Baki Volkan ÇETİN, Mehmet Akif ALTAY, Serkan SİPAHİOĞLU, İzzettin YAZAR

Ön Çapraz Bağ Rekonstrüksiyonu Sırasında Femoral Kalıntıların Korunmasının Fonksiyonel ve Klinik Sonuçlar Üzerine Etkisi

Amaç: Bu çalışmanın amacı, ön çapraz bağ (ÖÇB) yırtıklarının cerrahi tedavisinde, femoral kalıntıların korunduğu rekonstrüksiyon tekniği ile standart tekniğin fonksiyonel ve klinik sonuçlarının karşılaştırılmasıdır. Hastalar ve yöntemler: İleriye dönük randomize olarak planlanan çalışmaya, ÖÇB yırtığı nedeniyle cerrahi uygulanan 150 hasta (tamamı erkek) dahil edildi. Hastalar randomize olarak iki gruba ayrıldı. Grup A’da (n=75) hastalara hamstring tendon otogrefti kullanılarak tibial ve femoral kalıntıların korunduğu ÖÇB rekonstrüksiyonu uygulandı. Grup B’de (n=75) ise hamstring tendon otogrefti ile standart rekonstrüksiyon tekniği uygulandı ve tibial kalıntılar korunurken femoral kalıntılar temizlendi. Grup A hastaların yaş ortalaması, 27,23±5,64 yıl, Grup B’de ise 26,72±5,82 yıldı. Travma-operasyon arası geçen süre, Grup A’da 4,36±3,21 ay, Grup B’de 3,56±3,08 aydı. Hastaların takip süresi, Grup A için 38,05±6,11 ay, Grup B için ise 36,86±8,04 ay olarak hesaplandı. Her iki grup arasında, hastaların yaşları, travma-operasyon arası geçen süre ve takip süreleri açısından farklılık yoktu (p˃0,05). Cerrahinin klinik sonuçları Lysholm skorlaması, Uluslararası Diz Dokümantasyon Komitesi (IKDC) skoru, Subjektif IKDC 2000 diz skorlaması ve fiziksel instabilite testleriyle değerlendirildi. Bulgular: Grup A ve Grup B hastaların ameliyat öncesi Lysholm, sübjektif ve objektif IKDC diz skorlarında, eklem hareket açıklıklarında ve diz stabilite testlerinde ( Lachman, Pivot Şift, Öne Çekmece) ameliyat sonrası istatistiksel olarak anlamlı düzelme tespit edildi (p<0,001). Erken dönem (18 ay) kontrollerde gruplar arasında ameliyat öncesi ve sonrası karşılaştırma yapıldığında Lysholm, sübjektif ve objektif IKDC diz skorlarında Grup A lehine anlamlı yükseklik saptansa da (p˂0.05) hastaların son kontrollerinde Lysholm, sübjektif ve objektif IKDC diz skorlarında, eklem hareket açıklıklarında ve diz stabilite testleri (Lachman, Pivot Şift, Öne çekmece) açısından anlamlı farklılık izlenmedi (p˃0.05). Sonuç: ÖÇB yırtıklarının cerrahi tedavisinde, femoral kalıntılar korunarak yapılan ÖÇB rekonstrüksiyonunda, ÖÇB femoral kalıntıların histolojik olarak tespit edilen teorik katkısı, klinik ve fonksiyonel sonuçlarda belirgin olarak izlenmemektedir.

Anahtar Kelimeler:

Ön çapraz bağ yırtığı, artroskopik ÖÇB rekonstrüksiyonu, femoral kalıntı.

Effects of Femoral Remnant Preservation During Anterior Cruciate Ligament Reconstruction on the Clinical and Functional Outcomes

Background: The aim of this study is to compare the functional and clinical results of the femoral remnant-sparing reconstruction technique with the standard technique in the surgical reconstruction of anterior cruciate ligament (ACL) tears.Materials and Methods: 150 patients (all men) who underwent surgery for ACL tear were included in the pros-pective randomized study. The patients were randomly divided into two groups. In Group A (n=75), ACL reconst-ruction with preservation of tibial and femoral remnants was performed using hamstring tendon autograft. In group B (n=75), standard reconstruction technique was performed with hamstring tendon autograft and femoral remnants were removed while tibial remnants were preserved. The mean age of patients in Group A was 27.23±5.64 years, and 26.72±5.82 years in Group B. The interval between trauma and operation was 4.36±3.21 months in Group A and 3.56±3.08 months in Group B. The mean follow-up period of the patients was 38.05±6.11 months for Group A and 36.86±8.04 months for Group B. There was no difference between the two groups in terms of age of the patients, interval between trauma and operation and follow-up periods (p˃0.05). Clinical outcomes of surgery were evaluated using Lysholm score, International Knee Documentation Committee (IKDC) score, Subjective IKDC 2000 knee score, and physical instability tests.Results: Statistically significant improvement was detected in the preoperative Lysholm, subjective and objective IKDC knee scores, joint range of motion and knee stability tests (Lachman, Pivot Shift, Anterior Drawer) of Group A and Group B patients (p<0.001). When preoperative and postoperative comparisons were made between the groups in early (18 months) controls, a significant increase was found in favor of Group A in Lysholm, subjective and objective IKDC knee scores (p˂0.05). There were no significant differences in Lysholm, subjective and objecti-ve IKDC knee scores, joint range of motion, and knee stability tests (Lachman, Pivot Shift, Forward drawer) at the last follow-up of the patients (p˃0.05).Conclusions: In the surgical reconstruction of ACL tears, the histologically determined theoretical contribution of ACL femoral remnants in ACL reconstruction performed by preserving the femoral remnants is not clearly obser-ved in clinical and functional results.

Keywords:

Anterior cruciate ligament tear, arthroscopic ACL reconstruction, femoral remnant,

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1. Erden T, Toker B, Toprak A, Taşer Ö. Comparison of the outcomes of isolated anterior cruciate ligament reconstruction and combined anterolateral ligament suture tape augmentation and anterior cruciate ligament reconstruction. Jt Dis Relat Surg 2021;32(1):129-36
2. McGinty BJ. Operative Arthroscopy. Third Edition: Knee Arthroscopy. Philadelphia, Lippincott 2003;456-567.
3. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 2009;37:246-51.
4. Borbon CA, Mouzopoulos G, Siebold R. Why perform an ACL augmentation? Knee Surg Sports Traumatol Arthrosc 2012;20 (2): 245–51.
5. Arnoczki SP, Tavin GB, Marshall JL. Anterior cruciate replacement using patellar tendon. An evaluation of graft revascularization in the dog. Am J Bone Joint Surg 1982;64: 217–24.
6. Ochi M, Isawa J, Uchio Y, Adachi N, Sumen Y. The regeneration of sensory neurons in the reconstruction of the anterior cruciate ligament. Br J Bone Joint Surg 1999;81: 902–6.
7. Lee BI, Kwon SW, Kim JB, Choi HS, Min KD. Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft. Arthroscopy 2008;24: 560-8.
8. Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V. Sparing the anterior cruciate ligament remnant: Is it worth the hassle? Br Med Bull 2012;104: 91-111.
9. Dhillon MS, Bali K, Vasistha RK. Immunohistological evaluation of proprioceptive potential of the residual stump of injured anterior cruciate ligaments (ACL). Int Orthop 2010;34: 737-41.
10. Lee BI, Min KD, Choi HS, Kwon SW, Chun DI, Yun ES. Immunohistochemical study of mechanoreceptors in the tibial remnant of the ruptured anterior cruciate ligament in human knees. Knee Surg Sports Traumatol Arthrosc 2009;17:1095-101.
11. Schultz R A, Miller D C, Kerr C S, Micheli L. Mechanoreceptors in human cruciate ligaments: a histologic study. J Bone Joint Surg (Am) 1984; 66 (7):1072-76.
12. Denti M, Monteleone M, Berardi A, Panni A S. Anterior cruciate ligament mechanoreceptors. Clin Orthop 1994;308:29-32.
13. Adachi N, Ochi M, Uchio Y, Iwasa J, Ryoke K, Kuriwaka M. Mechanoreceptors in the anterior cruciate ligament contributeto the joint position sense. Acta Orthop Scand 2002;73:330-4.
14. Crain EH, Fithian DC, Paxton EW, Luetzow WF. Variation in anterior cruciate ligament scar pattern: does the scar pattern affect anterior laxity in anterior cruciate ligament-deficient knees? Arthroscopy 2005;21:19-24.
15. Panisset JC, Duraffour H, Vasconcelos W, Colombet P, Javois C, Potel JF. Clinical, radiological and arthroscopic analysis of the ACL tear. A prospective study of 418 cases. Rev Chir Orthop 2008;94(8 Suppl.):362-8.
16. Liu W, Maitland ME, Bell GD. A modeling study of partial ACL injury: simulated KT 2000 tests. J Biomech Eng 2002;124:294-301.
17. Song GY, Zhang H, Zhang J, Liu X, Chen XZ, Li Y, et al. The anterior cruciate ligament remnant: To leave it or not? Arthroscopy 2013;29:1253-62.
18. Wu B, Zhao Z, Li S, Sun L. Preservation of remnant attachment improves graft healing in a rabbit model of anterior cruciate ligament reconstruction. Arthroscopy 2013;29:1362-71.
19. Wang H, Liu Z, Li Y, Peng Y, Xu W, Hu N, et al. Is Remnant Preservation in Anterior Cruciate Ligament Reconstruction Superior to the Standard Technique? A Systematic Review and Meta-Analysis. Biomed Res Int 11;2019:1652901.
20. Nag HL, Gupta H. Anterior Cruciate Ligament Reconstruction With Preservation of Femoral Anterior Cruciate Ligament Stump. Arthroscopy Techniques 2014;3(5):575-7.
21. Kaseta MK, DeFrate LE, Charnock BL, Sullivan RT, Garrett WE. Reconstruction technique affects femoral tunnel placement during ACL reconstruction. Clin Orthop Relat Res 2008;466:1467-74.
22. Naraoka T, Kimura Y, Tsuda E, Yamamoto Y, Ishibashi Y. Is Remnant Preservation Truly Beneficial to Anterior Cruciate Ligament Reconstruction Healing? Am J Sports Med 2017;45(5):1049-58.
23. Andonovski A, Topuzovska S, Samardziski M, Bozinovski Z, Andonovska B, Temelkovski Z. The Influence of Anterior Cruciate Ligament Remnant on Postoperative Clinical Results in Patients with Remnant Preserving Anterior Cruciate Ligament Reconstruction. Maced J Med Sci 2017;5(5):624-9.
24. Löcherbach C, Zayni R, Chambat P, Sonnery-Cottet B. Biologically enhanced ACL reconstruction. Orthop Traumatol Surg Res 2010;96:810-5.
25. Bali K, Dhillon MS, Vasistha RK, Kakkar N, Chana R, Prabhakar S. Efficacy of immunohistological methods in detecting functionally viable mechanoreceptors in the remnant stumps of injured anterior cruciate ligaments and its clinical importance. Knee Surg Sports Traumatol Arthrosc 2012;20:75-80.
26. Wittstein J, Kaseta M, Sullivan R, Garrett WE. Incidence of the Remnant Femoral Attachment of the Ruptured ACL. Clin Orthop Relat Res 2009;467:2691-4.
27. Hantes ME, Dailiana Z, Zachos VC, Varitimidis SE. Anterior cruciate ligament reconstruction using the Bio-TransFix femoral fixation device and anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc 2006;14:497-501.
28. Amis AA, Jakob RP. Principles for placing the tibial tunnel and avoiding roof impingement during reconstruction of a torn anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 1994;2:138-46.
29. Demirağ B, Ermutlu C, Aydemir F, Durak K. A comparison of clinical outcome of augmentation and standard reconstruction techniques for partial anterior cruciate ligament tears. Jt Dis Relat Surg 2012;23(3):140-4.
30. Zhang Q, Zhang S, Cao X, Liu L, Liu Y, Li R. The effect of remnant preservation on tibial tunnel enlargement in ACL reconstruction with hamstring autograft: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2014;22(1):166-73.