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Heng CHY, Wong JYS, Tan AHC. Both Adjustable and Fixed Loop Hamstring Tendon Graft Fixation Have Similar Clinical and Patient-Reported Outcomes in Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100775. [PMID: 37583621 PMCID: PMC10424139 DOI: 10.1016/j.asmr.2023.100775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/15/2023] [Indexed: 08/17/2023] Open
Abstract
Purpose This study aims to compare the outcomes of fixed-loop device (FLD) vs adjustable-loop device (ALD) graft fixation with up to 2-year follow-up in patients undergoing primary anterior cruciate ligament reconstruction (ACLR) in a predominantly Asian setting. Methods Prospectively collected outcome measures as well as clinical records of patients who underwent primary ACLR using either FLD or ALD fixation of hamstring tendon autograft performed by a single surgeon were reviewed. The surgeon in this study used a fixed-loop device from 2018 to 2019 and then changed to adjustable loop from 2019 to 2020. Suspensory fixation was performed on the femoral side, and aperture (interference screw) fixation was performed on the tibial side. Outcome measures included knee range of motion, KT-1000 arthrometer testing, Lysholm knee score, and Tegner activity scale. Patients were assessed preoperatively and postoperatively at regular intervals of 6, 12, and 24 months. Results A total of 105 patients were identified. Forty-six were excluded due to incomplete follow-up data, so 59 patients with full 2-year follow-up were included in the final study group. Both groups (FLD vs ALD) were similar in demographics except for age (P = .042). Out of 105, there were 59 patients remaining in the study group with 2-year follow-up data. No significant differences were observed between the 2 groups at all respective testing intervals. Conclusions FLDs and ALDs for suspensory fixation of hamstring tendon autograft in ACLR had similar clinical outcomes with a minimum of 2-year follow up. There is no evidence of graft loosening from loop lengthening. Level of Evidence Level III, retrospective comparative trial.
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Affiliation(s)
| | - Joel Yat Seng Wong
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Koukoulias NE, Dimitriadis T, Vasiliadis AV, Germanou E, Boutovinos AP. ACL Reconstruction and Modified Lemaire Tenodesis Utilizing Common Suspensory Femoral Fixation. Arthrosc Tech 2022; 11:e2185-e2193. [PMID: 36632409 PMCID: PMC9826977 DOI: 10.1016/j.eats.2022.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/14/2022] [Indexed: 11/19/2022] Open
Abstract
Persistent rotatory instability after anterior cruciate ligament (ACL) reconstruction has been well studied and recognized as the cause of unsatisfactory clinical results. Various anterolateral techniques have been described as an adjunct to the ACL reconstruction to improve clinical outcomes. Modified deep Lemaire lateral extra-articular tenodesis has been tested both biomechanically and clinically and proved an efficient solution in controlling tibia internal rotation, when performed in conjunction with ACL reconstruction. We describe a simple, versatile, effective, and reproducible technique of lateral extra-articular tenodesis, using common suspensory femoral fixation, with no additional cost and surgical risk.
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Affiliation(s)
- Nikolaos E. Koukoulias
- Address correspondence to Nikolaos E. Koukoulias, M.D., Ph.D., 5 Agiou Georgiou Street, Pylaia, Thessaloniki, GR57001 Greece.
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Elmholt SB, Nielsen TG, Lind M. Fixed-loop vs. adjustable-loop cortical button devices for femoral fixation in ACL reconstruction - a systematic review and meta-analysis. J Exp Orthop 2022; 9:106. [PMID: 36269424 PMCID: PMC9587170 DOI: 10.1186/s40634-022-00544-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Simone Birkebæk Elmholt
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Torsten Grønbech Nielsen
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Martin Lind
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Adjustable-loop implants are non-inferior to fixed-loop implants for femoral fixation in anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2022; 31:1723-1732. [PMID: 35737010 DOI: 10.1007/s00167-022-07034-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Button implants with an adjustable-loop device (ALD) are often used in anterior cruciate ligament reconstruction (ACLR). Clinical research comparing ALDs with fixed-loop devices (FLD) has mainly been conducted in small patient populations with short follow-up times. To determine whether ALDs are safe to use in ACLR, a non-inferiority study with a large sample population and a long follow-up period would be beneficial. This study compared ALDs with FLDs to determine non-inferior revision surgery rates, knee stability, and patient-reported outcomes (PROM) in ACLRs. METHODS This non-inferiority register-based cohort study was conducted using data from the Danish Knee Ligament Reconstruction Registry (DKRR). A total of 12,723 patients > 15 years of age with primary ACLR using hamstring tendon autografts and either an FLD or ALD for femoral fixation were included: 9719 patients were in the FLD group, and 3014 patients were in the ALD group. The primary outcome was revision ACLR with a non-inferiority margin for ALDs at 4% at the 2-year follow-up. The secondary outcomes were anterior and rotatory knee stability and PROMs based on the Knee Injury and Osteoarthritis Outcome Score (KOOS) at the 1-year follow-up. RESULTS The crude cumulative revision rates in ALD implants at 2 and 5 years were 2.1% (95% CI 1.62-2.68) and 5.0% (95% CI 4.22-5.96), respectively. In the FLD group, the rates were 2.2% (95% CI 1.89-2.48) at 2 years and 4.7% (95% CI 4.31-5.20) at 5 years. The 1-year side-to-side differences were 0.97 mm (95% CI 0.90-1.03) in the ALD group and 1.45 mm (95% CI 1.41-1.49) in the FLD group. In the FLD group, 13% had a positive pivot shift, and in the ALD group, 6% had a positive pivot shift. There were no differences in KOOS. CONCLUSION ALDs were non-inferior to FLDs regarding revision rates, knee stability, and patient-reported outcomes. Based on this conclusion, ALDs are safe to use for femoral fixation in ACLR. LEVEL OF EVIDENCE III.
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Comparison of fixed versus adjustable-loop device for femoral graft fixation in anterior cruciate ligament reconstruction. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Asif N, Khan MJ, Haris KP, Waliullah S, Sharma A, Firoz D. A prospective randomized study of arthroscopic ACL reconstruction with adjustable- versus fixed-loop device for femoral side fixation. Knee Surg Relat Res 2021; 33:42. [PMID: 34863318 PMCID: PMC8642980 DOI: 10.1186/s43019-021-00124-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 11/07/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Suspensory devices are extensively used in the management of anterior cruciate ligament (ACL) tear. They include fixed- and adjustable-loop devices. There are only a few studies comparing the efficacy of these two devices in the available literature. Therefore, the aim of this study is to compare clinical outcomes between the adjustable-loop device (group I) and fixed-loop device (group II). Materials and methods This was a prospective randomized study. Both groups were equivalent in demographic, preoperative, and intraoperative variables. Twenty-three patients underwent femoral side graft fixation with adjustable-loop and 20 with fixed-loop devices. Four patients were lost to follow-up. Assessment of clinical outcome was done with International Knee Documentation Committee (IKDC) score, Lysholm score, and knee stability tests (Lachman test and pivot shift test). Patient evaluation was performed preoperatively and finally postoperatively 2 years after surgery. Results Postoperative IKDC scores of group I and II were 91.9 ± 3.6 and 91.5 ± 3.6, respectively, and Lysholm scores were 91.0 ± 3.6 and 91.4 ± 3.5, respectively, after 2 years; however, the difference in the outcomes was statistically insignificant (p > 0.05). Twenty patients (87%) in group I and 17 patients (85%) in group II had a negative Lachman test (p = 0.8). Twenty-two patients (95.7%) in group I and 19 patients (95%) in group II had a negative pivot shift test (p = 0.9). Conclusion ACL reconstruction with fixed- and adjustable-loop suspensory devices for graft fixation gives equivalent and satisfactory clinical results. Level of evidence 1.
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Affiliation(s)
- Naiyer Asif
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| | - Mohammad Jesan Khan
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India.
| | - K P Haris
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| | - Shah Waliullah
- Department of Orthopaedics, KGMU, Lucknow, Uttar Pradesh, India
| | - Anubhav Sharma
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| | - Danish Firoz
- Department of Orthopaedic Surgery, Faculty of Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India
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Abstract
In the last decade, there have been significant advances in our understanding of anterior cruciate ligament (ACL) reconstruction. Recent prospective cohort studies have identified risk factors for ACL reconstruction graft failure such as younger patient age, increased activity level, nonanatomic tunnel placement, and the use of allograft. Among these, the most easily modifiable risk factor is graft choice. Given that the surgeon's recommendation has been shown to be one of the most important factors behind patients' graft choice, it is critical that the operating surgeon have a thorough understanding of all the ACL graft options available to choose the graft that would be most suitable for the patient's personalized reconstruction (i.e., patient's anatomy, sport, level of competition, age, risk factors for failure, and graft used in previous ACL surgery). The purpose of this review is to provide an up-to-date understanding of the current ACL graft reconstruction options. The indications, advantages, and disadvantages of the different ACL reconstruction graft options available will be discussed.
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Uribe-Echevarria B, Magnuson JA, Amendola A, Bollier MJ, Wolf BR, Hettrich CM. Anterior Cruciate Ligament Reconstruction: A Comparative Clinical Study Between Adjustable and Fixed Length Suspension Devices. THE IOWA ORTHOPAEDIC JOURNAL 2020; 40:121-127. [PMID: 32742219 PMCID: PMC7368520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Adjustable-length cortical suspension devices provide technical advantages over fixed-length devices for femoral graft fixation during anterior cruciate ligament (ACL) reconstruction but have shown increased lengthening during cyclic loading in biomechanical studies. The purpose of this study was to prospectively measure graft elongation in vivo along with patient reported outcomes. METHODS Thirty-seven skeletally mature patients diagnosed with anterior cruciate insufficiency who underwent ACL reconstruction using autogenous hamstring graft were included in this study. Thirteen patients received an ACL reconstruction using a fixed loop device (FL) and twenty-four patients were treated with an adjustable-length device (AL) based on surgeon preference. Bilateral knee laxity was measured with a KT1000 Arthrometer before surgery and immediately after surgery with the patient under anesthesia, and at the 6-week, 3-month, and 6-month clinical follow-up appointments. All measurements were made by the same operator with maximum force testing. Differences between the affected knee and the contralateral knee were measured. Patient reported outcomes were collected at 6 and 24 months post-operatively. RESULTS No difference was found between the FL and AL groups in either knee laxity or patient reported outcomes. Average side-to-side difference at 6 months was 1.8 ± 2.6 mm for the FL group and 1.7 ± 2.4 mm for the AL group (p=.874). One patient in the FL group (7.7%) and two in the AL group (9.5%) had a side to side difference in laxity greater 5 mm. Patient reported outcomes did not differ between groups and no patients underwent revision surgery. CONCLUSIONS The adjustable-length cortical suspension device (AL) did not demonstrate increased laxity as compared to fixed-length devices. There was no difference in patient reported outcomes between the groups.Level of Evidence: IV.
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Affiliation(s)
| | | | | | | | - Brian R. Wolf
- University of Iowa Hospitals and Clinics, Iowa City, IA
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Fu FH. Editorial Commentary: Call for a Better Femoral Fixation Device in Anterior Cruciate Ligament Reconstruction: Adjustable-Loop Fixation Appears Better in Theory Than in Reality. Arthroscopy 2019; 35:2634-2635. [PMID: 31500749 DOI: 10.1016/j.arthro.2019.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 02/02/2023]
Abstract
Femoral tunnel widening after anterior cruciate ligament reconstruction is a major complication that results in more complex revision surgery. One prevailing theory of the source of this widening is the "bungee cord effect" resulting from suture fixation within the femoral tunnel. Adjustable-loop fixation devices were proposed to theoretically correct this by reducing the amount of suture within the femoral tunnel. Review of the current literature reveals mixed outcomes with most data pointing to no difference between the adjustable and fixed devices, especially with regard to tunnel widening. Adjustable-loop devices are not currently meeting the theoretical expectations, and the quest for improved femoral fixation continues.
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Kızılgöz V, Sivrioğlu AK, Aydın H, Ulusoy GR, Çetin T, Tuncer K. The Combined Effect of Body Mass Index and Tibial Slope Angles on Anterior Cruciate Ligament Injury Risk in Male Knees: A Case-Control Study. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2019; 12:1179544119867922. [PMID: 31427857 PMCID: PMC6681250 DOI: 10.1177/1179544119867922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
Abstract
Introduction: Tibial slope angles (TSAs) have been identified as potential risk factors of
anterior cruciate ligament (ACL) injury in the literature. A higher body
mass index (BMI) might increase the risk of ACL tear because of greater
axial compressive force. The aim of this study was to determine the
relationship of these factors and the combined effect of BMI and TSA in
determination of risk potential for ACL injury. Methods: The preoperative magnetic resonance (MR) images of 81 ACL-injured male knees
and of 68 male individuals with no ACL injuries were evaluated by 2
radiologists to measure the TSA. The Mann-Whitney U-test
was performed to indicate the significant difference in height, weight, and
BMI values. The independent samples t-test was used to
determine the differences between ACL-injured and non-injured groups
regarding TSA values. Odds ratios were calculated by logistic regression
tests, and receiver operating characteristics (ROC) curves revealed the area
under the receiver operating characteristics curve (AUC) values to compare
the relationships of these parameters with ACL injury. Results: Body mass index, lateral tibial slope (LTS), and medial tibial slope (MTS)
were predictive of ACL risk injury. Body mass index alone had the greatest
effect among these parameters, and there were no statistically significant
differences in coronal tibial slope values between the ACL-ruptured and
control groups. The greatest AUC was observed for the combination of BMI,
MTS, and LTS. Conclusions: Body mass index, LTS, and MTS angles were associated with ACL injury risk and
BMI + MTS + LTS together revealed the greatest effect on ACL injury.
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Affiliation(s)
- Volkan Kızılgöz
- Department of Radiology, Faculty of Medicine, Kafkas University, Kars, Turkey
| | - Ali Kemal Sivrioğlu
- Department of Radiology, Faculty of Medicine, Kocaeli University, Izmit, Turkey
| | - Hasan Aydın
- Department of Radiology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Gökhan Ragıp Ulusoy
- Department of Orthopaedics, Faculty of Medicine, Kafkas University, Kars, Turkey
| | - Türkhun Çetin
- Department of Radiology, Faculty of Medicine, Kafkas University, Kars, Turkey
| | - Kutsi Tuncer
- Department of Orthopaedics, Faculty of Medicine, Atatürk University, Erzurum, Turkey
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