Rev. bras. ortop. vol.50 número6

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w w w . r b o . o r g . b r

Original

Article

Functional

results

from

reconstruction

of

the

cruciate

ligament

using

the

central

third

of

the

patellar

ligament

and

flexor

tendons

夽

Marcos

George

de

Souza

Leao

∗

_,

_Abelardo

_Gautama

_Moreira

_Pampolha,

Nilton

Orlando

Junior

Fundac¸ãoHospitalAdrianoJorge,Manaus,AM,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received11September2014 Accepted23October2014 Availableonline17October2015

Keywords:

Anteriorcruciateligament Knee

Treatment

a

b

s

t

r

a

c

t

Objectives: Toevaluatekneefunctioninpatientsundergoingreconstructionoftheanterior

cruciateligament(ACL)usingthecentralthirdofthepatellarligamentorthemedialflexor tendonsoftheknee,i.e.quadrupleligamentsfromthesemitendinosusandgracilis(ST-G), bymeansoftheKneeSocietyScore(KSS)andtheLysholmscale.

Methods:Thiswasarandomizedprospectivelongitudinalstudyon40patientswho

under-wentarthroscopicACLreconstructionbetweenSeptember 2013andAugust2014. They comprised37malesandthreefemales,withagesrangingfrom16to52years.Thepatients werenumberedrandomlyfrom1to40:theevennumbersunderwentsurgicalcorrection usingtheST-Gtendonsandtheoddnumbers,usingthepatellartendon.Functional evalua-tionsweremadeusingtheKSSandLysholmscale,appliedintheeveningbeforethesurgical procedureandsixmonthsaftertheoperation.

Results:Fromthestatisticalanalysis,itcouldbeseenthatthepatients’functionalcapacity

wassignificantlygreateraftertheoperationthanbeforetheoperation.Therewasstrong evidencethatthetwoformsoftherapyhadsimilarresults(p=>0.05),inallthecomparisons.

Conclusions: TheresultsfromtheACLreconstructionsweresimilarwithregardtofunctional

recoveryofthekneeandimprovementofqualityoflife,independentofthetypeofgraft. Itwasnotpossibletoidentifythebestmethodofsurgicaltreatment.Thesurgeon’sclinical andtechnicalexperienceandthepatientarethefactorsthatdeterminethechoiceofgraft typeforuseinACLsurgery.

夽

WorkperformedattheFundac¸ãoHospitalAdrianoJorge,Manaus,AM,Brazil.

∗ _{Corresponding}_author_.

E-mail:mgsleao@uol.com.br(M.G.deSouzaLeao).

http://dx.doi.org/10.1016/j.rboe.2015.10.002

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Resultados

funcionais

da

reconstruc¸ão

do

ligamento

cruzado

com

o

terc¸o

central

do

ligamento

patelar

e

os

tendões

flexores

Palavras-chave:

Ligamentocruzadoanterior Joelho

Tratamento

r

e

s

u

m

o

Objetivos: Avaliarafunc¸ãodosjoelhosempacientessubmetidosàreconstruc¸ãodo

liga-mentocruzadoanterior(LCA),comoterc¸ocentraldoligamentodapatela(TP)ouostendões flexoresmediaisdojoelho(semitendíneoegrácilquádruplos:ST-G)ipsilaterais,pormeio doKneeSocietyScore(KSS)edaescaladeLysholm.

Métodos: Estudolongitudinal,prospectivoerandomizado,com40pacientessubmetidosà

reconstruçãodoLCAporviaartroscópica,desetembrode2013aagostode2014,dosquais 37eramdosexomasculinoetrêsdofeminino,comde16a52anos,enumeradosdeforma aleatóriade1a40.Osnúmerosparesforamsubmetidosàcorreçãocirúrgicacomostendões doST-GeosnúmerosimparescomoTP.ForamaplicadosparaaavaliaçãofuncionaloKSS eaescaladeLysholmnanoiteanterioraoprocedimentocirúrgicoecomseismesesde pós-operatório.

Resultados: Emanáliseestatísticafoipossívelobservarquenopós-operatórioacapacidade

funcionaldospacientesfoisignificativamentemaiordoquenopré-operatório.Háfortes evidênciasdequeambasasterapêuticassejamsimilaresemseusresultados(p=>0,05),em todasascomparac¸ões.

Conclusões: Osresultadosdareconstruc¸ãodoLCA,independentementedotipodeenxerto,

sãosimilaresnarecuperac¸ãofuncionaldojoelhoenamelhoriadaqualidadedevida.Nãofoi possívelidentificarmelhormétododetratamentocirúrgico.Aexperiênciaclínica,atécnica docirurgiãoeopacientesãoquemditamaescolhadotipodeenxertoquedeveráserusado paraacirurgiadoLCA.

Introduction

Anteriorcruciateligament(ACL)injuriesarethecommonest ligamentinjuriesoftheknee.Consideringthattearsofthis ligamentmainlyaffectyoungindividualswhopracticesports, thetreatmentinstitutedneedstoprovidethesepatientswith theconditionsforthemtoreturntotheirsport.1

Withtheaimofachievingthisobjective,manytechniques havebeen developedforreconstructingthe ACL,especially over the last 30 years, using autografts, allografts or syn-thetic grafts, including through advances in arthroscopic techniques.2 _Today, _the _two _options _most _commonly _used

forACL reconstructionusing autograftsinvolve use ofthe medialhamstring muscles, quadruple semitendinosusand gracilis(ST-G)and thecentralthirdofthe patellaligament (PT).3

Recently,manysystems havebeen developedfor evalu-ating the pre and postoperativeresults from patients who undergosurgicalproceduresontheknee.4_Use_of_these_scales

servesasanevaluationparameterandthusmakesit possi-blemeasurementstobestandardizedandmadeuniformand reproducible,inrelationtotreatmentproposals.

The Knee Society Score (KSS) combines subjective and objectiveinformation;separatesthekneescore(pain,stability, rangeofmotion,etc.)frompatients’functionalscores(ability towalkandgoupanddownstairs);andassessesthe clini-calconditionwithregardtopainintensity,rangeofmotion, anteroposteriorandmediolateralstability,contractures dur-ingflexion,deformitiesandmisalignment.5

TheLysholmscaleisoneofthequestionnairesmostused forevaluatingkneesymptoms.Itiscomposedofeight ques-tions,withclosedalternativesfortheresponses,andthefinal resultisexpressedbothinwordsandinnumbers:“excellent”, from95to100points;“good”,from84to94points;“fair”,from 65to83points;and“poor”,whenthevaluesarelessthanor equalto64points.6

Thepresentstudyhadtheaimofevaluatingpatientswho underwentsurgicaltreatmentforarthroscopicreconstruction oftheACLusinganautograftfromtheST-GorPT.Toachieve thisobjective,theKSSandLysholmscalesneededtobeused, appliedduringtheimmediatepreoperativeperiodandafter sixmonthsoffollow-up, inordertoascertainwhetherone techniquemightsuperiortotheother(ST-GversusPT).

Materials

and

methods

Between September 2013 and August 2014, a randomized prospectivelongitudinalstudywasconductedamongpatients for whom surgical treatment for ACL injuries had been indicated, becauseofcomplaintsofinstabilityand positive physicalandcomplementaryexaminations.Theseoperations wereperformedusinganipsilateralautografteitherfromthe centralthirdofthepatellarligament(PT)orfromthemedial flexortendonsoftheknee,i.e.thesemitendinosusandgracilis (ST-G).

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outpatientclinic,withaconfirmed diagnosis ofACLinjury alone, with anauthorization for hospitalization requested, andwithanoperationperformedonlybytheprincipal inves-tigator. The criteria considered for exclusions comprised situationsofcomplexkneeinjuries(involvingmultiple liga-ments,osteoarthritisandmeniscalinjuries),revisionsurgery, inflammatory pathological conditions, obesity (body mass index>30),withdrawalofthepatient,operationsperformed byothersurgeonsandrefusaltosignthefreeandinformed consentstatement. Patients were only counted withinthe methodologyandwithinthestatisticalanalysisontheresults iftheymetalloftheinclusioncriteria.

Forty authorizations for hospitalization were gathered from the appropriate sectorof our institution. From these documents,fortypatientswhohadbeenscheduledfor arthro-scopicACLreconstructionwerenumberedrandomly(from1to 40).Thosewithevennumbersunderwentsurgicalcorrection usingtheipsilateralST-G,fixedwithanEndobutton®_CL_in_the femurandatitaniuminterferencescrewinthetibia.Those withoddnumbersreceivedtheipsilateralPTbymeansofa singleincision,fixedwithtwotitaniuminterferencescrews, inthefemurandinthetibia.Allthesurgicalprocedureswere performedunderspinalanesthesia,withatourniquetatthe rootof the thigh of the limbto be operated, with a pres-sureof350mmHg.Thegraftswereharvestedaccordingtothe patient’sgroup.Arthroscopywasperformedandthefemoral tunnelwasconstructedstartingfromtheanteromedialportal atthecenterofthescarofthenativeACL.Thetibialtunnelwas createdusingaspecificguide,withtheexitatthecenterofthe nativeACL.Thepostoperativerehabilitationprotocolwasthe sameforallthepatients.Itwasimplementedatthe institu-tion’sownphysiotherapyservice,wherethephysiotherapists wereunawareoftheresearchprojectthatwasinprogress.

Thegroupofpatientswithevennumberswascomposedof onefemalepatient(5%)and19malepatients(95%).Theages ofthesepatientsrangedfrom16to52years,withameanof 32(standarddeviation±8years),andninepatients(45%)were intheagegroupfrom30to39years.Theleftandrightsides wereaffectedatthesamerate(50%).

Thegroupofpatientswithoddnumberswascomposedof twofemalepatients(10%)and18malepatients(90%).Theages ofthesepatientsrangedfrom18to48years,withameanof 32±9,andninepatientswereintheagegroupfrom30to39 years.Therightsidewasoperatedin11patients(55%)andthe leftinnine(45%).

The Knee Society Score and the Lysholm scale, which havebeenvalidatedforthePortugueselanguage,wereused to evaluatethe functional results. The first ofthese com-binessubjectiveandobjectiveinformationandthesecondof thesepresentseightquestionswithclosedalternativesasthe responses,andtheywere appliedintheeveningbeforethe surgicalprocedureandsixmonthsaftertheoperation,with anactivesearchforpatientsiftheydidnotreturnforthe out-patientconsultation. Allthe patientswere operatedbythe seniorauthor,whohasexperienceoftreatingkneeinjuries. Thisauthordidnotparticipateintheprocessofapplyingthe questionnairebeforeandaftertheoperation.

All the patients evaluated in this study signed a free and informed consent statement. The study was submit-tedtothe institution’s research ethicscommitteeand was

approvedundertheethicsassessmentcertificate(CAAE) num-ber18321113.5.0000.0007.

ThedataweretabulatedintheMicrosoftExcel®_software and the resultswerepresentedintables, graphsand mea-surements (mean, standard deviation (SD) and coefficient ofvariation).Descriptiveandinferentialanalyseswere per-formedontheresults.AllthecomparisonsrelatingtotheKSS andLysholmwereperformedbymeansoftheMann–Whitney test.Thesignificantlevelwastakentobe5%inallofthese comparisons. All of the variables were analyzed using the Minitabstatisticalsoftware,version14.1.

Results

Toensuretheprecisionofthecomparisons,thehomogeneity ofthetwosampleswasascertained.Takingthesignificance leveltobe5%,itwasobservedfromLevene’stestthat homo-geneityofthesamplewasassured(p>0.05).Inotherwords, theages,gendersandsidesaffectedwerestatisticallyequal

(Table1).

AmongtheACLreconstructionresults,bothfrompatients whoreceivedST-Gautografts(Table2)andfromthosewithPT grafts(Table3),itcouldbeseenthroughtheMann–Whitney

Table1–Homogeneitytestonthepatientsample studied,whounderwentACLreconstructionusingST-G andPTautografts.

Characteristics Standarddeviation pvaluea

ST-G PT

Age 8.565 9.136 0.782

Genderb _0.224 _0.308 _0.560

Sideaffectedb _0.513 _0.510 _0.664

ST-G,medialkneeflexors;PT,centralthirdofpatellartendon.

a _Levene’s_test.

b _Gender_and_side_affected_were_coded_numerically_in_order_to_apply

thetest.

Table2–Comparisonofthefunctionalcapacityofthe patientsoftheST-GgroupaccordingtotheKSSand Lysholmscales.

Methods Median pvalue

Beforeoperation Afteroperation

KSSknee 67.5 90.0 0.0001

KSSfunctional 80.0 90.0 0.0001

Lysholm 60.5 90.5 0.0001

Table3–Comparisonofthefunctionalcapacityofthe patientsofthePTgroupaccordingtotheKSSand Lysholmscales.

Methods Median pvalue

Beforeoperation Afteroperation

KSSknee 70.0 91.5 0.0001

KSSfunctional 80.0 90.0 0.0001

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100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0

0.0

KSS knee KSS functional Lysholm

Frequency, %

Before operation After operation

Methods

Fig.1–Comparisonofthemethodsforevaluatingthe functionalcapacitybeforeandaftertheoperation,among thepatientswhoreceivedST-Gautografts.

100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

KSS knee KSS functional Lysholm

Frequency, %

After operation Before operation

Methods

Fig.2–Comparisonofthemethodsforevaluatingthe functionalcapacitybeforeandaftertheoperation,among thepatientswhoreceivedPTautografts.

testthattherewasstrongevidencethataftertheoperation, thepatients’functionalcapacitywassignificantlygreaterthan beforethe operation,takingthesignificancelevel tobe5% (p<0.05).

Figs.1and2showgeometricallythatbothontheKSSand

on the Lysholmscale there wasa significantimprovement aftertheoperationinbothgroups(ST-GandPT,respectively). Incomparingfunctionalcapacityfrombeforetoafterthe operationamongpatientswhounderwent boththerapeutic methods(Table4),itcouldbeseenthroughtheMann–Whitney test(whichusesthemedianastheparameter)thattherewas strongevidencethatthetwotherapeuticmethodshadsimilar resultsinallcomparisons(p>0.05).

Discussion

The ACL presents poor potential for spontaneous healing whenitiscompletelytorn.Aroundtwo-thirdsofthepatients with this injury evolve to a high degree of knee instabil-ity, which worsens with the return to physical activities, resultsinrecurrentsubluxationandevolvestofuture func-tional incapacity,meniscallesionsand earlyappearanceof osteoarthrosis (OA).7–10 _Among_the _patients_with_ACL _tears

alone or in combination with meniscal lesions or injuries tocollateralligaments,60–90%evolvetoradiographic alter-ationsindicativeofosteoarthrosiswithin10–15years,withthe onsetofsymptomsoccurring10–20yearsearlierthanamong patientswithprimaryOA.11,12

Conservative treatment of ACL injuries may function reasonably well under certain circumstances, especially in patientswho presentminimal exposuretohigh-risk activi-tiesandgoodadaptationtoligamentinsufficiency,orwhen an advanced process of degenerative arthritis in the knee involvedcanalreadybeseen.13

Over the last two decades, the commonest question regarding ACL surgery has been “which is the best graft to choose?” The PT used to be considered to be the gold standardforACLreconstruction.Thereasonsforthisinclude thestrengthofthegraft,therelativeeaseofharvestingitand thebone-to-bonehealingwithsecurefixation.Recently,use ofST-Gautograftshasgainedinpopularityamongsurgeons’ choices.14_The_current_trend_toward_increased_use_of_the

ST-Gcomesfromthecaretakentoavoidthepotentialnegative effectontheextensormechanismthatmayensuefromthe PT, along withthe morbidity inthe PTdonor area, which may includeanterior knee pain and the risk of fracturing thepatella.15_Nonetheless,_despite_the_increasing_popularity

Table4–Comparisonoffunctionalcapacityfrombeforetoaftertheoperationamongthepatientswhounderwentboth therapeuticmethods(medialkneeflexorsandcentralthirdofthepatellarligament).

Time Therapy KSSknee KSSfunctional Lysholm

Median SD Median SD Median SD

Beforeoperation ST-G 67.5 11.1 80.0 14.4 60.5 12.9

PT 70.0 9.6 80.0 11.3 56.5 14.1

pvaluea _0.250 _0.449 _0.797

Afteroperation ST-G 90.0 7.1 90.0 10.8 90.5 10.0

PT 91.0 3.1 90.0 5.1 92.5 6.0

pvaluea _0.091 _0.273 _0.685

SD,standarddeviation;ST-G,medialkneeflexors;PT,centralthirdofpatellartendon.

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ofST-Ggrafts, theyalsohavepotential limitations, includ-ingslowergraftincorporationintothetunnelthanseenwith thePT,potential wideningofthe tunnelsandresidual lax-ityandfunctionalweaknessoftheflexormusculatureonthe sidefromwhichthegraftisharvested.16,17 _In_Brazil,_as_long

agoas 1999,CamanhoandAndrade18 _stated_that _although

themiddlethirdofthepatellarligamenttogetherwithbone fragmentsfromthepatellaandtibiawasforalongtime con-sideredtobetheidealgraft,useofautograftsfromthetendons ofthemedialflexormuscles wasbecomingwidely dissem-inatedbecause oftheirefficiency,fixation methodandlow aggressionofthedonorarea,andcomparisonswiththeuseof middlethirdofthepatellartendonwerestartingtobemade intheliterature.

However,inmaking comparisonsbetweenpatients with tornACLsthatweretreatedsurgicallyandpatientsfollowed upconservatively,Meunieretal.19_concluded_that_there_were

significantlymoremeniscallesionsinpatientswhowere man-agedconservatively,andthatone-thirdofthesecasesevolved tosurgicaltreatmentbecauseofjointinstability.

Amongauthorswhohaveconsideredthatsurgical treat-ment is the first option, ACL reconstruction has been advocatedwiththe objective ofrestoringthe normal kine-matics ofthejoint.In this manner,the instabilityand the potentialassociateddamagetothemenisciandchondral sur-facesareeliminated.Almostuniversally,indicationsforACL reconstructionaremadeinrelationtopatientswhopresent highrisksthroughtheirlifestyle,withdemandsthroughheavy work,sportsorrecreational activitiesthatmightreproduce episodesofsubluxationoftheknee.13

Many studies have already been conductedto compare theautograftsusedintreatmentsforACLinjuries,andthese haveshowedtheirbenefitsand harmforpatientsafterthe operation.20–28

Corry et al.20 _made _a _comparison _of _the _{postoperative}

resultsamongpatients whounderwent ACLreconstruction arthroscopically,using ST-GorPTautografts.Theycameto theconclusionthattherewasnostatisticallysignificant dif-ferencebetweenthetwogroups,intermsofligamentstability, rangeofmotion(ROM)andgeneralsymptoms,twoyearsafter theprocedure.

InastudybyKeaysetal.,21_similar_results_could_be_seen,

with restoration of clinical stability and muscle strength betweenthesurgicalgroupsandcontrols,althoughtherewas adeficitof6%inquadricepsstrengthafterusingPTgrafts.

Erikssonetal.22 _also_concluded_that_there_was _no

clini-caldifferenceover the mediumterm,betweengroupsthat underwentACLreconstructionwiththeST-GorPT.Likewise, AhlenandLiden23_did_not_find_any_{statistically}_significant

dif-ferencesinrelationtomusclestrength,jointinstabilityorROM amongtheirpatients,whowereevaluatedtwoyearsafterthe surgicalprocedure.

However,Samuelssonetal.24_and_Muellner_et_al.25_observed

that the autograft harvesting site initially affected muscle strengthandthatuse ofthePTproducedmorepaininthe anteriorregionofthekneethandidtheST-G.However,both oftheseauthorsstatedthatthesesymptomsdisappearedover thecourseoftime.

AccordingtoKeaysetal.,26_the_incidence_of_{osteoarthritis}

afterACLreconstructionisworrisome,withreportsthatup

to50%ofthesepatientsdevelopitmoderatelyorseverely,six yearsaftertheprocedure.Theseauthorsnotedthatthisevent occurredbecauseofthepresenceofchondrallesions,choice ofthePTastheautograft,presenceofaweakquadriceps,low resistanceratiosofthequadricepsandhamstringsand menis-cectomyperformedatthetimeofthesurgery.Basedonthese results,theyrecommendedthatinclinicallyunstableknees, ACLreconstructionshouldnotbeunnecessarilypostponed,so astoavoidfuturemeniscalandchondrallesions.

Pinczewskietal.27_found_{prospectively}_that_use_of_the_PT

increasedtheincidenceofosteoarthriticradiographic alter-ations inthesepatients’ knees,andalsothat theobserved fixeddeformitiesofflexioncouldpresagetheappearanceof degenerativelesions.

Nonetheless,theidealtimeforACLreconstruction prob-ablydependsontheindividualfactorsofeachpatient,such astheconditionofthekneeandthepatient’smotivationto undergosurgeryandrehabilitation.23

In2012,Mascarenhasetal.3_concluded_that_both_types_of

autograftallowedaround70%ofyoungathletestoreturnto somedegreeofvigorousorveryvigorousphysicalactivity(4–7 timesaweek).ACLreconstructionusingflexortendonsleads tobetterpreservationofextension,betterpatientscoresand less evidenceofosteoarthritis.Althoughwefound numeri-callysuperiorscoresinrelationtotheST-G,thesedifferences werenotstatisticallysignificant.

InalevelIsystematicreview,Reinhardtetal.28_concluded

thattheriskoffailureofACLreconstructionissignificantly greaterwiththeST-GthanwiththePT.TheST-Gwas supe-riorinrelationtoresiduallaxity.Anteriorkneepainwasmore presentinreconstructionsusingthePT.Inrelationto activ-ity leveland functional evaluations,neither techniquewas superiortotheother.

In 2013, Kim et al.29 _did _not _identify _any _significant

differencesintheclinicalresultsandstabilityafterACL recon-struction, inrelation tothe typeofgraft orfixation device chosen.Thus,surgeonsshouldselectthe“ideal”ACL recon-structionmethodaccordingtothepatient’sconditionsandthe surgeon’sexperience.29_These_findings_were_corroborated_by

Abbasetal.,30_who_highlighted_the_concerns_regarding

ante-riorkneepainandpatellofemoralsymptomsthroughuseof thePT.

In2014,Papaliaetal.31_showed_that_there_were_no

differ-encebetweengroupsreconstructedusingtheST-GorPT,in anyoftheclinicalscoresorfunctionaltests.

Inthepresentstudy,itcouldbeseenthattherewasa sta-tisticallysignificantimprovementaftertheoperation,among thepatientsinbothgroupsstudied(KneeSocietyScoreand Lysholm).Incomparingthepresentstudywiththose inves-tigatedinthe literature,similaritiesinthe resultscouldbe observedwhentheLysholmscalewasused.20–23_However,_no

relevantdatawerefoundinrelationtousingtheKSSscalein theliteratureinvestigated,whichthusmakesitimpossibleto comparetheresultsobtainedinthepresentstudy.

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quadricepsforthePTorflexorfortheST-G.Evaluationofthe criteriaforthereturn tosportwas notanobjectiveofthis study.

Conclusion

Theresults from the ACL reconstructions using autografts fromthecentralthirdofthepatellartendonormedialknee flexorsweresimilarwithregardtofunctionalrecoveryofthe kneeandimprovementofqualityoflife.Thus,becauseofthe proximityofthestatisticalresultsfromthisstudy,itwasnot possibletopreciselyidentifythesurgicaltreatmentthatwould providegreatest benefitforpatients, withleast aggression. Therefore,webelievethatclinicalexperience,thesurgeon’s techniqueandrespectforpatients’individualitymakethe dif-ferenceatthetimeofchoosingthetypeofautograftforusein surgicaltreatmenttoreconstructtheACL.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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s

1. GomesJLE,MarczykRLS.Reconstruc¸ãodosligamentos

cruzadosdojoelhocomotendãoduplodosemitendinoso.

RevBrasOrtop.2004;39(4):137–46.

2. GuimarãesMV.Reconstruc¸ãoartroscópicadoligamento

cruzadoanterior:estudocomparativoentreosenxertos

autólogosdeligamentopatelaredetendãodoquadríceps.

RevBrasOrtop.2004;39(1/2):30–41.

3. MascarenhasR,TranovichMJ,KropfEJ,FuFH,HarnerCD.

Bone-patellartendon-boneautograftversushamstring

autograftanteriorcruciateligamentreconstructioninthe

youngathlete:aretrospectivematchedanalysiswith2–10

yearfollow-up.KneeSurgSportsTraumatolArthrosc.

2012;20(8):1520–7.

4. AlbuquerqueRP,GiordanoV,CalixtoA,MalzacF,AguiarC,

AmaralNP,etal.AnálisedoprotocolofuncionaldeLysholm

modificadoempacientescomjoelhosnormais.RevBras

Ortop.2011;46(6):668–74.

5. SilvaALP,DemangeMK,GomesR,SilvaTFC,PécoraJR,Croci

AT.Traduc¸ãoevalidac¸ãodaescalakneesocietyscore:KSS

paraalínguaportuguesa.ActaOrtopBras.2012;20(1):

25–30.

6. PeccinM,CiconelliR,CohenM.Questionárioespecíficopara

sintomasdojoelhoLysholmkneescoringscale(traduc¸ãoe

validac¸ãoparaalínguaportuguesa).ActaOrtopBras.

2006;14(5):268–72.

7. O’DonoghueDH,RockwoodCAJr,FrankGR.RepairoftheACL

indogs.JBoneJointSurgAm.1966;48(3):503–19.

8. ArnoczkySP,RubinRM,MarshallJL.Microvasculatureofthe

cruciateligamentsanditsresponsetoinjury.JBoneJoint

SurgAm.1979;61(8):1221–9.

9. AmielD,KuiperS,AkesonW.Cruciateligaments.Responseto

injury.In:DanielDM,AkesonW,O’ConnorJ,editors.Knee

ligaments:structure,function,injuryandrepair.NewYork:

RavenPress;1990.p.365–77.

10.BeynnonBD,JohnsonRJ,AbateJA,FlemingBC,NicholsCE.

Treatmentofanteriorcruciateligamentinjuries,PartII.AmJ

SportsMed.2005;33(11):1752–67.

11.SegawaH,OmoriG,KogaY.Long-termresultsof

non-operativetreatmentofanteriorcruciateligamentinjury.

Knee.2001;8(1):5–11.

12.RoosH,AdalberthT,DahlbergL,LohmanderLS.

Osteoarthritisofthekneeafterinjurytotheanteriorcruciate

ligamentormeniscus:theinfluenceoftimeandage.

OsteoarthrCartil.1995;3(4):261–7.

13.BeynnonBD,JohnsonRJ,AbateJA,FlemingBC,NicholsCE.

Treatmentofanteriorcruciateligamentinjuries,PartI.AmJ

SportsMed.2005;33(10):1579–602.

14.McRaeS,ChahalJ,LeiterJ,MarxRG,McDonaldPB.Asurvey

studyofmembersoftheCanadianOrthopaedicAssociation

regardingthenaturalhistoryandtreatmentofanterior

cruciateligamentinjury.In:AOSSMAnnualMeeting.2009.

15.BiauDJ,TournouxC,KatsahianS,SchranzPJ.Bonepatellar

tendon-boneautograftsversushamstringautograftsfor

reconstructionofanteriorcruciateligament:meta-analysis.

BMJ.2006;332(7548):995–1001.

16.HollisR,WestH,GreisP,BrownN,BurksR.Autologousbone

effectsonfemoraltunnelwideninginhamstringanterior

cruciateligamentreconstruction.JKneeSurg.

2009;22(2):114–9.

17.BizziniM,GorelickM,MunzingerU,DrobnyT.Jointlaxityand

isokineticthighmusclestrengthcharacteristicsafteranterior

cruciateligamentreconstruction:bonepatellartendonbone

versusquadrupledhamstringautografts.ClinJSportMed.

2006;16(1):4–9.

18.CamanhoGL,AndradeMH.Estudocomparativoda

reabilitac¸ãodospacientessubmetidosàreconstruc¸ãodo

ligamentocruzadoanteriorcomenxertosdoterc¸omédiodo

tendãopatelarecomosdostendõesdosmúsculosflexores

mediaisdojoelho.RevBrasOrtop.1999;34(9/10):

513–8.

19.MeunierA,OdenstenM,GoodL.Long-termresultsafter

primaryrepairornon-surgicaltreatmentofanteriorcruciate

ligamentrupture:arandomizedstudywitha15-year

follow-up.ScandJMedSciSports.2007;17(3):230–7.

20.CorryIS,WebbJM,ClingelefferAJ,PinczewskiLA.

Arthroscopicreconstructionoftheanteriorcruciateligament:

acomparisonofpatellartendonautograftandfour-strand

hamstringtendonautograft.AmJSportsMed.

1999;27(3):444–54.

21.KeaysSL,Bullock-SaxtonJE,KeaysAC,NewcombePA,Bullock

MI.A6-yearfollow-upoftheeffectofgraftsiteonstrength,

stability,rangeofmotion,function,andjointdegeneration

afteranteriorcruciateligamentreconstruction:patellar

tendonversussemitendinosusandgracilistendongraft.AmJ

SportsMed.2007;35(5):729–39.

22.ErikssonK,AnderbergP,HambergP,LöfgrenAC,Bredenberg

M,WestmanI,etal.Acomparisonofquadruple

semitendinosusandpatellartendongraftsinreconstruction

oftheanteriorcruciateligament.JBoneJointSurgBr.

2001;83(3):348–54.

23.AhlenM,LidenM.Acomparisonoftheclinicaloutcomeafter

anteriorcruciateligamentreconstructionusingahamstring

tendonautograftwithspecialemphasisonthetimingofthe

reconstruction.KneeSurgSportsTraumatolArthrosc.

2011;19(3):488–94.

24.SamuelssonK,AnderssonD,KarlssonJ.Treatmentofanterior

cruciateligamentinjurieswithspecialreferencetografttype

andsurgicaltechnique:anassessmentofrandomized

controlledtrials.Arthroscopy.2009;25(10):1139–74.

25.MuellnerT,KaltenbrunnerW,NikolicA,MittlboeckM,

SchabusR,VecseiV.Shorteningofthepatellartendonafter

anteriorcruciateligamentreconstruction.Arthroscopy.

1998;14(6):592–6.

26.KeaysSL,NewcombePA,Bullock-SaxtonJE,BullockMI,Keays

(7)

afteranteriorcruciateligamentsurgery.AmJSportsMed. 2010;38(3):455–63.

27.PinczewskiLA,DeehanDJ,SalmonLJ,RussellVJ,Clingeleffer

A.Afive-yearcomparisonofpatellartendonversus

four-strandhamstringtendonautograftforarthroscopic

reconstructionoftheanteriorcruciateligament.AmJSports

Med.2002;30(4):523–36.

28.ReinhardtKR,HetsroniI,MarxRG.Graftselectionforanterior

cruciateligamentreconstruction:alevelIsystematicreview

comparingfailureratesandfunctionaloutcomes.OrthopClin

NorthAm.2010;41(2):249–62.

29.KimHS,SeonJK,JoAR.Currenttrendsinanteriorcruciate

ligamentreconstruction.KneeSurgRelatRes.

2013;25(4):165–73.

30.AbbasMM,AbulabanAA,DarwishHH.Functionaloutcomes

ofbonetendonboneversussofttissuearthroscopicanterior

cruciateligamentreconstruction:acomparativestudy.Saudi

MedJ.2013;34(2):153–60.

31.PapaliaR,FranceschiF,TecameA,D’AdamioS,MaffulliN,

DenaroV.Anteriorcruciateligamentreconstructionand

returntosportactivity:posturalcontrolasthekeytosuccess.