Summary

The study focuses on ribbon-like ACL reconstruction technique. Its' merits, key points and comprehensive three-year follow-up analysis backed up by the imaging diagnostics.

Abstract

Introduction

The paradigm of anterior cruciate ligament reconstruction (ACL-R) is undergoing changes. There are several techniques performed by the surgeons around the world, stirring much discussion.

Objective

This work is to present the outcomes of an original MARS ACL-R technique called the “ribbon technique” (ACL-RR), which is based on recent anatomical findings.

Methods

Eighty patients underwent a ribbon ACL-R with a central band of the quadriceps femoris (QF) tendon autograft. In 20 cases a pre-op CT scan was made. All patients had pre- and post-op MRI scans and bilateral X-Rays taken. The follow-up included physical examination at 3, 6, and 12 weeks and subsequently every 3 months up to 1 year, every 6 months after that. Follow-up MRIs were done at every 3 months post-op for a year, and then every 6 months. In 25 cases post-op CT scans were made (the post-op protocol was extended by a routine CT after several cases). The physical examination included: ROM assessment; oedema, swelling evaluation; pain (palpation); and instability tests, including Lachman and anterior drawer tests.

Results

In all cases the patients returned to their normal level of activity 6 months post-op. Structure-wise, there were no complications. A properly healing anatomical structure was restored with good graft ingrowth (CT&MRI). No anterior subluxation was recorded on MRIs. Tunnel widening was monitored on CTs, no significant changes recorded. Functionally, patients restored full range of motion, symmetrical stability in both lower limbs (negative Lachman and anterior drawer tests). Through proper physical therapy, monitored by the surgeon, patients achieved good to very good QF contraction 6 months post-op. No donor site morbidities.

Discussion

Recent years have brought to light new developments concerning the ACL’s structure. It has been previously assumed that the ligament consists of two bundles. However, more recent anatomical research concerning ACL anatomy, published in the last years, point out to a different concept. The results of cadaver studies indicate that, indeed, the ACL’s midsubstance, as well as its tibial and femoral footprints, are flat. Yet still, the way the flat, ribbon-like structure behaves while knee flexion and extension - the shift in ACL’s orientation, does create an illusion of a double-bundle structure. Therefore, we can in fact speak of functional bundles, but not structural ones. The newly-established ACL-R taking into account both the graft’s and tunnels’ anatomical shape and providing answers as to how to best restore it, shows very promising outcomes, especially with regard to the graft incorporation failure rate.

Conclusion

Ribbon technique provides great outcome, allowing patients to return to their normal lifestyle in short time.