Asian Journal of Arthroscopy – Insights

Sachin Tapasvi, Parag Sancheti, Ashok Shyam

Volume 1 | Issue 1 | April – Jun 2016 | Page 1-2

Author: Sachin Tapasvi [1], Parag Sancheti [2] , Ashok Shyam [2],[3]

[1]  Orthopaedic Specialty Clinic, Pune Maharashtra.
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[3]  Indian Orthopaedic Research Group, Thane, India

Address of Correspondence

Dr Ashok Shyam
AJA Editorial Office, A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [w], Maharashtra, India.
Email: editor@asianarthroscopy.com

“Technique, Technique, Technique”, although Dr David Hungerford quoted the above for arthroplasty surgery, the same applies to Arthroscopy. Surgical technique and skill are unique to Arthroscopy almost as if it is a distinct area of expertise. No other subspecialty of orthopaedics has such minimal overlap with general orthopaedics, in terms of surgical techniques. One of the major goals of Asian Journal of Arthroscopy (AJA) is propagation of arthroscopy techniques. ‘Training by Publication’ is one the founding pillars of AJA. We want to bring the best techniques and procedures to our readers. These techniques will be in form of articles, pictograms and videos with basic premise of ease of learning. The readers should be able to understand the principles of the surgery, the critical steps and also learn new tips and tricks. They should be able to execute steps on the surgery and possibly embark on the learning curve to master the technique. Although more work is needed in terms of envisioning the formats of the article, this remains the mail goal of AJA and in times to come we would look for ways and means to do this more effectively. Currently the Journal has a technical note/video technique section with guidelines to submit a video article. We will also be running pictograms or Photo-articles which will be more pictures and less text (something like a comic strip but with much more smiles for arthroscopy surgeons!). ArthroMedia is a special section on the AJA website which will host multiple media items like videos, powerpoints, PDF and other documents related to surgical skills and surgeries. This will be compiled from contributions of editorial board, reviewers board, authors and also from our readers. This section will be open for submission to all and will compile the best training content. We invite all of you to submit your content to ArthoMedia and help us build this portal.

Why the new Journal when there are already existing journals of Arthroscopy?
There are two main reasons; to produce a body of literature that is clinically relevant and to make this knowledge freely accessible to all. Journals have shown trend to move towards a more rigid framework of scientific publications, meanwhile losing the mail focus of scientific publications. Journals are meant to directly influence and improve patient care. Charging for downloading articles imposes another limitation on dispersion and use of knowledge. AJA intends to counter these two issues by creating a journal that is intelligent, interactive, and clinically relevant and at the same time completely Open Access. The entire format of the Journal will be one of ‘Integration’ with basic science, molecular research, clinical trials, clinical research, case based discussion, evidence based medicine, expert opinion and patients perspective, all aiming together to ‘Translate’ into betterment of Arthroscopy strategies and surgeries. Although the Journal will focus on Asian studies, it will be open to submissions from all across the globe.
The Journal will be open access, peer reviewed and will have three issues every year. It will be published in both online and print formats. The Journal is the official Arthroscopy Journal of the Orthopaedic Research Group. The Research Group has affiliation to Ebscohost and is a member of Crossref. Thus primarily the journal will be indexed with Ebscohost and will have a doi (digital object identifier) for each article. Within due course we aim to index the journal with all major indexes including Pubmed and Science citation index.

What is unique about AJA?
The most important unique point of AJA is that it is a Surgeon Initiated Journal. The entire concept of the journal, the designing of website, manuscript portal and guidelines are all made by a team of surgeons. The team will be self-publishing the Journal and there will be no external publisher involved. All the rights of the journal is with the editorial board and the core team of AJA and no rights belong to any external body. This gives us a lot of flexibility and helps the journal to adapt rapidly to changing needs of the readers and authors. The journal decisions can be taken rapidly and since the entire process is controlled by the AJA team, the quality of peer review and content will be excellent. With no constraint of a corporate publisher, we can lay down our own rules and regulations and provide best of services to the Arthroscopy community
We believe AJA is an ambitious project and has much potential to evolve along with the evolution of Arthroscopy Surgery. We have great plans for AJA and we hope for great co-operation from the Arthroscopy community. Please do send your suggestions, opinions and comments to us at the editorial email. AJA is a journal “By the Surgeon, for the Surgeon, and of the Surgeon” and together we can take it to great heights

Dr Sachin Tapsvi | Dr Parag Sancheti | Dr Ashok Shyam

How to Cite this article: Tapasvi S, Sancheti PK, Shyam AK. Asian Journal of Arthroscopy – Insights. Asian Journal of Arthroscopy  Apr- June 2016;1(1):1-2

Dr. Sachin Tapasvi

Dr. Sachin Tapasvi

Dr. Parag Sancheti

Dr. Parag Sancheti

Dr. Ashok Shyam

Dr. Ashok Shyam

(Abstract)      (Full Text HTML)      (Download PDF)

Arthroscopic reduction and Internal fixation (ARIF) using Parapatellar Approach – A modality for treating fracture Tibial eminence with ACL injury.

Vikram V Kadu, K A Saindane, Ninad Goghate, Neha N Godghate

Volume 1 | Issue 1 | April – Jun 2016 | Page 43-45

Author: Vikram V Kadu [1], K A Saindane [1], Ninad Goghate [1], Neha N Godghate [1]

[1] ACPM Medical College, Dhule – 424001, Maharashtra,  India

Address of Correspondence

Dr. Vikram V. Kadu
ACPM Medical College, Dhule – 424001, Maharashtra India
Email : vikram1065@gmail.com

Abstract

Introduction:Arthroscopic reduction and internal fixation (ARIF) of tibial intercondylar eminence fractures is the emerging state-of-the-art. Tibial eminence fractures underwent arthroscopic evaluation when closed reduction after aspiration failed to yield an anatomic reduction. Arthroscopic reduction and fixation of avulsion fractures of the tibial eminence restores the length of the ACL, provides stable fixation promoting early motion.
Materials and Methods: This is a retrospective study conducted between 2010 and 2012. All 40 patients suffering ACL injury with tibial eminence fracture were stabilized in the emergency room followed by above knee slab. Once the patient was stabilized surgery (Arthroscopic reduction and internal fixation) was performed. The technique involved arthroscopic placement of a 3.5-mm cannulated compression screw into the tibial eminence. Patients were placed in a standard postoperative ACL protocol. Assessment was done using knee society score.
Result: All fractures demonstrated radiographic healing by 8 weeks, and none of the patients had subjective complaints of pain and instability. At 2 yrs follow-up all the patients had functional range of motion (00-1600) and returned successfully to their previous work. In our series we didn’t come across any complication.
Conclusion: Arthroscopic reduction and screw fixation with a cannulated screw is a simple, effective, and safe technique providing stable fracture fixation to allow immediate mobilization with minimal loss of extension.
Key words : ACL avulsion fracture, Arthroscopic, cannulated screw

Introduction

The intercondylar eminence serves as the point of attachment for portions of the menisci and the anterior and posterior cruciate ligaments(1). In addition to disrupting ACL continuity, intercondylar eminence avulsion fractures, depending on size, may affect weight-bearing aspects of the articular surface of the tibia.
Fracture of the tibial intercondylar eminence is a consequence of ACL avulsion at its insertion(2). Mechanism being same as of ACL rupture it is pulled from the tibia with a piece of the bony plateau. These injuries are commonly related to high energy trauma usually road traffic accidents and have high incidence of associated injuries.
Fractures of the tibial intercondylar eminence were classified into 3 types3: type I, minimal or nondisplaced; type II, partially displaced or hinged fracture; and type III, completely displaced. Surgical treatment is currently recommended for type II and III displaced fractures. Open methods were conventionally used to fix these avulsions however now arthroscopic treatment is the standard of care. Most of the existing literature is from the western world and publications from India are very few. We present our series of arthroscopic fixation done for ACL avulsion fracture performed at a district level rural center in India

Materials and Methods:
This is a retrospective study conducted on 40 patients suffering ACL injury with tibial eminence fracture between 2010 and 2012. Patients were stabilized in the emergency room followed by above knee slab. Of the 40 patients 27 were male and 13 female. 26 were right sided and 14 left sided. 28 suffered RTA and 12 had fall. Mean age of the patient was 35 yrs (range 23 – 47 yrs). After stabilizing the patient, surgery (Arthroscopic reduction and internal fixation with 3.5 mm screw) was performed. The technique involved arthroscopic placement of a 3.5-mm cannulated compression screw into the tibial eminence. Patients were placed in a standard postoperative ACL protocol. All patients were clinically and radiographically reviewed for 2 years and assessed with knee society score.

Surgical Technique:
In supine position with the knee flexed 70° to 90°. Pneumatic tourniquet was used. Standard knee arthroscopy was performed with anterolateral and anteromedial portals. In all patients, an additional antero-superior parapatellar portal was used for wider and better view of the intercondylar tibial eminence.

Figure 1: showing the entry portals.

Figure 1: showing the entry portals.

Through the standard anteromedial portals, using Normal saline under gravity the hemarthrosis was washed out using the shaver, the hematomas at the fracture site were debrided, and the joint was inspected for the presence of any other intra-articular lesions. Turning the optics anteriorly, the intermeniscal ligament was identified, and in cases with interposition, the ligament was shifted aside using a probe introduced through the standard anteromedial portal to make reduction possible. Sometimes the ligament needs to be partially cut. After the anatomic condition and integrity of the ACL were carefully confirmed, the probe was then used via the anteromedial portal to reduce the fracture in its bony bed.
Under arthroscopic vision, the midpoint of the inferior non-articular surface of the patella is selected and a guide wire of 1.2 mm was then passed perpendicular to this surface, in the direction of the center of the fracture site with the knee flexed to approximately 70° to 90°. The portal was then drilled using a 2.7 mm cannulated drill bit and fragment was fixed with 3.5 mm cannulated screw.

Case: 30 yrs old male labourer by occupation suffered an RTA and presented with complaints of pain and swelling over left knee joint and restriction of movements. Clinically the patient had instability at the knee joint. X-rays both AP and Lateral view were taken (Fig 2A) which showed fracture tibial eminence. The patient was given above knee slab and was admitted. Surgery (Arthroscopic reduction and internal fixation with 3.5 mm screw) was performed. Post- operatively the patient was given long leg knee brace. Physiotherapy in the form of Quadriceps exercises was started immediately and knee bending (upto 30 degrees) and partial toe touch bearing walking with walker with long leg knee race on post-op day 2 once the drain was removed. Patient was followed up after 1 month (Fig 2B). X ray showed uniting fracture. Knee bending was increased from 30-60 degrees and 50 % weight bearing allowed. At 2 months (Fig 2C) X ray showed radiological union and patient was advised full weight bearing walking with walker and brace, knee ROM exercises were started and complete flexion and extension was allowed. At 12 weeks (Fig 2D). X rays at 10 months follow-up (Fig 2E). At 2 yrs and 7 months follow up (Fig 2F). The patient has full range of motion (0-160o) (Fig 2G &H) and returned to his previous work.

Figure A: pre-op AP and LAT view

Figure 2A: pre-op AP and LAT view

Figure B: Radiograph at 1 month follow-up

Figure 2B: Radiograph at 1 month follow-up

Figure C: Radiograph at 2 months follow-up

Figure 2C: Radiograph at 2 months follow-up

Figure D: Radiograph at 3 months follow-up

Figure 2D: Radiograph at 3 months follow-up

Figure E: Radiograph at 10 months follow-up

Figure 2E: Radiograph at 10 months follow-up

Figure F: Radiograph at 2yrs and 7 months follow-up

Figure 2F: Radiograph at 2yrs and 7 months follow-up

Figure 2G: Radiograph at 10 months follow-up

Figure 2G: Radiograph at 10 months follow-up

Figure 2H: Radiograph at 10 months follow-up

Figure 2H: Radiograph at 10 months follow-up

Observations and Results:
All the 40 patients were assessed at the end of 2 yrs and we found out that, all patients had functional range of movement of the knee joint and they returned to their previous work. There was no evidence of any infection or complication in our study. There was no failure of fixation and no other complications in our series

Discussion:
Tibial spine fractures usually result from a twisting movement of the knee. Abnormal valgus/varus or hyperflexion /hyperextension forces can cause avulsion of the tibial eminence. Such injuries are common after road traffic accidents or sporting activities.
Arthroscopic reduction internal fixation of intercondylar eminence avulsion is recommended for all displaced type III fractures and should be considered in all cases of displaced type II fractures. Various studies by different authors have been reported for these kind of fractures(2,4-10). Tibia eminence fracture results in anterior knee instability and occasionally anterior impingement during knee extension when the avulsion fragment is displaced(11). The goal of treatment for displaced tibial intercondylar eminence fracture is anatomic reduction. Disadvantages of screw fixation include risks of comminution of the fracture fragment, impingement due to prominent screw head, and the need for hardware removal. Because of these risks, some surgeons preferred arthroscopic reduction and internal fixation using non-absorbable sutures passed through drill holes. Suture techniques may obviate the need for a second surgery for implant removal and impingement; but arthrofibrosis and limitation of joint motion due to postoperative immobilization have been reported(2.) It has been found that antegrade screw fixation is more effective in obtaining initial rigid fixation than pull-out suture fixation for ACL avulsion fractures(12).
Tibial eminence fractures have excellent prognosis. Previously, prolonged immobilization may lead to arthrofibrosis and a permanent loss of full extension. Therefore, earlier rehabilitation is crucial as it encourages a faster recovery and prevents the development of secondary complications. Rehabilitation is similar to ACL tear protocols activities include static cycling, leg presses, elastic theraband or tubing exercises.
The technique described in this report not only helps achieve good interfragmentary compression, but also prevents undue prominence of the screw head owing to its proper direction. The bicortical purchase of the screw adds to the stability of fracture fixation, allowing early joint movement and weight bearing. The parapatellar portal secures good visualization of the operative field, enabling the screw to fix the fracture fragment perpendicularly. Although rare but chances of fracture in cases of poor bone quality is to be considered.

Conclusion

Arthroscopic reduction and internal fixation with cannulated screws for type 3B fractures having ACL injury is a novel method with good results and without any complications.

References

1. Wiss DA, Watson JT. Fractures of the tibial plateau. In:Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s fractures in adults.Philadelphia: Lippincott-Raven, 1996;1920-1953.
2. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy1993;9:446-450.
3. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1970; 52(8):1677-1684.
4. McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br1982;64:477-480.
5. Falstie-Jensen S, Sondergard Petersen PE. Incarceration of the meniscus in fractures of the intercondylar eminence of the tibia in children. Injury1984;15:236-238.
6. Matthews DE, Geissler WB. Arthroscopic suture fixation of displaced tibial eminence fractures.Arthroscopy1994;10:418-423.
7. Osti L, Merlo F, Bocchi L. Our experience in the arthroscopic treatment of fracture-avulsion of the tibial spine. Chir Organi Mov1997;82:295-299.
8. Kocher MS, Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: Prevalence of meniscal entrapment.Am J Sports Med2003;31:404-407.
9. Chandler JT, Miller TM: Tibial eminence fracture with meniscal entrapment.Arthroscopy1995;11:499-502.
10. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy1993;9:446-450.
11. Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw: Five-year results.Arthroscopy2003;19:54-61.
12. Kendall NS, Hsu SY, Chan KM. Fracture of the tibial spine in adults and children. A review of 31 cases. J Bone Joint Surg Br. 1992; 74(6):848-852.
13. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: failure of arthroscopic treatment.Arthroscopy. 1993; 9(4):446-450.
14. Tsukada H, Ishibashi Y, Tsuda E, Hiraga Y, Toh S. A biomechanical comparison of repair techniques for anterior cruciate ligament tibial avulsion fracture under cyclic loading. Arthroscopy. 2005; 21(10):1197-1201.

How to Cite this article: Kadu V V, Saindane K A, Goghate N, Godghate N N. Arthroscopic reduction and Internal fixation (ARIF) using Parapatellar Approach – A modality for treating fracture Tibial eminence with ACL injury . Asian Journal of Arthroscopy  Apr- June 2016;1(1):43-45 .

Dr. Vikram V. Kadu

Dr. Vikram V. Kadu

Dr. K. A. Saindane

Dr. K. A. Saindane

Dr. Ninad Godghate

Dr. Ninad Godghate

Dr. Neha N Godghate

Dr. Neha N Godghate

(Abstract)      (Full Text HTML)      (Download PDF)

Arthroscopic Biopsy and MRI Diagnosis in Monoarticular Joint Synovitis of Undifferentiated Origin – A retrospective study in 34 cases

Sundararajan S R, Jain Sachin Ramesh, S Rajasekaran

Volume 1 | Issue 1 | April – Jun 2016 | Page 38-42

Author:  Sundararajan S R [1], Jain Sachin Ramesh [1], S Rajasekaran [1]

[1] Ganga Hospital, 313, MTP road, Coimbatore , Tamilnadu, India Pin code – 641043

Address of Correspondence

Dr Sundararajan S R
Ganga hospital, 313, MTP road, Coimbatore , Tamilnadu, India,
Pin code – 641043
Email id – sundarbone70@hotmail.com

Abstract

Purpose: The main purpose of the study was to evaluate arthroscopic biopsy results and MRI findings in monoarticular joint synovitis with emphasis on differentiation between tuberculosis and rheumatoid cases using MRI features by Choi et al.
Materials and methods: Between 2010 and 2014, 34 patients were retrospectively analyzed from our database. Clinical history, MRI findings, arthroscopy findings & biopsy reports were evaluated. Findings of Choi et al was used to correlate MRI and biopsy results between rheumatoid and tuberculosis cases. Ability of MRI in diagnosing other cases like PVNS, hemangioma was also evaluated. Samples obtained from biopsy were sent to two laboratories in 23 of our cases where MRI was suggestive of infective or inflammatory etiology.
Results: Out of 34, 9(26.47%) cases were of chronic nonspecific synovitis, 7(20.58%) cases of tuberculous synovitis, 7(20.58%) cases of rheumatoid synovitis, 3(8.8%) cases of PVNS, 2(5.88%) cases of Synovial hemangioma, and 6 others. Out of 34, tissue biopsy diagnosis was made in 25(73.53%) and MRI diagnosis was obtained in 22/34 (65%) of our patients. Using features described by Choi et al, 100% of tuberculosis cases and 57.14% of rheumatoid cases were diagnosed on MRI. A mismatch of 4/23(17.4%) was found between the reports from two recognized labs.
Conclusions: Arthroscopic biopsy and MRI are reliable techniques, with better success rate in the diagnosis of monoarticular synovitis of unknown etiology. Choi et al’s MRI recommendations are reliable in differentiating between infective or inflammatory etiology.

Keywords: Synovitis, Monoarticular, Undifferentiated, arthroscopic biospy

Introduction

Monoarticular joint synovitis of undifferentiated etiology (1), presents with complaints of pain and swelling which is not responding to anti-inflammatory treatment. Diagnosis and approach to treatment in such cases is very important for satisfactory clinical results. Arthroscopy is the preferred mode for biopsy (2-7) and provides macroscopic evaluation(3,8,9) of the monoarticular joint disease. Early diagnosis of tubercular synovitis is important to prevent joint damage(7) within few days to weeks. Similarly, inflammatory synovitis like rheumatoid synovitis also carries a prognostic significance if diagnosed early and treated(8).
Plain radiograph in early synovial disease usually remains normal for at least 6 to 12 months after symptom onset(10). MRI is a highly sensitive tool to evaluate early undifferentiated synovitis and guide the management plan(11,12). It gives the extent of synovial hypertrophy(12) with sites of increased activity with gadolinium enhancement for directing biopsy(12,13). MRI features described by Choi et al(14), where they considered synovial thickening, bone erosions, rim enhancement at bone erosions, soft tissue edema and extraarticular cystic masses for differentiating tubercular and rheumatoid synovitis.
Our hypothesis is that MRI can diagnose the specific etiology, especially the tubercular and rheumatoid synovitis, in monoarticular joint synovitis of undifferentiated origin using the MRI features described by Choi et al (14).

Methods
The study was approved by ethics committee of our institution. Between 2010 and 2014, 34 patients were retrospectively analyzed from our database using the inclusion and exclusion criteria (Flowchart 1). Clinical history, MRI findings, arthroscopy findings and biopsy reports were evaluated. Blood investigation like Rheumatoid factor, anti cyclic citrullinated protein (CCP) was used to diagnose inflammatory arthritis like rheumatoid and those cases were excluded from our study. If a patient presenting to our center for the first time without any waiting period then our policy is to give 2 weeks of anti-inflammatory medications and if symptoms don’t subside than we go ahead with other investigation of MRI, blood tests and immediate arthroscopic biopsy depending on MRI reports. If patient has already has waited for more than 2 weeks then we directly investigate with MRI, blood tests and go ahead with arthroscopic treatment.

Flowchart 1: Total no of cases included with inclusion and exclusion criteria in the study

Flowchart 1: Total no of cases included with inclusion and exclusion criteria in the study

Out of 34 joints, 26 knees, 5 ankles, 2 hips and 1 shoulder joint were included. Out of 34 patients 22 were males and 12 females between ages 9 years and 70 years. According to Choi et al(14) as described in table 1, if uniform synovial thickening, large size of bone erosion, and extra articular cystic masses more frequent and more numerous, then tubercular synovitis(14) and if more the degree of synovial hypertrophy without associated findings were present then diagnosis of rheumatoid synovitis(14) was considered. We used these findings to correlate MRI and biopsy results retrospectively between rheumatoid and tuberculosis cases.

Table 1: Criteria and grading on MRI based on Choi et al14 to differentiate between rheumatoid and tubercular synovitis

Table 1: Criteria and grading on MRI based on Choi et al (14) to differentiate between rheumatoid and tubercular synovitis

Arthroscopic evaluation was performed by a single senior arthroscopy consultant of our institution. On arthroscopic evaluation, joint was thoroughly inspected through standard portals. Macroscopic evaluation of the joint done and the suspected area of increased activity were chosen for biopsy. At least 6 different sites in the joint was considered for biopsy, material was packed in formalin filled glass bottle and sent for histopathological examination. Arthroscopic partial or subtotal synovectomy was done if needed. Biopsy samples were sent to two different laboratories only when MRI diagnosis showed chronic synovitis of infective or inflammatory etiology, where the cause was doubtful. To be sure of the diagnosis, biopsy material was sent in these patients by two experienced senior pathologist. . Depending upon the biopsy results further treatment was initiated. No prophylactic anti-tubercular treatment was started as biopsy results usually arrived in a week for definitive treatment. Arthroscopic biopsy samples were sent to two labs for evaluation only where diagnosis of inflammatory or infective origin was doubtful on MRI in 23 out of 34 cases
Results
In our case series, Out of 34, 9(26.47%) cases were of chronic nonspecific synovitis, 7(20.58%) cases of tuberculous synovitis, 7(20.58%) cases of rheumatoid synovitis, 3(8.8%) cases of PVNS, 2(5.88%) cases of Synovial hemangioma, and 6 others. Out of 34, tissue biopsy diagnosis was made in 25(73.53%) and MRI diagnosis was obtained in 22/34 (65%) of our patients. Using features described by Choi et al, 100% of tuberculosis cases and 57.14% of rheumatoid cases were diagnosed on MRI (Table 1). There was a mismatch in biopsy results among 4 (17.4%) out of the 23 cases that were sent to two recognized laboratories simultaneously.

Discussion
Monoarticular synovitis of unexplained origin (5) needs a series of tests like blood investigation, MRI and biopsy to find out the causal factor. Effectiveness of arthroscopic biopsy in the diagnosis of monoarticular synovitis was discussed (4,6,17) earlier. We attempted to determine the same in this series along with effectiveness of MRI diagnosis. Conditions like synovial hemangioma and PVNS is done quite accurately (19,20,21) using MRI, but there is difficulty in diagnosing or differentiating infective versus inflammatory etiology. Choi et al(14) was the first to evaluate and differentiate these two conditions using MRI. We evaluated the suggested guidelines in this study.

Arthroscopy plays an important role in diagnosis(2,4,15). Major use is in the patients presenting with unexplained knee pain whose symptoms are disproportionate to the radiologic features or refractory to standard course of medical treatment(2). Arthroscopic synovial biopsy is considered as the ‘gold standard'(16) for biopsy in monoarticular joint synovitis. Arthroscopy is an excellent tool to visualize the synovium macroscopically(3,8,9), evaluate the villi precisely and obtain biopsy from site correlating with clinical findings for microscopic evaluation3,6,8. Macroscopic evaluation of normal synovium looks bland and devoid of villi, granularity or increased vascularity(8).

Figure 1a: Arthroscopic view of knee joint through anterolateral portal showing synovial hypertrophy (small arrows) in the suprapatellar fossa with 30 degree lens and camera facing 4 'o clock position.

Figure 1a: Arthroscopic view of knee joint through anterolateral portal showing synovial hypertrophy (small arrows) in the suprapatellar fossa with 30 degree lens and camera facing 4 ‘o clock position.

Figure 1b: MRI showing extensive bony edema(26.90mm), synovial hypertrophy(11.78mm), multiple bony erosions(14.44mm), and extra articular cystic masses(*) favoring diagnosis of tuberculous synovitis.

Figure 1b: MRI showing extensive bony edema(26.90mm), synovial hypertrophy(11.78mm), multiple bony erosions(14.44mm), and extra articular cystic masses(*) favoring diagnosis of tuberculous synovitis.

Figure 1c: Histopathology findings showing epitheloid cells and granulomatous inflammation (arrow) suggestive of tuberculosis.

Figure 1c: Histopathology findings showing epitheloid cells and granulomatous inflammation (arrow) suggestive of tuberculosis.

Arthroscopic findings can alter or add to the treatment plan which includes surgical tissue resection or medical treatment like Disease Modifying Anti-rheumatic Drugs (DMRD’s) to the current treatment(2). Goeb et al(22) suggested that early diagnosis and early treatment initiation in patients with inflammatory arthritis can be possible by precise arthroscopic biopsy sample from the most representative pathological areas. Chen et al(14) evaluated the role of arthroscopy in unilateral knee arthritis where they accurately diagnosed 71 cases and 3 cases were undiagnosable(4). They reported 39/74 (52.9%) cases as rheumatoid arthritis4. In our study, despite thorough arthroscopic and microscopic evaluation, we were not able to accurately diagnose in 26.47% of the patients, which were finally diagnosed as chronic non specific synovitis. Chronic non specific synovitis is also known as monoarthritis of unknown origin (5), 80% of these can go into complete remission over a period of two years(5) with just conservative treatment.

Figure 2a: Arthroscopic view of knee joint through anterolateral portalshowing reddish brown tumor with telangiectatic arterioles suggestive of hemangioma(H) in the lateral aspect of suprapatellar fossa with 30 degree lens and camera facing 12 'o clock position.

Figure 2a: Arthroscopic view of knee joint through anterolateral portalshowing reddish brown tumor with telangiectatic arterioles suggestive of hemangioma(H) in the lateral aspect of suprapatellar fossa with 30 degree lens and camera facing 12 ‘o clock position.

Figure 2b: Arthroscopic biopsy done through the anterolateral portal from multiple sites with basket punch. Note bleeding from the tumor site (arrow).

Figure 2b: Arthroscopic biopsy done through the anterolateral portal from multiple sites with basket punch. Note bleeding from the tumor site (arrow).

As definitive treatment with antitubercular medication is available, diagnosis of early tuberculous synovitis is very essential to prevent cartilage damage. Arthroscopic definitive tissue diagnosis and timely treatment helps in achieving excellent results in 3 – 4 months period (7), with complete symptomatic relief and full joint function restoration(7). Early rheumatoid arthritis carries a prognostic value as disease modifying agents can be introduced, which can reduce the aggressiveness of the disease by inhibiting the progressive structural damage (8). In inflammatory synovitis like early rheumatoid arthritis complete remission or marked improvement is seen in most of the patients(11,15,18).
Out of 34 cases, 23 cases had synovial hypertrophy arthroscopically for which partial or subtotal synovectomy was performed to aid in clinical remission. In case of pigmented villonodular synovitis and synovial hemangioma, MRI guides the diagnosis in all the patients following which arthroscopic extended synovectomy and arthroscopic excision is the preferred treatment(19,20,21) which was performed in our 4 cases.
MRI is a highly sensitive tool for evaluation of patients presenting with undifferentiated synovitis(1). It can detect bony edema, cartilage erosions also when combined with gadolinium enhancement, degree of synovial thickening (pannus) and intraarticular lesions can be picked up (1). In MRI, to differentiate between infective or inflammatory etiology is very difficult. But the extent of synovial hypertrophy, articular cartilage damage and other findings like cartilaginous loose bodies which are not visible on plain radiograph can be detected. Treatment plan can be based upon MRI to guide the site for arthroscopic biopsy, to have a baseline value of synovial hypertrophy if there is recurrence after synovectomy. MRI diagnosis in cases like synovial hemangioma and Pigmented villonodular synovitis (PVNS)(19,20,21) is accurate, as observed in this study too, where extended synovectomy can be planned preoperatively to avoid recurrence. However in a case report by Lee et al (23), where MRI suggested a diagnosis of Pigmented villonodular synovitis due to the hemosiderin deposits and a nodular mass around the knee joint but biopsy revealed it to be tuberculosis. They suggested that the first step in diagnosis of tuberculous knee arthritis is to have high index of suspicion (23). So, even biopsy remains the main means of diagnosis even in such cases.

Figure 2c: Piecemeal excision (arrow heads) of the tumor done with arthroscopic scissors through the anterolateral portal with 30 degree lens and camera facing 12' o clock position.

Figure 2c: Piecemeal excision (arrow heads) of the tumor done with arthroscopic scissors through the anterolateral portal with 30 degree lens and camera facing 12′ o clock position.

Figure 3a: MRI of right shoulder showing synovial hypertrophy (18.33mm) with rice bodies (arrow).

Figure 3a: MRI of right shoulder showing synovial hypertrophy (18.33mm) with rice bodies (arrow).

Figure 3b: Histopathology after arthroscopic biopsy of the same shoulder, showing synoviothelial hyperplasia (arrow). Perivascular aggregates of plasma cells with russel bodies (circled) suggestive of rheumatoid synovitis

Figure 3b: Histopathology after arthroscopic biopsy of the same shoulder, showing synoviothelial hyperplasia (arrow). Perivascular aggregates of plasma cells with russel bodies (circled) suggestive of rheumatoid synovitis

Overall, MRI agreed with biopsy in 22/34 (65%) of our patients. On using MRI features for finding rheumatoid and tuberculous synovitis, tuberculosis was diagnosed in 7/7(100%) and rheumatoid in 4/7(57.14%) of the cases (Table 2).

Table2: Arthroscopic biopsy results and its correlation with MRI

Table 2: Arthroscopic biopsy results and its correlation with MRI

Gadolinium enhancement was used in 3 (2 cases were rheumatoid and 1 case was tuberculosis) out of 14 of our patients with tuberculosis and rheumatoid. Enhancement of bone and synovium and also the rim enhancement was similar in both the scenarios. This led us look for other factors in these cases to differentiate between them. Lymph nodes were enlarged in tuberculosis as compared to none in rheumatoid. Also the erosions were multiple and large in tuberculosis as compared to rheumatoid cases. Overall, it was the combination of extensive synovial hypertrophy, multiple large bony erosions, extensive edema, extraarticular mass and enlarged lymph nodes which favored the diagnosis of tuberculosis. Also, synovial hypertrophy with minimal erosion, mild to moderate edema, with no extraarticular masses and no enlarged lymph nodes favored the diagnosis of rheumatoid. Further evaluation for the need of gadolinium contrast agent is needed to assess its real use in differentiating these two conditions.

Arthroscopic biopsy samples were sent to two labs for evaluation in 23 out of 34 cases. Out of which 20 reports matched each other. There was disagreement in 4 out of 23 (17.4%) cases. Out of 4 cases, 3 cases were reported by the lab as chronic non specific synovitis and 1 case of suppurative synovitis which was diagnosed by other lab as 3 cases of rheumatoid and 1 case of tuberculous synovitis, respectively. Implications of correct diagnosis are well known, especially in the case of tuberculosis where there is specific treatment available and complete remission is possible, if it is missed, complete destruction of the joint is inevitable. Therefore it is important to send biopsy samples to at least two laboratories that can increase the probability of correct diagnosis in patients.

Limitation of the study
Several limitations must be taken into consideration in this study. Firstly, the sample size of our study group is small and multiple joints were included, because of the rarity in monoarticular synovitis cases in general, but still it is better than most of the other studies. Secondly, analysis of the MRI was done by single experienced radiologist at our institution. So, effects of interobserver variability could not be assessed in this study. Thirdly, gadolinium enhancement was not performed on every case as we were in initial stages to give enhancement to monoarticular joint synovitis cases before this study was considered, so Choi et al.’s criteria couldn’t be replicated to the exact similarity. Finally, only 23 cases (out of 34) were sent to two laboratories, further reducing the sample size, because of the institute policy to send them to two labs only where diagnosis of inflammatory or infective origin was doubtful on MRI.

Conclusion

Arthroscopic biopsy and MRI both are reliable techniques, with better success rate in the diagnosis of monoarticular synovitis of unknown etiology. Choi et al’s MRI recommendations may aid in differentiating between infective or inflammatory etiology of monoarticular joint synovitis.

References

1. Yasser E, Yasser R. The diagnostic dilemma of undifferentiated inflammatory synovitis of the knee joint/joints: a comprehensive approach. APLAR Journal of Rheumatology 2007 Sep; 10(3):182–189
2. O’Rourke KS, Ike RW. Diagnostic arthroscopy in arthritis patient. Rheum Dis Clin North Am. 1994 May; 20(2):321-42
3. Kurosaka M, Ohno O, Hirohata K. Arthroscopic evaluation of synovitis in the knee joints. Arthroscopy. 1991; 7(2):162-70
4. Chen GQ, Zhang HW, Li ZF,Guo DM, Yu YT. Significance of arthroscopy in the diagnosis of unilateral knee arthritis. Zhonghua Yi Xue Za Zhi. 2010 Jun15; 90(23):1615-7.
5. Scherer T, Kieser C, Gerber H. Assessment and course of 110 patients with monoarthritis. Ther Umsch. 1989 Apr; 46(4):258-64
6. Schulte E, Fisseler-Eckhoff A, Muller KM. Differential diagnosis of synovitis. Correlation of arthroscopic-biopsy to clinical findings. Pathologe. 1994 Feb; 15(1):22-7
7. Cai D, Chen Y, Rong L. Arthroscopy in diagnosis and treatment of tuberculous synovitis. Zhonghua Jie He He Hu Xi Za Zhi. 1998 May; 21(5):276-7
8. Mihir D Wechalekar, Malcolm D Smith. Utility of arthroscopic guided synovial biopsy in understanding synovial tissue pathology in health and disease states. World J orthop 2014 Nov;5(5):566-573
9. Masahiro K, Osamu O, Kazushi H. Arthroscopic evaluation of synovitis in knee joints. Arthroscopy. 1991;7(2):162-170
10. Van der Heijde DM. Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. Baillieres Clin Rheumatol. 1996 Aug;10(3):435-53
11. M ostergaard, B Ejbjerg, M Stoltenberg et al. Quantitative magnetic resonance imaging as marker of synovial membrane regeneration and recurrence of synovitis after arthroscopic knee joint synovectomy: a one year follow up study. Ann Rheum Dis 2001;60:233-236
12. F.M.McQueen. Magnetic resonance imaging in early inflammatory arthritis: what is its role? Rheumatology 2000;39:700-706
13. Matthew A., Doris E., Mark A. MR imaging of synovial disorders of the knee: An update. Radiologic Clinics Of North America 2007;45:1017-1031
14. Jung-Ah Choi, Sung Hye Koh et al. Rheumatoid arthritis and tuberculous arthritis: Differentiating MRI features. American Journal of Roentgenology 2009 Nov;193(5):1347-1353
15. GAO Jun, GAO Chun-Sheng, GAOYa-zhou et al. Clinical study on arthroscopic examination in diagnosis and treatment of knee synovitis. Journal of clinical and experimental medicine 2013-09
16. Smith MD, Baeten D et al. Standardisation of synovial tissue infilterate analysis: how far we have come? How much further do we need to go? Ann Rheum Dis 2006;65:93-100
17. Onis Singhal, Viplesh kaur et al. Arthroscopic synovial biopsy in definitive diagnosis of joint diseases: An evaluation of efficacy and precision. International Journal of applied and basic medical research, 2012 Jul-Dec;2(2)
18. Ayral X, Bonvarlet JP et al. Arthroscopy-assisted synovectomy in the treatment of chronic synovitis of the knee. Revue du Rhumatisme, 1997,64(4):215-226
19. Rochwerger A, Groulier P et al. Pigmented villonodular synovitis of the knee. Treatment results in 22 cases. Revue de Chirurgie Orthopedique et Reparatrice de L’appareil Moteur, 1998; 84(7):600-606
20. Alessandro De Ponti, Valerio Sansone et al. Result of arthroscopic treatment of Pigmented villonodular synovitis of the knee. Arthroscopy, 2003 Jul-Aug;19(6):602-607
21. Jeung-Tak Suh, Sang-Jin Cheon, Sung-Jong Choi. Arthroscopy, 2003 Sep,19(7):e77-e80
22. Goeb V, Walsh CA, Reece RJ, et al. Potential role of arthroscopy in the management of inflammatory arthritis. Clin Exp Rheumatol, May-June 2012, 30(3) p429-35
23. Lee DH, Lee DK, Lee SH, et al. Tuberculous arthritis of knee joint mimicking pigmented villonodular synovitis. Knee Surg Sports Traumatol Arthrosc, May 2012, 20(5) p937-40

How to Cite this article:. Sundararajan SR, Jain SR, Rajasekaran S. Arthroscopic Biopsy and MRI Diagnosis in Monoarticular Joint Synovitis of Undifferentiated Origin – A retrospective study in 34 cases . Asian Journal of Arthroscopy  Apr- June 2016;1(1):38-42 .

Dr. Sundararajan S R

Dr. Sundararajan S R

Dr. Sachin Jain

Dr. Sachin Jain

Dr. S Rajasekaran

Dr. S Rajasekaran

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Intraoperative Graft Contamination – What Options Do We Have?

Parag Sancheti, Sachin R Jain, Ashok Shyam

Volume 1 | Issue 1 | April – Jun 2016 | Page 35-37

Author: Parag Sancheti [1], Sachin R Jain [1], Ashok Shyam [1],[2]

[1] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[2] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence

Dr Parag Sancheti
Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
Email: parag@sanchetihospital.com

Abstract

Background: Accidental graft contamination is not uncommon in a high volume centers practicing ligament reconstruction surgeries. There are several techniques of disinfecting the graft to prevent septic arthritis postoperatively. Aim of this review is to identify the different options of appropriate disinfectant and also the time interval for immersing the graft in the disinfectant solution for contaminated ACL graft.
Material and methods: MEDLINE, Pubmed and extensive searches of major arthroscopy journals identified several studies regarding graft contamination and its disinfection protocol which was used in this study.
Conclusion: 4% chlorhexidine or 10 % povidone iodine seem to be most effective in disinfecting contaminated graft after immersion for 3 min and 15 min respectively. All sutures should be removed prior to disinfection and proper antibiotic cover and follow up should be done to prevent any residual infection.
Keywords: Anterior cruciate ligament reconstruction, graft contamination, antiseptics

Introduction

Anterior Cruciate Ligament (ACL) reconstruction is the most common ligament reconstruction surgery done in the world(1). There is always a possibility of inadvertent graft contamination by dropping it accidentally on floor(2). 25% of fellows in sports medicine report at least one such event(3). Various treatment modalities exist to prevent postoperative infection due to contaminated graft such as cleansing alone with normal saline, immersion in 4 % chlorhexidine and bacitracin solution, 10% povidone – iodine solution, sodium hypochlorite solution or antibiotic solution wash (2,3,4,5). Other option is to discard the graft and harvest another graft or use an allograft, but this causes donor site morbidity or increased cost associated with use of allograft(3). Floor cultures can be simultaneously obtained to find out the organism grown during contamination.

Methods

MEDLINE, Pubmed and extensive searches of major arthroscopy journals identified several studies regarding graft contamination and its disinfection protocol which was used in this study. Aim of this review was to find out the epidemiology of graft contamination, different agents used for decontaminating the graft and its efficacy, organism grown in floor or contaminated graft culture, cleaning protocol for hamstring graft and for bone patellar bone tendon graft, preventing measures for graft contamination and finally treatment with antibiotic protocol postoperatively.

Discussion

Around 25% surgeons have reported to have a contaminated graft at least once with 35% of these surgeons performing at least 100 ACL surgeries annually (1). Sterilization by autoclaving destroys the material properties of collagenous tissue, so other sources of nondestructive disinfection must be considered (9).

Barbier et al(2) compared 4 groups after dropping graft on the floor with cultures taken after immersion in antiseptic solution for 15 min – 4 % chlorhexidine gluconate solution (group 1),  10% povidone–iodine solution (group 2), sodium hypochlorite solution (group 3) and (group 0) was cultured without being exposed to any solution. They found that floor swab cultures were positive in 96% of cases and rate of contamination was 40% in group 0, 8% in group 1, 4% in group 2, and 16% in group 3. There was a significant difference between groups 1 and 2 and group 0 (p < 0.05) but not between groups 3 and 0. They concluded both 4% chlorhexidine as well as povidone iodine solutions are effective in treatment of contaminated graft. Sodium hypochlorite is not so effective with this respect. Molina et al.(8) found that 58% of the dropped grafts had positive cultures and also, 4 % chlorhexidine and double antibiotic solution (neomycin and polymyxin B) successfully decontaminated dropped native ACLs at a rate of 98 and 94 %, respectively. The time duration used by different surgeon varies for different surgeons which ranges from 90 seconds to 30 minutes(1). The most common antiseptic solution chosen by the high volume surgeons was chlorhexidine(1). However, when povidone– iodine solution was used, 24 % of the ACL graft had resulted in positive cultures. Graft can be washed for a period 3 min to reduce undue delay of the surgery(3). Their limitation was that the graft was kept in the sterilizing agent for 90sec and then sent for culture. Pasque et al(10) suggested getting the graft off of the floor immediately, removing any suture material in the graft, cleansing the graft for 15 to 30 minutes each in chlorhexidine and triple antibiotic solution, followed by a normal saline rinse is associated with very less chance of infection. Casalonga et al. (11) followed the outcome of four patients in whom the B-T-B graft dropped onto the floor was re-implanted after decontamination with topic antibiotics. The grafts were soaked in rifamycin and then gentamycin for 10 min each along with postoperative antibiotics for 15 days. There were no complications or postoperative infections, and all patients were able to return to previous sport level. Cooper et al (12) after soaking contaminated grafts in antibiotic solution for 15 min suggested it may reduce the incidence of positive cultures but it may still result in a 30% incidence of nonsterile grafts. Floor cultures most commonly grow coagulase-negative Staphylococcus, bacillus species and diphtheroids(13, 3). The limitation of this study that it was done in cadavers. Plante et al (3) suggested that immediate graft retrieval (<5 sec) did not affect the rate of contamination when compared to fifteen-second exposure (33 vs. 23 %). Sobel et al(14) suggested that structural properties of human patellar tendon allografts are not significantly affected by soaking in 4% chlorhexidine gluconate for 30 minutes. Stanwood et al(1) stated that 71% of surgeons who experienced graft contamination cleansed the graft, and 75% contaminated grafts were cleansed and the ACL reconstruction proceeded as planned. In 18% an alternative autologous graft of contralateral patellar tendon or ipsilateral hamstrings was used to replace the contaminated graft and in 7% of cases, an allograft was used.

In general, the rate of contamination of graft if dropped on floor is between 63 to 96 % and the contaminant grown in culture is staphylococcus(12,8,10, 2). Also, the time interval of dropping the graft and its retrieval doesn’t influence the culture as the different studies have compared the different time interval i.e. 15 sec,  3 min which found similar growth(2). This suggests a definite need of treatment of graft after contamination irrespective of the time duration. Chlorhexidine and povidone iodine solutions both are broad spectrum antiseptics and chlorhexidine is activated in less than 1 min and 10% povidone-iodine takes a longer time to activate with increased activity after 5 min(2). This suggested the need of different immersion time required to disinfect the graft in different solution, in 4 % chlorhexidine solution 3 min may be adequate(8) whereas it may require upto 15min  immersion in 10% povidone-iodine solution(2). Soaking of grafts in antibiotic solutions might increase the risk of multiresistant organism being selected(2) also there is 30% risk of getting non sterile graft(12). If a sutured hamstring graft is contaminated then all the sutures are to be removed before immersion in a disinfectant solution(2).

Jones et al(15) studied the mechanical properties patellar tendon allograft subjected to chemical sterilization(BioCleanse) and found that preimplantation mechanical properties of BPTB allografts treated with BioCleanse are not significantly different from those of untreated controls.

Other than dropping of graft on floor, graft contamination during surgery may occur at various steps of surgery before implantation. Hantes et al (6) studied various sources of contamination of hamstring and patellar tendon autograft. Three tissue samples were obtained for culture from each graft at different time-intervals during graft preparation process, during graft preparation completion and during graft implantation. In addition, the erythrocyte sedimentation rate and the C-reactive protein level were evaluated preoperatively and on the third, seventh, and twentieth postoperative days. Authors concluded that a high rate (12%) of autograft contamination can be expected during autograft preparation for anterior cruciate ligament reconstruction. The contamination rate is almost equal for both bone-patellar tendon-bone and hamstring tendon autografts which was confirmed with normal ESR and CRP reports. However, there was no evidence of postoperative infection with intraoperative contamination results in their series. They further suggested that no excessive antibiotic is required for positive cultures and no evidence of clinical signs of infection. Postimplantation of the contaminated graft after disinfection, it is advised to treat the patient with IV antibiotics and/or oral antibiotics for 1 or 2 weeks. Also, a close watch to be kept until 6 weeks of surgery ifany signs of infection develops(10).

There is a very high chance of contamination of graft when a new staff is given the responsibility of holding graft or surgeon goes to a new setup(10). To prevent this, surgeon should personally get the graft from the time of harvest till getting it on the preparation table. Similarly, new staff or resident who is preparing the graft should be adequately trained and strictly monitored to prevent dropping of graft. Finally all the OR personnel should realize the importance of surgery and be careful at all times especially while transfer of graft from preparation table to implantation site and vice versa.

Conclusion

4% Chlorhexidine with or without bacitracin is the best solution for disinfection of contaminated graft. Graft has to be minimum kept for 3 min immersed in the solution for proper disinfection. If 10% povidone-iodine is to be used graft has to be immersed at least 15 minutes. Earlier the retrieval of graft, better the disinfection as shown comparison between less than 5 second retrieval and 15 sec graft retrieval from floor. All suture material must be removed while disinfecting the graft. Post implantation, antibiotics have to be given for a period of 1 or 2 weeks and have to be followed for at least 6 weeks

References

  1. Stanwood W, Levine WN, Ahmad CS. A Survey of Sports Medicine Specialists Investigating the Ligament Grafts. 2005;21(11):1348–53.
  1. Barbier O, Danis J, Versier G, Ollat D. The Knee When the tendon autograft is dropped accidently on the fl oor : A study about bacterial contamination and antiseptic ef fi cacy. Knee [Internet]. Elsevier B.V.; 2016;22(5):380–3. Available from: http://dx.doi.org/10.1016/j.knee.2014.07.027
  1. Plante MJ, Li X, Brown MA, Busconi D, Deangelis NA. Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction. 2013;21(3):696–701.
  1. McAllister DR, Parker RD, Cooper AE, Recht MP AJ. Outcomes of post-operative septic arthritis after anterior cruciate ligament reconstruction. Am J Sport Med. 1999;27:562–70.
  1. Schollin-Borg M M elsson, Micha¨ elsson K RH. Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study. Arthroscopy. 2003;19:941–7.
  1. Me H, Gk B, Se V, Giotikas D, Petinaki E, Kn M. Autograft Contamination During Preparation for. 2008;760–4.
  1. Stanford R, Solomon M, Levick M, Kohan L, Bell S. Sterilization of Contaminated Bone-Tendon Autografts Using 10% Povidone-Iodine Solution. Orthopedics. 1999;22:601–4.
  1. Molina ME, Nonweiller DE, Evans JA, Delee JC. Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy. 2000 May-Jun;16(4):373-8.
  1. Davis KW, Stauderman WE, Mayfield J WJ. Gamma radiation dose setting and auditing strategies for sterilization of medical devices. In: Gaughran ERL, Morri-of medical products. Montreal. Steriliz Multiscience Publ Ltd. 1981; Vol 2:34-102
  1. Pasque C, Geib T. Intraoperative Anterior Cruciate Ligament Graft Contamination. 2016;23(3):329–31.
  1. Casalonga D, Ait Si Selmi T RA et al. Peroperative accidental contamination of bone-tendon-bone graft for the reconstruction of the anterior cruciate ligament. Report of 4 cases. Rev Chir Orthop Reparatrice Appar Mot. 1999;85(7):740–3.
  1. Cooper DE, Arnoczky SP, Warren RF. Contaminated Patellar Tendon Grafts : Incidence of Positive Cultures and Efficacy of an Antibiotic Solution Soak-An In Vitro Study. 1991;272–4.
  1. Richard D. Parker, Evan J. Bachner, Michael J. Dul, Dirk Treleven, Matthew E. Levy and PP. The Scientific Basis for the Management of Contam- inated Bone-Tendon Grafts: The Serial Dilution/ Mechanical Agitation Technique. Arthroscopy. 1993;9(3):354.
  1. Sobel AD, Hohman D, Jones J, Bisson LJ. Structural Properties of Human Patellar Tendon Allografts. YJARS [Internet]. Elsevier Inc.; 2016;28(12):1862–6.
  1. Jones DB, Huddleston PM, Zobitz ME, Stuart MJ. Mechanical Properties of Patellar Tendon Allografts Subjected. 2007;23(4):400–4.
How to Cite this article:. Sancheti P, Jain SR, Shyam AK. Intraoperative Graft Contamination – What Options Do We Have? Asian Journal of Arthroscopy  Apr- June 2016;1(1):35-37 .

Dr. Parag Sancheti

Dr. Parag Sancheti

Dr. Sachin Jain

Dr. Sachin Jain

Dr. Ashok Shyam

Dr. Ashok Shyam

 

(Abstract)      (Full Text HTML)      (Download PDF)

Future Trends In Grafts Used In ACL Reconstruction

S R Sundararajan, Balaji Sambandam, S Rajasekaran

Volume 1 | Issue 1 | April – Jun 2016 | Page 29-34|

Author: S R Sundararajan [1], Balaji Sambandam [1], S Rajasekaran [1]

[1] Ganga Hospital, 313, MTP road, Coimbatore , Tamilnadu, India Pin code – 641043

Address of Correspondence

Dr Sundararajan S R
Ganga hospital,313, MTP road, Coimbatore , Tamilnadu, India, Pin code – 641043
Email id – sundarbone70@hotmail.com

Abstract

Anterior cruciate ligament injury is the commonest sports injury in day to day orthopaedic practice and arthroscopic reconstruction of anterior cruciate ligament is the standard of care. This gold standard procedure has evolved continuously since the time of its inception in terms of technique, implant used for fixation and most importantly the graft used. Each period of time was dominated and fascinated by a particular graft option. Though numerous came into the picture only few stood the test of time. Search for the perfect graft for ACL reconstruction still continues. Ideally it should have adequate biomechanical strength, should be easily available and doesn’t cause any harm during harvest or implantation. Today we have the option of autografts, allografts and even synthetic grafts. In the future tissue engineering and gene therapy might play a major role in graft production.
Keywords: Anterior cruciate ligament reconstruction, allograft, synthetic graft

Introduction

History of using tendon grafts for ACL reconstruction started in the early sixties. Kenneth Jones(1) was one of the early surgeons who started using tendon for ACL reconstruction. From then on grafts for ACL reconstruction surgery continued to evolve. Every new source of graft had its own advantages and disadvantages. An ideal graft should be one which is easily available, have the properties similar to the native ACL, get incorporated to the bone easily and don’t cause any donor site morbidity. As of now, there is no such graft which can completely reproduce the structural and biological characteristics of native ACL without causing an untoward effect. Today we have the option of autografts, allografts and few synthetic grafts. The failures are not only because of the characteristics of the graft but also due to graft healing in the bone tunnel. The future trend of grafts for ACL reconstruction might not be same as we see today because of on going research like tissue engineering. In this article we reviewed the commonly used grafts at present and the future evolving concepts.

1. Tendon grafts
The usage of tendon grafts as a substitute to ligament is due to the fact that they are anatomically and histologically similar. These connective tissues are made up of bundles of collagenous fibers arranged in parallel, slightly wavy or curved arrays. Twenty percent of their mass is made up of cellular component and the remaining 80% is the extracellular components. Fibrocytes and fibroblast comprise the cellular component. 80% of their mass is water. Collagen fibers make 65 to 80% of the dry mass. Type 1 collagen is the one which is abundant in both with some type 3 collagen. Amount of collagen and the ratio between type 1 and type 3 are the differences between the two. The amount of collagen is more in tendons than the ligaments and the ratio between type 1 and 3 is 99:1 in tendons where as it is 90:10 in case of ligaments. Apart from anatomical and histological similarity the strength and other biomechanical properties should be similar between the tendon and the ligament to be replaced. Noyes et al[2] did a biomechanical testing to test the strength between natural ACL and various grafts after excluding age and disuse related factors. They found that semitendinosus and gracillis had 70 and 49 % of the strength of natural ACL while patellar tendon has 159 to 168 % strength compared with natural ACL.
The bone tendon interface is composed of a tissue called enthesis which is a transitional zone transmitting the stress from bone to tendon and vice versa. Enthesis is of two types(3). The first type is the direct insertion type which is typically seen in ACL, patellar tendon, rotator cuff, Achilles tendon and femoral attachment of MCL. Here there is a gradual transition from tendon to bone. Microscopically the attachment point shows interdigitation of collagen fibers with transition from tendon, unmineralized fibrocartilage, mineralized fibrocartilage and bone. The superficial fibers are inserted into the periosteum and the deep fibers are attached at right angles or tangentially to the bone in the transition zone. The second type is the indirect type observed in tibial attachment of MCL and deltoid insertion in humerus. Here there is no fibrocartlaginous transition and the tendon fibers pass obliquely along the bony surface and inserts at an acute angle into the periosteum. They are connected by Sharpey’s fibers(4,5). The healing between tendon and bone in case of ligament reconstruction surgery is slightly different. Here there forms a vascularised granulation tissue in the junction which gets replaced by Sharpey’s collagen fibers gradually. The attachment gets further strength when bone grows between the interfaces.
Patellar tendon, hamstring tendon and quadriceps tendon are the three most commonly used autografts. Even among them there is no single outstandingly performing graft. Each one has its own advantage and disadvantage. In a meta analysis done by Li et all (6) patellar tendon graft had favorable outcome in terms of KT-1000 arthrometer values, negative rates of Lachman test and pivot shift while hamstring tendon graft was better in avoiding anterior knee pain, kneeling pain and extension loss. There was no difference in postoperative graft failure rate.

Bone Patellar tendon bone grafts.
BPTB grafts since the time of Jones evolved into a gold standard for ACL reconstruction in last few decades. Jones(1) made a medial parapatellar incision one inch distal to the patella extending just distal to the tibial tubercle. Then a femoral tunnel was made. The central third of the patellar tendon was incised along with a bloc of bone from the patella. The tibial attachment was left intact and the bone block is fixed to the femoral tunnel. Because the graft was attached to the natural insertion site in tibia the length was small making the femoral tunnel to be more anterior than anatomical. Franke was the first to describe the free patellar tendon graft as we use it today(7). By the nineties free bone patellar tendon bone graft became the standard graft for ACL reconstruction and was commonly used. Advantages of this graft are the mechanical strength and the bone to bone healing which occurs with this graft. Anterior knee pain is the major limiting factor for BPTB graft with a reported incidence of 4 to 60 percent(8, 9). The reason for anterior knee pain can be injury to the infrapatellar branch of saphenous nerve, the inflammatory response that occurs during healing of the donor site and even the shortening of the tendon which occurs after graft harvest. To prevent these complications there were many attempts to modify the graft harvesting technique. Berg and Liu sutured the peritenon and filled the bone harvesting site[10, 11]. But these modifications were not entirely satisfactory as seen in further studies[12, 13]. In order to reduce the injury to infrapatellar branch of saphenous nerve, newer minimally invasive two incision techniques were devised. Other more important aspect of concern in this graft is regaining the original strength in the donor site. There are many MRI and ultrasound based studies which showed near complete regain of cross-section area after harvest(14-16). But still rupture of patellar tendon does exist. The risk of rupture is high when closing the defect in the middle with undue tension. Also a tight closure can cause necrosis, fibrosis and shortening of the tendon.When excessive patellar bone is harvested or the intraosseous midpatellar and polar vascular channels are damaged patella fracture can occur(17). There are further modifications in the graft harvesting technique to reduce these complications where instead of the middle third medial third was used(18). Proponents of this technique advocate many advantage of this technique over the classic middle third. Graft can be harvested by a single cut, there is no need to approximate the peritenon and the risk of patellar tendon rupture, shortening, patellar fracture and maltracking are reduced. Today patellar tendon grafts are less frequently used when compared to hamstring tendon grafts. But still it is the graft choice when early bone to bone healing is needed; particularly in sports personnel and athletes who need faster recovery. It is also commonly used in revision surgeries and multiligamenous injuries.

Hamstring tendon graft
Hamstring tendon graft is the commonly preferred graft at present because it can be easily harvested, more cosmetic with few donor site complications with same functional outcome when compared to bone patellar bone graft. Though the use of hamstring tendon as graft became popular in recent time its usage started very early. Galeazzi(19) was the first to use them in 1934. He used semitendinosus tendon to reconstruct ACL. The usage was further made popular by many surgeons like Macey, Lindemann, Agustine(20-22). The reason behind the success of this tendon graft is good clinical outcome and lesser donor site morbidities. Hamstring tendon regenerates after harvest but the time it takes to regenerate and the strength of the newly formed tendon is not clear yet. Careful repair of the facial layer is needed so that the space between layer 1 and 2 in the knee provides a tubular compartment for the tendon to regenerate from the tip of the muscle. This is akin to the nerve regeneration within the endoneurium. Injury to infrapatellar branch of saphenous nerve is a commonly reported complication after the harvest of hamstring tendon graft. Sgaglione(23) et al has reported this complication in up to 70% of the cases. Making an oblique incision instead of the usual vertical incision reduced its incidence(24). De Padua et al (25) had shown that harvesting semitendinosis alone reduces the incidence of nerve injury
Since bone to tendon healing takes longer time rehabilitation after its usage is prolonged. To enhance the incorporation of hamstring tendon people are injecting platelet rich plasma into the tunnels before fixing the hamstring grafts(26). Platelet rich plasma which is supposed to contain numerous growth factors will enhance the bone to tendon healing. But there is no clear cut evidence for this till now. Weakness of knee flexion is also a concern after hamstring tendon graft harvest. However Lipscomb et al(27) had shown that harvesting the both tendons does not affect the knee flexors strength
When compared to patellar tendon graft which has a bone plug, hamstring tendon grafts are known to cause more tunnel widening. L’Insalta et al(28) in their study of 60 patients who underwent ACL reconstruction observed a significantly increased tunnel widening in the group of patients with hamstring tendon graft compared with the other group of patellar tendon grafts. But it doesn’t seem to affect the clinical outcome; although it might cause problems during a revision procedure. In a study done by Clatworthy et al(29) comparing the hamstring tendon graft with the patellar tendon graft there was no significant difference in outcome even though tunnel widening was significantly more in the hamstring tendon group.

Quadriceps tendon graft
Quadriceps tendon graft usage was first reported by Fulkerson and Langeland(30) in 1995. Gradually its usage started to increase. But still today it is the least commonly used tendon autograft for ACL reconstruction. The ultimate tensile strength of this graft is more than the native ACL and that of patellar tendon graft(31). It has been shown in a MRI study that a 10mm central strip of quadriceps tendon has 88 percent more volume than a 10mm central strip of patellar tendon(32). There are evidences that volume of the graft directly correlates with the structural properties of the incorporated graft, and also an increased failure rate with decreased graft size(33-34). Similar to patellar tendon graft the major problem with this type of graft is the donor site morbidities like pain and patella fracture. Patella fracture remains a possibility after this graft harvest. In order to reduce this complication people have modified the graft harvesting technique. Quadriceps tendon graft without the bone plug was tried and found to give comparable results(35). But the bone to bone healing which this grafts provide will be lost and the length of the graft will be reduced. The natural insertion of this tendon into the patella is not in the middle but slightly lateralized. So if we go by the centre of the patellar tendon then the bone plug in the patella will be more lateral. According to Scully et al(36) harvesting this bone plug from a slightly lateral portion of patella will predispose to fractures. So they devised a technique to medialize the graft harvest centering over to patella to obtain a bone plug from the middle of the patella. Despite improved harvesting techniques quadriceps graft is less commonly used because of the donor site morbidities. But it provides a valuable option when the other two more commonly used tendons are not available for some reason

2. Allograft
Rise of the allograft occurred in order to reduce the donor site morbidity, reduce postoperative pain and operative time. Eugene Bircher(37) was the first to use this in 1929. He used tendons harvested from kangaroo as an augment or a sole graft. Following this there were few others who used xenografts after which it became unpopular. Then was the time of allografts from human cadavers. Achilles tendon, tibialis anterior, tibialis posterior, hamstrings and patellar tendon were the major allografts harvested from cadavers for ligament reconstruction. But the increase in parenteral viral infection led to its unpopularity in the nineties. The sterilization processes like high dose radiation and ethylene glycol available during those periods affected the mechanical properties of the graft. Many studies have been published which demonstrated the deleterious effect of irradiation and ethelene oxide on allograft(38-39). Improved sterilization techniques and screening techniques revived the allograft in recent times. Data suggests that in 2002 an approximate one million musculoskeletal allografts were used in United States alone as against only 350,000 were used in 1990(40). The Bio Cleanse tissue sterilization system(41) is a recently available system which doesn’t affect the mechanical properties of the allograft. It is combination of mechanical and chemical techniques. The graft is subjected to an oscillating positive and negative pressure and treated with chemical agents like detergents and sterilants. This process removes the blood and lipids and destroys the microorganisms. The graft is repeatedly rinsed when the debris and the residual chemicals were removed. Non irradiated grafts are being favored over irradiated grafts in recent times. Prodromoset al(42) did a meta analysis and found that irradiated grafts have an abnormal stability rate in comparison to non irradiated grafts. Apart from transmission of infection from donor to the reciepient, bacterial contamination while processing and preserving these allografts was also a concern. But Greenberg et al[43] showed there was no increased risk of infection with the use of allograft compared with autograft in primary anterior cruciate ligament reconstruction. Most important problem with allograft is slow incorporation of the allograft tissue to bone and decreased failure load till it gets incorporated into the host. Many animal studies and MRI studies in humans have demonstrated this(44-46). Immunogenic reaction of the host to the graft tissue is one more possible complication. Literature evidence regarding the outcome and revision rates of allograft was not always uniform. In a meta-analysis done by Yao et al(47) there was no significant difference in patient reported outcomes scores, range of motion or the tests for laxity between BPTB autograft and allograft. But the revision rates were significantly higher in the allograft groups. Mariscalco et al(48) did a meta-analysis and compared non irradiated allografts with autografts and found no difference between the two in terms of graft failure rates, postoperative laxity and patient reported outcome scores. However allografts are not routinely used because of the cost and availability. Allograft could be the answer when the donor site morbidities and operative time have to be reduced. Improved harvest and storage techniques will increase the availability of the allografts in future

3. Synthetic grafts
Further in line are the synthetic grafts. Synthetic graft is an artificial graft prepared for two purposes. They can either act as the sole graft scaffold over which fibrous tissues develop to provide the stability as that of the native ACL. Or it can be used as a load sharer until the autograft tissue heals and take over the role. To perform this synthetic graft should be chemically stable, biocompatible, should not contain harmful additives, should not be hygroscopic and should contain pores for fibroblasts ingrowths. Above all they should have the physical characters of plasticity, stiffness, strength and traction resistance similar to the original ligament. The drawbacks associated with today’s synthetics are adverse immunological reaction, debris dispersion, failure of ligamentization process, breakage, synovitis and chronic effusion. Synthetics made of carbon were the first to enter the market. Jenkins et al(49) developed a carbon made synthetic ligament in 1977. It was initially employed for tendon suturing and later extended to knee ligament reconstruction surgeries. Dandy et al(50) were the first to introduce synthetic grafts in ACL reconstruction. His graft was also made of carbon fibers. Initially these carbon made synthetic grafts were received well, but later they went into disrepute because of early failure due to incompetency to resist torsion forces, inflammatory synovitis and carbon deposition in liver. Came next was the graft made of single strand of polytetraflouroethelene wounded into multiple loops(PTFE/ Gore-tex). Initially this was approved by the US government to be used in cases with failed autografts. It was perceived as the complete graft because of its tensile strength of 5300N, greatest of all synthetic grafts manufactured till date(51). But soon later studies found its deficiencies. After some initial encouraging results Woods et al(52) observed worsening knee stability in long term. Similarly Ferkel et al(53) performed a second look arthroscopy 11 months after 21 ACL reconstructions and found partial damage in 6 cases and complete damage in 4 cases. Soon Gore-tex was withdrawn from the market due to higher failure rate and complications like tunnel osteolysis and deposition of the PFTE particles in lymph nodes.Dacron graft made of polyester was one more product of this breed. It was made up of polyester and had an 8mm sleeve of loosely woven velour and a central core of four tightly woven tapes with a mean strength of 3631N(54). It was first used in acromio-clavicular injuries and later in ACL reconstruction. But this too failed in the long run due to high failure rates.The augmentation concept of synthetics was first given by John Kennedy in 1975 when he introduced a polypropylene ribbon for augmenting the autograft.51 This concept tried providing a support for the autografts until the healing becomes complete. The Leeds-Keio ligament(55) or the LK ligament developed in 1982 with the collaboration of Leeds university of UK and Keio university of Japan met with little success. It was made up of woven polyester fibers in tubular bundle and measured 10 mm in diameter. It acted as a scaffold and induced tissue growth. Porous coating over it allowed the tissue to grow in and form a new ligament. This too failed after it made an early impact. Murray and Macnicol(56) made a long term follow up of 10 to 16 years following ACL reconstruction with LK ligament and found a high failure rate of 28 percent and increased degenerative changes compared with the opposite side.
However the most successful of all the synthetic grafts was the Ligament Advanced Reinforcement system (LARS ligament) made up of polyethylene terephthalate(57). This also acted as a scaffold over which tissue in growth occurs. Its short term follow up showed encouraging results but the long term results are still awaited. Liu et al(58) retrospectively made a comparison between LARS and four strands hamstring tendon autografts and observed excellent functional outcomes and higher knee stability in LARS. Polyethylene teraphthalate materials were most commonly used to augment the tissue grafts. Despite repeated failures synthetic grafts continues to evolve over time and manufacturers kept pulling out a new product out of their sleeve every now and then. Confidence over the synthetics is still maintained because of the few studies which showed promising results(55, 57-58).
4. Tissue engineered grafts
This could be the future of ligament reconstruction surgeries. This technology was originally devised to repair skin, cartilage and bones but could be extended to ligaments in the near future. Tissue engineering is basically a combination of engineering, molecular biology and medical knowledge to create biological tissues or organ in vitro. Here organ or tissue growth is done in vitro over a scaffold(59). It is made by nanotechnology which produces a biomimetic structure to replicate the native architecture of the tendon extracellular matrix. Extracellular matrix of the tendon is made up of interconnected porous microstructure composed of collagen fibers. This scaffold provides the structural support over which cells grows due to chemical and mechanical stimulus. The scaffold used will be biodegradable and biocompatible along with the desired biomechanical properties. Both natural and synthetic scaffolds are being used. Collagen, silk, hyaluronic acid are examples of naturally available scaffolds while Dacron polyester, polyglycolic acid and polylactic acid are examples of synthetic scaffolds. Once the engineered graft is taken up the scaffold will gradually degrade and the cells should take over their place. Cells employed here can be mesenchymal stem cells or a tenocyte. In a study done by Kryger et al(60) tenocytes, bone marrow derived mesenchymal stem cells, adipose tissue derived mesenchymal stem cells and tendon sheath fibroblast were seeded into acellularised tendon tissue and implanted in vivo into a flexor tendon defect. After 6 weeks histological analysis revealed viable cells in all four types. But the mechanical property of each type was not analyzed.Best cells to be employed for engineering a tendon is still not clear. Currently no case of ACL was operated with a tissue engineered graft as this is a newly developing technology. Gene therapy will come to play a role in tissue engineered ACL grafts. Currently gene therapy is being researched in repairing tendon injuries(61) and the same can be applicable in ligament injuries. There are two different strategies in gene therapy(62). One is in vivo transfer of the gene within a vector which is then directly applied to the target tissues. Lou et al(63) used BMP-12 gene to treat complete tendon laceration in chicken model and found a two fold increase in tensile strength and stiffness of the repaired tendon. The disadvantage of this strategy is that there is always a possibility of transfecting the cells adjacent to the target tissue. Another disadvantage is the development of immune response to the vector. The second strategy involves harvesting the target tissues from the body, trasfecting them with the vector and then allow them to grow in a culture in vitro. Once the tissue gets matured they can be transferred to the target area. This approach seems very promising for ligament reconstruction surgeries. The idea of using stem cells in ligament injuries can become feasible in the near future. Stem cells could be harvested and induced to grow a particular mesenchymal lineage to repair the injured ligament.

conclusions

Tendon grafts continue to be the commonly used material for ACL reconstruction surgeries. Both autografts and allografts have its own pros and cons. Each surgical case should be individualized and the choice of the graft should be made. Allografts usage continues to grow. In the future with appropriate precautions this might become a major source for ACL reconstruction. Synthetic grafts and tissue engineered grafts are still in the developing phase. The usage of these grafts has a long way to go. Till then autografts and allografts are the choices of graft for ACL reconstruction.

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How to Cite this article:. Sundararajan SR,  Sambandam B, Rajasekaran S. Future Trends In Grafts Used In ACL Reconstruction. Asian Journal of Arthroscopy  Apr- June 2016;1(1):29-34 .

Dr. Sundararajan S R

Dr. Sundararajan S R

Dr. Balaji Sambandam

Dr. Balaji Sambandam

Dr. S Rajasekaran

Dr. S Rajasekaran

(Abstract)      (Full Text HTML)      (Download PDF)

Biologics in Primary Anterior Cruciate Ligament Reconstruction

Vijay D Shetty, Karan Alva, Varun Gupta

Volume 1 | Issue 1 | April – Jun 2016 | Page 25-28

Author: Vijay D Shetty [1], Karan Alva [1], Varun Gupta [1]

[1] LH Hiranandani Hospital, Hiranandani Orthopaedic Medical Education (HOME), Mumbai 400 076,India.

Address of Correspondence

Dr Vijay D Shetty
Dr LH Hiranandani Hospital
Hiranandani Orthopaedic Medical Education (HOME)
Mumbai 400 076 India
Email id – vijaydshetty@gmail.com

Abstract

The success of anterior cruciate ligament reconstruction depends on the healing and integration of the graft in the bony tunnels. Recently there has been lot of interest in biological augmentation techniques to improve the biological milieu in the knee joint so as to enhance this healing process. These techniques include use of platelet rich plasma, periosteum and bone morphogenetic proteins (BMPs). The present article is a review of current literature exploring the effectiveness of these techniques and the future scope
Keywords: anterior cruciate ligament reconstruction, platelet rich plasma, bone morphogenetic proteins

Introduction

The anterior cruciate ligament (ACL) is the most commonly injured knee ligament, frequently requiring surgery and extensive rehabilitation(1). Primary repair of the ACL has a high failure rate of 40% to 100% mandating the need for ACL reconstruction (ACLR)(2). However, success of ACLR depends mainly on the healing and integration of graft into the femoral and tibial tunnels(3,4,5). Various factors such as graft selection, graft incorporation and pre-injury activity level influence the clinical outcome of ACLR(6,7). Studies have shown that younger the age of the patient and, more athletic the demand, higher is the expectation from the surgery(8,9).
Graft-bone healing has been always an issue with ACLR. Recent years have seen a number of publications indicating the use of biological augmentation techniques to enhance graft-bone healing(10,11). These include the use of platelet rich plasma, periosteum and bone morphogenetic proteins (BMPs). This article attempts to explore the current thinking in the use of biologics in enhancing bone-graft healing in ACLR.

Graft healing
Natural healing of torn ACL is one of the challenging problems encountered by surgeons. The hypo-vascular and hypo-cellular nature of ACL retards its self regeneration capacity and results in poor healing. Further, following ACL injury, the thin synovial sheath surrounding the ACL gets disrupted resulting in mixing of blood with the native synovial fluid. As a result, haematoma formation is delayed and this prevents the aggregation of factors (cytokines, growth factors and reparative cells) responsible for natural healing(12). This forms the basis of non-healing of injured ACL. Therefore, the best option to address this issue would be a reconstruction rather than repair.
Normally, ACL inserts directly into the bone, thus forming a transition zone from the tendon-to-bone consisting of the tendon, non-mineralized fibrocartilage, mineralized fibrocartilage and bone (Figure 1). The fibrocartilage at the insertion site contains cartilage-specific collagens, type II, IX, X and XI, with the interface between mineralized and demineralized bone maintained by collagen X(13). Besides, obliquely running Sharpey fibres are present at insertion sites which anchors the ligament to bone, providing the fundamental mechanical strength. ACLR with tendon grafts fails to reproduce the same arrangement. It has been shown by various studies that graft healing in ACLR occurs by an interposed layer of fibro-vascular scar tissue at the graft tunnel site(14). This fibro-vascular scar tissue becomes mineralized and incorporates the tendon graft into the surrounding bone. The tendon bone junction is restored by the re-growth of collagen fibres between the tendon and bone(15,16,17,18,19). The formation of collagens and Sharpey fibres occurs after 6 weeks of surgery and bone tunnel healing of graft is completed by 6-10 months after surgery(20). However poor osteo-integration of the graft in ACLR is common and is associated with anterior –posterior laxity postoperatively (21). Thus, to achieve earlier return to functional activities and better clinical outcomes, acceleration of healing between tendon graft and bone is the most enduring challenge. In order to improve graft bone healing, various biologically engineered strategies are being studied. These biological strategies aim to enhance intra-articular and intra-osseous healing.

Figure 1: Organised transition from tendon (T) to demineralised fibrocartilage (UFC) to mineralized fibrocartilage (MFC) and bone (B). Courtesy: Muller et al, 2013.

Figure 1: Organised transition from tendon (T) to demineralised fibrocartilage (UFC) to mineralized fibrocartilage (MFC) and bone (B). Courtesy: Muller et al, 2013.

Figure 2: The periosteum is wrapped with the cambium layer facing the tunnel wall and then sutured on the tendon at both sides with a No. 3-0 Vicryl suture where the tendon graft approached the tunnel opening. Courtesy: Chen at al, 2010.

Figure 2: The periosteum is wrapped with the cambium layer facing the tunnel wall and then sutured on the tendon at both sides with a No. 3-0 Vicryl suture where the tendon graft approached the tunnel opening. Courtesy: Chen at al, 2010.

Biological strategies to enhance tendon graft healing in ACLR
Platelet-rich plasma
Platelet-rich plasma (PRP) is an autologous concentration of platelets. The concentration of these platelets, in a given formulation, is much above the normal physiological levels. Platelets are the precursors of the megakaryocytes having an irregular shape with non-nucleated cytoplasmic bodies. The glycoprotein’s expressed on their cell membranes play an important role in haemostasis and wound healing by formatting fibrin clots(22). Platelets are the source of various growth factors including platelet-derived growth factor (PDGF), epidermal growth factor (EGF), transforming growth factor-beta 1 (TGF-β1), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (FGF), hepatocyte growth factor (HGF), and insulin-like growth factor (IGF-I) which are involved in different stages of cell proliferation(23,24,25).
Versatility of PRP lies in the fact that it can be easily prepared and can be applied directly in the operation theatre. Various methods of its application are intra- articular injection or in the form of a membrane that can be applied directly to target site. Several studies have shown that the healing potential of PRP in articular tissues, cartilage, ligaments, tendons and synovium(26,27,28). Infiltration of PRP causes increase in the extracellular matrix deposition, anabolic reaction towards cells, reduction of pro apoptotic signals and also has anti–inflammatory effect in the joint environment(26). Studies have shown that application of PRP in ACL reconstruction procedure not only causes better and faster ligamentization of the graft, but also contributes to a better integration of the graft within the bone tunnels. Enlargement of bone tunnels can thus be prevented and faster healing can be promoted.

Periosteum
Periosteum is a bilayered tissue between the bone and soft tissue. It had an outer fibrous layer which is rich in fibroblasts while the inner cambium layer is rich in multipotent mesodermal cells. It also consists of chondro-progenitor and osteo-progenitor cells, which can differentiate into both cartilage and bone(29,30). It can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting (Figure 2). The tendon reconstruction is said to be successful if there is bony in-growth into the tendon.8 The periosteum may be used to enhance the healing between the bone and graft by forming fibrocartilage and calcified fibrocartilage(31,32). Besides, it can also help to seal the intra-articular tunnel opening in the early postoperative period, thus avoiding synovial fluid reflux into the tunnel(33,34). Studies have shown favourable outcome with the use of periosteum to enhance tendon-bone healing post ACLR. In a study by Chen et al, (31) knees were followed up for a mean of 4.6 years post ACLR which showed statistically significant results with periosteum-enveloping hamstring tendon single bundle ACLR when compared to other studies with comparable fixation(35).

Bone morphogenetic protein
Bone morphogenetic proteins (BMPs) are signalling proteins which interact with tissue structures in the body to enhance the skeletal development. Animals studies have shown that both BMP-2 and BMP-7 have the ability to increase the graft fixation strength in bone tunnels(36,37,38). A study by Sunder S et al in bovine models showed that demineralised bone matrix (DBM) is a source of BMPs which enhances tendon-bone healing and tendon-bone fixation strength(39). Further, Chen CH et al concluded that BMP-2 and periosteal progenitor cells induce rapid tendon-bone integration(21). However, there is much debate about the use of BMPs in ACLR surgeries in human being despite the theoretical advantages(21).

Discussion
The main goal of ACLR is to make the patient return to pre-injury level, and therefore return to sports, as soon as possible. In this direction, there have been a number of technological advances, in recent years, with respect to ACLR. Last few years have seen an increase in the number of publications on best surgical techniques, anatomical tunnel placements, use of scaffolds and augmentation with various biological products. Enhancing the tendon-to-bone healing has been the centre of research in ACLR(28,40,41).
It has been established that the tendon-bone healing occurs by collagen fibre scarring tissue which then reorganises to form a dense matrix. This is then followed by the appearance of Sharpey’s fibres. This collagen fiber continuity between the tendon and bone establishes the tendo-osseous junction and has been described as the earliest sign of osteo-integration(42,43).
Periosteum is rich in multipotent mesodermal cells and has osteogenic capacity. It has the ability to promote cartilage formation and also initiate enchondral ossification by inducing differentiation of mesenchymal cells into chondroblasts and subsequently into osteoblasts. It can also augment bone ingrowth into collagenous tissue and help induce ossification. When we incorporate periosteum in our graft by suturing on the surface of the tendon and then transplanting into the bony tunnel, the cambium layer of the periosteum serves as a fibrous layer between the tendon and bone interface. Studies have shown that by around 4 weeks, there is inter-digitation between the periosteum tissue and tendon resulting in progressive incorporation over time. Because of the effect of periosteum on promoting bony ingrowth and increasing the strength of the fixation, enveloping the tendon with it may be an effective way to enhance graft incorporation. Tunnel widening following ACLR is significantly greater with hamstring tendon. This is attributed to the greater distance from the normal insertion site and biomechanical point of action of the ACL, creating a larger force moment during graft cycling leading to greater expansion of the tunnels (44)
Platelet-rich plasma is another biological product that is frequently used to enhance tendon bone healing in ACLR. A prospective study by Radice et al compared the MRI findings between ACLR with biological augmentation and without biological augmentation(45). Post-operative MRIs showed that a 48% of time shortening, in healing, was achieved in augmentation group. Another study by Magnussen et al (46) compared 50 patients of allograft ACLR supplemented with platelet rich plasma, intra-operatively, with 50 patients of allograft ACLR without the use of platelet rich plasma using similar operative techniques. The results showed minor short-term clinical benefits, with biological augmentation, at two year post surgery. This, perhaps, indicates that biological augmentation is not that promising when allografts are used for ACLR. Further, a study by Mirzatolooei et al (47) evaluated tunnel diameters, in augmentation group and non-augmentation group, using CT scans on the day of surgery and at three months after surgery. Their results did not show a statistically significant change in the tunnel diameter between the augmentation group and non-augmentation group.

Conclusions

It appears, from the available literature, that biological augmentation in ACLR is an attractive option. However, at the moment, there is no concrete evidence to suggest that biologics work well with allografts. Besides, the tunnel widening issue still remains a major concern in ACLR and, there is conflicting evidence to support the idea of using biologics to address tunnel widening in ACLR.   Although the jury is still out on specific advantages, it appears that there is no harm in using biologics in ACLR. It remains to be seen whether future level I studies will throw more light into the use of biological augmentation in ACLR procedures.

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How to Cite this article:. Shetty VD, Alva K, Gupta V. Biologics in Primary Anterior Cruciate Ligament Reconstruction.  Asian Journal of Arthroscopy  Apr- June 2016;1(1):25-28 .

Dr Vijay D Shetty

Dr Vijay D Shetty

Dr Karan Alva

Dr Karan Alva

Dr Varun Gupta

Dr Varun Gupta

(Abstract)      (Full Text HTML)      (Download PDF)

Biology of Graft Incorporation

Elmar Herbst, Marcio B. V. Albers, Michaela Kopka, Humza Shaikh, Freddie H. Fu

Volume 1 | Issue 1 | April – Jun 2016 | Page 20-24

Author: Elmar Herbst [1], Marcio B. V. Albers [1], Michaela Kopka [1], Humza Shaikh [1], Freddie H. Fu [1]

[1] Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213-0802

Address of Correspondence

Prof. & Chair. Dr. Freddie H. Fu
Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213-0802.
E-mail: ffu@upmc.edu

Abstract

In order to achieve good long-term results after anterior cruciate ligament (ACL) reconstruction, appropriate graft-to-bone healing is essential. The ACL graft is most vulnerable to re-injury during the early post-reconstruction phase. This is due to the decrease in biomechanical properties that occurs throughout the remodeling and graft-to-bone healing process. These processes are highly dependent on the biological and mechanical environment of the knee. The majority of the evidence regarding graft-to-bone healing is based on animal research. However, radiographic and histologic studies in humans reveal a slow incorporation process, which must be respected in post-operative rehabilitation planning. Significant differences between the healing behavior of soft tissue and bone-tendon-bone grafts, as well as between auto- and allografts have been identified. While tendon-to-bone healing occurs with dense fibrous tissue, bone blocks become incorporated into the surrounding tunnels via primary bone healing. Consequently, bone-tendon-bone grafts reveal a different microscopic appearance and slightly faster tunnel incorporation than soft tissue grafts. In anatomic ACL reconstruction, postoperative rehabilitation protocols should be tailored to allow optimum graft-to-bone healing, thereby minimizing tunnel enlargement and risk of graft failure.
Key Words: anterior cruciate ligament, graft, healing, tendon to bone, bone to bone, biology

Introduction

The bony insertion of the anterior cruciate ligament (ACL) is comprised of four distinct zones: ligamentous tissue, non-calcified fibrocartilage, calcified fibrocartilage, and bone. This “enthesis” is responsible for effectively transmitting the forces from the elastic ligament to the stiff bone. Despite its well organized structure, the enthesis has limited vascularity and thereby poor healing capacity(16, 40). As a result, primary repair of a torn ACL has been shown to be ineffective in restoring knee kinematics and stability, and reconstruction of the ligament (with autogenous or allogenous tissue) has become the standard of care. Although the outcomes following ACL reconstruction are generally good, there remains a 7-10 % overall re-rupture rate which warrants further evaluation(11). Technical errors (most frequently malposition of the femoral tunnel) are the most common cause of graft failure(18). However, 3 – 27% of ACL re-ruptures are considered “biologic” graft failures, which occur due to inappropriate graft ligamentization and inadequate graft-to-bone tunnel healing(18).
In the early post-operative phase, the primary strength of an ACL graft is afforded by the means of femoral and tibial fixation. However, long-term stability and the ultimate success of ACL reconstruction are dependent mainly on the secondary mechanical properties of the graft – instilled through the remodeling and graft-to-bone incorporation processes28. The purpose of this review is to discuss the important aspects of graft-to-bone healing and highlight their clinical relevance in anatomic ACL reconstruction.

Figure 1: Magnetic resonance imaging (MRI) of a left knee of a 21-years old male patient one year after ACL reconstruction with an autologous quadriceps tendon grafts. A) Coronal T2-weighted coronal image with the arrow indicating the fibrous interface between the soft tissue graft and the bone tunnel. B) T1-weighted coronal cut with a homogenous intra-tunnel portion of the graft (arrow). C) T1-weighted sagittal image. At the distal part of the tibial bone tunnel the interference screw is visible. The arrow proximal to the interference screw highlights the fibrous interface in the anterior part of the bone tunnel.

Figure 1: Magnetic resonance imaging (MRI) of a left knee of a 21-years old male patient one year after ACL reconstruction with an autologous quadriceps tendon grafts. A) Coronal T2-weighted coronal image with the arrow indicating the fibrous interface between the soft tissue graft and the bone tunnel. B) T1-weighted coronal cut with a homogenous intra-tunnel portion of the graft (arrow). C) T1-weighted sagittal image. At the distal part of the tibial bone tunnel the interference screw is visible. The arrow proximal to the interference screw highlights the fibrous interface in the anterior part of the bone tunnel.

The four stages of graft incorporation
Analogous to the intra-articular graft remodeling process, graft-to-bone healing can be subdivided into four stages: 1) inflammatory phase, 2) proliferative phase, 3) matrix synthesis, and 4) matrix remodeling(16). The similarity ends there, however, as each stage is distinctly different between the two processes. During the initial inflammatory response, the ACL graft undergoes partial necrosis. This stimulates the release of a cocktail of growth factors, which induce the proliferative phase and promote neovascularization and nerve ingrowth. The matrix synthesis and remodeling phases result in bone or collagen fiber formation at the bone-tendon-bone (BTB) and soft tissue graft-tunnel interface, respectively(6, 16, 28, 39). This complex process is affected by a variety of biologic and technical factors. Of the technical – and thereby controllable – factors, graft type and tunnel position are likely the most important(5, 37).

The influence of different graft types
Animal studies
In general, both the ACL graft remodeling and incorporation processes are different and faster in animals compared to humans. Therefore, histologic and biomechanical data from animal studies cannot be directly transferred to humans and must be interpreted in the appropriate context.

Soft tissue graft incorporation
Incorporation of soft tissue ACL grafts begins with the development of granulation tissue and perpendicular collagen (Sharpey-like) fibers at the tendon-bone interface. This process usually occurs during the first 3-4 weeks. The granulation tissue surrounding the graft expresses high levels of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF), which leads to an increase in the amount of fibroblasts and blood vessels(14, 23). This rudimentary scar tissue is characterized by loose and poorly organized collagen types I, II, and III fibers. Over time, the amount of type II collagen decreases, and the remaining type I and III fibers become more dense and organized(14, 16, 26, 33).
The biology of the later stages of graft incorporation is less consistently reported in the literature. Some authors suggest that the graft becomes incorporated into the tunnel by woven bone as early as six weeks(19), while others have shown that dense collagen fibers predominate at the interface during this time33. The majority of the studies agree that bony ingrowth begins between 6-8 weeks(19, 23, 26). However, despite the formation of distinct cartilaginous (type-II collagen) tissue at the graft-tunnel interface, no direct insertion of fibrocartilaginous tissue is present at this time. Furthermore, the expression of VEGF, b-FGF, and collagen types II and III remains similar to the earlier stages of the incorporation process(13, 15, 26). At 12 weeks, a calcified cartilage zone similar to the native ACL insertion can be observed at the intra-articular tunnel aperture(19). This was demonstrated by Weiler et al., who showed that a mature fibrocartilaginous tendon-to-bone junction was present at 12 weeks in an interference-fit fixation study(29, 35). Others have disputed these findings, suggesting instead that the fibrocartilaginous tissue becomes more dense leading to bone tunnel sclerosis(33). The late stages of soft tissue graft incorporation are characterized by a decrease in cartilage metaplasia and resultant bony ingrowth (26). At six months following ACL reconstruction, significant ossification and formation of a four phase insertion can be observed at the graft-bone interface(19,35). This process continues along the length of the tunnel well beyond one year post-operatively. In a sheep model, Hunt et al. demonstrated that the intra-tunnel portion of the soft tissue ACL graft loses its tendinous structure and begins to show evidence of bony ingrowth at 2 years following reconstruction(10).

Bone-tendon-bone graft incorporation
Bone-to-bone healing is a different and much faster process than tendon-to-bone healing. During the first four weeks, granulation tissue develops at the bone graft-tunnel interface, and partial necrosis of the bone block occurs due to increased osteoclast activity(23, 33). Unlike soft tissue graft incorporation, only a small amount of fibrous tissue is formed(23). Studies have shown that BTB ACL grafts are at least partially incorporated into the tunnels after only 6 weeks(19, 23, 33). At 24 weeks, a fibrocartilaginous ligament-like insertion develops at the tunnel aperture, and by 6 months the graft is completely incorporated into the surrounding bone(38,19, 29).

Allograft incorporation
The intra-articular remodeling as well as the graft incorporation processes are much slower in allografts compared to autografts(3). Harris et al. investigated the graft-to-bone incorporation of BTB allografts in goats. At 18 weeks following surgery, they found no evidence of bony incorporation and only a connective tissue interface at the graft-tunnel junction. Not until 36 weeks did the bone blocks become fully incorporated(9).

Biomechanical consequences of graft incorporation and remodeling
Several studies have shown that the biomechanical properties of ACL grafts decrease steadily during the first few months following reconstruction(19). It is well documented that the intra-articular portion of the graft undergoes a distinct remodeling process that results in an initial decrease in strength and load to failure. However, the graft-to-bone incorporation must also be considered as a contributing factor to the overall decrease in the biomechanical properties seen in the early stages of graft healing.
In a canine model, the load to failure at three weeks following surgery was significantly lower in soft tissue compared to BTB grafts (p = 0.021). No significant difference was identified at six weeks. Interestingly, at 12 weeks, the soft tissue grafts exhibited a higher load to failure than the BTB grafts(33). Mayr et al. showed that all failures occurred in the mid-substance at six weeks and at the graft-tunnel junction at 3-6 months, regardless of graft type(19). These findings are supported by other studies, and suggest that intra-articular graft remodeling is more important early on, while graft incorporation becomes significant at the later stages of healing(23, 33). Given that graft remodeling and incorporation continue well beyond one year following surgery, the biomechanical properties correspondingly increase in this later time frame(14, 36).

Figure 2: Sagittal and coronal computed tomography image of a left knee of a patient six months after ACL reconstruction with an aoutologous quadriceps tendon with a patellar bone block in the femoral tunnel. The bone block is partially integrated in the surrounding bone (arrow). The bone tunnel is surrounded by a thin sclerotic wall (arrow).

Figure 2: Sagittal and coronal computed tomography image of a left knee of a patient six months after ACL reconstruction with an aoutologous quadriceps tendon with a patellar bone block in the femoral tunnel. The bone block is partially integrated in the surrounding bone (arrow). The bone tunnel is surrounded by a thin sclerotic wall (arrow).

Figure 3: T2-weighted MRI of a left knee of a patients four years following ACL revision with soft tissue allograft and a bony reaction with consecutive tibial bone tunnel widening due to a fixation device. The graft in the bone tunnel is not homogenous and surrounded by irregular fibrous tissue. At the proximal part of the bone tunnel an evident synovial influx is visible.

Figure 3: T2-weighted MRI of a left knee of a patients four years following ACL revision with soft tissue allograft and a bony reaction with consecutive tibial bone tunnel widening due to a fixation device. The graft in the bone tunnel is not homogenous and surrounded by irregular fibrous tissue. At the proximal part of the bone tunnel an evident synovial influx is visible.

Histological findings in humans
The evidence surrounding graft-to-bone healing in humans is limited to a few case series, and therefore it is difficult to draw definitive conclusion from the data. Nevertheless, it is important to consider some of the key differences observed in human patients.

Hamstring tendon grafts
The process of soft tissue autograft incorporation into the surrounding bone tunnel is through formation of woven bone, which is penetrated by type I and III collagen fibers(24). In the first three months following reconstruction, the graft-bone interface consists primarily of dense, vascularized fibrous tissue surrounded by a layer of calcified osteoid. In this early phase, the fibrous tissue has no direct contact to the surrounding lamellar bone(25). At 5-6 months, the graft becomes surrounded by irregular fibrovascular granulation tissue with some areas of woven bone. Sharpey-like fibers begin to connect the graft to the bone, however, there is no evidence of bony ingrowth at this time(20, 25). Histological analyses of the graft-bone interface at 8-12 months following ACL reconstruction with hamstring tendon autograft show a firm attachment of the tendinous graft to the bone in some studies, and a persistent fibrous attachment in others(25,20). At one year following surgery, histological analyses show ongoing maturation of the graft-bone interface with an increase in Sharpey-like fibers and some evidence of peripheral bony ingrowth(20, 25).

Bone-tendon-bone grafts
In bone-tendon-bone grafts, the four-phase insertion of fibrocartilage can be preserved by ensuring that the bone plug rests flush with the intra-articular tunnel aperture. In this instance, the BTB graft becomes incorporated into the tunnel by direct bone healing. When the bone plug is recessed within the tunnel, the tendon-bone interface becomes incorporated via fibrocartilage(24). Ishibashi et al. performed histological analyses on the BTB graft-tunnel interface in patients who had undergone primary ACL reconstruction. Prior to one year from the time of surgery, granulation tissue was present between the tendinous portion of the graft and the bone tunnel. After one year, the granulation tissue was replaced by fibrous tissue containing collagen fibers, but without an obvious fibrocartilaginous insertion. The bone block, in contrast, was completely incorporated and could not be distinguished from the surrounding bone by one year postoperatively(12).

Imaging of graft incorporation
The incorporation of BTB grafts into the surrounding bone can be readily evaluated by computed tomography (CT) and magnetic resonance imaging (MRI) (Fig. 1, Fig. 2). Suzuki et al. used CT scans to show that the majority of BTB grafts were near-completely incorporated within the bone tunnel by eight weeks post-operatively(31). In contrast, the use of imaging to assess graft-to-bone healing of soft tissue grafts is much more demanding. A high resolution MRI can often be helpful in visualizing the remodelling and bone incorporation process8. However, accurate assessment of graft revascularization requires the use of contrast-enhaced MRI or MR angiography.
MRI studies have shown that the revascularization process peaks at two months following ACL reconstruction and then decreases steadily over time(32). Interestingly, revascularization of BTB grafts is significantly faster in the intra-articular portion of the graft compared to the intra-tunnel segment. A recent MRI study revealed that revascularization of the intra-tunnel portion of the BTB graft persists beyond one year after surgery, suggesting that bone-to-bone incorporation may be slower than initially demonstrated by histological studies(21). Similar results were obtained when investigating the revascularization of soft tissue autografts(22, 27).

Clinical implications of incomplete graft incorporation
Early return to function is a common goal following ACL reconstruction and modern rehabilitation protocols have been tailored accordingly. Range of motion exercises and gentle strengthening are important to maintain quadriceps function and mitigate the risk of arthrofibrosis. While femoral and tibial fixation techniques are responsible for maintaining graft strength in the early postoperative period, it is the graft remodeling and graft-to-bone incorporation processes that determine the long-term stability success of an ACL reconstruction4.
An important clinical problem in graft-to-bone incorporation is tunnel enlargement (Figure 3). Although this is a multi-factorial issue, one contributing factor is the discrepancy of the healing process across different segments of the bone tunnel. Studies show that the number of osteoclasts as well as their activity level is higher at the intra-articular bone tunnel aperture1. Consequently, bony ingrowth occurs preferentially at the peripheral end of the bone tunnel(2). This in combination with an increased graft motion near the intra-articular tunnel aperture can result in tunnel widening and impaired graft-to-bone healing(26). This finding is corroborated by a number of clinical studies(34), whereas others found that bone tunnel widening does not influence graft incorporation(17).
Another issue which may predispose to tunnel enlargement is the graft bending angle. In anatomic ACL reconstruction, a bend develops as the graft transitions from the intra-articular portion into the tunnel. Particularly with soft tissue grafts, this results in an asymmetric position of the graft at the tunnel aperture and formation of a gap between the graft and the tunnel wall(7). Synovial fluid and osteoclasts can enter this space and stimulate tunnel widening.
Finally, the position of the bone socket plays a critical role in the motion of the graft within the tunnel(30). This was demonstrated by Ekdahl et al., who showed that bone tunnel enlargement is significantly decreased in anatomic ACL reconstruction compared to non-anatomic tunnel placement. The non-anatomic reconstructions revealed an increased amount of osteoclasts and a decreased amount of vascularization compared to the anatomic reconstructions(5).

Conclusions

Successful graft-to-bone incorporation plays an integral role in the long-term outcomes following ACL reconstruction. Animal studies provide some understanding of this complex process and highlight the differences between graft and tissue types. However, the results of animal studies are not analogous to human data, which reveals a distinct and much slower incorporation process. The available evidence suggests that anatomic ACL reconstruction and likely a less aggressive rehabilitation protocol are both important variables in optimizing graft incorporation and improving patient outcomes.

References

1. Bedi A, Kawamura S, Ying L, Rodeo SA. Differences in Tendon Graft Healing Between the Intra-articular and Extra-articular Ends of a Bone Tunnel. HSS Journal. 2008;5(1):51-57.
2. Berg EE, Pollard ME, Kang Q. Interarticular bone tunnel healing. Arthroscopy. 2001;17(2):189-195.
3. Bhatia S, Bell R, Frank RM, et al. Bony Incorporation of Soft Tissue Anterior Cruciate Ligament Grafts in an Animal Model: Autograft Versus Allograft With Low-Dose Gamma Irradiation. Am J Sports Med. 2012;40(8):1789-1798.
4. Brophy RH, Kovacevic D, Imhauser CW, et al. Effect of short-duration low-magnitude cyclic loading versus immobilization on tendon-bone healing after ACL reconstruction in a rat model. J Bone Joint Surg Am. 2011;93(4):381-393.
5. Ekdahl M, Nozaki M, Ferretti M, Tsai A, Smolinski P, Fu FH. The Effect of Tunnel Placement on Bone-Tendon Healing in Anterior Cruciate Ligament Reconstruction in a Goat Model. Am J Sports Med. 2009;37(8):1522-1530.
6. Ekdahl M, Wang JH-C, Ronga M, Fu FH. Graft healing in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16(10):935-947.
7. Fujii M, Sasaki Y, Araki D, et al. Evaluation of the semitendinosus tendon graft shift in the bone tunnel: an experimental study. Knee Surg Sports Traumatol Arthrosc. 2014:1-5.
8. Ge Y, Li H, Tao H, Hua Y, Chen J, Chen S. Comparison of tendon–bone healing between autografts and allografts after anterior cruciate ligament reconstruction using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc. 2013;23(4):954-960.
9. Harris NL, Indelicato PA, Bloomberg MS, Meister K, Wheeler DL. Radiographic and histologic analysis of the tibial tunnel after allograft anterior cruciate ligament reconstruction in goats. Am J Sports Med. 2002;30(3):368-373.
10. Hunt P, Rehm O, Weiler A. Soft tissue graft interference fit fixation: observations on graft insertion site healing and tunnel remodeling 2 years after ACL reconstruction in sheep. Knee Surg Sports Traumatol Arthrosc. 2006;14(12):1245-1251.
11. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery: a prospective study comparing anatomic single- and double-bundle reconstruction. Am J Sports Med. 2012;40(8):1781-1788.
12. Ishibashi Y, Toh S, Okamura Y, Sasaki T, Kusumi T. Graft incorporation within the tibial bone tunnel after anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft. Am J Sports Med. 2001;29(4):473-479.
13. Kanazawa T, Soejima T, Murakami H, Inoue T, Katouda M, Nagata K. An immunohistological study of the integration at the bone-tendon interface after reconstruction of the anterior cruciate ligament in rabbits. J Bone Joint Surg Br. 2006;88(5):682-687.
14. Kondo E, Yasuda K, Katsura T, Hayashi R, Kotani Y, Tohyama H. Biomechanical and Histological Evaluations of the Doubled Semitendinosus Tendon Autograft After Anterior Cruciate Ligament Reconstruction in Sheep. Am J Sports Med. 2012;40(2):315-324.
15. Liu SH, Panossian V, al-Shaikh R, et al. Morphology and matrix composition during early tendon to bone healing. Clin Orthop Relat Res. 1997(339):253-260.
16. Lui P, Zhang P, Chan KM, Qin L. Biology and augmentation of tendon-bone insertion repair. J Orthop Surg Res. 2010;5(1):59-14.
17. Lui PPY, Lee YW, Mok TY, Cheuk YC. Peri-tunnel bone loss: does it affect early tendon graft to bone tunnel healing after ACL reconstruction? Knee Surg Sports Traumatol Arthrosc. 2013;23(3):740-751.
18. Magnussen RA, Trojani C, Granan LP, et al. Patient demographics and surgical characteristics in ACL revision: a comparison of French, Norwegian, and North American cohorts. Knee Surg Sports Traumatol Arthrosc. 2015;23(8):2339-2348.
19. Mayr HO, Stoehr A, Dietrich M, et al. Graft-dependent differences in the ligamentization process of anterior cruciate ligament grafts in a sheep trial. Knee Surg Sports Traumatol Arthrosc. 2011;20(5):947-956.
20. Nebelung W, Becker R, Urbach D, Röpke M, Roessner A. Histological findings of tendon-bone healing following anterior cruciate ligament reconstruction with hamstring grafts. Arch Orthop Trauma Surg. 2003;123(4):158-163.
21. Ntoulia A, Papadopoulou F, Ristanis S, Argyropoulou M, Georgoulis AD. Revascularization Process of the Bone-Patellar Tendon-Bone Autograft Evaluated by Contrast-Enhanced Magnetic Resonance Imaging 6 and 12 Months After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2011;39(7):1478-1486.
22. Ntoulia A, Papadopoulou F, Zampeli F, Ristanis S, Argyropoulou M, Georgoulis A. Evaluation with contrast-enhanced magnetic resonance imaging of the anterior cruciate ligament graft during its healing process: a two-year prospective study. Skeletal Radiol. 2012;42(4):541-552.
23. Papageorgiou CD, Ma CB, Abramowitch SD, Clineff TD, Woo SL. A multidisciplinary study of the healing of an intraarticular anterior cruciate ligament graft in a goat model. Am J Sports Med. 2001;29(5):620-626.
24. Petersen W, Laprell H. Insertion of autologous tendon grafts to the bone: a histological and immunohistochemical study of hamstring and patellar tendon grafts. Knee Surg Sports Traumatol Arthrosc. 2000;8(1):26-31.
25. Robert H, Es-Sayeh J, Heymann D, Passuti N, Eloit S, Vaneenoge E. Hamstring insertion site healing after anterior cruciate ligament reconstruction in patients with symptomatic hardware or repeat rupture: a histologic study in 12 patients. Arthroscopy. 2003;19(9):948-954.
26. Rodeo SA, Kawamura S, Kim HJ, Dynybil C, Ying L. Tendon Healing in a Bone Tunnel Differs at the Tunnel Entrance Versus the Tunnel Exit: An Effect of Graft-Tunnel Motion? Am J Sports Med. 2006;34(11):1790-1800.
27. Rupreht M, Jevtič V, Serša I, Vogrin M, Šeruga T, Jevšek M. Quantitative evaluation of the tibial tunnel after anterior cruciate ligament reconstruction using diffusion weighted and dynamic contrast enhanced MRI: a follow-up feasibility study. Skeletal Radiol. 2011;41(5):569-574.
28. Scheffler SU, Unterhauser FN, Weiler A. Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16(9):834-842.
29. Schiavone Panni A, Fabbriciani C, Delcogliano A, Franzese S. Bone-ligament interaction in patellar tendon reconstruction of the ACL. Knee Surg Sports Traumatol Arthrosc. 1993;1(1):4-8.
30. Silva A, Sampaio R, Pinto E. Femoral tunnel enlargement after anatomic ACL reconstruction: a biological problem? Knee Surg Sports Traumatol Arthrosc. 2010;18(9):1189-1194.
31. Suzuki T, Shino K, Nakagawa S, et al. Early integration of a bone plug in the femoral tunnel in rectangular tunnel ACL reconstruction with a bone-patellar tendon-bone graft: a prospective computed tomography analysis. Knee Surg Sports Traumatol Arthrosc. 2011;19(S1):29-35.
32. Terauchi R, Arai Y, Hara K, et al. Magnetic resonance angiography evaluation of the bone tunnel and graft following ACL reconstruction with a hamstring tendon autograft. Knee Surg Sports Traumatol Arthrosc. 2016;24(1):169-175.
33. Tomita F, Yasuda K, Mikami S, Sakai T, Yamazaki S, Tohyama H. Comparisons of intraosseous graft healing between the doubled flexor tendon graft and the bone–Patellar tendon–Bone graft in anterior cruciate ligament reconstruction. Arthroscopy. 2001;17(5):461-476.
34. Weber AE, Delos D, Oltean HN, et al. Tibial and Femoral Tunnel Changes After ACL Reconstruction: A Prospective 2-Year Longitudinal MRI Study. Am J Sports Med. 2015;43(5):1147-1156.
35. Weiler A, Hoffmann RFG, Bail HJ, Rehm O, Südkamp NP. Tendon Healing in a Bone Tunnel. Part II: Histologic Analysis After Biodegradable Interference Fit Fixation in a Model of Anterior Cruciate Ligament Reconstruction in Sheep. Arthroscopy. 2002;18(2):124-135.
36. Weiler A, Peine R, Pashmineh-Azar A, Abel C, Südkamp NP, Hoffmann RFG. Tendon Healing in a Bone Tunnel. Part I: Biomechanical Results After Biodegradable Interference Fit Fixation in a Model of Anterior Cruciate Ligament Reconstruction in Sheep. Arthroscopy. 2002;18(2):113-123.
37. Yamazaki S, Yasuda K, Tomita F, Minami A, Tohyama H. The effect of intraosseous graft length on tendon-bone healing in anterior cruciate ligament reconstruction using flexor tendon. Knee Surg Sports Traumatol Arthrosc. 2006;14(11):1086-1093.
38. Yoshiya S, Nagano M, Kurosaka M, Muratsu H, Mizuno K. Graft healing in the bone tunnel in anterior cruciate ligament reconstruction. Clin Orthop Relat Res. 2000(376):278-286.
39. Zantop T, Ferretti M, Bell KM, Brucker PU, Gilbertson L, Fu FH. Effect of Tunnel-Graft Length on the Biomechanics of Anterior Cruciate Ligament-Reconstructed Knees: Intra-articular Study in a Goat Model. Am J Sports Med. 2008;36(11):2158-2166.
40. Zhao L, Thambyah A, Broom ND. A multi-scale structural study of the porcine anterior cruciate ligament tibial enthesis. J Anat. 2014;224(6):624-633.

How to Cite this article:. Herbst E, Albers M,  Kopka M, Shaikh H, Fu FH, . Biology of Graft Incorporation. Asian Journal of Arthroscopy  Apr- June 2016;1(1):20-24 .

Dr. Elmar Herbst

Dr. Elmar Herbst

Dr. Marcio B. V. Albers

Dr. Marcio B. V. Albers

Dr. Michaela Kopka

Dr. Michaela Kopka

Dr. Humza Shaikh

Dr. Humza Shaikh

Prof. Freddie H. Fu

Prof. Freddie H. Fu

 

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Synthetic Grafts in Anterior Cruciate Ligament Reconstruction

Jonathan Herald, Sagar Kakatkar

Volume 1 | Issue 1 | April – Jun 2016 | Page 16-19

Author: Jonathan Herald [1], Sagar Kakatkar [1]

[1] Orthoclinic, Sydney, Australia.
[2] Dr. Vasantrao Pawar Medical College and Hospital, Nashik, India.

Address of Correspondence

Dr. Sagar Kakatkar
Orthoclinic Sydney, Suite 1606, Level 16, 109 Pitt Street
Sydney NSW 2000 Sydney, Australia

Abstract

Immediate post-operative knee stability and early return to pre-injury activities are two goals of ACL reconstruction today. Autografts and Allografts when used for the ACL reconstruction are based on a principle of graft incorporation in the tunnels which renders them inefficient in providing immediate stability after the surgery. Since post-operative rehabilitation protocols after allograft or autograft ACL reconstruction are designed to protect the grafts for a certain period, early return to pre-injury functional status is not possible. Apart from these disadvantages, graft related complications and availability of the grafts are problems for both autografts and allografts. Synthetic ACL substitutes have been developed, modified and re-modified according to the clinical outcomes and reported complications. And although few of them have shown early promising results, whether they can stand the test of time or not is still to be seen.
Key words: Anterior cruciate Ligament (ACL), Ligament Advanced Reinforcement System (LARS), Synthetic grafts, Tissue engineering, Leeds-Keio artificial ligament, ligament augmentation device(LAD)

Introduction

Improving the quality of life has been the principle focus of modern health care. Correspondingly, evaluation criteria for surgical outcomes have also changed. Achieving post-operative stability is no longer the only goal after ACL reconstruction; but ‘Early’ and ‘Sustained’ return to pre injury levels of activities is now considered as the measuring tool for success. ACL injury is the most common knee ligamentous injury in sports related activities and a delay in returning to sports is enough to ruin a sportsman’s career. Autografts and Allografts have been the main graft choices for ACL reconstruction. Autografts have shortcomings such as inadequate graft length or diameter and donor site morbidity while; allografts on the other hand have problems of allogenicity, insufficient supply of grafts, high costs, etc. A common disadvantage that both these grafts share is the requirement of integration of the graft in the osseous tunnels. Time required for this integration process is variable and subjective and is more for allografts than autografts (14).
Extensive research has been done to overcome these problems associated with autografts and allografts and to develop a suitable synthetic substitute for ACL reconstruction. But since 1918 when Alwyn- Smith tried ACL reconstruction with silk sutures for the first time, use of synthetic grafts for the ACL reconstruction has been a tale of failures(16).

Expectations from Synthetic grafts and the their Evolution
Synthetic graft technology has evolved from non-biological to biological grafts. The grafts are developed so as to have better strength compared to native ACL. Their use is designed to reduce not only the donor site morbidity but surgical time also. The greatest function which they are supposed to serve is to provide immediate post-operative stability to the knee thus promoting early mobilization, faster rehabilitation and quicker return to pre injury level activities.
The synthetic replacements that have been used for the ACL can be broadly classified into three types which also follows their chronological order(16).
Class 1: Graft Fibers:
These include fibers of polyethylene, PTFE (Polytetrafluoroethylene). These were one of the few earlier graft substitutes and had high failure rates because of graft breakage.
Class 2: Ligament Augmentation devices (LAD):
These include polypropylene polyesters which were strong. These devices were used along with ACL autografts or allografts and were supposed to provide immediate structural support to the grafts so that to enhance their integration. But unfortunately these augments caused ‘stress shielding’ and led to delayed graft integration thus leading to higher incidences of graft failures.
Class 3: Prosthetic materials:
The earlier generations of these prostheses did not allow any soft tissue ingrowth and thus although they had good early functional results, the long term follow ups reported high failure rates. Second generation prostheses developed were based on the principles of combining structural properties of prosthetic material with tissue engineering to develop scaffolds for ACL reconstruction. These were supposed to provide good initial strength and then allow gradual soft tissue ingrowth for longevity. Following are the different types of prosthetic materials used clinically:

 

Figure 1 & 2: Show how the graft passage for the LARS should be sequential and gradual so as to correctly position the intraarticular and intraosseous parts of the LARS in their proper positions.

4. fig1 n2

Figure 1 & 2: Show how the graft passage for the LARS should be sequential and gradual so as to correctly position the intraarticular and intraosseous parts of the LARS in their proper positions.

a) Carbon based prosthetic devices: These allowed collagen ingrowth but histopathological studies of the tissues tested showed accumulation of carbon particles in the lymphatic system of the individuals. Also these had high incidences of graft ruptures, disintegration and failures, so were discontinued.
b) Gore-Tex: These were probably the strongest synthetic graft substitutes which included expanded Polytetrafluoroethylene fiber looped on itself. Their use in ACL reconstruction had good functional outcomes and hence gained the FDA approval for use in patients with failed autologous intraarticular graft procedures i.e. for revision cases. However long term follow up showed increased incidences of loosening of the grafts which led to detrimental functional outcomes.
c) Leeds- Keio Artificial Ligament: Was developed by Fujikawa and Seedhom. This was one of the most popular synthetic substitute for the ACL reconstruction because of good early functional outcomes. The ligament was composed of a polyester mesh with tibial and femoral bone plugs attached for anchorage in the tunnels. It provided good soft tissue ingrowth and had good shear resistance. But because of its high tensile strength it acted as mainly a load bearing prosthesis and had poor long term results. There were many clinical studies reporting long term graft failures (8).
d) Kennedy ligament augmentation device (LAD): The good clinical results of LAD as reported by its developers were non reproducible and this synthetic substitute led to post-operative synovitis due to its Polypropylene structural units. The implant graft interface when used as an augmentation device was the weakest area of the construct and thus had graft failures.
A Landmark study done by Marie –France Guidoin, et al.(13) reported causes of failures in 117 synthetic ligamentous prosthesis which had failed either because of the rupture or recurrent synovitis. The type of prostheses excised include Gore-Tex, Kennedy LAD, PET based prostheses, etc. These prostheses were tested under scanning electron microscope (SEM) and following three mechanisms involved in the failure of these ACL prostheses were noted. 1) Failure because of inadequate fiber abrasion resistance against osseous structure 2) Flexural and rotational fatigue of the fibers 3) Loss of integrity of the textile structure due to tissue infiltration during healing. The second and third mechanism of failure were the most difficult problems to address.
e) LARS (Ligament Advanced reinforcement system): This is the latest development in the synthetic ligament substitutes. It consists of polyethylene tetraphthalate (PET) as the structural component. The LARS has been designed to mimic ligamentous anatomy. It has 2 parts i.e. intra articular and intraosseous part. The intraosseous part is composed of longitudinal fibers of PET held together with transverse knitted structure. While the intraarticular part has parallel longitudinal fibers of PET twisted perpendicular to each other. These parts should be aligned perfectly while doing the ACL reconstruction to avoid early graft failures (Figure 3). The orientation of the fibers is modified to be side specific i.e. different for left and right knees thus mimicking the 3D cross-sectional anatomy of intraarticular part the native ACL. This is supposed to help overcome rotational fatigue of the synthetic ligament. Although this is a far superior structural construct compared to other synthetic substitutes, getting the LARS intraosseous part and intraarticular part exactly in their place during the surgery requires excellent surgical skill (Figure 1 and 2). The LARS also promotes tissue ingrowth(17).

Figure 3: Arrangement of the LARS-autograft construct during ACL reconstruction (Figure3 Courtesy: Athens Sports Medicine, Greece)

Figure 3: Arrangement of the LARS-autograft construct during ACL reconstruction (Figure 3 Courtesy: Athens Sports Medicine, Greece)

 

Figure 4 & 5: Ruptured LARS with Secondary arthritis of the knee joint evident on MRI films

fig4

Figure 4 & 5: Ruptured LARS with Secondary arthritis of the knee joint evident on MRI films

 

Several studies considering the outcomes following LARS for the ligamentous reconstruction showed good to excellent functional outcomes and good patient satisfaction (4, 7, 9, 10, 12, 15). A few of the papers even rated LARS as better than the autograft ACL reconstructions (9,6, 18). Histopathological studies do support the cellular ingrowth with LARS acting as a scaffold (17).
If return to pre injury level is considered as the criteria for success, few studies report LARS enabling patients to go back to active sports related activities within 2-3 months of the surgery (19). But the study done by Zuzana Makotka et al. in 2010 which was a meta-analysis of the literature published on LARS for ACL reconstruction from year 2000 to 2010 showed that none of the studies done on LARS autologous ‘ligamentous’ healing along the synthetic meshwork of LARS. Even though LARS is thought to reduce the surgical time, none of the studies had commented about the duration of surgery with the LARS ACL reconstruction. None of the study compared return to previous level of function with LARS and with traditional ACL reconstruction. This metaanalysis was based on the 4 studies and also stated that LARS may not be good for chronic ACL injuries as in such cases quality of remnant of the ACL i.e. ACL stump is not good and LARS may not have good ligamentous ingrowth on fibrotic stump.
Considering the latest literature, Alberto et al. in their study published in 2014 showed that a few patients with failed reconstruction with Polyethylene tetraphthalate (PET) synthetic grafts (1). Fourteen of such patients underwent revision surgery performed as two-staged revision. All these patients has histopathological evidence of granulomatous reaction due to PET. And even the revision surgeries done with the autografts did not improve functional status of these patients or stop the progressive Osteoarthritis occurring in these patients. In another study the rate of failure of LARS in a 19 year outcome study was reported to be 27.5% with 100% patients presenting with degenerative arthritis (2).A few other studies report disabling synovitis secondary to LARS ACL reconstructions (5).
Hence till date, the literature regarding the LARS remains controversial and there are no studies comparing early on long term outcomes of the LARS and those with autograft/ Allograft ACL reconstructions.
In authors practice, several cases treated by LARS ACL reconstruction elsewhere, which are symptomatic either because of graft loosening or graft failure have been encountered(Figure 4,5,6). Of those patients who underwent revision surgeries, histopathological examination of the synovial tissue collected during surgery showed chronic granulomatous inflammation and the patients, in spite of attaining knee stability continued to have symptoms due to inflammatory synovitis and progression of arthritis. When tested using new battery of tests which used to evaluate return to sports status of the patients with ACL reconstruction; patient’s ability to return to sports related activities was better in patients treated with autograft ACL reconstruction than LARS ACL reconstruction and further evaluation of these patients is being done (4).
Apart from studies on LARS, latest literature which is a randomized study with or without synthetic degradable augmentation device to support autograft in ACL reconstruction, no significant difference in clinical outcomes in short, intermediate and long term prospective was found in between the two groups i.e. one group with the use of poly (urethane urea) augmentation device and other without it (11).

Figure 6: Arthroscopic picture of ruptured LARS stump with visible particulate debris of the LARS visible on the background of PCL

Figure 6: Arthroscopic picture of ruptured LARS stump with visible particulate debris of the LARS visible on the background of PCL

Future Prospects
Development of ideal synthetic scaffold for the ACL reconstruction is a difficult task to achieve. Efforts are in place to create a synthetic substitute which can provide immediate functional stability and which can degrade at a rate similar to that of the tissue ingrowth. With advancements in tissue engineering, several polymers with a variety of different cell types have been developed for the scaffolds. Since the Fibroblast added collagen scaffolds had problems of immunogenicity and variable physical properties, biodegradable polymers such as Polyglycolic acid scaffolds have been developed and have been tested on animal models. Several studies using bone marrow stromal cells for formation of fibroblasts and smooth muscle cells with slow degrading properties of the scaffolds have been done (16).
With constant improvements in the tissue engineering techniques, future seems to be bright for synthetic ligamentous substitutes but for now, we are yet to supersede the biological grafts for the ACL reconstruction.

References

1. Alberto Venturo, Claudio Legnani, Clara Terzaghi, Enrico Borgo, Walter Albisetti “Revision surgery after failed ACL reconstruction with artificial ligament: Clinical, Histological and Radiographic Evaluation’. Eur Journal Orthop Surgery Traumatol 2014 24:93-98.
2. Alberto Venturo, Claudio Legnani, Clara Terzaghi, Enrico Borgo, Walter Albisetti “Synthetic graft for anterior cruciate ligament rupture 19 year outcome study” The Knee 17 (2010) 108–113.
3. Caroline Hildebrandt, Lisa Muller, Barbara Zisch, Reinhard Huber, Christian Flink, Christian Raschner “ Functional Assessment for decision making regarding return to sports following ACL reconstruction Part 1: development of new test battery. Knee Surg Sports Traumatol Arthrosc 2015 23: 1273-1281.
4. Cerulli, G. et al. (2007). ACL reconstruction using artificial ligaments: Five years follow-up. S.I.O.T, 33 (3suppl. 1), pp. 8238-8242.
5. Constantine M. Glezos, Alison Waller, Henry E. Bourke, Lucy J. Salmon and Leo A. Pinczewski “Disabling Synovitis Associated With LARS Artificial Ligament Use in Anterior Cruciate Ligament Reconstruction: A Case Report” Am J Sports Med 2012 40: 1167.
6. Fan, Q. et al. (2008) Comparison between four-strand semitendinosus tendon autograft and ligament advanced reinforcement system for anterior cruciate ligament reconstruction by arthroscopy. Chinese Journal of Reparative and Reconstructive Surgery 2008 June (6): 676-9 2008.
7. Huang Jian-ming et al (2010) cruciate ligament reconstruction using LARS artificial ligament under arthroscopy: 81 cases report. Chinese Medical Journal, 2010; 132(2):160-164.
8. Jan Riding, Lars Peterson “ Clinical experience with the Leeds-Keio Artificial Ligament in Anterior cruciate ligament reconstruction: A prospective 2 year follow-up study The American Journal of sports medicine Vole 23, no 3,1995.
9. Jiao Chen ,AquinoGU, Haiti Jiang, Winnie Zhang ,Xian Grong Yu “A comparison of acute and chronic anterior cruciate ligamentreconstruction using LARS artificial ligaments: a randomizedprospective study with a 5-year follow-up” Arch Northup Trauma Surge (2015) 135:95–102.
10. Kai Ago, M.D., Shay Chen, M.D., Ph.D., Lied Wang, M.D., Weiguo Zhang, M.D.,Yifan Kang, M.D., Qirong Dong, M.D., Haibin Zhou, M.D., and Linan Li, M.D. “Anterior Cruciate Ligament Reconstruction with LARS ArtificialLigament: A Multicenter Study With 3- to 5-Year Follow-up” Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 4 (April), 2010: pp 515-523.
11. Lars Peterson, Ulf Eklund, Bjorn Engstorm, Magnus Forssblad “ Long term results of a randomized study on ACL reconstruction with or without a synthetic degradable augmentation device to support autograft” KSSTA 2014,22: 2109-2120.
12. Lavoie, P. et al. (2000). Patient satisfaction needs as related to knee stability and objective findings after ACL reconstruction using LARS artificial ligament. The Knee, 7, pp. 157-163.
13. Marie-France Guidoin, Yves Marois, Jaques Bejui, Nicolas Poddevin, Robert Guidoin,et al. “ Analysis of retrieved polymer fibers based replacement” Biomaterials 21(2000), 2461-2474.
14. Meinolf Goertzen, M.D. PhD “Donor tissue choices in ACL revision” Sports Medicine and Arthroscopy review 5: 128-135,1997.
15. Papadopoulos, G. et al. (2005). Long – Term Results In The Treatment Of Acl Ruptures Using The LARS – Artificial Ligament. A.L.S. , Salzburg, June , 10-12 , 2005.
16. Saccomanni Bernardino “ ACL prosthesis- Any promise for future” Knee Surg Sports Traumatol Arthros 2010 18: 797-804.
17. Trieb, K. et al. (2004). In vivo and in vitro cellular ingrowth into a new generation of artificial ligament, Eur Surg Res. May-Jun;36(3):148-51.
18. Zhong-tang Liu & Xian-long Zhang & Yao Jiang & Bing-Fang Zeng “Four-strand hamstring tendon autograft versus LARSartificial ligament for anterior cruciateligament reconstruction” International Orthopaedics (SICOT) (2010) 34:45–49.
19. Zuzana Makotka, Ian Scarborough, Sarvana Kumar, Luke Parraton, et al. “Anterior cruciate ligament repairs with LARS: A systemic review. Sports Med Arthroscopy, Rehab, Therapy and technology 2010, 2: 29.

How to Cite this article:. Herald J, Kakatkar S. Synthetic Grafts in Anterior Cruciate Ligament Reconstruction. Asian Journal of Arthroscopy  Apr- June 2016;1(1):16-19 .

Dr. Jonathan Herald

Dr. Jonathan Herald

Dr. Sagar Kakatkar

Dr. Sagar Kakatkar

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BTB Vs Hamsrtings – Is There a Winner Yet ?

Sachin Tapasvi, Sachin Jain, Ashok Shyam

Volume 1 | Issue 1 | April – Jun 2016 | Page 11-15

Author: Sachin Tapasvi [1 ], Sachin Jain [2], Ashok Shyam [2],[3]

[1] Orthopaedic Specialty Clinic, Pune, Maharashtra. India
[2] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
[3] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence

Dr Sachin Tapasvi
Orthopaedic Specialty Clinic, Pune Maharashtra. India.
Email: stapasvi@gmail.com

Abstract

Bone patella tendon bone (BPTB) graft versus Hamstring (HT) Graft is still an issue that is debated. Both the graft have stood the test of time with high patient satisfaction however each have their own advantages and disadvantages. BPTB has advantages of good stability and bone to bone healing and disadvantage of anterior knee pain, numbness and quadriceps weakness. HT graft have advantage of less donor site morbidity, less extension deficit and disadvantage of having a slightly higher failure rate and hamstring weakness. Irrespective of these named advantages and disadvantages the patient reported outcomes are similar with both graft and difference in choice of graft is poorly understood. In this review we simply try to bring our reader up-to-date with the current literature on this controversy
Keywords: Bone patella tendon bone graft, hamstring graft, anterior cruciate ligament reconstruction.

Introduction

Anterior cruciate ligament (ACL) is required for static and dynamic stabiliser of the knee joint and purpose of ACL reconstruction is to stabilize and to resume function to maximum extent (1, 2). The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity (3). Moreover, these properties should be present at the time of graft implantation and persist throughout the incorporation period too (3).
Graft options available are broadly grouped into autograft such as bone patellar bone tendon graft (BPTB), hamstring graft, Quadriceps graft and allograft such quadriceps, patellar, Achilles, hamstring, and anterior and posterior tibialis tendon graft (3-6). Allografts are useful to minimize donor site morbidity but are associated with increased cost, slower incorporation time, increased risk of disease transmission, and a higher failure rate (2). The synthetic grafts are yet to prove themselves and currently the most commonly used graft used for ACL reconstruction are autografts namely hamstring or BPTB graft. With BPTB graft comes with advantages of excellent initial fixation, biomechanical properties, durability, success at long- term follow-up with reduced pivot shift test (7, 8) and disadvantage of few reports suggesting donor site morbidity of patellofemoral osteoarthritis, scar formation with shortening of the patellar tendon, loss of terminal knee extension, and patellofemoral pain(2,9,10).
Semitendinosus and gracilis tendons (quadrupled hamstring tendon [HT]) have found to minimize donor site morbidity causing less anterior pain(8) with disadvantage of numbness of the anterior knee caused by injury to the infrapatellar branch of the saphenous nerve during graft harvest(2), longer rehabilitation period(3,10) and persisting pivot shift test at long term follow up(7). There are multiple extrinsic and intrinsic confounding variables(11) while studying the results of ACL reconstruction out of which isolated effects of a single extrinsic variable of graft choice is to be made.

Method of Review
There are several review articles published in literature including Pubmed, Medline and Cochrane database to compare of graft superiority (hamstring versus BPTB) in ACL reconstruction. We primarily did a pubmed search with Bone-Patellar Tendon-Bone Grafting as the Mesh major keyword. Two hundred and eighty five article were found and reviewed. There were 51 articles that either compared the two grafts or were meta-analysis of such articles. These 51 articles were then further reviewed to construct this review. There were 9 metanalysis among these 51 articles and 3 additional systematic reviews (1,4,7, 11-20). The Cochrane review of 2011 and a systematic summary of systematic reviews was also added to this list (21,22). Results of all these reviews were compiled and presented in Table 1. Other relevant articles were added to the review depending on the significance of their findings. It was noted that in most article the main areas of comparison between the two grafts were stability, donor site morbidity, complications, rehabilitation status, functional outcomes and revision rates due to graft. The present review is also arranged in this format.

Functional outcome
Functional outcome was measured in most of the articles using scores like Lysholm knee score, Tegner activity level, International Knee Documentation Committee (IKDC) scores etc. None of the studies found any difference in functional outcome measured (1,4,7,11-19,23-25) and hence both the grafts are equally effective in terms of restoring the functional ability of the patients. Pinczewski et al noted that Level 1 and 2 sports activities were significantly reduced from 73 to 85% (short term) to 45-57% (long term results) in both HT and BTPB groups (11). Recent review mentions that patients with HT graft are almost twice more likely to return to sports but patient with BPTB Graft are more likely to return or exceed the preoperative sports level (22). Other also indicate that patients with BPTB graft return to activity earlier than the HT graft (12). This may be probably because BPTB graft provide more static and rotational stability (1,15). Poolman et al (17) commented that modern techniques of HT graft will further increase stability and improve return to activity. However this is not confirmed by recent articles and possibly better controlled trials will be needed to eventually answer the question.

Donor site morbidity and complication after graft harvesting
When overall incidence of morbidity was reviewed, HT graft patient have lower incidence of morbidity (12,15). Anterior knee pain and kneeling pain was significant in BTPB group as compared with HT group(1–3,11,23). Anterior knee pain is related to the secondary chondromalacia patella which happens after ACL reconstruction regardless of graft type but it is noted that it can be five times greater in BPTB group versus HT group(2). There was a significant extension loss of >5 degrees in BPTB group versus HT group(1). It is noted that there was a concentric and eccentric reduction in Quadriceps power which was related to poor satisfaction rates (23). The Cochrane review in 2011 noted that BPTB Graft resulted in loss of knee extension range and strength while HT graft showed trend toward loss of flexion range and strength (21). There was a slight risk of patellar fracture which was mainly related to the errors in the surgical technique or use of unnecessary deeper saw cuts or osteotomes(23). Other donor site problems noted are patellar tendinitis, rupture of patellar tendon, increased joint stiffness, late chondromalacia and injury to infrapatellar branch of saphenous nerve(2,3,23). Reduced ultimate range of motion may be related to the rigid construct used in fixing BPTB graft (2). Other disadvantage of hamstring graft are injury to the superficial branch saphenous nerve and weakness of the hamstring muscles after operation (23, 24).

Stability
Stability has shown varied results in different studies and possible is a function of surgical technique and rehabilitation [Table 1].

Table 1: Comparative analysis of meta-analysis comparing BPTB and HT autograft

Table 1: Comparative analysis of meta-analysis comparing BPTB and HT autograft

Stability was assessed by Lachman test, pivot shift test and KT -1000 arthrometer in most series. Some authors reported no significant difference between either HT or BPTB group at long term follow up (11, 2). However, in mid-term follow up the side-to-side instrumented laxity (>2 mm) was greater in HT group as compared to BPTB group (7). BTPB is also found to be more rotationally stable with respect to pivot shift test (1).
Stability in case of HT graft was based on the number of strands used during surgery when compared with BPTB graft (1). When a 2 strand HT graft was used a statistical difference was noted in case of KT – 1000 and pivot shift test in favour of BPTB graft whereas Lachman test was not significant in both groups. If a 4 strand HT graft with a suspensory fixation like endobutton was used then the statistical difference was not significant in both the groups and had near normal Lachman, pivot shift tests and KT – 1000 testing(1,10,26–28). There is a slightly higher degrees of laxity noted in quadrupled hamstring graft as compared with BPTB graft especially in females in long term studies(2,20). Cochrane review noted that BPTB reconstructions are more likely to result in statically stable knees but they are also associated with more anterior knee problems. However there is insufficient evidence to predict superiority of one graft over other in long results in respect to functional outcome(21). In a study, comparing double bundle reconstruction with HT graft and anatomical BPTB graft positioning equal results are found with respect to stability and laxity throughout the range of motion(29). The recent summary of meta-analysis however concluded that BPTB graft are more stable as per the current available evidence (22)

Rehabilitation
It is noted that integration of bone to bone healing with direct insertion is much faster in BPTB graft as compared to bone to soft tissue healing by means of indirect insertions with sharpey’s fibres in case of HT graft(23). So with rapid incorporation with graft healing to bone, there is potential for accelerated rehabilitation in BPTB graft and may be earlier return to play sports activities(3,23). It usually takes 6 weeks for a BPTB to incorporate in the host bone whereas around 8 to 12 weeks with HT graft(3). Short term studies showed mixed results of quadriceps strength with HT graft harvest whereas long term studies shows no difference in quadriceps strength with BPTB versus HT graft(8,20). Evaluation of functional capacities: power, strength, velocity and dynamic stability of knee extensor and flexor muscles after ACL reconstruction showed that use of a BPTB autograft achieved better muscular and functional capacities than the HT autograft(6). During rehabilitation with hamstring graft requires less supervision with less risk of complications such as the infrapatellar contracture syndrome, arthrofibrosis or persisting pain(23).

Osteoarthritis Risk
Radiographic assessment showed no significant differences between the two groups in terms of osteoarthritic findings classified according to the Fairbank and Ahlback rating systems in short term studies(26) and mild osteoarthritic changes in BPTB group at mid and long term follow up as compared with HT group(11). Overall, osteoarthritis was identified in 16% (BPTB 19%; ST 13%.) according to the Ahlback rating system and 68% (BPTB 67%; ST 70%; ) according to the Fairbank rating system(26). Xie et al found the risk of development of OA was around 61% greater in BPTB graft as compared to HT Graft (14). Early osteoarthritic changes are also function of primary injury and associated injuries like meniscal injuries and cartilage injuries (30). However late onset osteoarthritis will require much longer follow up and none of the current studies offer much insight into development of OA in long term (22)

Failure rates
There is no obvious difference in the occurrence of ligament failure between HT group and the BPTB group after ACL reconstruction in long term studies but a few studies demonstrate reduced failure rates with BPTB graft(1). Hamstring graft harvest weakens the knee flexor strength leading to slightly higher degrees of graft failure (2,4). However, these studies had a selection bias which had included studies using double or triple strand graft which gave slightly higher failure rates. Long term studies have shown to have equal success rates with quadrupled hamstring graft or BPTB graft(8,20). Moreover, it is also noted that the fixation modality and anatomical placement of ACL is responsible for low failure rates(20) It has been noted that contralateral ACL tear with BPTB graft is statistically significant as compared to HT graft in short term studies whereas in long term studies there is no increase in contralateral ACL tear(8). A risk factor for contralateral ACL rupture was a return to sports that involved sidestepping, pivoting, and jumping (8). In a registry study based on 45,998 primary ACL Reconstructions in Scandinavi it was found that patients receiving patellar tendon autografts have a statistically significantly lower risk of revision compared with patients receiving hamstring autografts(5).

Conclusions

As per current reviews and evidence, both graft achieve good functional outcome in patients. BPTB graft may offer a more stable knee and possible achieve rapid and effective return to preinjury activity level. HT graft have less donor site morbidity and with new effective fixation modalities, they may also match the stability achieved by BPTB grafts. However there is insufficient evidence to clearly establish a winner and probably more robust future studies will be better able to define the role of each of these autograft options

References

1. Li S, Su W, Zhao J, Xu Y, Bo Z, Ding X, et al. Review A meta-analysis of hamstring autografts versus bone – patellar tendon – bone autografts for reconstruction of the anterior cruciate ligament. Knee 2011;18(5):287–93.
2. Shelton WR, Fagan BC. Autografts Commonly Used in Anterior Cruciate Ligament. J Am Acad Orthop Surg. 2011;19(5):259–64.
3. West R V, Harner CD. Graft Selection in Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2005;13(3):197–207.
4. Reinhardt KR, Hetsroni I. Graft Selection for Anterior Cruciate Ligament Reconstruction : A Level I Systematic Review Comparing Failure Rates and Functional Outcomes. Orthop Clin NA [Internet]. Elsevier Ltd; 2010;41(2):249–62.
5. Gifstad T, Foss OA, Engebretsen L, Lind M, Forssblad M, Albrektsen G. Lower Risk of Revision With Patellar Tendon Autografts Compared With Hamstring Autografts A Registry Study Based on 45 , 998 Primary ACL Reconstructions in Scandinavia. Am J Sports Med. 2014;42(10):2319–28.
6. Baur C, Mathieu N, Delamorclaz S, Hilfiker R, Blatter S, Siegrist O, et al. Anterior cruciate ligament reconstruction : Hamstring Tendon autograft versus Bone Patellar Tendon Bone autograft : what about muscular and functional capacities ? Schweizerische Zeitschrift für Sport und Sport. 2015;63(2):18–22.
7. Biau DJ, Katsahian S, Kartus J, Harilainen A, Feller JA, Sajovic M, et al. Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament : A Meta-Analysis Based on Individual Patient Data. Am J Sports Med. 2009;37(12):2470–8.
8. Macaulay AA, Perfetti DC, Levine WN, Macaulay AA, Perfetti DC, Levine WN. Anterior Cruciate Ligament Graft Choices. Sport Heal A Multidiscip Approach. 2012;4(1).
9. Dahm DL. A Meta-analysis of Patellar Tendon Autograft Versus Patellar Tendon Allograft in Anterior Cruciate Ligament Reconstruction. Arthrosc J Arthrosc Relat Surg. 2008;24(3):292–8.
10. Siebold R, Webster ÆKE, Feller ÆJA, Sutherland AG, Elliott ÆJ. Anterior cruciate ligament reconstruction in females : a comparison of hamstring tendon and patellar tendon autografts. Knee. 2006;14:1070–6.
11. Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J. A 10-Year Comparison of Anterior Cruciate Ligament Reconstructions With Hamstring Tendon and Patellar Tendon Autograft A Controlled , Prospective Trial. Am J Sports Med. 2007;10(10):1–11.
12. Xie X, Liu X, Chen Z, Yu Y, Peng S, Li Q. A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. Knee. 2015 Mar;22(2):100-10
13: Yao LW, Wang Q, Zhang L, Zhang C, Zhang B, Zhang YJ, Feng SQ. Patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol. 2015 Feb;25(2):355-65.
14. Xie X, Xiao Z, Li Q, Zhu B, Chen J, Chen H, Yang F, Chen Y, Lai Q, Liu X. Increased incidence of osteoarthritis of knee joint after ACL reconstruction with bone-patellar tendon-bone autografts than hamstring autografts: a meta-analysis of 1,443 patients at a minimum of 5 years. Eur J Orthop Surg Traumatol. 2015 Jan;25(1):149-59.
15. Li S, Chen Y, Lin Z, Cui W, Zhao J, Su W. A systematic review of randomized controlled clinical trials comparing hamstring autografts versus bone-patellar tendon-bone autografts for the reconstruction of the anterior cruciate ligament. Arch Orthop Trauma Surg. 2012 Sep;132(9):1287-97
16. Biau DJ, Katsahian S, Nizard R. Hamstring tendon autograft better than bone-patellar tendon-bone autograft in ACL reconstruction – a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis. Acta Orthop. 2007 Oct;78(5):705-7
17. Poolman RW, Farrokhyar F, Bhandari M. Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis. Acta Orthop. 2007 Jun;78(3):350-4.
18. Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS. Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ. 2006 Apr 29;332(7548):995-1001.
19. 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 Jun;14(6):517-28.
20. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE Jr. Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review. Am J Sports Med. 2004 Dec;32(8):1986-95.
21. Mohtadi NG, Chan DS, Dainty KN, Whelan DB. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD005960.
22. Anderson MJ, Browning WM 3rd, Urband CE, Kluczynski MA, Bisson LJ. A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthop J Sports Med. 2016 Mar 15;4(3):2325967116634074.
23. Bartlett RJ, Clatworthy MG, Nguyen TN V. Review article GRAFT SELECTION IN RECONSTRUCTION OF THE ANTERIOR CRUCIATE LIGAMENT. J Bone Joint Surg Br. 2001;83(July):625–34.
24. Matjaz S, Andrej S, Radko K, Mojca D. The effect of graft choice on functional outcome in anterior cruciate ligament reconstruction. Int Orthop. 2008;32:473–8.
25. Martin NJ, Shishir SM, Kanagasabai R, Najimudeen S, Gnanadoss JJ. “ Quadruple hamstring tendon graft versus Bone-Patellar- Tendon-Graft for arthroscopic Anterior Cruciate Ligament reconstruction- comparison study with follow up of 2 years .” IOSR J Dent Med Sci. 2014;13(11):6–13.

26. Ahlde M. Knee laxity measurements after anterior cruciate ligament reconstruction , using either bone – patellar – tendon – bone or hamstring tendon autografts , with special emphasis on comparison over time. Knee. 2009;17:1117–24.
27. Svensson M, Ejerhed L, Kartus T. A prospective comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction in female patients. Knee Surgery, Sport Traumatol Arthrosc. 2006;14:278–86.
28. Gauti L, Ninni S, Lars E, Jon K, Juri K. A prospective comparison of bone-patellar tendon-bone and hamstring tendon grafts for anterior cruciate ligament reconstruction in male patients. Knee. 2007;15:115–25.
29. Ishibashi Y, Tsuda E, Fukuda A, Tsukada H. Intraoperative Biomechanical Evaluation of Anatomic Anterior Cruciate Ligament Reconstruction Using a Navigation System Comparison of Hamstring Tendon and Bone – Patellar Tendon – Bone Graft. Am J Sports Med. 2008;36(10):1903–12.
30. 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 Jun;25(6):653-85

How to Cite this article:. Tapasvi S, Jain S, Shyam AK. BTB Vs Hamsrtings – Is There a Winner Yet ?. Asian Journal of Arthroscopy  Apr-June 2016;1(1):11-15 .

 

Dr. Sachin Tapasvi

Dr. Sachin Tapasvi

Dr. Sachin Jain

Dr. Sachin Jain

Dr. Ashok Shyam

Dr. Ashok Shyam

(Abstract)      (Full Text HTML)      (Download PDF)

ACL Treatment in 2016 – Controversy and Consensus

Renato Andrade, Hélder Pereira, João Espregueira-Mendes

Asian Journal of Arthroscopy | Volume 1 | Issue 1 | April – Jun 2016 | Page 3-10

Author: Renato Andrade[1],[2],[3], Hélder Pereira[3],[4],[5],[6],[7], João Espregueira-Mendes[2],[3],[5],[6],[8]

[1] Faculty of Sports, University of Porto, Porto, Portugal
[2] Clínica do Dragão, Espregueira-Mendes Sports Centre – FIFA Medical Centre of Excellence, Porto, Portugal
[3] Dom Henrique Research Centre, Porto, Portugal.
[4] Orthopedic Department, Centro Hospitalar Póvoa de Varzim – Vila do Conde, Póvoa de Varzim, Portugal
[5] 3B’s Research Group – Biomaterials, Biodegradables and Biomimetics, Univ. Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark – Parque de Ciência e Tecnologia, Zona Industrial da Gandra, 4805-017 Guimarães, Portugal;
[6] ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal
[7] Ripoll y De Prado Sports Clinic FIFA Medical Centre of Excellence, Murcia-Madrid, Spain
[8] Orthopaedics Department of Minho University, Minho, Portugal

Address of Correspondence

Dr João Espregueira-Mendes
Via Futebol Clube do Porto – F. C. Porto Stadium, Porto, Portugal
Email: espregueira@dhresearchcentre.com

Abstract

The incidence of anterior cruciate ligament (ACL) injuries has been increasing in the last few decades and, along with it, the number of ACL reconstruction failures has also been growing. To overcome the surgical complications and failures, several developments have been made in regard to the ACL treatment. Nowadays, the ACL reconstruction has become more anatomic and individualized, aiming for the closest replication of the native ACL anatomy and biomechanics. As the knowledge regarding the ACL anatomy and biomechanics moves forward, novel surgical techniques and fixation devices have been developed to keep up the patient’s demands and further prevent the early onset of osteoarthritis. Nonetheless, a considerable number of controversies are still under debate. This review will outline the current concepts of ACL treatment, focusing its consensus and controversies.
Key-words: ACL; Anterior cruciate ligament; Reconstruction; Treatment; Current concepts

Introduction

Anterior cruciate ligament (ACL) ruptures are a common injury worldwide, with an estimated incidence of 80,000 to more than 250,000 every year(1), affecting mostly the young athletes under 25 years old. Several risk factors seems to be predisposing the individuals to a higher risk of injury, such as, environmental (meteorological conditions, field surface and footwear), anatomical (Q angle, knee valgus, foot pronation, body mass index, bone morphology – e.g. narrow intercondylar notch, and steeper tibial slopes) and neuromuscular risk factors (altered movement patterns and muscle activation patterns and inadequate muscle stiffness)(1-3). In addition, it was suggested that greater anteroposterior (AP) lengths and height of the lateral femoral condyle in relation to a smaller AP diameter of the lateral tibial plateau can predispose the higher risk of ACL injury (4). If these injuries are left without proper treatment, it will result in increased knee laxity and instability, decreased levels of physical and sporting activities and, eventually lead to degenerative changes of the knee joint(5-8). In this sense, the ACL reconstruction aims to restore the knee stability and function, the normal knee kinematics and prevent the early onset of osteoarthritis.
Traditionally, ACL ruptures were surgically treated through non-anatomic ACL reconstructions, with the graft in the isometric position and out of the femoral footprint. However, the non-anatomic ACL reconstruction often resulted residual rotational laxity(9, 10). Nowadays, the focus has shifted towards the anatomic reconstruction highlighting the importance of the correct tunnel position in the native ACL footprint. This concept relies upon the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites, taking into account the individual anatomical, morphological characteristics and biomechanical demands of each patient(11). In this sense, Karlsson, Irrgang (12) identified four key principles: restoration of the native insertion site anatomy by placing the tunnels in the correct position; restoration of the two functional bundles (anteromedial and posterolateral; Figure 1); provide the appropriate tension; individualize the surgical procedure for each patient in terms of graft type, tunnel size and graft diameter.
In this review, it will be presented an overview of the current concepts and state-of-art of ACL treatment, focusing the consensus and controversies related to this topic.

fig1

Figure 1: Arthroscopic view of intact native ACL, where it is displayed the two functional bundles, anteromedial (AM) and posterolateral (PL).

Diagnostic procedures and laxity measurement
A comprehensive medical history, musculoskeletal physical examination and imaging procedures play a crucial role in the diagnosis of an ACL injury(13). The taking of medical history should be comprehensive enough to provide information regarding the time and mechanism of injury, rupture pattern and the patient’s activity level(14, 15). The physical examination should comprise valid and reproducible examination tests in order to accurately lead the diagnostic process including the Lachman, pivot-shift and anterior drawer tests. In this sense, the Lachman test is the most sensitive test (87%) and the pivot-shift the most specific (98%)(16). The magnetic resonance imaging (MRI) has been reported to be useful in the ACL injury diagnostics, often capable of identifying complete and partial ACL ruptures (17). In addition, it is helpful in identifying concomitant knee pathology such as other ligament, meniscal, or articular cartilage injury(13). Nonetheless, the abovementioned procedures fail to provide an objective quantitative measure of the ACL laxity. To overcome this issue, several mechanical testing devices have been used in order to measure tibiofemoral AP translation and rotational laxity (18). However, the reliability and diagnostic accuracy of some of them, such as, the KT-1000™, has been questioned(19, 20). Therefore, the ideal tool should be able to assess both “anatomy” and “function” on the same examination. In this sense, the Porto-Knee Testing Device (PKTD) is a safe and MRI-compatible knee laxity testing device, capable of measuring the AP tibial translation and tibial internal and external rotation (Figure 2)(21).

Figure 2: Demonstrative image of PKTD assessment. Left arrow indicates the tibial AP translation induced by the pressure applied in the posterior proximal calf region through the actuators pressurizing. Right arrow indicates the tibial internal rotation through pressure applied at the footplate axis.

Figure 2: Demonstrative image of PKTD assessment. Left arrow indicates the tibial AP translation induced by the pressure applied in the posterior proximal calf region through the actuators pressurizing. Right arrow indicates the tibial internal rotation through pressure applied at the footplate axis.

Case 1
A twenty-year-old male athlete presented to the sports clinic 4 months following a motorcycle fall. There was no knee effusion evident, however the patient reported residual pain on his right knee. During the physical examination, the patient showed positive Lachman (+/++) and lateral pivot-shift (+) tests, suggesting an increased ACL laxity. Given the medical history and physical examination, the patient was directed for conventional and PKTD MRI examination to assess the presence of further lesions.
The conventional MRI showed bony contusions on the lateral femoral condyle and lateral tibial plateau. In addition, there was evidence of increased signal in one of the bundles, suggesting an ACL partial rupture (Figure 3A). During the PKTD MRI examination, there was tibial PA subluxation (Figure 3B), which increased by 7 mm when submitted to PA stress and internal rotation of the foot (Figure 3C). The conventional MRI examination showed evidence of potential partial rupture, which was confirmed by the PKTD examination, revealing a non-functional ACL.

Figure 3: Knee conventional and PKTD MRI examination, with sagittal images of the lateral femoral condyle and lateral tibial plateau of the right knee. A) Knee conventional MRI examination; B) PKTD without stress (13 mm); C) PKTD with PA stress and internal rotation of the foot (20 mm).

Figure 3: Knee conventional and PKTD MRI examination, with sagittal images of the lateral femoral condyle and lateral tibial plateau of the right knee. A) Knee conventional MRI examination; B) PKTD without stress (13 mm); C) PKTD with PA stress and internal rotation of the foot (20 mm).

In partial ACL ruptures, there is often loss of the functional integrity of the remaining ligamentous fibers, resulting in knee instability and symptomatology of impaired knee function. In cases where the remaining fibers retain their functional capacity, an augmentation procedure will be more suitable

Surgical indications
The decision upon the surgical treatment must be made taking into account the patient’s age, demands of their sports or physical activities, expectation and presence of concomitant injuries(22). In this sense, the indications for ACL reconstruction are young and active adults (18-35 years old) that have sustained an acute ACL injury and signs of instability(13). At this point, concomitant injuries (such as, meniscus, ligamentous or cartilaginous injuries) must be addressed in combination with the ACL reconstruction in order to improve the surgical outcomes(13, 23).

Time-to-surgery
As soon as the decision to operate is made, the surgeon must consider the ideal time to perform the reconstruction. Several prognosis variables (pre-operative range of motion, swelling and quadriceps strength) should be analyzed before proceeding to surgery as these will affect the ACL reconstruction outcome and success(24, 25). Moreover, delaying tACL reconstruction will increase the possibility for the development of other concomitant injuries, such as, cartilage lesions or meniscal lesions(26, 27). In this sense, it has been recommended to perform the ACL reconstruction as soon as pre-operative problems are resolved (no pain, no swelling and at least 90º of flexion)(28) and within 5 months from injury to preserve from further meniscus and/or cartilage damage(13, 29).
ACL reconstruction techniques
The technique for the ACL reconstruction should be taolored to the needs of the patient-tailored and follow the anatomic reconstruction concept. A consensus on which is the best approach, either single-bundle or double-bundle reconstructions, has not been reached however both techniques achieve similar results(13, 30, 31). Thus, the choice of one of these techniques should be based upon different criteria, mostly related to the visualization of the insertion sites and length of tibial and femoral insertion sites (cut-off at 14 mm), which was proposed in ACL reconstruction flowchart by Lesniak et al (11)
Partial ACL ruptures are known to be multifactorial and a consensus on its definition has not been determined (32). In cases which a single bundle (anteromedial or posterolateral) is ruptured or non-functional and the other bundle is well-preserved, a single-bundle augmentation surgery may be deliberated (17, 33, 34). The augmentation technique for the remnant bundle may provide greater vascularization and proprioception, optimize the accuracy of the reconstruction and enhance greater stability and clinical and functional outcomes (33-35). In cases of partial ACL ruptures, the PKTD can be useful in evaluating the individual biomechanical contribution of the remaining bundle functionality (17).

Tunnel placement
Nowadays the anatomic position of the graft within the native footprint has gain increasing popularity and, therefore, the proper tunnel placement plays a crucial role. A 3-portal approach comprising the standard anterolateral and central medial portals and, in addition, an accessory anteromedial portal (superior to the medial joint line approximately 2 cm medial to the medial border of the patellar tendon) has been suggested(36).
Performing the ACL reconstruction with the 3-portal approach will allow the surgeon to visualize the entire ACL and its femoral and tibial insertions(12). In this sense, several landmarks to identify the ACL femoral native footprints have been suggested including lateral intercondylar ridge (most anterior border), lateral bifurcate ridge (division into anteromedial and posterolateral bundles) and the posterior cartilage border (37). If these landmarks are absent, the ACL femoral footprint is known to be at the lower 30-35% of the notch wall with the knee at 90º of flexion. The ACL tibial native footprint can be found through the tibial spines, anterior and posterior horns of the lateral meniscus and posterior cruciate ligament insertion site(12).
Since graft malposition has been reported as one of the most common technical errors(38), several femoral tunnel drilling techniques have been developed, such as, the anteromedial portal, the outside-in and outside-in retrograde drilling techniques(39). It has been shown that transtibial technique yields more subjectively poorly positioned tunnels than the two-incision and medial portal techniques(40). Nevertheless, excellent outcomes have also been reported with a modified transtibial technique(41). In this sense, all the four techniques have shown different advantages and disadvantages, and a clear consensus on which is the best technique for creating the femoral ACL socket has not been reached so far(39). Our recommendations, based on daily practice, is to use the anteromedial and the possibility to add an accessory anteromedial portal.
The accuracy of the tunnel position (tunnel angle and implant position and length) can be further evaluated through radiography, MRI or three-dimensional computed tomography (CT). In this sense, the three-dimensional CT (Figure 4) is considered gold-standard since its measurements provide the highest reliability (42, 43).

Figure 4: Three-dimensional CT image demonstrating the tibial (image on the left) and femoral (image on the right) tunnel placement in single-bundle ACL reconstruction.

Figure 4: Three-dimensional CT image demonstrating the tibial (image on the left) and femoral (image on the right) tunnel placement in single-bundle ACL reconstruction.

Graft choice
The choice of the correct graft for the ACL reconstruction plays an essential role in the success of the surgery. Regarding the graft choice there is “no one-size-fits-all” concept and, therefore, the decision of the graft should be based on the patient age, size and gender, physical demands, associated injuries, degree of laxity, patient’s anatomy, patient’s choice and expectations and, ultimately, the surgeon preferences, experiences and beliefs. Moreover, the chosen graft should replicate the anatomical and biomechanical properties of the native ligament, guarantee a safe and longstanding fixation, and provide rapid biological integration and low donor-site morbidity(44). In this sense, three different types of graft can be considered including the autografts, allografts and synthetic grafts.
Autografts usually include the bone-patellar tendon-bone (BPTB), the hamstrings tendons (HS) and the quadriceps tendon (QT). The autografts have the advantage of being immediately available and biological healing potential, without risk of additional disease transmission and without additional costs(45). Strong evidence has been shown towards the use of BPTB (Figure 5) or HS grafts once the overall reported follow-up measured outcomes are similar(13). The central QT graft is not recommended for primary ACL reconstruction but often considered for revision cases(45). Recent studies show promising results and low donor-site morbidity levels(46). When comparing the BPTB and HS autografts, the most recent systematic reviews show no significant differences regarding the return to activity, clinical, functional and subjective outcomes (47-50). Nonetheless, the BPBT seems to cause more morbidity (anterior knee and kneeling pain) but increased knee stability, with higher levels of activity(47-50). In addition, other advantages and disadvantages have been pointed out to the different available autografts(15, 22, 44).
The allografts have advantage over the autografts regarding donor-site harvesting morbidity, less operative time and have no limits regarding the number, size and shape(45). Nevertheless, they can result in disease transmission (low risk), higher costs, longer healing time frame and increased risk of failure (specially in young patients and irradiated grafts)(22, 51). The tibialis posterior/anterior, peroneous longus and Achilles tendon allografts are the most commonly used, however the patellar tendon and HS are also easily available(45). Indications for allograft usually included athletes that might be affected by the harvesting symptomatic and functional deficits, ACL revision surgeries and complex multiligament reconstructions(52). When compared to autografts, the current scientific evidence show no significant differences regarding the re-rupture rate, clinical, functional and subjective outcomes(53, 54).
The synthetic grafts are often seen as intra-articular braces and are now into their third generation with several synthetic devices under development. The Ligament Advanced Reinforcement System (LARS) device has shown some favorable outcome in selected patients(55). Their role in ACL reconstruction still remains to be defined(55), however usual indications are rare including healing augmentation in symptomatic and active individuals (>40 years) with an acute ACL injury requiring a fast post-operative recovery(44, 56).

Figure 5: BPBT autograft preparation to single bundle ACL reconstruction. By twisting the autograft 90 degrees, it is possible to approximate the autograft to the native ACL anatomy and biomechanics, resembling the ACL double-bundle anatomy concept (AM, anteromedial bundle; PL, posterolateral bundle).

Figure 5: BPBT autograft preparation to single bundle ACL reconstruction. By twisting the autograft 90 degrees, it is possible to approximate the autograft to the native ACL anatomy and biomechanics, resembling the ACL double-bundle anatomy concept (AM, anteromedial bundle; PL, posterolateral bundle).

Graft fixation
Over the last decade, we have been witnessing significant developments concerning the bone plug and soft tissue fixation devices. These fixation devices can be further divided into aperture fixation and suspensory fixation(57). The fixation device for the ACL reconstruction graft should be secure and maintain the optimal tension until full integration of the graft has occurred. In addition, it should provide strength enough to prevent graft failure, stiffness enough to restore stability and provide biomechanical properties to the graft that replicate the native ACL(15, 45). The strength provided should be enough to allow immediate range of movement and weight bearing exercises and permit an early return to sports(57).
The most common bone plug fixation devices for the tibial and femoral fixation are the metal or bio-interferences screws (Figure 6)(15, 45). The bioabsorbable screws have the advantage of faster degradation, promoting the bone ingrowth, incorporation of the graft into the surround tissue, lower need for implant removal and reduced MRI interference(45). Nevertheless, caution should be taken upon the the possible migration of the bioabsorbable screws(58). When considering bioabsorbable against metallic interference screws, both provide similar clinical and functional outcomes, however the bioabsorbable interference screws are more associated with prolonged knee effusion, increased femoral tunnel widening, and increased screw breakage(59).

When considering soft tissue fixation devices, the suspensory devices are more commonly used for the femoral tunnel fixation and the interference screws for the tibial side(15). In regard to the suspensory devices, they have been widely used for graft fixation, providing reduced stiffness than interference screws and higher load to failure. Moreover, it avoids disruption of the insertion site (Figure 7)(15). However, there have been reports of tunnel enlargement(60). When comparing the interference screws with suspensory fixation, corticocancellous fixation and cross biodegradable pins for femoral soft tissue fixation, it was shown that interference screws resulted in decreased risk of surgical failure but no differences were found when postoperative functional outcomes are compared(61). Mechanical properties of cortical suspension and screws fixation for the soft tissue femoral and tibial side are already available in the literature(62, 63).

Biological enhancement of the ACL primary repair
During the past decade, several bio-enhancement tissue engineering regenerative medicine (TERM) approaches have been reported for the primary reconstruction of ACL ruptures, including cell-based therapy, artificial ligament systems, platelet-rich plasma (PRP), growth factors and cytokines, calcium phosphate (hybridized tendon), biodegradable biomaterials and mechanical stimulation (low-intensity pulsed ultrasound). These TERM approaches have been showing promising results as they can work in synergy with the ACL reconstruction and have the potential advantages of enhancing better ligamentization and faster recovery(64). The addition of PRP to ACL treatment has shown promising results in accelerating the graft maturation. However, there is no clear evidence of the benefits of PRP on tunnel and tendon-to-bone healing and enhancing better clinical and functional outcomes(65, 66).

Rehabilitation and prevention
The rehabilitation plays an important role in the success of the ACL reconstruction. In this sense, current trends are towards individualized, patient-tailored, progression-based accelerated (or non-accelerated) rehabilitation protocols in order to achieve better clinical and functional outcomes, as well as, returning faster to the competition. Along this line, the patient adherence and compliance to the rehabilitation protocol are crucial. Moreover, the timeframe of the tissue healing must be respected(67, 68). In addition, these protocols must be adapted to the graft type and concomitant surgical procedures (such as, meniscal or cartilage repair)(69). They include immediately knee full extension, immediate partial weight bearing (in exception when associated lesions are present and a concurrent surgical procedure was performed, such as, meniscus or cartilage repair). Full description of criteria progression-based rehabilitation protocols have already been published in the scientific literature(69, 70).
Prevention programs are the keystone for reducing the rate of non-contact ACL injuries and should focus in adjusting the neuromuscular and biomechanical modifiable risk factors. These often include sportive technique modification, neuromuscular training, stretching, plyometric training, balancing the hamstring/quadriceps ratios, and trunk/core control training(71). A wide range of prevention programs have been developed, with good results being reported(13, 71, 72). In addition, a comprehensive follow-up of the patient’s neuromuscular and biomechanical potential deficits (such as, dynamic knee valgus and high abduction loads) after ACL reconstruction plays a critical role in preventing recurrence of the ACL injury (secondary prevention)(73).

Return to sports
Returning to pre injury level of sports is the main goal of every young athlete but still a controversial issue in the sports medicine community. The timing of returning to competition is multifactorial and therefore several preoperative (age, preoperative rehabilitation, full knee extension and neuromuscular control), intraoperative (graft choice) and postoperative factors (rehabilitation protocol and psychological factors) have been suggested to influence the return to play(74). Clearance to return to competition should be a multidisciplinary decision and take into account objective criteria instead of time frames(67). In this sense, several objective criteria have been proposed and the most important are: no pain or swelling; full active knee range of motion; isokinetic unilateral and bilateral balance and functional hop testing (side-to-side difference <15%); functional and static knee stability(67, 70). In a meta-analysis, comprising a total of 5770 patients (from 48 studies) and a mean follow-up of 41.5 months, 82% of the participants returned to some kind of sports participation, while only 63% returned to their pre-injury level and 44% to competitive sports(75).

Case 2
A 21-years-old amateur male football player presented to the sports clinic reporting symptoms of knee instability (give-away). During the medical history taking, the patient reported that he had 3 years ago an ACL rupture, which was reconstructed with a HS autograft on the 20th day from injury. The surgery and subsequent rehabilitation underwent without any complications and the football player returned to play at the 9th month. During the physical examination, there was present an increased tibial PA and rotation laxity, evidenced by the Lachman (+) and lateral pivot-shift (++) tests, specially when compared to the contralateral healthy knee. There was no knee effusion, stiffness or loss of range of motion. In light of these clinical findings, the patient was referred for MRI with PKTD examination to assess the autograft status and the presence of pathological laxity.
Although the football player underwent all the rehabilitation phases and had returned to competition without complications, three years after the ACL reconstruction he begin to feel symptomatology of instability. The MRI exam with the PKTD showed that he had significant residual laxity on his right knee, with side-to-side differences of 6 mm on the medial side and 10 mm on the lateral side (Figure 8).
Despite the several developments in the orthopaedic surgery, residual laxity after ACL reconstruction is still an issue to overcome. This residual laxity often results from permanent deformation of the graft tissue that precluded the restoration of the normal knee stability. This residual laxity may result from technical errors, such as, graft undertensioning, graft slippage or micromotion (due to improper tibial fixation), incomplete healing (integration of the graft), incorrect tunnel placement, inadequate graft fixation, missed associated laxities (specially, the posterolateral corner laxity) and divergent screws placed (>15º). In addition, traumatic re-rupture, aggressive rehabilitation or early return to play may also lead to residual laxity.

Conclusions

A great deal of focus from the orthopaedic and sports medicine communities has been on the ACL treatment. There is still an open debate in many features of the ACL injury management, while considerable developments have been made over the past few decades. In this review it is outlined and discussed the current consensus and controversies of the ACL treatment and the summary of the key points is presented below.
A complete and reliable diagnostic process should comprise a comprehensive medical history, musculoskeletal physical examination and imaging procedures (radiography and MRI). This can be complemented with laxity measurements with arthrometers (KT-1000) or better with MRI-compatible devices (PKTD).
Young and active adults with acute ACL injury and signs of instability are candidates for ACL reconstruction.
The surgery should be performed after the acute signs are resolved and within the first five months of injury.
Current trends of ACL reconstruction are towards the anatomic and individualized reconstruction.
In partial ACL ruptures, single-bundle augmentation surgery may be an option.
Femoral tunnel placement should be made through a tibial independent approach.
No consensus regarding the graft type (autograft vs. allograft) or autograft source (BPTB vs. HS).
No consensus concerning the graft fixation. For bone plugs fixation, metal or bio-screws are more commonly used. For soft tissue fixation, suspension devices for the femoral side and interference screws for the tibial side.
Although the promising results, the additional value of TERM approaches is not still well established in the literature.
The postoperative rehabilitation should be made through individualized, patient-tailored, progression-based accelerated (or non-accelerated) rehabilitation protocols.
Prevention programs are effective in reducing the rate of non-contact ACL injuries and a comprehensive follow-up of neuromuscular and biomechanical deficits is crucial for the secondary prevention.
The return to competition should be a multidisciplinary decision and be based in objective criteria.

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How to Cite this article:. Andrade R, Pereira H, Mendes JE. ACL Treatment in 2016 – Controversy and Consensus. Asian Journal of Arthroscopy  Apr- June 2016;1(1):3-10 .

Dr. Renato Andrade

Dr. Renato Andrade

Dr. Hélder Pereira

Dr. Hélder Pereira

Prof. Dr. João Espregueira-Mendes

Prof. Dr. João Espregueira-Mendes

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