A NEW APPROACH TO ARTHROSCOPIC AUTOPLASTY OF ANTERIOR CRUCIATE LIGAMENT AFTER TRAUMATIC INJURY

A NEW APPROACH TO ARTHROSCOPIC AUTOPLASTY OF ANTERIOR CRUCIATE LIGAMENT AFTER TRAUMATIC INJURY

Leonova S.N., Monastyrev V.V., Ponomarenko N.S.

  Irkutsk Research Center of Surgery and Traumatology, Irkutsk, Russia 

A traumatic injury to the anterior cruciate ligament of the knee joint is common for individuals of active life-style, and for sportsmen, mainly of young age. Currently, the anterior cruciate ligament is recovered with arthroscopic plasty with use of various grafts. The importance of the problem of treatment of injuries to the anterior cruciate ligament is determined by the incidence of the injury and by presence of poor outcomes.
Despite of improvements in arthroscopic autoplasty techniques for the anterior cruciate ligament, some postsurgical problems can remain including persistent pain, joint inflammation, residual instability, contracture, the joint’s function disordering, ruptures and detachment of the autograft. According to our opinion, there are some objective causes leading to poor outcomes.
Realization of arthroscopic autotendinous plasty for the anterior cruciate ligament includes the formation of the autograft with the sizes, which are possible due to sizes of the taken tendon. Then, one or another technique of arthroscopic plasty is carried out with consideration of parameters of the autograft. However, this tendon can be insufficient for formation of optimal autograft, especially in cases with thinness and fraying of tendon ends [1]. Moreover, fixation of the autograft in bone channels can be insufficiently dense, resulting in accumulation of synovial fluid in the channel, disorder of the process of integration, and detachment of the autograft [2].
The improvement in results of arthroscopic autoplasty of the anterior cruciate ligament is possible only with use of precise individual calculations of length and thickness of the autograft for each patient.
Objective – to show the clinical example of the procedure and the result of individual approach to arthroscopic autoplasty of the anterior cruciate ligament after its traumatic injury.
The study corresponded to the ethical principles and the standards of the laws of the Russian Federation. The patient gave the written consent for publishing the clinical case.

CLINICAL CASE

A patient, male, age of 35, addressed to Irkutsk Research Center of Surgery and Traumatology. The diagnosis was: “Old complete laceration of anterior cruciate ligament, of medial meniscus of left knee joint. Gonarthrosis of degree 2 to the left. Anterior instability of left knee joint of degree 3. Extensive contracture of left knee joint. Pain syndrome”.
The patient complained of pain in his left knee which intensified during physical load, as well as of the feeling of knee instability, and impossibility of appropriate use of the left lower extremity.
The history of the disease was as described below. He received a sports injury on August, 2013. He turned his left ankle and felt sharp pain in the knee joint. The patient addressed to the first-aid station. X-ray imaging of the knee joint was conducted, and it did not find any bone injuries. The patient received the conservative treatment. It gave some positive effects, but he could not use his left lower extremity to the full degree. On May 24, 2017, he suffered from a recurrent home injury after turning his left ankle. In the first-aid station, the left knee puncture was performed, and hemorrhagic contents were removed. MRI showed a complete laceration of the left anterior cruciate ligament (Fig. 1).

Figure 1. MRI-appearance of complete rupture of anterior cruciate ligament

The surgical treatment with use of the new approach was recommended (a technique of arthroscopic plasty for anterior cruciate ligament with the autograft: the application for invention of RF, No.2019123703, 22 July, 2019). On April 18, 2018, the patient was admitted to the trauma orthopedics unit of Irkutsk Research Center of Surgery and Traumatology. The patient could move without additional supports and was lame in his left leg. The examination of the left knee joint showed the clean skin, and smoothed contours of the joint. There was no edema. Palpation supposed the pain in the plane of articular cavity which was stronger along medial surface. There were weak positive Baykov, Steinmann and Perelman’s symptoms. Palpation of articular facet of the patella was painful. The ligamentous component was associated with anterior drawer sign, Lachman’s test ++++, negative posterior drawer sign, negative symptoms of external and internal swing. The movements in the left knee joint: flexion/extension 110/0/0, pain in end positions; to the right – 140/0/0. Axial load was painful. There were not any vascular, motor or sensitive disorders in distal parts of the extremities.
The X-ray images of the left knee joint showed gonarthrosis of degree 2 without bone pathology (Fig. 2).

Figure 2. X-ray images of left knee before surgery: a) frontal view; b) lateral view

After the clinical radiologic examination, the surgical treatment was initiated: arthroscopic plasty of the anterior cruciate ligament of the left knee joint with use of the autograft. Arthroscope (lookout angle – 30 degrees) was introduced into the left knee joint cavity through two standard parapatellar approaches in aseptic conditions in supine position under spinal anesthesia. The examination of the joint cavity identified the following: chondromalacia (degree 2) of the patella and adjacent surface of the hip; smooth chondromalacia of the loaded surface of medial and lateral condyles of degree 2; a complete rupture of the anterior cruciate ligament with its detachment from the femoral bone; positive (++++) anterior drawer sign under spinal anesthesia, longitudinal flapped injury to the posterior horn of medial meniscus with a floating edge and entrapment; intact posterior cruciate ligament and lateral meniscus. Partial and modeling resection of the injured part of medial meniscus was completed. The intercondylar space was prepared with corneoscleral punches. The cold-plasma ablator was used for removal of the stump of the injured anterior cruciate ligament.
Then a new approach for the arthroscopic stage of plasty for the anterior cruciate ligament was used (Fig. 3). The points of adherence of the ligament to the femoral and tibial bones were marked. Before taking the autotendons, the arthroscopic estimation of required length of the autograft was performed for compliance with individual sizes of the anterior cruciate ligament in this patient. The required thickness of the autograft was measured with the length of distance between medial and lateral intercondylar tubercles of tibial intermediate eminence. It was 10.5 mm. With arthroscopic medial approach and the guide, the end-to-end channel (diameter of 2.4 mm) was made in the tibia. It ended in the end of adherence of the anterior cruciate ligament. The tibial bone channel was used for measurement of intraarticular distance from the point of adherence of the anterior cruciate ligament to the tibia to the point of adherence to the femoral bone (15 mm). Then the reverse burr was used for formation of the channel (length – 30 mm, diameter – 10 mm) for fixation of the autograft in the tibia from the adherence to the anterior cruciate ligament to the tibia. With use of the guide and the reverse burr, the femoral end-to-end channel was formed from the point of adherence of the anterior cruciate ligament to the femoral bone to fix the autograft (length – 25mm, diameter – 10 mm). The following values were summed during calculation of the required length of the autograft: the distance between the points of adherence of the anterior cruciate ligament to the tibia and the femoral bone (15 mm), the length of drilled bone channels for fixation of the autograft (30 mm and 25 mm). 5 millimeters were subtracted from this sum; it was the distance of possible extension of the autograft during its tension and fixation in bone channels. Therefore, the required length of the autograft was 65 mm for that patient.

Figure 3. The scheme of surgical restoration of anterior cruciate ligament of knee joint: 1 – femoral bone; 2 – tibial bone; 3 – a point of fixation of anterior cruciate ligament to femoral bone; 4 –  a point of fixation of anterior cruciate ligament to tibial bone; 5 – medial intercondylar tubercle of intercondylar eminence of tibial bone; 6 – lateral intercondylar tubercle of intercondylar eminence of tibial bone; 7 – a canal for fixation of autograft to tibial bone; 8 – a canal for fixation of autograft to femoral bone

The autotendons were taken through the approach along the posterior medial surface in the popliteal region. The tendons of semitendinous muscle and gracilis muscle were palpated. By means of finger’s pressure onto the skin under these tendons, a skin fold was formed which indicated the direction of the cleavage line. Along the skin fold above the tendon of the semitendinous muscle, a direct skin incision of 2 cm was made. The tendons of the semitendinous muscle and the gracilis muscle were separated and derived from the wound with use of ligatures. With use of the tenotome, the proximal part of each tendon was dissected from the muscle. Then the tendons of the semitendinous muscle and the gracilis muscle were guided into the tenotome, which was moved distally. At the same moment, both tendons and the general tendinous pedicle were dissected from the tibial bone. It also was the new approach to the stage of taking the tendons. Both tendons were wrapped into the sterile gauze moistened with saline. On the preparing table, the tendons of the semitendinous muscle and the gracilis muscle (connected with the tendinous pedicle) were turned around and cleaned from fat tissue and muscle fibers (Fig. 4). The fixators with the self-tightening loop were placed into both holders of the preparing table. The final tendon was run through the loop of the fixators, with making several layers, tensing the holders of the preparing table, and controlling the required length of 65 mm with the measuring bar. The required length of the autograft was controlled by means of the batched tendon through the measuring hole (diameter of 10.5 mm).

Figure 4. General view of autotendons on preparation table: 1 – preparation table; 2 – semitendinous muscle tendon; 3 – gracilis muscle tendon; 4 – tendon pedicle


After achievement of required sizes (the tendon was folded into eight folds), the excesses of the tendon were dissected. Each fold was sutured in twisted manner with non-absorbable monofilaments into the whole, resulting in the formed tendinous autograft with required length of 65 mm and thickness of 10.5 mm. Through the arthroscopic approach, the autograft was moved into the articular cavity. The autograft was stretched through the whole length of the femoral channel and was fixed with the button. The remaining part of the autograft was placed into the tibial bone channel, was tensioned up to correction of knee joint instability and was fixed with the button. The range of motions in the knee joint was full. The arthroscopic control showed the following moments: satisfactory tension of the autograft, correct orientation, negative anterior drawer sign, absence of impingement when the knee joint is completely extended. Hemostasis was completed. The sutures were applied to the wound. The knee joint was drained actively. The aseptic dressing was applied. The elastic bandage was used for the lower extremities. The left knee joint was fixed with the orthosis when the joint was extended completely.
The control X-ray images of the joint showed the gonarthrosis of degree 2, and the correct position of the buttons on the femoral and tibial bones (Fig. 5).

Figure 5. X-ray images of left knee joint after surgery: a) frontal view; b) lateral view

The postsurgical period was without complications. The patient received the course of remedial gymnastics and massage. One month after surgery, the patient did not have any complaints and did not show any signs of edema, synovitis and instability of the left knee joint. Movements were accompanied by low pain in full flexion of the joint. Two months after surgery, the patient resumed his professional activity as excavator operator.
The control examination was conducted after three months from the surgery. The patient did not have any complaints. He was active and could move without additional support, without limp. In the region of the left knee joint, the postsurgical scars without signs of inflammation and pain. The meniscus signs of Baykov, Steinmann and Perelman were negative. The ligamentous component was stable: negative anterior drawer sign; negative Lachman’s test; negative signs of external and internal lateral swing. The movements in the left knee joint were within the full range: flexion/extension 140/0/0; painful movements in end positions. Vascular, motor and sensitive disorders in distal parts of the extremities were not found. Three months after the surgery, the control MRI examination showed the intact autograft, absent lysis around the autograft, and the diameter of bone channels without changes (10 mm) (Fig. 6).

Figure 6. MRI-appearance of location of autograft in bone canals

The patient was satisfied with the results of the surgical management, with significant improvement in the left knee joint functioning, with possibility for active physical load, and with full recovery of professional activity. 

CONCLUSION

During arthroscopy, before taking the autotendons, the estimation of required thickness and length of the autograft allows considering the individual parameters of the anterior cruciate ligament and forming the autograft of correct size for anatomical recovery of the anterior cruciate ligament and statodynamic function of the knee joint, without lacerations of the autograft in the postsurgical period.
Taking of two tendons (from the semitendinous muscle and the gracilis muscle) increases the length of the tendons, gives the uniform and enough long tendon with possibility for formation of six-, seven- or eight-bundled autograft with required thickness and length, thereby creating the initial sizes of the anterior cruciate ligament.
The drilling of channels (with diameter 0.5 mm less than thickness of the autograft) in the tibia and in the femoral bone is performed for achievement of full contact between the autograft and the wall of the bone channel. As result, the synovial fluid, which hinders the regeneration process, did not enter the bone channels, and the autograft is integrated with bone tissue over sufficient surface, providing the consistency of its fixation and stability of the knee joint.
This clinical case of surgical management of the patient with the traumatic injury to the anterior cruciate ligament with use of the new approach to arthroscopic autoplasty can be interesting for orthopedic surgeons since it demonstrates some ways for solution of the problems relating to increasing endurance of the autograft and appropriate fixation in bone channels, and will favor the improvement in treatment outcomes.

Information on financing and conflict of interests

The study was conducted in compliance with the research plan of Irkutsk Research Center of Surgery and Traumatology.
The authors declare the absence of any clear or potential conflicts of interests relating to publishing of this article.        

REFERENCES:

1.      Slastilin VV, Fayn AM, Vaza AYu. Using transplant from popliteal muscle tendons for the arthroplasty of anterior cruciate ligament (advantages, problems and ways for their solution). Transplantology. 2017; 9(4): 317-324. Russian (Сластилин В.В., Файн А.М., Ваза А.Ю. Использование трансплантата из сухожилий подколенных мышц для пластики передней крестообразной связки (преимущества, проблемы и пути их решения) //Трансплантология. 2017. Т. 9, № 4. С. 317-324)

2.      Rikun OV, Khominets VV, Fedotov AO. Modern trends in surgical treatment of patients with ruptures of anterior cruciate ligament (review of literature). Traumatology and Orthopedics of Russia. 2017; 23(4): 134-145. Russian (Рикун О.В., Хоминец В.В., Федотов А.О. Современные тенденции в хирургическом лечении пациентов с разрывами передней крестообразной связки (обзор литературы) // равматология и ортопедия России. 2017. Т. 23, № 4. С. 134-145)

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