Clinical and Functional Outcomes of Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years Using Adjustable Suspensory Fixation in Both the Femur and Tibia: A Prospective Study

Philippe Colombet, Mo Saffarini, Nicolas Bouguennec, Philippe Colombet, Mo Saffarini, Nicolas Bouguennec

Abstract

Background: The success of anterior cruciate ligament (ACL) reconstruction requires reliable and rigid graft fixation. Cortical suspensory fixation (CSF) devices have become an acceptable alternative to interference screws for soft tissue ACL grafts. However, CSF devices have been reported to be associated with tunnel widening and increased postoperative anterior laxity compared with interference screw fixation. Adjustable CSF devices were introduced to avoid these problems but have been associated with graft lengthening and inconsistent outcomes.

Purpose: To (1) report the side-to-side difference (SSD) in anterior laxity at 150 N, clinical scores, and failure rates 2 years after ACL reconstruction with 4-strand semitendinosus autografts using an adjustable CSF device and (2) determine the preoperative factors associated with clinical outcomes.

Study design: Case-control study; Level of evidence, 3.

Methods: A total of 131 patients who had undergone primary ACL reconstruction, performed with 4-strand semitendinosus grafts that were secured using Pullup adjustable-length CSF devices with femoral and tibial fixation techniques, were prospectively enrolled in this study; 34 patients were excluded because of contralateral instability or ipsilateral knee injuries that required additional surgery. This left a cohort of 97 patients who were evaluated preoperatively and at 6, 12, and 24 months. The evaluation consisted of measuring the SSD in anterior laxity and patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Lysholm scores). Regression analyses were performed to determine associations between these outcomes and 9 preoperative variables.

Results: Only 2 patients could not be reached, 2 could not be evaluated because of contralateral ACL tears, and 2 had graft failure. At 2-year follow-up, the remaining 91 patients had a mean SSD in anterior laxity of 0.8 ± 1.8 mm (range, -4.2 to 5.3 mm), mean IKDC score of 87.6 ± 10.6 (range, 43.7-100.0), and mean Lysholm score of 90.8 ± 9.3 (range, 56.0-100.0). At final follow-up, compared with knees with partial ruptures, those with complete ruptures had equivalent laxity (P = .266) and Lysholm scores (P = .352) but lower IKDC scores (P = .009). Multivariable regression revealed that the IKDC score decreased with increased preoperative laxity (β = -1.35 [95% CI, -2.48 to -0.23]; P = .019).

Conclusion: The novel adjustable-length CSF device produced satisfactory anterior laxity and clinical outcomes, with a failure rate of 2.1%, which compare favorably with those reported for nonadjustable CSF devices.

Keywords: ACL repair; adjustable suspensory fixation; anterior cruciate ligament; hamstring autografts.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: P.C. receives royalties from SBM France. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.
Figure 1.
Flowchart of patients enrolled in the study.
Figure 2.
Figure 2.
Image of the GraftTech preparation station used to tension the graft and install it on the suspension device.
Figure 3.
Figure 3.
Drawing of the graft after installation.
Figure 4.
Figure 4.
Box plots indicating improvements in knee laxity and clinical scores at different follow-up visits. P values indicate the significance of overall trends (Kruskal-Wallis test) as well as differences between consecutive follow-up visits (Mann-Whitney test). Dots indicate outliers. SSD, side-to-side difference.
Figure 5.
Figure 5.
Bar charts indicating improvements in various subcomponents of the International Knee Documentation Committee (IKDC) score at different follow-up visits: A, normal (green); B, nearly normal (blue); C, abnormal (yellow); and D, severely abnormal (red).
Figure 6.
Figure 6.
Box plots comparing 2-year knee laxity and clinical scores for patients with partial or complete anterior cruciate ligament ruptures. P values indicate the significance of differences between the 2 groups (Mann-Whitney test). Dots indicate outliers. IKDC, International Knee Documentation Committee; SSD, side-to-side difference.

References

    1. Agrawal CM, Athanasiou KA. Technique to control pH in vicinity of biodegrading PLA-PGA implants. J Biomed Mater Res. 1997;38(2):105–114.
    1. Ahn JH, Bae TS, Kang KS, Kang SY, Lee SH. Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability. Am J Sports Med. 2011;39(10):2187–2193.
    1. Ali AA, Harris MD, Shalhoub S, Maletsky LP, Rullkoetter PJ, Shelburne KB. Combined measurement and modeling of specimen-specific knee mechanics for healthy and ACL-deficient conditions. J Biomech. 2017;57:117–124.
    1. Aunoble S, Clement D, Frayssinet P, Harmand MF, Le Huec JC. Biological performance of a new beta-TCP/PLLA composite material for applications in spine surgery: in vitro and in vivo studies. J Biomed Mater Res A. 2006;78(2):416–422.
    1. Austin PC, Steyerberg EW. The number of subjects per variable required in linear regression analyses. J Clin Epidemiol. 2015;68(6):627–636.
    1. Aydin D, Ozcan M. Evaluation and comparison of clinical results of femoral fixation devices in arthroscopic anterior cruciate ligament reconstruction. Knee. 2016;23(2):227–232.
    1. Barber FA, Dockery WD. Long-term absorption of beta-tricalcium phosphate poly-L-lactic acid interference screws. Arthroscopy. 2008;24(4):441–447.
    1. Basson B, Philippot R, Neri T, Meucci JF, Boyer B, Farizon F. The effect of femoral tunnel widening on one-year clinical outcome after anterior cruciate ligament reconstruction using ZipLoop(R) technology for fixation in the cortical bone of the femur. Knee. 2016;23(2):233–236.
    1. Bouguennec N, Odri GA, Graveleau N, Colombet P. Comparative reproducibility of TELOS and GNRB® for instrumental measurement of anterior tibial translation in normal knees. Orthop Traumatol Surg Res. 2015;101(3):301–305.
    1. Boyle MJ, Vovos TJ, Walker CG, Stabile KJ, Roth JM, Garrett WE., Jr Does adjustable-loop femoral cortical suspension loosen after anterior cruciate ligament reconstruction? A retrospective comparative study. Knee. 2015;22(4):304–308.
    1. Bressy G, Brun V, Ferrier A, et al. Lack of stability at more than 12 months of follow-up after anterior cruciate ligament reconstruction using all-inside quadruple-stranded semitendinosus graft with adjustable cortical button fixation in both femoral and tibial sides. Orthop Traumatol Surg Res. 2016;102(7):867–872.
    1. Browning WM, 3rd, Kluczynski MA, Curatolo C, Marzo JM. Suspensory versus aperture fixation of a quadrupled hamstring tendon autograft in anterior cruciate ligament reconstruction: a meta-analysis. Am J Sports Med. 2017;45(10):2418–2427.
    1. Buck DC, Simonian PT, Larson RV, Borrow J, Nathanson DA. Timeline of tibial tunnel expansion after single-incision hamstring anterior cruciate ligament reconstruction. Arthroscopy. 2004;20(1):34–36.
    1. Choi NH, Oh JS, Jung SH, Victoroff BN. Correlation between endobutton loop length and tunnel widening after hamstring anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41(1):101–106.
    1. Choi NH, Yang BS, Victoroff BN. Clinical and radiological outcomes after hamstring anterior cruciate ligament reconstructions: comparison between fixed-loop and adjustable-loop cortical suspension devices. Am J Sports Med. 2017;45(4):826–831.
    1. Collins NJ, Misra D, Felson DT, Crossley KM, Roos EM. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken). 2011;63(suppl 11):S208–S228.
    1. Colombet P, Bouguennec N. Suspensory fixation device for use with bone-patellar tendon-bone grafts. Arthrosc Tech. 2017;6(3):e833–e838.
    1. Colombet P, Graveleau N. An anterior cruciate ligament reconstruction technique with 4-strand semitendinosus grafts, using outside-in tibial tunnel drilling and suspensory fixation devices. Arthrosc Tech. 2015;4(5):e507–e511.
    1. Colombet P, Graveleau N, Jambou S. Incorporation of hamstring grafts within the tibial tunnel after anterior cruciate ligament reconstruction: magnetic resonance imaging of suspensory fixation versus interference screws. Am J Sports Med. 2016;44(11):2838–2845.
    1. Colombet P, Robinson J, Christel P, et al. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. Arthroscopy. 2006;22(9):984–992.
    1. Drogset JO, Grontvedt T, Myhr G. Magnetic resonance imaging analysis of bioabsorbable interference screws used for fixation of bone-patellar tendon-bone autografts in endoscopic reconstruction of the anterior cruciate ligament. Am J Sports Med. 2006;34(7):1164–1169.
    1. Eysturoy NH, Nissen KA, Nielsen T, Lind M. The influence of graft fixation methods on revision rates after primary anterior cruciate ligament reconstruction. Am J Sports Med. 2018;46(3):524–530.
    1. Firat A, Catma F, Tunc B, et al. The attic of the femoral tunnel in anterior cruciate ligament reconstruction: a comparison of outcomes of two suspensory femoral fixation systems. Knee Surg Sports Traumatol Arthrosc. 2014;22(5):1097–1105.
    1. Gaweda K, Walawski J, Weglowski R, Krzyzanowski W. Comparison of bioabsorbable interference screws and posts for distal fixation in anterior cruciate ligament reconstruction. Int Orthop. 2009;33(1):123–127.
    1. Gifstad T, Drogset JO, Grontvedt T, Hortemo GS. Femoral fixation of hamstring tendon grafts in ACL reconstructions: the 2-year follow-up results of a prospective randomized controlled study. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2153–2162.
    1. Gobbi A, Domzalski M, Pascual J, Zanazzo M. Hamstring anterior cruciate ligament reconstruction: is it necessary to sacrifice the gracilis? Arthroscopy. 2005;21(3):275–280.
    1. Gobbi A, Mahajan V, Karnatzikos G, Nakamura N. Single- versus double-bundle ACL reconstruction: is there any difference in stability and function at 3-year followup? Clin Orthop Relat Res. 2012;470(3):824–834.
    1. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med. 2012;40(3):512–520.
    1. Ibrahim SA, Abdul Ghafar S, Marwan Y, et al. Intratunnel versus extratunnel autologous hamstring double-bundle graft for anterior cruciate ligament reconstruction: a comparison of 2 femoral fixation procedures. Am J Sports Med. 2015;43(1):161–168.
    1. Ibrahim SA, Hamido F, Al Misfer AK, Mahgoob A, Ghafar SA, Alhran H. Anterior cruciate ligament reconstruction using autologous hamstring double bundle graft compared with single bundle procedures. J Bone Joint Surg Br. 2009;91(10):1310–1315.
    1. Jenny JY, Puliero B, Schockmel G, Harnoist S, Clavert P. Experimental validation of the GNRB® for measuring anterior tibial translation. Orthop Traumatol Surg Res. 2017;103(3):363–366.
    1. Johnston M, Morse A, Arrington J, Pliner M, Gasser S. Resorption and remodeling of hydroxyapatite-poly-L-lactic acid composite anterior cruciate ligament interference screws. Arthroscopy. 2011;27(12):1671–1678.
    1. Kamath GV, Redfern JC, Greis PE, Burks RT. Revision anterior cruciate ligament reconstruction. Am J Sports Med. 2011;39(1):199–217.
    1. Kamelger FS, Onder U, Schmoelz W, Tecklenburg K, Arora R, Fink C. Suspensory fixation of grafts in anterior cruciate ligament reconstruction: a biomechanical comparison of 3 implants. Arthroscopy. 2009;25(7):767–776.
    1. Kamien PM, Hydrick JM, Replogle WH, Go LT, Barrett GR. Age, graft size, and Tegner activity level as predictors of failure in anterior cruciate ligament reconstruction with hamstring autograft. Am J Sports Med. 2013;41(8):1808–1812.
    1. Lind M, Feller J, Webster KE. Bone tunnel widening after anterior cruciate ligament reconstruction using EndoButton or EndoButton continuous loop. Arthroscopy. 2009;25(11):1275–1280.
    1. Lorbach O, Kieb M, Domnick C, et al. Biomechanical evaluation of knee kinematics after anatomic single- and anatomic double-bundle ACL reconstructions with medial meniscal repair. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2734–2741.
    1. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012;28(4):526–531.
    1. Marchant MH, Jr, Willimon SC, Vinson E, Pietrobon R, Garrett WE, Higgins LD. Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18(8):1059–1064.
    1. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy. 2013;29(12):1948–1953.
    1. Mermerkaya MU, Atay OA, Kaymaz B, Bekmez S, Karaaslan F, Doral MN. Anterior cruciate ligament reconstruction using a hamstring graft: a retrospective comparison of tunnel widening upon use of two different femoral fixation methods. Knee Surg Sports Traumatol Arthrosc. 2015;23(8):2283–2291.
    1. 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;(9):CD005960.
    1. Morgan JA, Dahm D, Levy B, Stuart MJ. Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg. 2012;25(5):361–368.
    1. Muneta T, Koga H, Morito T, Yagishita K, Sekiya I. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction. Arthroscopy. 2006;22(3):252–258.
    1. Mutsuzaki H, Kanamori A, Ikeda K, Hioki S, Kinugasa T, Sakane M. Effect of calcium phosphate-hybridized tendon graft in anterior cruciate ligament reconstruction: a randomized controlled trial. Am J Sports Med. 2012;40(8):1772–1780.
    1. Ntagiopoulos PG, Demey G, Tavernier T, Dejour D. Comparison of resorption and remodeling of bioabsorbable interference screws in anterior cruciate ligament reconstruction. Int Orthop. 2015;39(4):697–706.
    1. Nye DD, Mitchell WR, Liu W, Ostrander RV. Biomechanical comparison of fixed-loop and adjustable-loop cortical suspensory devices for metaphyseal femoral-sided soft tissue graft fixation in anatomic anterior cruciate ligament reconstruction using a porcine model. Arthroscopy. 2017;33(6):1225–1232.
    1. Pereira H, Correlo VM, Silva-Correia J, Oliveira JM, Reis RL, Espregueira-Mendes J. Migration of “bioabsorbable” screws in ACL repair: how much do we know? A systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(4):986–994.
    1. Persson A, Gifstad T, Lind M, et al. Graft fixation influences revision risk after ACL reconstruction with hamstring tendon autografts. Acta Orthop. 2018;89(2):204–210.
    1. Persson A, Kjellsen AB, Fjeldsgaard K, Engebretsen L, Espehaug B, Fevang JM. Registry data highlight increased revision rates for endobutton/biosure HA in ACL reconstruction with hamstring tendon autograft: a nationwide cohort study from the Norwegian Knee Ligament Registry, 2004-2013. Am J Sports Med. 2015;43(9):2182–2188.
    1. Petre BM, Smith SD, Jansson KS, et al. Femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction: a comparative biomechanical study. Am J Sports Med. 2013;41(2):416–422.
    1. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind M. Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the Danish registry of knee ligament reconstruction. Am J Sports Med. 2014;42(2):278–284.
    1. Ryu SM, Na HD, Shon OJ. Diagnostic tools for acute anterior cruciate ligament injury: GNRB, Lachman test, and Telos. Knee Surg Relat Res. 2018;30(2):121–127.
    1. Sabat D, Kundu K, Arora S, Kumar V. Tunnel widening after anterior cruciate ligament reconstruction: a prospective randomized computed tomography–based study comparing 2 different femoral fixation methods for hamstring graft. Arthroscopy. 2011;27(6):776–783.
    1. Samuelsen BT, Webster KE, Johnson NR, Hewett TE, Krych AJ. Hamstring autograft versus patellar tendon autograft for ACL reconstruction: is there a difference in graft failure rate? A meta-analysis of 47,613 patients. Clin Orthop Relat Res. 2017;475(10):2459–2468.
    1. Sastre S, Popescu D, Nunez M, Pomes J, Tomas X, Peidro L. Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study. Knee Surg Sports Traumatol Arthrosc. 2010;18(1):32–36.
    1. Schurz M, Tiefenboeck TM, Winnisch M, et al. Clinical and functional outcome of all-inside anterior cruciate ligament reconstruction at a minimum of 2 years’ follow-up. Arthroscopy. 2016;32(2):332–337.
    1. Siebold R, Ellert T, Metz S, Metz J. Femoral insertions of the anteromedial and posterolateral bundles of the anterior cruciate ligament: morphometry and arthroscopic orientation models for double-bundle bone tunnel placement. A cadaver study. Arthroscopy. 2008;24(5):585–592.
    1. Smigielski R, Zdanowicz U, Drwiega M, Ciszek B, Williams A. The anatomy of the anterior cruciate ligament and its relevance to the technique of reconstruction. Bone Joint J. 2016;98-B(8):1020–1026.
    1. Sonnery-Cottet B, Saithna A, Cavalier M, et al. Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med. 2017;45(7):1547–1557.
    1. Stener S, Ejerhed L, Sernert N, Laxdal G, Rostgard-Christensen L, Kartus J. A long-term, prospective, randomized study comparing biodegradable and metal interference screws in anterior cruciate ligament reconstruction surgery: radiographic results and clinical outcome. Am J Sports Med. 2010;38(8):1598–1605.
    1. Streich NA, Friedrich K, Gotterbarm T, Schmitt H. Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc. 2008;16(3):232–238.
    1. Sun K, Zhang J, Wang Y, et al. Arthroscopic anterior cruciate ligament reconstruction with at least 2.5 years’ follow-up comparing hamstring tendon autograft and irradiated allograft. Arthroscopy. 2011;27(9):1195–1202.
    1. Trojani C, d’Ollonne T, Saragaglia D, Vielpeau C, Carles M, Prudhon JL. One-stage bilateral total hip arthroplasty: functional outcomes and complications in 112 patients. Orthop Traumatol Surg Res. 2012;98(suppl 6):S120–S123.
    1. Watson JN, McQueen P, Kim W, Hutchinson MR. Bioabsorbable interference screw failure in anterior cruciate ligament reconstruction: a case series and review of the literature. Knee. 2015;22(3):256–261.
    1. 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;22(2):100–110.
    1. Yang C, Tashiro Y, Lynch A, Fu F, Anderst W. Kinematics and arthrokinematics in the chronic ACL-deficient knee are altered even in the absence of instability symptoms. Knee Surg Sports Traumatol Arthrosc. 2018;26(5):1406–1413.
    1. Yasen SK, Borton ZM, Eyre-Brook AI, et al. Clinical outcomes of anatomic, all-inside, anterior cruciate ligament (ACL) reconstruction. Knee. 2017;24(1):55–62.

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