2015 ISAKOS Biennial Congress ePoster #1294
The Problem of Loss of Knee Extension After Anterior Cruciate Ligament Reconstruction With Remnant Preservation
Hiroshi Nakayama, MD, Nishinomiya, Hyogo JAPAN
Tomoya Iseki, MD. PhD., Nishinomiya, Hyogo JAPAN
Kaori Kashiwa, MD, Sasayama, Hyogo JAPAN
Shinichi Yoshiya, MD, Nishinomiya, Hyogo, Hyogo JAPAN
Hyogo College of Medicine, Nishinomiya, JAPAN
FDA Status Not Applicable
Summary: Extension loss due to excessive tissue proliferation anterior to the reconstructed graft was encountered more often when the remnant tissue was preserved. The results of this clinical review may indicate potential problem associated with excessive tissue preservation in ACL reconstruction.
Significance of preserving remnant ligamentous tissue in anterior cruciate ligament (ACL) reconstruction has been addressed in recent literatures. In our clinical practice, anatomic double-bundle hamstring reconstruction has been our procedure of principal choice and remnant ACL has been preserved attempt as much as possible when deemed possible. In reviewing our experience with this procedure modification, however, increased incidence of extension loss in early postoperative period (within 6 months after surgery) has been noted as a problem.
The purpose of this study was to investigate the incidence and clinical features of extension loss in patients who underwent anatomic double-bundle hamstring ACL reconstruction with remnant preservation.
Patients and Methods
One hundred and twentyfive consecutive patients who underwent unilateral anatomic double-bundle ACL reconstruction with semitendinousus tendon autograft from June 2011 to July 2013 constituted the basis of this study. During the study period, attempt was made to preserve the remnant tissue as much as possible; however, poor quality and volume of the remnant tissue hindered remnant preservation in some knees. Among the 125 subjects, remnant was preserved in 50 knees (preservation group) and preservation was not feasible in 75 knees (non-preservation group). The mean age at surgery was 26.6 years and 26.4 years respectively. During the procedure, sutures were applied to the proximal end of the remnant ACL (usually three stitches with absorbable monofilament sutures) using a suture hook. At passage of the anteromedial bundle ACL graft through the femoral bone tunnel, the sutures were pulled through the tunnel along with the tendon graft. Postoperative rehabilitation program was identical for both groups. Loss of extension was assessed by heel height difference (HHD). HHD was measured at 1, 2, 3, 6, 1Y months after surgery.
The average HHD values at 1, 2, 3, 6, 1Y months were 3.7 ± 3.4 cm, 1.9 ± 2.6 cm, 1.5 ± 1.9 cm, 1.1 ± 1.6cm, 0.8 ± 1.2cm and 0.6 ± 0.8cm respectively in the preservation group, while the corresponding values in the non-preservation group were 3.3 ± 3.8 cm, 1.5 ± 2.4 cm, 0.8 ± 1.6 cm, 0.4 ± 0.9cm and 0.3 ± 0.8cm respectively. The HHD value at 3 and 6 months were significantly larger in the preservation group (P=0.04 and P=0.01, respectively). Arthroscopic debridement due to extension loss with pain was required within 6 months in 6 knees (12.0%) in the preservation group and 3 knees (4.0%) in the non-preservation group. At the repeat arthroscopy, graft impingement at extension caused by anterior tissue proliferation was observed in those knees. The regenerative tissue appeared extending from the preserved tissue along the reconstructed graft.
There have been studies addressing advantages of remnant preservation in ACL reconstruction. Nevertheless, this study showed that extension loss due to excessive tissue proliferation anterior to the reconstructed graft was encountered more often when the remnant tissue was preserved. The results of this clinical review may indicate potential problem associated with excessive tissue preservation in ACL reconstruction. Reducing the volume of preserved tissue may help avoid the risk for this complication.