The incidence of ligament injuries of the knee is on a rise. In providing quality arthroscopic treatments for complex knee ligament injuries, particularly in rural and semi-urban areas of India, important hurdles are the high cost of the procedures and lack of sophisticated options like allografts. To overcome these hurdles, we have developed some simple yet effective Implant-Free Reconstruction Techniques (IFRTs) where we minimize the use of implants as well as allografts for reconstruction of the ligaments around the knee.
We developed 4 different IFRTs that can be used for the reconstruction of the various ligaments of the knee. These techniques are mainly used to bypass implants for graft fixation at the graft-bone interface at least one end of the graft. The techniques include
1. Confluent tunnel technique for combined ACL and LCL reconstruction, combined PCL and MCL reconstruction, and combined ACL and ALL reconstruction where a confluent tunnel is used to bypass the fixations.
2. Suture bridge technique for the MPFL reconstruction where a bridge of sutures is used to bypass the fixation at the patellar side
3. Bone Bridge technique for the combined ACL reconstruction and meniscal root fixation, combined ACL, and ALL reconstruction, and isolated MCL reconstruction where a bridge of bone is used to bypass the fixation.
4. Cinch knot technique for the isolated LCL reconstruction where the cinch knot is used to bypass fixation at the fibular end. Biomechanical analysis of these techniques was done. Then, the techniques were followed in a consecutive set of non-athletic patients and the outcomes were noted. The cost-effectiveness of the techniques was also studied.
The biomechanical analysis in bovine models showed that all these techniques were comparable to the conventional techniques. We operated on 143 patients using these techniques (ACL+ALL reconstruction– 31, PCL+MCL reconstruction – 11, ACL+LCL reconstruction – 10, LCL reconstruction – 11, ACL reconstruction + meniscal root repair – 6, MPFL reconstruction – 74). The average follow-up period was 12 months (9 to 18 months). IFRTs reduced implant costs by 30% to 80% depending on the procedure. Cost per QALY was low when compared to traditional techniques. Patients showed good to excellent functional outcomes with Tegner Lysholm and Kujala scores, with no major complications. In multi-ligamentous injuries, IFRTs helped us minimize the use of grafts thereby avoiding the need for allografts. In smaller knees, IRFTs also helped us avoid problems of tunnel convergence and minimized the loss of bone stock due to the drilling of multiple tunnels.
IFRTs helped us minimize the cost and graft usage and preserve the bone stock. The short-term functional outcomes have been good with no significant complications. These simple techniques can be followed without the need for special instrumentations. However, longer-term follow-up and comparative studies are needed to validate these techniques further.