Anterior cruciate ligament reconstruction using double hamstrings tendon graft and the femoral fixation by Rigidifix®: preliminary Study

Abstracts

O autor descreve a técnica de reconstrução do LCA no tratamento das instabilidades anterior do joelho, utilizando os tendões dos músculos flexores mediais do joelho (semitendíneo e grácil), fixados no fêmur pelo sistema de Rigidfix®; e na tíbia, com parafuso de interferência absorvível, através de um estudo preliminar de 54 joelhos operados. Na avaliação final pela escala de Lysholm os pacientes evoluíram de 46 pontos no pré-operatório para 92 pontos no pós-operatório.

Ligamento cruzado anterior; Joelho; Reconstrução

ORIGINAL ARTICLE

Anterior cruciate ligament reconstruction using double hamstrings tendon graft and the femoral fixation by Rigidifix^® - Preliminary Study

Carlos Alberto Cury Faustino

Orthopaedist Doctor

^{Correspondence}

SUMMARY

The author describes the reconstruction technique of the anterior cruciate ligament reconstruction using the hamstrings tendon (semitendinosus and gracilis) in the management of anterior instabilities of the knee joint. Rigidfix^® system is used to fix the graft on the femur and an absorbable interference screw was used for tibial fixation in a preliminary study in 54 knees.

The final evaluation based on Lysholm score showed an improvement from 46 (preoperative) to 92 (postoperative).

Keywords: Anterior cruciate ligament; Knee; Reconstruction.

INTRODUCTION

Reconstruction techniques of the anterior cruciate ligament (ACL) have been continuously improved. The ideal graft and fixation method, however, have not yet been defined.

Several intraarticular substitutes of ACL have been described, including autologous, heterologous, and synthetic grafts. As for autologous grafts authors have given their preference for the central third of the patellar ligament ^{(1, 4,12)}, and triple semitendinosus, and semitendinosus and gracilis tendons ^{(3,7,11,16,17)}. Their advantages and disadvantages have been described and evaluated elsewhere.

Another important and widely discussed point ^{(10, 15)} is the graft fixation method.

The present study does not aim to evaluate long-term results for the surgical technique. It is a preliminary study.

MATERIAL AND METHODS

From October 2001 to October 2002, 54 knee joints from 54 patients were submitted to ACL reconstruction with tendons of the medial flexor muscles of the knee joint (semitendinosus, gracilis) fixed on the femur with the Rigidfix^® system and on the tibia with an absorbable interference screw at the Orthoservice in São José dos Campos, SP.

Fifty male and four female patients aged 16 to 50 years (mean age: 27 years) were included into the study. The right and the left knee joints were operated in 30 and 24 cases, respectively.

Surgery was carried out through the arthroscopic route and the following associated lesions were found: medial meniscus in 34; lateral meniscus in 7; both menisci in 5; femoral chondral lesion in 4. Isolated lesion of the anterior cruciate ligament was found in only 4 cases.

SURGICAL TECHNIQUE

Following conventional procedures of knee joint surgery, a 4-cm incision of skin and subcutaneous cellular tissue was performed on the anteromedial face of the proximal third of the affected leg as posterior as possible from insertion of the tendon of medial flexor muscles. The following steps were carried out: careful dissection and identification of tendons of semitendinosus and gracilis muscles; repair and disinsertion through a tendon extractor. Tendons were prepared on the accessory table and were put one on the other; tendons were then folded over a Ethibond^® 5 thread. Two stitches were made with Vicril^® 0 1 cm away from the proximal end of grafts so as to allow insertion of Rigidfix^® pins through the graft (Figure 1).

Associated intrinsecal lesions were treated and ACL rests were excised through the conventional triangulaton route for arthroscopic procedures of the knee joint.

Tibial and femoral tunnels were performed at the anatomical points of origin and insertion of the ACL. The diameter of these tunnels were equal to that of the graft.

With the appropriate femoral guide we inserted the Rigidfix^® guide-pins through two perforations from the outside to the inside of the tunnel (Figure 2).

The graft was inserted from tibia to femur where it was fixed with two pins of Rigidfix^®. Pretensioning was carried out in situ. Tibial fixation was performed with an absorbable interference screw of a diameter equal to or, when needed, greater than that of the tunnel with the knee joint in extension (Figure 3).

Conventional joint stability tests were carried out, a drainage tube was inserted and kept in place for 24 h, surgical wound was closed, and brace-type immobilization was used.

Partial load was allowed 24 h following hospital discharge, and isometric and flexion-extension exercises were carried out from the 4th postoperative day on.

Stitches are removed 15 days following surgery and patients are referred to specialized clinics for a rehabilitation program.

RESULTS

All 54 patients were operated and followed by the author. Follow-up ranged from 6 to 18 months (mean follow-up: 12 months).

Preoperative evaluation showed a score of 46 upon Lysholm scale versus 92 following surgery. The following results were obtained: excellent in 28 knee joints (52%), good in 20 knee joints (37%), regular in 4 knee joints (7%), and poor in 2 knee joints (4%).

The following complications developed: a superficial infection that was resolved with specific antibiotic therapy in one case; graft rupture following an accidental fall in one case five months after surgery; a decrease in the last flexion 15° in two cases; and pain upon physical exercises in two cases.

A poor result was obtained in two cases with instability recurrence due to accidental fall in one case and progressive loosening of the graft and corresponding symptoms.

In cases where magnetic resonance imaging was used, an excellent pattern of images was obtained with few artifacts. Therefore, a detailed analysis of all joint structures was possible. The same is not true for patients in whom metallic fixation is used (Figures 4 and 5).

DISCUSSION

The quadruple graft of medial flexor muscles of the knee (semitendinosus and gracilis) has been increasingly used due to complications developed with the use of the central third of the patellar ligament. Biomechanical studies have shown that the physical behavior of both grafts is similar.

In 1980 Puddu⁽¹³⁾ was the first to use the tendons of medial flexor muscles. In our country, Gomes e Marczyk⁽⁵⁾ used this graft in 1981.

Camanho and Olivi⁽²⁾ used a similar technique with Endobutton^® fixation on the femur in 1996.

Krause et al⁽⁹⁾. suggested the use of pretensioning to reduce the Endobuttonâ system elasticity in 1998.

In 2001 Severino et al⁽¹⁴⁾ and col. published a similar technique as far as graft use is concerned.

They used, however, "BoneMuch^®" screw for femoral fixation and "WasherLoc^® for tibial fixation with good results.

In a preliminary study Zekcer et al⁽¹⁸⁾ and col. used a similar technique also in 2001. However, they used the Transfixâ method to fix the graft on the femur with good results.

Gali et al⁽⁶⁾ described the quadruple use of tendons of the medial flexor muscles of the knee and fixation with metallic interference screws with excellent results in 2002.

The technique recommending the use of Rigidfix^® for femoral fixation uses two pins across the graft and femoral tunnel while the Transfixâ system uses only one pin and requires a longer training.

This technique prevents the risk for fracture of the posterior cortical of the femur.

However, it can still occur when the central third of the patellar ligament is fixed with interference screws.

In addition, one must take into account the decrease in the "windshield wiper effect"⁽⁶⁾ associated with the Endobutton^® system since the Rigidfix^® system fixes the femoral graft transversally and "in situ", thus preventing mobility between the graft end and the fixation system.

We believe that the absorbable interference screw on tibia can lead to loosening of the set. Therefore, whenever possible, we use a screw of a greater diameter than that of the tibial tunnel.

The success rate of surgery was similar to that reported in literature ^(2,6,14,18).

Rehabilitation can be more aggressive as described by Howell and Gottilieb⁽⁸⁾ due to less painful condition following surgery and less morbidity in the donor area.

CONCLUSIONS

The present study showed that the use of Rigidfix^® for tendon fixation with no interface between elements in the femur led to 92% of excellent and good results, low rates of complications, a low learning curve, good visualization of joint structures upon magnetic resonance imaging, as necessary.

REFERÊNCIAS BIBLIOGRÁFICAS

Trabalho recebido em 02/02/2003.

Aprovado em 10/08/2004

Work performed at the Orthoservice – Orthopedic Emergency Room

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Publication Dates

• Publication in this collection
  01 Mar 2005
• Date of issue
  Dec 2004

History

• Received
  02 Feb 2003
• Accepted
  10 Aug 2004