Anterior cruciate ligament rupture is one of the most common injuries in orthopedic sports trauma. The most common surgical treatment performed is arthroscopic anterior cruciate ligament (ACL) reconstructive surgery and the results are excellent. There are many issues and controversies related to anterior cruciate ligament reconstruction and are often a cause of dispute between surgeons. Common issues are as follows: operative indication, graft selection, femoral tunnel position, tibial tunnel position, tibia graft fixation method, anterolateral ligament reconstruction, and rehabilitation. The authors, along with other experts from different Asian countries, attended the Asian Consensus meeting of ACL recon- struction held last March 25, 2016. A survey was performed and arrived with the following results.
Keywords: Anterior cruciate ligament; Femoral tunnel; Graft selection; Outside in technique; Rehabilitation
A survey on anterior cruciate ligament reconstruction:
an Asian perspective
Jeong Ku Ha
1, Jin Goo Kim
2, Dal Jae Jun
1, Sang Bum Kim
1, Sung Tae Kim
1Departments of Orthopedic Surgery, 1Inje University Seoul Paik Hospital, 2Konkuk University Medical Center, Seoul, Korea
Copyright © 2016 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved.
CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received June 25, 2016; Revised July 1, 2016; Accepted July 1, 2016
Correspondence to: Jin Goo Kim, Department of Orthopedic Surgery, Konkuk University Medical Center, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea. Tel: +82-2-2030-7070, Fax: +82-2-2030-5009, E-mail: [email protected]
Arthroscopy and Orthopedic Sports Medicine
AOSM
INTRODUCTION
Injury of the anterior cruciate ligament (ACL) is among the most common sports injuries encountered by ortho- pedic surgeons. Reconstruction surgery is the gold stan- dard of treatment for these injuries, and the treatment has been shown to be associated with excellent clinical outcomes [1]. By contrast, recent anatomical and bio- mechanical studies related to ACL reconstruction have highlighted the pitfalls of current surgical techniques and the need for improvement. Active research and stimulat- ing discussions are currently underway with regards to ACL reconstruction with the aim to improve the surgical techniques and the clinical outcomes.
Issues relating to ACL reconstruction frequently arise and are of keen interest to the medical orthopedic com- munity. Examples of a few of the topical and controversial subjects regarding ACL reconstruction are surgical indi- cations for ACL reconstruction, the choice of graft, femo- ral tunnel placement, the method of femoral fixation, tibial tunnel placement, the method of tibial fixation, the anterolateral ligament (ALL), and the rehabilitation
process (weight-bearing exercises, joint exercises, and the use of knee braces). The authors compiled the results of a survey on current issues of ACL reconstruction by the participants of the Asian Consensus Meeting held on March 25, 2016. Participants of the meeting comprised current and retired medical doctors from around Asia. We present the results of the survey here. A total of ten ortho- pedic specialists responded to the survey, and the medi- cal specialist who participated in the survey are listed follows as: Myung Chul Lee (Seoul National University Hospital), Sang Hak Lee (Kyung Hee University Hospital at Gangdong), Patrick Yung (Chinese University of Hong Kong), Feng Hua (Beijing Jishuitan Hospital), Chong Bum Chang (SNU Boramae Medical Center), Kyoung Ho Yoon (Kyung Hee University Medical Center), Jin Goo Kim (Konkuk University Medical Center), Nobuo Adachi (Hiroshima University), Andri Rubis (University of Indo- nesia), Jin whan Ahn (Kangbuk Samsung Hospital).
RESULTS OF SURVEILLANCE
Question 1. Graft selection (ten responses) 1. Semitendinosus + gracilis (autograft): 7 2. Semitendinosus only (autograft): 2 3. Bone-patellar tendon-bone (autograft): 0 4. Quadriceps tendon (autograft): 1 5. Allograft: 0
Most respondents said that their ideal choice of graft for ACL reconstruction was the hamstring autograft. Only one replied as using the quadriceps as their first line of choice. Since most of the survey participants were from Asia, none responded as using the bone-patella tendon- bone autograft (Fig. 1).
Question 2. Graft bundle (ten responses) 1. Single bundle: 6
2. Double bundle: 1
3. Single + sometimes double: 2 4. Double + sometimes single: 1
In terms of graft bundle preference, six respondents replied that they use only the single bundle, and four replied that they use only the double bundle. The survey data suggests that among our survey participants the single bundle is more often used than the double bundle (Fig. 2).
Question 3. The approach technique (ten responses) 1. Transtibial: 3
2. Transportal: 5 3. Outside-in: 2
A recent direction towards a consensus regarding the optimal placement of femoral tunnels has led clinicians to favor positioning the femoral tunnels in the anatomi- cal foot print. Our survey results are reflective of this change in trend because our respondents in general pre- ferred using the transportal approach or the outside-in method over the traditional transtibial technique (Fig. 3).
Question 4. Femoral tunnel fixation methods (ten responses)
1. Suspension device: 8 2. RigidFix: 0
3. Suspention device + RigidFix: 1 4. Interference screws: 1
Most of the survey respondents replied as using the suspension device as their preferred method of femoral
Fig. 1. The majority of respondents use autologous tendon as their choice of graft selection.
2. Semitendinosus only (autograft): 2
3. Bone-patellar tendon-bone (autograft): 0
4. Quadriceps tendon (autograft): 1 5. Allograft: 0
1. Semitendinosus + gracilis (autograft): 7
Fig. 2. The proportion of graft bundles used in anterior cruciate ligament reconstruction.
2. Double bundle: 1 3. Single + sometimes
double: 2
4. D +
single: 1
ouble sometimes
1. Single bundle: 6
Fig. 3. The proportion of techniques used for femoral tunnel drilling.
2. Transportal: 5
1. Transtibial: 3 3. Outside-in: 2
tunnel fixation. Graft selection is directly intertwined with the procedural aspects of the surgical approach for ACL re- construction. For instance, when hamstring autografts are used for either the transportal approach or the outside-in method, it necessitates the use of a suspension device. Ac- cordingly, for our survey participants whose major choice of graft is the hamstring autograft method, the suspension device is the major device employed for femoral tunnel fixation.
Question 5. Tibial tunnel fixation method (ten responses) 1. Aperture fixation + post-tie: 7
2. Aperture fixation only: 2 3. Post-tie only: 1
Our survey data show that most respondents use fixa- tion methods that use interference screws, such as the aperture fixation method. Among those who replied as using the aperture fixation for tibial tunnel placement, the majority said they made additional fixations.
Question 6. The postoperative period at which range of motion (ROM) is begun (ten responses)
1. As early as possible, or immediately: 9 2. At the 1st postoperative week: 0 3. At the 2nd postoperative week: 0 4. At the 3rd postoperative week: 1
We found that postoperative ROM was implemen ted immediately or as early as possible after the surgery in all respondents save one.
Question 7. The period at which postoperative, full ROM exercises are implemented (eight responses) 1. At the 1st postoperative week: 1
2. At the 4th postoperative week: 2 3. At the 6th postoperative week: 2 4. At the 8th postoperative week: 2 5. On the 6th postoperative month: 1
Of all the questions, the response to this question was most heterogeneous, implying that the period at which full ROM is commenced lacks a definite consensus.
Question 8. Immediate postoperative weight-bearing ambulation (ten responses)
1. Immediate full weight-bearing: 3 2. Gradual full weight-bearing: 7
Our survey results show that the majority of respon- dents (seven out of ten) replied that full weight-bearing was achieved gradually, whereas three respondents
replied it was achieved immediately after the ACL recon- struction.
Question 9. The postoperative period at which full weight bearing ambulation is commenced (nine responses) 1. As soon as possible: 4
2. Full weight bearing at 2 weeks: 1 3. Full weight bearing at 4 weeks: 3 4. Full weight bearing at 6 weeks: 1
Like the response to question 8, the response to ques- tion 9 was heterogeneously distributed. The results of this question provide qualitative information concerning how those who employ gradual full weight bearing regulate the timing.
Question 10. How long are the rehabilitative braces, either the knee brace or the splint, administered?
(All respondents said their medical institution use the knee brace.) (nine responses)
1. 3 weeks: 1 2. 6 weeks: 5 3. 8 weeks: 2 4. 12 weeks: 1
All respondents replied that they administer postopera- tive knee braces to all patients after ACL reconstruction.
And the duration of brace administration was varied: the survey results show that in general braces are used for 6 to 8 weeks during the rehabilitation.
Question 11. Concerning the preservation of remnant, all the respondents said they tend to preserve the ACL remnant. And the majority said they leave as much remnant in the tibial insertion area as possible.
Direct quotations from respondent replies:
“Try to preserve the remnant start drilling wire smaller drill.”
“Principal concept is to preserve remnant as much as possible. Only very thin scar remnant is removed for bet- ter visualization of the attachment.”
“Remove only femoral insertion that was located in my preferred femoral tunnel.”
“Preserve the tibial remnant as much as possible, but given that it is not affecting the preparation of the tunnels at the anatomical footprint, as well not causing any risk of impingement or loose tissue later on”
“Only about 10% to 15%. Mainly anteromedial (AM) bundle reconstruction with preservation of relatively in- tact posterolateral (PL) bundle sometimes preserve tibial
remnant if the remnant looks healthy. Incise the tibial remnant and performs reconstruction with usual man- ner.”
“Preserve the remaining ACL at tibial insertion area as much as possible. Femoral insertion: Preserve if the fiber firmly insert into footprint. Remove torn fiber to expose bony femoral footprint landmark.”
“The bridging of the remnant bundle between the fe- mur and the tibia, the thickness of ACL exceeding more than 50% of that of AM bundle or PL bundle and a laxity of less than 5 mm when drawn by a probe.”
Question 12. The criteria to return to sports suggested by survey respondents (Table 1)
Question 13. When asked whether they agreed or disagreed to performing direct fiber reconstruction [2,3], 75% of respondents agreed and 25%, disagreed.
Table 1. The criteria for return to sports suggested by survey respondents
Physician Criteria
1 -At the 10th postoperative month -Graft should be stabilized.
-Restored muscle function after testing with Biodex (quadriceps and hamstring) -A normal ROM
-A satisfactory functional evaluation (for example, jogging, pivoting, long jumping, and high jumping) 2 Dependent on the outcomes of various scales (Lysholm, IKDC, and Tegner scores)
Physician 2 suggests that the outcomes of the tests below should not be greater than 20% than the normal value before the patient is allowed to return to sports.
-Telos stress X-ray -KT-1000 arthrometer -Biodex isokinetic test
-One leg hop, FPT (functional performance test) 3 -Outcome scales (Lysholm, HSS, IKDC, Tegner)
-Telos device -BTE isokinetic test
4 -A good ROM
-Absence of pain
-At the 6 postoperative month
5 -At least an 80% recovery of the flexor and extensor muscle function as evaluated on Cybex isokinetic device 6 - After 9th postoperative months
-When muscle strength of the affected side is at least over 80% of that of the healthy contralateral side.
- Physician 6 noted that they periodically check the stability and the proprioceptive functions after surgery. Yet, they also noted that these results have no bearing on the timing of the return to sports.
7 -A full ROM, especially full extension must be achieved.
-An absence of pain and swelling
-Normal results on Lachman and KT-1000/2000 tests -A normal IKDC score
-Isokinetic muscle tests show quadriceps and hamstring functions are at least 80% of the normal contralateral side.
-A HQ ratio of no less than 0.7
-Good proprioception as determined through objective assessments (leg repositioning and balance master) -Good results on functional tests (single leg hoop, triple leg hoop, and carioca)
8 -A full ROM, especially full extension must be achieved.
-An absence of pain and swelling
-Normal results on Lachman and KT-1000/2000 tests -A normal IKDC score
-Isokinetic muscle tests show quadriceps and hamstring functions are at least 80% of the normal contralateral side.
-A HQ ratio of no less than 0.7
-Good proprioception as determined through objective assessments (leg repositioning and balance master) -Good results on functional tests (single leg hoop, triple leg hoop, and carioca)
ROM, range of motion; IKDC, International Knee Documentation Committee; HSS, Hospital for Special Surgery; HQ, hamstring quadriceps.
Question 14. When asked whether they agreed to performing ALL reconstruction [4–6], 67% of respondents agreed and 33%, disagreed.
When respondents were asked in the event an acute ACL tear was combined with a second fracture under what kind of situations they would chose to proceed with the operation. The respondents replied that they would per- form the operation for revision reconstruction ACL or if the professional athlete showed a pivot shifting of more than Grade III.
Question 13. Following the question concerning the femoral tunnel placement, we asked the respondents to mark where they would insert the tunnel on a schematic illustration, which was included in the survey, depicting a lateral intercondylar ridge and a bifurcate ridge on the medial wall of the femur lateral condyle (Fig. 4). In gen- eral, the respondents drew the tunnel between the antero-
medial bundle and the PL bundle or slightly towards the AM bundle.
Question 14. Following the question of tibial tunnel placement, we asked respondents to indicate the posi- tion where they would insert the tunnel on a schematic drawing of the ACL footpint. Most respondents drew the tunnel in the center of the ACL foot print or slightly pos- teriorly (Fig. 5).
DISCUSSION
No other topic in orthopedics has sparked a debate as vibrant as that sparked by ACL reconstruction. This is not only because ACL injury is one of the most common injuries encountered by orthopedic surgeons but also be- cause the surgical outcomes of ACL reconstruction have not reached the stage of being satisfactory; thus, the area
Fig. 4. The femoral tunnel positions were marked by survey respondents. A representative response with regards to the placement of the femoral tunnel was that the tunnel is positioned either between the anteromedial (AM) bundle and posterolateral (PL) bundle or between the two bundles but slightly more towards the AM bundle.
Lateral intercondylar ridge
Bifurcate ridge AM
PL
AM PL
AM PL
AM PL AM
PL AM
PL Lateral intercondylar ridge
Bifurcate ridge
AM PL Lateral intercondylar ridge
Bifurcate ridge
AM PL
of ACL reconstruction requires more research to be done.
Debates on the types of surgical method stimulate and propagate the anatomical and biomechanical studies on ACL reconstruction and vice versa. Also, the develop- ments in surgical tools such as fixation instruments have corresponded to the advancement of surgical methods of ACL reconstruction. With the advent of the anatomical concept of ACL reconstruction, the concept of isometric reconstruction became less commonplace among physi- cians. As such, the outside-in method and the transportal method have replaced to some extent the preceding transtibial method, which used fixation devices such as interference screws. Accordingly, various types of suspen- sion fixation methods have now replaced the conserva- tive methods [7].
New approaches have been proposed in response to increasing concerns regarding the limitations of the
traditional isometric reconstruction, such as the non- anatomical placement of femoral tunnels and rotational instability. Of the various novel approaches, the two most widely accepted are the anatomical reconstruction, and the double bundle reconstruction. However, there is lack of consensus as to whether the double bundle recon- struction provides a more superior clinical outcome than the single bundle reconstruction. In addition, in direct comparison to the traditional double bundle concept of ACL [8], novel concepts of ACL anatomy such as the concepts of direct and indirect fibers [3] and of ribbon shaped-anatomy [9] have been proposed. These new concepts may either be corroborated and accepted or be questioned and counter-argued by prospective studies.
As such, depending on the outcome of those refutations the methods of ACL reconstruction may also evolve over time.
Fig. 5. The survey respondents positioned the tibia tunnel either in the center of the anterior cruciate ligament foot print or slightly posterior to it. AM, anteromedial; PL, posterolateral.
AM
*
PL AM*
PL AM*
PLPL PL
*
AM
*
*
PLAM
*
PL AM*
PL AM*
PLNumerous studies have investigated the rehabilitation of ACL reconstruction with interesting findings. Factors that influence the aspects of rehabilitation include graft selection, fixation method, tunnel placement, and etc.
Also, rehabilitation tends to be closely influenced by sur- gery-related factors. For instance, reconstruction using bone-patella tendon-bone autografts facilitates an early fixation, thereby, accelerating rehabilitation. Reconstruc- tion using hamstring grafts has also advanced to the stage where early fixation has become feasible as a result in the development of fixation instruments. In this way, the time of rehabilitation has gradually decreased over time.
With the emphasis placed on an anatomical reconstruc- tion for an injured ACL, the position of the femoral tunnel has switched to a more distal position than previously; it has been shown that this change increases the angle that forms between the graft and tunnel [10]. An increased angle between the graft and tunnel has been shown to compromise the integrity of the graft; therefore, this questions whether the expedited rehabilitative procedure that has worked for traditional methods can be applied to the modified anatomical approach with the same clini- cal outcomes. Further, a side-effect of using suspension fixation is an expanded femoral tunnel. In accordance to the increased trend in the use of suspension fixation, prospective studies should investigate what effects an expanded femoral tunnel have on the rehabilitation pro- cess.
The issue of ALL is one of the current controversial top- ics [11]. Reconstruction of the intraarticular ACL alone is insufficient to overcome rotational instability in ACL
injury. Debates on ALL reconstruction uniformly high- light the fact that concomitant injury of the ALL must be affirmed. And numerous anatomical and biomechanical studies have suggested that its functional restoration is key to achieve rotational stability and for the pivot shift phenomenon [12,13]. Further, novel surgical instruments have been devised for ALL reconstruction, and the clini- cal outcomes after their use have been reported [14]. In this survey, two thirds of respondents agreed to the need to reconstruct ALL. Prospective studies are anticipated to delineate and resolve controversial issues that still remain in this field.
The results of this survey are based on answers from a limited number of participants; thus, it is difficult to say they have significant implications or significant repre- sentative power. Still, we believe that our survey results provide some insight into current trends since the re- spondents are eminent, leading researchers in their fields from across Asia. In the future, by taking advantage of meetings such as the Asian Consensus Meeting where a specific subset of potential survey participants can be attained effectively and in an administratively simple method, we anticipate that the results of those surveys will elucidate trending topics of interest that is mean- ingful, characteristics, and specific to the Asian medical population.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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