Bekir Murat ÇINAR, Sercan AKPINAR, Murat Ali HERSEKLİ, Mustafa UYSAL, Necip CESUR, Ayşin POURBAGHER, Alihan DERİNCEK

Hamstring tendon otogrefti ile yapılan ön çapraz bağ rekonstrüksiyonunda iki farklı tespit yönteminin femoral kemik tünel genişlemesi ve klinik sonuçlar üzerine etkisi

Amaç: Bu çalışmada, ön çapraz bağ (ÖÇB) rekonstrüksiyonunda tendon tespitinin tünel içinde anatomik ve tünel dışında anatomik olmayan bölgeden yapılmasının femoral tünel genişlemesine ve klinik sonuçlara etkisi araştırıldı. Çalışma planı: Dörtlü hamstring tendon grefti kullanılarak artroskopik ÖÇB rekonstrüksiyonu uygulanan 35 hasta geriye dönük olarak değerlendirildi. On sekiz hastada (ort. yaş 32), greft tespitini tünel içinde yapan ve transkondiler olarak uygulanan RigidFix çivisi (grup 1), 17 hastada (ort. yaş 30) ise greft tespitini tünel dışında korteks üzerinde yapan EndoButton CL (grup 2) kullanıldı. Hastalar IKDC (International Knee Documentation Committee) diz skoru ve Lysholm skoru, tünel genişliği ise bilgisayarlı tomograﬁ ile değerlendirildi. Rolimeter diz test cihazı ile iki dizde bağ gevşekliği ölçüldü. Ortalama takip süresi grup 1’de 24 ay (dağılım 21-38 ay), grup 2’de 24.6 ay (dağılım 12-36 ay) idi. Sonuçlar: İki grup arasında yaş ve cinsiyet dağılımı, ameliyat edilen taraf, ameliyat sırasında açılan tünel boyutu ve takip süresi açısından farklılık yoktu (p>0.05). Ameliyat sonrası klinik sonuçlar iki grupta anlamlı farklılık göstermedi (p>0.05). Kemik tünel boyutları grup 1’de 14 hastada (%77.8), grup 2’de 15 hastada (%88.2) belirgin ve aşırı genişlemiş bulundu; iki grup arasında tünel genişlemesi açısından fark görülmedi (p>0.05). Bağ gevşekliği grup 1’de sekiz hastada (%44.4), grup 2’de üç hastada (%17.7) 3 mm üzerinde bulundu (p0.05; grup 1 için r=0.175, grup 2 için r=-0.01). Çıkarımlar: Tespit yerinin farklı olmasının tünel genişlemesi üzerinde etkisinin olmadığı görüldü. Eklem gevşekliği açısından fark olması, materyallerin biyomekanik özelliklerinden kaynaklanmış olabilir.

Anahtar Kelimeler:

Tendonlar, Artroskopi, Diz eklemi, Ortopedik fiksasyon araçları, Ön çapraz bağ

The effects of two different ﬁxation methods on femoral bone tunnel enlargement and clinical results in anterior cruciate ligament reconstruction with hamstring tendon graft

Objectives: We investigated the effects of anatomic and nonanatomic tunnel ﬁxations on femoral tunnel widening and clinical results in anterior cruciate ligament (ACL) reconstructions. Methods: We retrospectively evaluated 35 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring tendon graft. Fixation was performed in the tunnel using the transcondylar RigidFix pin (group 1) in 18 patients (mean age 32 years), and from outside the tunnel using the EndoButton-CL device (group 2) in 17 patients (mean age 30 years). The patients were assessed using the IKDC (International Knee Documentation Committee) and Lysholm knee scores and tunnel widening was assessed by computed tomography. Ligament laxity was measured bilaterally using the Rolimeter knee tester. The mean follow-up was 24 months (range 21 to 38 months) in group 1, and 24.6 months (range 12 to 36 months) in group 2. Results: The two groups were similar with respect to age and sex distribution, operated side, the size of the tunnel created, and follow-up period (p>0.05). Postoperative knee scores did not show a signiﬁcant difference (p>0.05). There was marked and excessive tunnel enlargement in 14 patients (77.8%) in group 1, and in 15 patients (88.2%) in group 2, with no signiﬁcant difference between the two groups (p>0.05). Ligament laxity exceeded 3 mm in eight patients (44.4%) in group 1, and in three patients (17.7%) in group 2 (p<0.001). There was no relationship between tunnel widening and ligament laxity (p>0.05; r=0.175 and r=-0.01 for group 1 and group 2, respectively). Conclusion: Our results suggest that differences in the localization of the tunnel ﬁxation have no effect on tunnel enlargement and that joint laxity may be affected by biomechanical properties of ﬁxation materials.

Keywords:

Tendons, Arthroscopy, Knee Joint, Orthopedic Fixation Devices, Anterior Cruciate Ligament,

___

1. Wilson TC, Kantaras A, Atay A, Johnson DL. Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med 2004;32:543-9.
2. Höher J, Möller HD, Fu FH. Bone tunnel enlargement after anterior cruciate ligament reconstruction: fact or fiction? Knee Surg Sports Traumatol Arthrosc 1998;6:231-40.
3. Fauno P, Kaalund S. Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: a prospective randomized study. Arthroscopy 2005;21:1337-41.
4. Singhal MC, Fites BS, Johnson DL. Fixation devices in ACL surgery: what do I need to know? Orthopedics 2005; 28:920-4.
5. Iorio R, Vadalà A, Argento G, Di Sanzo V, Ferretti A. Bone tunnel enlargement after ACL reconstruction using autologous hamstring tendons: a CT study. Int Orthop 2007;31:49-55.
6. Buelow JU, Siebold R, Ellermann A. A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation. Knee Surg Sports Traumatol Arthrosc 2002;10:80-5.
7. Nebelung W, Becker R, Merkel M, Röpke M. Bone tunnel enlargement after anterior cruciate ligament reconstruction with semitendinosus tendon using Endobutton fixation on the femoral side. Arthroscopy 1998;14:810-5.
8. Kousa P, Järvinen TL, Vihavainen M, Kannus P, Järvinen M. The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part I: femoral site. Am J Sports Med 2003;31:174-81.
9. Clatworthy MG, Annear P, Bulow JU, Bartlett RJ. Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc 1999;7:138-45.
10. Balasch H, Schiller M, Friebel H, Hoffmann F. Evaluation of anterior knee joint instability with the Rolimeter. A test in comparison with manual assessment and measuring with the KT-1000 arthrometer. Knee Surg Sports Traumatol Arthrosc 1999;7:204-8.
11. Klein JP, Lintner DM, Downs D, Vavrenka K. The incidence and significance of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation. Arthroscopy 2003;19:470-6.
12. L’Insalata JC, Klatt B, Fu FH, Harner CD. Tunnel expansion following anterior cruciate ligament reconstruction: a comparison of hamstring and patellar tendon autografts. Knee Surg Sports Traumatol Arthrosc 1997;5:234-8.
13. Hersekli MA, Akpınar S, Özalay M, Özkoç G, Cesur N, Uysal M, et al. Tunnel enlargement after arthroscopic anterior cruciate ligament reconstruction: comparison of bonepatellar tendon-bone and hamstring autografts. Adv Ther 2004;21:123-31.
14. Peyrache MD, Djian P, Christel P, Witvoet J. Tibial tunnel enlargement after anterior cruciate ligament reconstruction by autogenous bone-patellar tendon-bone graft. Knee Surg Sports Traumatol Arthrosc 1996;4:2-8.
15. Milano G, Mulas PD, Ziranu F, Piras S, Manunta A, Fabbriciani C. Comparison between different femoral fixation devices for ACL reconstruction with doubled hamstring tendon graft: a biomechanical analysis. Arthroscopy 2006; 22:660-8.
16. Zantop T, Weimann A, Rümmler M, Hassenpflug J, Petersen W. Initial fixation strength of two bioabsorbable pins for the fixation of hamstring grafts compared to interference screw fixation: single cycle and cyclic loading. Am J Sports Med 2004;32:641-9.
17. Rodeo SA, Arnoczky SP, Torzilli PA, Hidaka C, Warren RF. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg [Am] 1993;75:1795-803.
18. Ahmad CS, Gardner TR, Groh M, Arnouk J, Levine WN. Mechanical properties of soft tissue femoral fixation devices for anterior cruciate ligament reconstruction. Am J Sports Med 2004;32:635-40.
19. Fink C, Zapp M, Benedetto KP, Hackl W, Hoser C, Rieger M. Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon autograft. Arthroscopy 2001;17:138-43.
20. Magen HE, Howell SM, Hull ML. Structural properties of six tibial fixation methods for anterior cruciate ligament soft tissue grafts. Am J Sports Med 1999;27:35-43.
21. Lopez MJ, Spencer N, Casey JP, Monroe WT. Biomechanical characteristics of an implant used to secure semitendinosus-gracilis tendon grafts in a canine model of extra-articular anterior cruciate ligament reconstruction. Vet Surg 2007;36:599-604.