A Novel Graft Preparation Technique of the Quadriceps Tendon for Arthroscopic Double-Bundle Anterior Cruciate Ligament Reconstruction Sang Eun Park, M.D., and Yujin Ko
Abstract: Surgical reconstruction is a general approach for an anterior cruciate ligament rupture. Techniques have evolved from single-bundle to double-bundle reconstruction to restore the 2 anatomically and functionally different bundles as much as possible. However, there is controversy regarding which method yields superior clinical outcomes. The purpose of this article is to introduce our new graft preparation method, which will potentially address the limitations of currently available double-bundle anterior cruciate ligament reconstruction procedures using the quadriceps tendon. The proximal portion of the graft is preserved in our method, instead of completely being split into 2 distinct graft bundles as previously suggested. We believe that the preserved portion can act as a biofunctional “safety circuit” in case of overloading and also help some synergistic actions of the 2 bundles.
T
he anterior cruciate ligament (ACL) consists of 2 distinct bundles: anteromedial (AM) and posterolateral (PL).1 Studies have shown different functions of the bundles,2 and therefore surgical techniques have been developed to reconstruct 2 functional bundles more closely in cases of an ACL rupture. Despite the theoretic benefits of the double-bundle reconstruction, there is controversy regarding the superiority of the technique in comparison to the previously accepted single-bundle reconstruction.3-5 To further examine this technique, double-bundle ACL reconstruction was performed by use of the quadriceps tendon, without separation of the proximal portion of the tendon. The purpose of this report is to introduce a new graft preparation technique of the quadriceps tendon in double-bundle ACL reconstruction to ensure better clinical outcomes.
From the Department of Orthopaedic Surgery, Dongguk University International Hospital (S.E.P.), Ilsan, Republic of Korea; and the School of Medicine, University of Queensland (Y.K.), St. Lucia, Queensland, Australia. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received January 7, 2013; accepted February 13, 2013. Address correspondence to Sang Eun Park, M.D., Department of Orthopaedic Surgery, Dongguk University International Hospital, 814 Siksadong, Ilsandonggu, Goyangsi, Gyeonggido 411-773, Republic of Korea. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/1320/$36.00 http://dx.doi.org/10.1016/j.eats.2013.02.004
Case Report A 43-year-old male patient presented with left knee pain, which began 2 weeks earlier. While playing volleyball, he jumped and landed on another player’s foot, which resulted in a rotational knee injury. On physical examination, the range of motion was normal but the left knee showed effusion and joint-line tenderness. Results of the anterior drawer test, Lachman test, and pivot-shift test were all positive; thus an ACL rupture was suspected. According to the radiograph, the left tibia showed 4.4 mm of anterior translation with respect to the femur, at 30 lb with the KT-2000 arthrometer (MEDmetric, San Diego, CA). An ACL tear at the femur attachment site was confirmed by the presence of discontinuity on magnetic resonance imaging. Double-bundle ACL reconstruction was performed with a quadriceps tendonepatellar bone autograft. A novel graft preparation was performed to restore the normal biomechanical function of the ligament.
Surgical Technique The patient was placed in a supine position, and 3 portals were made on the knee, at the anterolateral, central, and medial aspects of the joint. Diagnostic arthroscopy was performed, and a probe was then used to confirm a complete rupture of the ACL without other associated pathology. A shaver was used to completely remove the remaining ligament. Native insertion sites of the AM and PL bundles were marked with a thermal device.
Arthroscopy Techniques, Vol 2, No 3 (August), 2013: pp e197-e200
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Table 1. Tips for ACL Double-Bundle Reconstruction With New Quadriceps Tendon Graft Preparation Technique Description Quadriceps tendon layers Graft splitting
AM tendon Central portal
All 4 layers should be harvested, including the vastus intermedius tendon. The vastus intermedius tendon was used as the PL bundle in the past; however, it was not sufficient to withstand overloading. Instead, the conjoined tendon of all 4 layers should be split into the AM bundle, with a diameter of 8 mm, and the PL bundle, with a diameter of 7 mm. The AM bundle forms an acute angle when entering through the tibial tunnel, and thus the bundle should be trimmed to maintain the smoothness. The central portal should be widened by 1.5 cm before graft passage to provide a sufficient space for the proximal bone plug. In addition, maximal flexion is required while the arthroscopic view is maintained during the graft passage. The suture at the bone plug should be pulled slowly, and by doing so, the graft can be easily placed in the required position.
The surgeon made a 4-cm incision at the distal femur and harvested the quadriceps tendonepatellar bone. All 4 layers of the quadriceps tendon were used, giving a sufficient depth of 13 mm, with a width of 10 mm and length of 130 mm (Table 1). The patellar bone plug with a length of 25 mm, width of 10 mm, and depth of 10 mm was also harvested in a continuous form. The orientation of the graft was switched such that the bone plug would fit into the femoral insertion site. The patellar bone plug end was marked with a pen and the other ends were split longitudinally into 2 bundles, whereas the 15-mm-long proximal portion was preserved (Fig 1). All 3 free ends were sutured, and the split ends were trimmed to provide the AM and PL bundles with diameters of 8 mm and 7 mm, respectively. The defect at the donor site and the incision site were sutured at the same time. A femoral tunnel was made at the center of the AM and PL bundle insertion sites with a half-retractor laterally placed to prevent any femoral condylar damage. The tunnel was reamed to a depth of 25 mm, allowing a patellar bone plug passage. A Beath pin (Arthrex, Naples, FL) was passed through the femoral tunnel, and a suture loop was retrieved from the central portal. Separate AM and PL tibial tunnels were then drilled at the native femoral and tibial insertion sites, and their suture loops were also retrieved from the central portal. The sutures of the AM and PL bundles were passed through their suture loops and were pulled slowly from the tibial tunnels, such that the bundles could be placed in the tunnels. The bone plug was placed in the femoral tunnel in the same manner. An interference screw was drilled to ensure bone fixation at the femur. To maintain the tensile strength, the AM bundle graft was fixed while the knee was flexed at 45 , whereas the PL graft was fixed in the fully extended knee. A probe was used to confirm that there was no impingement. Video 1 demonstrates the technique.
double-bundle reconstruction, which will potentially address the limitations of the previous double-bundle procedures. Studies have identified that the ACL consists of 2 distinct bundles, which are the AM and PL bundles according to their tibial insertion sites.1 The roles of the 2 bundles are yet to be clearly defined. However, it is generally understood that the AM bundle mainly resists anterior translation of the tibia whereas the PL bundle has an important role in controlling rotation of the tibia.2 Surgical procedures have constantly evolved to optimally restore normal function and anatomy of the ACL
Discussion The main purpose of this report is to introduce a new graft preparation technique of the quadriceps tendon in
Fig 1. The graft is split into 2 bundles; however, 15 mm of the proximal portion is preserved intact.
QUADRICEPS PREPARATION FOR ACL RECONSTRUCTION
Fig 2. Schema of graft. The straight lines indicate sutures at each free end, and the arrow shows the workload redistribution route when overloading occurs in the PL bundle. (A, patellar bone plug; AM, anteromedial bundle; B, intact portion acting as biofunctional safety circuit; PL, posterolateral bundle.)
in cases of a rupture. A single-bundle technique was first introduced, and recently, a double-bundle reconstruction technique was developed. For example, Muller et al.2 suggested a double-bundle ACL reconstruction technique using the quadriceps tendon with a bone plug, which involves a complete splitting of the graft tendon into 2 distinct bundles: AM and PL. According to Petersen et al.,6 the double-bundle reconstruction could more effectively restore anterior laxity, as well as graft forces, to the intact level under an anterior tibial load, when compared with the singlebundle reconstruction. Moreover, Tashman et al.7 reported that the single-bundle reconstruction could not optimally restore normal rotational knee kinematics. Therefore a double-bundle reconstruction technique may provide superior clinical outcomes. However, there is no general consensus as to which procedure yields better outcomes. Numerous studies have been conducted to date, and the results seem inconclusive. Some report that the double-bundle
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technique is superior,4,5 whereas others suggest that there is no significant difference.3 In addition, Seon et al.5 found that overloading could occur in the PL bundle in a double-bundle reconstruction. The controversy surrounding the procedures may be partly because of this overloading, which could lead to weakness and an eventual rupture of the PL bundle in the long-term. Hence we developed a new graft preparation technique, as shown in Fig 2. The proximal portion of the bundle graft is preserved, whereas the distal part is split into 2 to provide the anatomic double-bundle structure of the ligament. It is predicted that when overloading occurs in the PL bundle, the intact portion would act as a biofunctional “safety circuit” and serve as a redistribution route. Therefore the AM bundle would share the PL bundle’s workload. Recent studies suggest that the functions of the 2 bundles are not always distinct but they can also work synergistically. The PL bundle also contributes to resisting tibial anterior translation at low flexion angles (0 to 30 ), supporting the AM bundle. In full extension, both bundles become taut.2 Further studies also suggest that the ACL can be divided into more than 2 bundles. Kato et al.8 divided the ACL into intermediate, AM, and PL bundles and claimed that the intermediate bundle assists both the AM and PL bundles through all flexion angles against a rotatory load. The studies mentioned earlier further support our hypothesis that having 2 bundles that are completely separate would not yield better outcomes. The long-term effects and the full extent of advantages and disadvantages of our novel procedure are yet to be evaluated. However, we believe that our graft preparation method would provide a better clinical outcome, because it can provide an ACL reconstruction that resembles the normal anatomy to a greater degree in comparison to outcomes provided by current techniques.
References 1. Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 1991;73: 260-267. 2. Muller B, Hofbauer M, Wongcharoenwatana J, Fu FH. Indications and contraindications for double-bundle ACL reconstruction. Int Orthop 2013;37:239-246. 3. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and doublebundle reconstruction. Am J Sports Med 2012;40:1781-1788. 4. Li X, Xu CP, Song JQ, Jiang N, Yu B. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: An up-to-date meta-analysis. Int Orthop 2013;37:213-226. 5. Seon JK, Gadikota HR, Wu JL, Sutton K, Gill TJ, Li G. Comparison of single- and double-bundle anterior cruciate ligament reconstructions in restoration of knee kinematics
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and anterior cruciate ligament forces. Am J Sports Med 2010;38:1359-1367. 6. Petersen W, Tretow H, Weimann A, et al. Biomechanical evaluation of two techniques for double-bundle anterior cruciate ligament reconstruction: One tibial tunnel versus two tibial tunnels. Am J Sports Med 2007;35:228-234.
7. Tashman S, Kolowich P, Collon D, Anderson K, Anderst W. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res 2007;454:66-73. 8. Kato Y, Ingham SJ, Maeyama A, et al. Biomechanics of the human triple-bundle anterior cruciate ligament. Arthroscopy 2012;28:247-254.
Abstract: Surgical reconstruction is a general approach for an anterior cruciate ligament rupture. Techniques have evolved from single-bundle to double-bundle reconstruction to restore the 2 anatomically and functionally different bundles as much as possible. However, there is controversy regarding which method yields superior clinical outcomes. The purpose of this article is to introduce our new graft preparation method, which will potentially address the limitations of currently available double-bundle anterior cruciate ligament reconstruction procedures using the quadriceps tendon. The proximal portion of the graft is preserved in our method, instead of completely being split into 2 distinct graft bundles as previously suggested. We believe that the preserved portion can act as a biofunctional “safety circuit” in case of overloading and also help some synergistic actions of the 2 bundles.
T
he anterior cruciate ligament (ACL) consists of 2 distinct bundles: anteromedial (AM) and posterolateral (PL).1 Studies have shown different functions of the bundles,2 and therefore surgical techniques have been developed to reconstruct 2 functional bundles more closely in cases of an ACL rupture. Despite the theoretic benefits of the double-bundle reconstruction, there is controversy regarding the superiority of the technique in comparison to the previously accepted single-bundle reconstruction.3-5 To further examine this technique, double-bundle ACL reconstruction was performed by use of the quadriceps tendon, without separation of the proximal portion of the tendon. The purpose of this report is to introduce a new graft preparation technique of the quadriceps tendon in double-bundle ACL reconstruction to ensure better clinical outcomes.
From the Department of Orthopaedic Surgery, Dongguk University International Hospital (S.E.P.), Ilsan, Republic of Korea; and the School of Medicine, University of Queensland (Y.K.), St. Lucia, Queensland, Australia. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received January 7, 2013; accepted February 13, 2013. Address correspondence to Sang Eun Park, M.D., Department of Orthopaedic Surgery, Dongguk University International Hospital, 814 Siksadong, Ilsandonggu, Goyangsi, Gyeonggido 411-773, Republic of Korea. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/1320/$36.00 http://dx.doi.org/10.1016/j.eats.2013.02.004
Case Report A 43-year-old male patient presented with left knee pain, which began 2 weeks earlier. While playing volleyball, he jumped and landed on another player’s foot, which resulted in a rotational knee injury. On physical examination, the range of motion was normal but the left knee showed effusion and joint-line tenderness. Results of the anterior drawer test, Lachman test, and pivot-shift test were all positive; thus an ACL rupture was suspected. According to the radiograph, the left tibia showed 4.4 mm of anterior translation with respect to the femur, at 30 lb with the KT-2000 arthrometer (MEDmetric, San Diego, CA). An ACL tear at the femur attachment site was confirmed by the presence of discontinuity on magnetic resonance imaging. Double-bundle ACL reconstruction was performed with a quadriceps tendonepatellar bone autograft. A novel graft preparation was performed to restore the normal biomechanical function of the ligament.
Surgical Technique The patient was placed in a supine position, and 3 portals were made on the knee, at the anterolateral, central, and medial aspects of the joint. Diagnostic arthroscopy was performed, and a probe was then used to confirm a complete rupture of the ACL without other associated pathology. A shaver was used to completely remove the remaining ligament. Native insertion sites of the AM and PL bundles were marked with a thermal device.
Arthroscopy Techniques, Vol 2, No 3 (August), 2013: pp e197-e200
e197
e198
S. E. PARK AND Y. KO
Table 1. Tips for ACL Double-Bundle Reconstruction With New Quadriceps Tendon Graft Preparation Technique Description Quadriceps tendon layers Graft splitting
AM tendon Central portal
All 4 layers should be harvested, including the vastus intermedius tendon. The vastus intermedius tendon was used as the PL bundle in the past; however, it was not sufficient to withstand overloading. Instead, the conjoined tendon of all 4 layers should be split into the AM bundle, with a diameter of 8 mm, and the PL bundle, with a diameter of 7 mm. The AM bundle forms an acute angle when entering through the tibial tunnel, and thus the bundle should be trimmed to maintain the smoothness. The central portal should be widened by 1.5 cm before graft passage to provide a sufficient space for the proximal bone plug. In addition, maximal flexion is required while the arthroscopic view is maintained during the graft passage. The suture at the bone plug should be pulled slowly, and by doing so, the graft can be easily placed in the required position.
The surgeon made a 4-cm incision at the distal femur and harvested the quadriceps tendonepatellar bone. All 4 layers of the quadriceps tendon were used, giving a sufficient depth of 13 mm, with a width of 10 mm and length of 130 mm (Table 1). The patellar bone plug with a length of 25 mm, width of 10 mm, and depth of 10 mm was also harvested in a continuous form. The orientation of the graft was switched such that the bone plug would fit into the femoral insertion site. The patellar bone plug end was marked with a pen and the other ends were split longitudinally into 2 bundles, whereas the 15-mm-long proximal portion was preserved (Fig 1). All 3 free ends were sutured, and the split ends were trimmed to provide the AM and PL bundles with diameters of 8 mm and 7 mm, respectively. The defect at the donor site and the incision site were sutured at the same time. A femoral tunnel was made at the center of the AM and PL bundle insertion sites with a half-retractor laterally placed to prevent any femoral condylar damage. The tunnel was reamed to a depth of 25 mm, allowing a patellar bone plug passage. A Beath pin (Arthrex, Naples, FL) was passed through the femoral tunnel, and a suture loop was retrieved from the central portal. Separate AM and PL tibial tunnels were then drilled at the native femoral and tibial insertion sites, and their suture loops were also retrieved from the central portal. The sutures of the AM and PL bundles were passed through their suture loops and were pulled slowly from the tibial tunnels, such that the bundles could be placed in the tunnels. The bone plug was placed in the femoral tunnel in the same manner. An interference screw was drilled to ensure bone fixation at the femur. To maintain the tensile strength, the AM bundle graft was fixed while the knee was flexed at 45 , whereas the PL graft was fixed in the fully extended knee. A probe was used to confirm that there was no impingement. Video 1 demonstrates the technique.
double-bundle reconstruction, which will potentially address the limitations of the previous double-bundle procedures. Studies have identified that the ACL consists of 2 distinct bundles, which are the AM and PL bundles according to their tibial insertion sites.1 The roles of the 2 bundles are yet to be clearly defined. However, it is generally understood that the AM bundle mainly resists anterior translation of the tibia whereas the PL bundle has an important role in controlling rotation of the tibia.2 Surgical procedures have constantly evolved to optimally restore normal function and anatomy of the ACL
Discussion The main purpose of this report is to introduce a new graft preparation technique of the quadriceps tendon in
Fig 1. The graft is split into 2 bundles; however, 15 mm of the proximal portion is preserved intact.
QUADRICEPS PREPARATION FOR ACL RECONSTRUCTION
Fig 2. Schema of graft. The straight lines indicate sutures at each free end, and the arrow shows the workload redistribution route when overloading occurs in the PL bundle. (A, patellar bone plug; AM, anteromedial bundle; B, intact portion acting as biofunctional safety circuit; PL, posterolateral bundle.)
in cases of a rupture. A single-bundle technique was first introduced, and recently, a double-bundle reconstruction technique was developed. For example, Muller et al.2 suggested a double-bundle ACL reconstruction technique using the quadriceps tendon with a bone plug, which involves a complete splitting of the graft tendon into 2 distinct bundles: AM and PL. According to Petersen et al.,6 the double-bundle reconstruction could more effectively restore anterior laxity, as well as graft forces, to the intact level under an anterior tibial load, when compared with the singlebundle reconstruction. Moreover, Tashman et al.7 reported that the single-bundle reconstruction could not optimally restore normal rotational knee kinematics. Therefore a double-bundle reconstruction technique may provide superior clinical outcomes. However, there is no general consensus as to which procedure yields better outcomes. Numerous studies have been conducted to date, and the results seem inconclusive. Some report that the double-bundle
e199
technique is superior,4,5 whereas others suggest that there is no significant difference.3 In addition, Seon et al.5 found that overloading could occur in the PL bundle in a double-bundle reconstruction. The controversy surrounding the procedures may be partly because of this overloading, which could lead to weakness and an eventual rupture of the PL bundle in the long-term. Hence we developed a new graft preparation technique, as shown in Fig 2. The proximal portion of the bundle graft is preserved, whereas the distal part is split into 2 to provide the anatomic double-bundle structure of the ligament. It is predicted that when overloading occurs in the PL bundle, the intact portion would act as a biofunctional “safety circuit” and serve as a redistribution route. Therefore the AM bundle would share the PL bundle’s workload. Recent studies suggest that the functions of the 2 bundles are not always distinct but they can also work synergistically. The PL bundle also contributes to resisting tibial anterior translation at low flexion angles (0 to 30 ), supporting the AM bundle. In full extension, both bundles become taut.2 Further studies also suggest that the ACL can be divided into more than 2 bundles. Kato et al.8 divided the ACL into intermediate, AM, and PL bundles and claimed that the intermediate bundle assists both the AM and PL bundles through all flexion angles against a rotatory load. The studies mentioned earlier further support our hypothesis that having 2 bundles that are completely separate would not yield better outcomes. The long-term effects and the full extent of advantages and disadvantages of our novel procedure are yet to be evaluated. However, we believe that our graft preparation method would provide a better clinical outcome, because it can provide an ACL reconstruction that resembles the normal anatomy to a greater degree in comparison to outcomes provided by current techniques.
References 1. Amis AA, Dawkins GP. Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br 1991;73: 260-267. 2. Muller B, Hofbauer M, Wongcharoenwatana J, Fu FH. Indications and contraindications for double-bundle ACL reconstruction. Int Orthop 2013;37:239-246. 3. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and doublebundle reconstruction. Am J Sports Med 2012;40:1781-1788. 4. Li X, Xu CP, Song JQ, Jiang N, Yu B. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: An up-to-date meta-analysis. Int Orthop 2013;37:213-226. 5. Seon JK, Gadikota HR, Wu JL, Sutton K, Gill TJ, Li G. Comparison of single- and double-bundle anterior cruciate ligament reconstructions in restoration of knee kinematics
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S. E. PARK AND Y. KO
and anterior cruciate ligament forces. Am J Sports Med 2010;38:1359-1367. 6. Petersen W, Tretow H, Weimann A, et al. Biomechanical evaluation of two techniques for double-bundle anterior cruciate ligament reconstruction: One tibial tunnel versus two tibial tunnels. Am J Sports Med 2007;35:228-234.
7. Tashman S, Kolowich P, Collon D, Anderson K, Anderst W. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res 2007;454:66-73. 8. Kato Y, Ingham SJ, Maeyama A, et al. Biomechanics of the human triple-bundle anterior cruciate ligament. Arthroscopy 2012;28:247-254.
