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Autologous Hamstring Anterior Cruciate Ligament Graft Failure Using the Anteromedial Portal Technique With Suspensory Femoral Fixation: A Case Series of 7 Patients.

Galdi B, Reyes A, Brabston EW, Levine WN - Orthop J Sports Med (2015)

Bottom Line: The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint.Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition.The final patient sustained a rerupture 10 months after being cleared to play.

View Article: PubMed Central - PubMed

Affiliation: Rutgers New Jersey Medical School, Newark, New Jersey, USA.

ABSTRACT

Background: The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint. Furthermore, suspensory fixation of soft tissue grafts has become popularized because of complications associated with cross-pin fixation. Concerns regarding the use of both have recently arisen.

Purpose: To raise awareness of the increased risk of graft failure when using the anteromedial portal technique with suspensory femoral fixation during ACL reconstruction.

Study design: Cohort study; Level of evidence, 3.

Methods: From November 1998 to August 2012, a total of 465 primary ACL reconstructions were performed using quadrupled hamstring autograft tendons, with drilling of the femoral tunnel performed via the transtibial portal. Graft fixation on the femur was achieved with cross-pin fixation, while interference screw fixation was used on the tibia. From September 2012 to October 2013, there were 69 reconstructions performed through an anteromedial portal. While there was no change in graft choice, a change was made to using suspensory femoral fixation. No other surgical or postoperative rehabilitation changes were made.

Results: During the 14-year period in which ACL reconstructions were performed via the transtibial portal and with cross-pin fixation, 2 graft failures (0.4% failure rate) were reported. After switching to the anteromedial portal with suspensory fixation, 7 graft failures (10.1% failure rate) were reported over a 13-month period. These were 5 male and 2 female patients, with a mean age of 18.8 years-all elite athletes. The same surgical technique was used in all patients, and all patients had at least an 8 mm-diameter graft. Patients were cleared to return to sport at an average of 8.4 months postoperatively, after completing functional performance tests. Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition. The final patient sustained a rerupture 10 months after being cleared to play.

Conclusion: Compared with the transtibial technique with cross-pin graft fixation, there is an increased risk of graft failure when performing autologous hamstring ACL reconstructions using the anteromedial portal technique with cortical suspensory fixation.

No MeSH data available.


Related in: MedlinePlus

Images taken during (A) initial surgery and (B) second-look arthroscopy 6 months later on a patient who underwent anteromedial anterior cruciate ligament reconstruction with suspensory femoral soft tissue fixation. Significant fraying of the anterolateral fibers of the graft was noted at second surgery.
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fig1-2325967114566599: Images taken during (A) initial surgery and (B) second-look arthroscopy 6 months later on a patient who underwent anteromedial anterior cruciate ligament reconstruction with suspensory femoral soft tissue fixation. Significant fraying of the anterolateral fibers of the graft was noted at second surgery.

Mentions: We performed a second-look arthroscopy during a separate procedure on a 36-year-old woman who had undergone anteromedial ACL reconstruction with cross-pin fixation 6 months prior but did not rupture her graft. Although the majority of the graft was intact, there was significant fraying of the lateral fibers of the graft (Figure 1). This was likely the result of impingement of the graft on the inferior aspect of the lateral wall. However, during the initial procedure, the lateral wall was debrided so that after graft passage, there was no impingement of the graft after careful examination in both full flexion and extension. It is interesting to note that of the 7 graft failures, 6 occurred within the first 2 weeks that patients were cleared to return to all sporting activities. All 7 graft failures underwent revision ACL reconstruction by the senior author, and all were noted to have a midsubstance tear with a component of lateral wall hypertrophy at the time of their second surgery. Although all patients demonstrated objective signs of healing on physical examination along with successful completion of functional evaluation tests, all failures likely had fraying of the graft similar to that described above, which predisposed them to rerupture. Given that 2 variables were changed, it is difficult to isolate the exact root of the drastically increased failure rate. We believe that the cause is multifactorial and a combination of both technical changes. While neither cross-pin fixation nor suspensory fixation is aperture fixation, the distance from the point of fixation to the intra-articular portion of the graft is significantly more with suspensory fixation, leading to increased graft motion. Our hypothesis as to the increased failure rate is as follows. Since the femoral tunnel is placed further down at the 2 or 10 o’clock position with the anteromedial technique, the graft is significantly closer to the lateral wall than when drilled transtibial. Even if no impingement is noted intraoperatively, the graft is situated within millimeters of the wall. As a result of graft motion and tunnel widening associated with suspensory fixation, there is movement of the graft into a position of lateral wall impingement that may be exacerbated by lateral wall hypertrophy. Repetitive impingement subsequently results in fraying of the graft fibers, causing an alteration in its mechanical properties and resulting in decreased load to failure. While this may not be apparent on clinical examination and functional testing, graft rupture occurs when patients return to high-demand pivoting activities.


Autologous Hamstring Anterior Cruciate Ligament Graft Failure Using the Anteromedial Portal Technique With Suspensory Femoral Fixation: A Case Series of 7 Patients.

Galdi B, Reyes A, Brabston EW, Levine WN - Orthop J Sports Med (2015)

Images taken during (A) initial surgery and (B) second-look arthroscopy 6 months later on a patient who underwent anteromedial anterior cruciate ligament reconstruction with suspensory femoral soft tissue fixation. Significant fraying of the anterolateral fibers of the graft was noted at second surgery.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License 1 - License 2 - License 3
Show All Figures
getmorefigures.php?uid=PMC4555582&req=5

fig1-2325967114566599: Images taken during (A) initial surgery and (B) second-look arthroscopy 6 months later on a patient who underwent anteromedial anterior cruciate ligament reconstruction with suspensory femoral soft tissue fixation. Significant fraying of the anterolateral fibers of the graft was noted at second surgery.
Mentions: We performed a second-look arthroscopy during a separate procedure on a 36-year-old woman who had undergone anteromedial ACL reconstruction with cross-pin fixation 6 months prior but did not rupture her graft. Although the majority of the graft was intact, there was significant fraying of the lateral fibers of the graft (Figure 1). This was likely the result of impingement of the graft on the inferior aspect of the lateral wall. However, during the initial procedure, the lateral wall was debrided so that after graft passage, there was no impingement of the graft after careful examination in both full flexion and extension. It is interesting to note that of the 7 graft failures, 6 occurred within the first 2 weeks that patients were cleared to return to all sporting activities. All 7 graft failures underwent revision ACL reconstruction by the senior author, and all were noted to have a midsubstance tear with a component of lateral wall hypertrophy at the time of their second surgery. Although all patients demonstrated objective signs of healing on physical examination along with successful completion of functional evaluation tests, all failures likely had fraying of the graft similar to that described above, which predisposed them to rerupture. Given that 2 variables were changed, it is difficult to isolate the exact root of the drastically increased failure rate. We believe that the cause is multifactorial and a combination of both technical changes. While neither cross-pin fixation nor suspensory fixation is aperture fixation, the distance from the point of fixation to the intra-articular portion of the graft is significantly more with suspensory fixation, leading to increased graft motion. Our hypothesis as to the increased failure rate is as follows. Since the femoral tunnel is placed further down at the 2 or 10 o’clock position with the anteromedial technique, the graft is significantly closer to the lateral wall than when drilled transtibial. Even if no impingement is noted intraoperatively, the graft is situated within millimeters of the wall. As a result of graft motion and tunnel widening associated with suspensory fixation, there is movement of the graft into a position of lateral wall impingement that may be exacerbated by lateral wall hypertrophy. Repetitive impingement subsequently results in fraying of the graft fibers, causing an alteration in its mechanical properties and resulting in decreased load to failure. While this may not be apparent on clinical examination and functional testing, graft rupture occurs when patients return to high-demand pivoting activities.

Bottom Line: The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint.Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition.The final patient sustained a rerupture 10 months after being cleared to play.

View Article: PubMed Central - PubMed

Affiliation: Rutgers New Jersey Medical School, Newark, New Jersey, USA.

ABSTRACT

Background: The anteromedial portal technique for drilling of the femoral tunnel during anterior cruciate ligament (ACL) reconstruction has been advocated by many surgeons as allowing improved access to the anatomical footprint. Furthermore, suspensory fixation of soft tissue grafts has become popularized because of complications associated with cross-pin fixation. Concerns regarding the use of both have recently arisen.

Purpose: To raise awareness of the increased risk of graft failure when using the anteromedial portal technique with suspensory femoral fixation during ACL reconstruction.

Study design: Cohort study; Level of evidence, 3.

Methods: From November 1998 to August 2012, a total of 465 primary ACL reconstructions were performed using quadrupled hamstring autograft tendons, with drilling of the femoral tunnel performed via the transtibial portal. Graft fixation on the femur was achieved with cross-pin fixation, while interference screw fixation was used on the tibia. From September 2012 to October 2013, there were 69 reconstructions performed through an anteromedial portal. While there was no change in graft choice, a change was made to using suspensory femoral fixation. No other surgical or postoperative rehabilitation changes were made.

Results: During the 14-year period in which ACL reconstructions were performed via the transtibial portal and with cross-pin fixation, 2 graft failures (0.4% failure rate) were reported. After switching to the anteromedial portal with suspensory fixation, 7 graft failures (10.1% failure rate) were reported over a 13-month period. These were 5 male and 2 female patients, with a mean age of 18.8 years-all elite athletes. The same surgical technique was used in all patients, and all patients had at least an 8 mm-diameter graft. Patients were cleared to return to sport at an average of 8.4 months postoperatively, after completing functional performance tests. Of the 7 patients, 6 sustained a rerupture of the graft within 2 weeks of returning to full competition. The final patient sustained a rerupture 10 months after being cleared to play.

Conclusion: Compared with the transtibial technique with cross-pin graft fixation, there is an increased risk of graft failure when performing autologous hamstring ACL reconstructions using the anteromedial portal technique with cortical suspensory fixation.

No MeSH data available.


Related in: MedlinePlus