Modified exorotation graft tension for tibial fixation in anterior cruciate ligament reconstruction: a randomized controlled trial
AbstractBackground: The inability of anterior cruciate ligament reconstruction (ACLR) surgery to reduce tibial internal rotation causes many problems. A large tibial internal rotation will result in a patellofemoral pain syndrome. This study aimed to introduce a new technique of modified exorotation graft tension at tibial fixation to minimize endorotation, reduce tibial internal rotation, and prevent patellofemoral pain syndrome.
Methods: This study was a randomized double-blind controlled clinical trial. ACL rupture patients underwent ACLR surgery between December 2014 and Februrary 2015. They were randomized to standard endorotation group or modified exorotation group. Hamstring autograft was used and fixed with an EndoButtonÂ® and bioabsorbable interference screw. Tibial tubercle to trochlear grove (TTTG) was used to evaluate rotation, whereas cartilage oligomeric matrix protein (COMP) was employed to analyze cartilage breakdown. The functional outcome was measured using the Kujala score to assess patellofemoral joint function. Evaluations were conducted before the surgery and at 6 months postoperation.
Results: A total of 29 subjects were recruited. Sixteen subjects were allocated into the standard endorotation group, and 13 were assigned to the modified exorotation group. The exorotation group demonstrated better results than the endorotation group in all three parameters: TTTG (p=0.028), COMP (p<0.001), and Kujala score (p=0.015).
Conclusion: A new technique of modified exorotation direction of graft tension for ACL reconstructive surgery at tibial fixation showed a significant reduction in tibial internal rotation and cartilage breakdown. The proposed method could significantly improve the functional outcome of those with total ACL rupture.
Fu FH, van Eck CF, Tashman S, Irrgang JJ, Moreland MS. Anatomic anterior cruciate ligament reconstruction: a changing paradigm. Knee Surg Sports Traumatol Arthrosc. 2015;23(3):640â8. https://doi.org/10.1007/s00167-014-3209-9
Andersson D, Samuelsson K, Karlsson J. Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials. Arthroscopy. 2009;25(6):653â85. https://doi.org/10.1016/j.arthro.2009.04.066
Costa LA, Foni NO, Antonioli E, de Carvalho RT, PaiÃ£o ID, Lenza M, et al. Analysis of 500 anterior cruciate ligament reconstructions from a private institutional register. PLoS One. 2018;13(1):e0191414. https://doi.org/10.1371/journal.pone.0191414
Schub D, Saluan P. Anterior cruciate ligament injuries in the young athlete: evaluation and treatment. Sports Med Arthrosc Rev. 2011;19(1):34â43. https://doi.org/10.1097/JSA.0b013e31820b960d
Cheatham SA, Johnson DL. Anatomic revision ACL reconstruction. Sports Med Arthrosc Rev. 2010;18(1):33â9. https://doi.org/10.1097/JSA.0b013e3181c14998
Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am. 2009;91(10):2321â8. https://doi.org/10.2106/JBJS.H.00539
Van de Velde SK, Gill TJ, DeFrate LE, Papannagari R, Li G. The effect of anterior cruciate ligament deficiency and reconstruction on the patellofemoral joint. Am J Sport Med. 2008;36(6):1150â9. https://doi.org/10.1177/0363546508314404
Osman NM, Ebrahim SM. Patellofemoral instability: quantitative evaluation of predisposing factors by MRI. Egypt J Radiol Nucl Med. 2016;47(4):1529â38. https://doi.org/10.1016/j.ejrnm.2016.09.020
Das Gupta E, Ng WR, Wong SF, Bhurhanudeen AK, Yeap SS. Correlation of serum cartilage oligometric matrix protein (COMP) and interleukin-16 (IL-16) levels with disease severity in primary knee osteoarthritis: a pilot study in a Malaysian population. PLoS One. 2017;12(9):e0184802. https://doi.org/10.1371/journal.pone.0184802
Camp CL, Stuart MJ, Krych AJ, Levy BA, Bond JR, Collins MS, et al. CT and MRI measurements of tibial tubercle-trochlear groove distances are not equivalent in patients with patellar instability. Am J Sports Med. 2013;41(8):1835â40. https://doi.org/10.1177/0363546513484895
Pandit S, Frampton C, Stoddart J, Lynskey T. Magnetic resonance imaging assessment of tibial tuberosity-trochlear groove distance: normal values for males and females. Int Orthop. 2011;35(12):1799â803. https://doi.org/10.1007/s00264-011-1240-8
Saper MG, Popovich JM, Fajardo R, Hess S, Pascotto JL, Shingles M. The relationship between tibial tubercleâ trochlear groove distance and noncontact anterior cruciate ligament injuries in adolescents and young adults. Arthroscopy. 2016;32(1):63â8. https://doi.org/10.1016/j.arthro.2015.06.036
Shakespeare D, Fick D. Patellar instabilityâcan the TTâTG distance be measured clinically? Knee. 2005;12(3):201â4. https://doi.org/10.1016/j.knee.2003.08.007
Neidhart M, Hauser N, Paulsson M, DiCesare PE, Michel BA, HÃ¤uselmann HJ. Small fragments of cartilage oligomeric matrix protein in synovial fluid and serum as markers for cartilage degradation. Br J Rheumatol. 1997;36(11):1151â60. https://doi.org/10.1093/rheumatology/36.11.1151
Streich NA, Zimmermann D, Schmitt H, Bode G. Biochemical markers in the diagnosis of chondral defects following anterior cruciate ligament insufficiency. Int Orthop. 2011;35(11):1633â7. https://doi.org/10.1007/s00264-010-1191-5
Mendias CL, Lynch EB, Davis ME, Enselman ER, Harning JA, DeWolf PD, et al. Changes in circulating biomarkers of muscle atrophy, inflammation, and cartilage turnover in patients undergoing anterior cruciate ligament reconstruction and rehabilitation. Am J Sports Med. 2013;41(8):1819â26. https://doi.org/10.1177/0363546513490651
Smith TO, Davies L, O'Driscoll ML, Donell ST. An evaluation of the clinical tests and outcome measures used to assess patellar instability. Knee. 2008;15(4):255â62. https://doi.org/10.1016/j.knee.2008.02.001
Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res. 2007;454:100â7. https://doi.org/10.1097/BLO.0b013e31802ba45c
Mihelic R, Jurdana H, Jotanovic Z, Madjarevic T, Tudor A. Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17â20 years. Int Orthop. 2011;35(7):1093â7. https://doi.org/10.1007/s00264-011-1206-x
Leys T, Salmon L, Waller A, Linklater J, Pinczewski L. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. Am J Sports Med. 2012;40(3):595â605. https://doi.org/10.1177/0363546511430375
Kuru T, Dereli EE, Yaliman A. Validity of the Turkish version of the Kujala patellofemoral score in patellofemoral pain syndrome. Acta Orthop Traumatol Turc. 2010;44(2):152â6. https://doi.org/10.3944/AOTT.2010.2252
Chiu JK, Wong YM, Yung PS, Ng GY. The effects of quadriceps strengthening on pain, function, and patellofemoral joint contact area in persons with patellofemoral pain. Am J Phys Med Rehabil. 2012;91(2):98â106. https://doi.org/10.1097/PHM.0b013e318228c505
Harilainen A, Linko E, Sandelin J. Randomized prospective study of ACL reconstruction with interference screw fixation in patellar tendon autografts versus femoral metal plate suspension and tibial post fixation in hamstring tendon autografts: 5-year clinical and radiological follow-up results. Knee Surg Sports Traumatol Arthrosc. 2006;14(6):517â28. https://doi.org/10.1007/s00167-006-0059-0
Oliveira JP, Fonseca F, Noronha JC. Anterior knee pain and sensitivity after anterior cruciate ligament: its impact on sports. OA Orthopaedics. 2013;1(2):13. https://doi.org/10.13172/2052-9627-1-2-767
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