonbetweenthegroupsregarding
alterationsinthegraftdonorareas.
Group comparison using distribution of anterior knee pain
7.1% 7.7% m 6 m 3 m 1 100% 50% 0% Group A
A
B
C
A
B
C A
B
Group B
78.6%
69.2%
14.3% 23.1% 28.6%
53.8% 71.4% 38.5% 0.0% 7.7% 78.6% 84.6% 21.4% 15.4%
Fig.8–Comparisonbetweenthegroupsregardinganterior kneepain.
whiletherewasafallto84.6%ingroupB.Attheendofthe sixthmonth,groupBpresentedatendencytowardless ante-riorizationofthetibia(Table2).
Regardingthe ligamentevaluationoverall (i.e.Lachman, “full stop”, anterior drawer, posteriorization of the tibia, medialandlateralopeningandpivotshift),groupsAandB didnotpresentanydifferencesintheirresults,inanyofthe evaluations.
Table1–Comparisonbetweenthegroupsthrough assessmentbymeansoftheLachmantest.
Lachman GroupA GroupB p-Value
N % N %
1m A 11 78.6% 13 100% 0.077
B 3 21.4% 0 0% 0.077
3m A 8 57.1% 13 100% 0.007
B 6 42.9% 0 0% 0.007
6m A 8 57.1% 13 100% 0.007
B 6 42.9% 0 0% 0.007
Table2–Comparisonbetweenthegroupsthrough assessmentbymeansoftheanteriordrawertest.
Anteriordrawer GroupA GroupB p-Value
N % N %
1m A 8 57.1% 13 100% 0.007
B 6 42.9% 0 0% 0.007
3m A 5 35.7% 11 84.6% 0.010
B 9 64.3% 2 15.4% 0.010
6m A 5 35.7% 9 69.2% 0.082
B 9 64.3% 4 30.8% 0.082
Discussion
ACL reconstruction hasbeen widelydiscussed over recent
years.Theseinjuriesoccurfrequently,especiallyintheage groupfrom20to40years.Foralongtime,thepatellar ten-donwaschosenasthemainsourceofgrafts,14butbecauseof
themorbiditiespresented,someauthorshavechosentouse flexortendons.Thishasledtomanycomparativestudies.9
In2001,Erikssonetal.15demonstratedthatusingthe
patel-lartendonproducedaslightadvantageinrelationtostability. On the other hand,in ameta-analysis in2005,Prodromos etal.16showedthatinstabilityandlaxityamonggraftsfrom
theflexortendonsoccurredbecauseofthefixationmethods used,andthatifmethodsthatweremoreeffectivewereused, theresultsweresimilartothoseusinggraftsfromthepatellar tendon.17,18
Inthepresentstudy,itwasdecidedtofixthegraftsfrom thepatellarandflexortendons,bothinthetibialandinthe femoraltunnel,usinganabsorbableinterferencescrew,since thishasbeenshowntopresentexcellentfixationresults,with adequatestiffness.19–22
Inadditiontogoodfixation,theobjectivenowadaysisto achieveanatomicalreconstructionoftheACL,soasto reestab-lishthestructuralandbiomechanicalpropertiesoftheknee,7,8
especiallyinrelationtorotationalinstability.8Recentstudies
havecomparedanatomicACLreconstructionusingadouble bandandasingleband.7,23AccordingtoMisonooetal.,7there
arenostatisticaldifferencesregardingrotationalstability.In thepresentstudy,itwasdecidedtoperformanatomical recon-struction usingasingleband,sincethe techniquepresents lower complexity and lower cost and it facilitatespossible revisions.7
Thepresentstudydidnotpresentanystatistically signif-icantdifferenceincomparativeanalysisbetweengraftsfrom thepatellarandflexortendons,asobservedusingtheLysholm method,whichsubjectivelyevaluateskneefunctionand pro-ducedexcellentresultsattheendofthesixth month.This resulthasalsobeenseeninotherpublishedstudies.9,22,24
Asalsoobservedbyotherauthors,nodifferenceingraft use was observed whenthis was assessed usingthe IKDC scale.24–26
In2003,Janssonetal.27conductedaprospective
random-izedstudyon89patientswhowerefollowedupfor21months, in which they observedthat ACL reconstruction using the patellartendonpresentedlimitationofextensionduringthe firstyearandbecamenormalbytheendofthisperiod. Gold-blattetal.28demonstratedin2005thatpatientsinwhomthe
patellartendonwasusedasagraftpresentedgreater exten-sion deficits (5◦ or more), whilethose in whom the flexor
tendonswereusedpresentedflexiondeficitsof5◦ormore.In
2007,inaprospectivestudy,Laxdaletal.26didnotobserveany
statisticallysignificantdifferenceinrangeofmotionbetween thegroupsstudied,asalsoseeninthepresentstudy.
Some studies have shown thatpatients present greater complaintsofpainintheanteriorregionoftheknee, particu-larlywhenkneelingdown,whenthepatellartendonisusedas agraft.9,25,27InastudybyVasconcelosetal.,25amongpatients
otherstudieshavereportedthattherewasnostatistical dif-ferenceinkneepainbetweenthegraftsused,15,18inthesame
wayasseenintheresultsfromthepresentstudy.
Overall,theligamentevaluationsinkneesthatunderwent ACLreconstructiondidnotshowany statisticaldifferences between the groups observed, either in our study or in others.15,27,29 Usingthe anteriordrawertestaloneto
evalu-atethereconstructedtendon,itwasobservedoverthefirst threepostoperativemonthsthattheanteriortranslationofthe tibiaatflexionof90◦wasgreaterinthegroupinwhichflexor
tendonswereused.Aftersixmonthsofevaluation,therewas nodifferencebetweenthegroups.22IntheLachmantest,
bet-terresultswereobservedinthethirdandsixthmonthsafter theoperation,inthepatientsinwhomtheligament recon-structionwasperformedusingthepatellartendon.Thisresult differedfromwhatwasobservedinthestudybyPinczewski etal.,24inwhichnodifferencebetweenthegroupsafter10
yearsoffollow-up.
Thepresentstudycanbecriticizedintermsofthesmall numberofpatientsselected(n=27),theshortlengthof follow-up,the greaterproportionofmalepatients, theabsence of statisticalevaluation on associatedlesions and the lackof arthrometerforgreaterprecisionofevaluationonthe recon-structedligament.
Conclusion
AccordingtotheLysholmfunctionalevaluationandtheIKDC subjectiveassessment,therewasno statisticallysignificant differenceintheresultsbetweenthegroups.Itissuggested thatinfuturestudies,associatedlesionsshouldbeevaluated, withlongerfollow-upanduseofanarthrometerfor assess-mentsofgreaterprecision.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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