Arthroscopic anterior cruciate ligament reconstruction using autogenous hamstring tendon graft without detachment of the tibial insertion

This article describes a modified arthroscopic technique of anterior cruciate ligament reconstruction using quadrupled hamstring tendon graft. The autogenous semitendinosus and gracilis grafts are harvested without detachment of the tibial insertion. To obtain longer grafts, the accessory tibial insertions of the hamstring tendons are dissected. The EndoButton (Acufex Microsurgical, Andover, MA) is used for femoral fixation and two spiked staples are used for tibial fixation in a belt buckle fashion. Then the residual anterior laxity is restored by additional absorbable interference screw fixations. In this technique, more viable graft is obtained and more firm distal fixation is achieved by preservation of the tibial insertion of hamstring tendons.     

Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament

Anterior cruciate ligament (ACL) reconstruction using four-strand hamstring graft with round-headed, cannulated, interference (RCI) screw fixation requires osteointegration of the tendon graft. This report describes the histology at the bone-tendon junction of two specimens retrieved from patients undergoing revision surgery after traumatic mid-substance ACL graft rupture at 6 and 10 weeks after initial reconstruction. Revision was performed at 12 and 15 weeks. Integration of the graft was evident by observation of collagen fiber continuity between bone and tendon. This histology plus the low incidence of early graft failure suggest that free tendon autograft attached to bone by RCI screw allows adequate osteointegration between 6 and 15 weeks after surgery.     

An experimental study on the replacement of the anterior cruciate ligament of the rabbit''s knee using an augmented substitute

This study was designed to test the putative role of plasma cholecystokinin (CCK) in eating behaviour by examining the relationships between bioassayed plasma CCK concentrations and rated sensations of satiety and hunger following the ingestion of an appetizing nutrient-dense meal and between plasma profiles of CCK and scintigraphically determined gastric emptying in nine healthy male volunteers. Mean plasma CCK levels from the whole group showed a significant negative correlation with mean hunger ratings (r = -0.64) and a positive correlation with fullness (r = +0.68). However, there was considerable interindividual variation and negative correlations with hunger were only seen in three out of nine subjects and positive correlations with fullness in four out of nine subjects. In contrast, there was a strong relationship between the plasma CCK produced over the first 2 h after the meal and the half time for gastric emptying of the meal (r = -0.81). These data do not support a direct role for circulating levels of CCK in the control of hunger and satiety following a meal. Instead, the strong correlation with gastric emptying is compatible with release of CCK in response to nutrient delivery into the small intestine.     

The semitendinosus tendon as replacement for the anterior cruciate ligament

This article describes the history, advantages, biomechanical properties, operative technique, and results of replacement of the anterior cruciate ligament using the semitendinosus tendon. After arthroscopic ACL replacement using the doubled semitendinosus tendon in combination with an extraarticular lateral repair in 65 consecutive patients (20 acute, 45 chronic instabilities) we found after 2 years in 51 patients (78%) an excellent or good result with less than 3 mm difference in the Lachman test measured with the KT-1000 arthrometer (MMD). After 6 years 40 out of the 45 patients with chronic instabilities could be examined again. Only 28 patients (70%) showed a difference in anterior translation of less than 3 mm. A positive pivot shift sign could be seen in 11% of the patients after 2 years and in 20% after 6 years. The Tegner score increased from 6.0 after 2 years to 6.2 after 6 years, the Lysholm score decreased from 93 to 91 in the same interval. 89% of the patients had a free range of knee motion after 2 years and 92.5% after 6 years. There were 10% normal, 50% nearly normal, 25% abnormal, and 15% severely abnormal knees in the IKDC evaluation after 6 years. In the last 4 years we are using the quadrupled semitendinosus tendon in an arthroscopic single incision technique for ACL replacement with femoral Endobutton fixation, because the doubled semitendinosus tendon seems to elongate over time. After 23 months on average (12-36 months) the preoperative anterior translation of 7.5 mm could be decreased to 1.9 mm in 35 patients.     

The effects of an artificial meniscus substitute in a knee joint with a resected anterior cruciate ligament. An experimental study in rabbits

A Dacron meniscus prosthesis was substituted for the medial meniscus in an anterior cruciate ligament (ACL) resected rabbit knee. At three months, the joints were evaluated biomechanically, with gross and histologic inspection. In a paired comparison with the contralateral knee, differences between ACL resection with intact, incised, or resected medial menisci were evaluated. Knees with intact menisci and ligaments served as controls. Because of cartilage destruction, soft-tissue hypertrophy, and increased anterior laxity, joint stiffness was less than normal in all ACL-resected knees. Ingrowth and stable fixation, especially of the posterior horns of the prostheses and the incised menisci, were rare. Almost all normal menisci had ruptured in the same area. Anterior cruciate ligament resection led to severe osteoarthrosis in both compartments, regardless of initial meniscal treatment. Knees with prostheses had the same incidence and severity of osteoarthrosis as knees with meniscus resection. Anterior cruciate ligament resection alone induced excessive osteoarthrosis and synovitis and diminished the effects of different meniscal treatments three months earlier.     

Arthroscopic replacement of the anterior cruciate ligament with a double semitendinosus tendon

At the university hospital of emergency surgery in Innsburck and at the emergency services department of the hospital in Schwaz, anterior cruciate ligament reconstruction was performed in 467 patients between January 1992 and September 1993. In 117 cases, a double semitendinous tendon was used as an autograft. A total of 60 of these patients were followed up at an average of 20 months (13-33) after reconstruction. The results were rated according to the OAK and the Tegner scores. Objective measurements of instability were carried out by a KT 1000 arthrometer. In addition, 21 patients underwent computer-interfaced dynamometer testing using a Cybex 6000. Standardized loading of the thigh muscles was performed at angular velocities of 60 degrees/s (3 repetitions) and 240 degrees/s (30 repetitions): peak torques and total work were analyzed. The mean age was 23.5 years (17-55): 48 were male, 21 female. The main reasons for the ACL ruptures were sports injuries (51 cases). The patients were classified into three groups according to the data of the repair (group 1 reconstruction up to 1 week after trauma-28 patients: group 2: reconstruction between the 2nd and 6th week after trauma-15 patients: group 3: reconstruction 6 and more weeks after trauma-26 patients). In group 1. additional ruptures of the menisci. lesions of the MCL. and chondromalacia were seen in 71.4%. in group 2 in 73.3% and in group 3 in 80.8%. The average rating in the OAK score was 90.16 points: 38 patients (55.70%) had excellent results. 18(26.09%) were good. 9(13.04%) were fair and 4(5.80%) were poor. The Tegner activity score showed a reduction of 0.36 points on average. The largest amount of anterior translation was performed with the KT 1000 manual drawer test (2.29 mm on average compared with the contralateral side). Dynamometer testing showed a statistically significant difference in flexor and extensor mechanism (compared with the non-involved side) in both peak torques and total work. A repeat arthroscopy became necessary in five cases: arthrofibrosis in three and incipient joint infection in two cases.     

All-inside anterior cruciate ligament reconstruction using semitendinosus tendon and soft threaded biodegradable interference screw fixation

A modification of anterior cruciate ligament (ACL) reconstruction using a minimally invasive and endoscopic all-inside technique is presented. Both the femoral and tibial socket are approached through the joint so that there is no open tibial tunnel, which otherwise often causes significant pain and discomfort during early rehabilitation. The autologous semitendinosus tendon is harvested with a bone plug attached to its tibial insertion. The triple-stranded semitendinosus tendon is looped around the adjacent bone plug and fixed at the original tibial attachment site of the ACL using a soft threaded biodegradable poly-(D,L-lactide) interference screw. The screw is inserted endoscopically in an inside-out direction. In the femoral socket the graft is fixed without a bone plug directly to the tunnel wall using the biodegradable screw. The free part of the graft is thus not longer than the intra-articular distance, which may increase stiffness of the construct.     

Iliotibial band for anterior cruciate ligament reconstruction: a new technique for graft augmentation, placement and fixation

A simple surgical technique to reconstruct the ACL deficient knee was described. A strip of ITB and fascia lata augmented by degradable suture materials was used as the substitute. The strip was introduced into the isometric area of the original ACL attachment through a drill hole made in the lateral femoral condyle. Drilling was guided by the anatomical landmarks without using special device. The graft was then rigidly fixed to the tibia by intraosseous compression, the method previously described by the author. Clinical results were assessed by both subjective symptoms and physical examinations. In 33 patients followed-up for an average of 34.1 months, thirty of them who were chronic cases had few or no symptoms concerning pain, swelling, laxity and stiffness at the last visit. Lachman test, anterior drawer and Slocum test were negative in 87.92, 81.87 and 100 per cent respectively. This technique requires only basic instruments and skill, and is thus generalizable to institutions having limited surgical facilities.     

Periarticular heterotopic ossification: a complication of arthroscopic anterior cruciate ligament reconstruction using a two-incision technique

Extra-articular heterotopic bone formation was recognized as a postoperative complication of arthroscopic anterior cruciate ligament reconstructions in four knees around the femoral drill hole. Although laxity of the reconstructed anterior cruciate ligament was not observed in these patients, local pain, swelling, and deformity at the site of heterotopic ossification required surgical intervention. The ectopic bone can be successfully excised with restoration of function. The incidence rate of this complication is less than 1%.     

Bone graft procurement for patellar defect grafting in anterior cruciate ligament reconstruction

OBJECTIVE: To report a possible case of leukocytoclastic vasculitis associated with clarithromycin therapy. CASE SUMMARY: An 83-year-old white woman was prescribed clarithromycin for pneumonia. Six days after her initial presentation, she developed lesions on her palms. Clarithromycin was discontinued at that time. The following day she developed purpuric eccymotic nonblanching lesions that primarily appeared on the lower extremities, buttocks, and abdomen. Colonoscopy revealed generalized erythema and edema of the bowel mucosa. Gastroscopy revealed duodenitis and gastritis, but no bleeding or ulceration. Skin biopsy of the lesions was compatible with leukocytoclastic vasculitis. Renal function was not affected, although hematuria was noted. All symptoms resolved after drug withdrawal and a short course of corticosteroids. DATA SOURCES: Searches were performed on MEDLINE, Embase, International Pharmaceutical Abstracts, and major adverse drug reaction databases to identify reports and articles discussing clarithromycin- and macrolide-induced leukocytoclastic vasculitis. DISCUSSION: Leukocytoclastic vasculitis is one category of drug hypersensitivity reactions characterized by distinctive patterns of perivascular inflammation. The case described here is consistent with the diagnosis of leukocytoclastic vasculitis, and is similar to the other single published case report associated with clarithromycin. CONCLUSIONS: Leukocytoclastic vasculitis induced by clarithromycin is a rare but serious potential adverse effect.     

A prospective study of the outcome of anterior laxity of the knee after anterior cruciate ligament reconstruction with procedures using two different patellar tendon grafting methods

Oligonucleotides coding for linear epitopes of the fimbrial colonization factor antigen I (CFA/I) of enterotoxigenic Escherichia coli (ETEC) were cloned and expressed in a deleted form of the Salmonella muenchen flagellin fliC (H1-d) gene. Four synthetic oligonucleotide pairs coding for regions corresponding to amino acids 1 to 15 (region I), amino acids 11 to 25 (region II), amino acids 32 to 45 (region III) and amino acids 88 to 102 (region IV) were synthesized and cloned in the Salmonella flagellin-coding gene. All four hybrid flagellins were exported to the bacterial surface where they produced flagella, but only three constructs were fully motile. Sera recovered from mice immunized with intraperitoneal injections of purified flagella containing region II (FlaII) or region IV (FlaIV) showed high titres against dissociated solid-phase-bound CFA/I subunits. Hybrid flagellins containing region I (FlaI) or region III (FlaIII) elicited a weak immune response as measured in enzyme-linked immunosorbent assay (ELISA) with dissociated CFA/I subunits. None of the sera prepared with purified hybrid flagella were able to agglutinate or inhibit haemagglutination promoted by CFA/I-positive strains. Moreover, inhibition ELISA tests indicated that antisera directed against region I, II, III or IV cloned in flagellin were not able to recognize surface-exposed regions on the intact CFA/I fimbriae.     

Isolated tear of the anterior cruciate ligament: 5-year follow-up study

During the period 1967 to 1971, 64 cadets at the United States Military Academy, West Point, New York, had surgical repair for isolated tear of the anterior cruciate ligament. In a 5-year follow-up study to determine the functional impairment, present disability, and reinjury to the knee, 32 of the 64 patients were located and evaluated by radiographic examination and either by interview or by questionnaire. Twenty-two were commissioned to full duty. 23 had attended ranger or airborne school, and 16 had been in combat. Impairment of ordinary activities was noted by 12 and impairment of athletic endeavors by 24; pain by 71%; swelling by 66%; stiffness by 71%; and instability by 94%. Seventeen of the 32 had had a significant reinjury after the repair of the anterior cruciate ligament. Clinically, we can diagnose the isolated tear of the anterior cruciate ligament by four essential ingredients--a pop at time of injury, inability to continue participation, gross swelling of knee, and maximal swelling within 12 hr. The mechanism of injury is usually deceleration and change of direction, not contact with another player. The follow-up study on this small series indicates that the patients have progressive deterioration of the knee.     

Bone tunnel enlargement after anterior cruciate ligament reconstruction with semitendinosus tendon using Endobutton fixation on the femoral side

We evaluated 29 knees with a minimum follow-up of 2 years after anterior cruciate ligament (ACL) reconstruction using doubled autogenous semitendinosus tendons. On the femoral side, a 5-mm Mersilene tape (Ethicon, Norderstedt, Germany) with an Endobutton (Acufex Microsurgical, Mansfield, MA) was used. The tendon was fixed on the tibial side with two staples. Regarding the IKDC score, 66% of the patients were graded as normal or nearly normal. The anterior laxity side-to-side difference (KT 1000, man-max-drawer) was under 3 mm in 55% and under 5 mm in 90%. Radiographs taken in the lateral and anteroposterior projections of the knee showed sclerotic bone tunnel margins. The diameter of the bone tunnels were measured, corrected for magnification, then compared with the original reamed diameter to determine any change in size. Enlargement of at least 2 mm was identified in 72% of the femoral tunnels and 38% of the tibial tunnels. No correlation was found concerning the enlargement of the tunnel and the IKDC score or the residual joint laxity. We conclude that using an Endobutton-Mersilene construct in ACL reconstruction leads to femoral and tibial bone tunnel enlargement at follow-up of 2 years.     

Value of posterior cruciate ligament index in the diagnosis of anterior cruciate ligament injuries

Several EF-hand recoverin mutants were obtained and their abilities to bind to photoreceptor membranes and to inhibit rhodopsin kinase were determined. The mutants with the 'spoiled' 2nd, 3rd or (2nd+3rd) EF-hand structures did not act upon the kinase activity in the microM range of Ca2+ concentrations. Mutations of the 4th EF hand, which 'repaired' its Ca2+-binding activity, resulted in recoverin with three 'working' Ca2+-binding sites. The latter mutant inhibited rhodopsin kinase even more effectively than the wild-type recoverin, containing two working Ca2+-binding structures.     

Failure mechanisms of anterior cruciate ligament prostheses: in vitro wear study

Previous retrieval studies analyzing the cause of failure of anterior cruciate ligament (ACL) prostheses identified a wear mechanism. However, the relative importance of yarn on bone compared to yarn on yarn wear has not been clearly understood. Therefore, the objective of this study was to elucidate which type of wear is the dominant cause of clinical failure. A variety of ACL prosthetic structures were exposed to two in vitro tests: one for yarn on yarn and the other for a novel yarn on bone wear test system. The latter included the use of both smooth (uncut) and rough (cut) bone surfaces to simulate the conditions around the condyle and at the exit of the tibial tunnel, respectively. The damaged textile structures were viewed by SEM. The various fiber fracture morphologies were identified and classified for the two types of wear tests; for the smooth and rough bone surfaces; for the braided, knitted, woven, and twisted textile structures; and for the three types of fibers that were included: polyethylene terephthalate, polypropylene, and ultrahigh molecular weight polyethylene. The results confirmed that yarn on bone and yarn on yarn wear phenomena are associated with significantly different failure mechanisms. While the more aggressive rough (or cut) bone causes more rapid and intense fiber damage and faster ACL failure than the smooth (uncut) osseous surface, both abradants cause the same type of abrasive wear phenomenon. Differences in failure mechanisms were identified between the different textile structures and the different fiber types. By interpreting the damaged fiber images from clinically failed and retrieved ACL prostheses, we are now able to confirm that the predominant cause of synthetic ACL failure is yarn on bone abrasion. Improvements in future ACL prosthesis designs will only be possible by eliminating or minimizing the effect of this type of abrasive wear.     

Tendon repair using flexor tendon splints: an experimental study

Mechanical strength of tendon repair using Dacron tendon splints across the laceration site were evaluated in human cadaver profundus tendons; the splints were placed both on the dorsal surface and internally within the tendon substance. Comparison was made to modified Kessler, Becker, and Savage repair techniques. Ultimate tensile strength was 2.55 kgf for the Kessler, 3.00 kgf for the Becker, 8.29 kgf for the Savage, 8.46 kgf for the internal tendon splint, and 8.10 kgf for the dorsal tendon splint; the Savage and both Tendon Splints techniques had significant higher tensile strength than the Kessler and Becker. Gap strength was 1.44 kgf for the Kessler, 2.22 kgf for the Becker, 2.45 kgf for the Savage, 2.05 kgf for internal tendon splint, and 3.15 kgf for the dorsal tendon splint. The dorsal tendon splint technique showed significant greater gap strength than the other four techniques. There was no significant difference in the magnitude of the gap during cyclic testing of these techniques; however, three of seven Kessler repairs failed and one of six Becker repairs failed. The results of these cadaver studies suggest that both tendon splint repair techniques are comparable to the Savage and may have sufficient strength to allow postoperative active motion against minimal resistance. Further in vivo testing is in order.     

Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage

To test if anterior cruciate ligament reconstruction with autogenous patellar tendon can alleviate symptoms and functional limitations and increase activity levels in patients with advanced articular cartilage damage, we looked at 53 patients with arthroscopically documented cartilage damage. In this group, a mean of 7.5 years had elapsed between the original injury and the reconstruction, and 90 prior operative procedures had been done. Postoperatively, all patients had immediate motion and early functional rehabilitation. The results were assessed with the Cincinnati Knee Rating System. At followup (mean, 27 months), significant improvements were found for pain, swelling, giving way, functional limitations with daily and sports activities, and the overall rating score. Forty-two patients (79%) had returned to some type of athletic activity. Only three patients (6%) had failed results. In the patients' own ratings of the overall knee condition, 8 of 51 (16%) rated their knees as normal, 28 (55%) as very good, 7 (14%) as good, 5 (10%) as fair, and 3 (6%) as poor. We concluded that the majority of patients benefited from the arthroscopically assisted anterior cruciate ligament reconstruction because it decreased episodes of giving way with daily activities and increased activity without aggravating the preexisting arthrosis.     

Medial collateral knee ligament healing. Combined medial collateral and anterior cruciate ligament injuries studied in rabbits

BACKGROUND: Antineutrophil cytoplasmic antibodies (ANCA), particularly perinuclear ANCA (p-ANCA), have been found more frequently in sera from patients with ulcerative colitis (UC) than in sera from Crohn's disease (CD) or unclassified enterocolitis (UE) patients. This 2-center study examined sera from 102 pediatric patients with inflammatory bowel disease (IBD) to evaluate their diagnostic value and assess their relationship with disease features, distribution, activity and treatment. METHODS: The serum ANCA of 102 children with IBD were measured: 33 UC, 64 CD and 5 UE with various disease locations and degrees of activity. The mean age at the onset of symptoms was 10.7 years (1 to 16.3 years). Sera from 26 unaffected first degree relatives and 20 children without IBD were also investigated. ANCA were detected using indirect immunofluorescence of ethanol-fixed granulocytes. RESULTS: There were ANCA in the sera of 24/33 children with UC (73%), 9/64 with CD (14%) and 4/5 with UE (80%). p-ANCA were more frequent than cytoplasmic-ANCA in positive sera: UC = 67%, CD = 57% and UE = 75%. The presence of ANCA was 73% sensitive and 81% specific for a diagnosis of UC, compared to other IBD (p < 0.001). Three children with proved sclerosing cholangitis associated with UC were all positive. There was no link between ANCA-positive sera and disease activity, or other endoscopic or clinical criteria. ANCA were detected in 4/26 first degree relatives (15%) and in 1/20 control subjects (5%). CONCLUSIONS: Because of their sensitivity and specificity, ANCA may be helpful in the clinical assessment of patients with IBD, and especially those with UC. However, there is no link between the pressure of p-ANCA and the site of UC or its activity, so that it cannot be used to monitor medical treatment or surgical indications.