Clin Orthop Surg.  2011 Dec;3(4):285-294. 10.4055/cios.2011.3.4.285.

Clinical Results of Technique for Double Bundle Anterior Cruciate Ligament Reconstruction Using Hybrid Femoral Fixation and Retroscrew

• Kim DS
• Yi CH
• Chung HJ
• Yoon YS

• KMID: 1097166
• DOI: http://doi.org/10.4055/cios.2011.3.4.285

Abstract

BACKGROUND
Anatomic anterior cruciate ligament (ACL) reconstruction has been presented as a means to more accurately restore the native anatomy of this ligament. This article describes a new method that uses a double bundle to perform ACL reconstruction and to evaluate the clinical outcome.
METHODS
Grafts are tibialis anterior tendon allograft for anteromedial bundle (AMB) and hamstring tendon autograft without detachment of the tibial insertion for posterolateral bundle (PLB). This technique creates 2 tunnels in both the femur and tibia. Femoral fixation was done by hybrid fixation using Endobutton and Rigidfix for AMB and by biointerference screw for PLB. Tibial fixations are done by Retroscrew for AMB and by native insertion of hamstring tendon for PLB. Both bundles are independently and differently tensioned. We performed ACL reconstruction in 63 patients using our new technique. Among them, 47 participated in this study. The patients were followed up with clinical examination, Lysholm scales and International Knee Documentation Committee (IKDC) scoring system and radiological examination with a minimum 12 month follow-up duration.
RESULTS
Significant improvement was seen on Lachman test and pivot-shift test between preoperative and last follow-up. Only one of participants had flexion contracture about 5 degrees at last follow-up. In anterior drawer test by KT-1000, authors found improvement from average 8.3 mm (range, 4 to 18 mm) preoperatively to average 1.4 mm (range, 0 to 6 mm) at last follow-up. Average Lysholm score of all patients was 72.7 +/- 8.8 (range, 54 to 79) preoperatively and significant improvement was seen, score was 92.2 +/- 5.3 (range, 74 to 97; p < 0.05) at last follow-up. Also IKDC score was normal in 35 cases, near normal in 11 cases, abnormal in 1 case at last follow-up.
CONCLUSIONS
Our new double bundle ACL reconstruction technique used hybrid fixation and Retroscrew had favorable outcomes.

Keyword

KAnterior cruciate ligament reconstruction; Double bundle; Anatomical; Hybrid fixation; Retroscrew

MeSH Terms

Adult
Anterior Cruciate Ligament/*surgery
Bone Screws
Female
Femur
Humans
Male
Orthopedic Procedures/*methods
Prospective Studies
Tendons/transplantation
Treatment Outcome
Young Adult

Figure

• 

  Fig. 1 (A) The tibialis allograft is prepared (a, 30 mm for the femoral tunnel; b, 30 mm for the intra-articular space; c, 40 mm for the tibial tunnel). Mersilene tape of the Endobutton is suspended at the looped portion of the allograft. Whipstitch sutures with No. 2 Ethibond are placed 3 cm below the suspended site. (B) Anterolateral view of the operative right knee: The hamstring tendon autograft was harvested and prepared. The gracillis and semi-tendinosus tendons are stripped from the femoral side without detachment of the tibial insertion site (left) (a, 40 mm for the tibial tunnel; b, 20 mm for the intra-articular space; c, 30 mm for the femoral tunnel). The portion for tibial tunnel of graft was prepared with Ethibond (right).

• 

  Fig. 2 (A) Tibial tunnel for posterolateral (PL) bundle and anteromedial (AM) bundle was seen on arthroscopic view. (B) Anterior cruciate ligament (ACL) footprint of PL bundle (arrow) was seen on intercondylar notch of femoral condyle (left) and femoral tunnel of the PL bundle was guided at remnant of the ACL footprint using outside-in technique (right).

• 

  Fig. 3 (A) Wire loop is introduced through the posterolateral (PL) femoral tunnel via outside-in technique (left) and a femoral Ethibond suture of the graft for the PL bundle is suspended to a wire loop that is pulled out of the PL tibial tunnel and the graft for the PL bundle is introduced through the femoral tunnel via a wire loop (right). (B) Lateral view of operative right knee: a Rigidfix fixation guide system is introduced into the anteromedial femoral tunnel through a transtibial approach. The guide sheaths are carefully positioned in the lateral epicondylar area 1 cm above the PL femoral tunnel through the skin incision for the fixation of the bundle in order to prevent the graft from wrapping around the sheath. (C) Anteromedial (AM) bundle was fixed with Retroscrew at tibial articular side (left) and with 1 spiked washer screw outside the tibia. Hamstring autograft for PL bundle was seen at medial side of AM bundle with no fixation (arrow) (right). (D) Final view of the construct at 90° of flexion showing the PL bundle crossing the AM bundle from the back.

• 

  Fig. 4 Schematic view of double bundle reconstruction of anterior cruciate ligament with hybrid femoral fixation and Retroscrew.

Reference

1. Aglietti P, Buzzi R, Zaccherotti G, De Biase P. Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med. 1994. 22(2):211–217.

2. Kim SJ, Jung KA, Song DH. Arthroscopic double-bundle anterior cruciate ligament reconstruction using autogenous quadriceps tendon. Arthroscopy. 2006. 22(7):797.e1–797.e5.

3. Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o'clock and 10 o'clock femoral tunnel placement. 2002 Richard O'Connor Award paper. Arthroscopy. 2003. 19(3):297–304.

4. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002. 30(5):660–666.

5. Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy. 2004. 20(10):1015–1025.

6. Aglietti P, Giron F, Cuomo P, Losco M, Mondanelli N. Single- and double-incision double-bundle ACL reconstruction. Clin Orthop Relat Res. 2007. 454:108–113.

7. Muneta T, Koga H, Mochizuki T, et al. A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing singlebundle and double-bundle techniques. Arthroscopy. 2007. 23(6):618–628.

8. Muneta T, Sekiya I, Yagishita K, Ogiuchi T, Yamamoto H, Shinomiya K. Two-bundle reconstruction of the anterior cruciate ligament using semitendinosus tendon with endobuttons: operative technique and preliminary results. Arthroscopy. 1999. 15(6):618–624.

9. Hamada M, Shino K, Horibe S, et al. Single- versus bisocket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endobutton femoral fixation: a prospective study. Arthroscopy. 2001. 17(8):801–807.

10. Yamazaki S, Yasuda K, Tomita F, Minami A, Tohyama H. The effect of graft-tunnel diameter disparity on intraosseous healing of the flexor tendon graft in anterior cruciate ligament reconstruction. Am J Sports Med. 2002. 30(4):498–505.

11. Morgan CD, Stein DA, Leitman EH, Kalman VR. Anatomic tibial graft fixation using a retrograde bio-interference screw for endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 2002. 18(7):E38.

12. Reicher MA, Hartzman S, Duckwiler GR, Bassett LW, Anderson LJ, Gold RH. Meniscal injuries: detection using MR imaging. Radiology. 1986. 159(3):753–757.

13. Ahn JH, Cho YB, Lee JY. Second-look arthroscopy after ACL reconstruction: comparison of patellar tendon autografts with hamstring tendon autografts. J Korean Orthop Assoc. 2003. 38(2):159–164.

14. Kim SJ, Kim HK, Lee YT. Arthroscopic anterior cruciate ligament reconstruction using autogenous hamstring tendon graft without detachment of the tibial insertion. Arthroscopy. 1997. 13(5):656–660.

15. Edwards TB, Guanche CA, Petrie SG, Th omas KA. In vitro comparison of elongation of the anterior cruciate ligament and single- and dual-tunnel anterior cruciate ligament reconstructions. Orthopedics. 1999. 22(6):577–584.

16. Siebold R, Dehler C, Ellert T. Prospective randomized comparison of double-bundle versus single-bundle anterior cruciate ligament reconstruction. Arthroscopy. 2008. 24(2):137–145.

17. Kuhn MA, Ross G. Allografts in the treatment of anterior cruciate ligament injuries. Sports Med Arthrosc. 2007. 15(3):133–138.

18. Royalty RN, Junkin DM Jr, Johnson DL. Anatomic double-bundle revision anterior cruciate ligament surgery using fresh-frozen allograft tissue. Clin Sports Med. 2009. 28(2):311–326.

19. Lee JH, Bae DK, Song SJ, Cho SM, Yoon KH. Comparison of clinical results and second-look arthroscopy findings after arthroscopic anterior cruciate ligament reconstruction using 3 different types of grafts. Arthroscopy. 2010. 26(1):41–49.

20. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin North Am. 2010. 41(2):249–262.

21. Harilainen A, Sandelin J. A prospective comparison of 3 hamstring ACL fixation devices--Rigidfix, BioScrew, and Intrafix--randomized into 4 groups with 2 years of follow-up. Am J Sports Med. 2009. 37(4):699–706.

22. Kousa P, Jarvinen TL, Vihavainen M, Kannus P, Jarvinen M. The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part I: femoral site. Am J Sports Med. 2003. 31(2):174–181.

23. Han I, Kim YH, Yoo JH, Seong SC, Kim TK. Broken bioabsorbable femoral cross-pin after anterior cruciate ligament reconstruction with hamstring tendon graft: a case report. Am J Sports Med. 2005. 33(11):1742–1745.

24. Chang HC, Nyland J, Nawab A, Burden R, Caborn DN. Biomechanical comparison of the bioabsorbable RetroScrew system, BioScrew XtraLok with stress equalization tensioner, and 35-mm Delta Screws for tibialis anterior graft-tibial tunnel fixation in porcine tibiae. Am J Sports Med. 2005. 33(7):1057–1064.

25. Kubo T, Hara K, Suginoshita T, et al. Anterior cruciate ligament reconstruction using the double bundle method. J Orthop Surg (Hong Kong). 2000. 8(2):59–63.

26. Hara K, Kubo T, Suginoshita T, Shimizu C, Hirasawa Y. Reconstruction of the anterior cruciate ligament using a double bundle. Arthroscopy. 2000. 16(8):860–864.

27. Siebold R, Cafaltzis K. Differentiation between intraoperative and postoperative bone tunnel widening and communication in double-bundle anterior cruciate ligament reconstruction: a prospective study. Arthroscopy. 2010. 26(8):1066–1073.

28. Anderson CJ, Westerhaus BD, Pietrini SD, et al. Kinematic impact of anteromedial and posterolateral bundle graft fixation angles on double-bundle anterior cruciate ligament reconstructions. Am J Sports Med. 2010. 38(8):1575–1583.

29. Giron F, Cuomo P, Edwards A, Bull AM, Amis AA, Aglietti P. Double-bundle "anatomic" anterior cruciate ligament reconstruction: a cadaveric study of tunnel positioning with a transtibial technique. Arthroscopy. 2007. 23(1):7–13.

30. Taketomi S, Nakagawa T, Takeda H, et al. Anatomical placement of double femoral tunnels in anterior cruciate ligament reconstruction: anteromedial tunnel first or posterolateral tunnel first? Knee Surg Sports Traumatol Arthrosc. 2011. 19(3):424–431.