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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1511-1516

Management of partial tears of the anterior cruciate ligament by single-bundle augmentation


1 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Orthopedic Surgery, Menoufia University Students Hospital, Menoufia, Egypt

Date of Submission06-Mar-2021
Date of Decision04-Apr-2021
Date of Acceptance11-Apr-2021
Date of Web Publication29-Oct-2022

Correspondence Address:
Ahmed M Mostafa
Shebin El Kom, Menoufia 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_60_21

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  Abstract 


Objective
The aim was to evaluate early results of single-bundle augmentation of partial tears of the anterior cruciate ligament (ACL) with an autogenous hamstring graft.
Background
Intact fibers of the partially torn ACL preserve some of the proprioception of the knee joint. It adds some biomechanical strength and protection to the newly inserted augmentation graft in the early postoperative period and helps in early revascularization, ligamentization, and reinnervation of the newly inserted augmentation graft.
Patients and methods
A prospective study was performed for 20 patients with partial ACL tears treated with arthroscopic single-bundle augmentation with an autogenous hamstring graft. Patients were subjected to preoperative and postoperative evaluation according to Lysholm score, anterior drawer test, Lachman test, pain, and instability.
Results
There was a significant improvement after arthroscopic augmentation in Lysholm score, anterior drawer test, Lachman test, pain, and instability (P < 0.001).
Conclusion
The single-bundle augmentation technique, preserving intact fibers of the ACL, can be considered as a suitable method of treatment of symptomatic partial tears of the anterior cruciate ligament.

Keywords: anterior cruciate ligament, partial tears, preserving intact fibers, single-bundle augmentation


How to cite this article:
Badawy EB, El-Naggar MH, El-Mowafy HM, Mostafa AM. Management of partial tears of the anterior cruciate ligament by single-bundle augmentation. Menoufia Med J 2022;35:1511-6

How to cite this URL:
Badawy EB, El-Naggar MH, El-Mowafy HM, Mostafa AM. Management of partial tears of the anterior cruciate ligament by single-bundle augmentation. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1511-6. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1511/359514




  Introduction Top


Partial tears of the anterior cruciate ligament (ACL) represent about 28–38% of knee traumatic injuries[1]. Diagnosis of partial ACL tears is based on a combination of patient history, complaints, clinical examination, and MRI, with the definitive diagnosis reached through arthroscopic assessment, when this is indicated[2].

Symptomatic partial tears of the ACL cause significant knee instability, pain, and swelling[3]. Conservative treatment in such cases is often unsatisfactory, especially in young active patients with high functional demand, and can evolve to a complete tear with an increased incidence of meniscal injury and articular cartilage damage[4].

After the failure of direct repair of the partially torn ACL[5], standard ACL reconstruction was widely used to treat partial tears of ACL, sacrificing the residual portion of remnant fibers[6].

Intact fibers of the partially torn ACL preserve some of the proprioception of the knee joint, as these remnants contain residual proprioceptive receptors, and help in early reinnervation of the newly inserted augmentation graft[7]. Intact ACL fibers add some biomechanical strength and protection to the newly inserted augmentation graft in the early postoperative period[8] and help in early revascularization and ligamentization of the newly inserted augmentation graft[9], as they already contain periligamentous and endoligamentous vessels present in the native ACL tissue[10].

Augmenting the intact fibers and substituting the torn fibers or bundles preserves the double-bundle structure of ACL with a lot of its native characteristics due to the presence of native intact ACL fibers.

The aim of the study was to evaluate early results of single-bundle augmentation of partial tears of the ACL with an autogenous hamstring graft.


  Patients and methods Top


This study is a prospective study performed from December 2017 to August 2020. This study included 20 patients with a partial-thickness ACL tear diagnosed by MRI and complaining of knee instability with positive Lachman or anterior drawer tests. Patients excluded from this study were those with a complete ACL tear on MRI or diagnosed intraoperative and those with associated other knee ligamentous injuries.

All cases were treated with arthroscopic single-bundle augmentation at Menofia University hospitals. The study was approved by the Menofia University Ethical Committee and the patient signed informed consent. The follow-up of the cases was for 6 months as minimum duration.

All patients were evaluated preoperatively, a detailed history was taken and recorded. A preoperative Lysholm functional score was obtained. All patients were examined by inspection, palpation, testing range of motion, and special tests such as Lachman and anterior drawer tests. Radiographies (anteroposterior and lateral views) were obtained to exclude fractures. MRI axial, coronal, and sagittal views were obtained in all cases. It was used to confirm clinical findings since it had good positive value in detecting ACL and other ligamentous injuries. ACL fibers appeared to be partially disrupted or lax [Figure 1].
Figure 1: MRI of the knee (red arrow indicates partial rupture of anterior cruciate ligament at the femoral footprint).

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All patients were prepared for operation. They were positioned supine under general or spinal anesthesia with a well-padded tourniquet placed on the proximal thigh. A lateral side support and leg post were applied.

Standard anterolateral (AL) and anteromedial (AM) portals were done. The AL portal was toward the top of the lateral triangle soft spot, adjacent to, but not crossing the patellar tendon's lateral border. The AM portal was slightly lower, ∼1 cm above the joint line. The AM portal was checked, under direct visualization of the arthroscope, with a small gauge needle to ensure that the medial meniscus (MM) was avoided.

Routine diagnostic arthroscopy was initially performed, via AL and AM portals. The ACL arthroscopic assessment was done to ensure the diagnosis of partial tear of ACL and the ACL was probed to detect the extent of the tear [Figure 2]. Any meniscal problems were treated before proceeding to the augmentation, but it did not include any meniscal repair. Gentle debridement of the torn fibers and their footprint was done leaving the intact ACL fibers.
Figure 2: Arthroscopic assessment of anterior cruciate ligament (ACL) (arthroscopic images of the right knee showing (a) midsubstance of ACL, (b) probing of midsubstance of ACL, and (c, d) probing of ACL at the femoral attachment showing partial tear of ACL).

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The semitendinosus and gracilis tendons were then harvested through an oblique incision one-centimeter medial and distal to the tibial tubercle. The tendons were harvested separately using an open-tendon stripper and excised from its insertion site at the tibia.

The graft was then prepared, the muscle fibers were removed using a scalpel taking care not to cut the tendon itself. The whole graft was folded and looped over a heavy traction suture so that the looped end is the femoral end and the free ends are the tibial end. Both ends were sutured with a modified baseball stitch so that more than 25 mm of graft can be fixed within the femoral and tibial tunnels.

The knee was positioned in about 120° flexion. Gentle debridement of the femoral footprint of the injured bundle was performed. Guided by the footprint of the attached remains, a guidewire with a pinhole was inserted at the femoral footprint and drilled through the femur, and pushed through the skin of the AL thigh used to establish the line of the femoral tunnel.

The drill bit was placed free-handed first, to avoid injury of intact fibers, over the previously positioned guidewire, its diameter was determined according to the diameter of the proximal portion of the graft. The depth was set between 30 and 35 mm and advanced under the direct vision of the laser mark on the drill bit. Then the drill bit was removed, leaving the guidewire in position in order to pass a prolene loop through the femoral tunnel.

The tibial tunnel was made with the aid of a C-guide tip aimer, guided by remnants of ACL; the tip of the C-guide was placed. A tipped guidewire was drilled from outside to inside the joint to establish the line of the tibial tunnel. The C-guide was removed leaving the guidewire in position. The drill bit was placed over the previously positioned guidewire, its diameter was determined by the diameter of the distal portion of the graft, and advanced till it just appeared inside the joint.

The prolene loop passed previously from the AM port to the femoral tunnel was then grasped from within the tibial tunnel and passed outside the tibial tunnel.

The graft was passed from tibia to femur using the prolene loop. Then the graft was fixed by using bioabsorbable interference screws. The femoral interference screw was fixed first, while the knee in 120° flexion, then the knee was cycled, and the tibial interference screw was then fixed while tensioning the graft in 30° knee flexion while pushing the tibia posteriorly. The knee was then fully extended to 0° to ensure that full extension can be achieved.

Re-assessment of the graft was done after the fixation of the tibial interference screw to ensure the tension of the graft [Figure 3]. The surgical wound and portals were sutured. Dressing and crepe bandage were applied.
Figure 3: Arthroscopic re-assessment after augmentation (red line represents native intact anterior cruciate ligament fibers, blue line represents the newly inserted augmentation graft).

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All patients were subjected to postoperative rehabilitation. The goal of rehabilitation was to relieve pain and swelling, maintain a normal range of motion, and strengthening muscles to be sufficient for normal gait and activities.

The patient was taught from day one postoperative to achieve full extension, quadriceps exercises, and ice for the first 24 h. Gradual weight-bearing and gradual flexion started after the first week as tolerated. Light running was allowed 3 months after surgery and return to normal activities was after 6 months. Follow-up was at 2 weeks, 1 month, 3 months, and 6 months. Then, every year, for cases followed up for more than 1 year. All patients were re-evaluated and the Lysholm score was obtained postoperatively.

Statistics analysis

Data were collected, revised, fed to the computer, and analyzed using SPSS (statistical package for the social sciences) software package version 26 (IBM Corp., Armonk, New York, USA). Qualitative data were described using frequency and percentage. Quantitative data were described using mean ± SD and ranges. The Kolmogorov–Smirnov and the Shapiro–Wilk statistic tests were used to verify the normality of distribution. Wilcoxon signed-rank test was used to calculate the difference between quantitative variables, while McNemar and Marginal Homogeneity tests were used to calculate the difference between qualitative variables in the same group, preoperative and postoperative, in not-normally distributed data. The level of significance was set at P values of less than 0.05.


  Results Top


This study included 20 cases, 19 males (95%) and one female (5%). All cases (100%) in this study were young, their age ranged from 18 to 24 years with a mean age of 20.65 ± 1.631 years. All cases (100%) were active with high functional demand. All cases (100%) were due to sports injury. All cases (100%) had a partial tear of ACL confirmed by arthroscopy. All cases (100%) had a complaint of giving way. Eighteen cases (90%) had a complaint of pain. Thirteen cases (65%) had a complaint of knee swelling. The injury interval (duration from injury to operation) ranged from 1 to 48 months with a mean of 8.2 ± 10.88 months.

The anterior drawer test was positive (grades one and two), and Lachman test was positive with a firm endpoint in the preoperative examination of all cases (100%), while postoperatively, they were all negative with stable knees. All cases (100%) had no limitation of movement, no previous knee surgery, and no medical problems.

Eleven cases (55%) had partial tear mainly to AM bundle fibers, while nine cases (45%) had partial tear mainly to PL bundle fibers.

The arthroscopic assessment revealed that nine cases (45%) had no associated meniscal injury, eight cases (40%) had MM injury, and three cases (15%) had lateral meniscus (LM) injury. Cases of associated meniscal injury were treated by shaving or partial meniscectomy. No meniscal repairs were performed in any of the cases.

Preoperative Lysholm score ranged from 17 to 71 with a mean of 47.65 ± 18.112. Fifteen cases (75%) had poor scores (<64), while five cases (15%) had fair scores (from 65:83). The follow-up duration ranged from 6 to 36 months with a mean of 21.35 ± 7.822 months postoperatively. Postoperative Lysholm score ranged from 85 to 100 with a mean of 96.8 ± 5.809. Four cases (20%) had good scores (from 84:94), while 16 cases (80%) had excellent scores (from 95:100).

No cases had complications like infection or deep venous thrombosis. One case (5%) had developed cyclops syndrome with a minimal limitation to full extension and was treated by arthroscopic lysis of adhesions with no loss of graft integrity, full extension was achieved with no affection of knee stability.

[Table 1] shows that there is a significant difference between preoperative and postoperative Lysholm scores.
Table 1: Comparison between preoperative and postoperative Lysholm score

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[Table 2] shows that there is a significant difference between preoperative and postoperative anterior drawer and Lachman tests.
Table 2: Comparison between preoperative and postoperative anterior drawer and Lachman tests

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[Table 3] shows that there is a significant difference between preoperative and postoperative pain and instability severity.
Table 3: Comparison between preoperative and postoperative pain severity and instability severity

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  Discussion Top


In our study, there was a significant improvement in patient outcome following single-bundle augmentation of partial tears of ACL, preserving intact ACL fibers, in young active patients with high functional demand. The results according to Lysholm score improved from 47.65 ± 18.112 (range: 17–71) to 96.8 ± 5.809 (range: 85–100). This is similar to that of Salama et al.[11], whose Lysholm score improved from 64.9 ± 9.07 to 95.3 ± 3.4, and close to that of Ochi et al.[12], whose Lysholm score improved from 75 (range: 44–95) to 100 (range: 81–100). It was close to that of El-Desoky et al.[13], whose Lysholm knee scores improved from 65.5 (range: 30–89) to 91(range: 61–100).

In our study, male: female ratio was 19: 1. This is similar to the study by Salama[11], in which male: female ratio was 14: 1, and close to Abat et al.[14], in which male: female ratio was 3: 1, but was not similar to Sonnery-Cottet et al.[15], in which male: female ratio was 22: 17, and also not similar to Pyjol et al.[3], in which male: female ratio was 16: 13.

In our study, there were 11 patients (55%) having a meniscal injury, eight patients had MM tear (40%), while three patients had LM tear (15%), the ratio of MM injury: LM injury was 8: 3. That is similar to Salama et al.[11], there were 17 patients (56.6%) having a meniscal injury, 15 patients had MM tear (50%), while two patients had LM tear (6.6%), the ratio of MM injury: LM injury was 15: 2. That is not similar to Sonnery-Cottet et al.[15] study, in which 12 patients had meniscal injury (30.8%), eight patients had MM tear (20.5%), while four patients had LM tear (10.3%), the ratio of MM injury: LM injury was 2: 1, which was not close to Pyjol et al.[3], eight patients were having meniscal injury (27.5%), three patients had MM tear (10.3%), while five patients had LM tear (17.2%), the ratio of MM injury: LM injury was 3: 5.

In our study, the main cause of injury was sports injuries (100%), similar to the study by Salama et al.[11], in which the main cause of injury was sports injury (56.7%), and also similar to Sonnery-Cottet et al.[15], in which the main cause of injury was sports injury (52%).

According to Korpershoek et al.[16], ACL reconstruction has shown superiority over conservative treatment of ACL tears due to the protective effect of ACL reconstruction on the meniscus and even on a repaired meniscus. Meniscal repair failure was reported to be high in ACL-deficient knees. Furthermore, early ACL reconstruction is better than delayed ACL reconstruction in reducing secondary meniscal injury.

Regarding Carulli et al.[8] and Won et al.[17], selective reconstruction of the partially torn ACL fibers, preserving the intact fibers of ACL, is better than sacrificing the residual portion in ACL reconstruction. There were significant improvements in the subjective and objective scores in all examined studies. It reduces postoperative knee laxity and adds joint stability and proprioception, thanks to the preservation of a greater amount of mechanoreceptors. It allows early rehabilitation and recovery. Gohil[18] reported earlier revascularization at 2 months with remnants' preservation using contrast-enhanced MRI scans. Graft reinnervation is also enhanced according to Nayak et al.[7]; thus, preservation of remnant fibers in partial ACL reconstruction is preferred.

Besides, augmenting the intact fibers and substituting the torn ones or bundles preserves the double-bundle structure of ACL with a lot of its native characteristics due to the presence of native intact ACL fibers.


  Conclusion Top


The single-bundle augmentation technique, preserving intact fibers of ACL, can be considered as a suitable method of treatment of symptomatic partial tears of ACL in young-age cases with high functional demand. This technique has shown promising results in our study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sabat D, Kumar V. Partial tears of anterior cruciate ligament: Results of single bundle augmentation. Indian J Orthop 2015; 49:129–135.  Back to cited text no. 1
    
2.
Temponi EF, de Carvalho Júnior LH, Sonnery-Cottet B, Chambat P. Partial tearing of the anterior cruciate ligament: diagnosis and treatment. Rev Bras Ortop 2015; 50:9–15.  Back to cited text no. 2
    
3.
Pujol N, Colombet P, Potel JF, Cucurulo T, Graveleau N, Hulet C, et al. Anterior cruciate ligament reconstruction in partial tear: Selective anteromedial bundle reconstruction conserving the posterolateral remnant versus single-bundle anatomic ACL reconstruction: Preliminary 1-year results of a prospective randomized study. Orthop Traumatol Surg Res 2012; 98:S171–S177.  Back to cited text no. 3
    
4.
Fayard J-M, Sonnery-Cottet B, Vrgoc G, O'Loughlin P, de Mont Marin GD, Freychet B, et al. Incidence and risk factors for a partial anterior cruciate ligament tear progressing to a complete tear after nonoperative treatment in patients younger than 30 years. Orthop J Sport Med 2019; 7:232596711985662.  Back to cited text no. 4
    
5.
Dallo I, Chahla J, Mitchell JJ, Pascual-Garrido C, Feagin JA, LaPrade RF. Biologic approaches for the treatment of partial tears of the anterior cruciate ligament. Orthop J Sport Med 2017; 5:232596711668172.  Back to cited text no. 5
    
6.
Mather RC, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, et al. Societal and economic impact of anterior cruciate ligament tears. J Bone Jt Surg 2013; 95:1751–1759.  Back to cited text no. 6
    
7.
Nayak M, Nag HL, Gaba S, Nag TC, Sharma S. Quantitative correlation of mechanoreceptors in tibial remnant of ruptured human anterior cruciate ligament with duration of injury and its significance: an immunohistochemistry-based observational study. J Orthop Traumatol. 2019; 19:5.  Back to cited text no. 7
    
8.
Carulli C, Innocenti M, Roselli G, Sirleo L, Matassi F, Innocenti M. Partial rupture of anterior cruciate ligament: preliminary experience of selective reconstruction. J Orthop Traumatol 2020; 21:5.  Back to cited text no. 8
    
9.
Takazawa Y, Ikeda H, Kawasaki T, Ishijima M, Kubota M, Saita Y, et al. ACL reconstruction preserving the ACL remnant achieves good clinical outcomes and can reduce subsequent graft rupture. Orthop J Sport Med 2013; 1:232596711350507.  Back to cited text no. 9
    
10.
Colombet P, Dejour D, Panisset J-C, Siebold R. Current concept of partial anterior cruciate ligament ruptures. Orthop Traumatol Surg Res 2010; 96:S109–S118.  Back to cited text no. 10
    
11.
Salama M, Elelesh H, Elmesallamy S, Elattar M. Selective bundle reconstruction in partial anterior cruciate ligament tears. Int J Adv Res 2018; 6:997–1010.  Back to cited text no. 11
    
12.
Ochi M, Adachi N, Uchio Y, Deie M, Kumahashi N, Ishikawa M, et al. A minimum 2-year follow-up after selective anteromedial or posterolateral bundle anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg 2009; 25:117–122.  Back to cited text no. 12
    
13.
El-Desoky E, Rizk A, Abdullah S, Abdel-Aziz A. Reconstruction of posterolateral bundle in partially torn anterior cruciate ligament using hamstring tendons. Egypt Orthop J 2017; 52:26–31.  Back to cited text no. 13
    
14.
Abat F, Gelber PE, Erquicia JI, Pelfort X, Tey M, Monllau JC. Promising short-term results following selective bundle reconstruction in partial anterior cruciate ligament tears. Knee 2013; 20:332–338.  Back to cited text no. 14
    
15.
Sonnery-Cottet B, Zayni R, Conteduca J, Archbold P, Prost T, Carrillon Y, et al. Posterolateral bundle reconstruction with anteromedial bundle remnant preservation in ACL tears: clinical and mri evaluation of 39 patients with 24-month follow-up. Orthop J Sport Med 2013; 1:1–8.  Back to cited text no. 15
    
16.
Korpershoek JV, de Windt TS, Vonk LA, Krych AJ, Saris DB. Does anterior cruciate ligament reconstruction protect the meniscus and its repair? A systematic review. Orthop J Sport Med 2020; 8:1–10.  Back to cited text no. 16
    
17.
Won SH, Lee B-I, Park SY, Min K-D, Kim J-BJ-H, Kwon S-W, et al. Outcome differences of remnant- preserving versus non-preserving methods in arthroscopic anterior cruciate ligament reconstruction: a meta-analysis with subgroup analysis. Knee Surg Relat Res 2020; 32:7.  Back to cited text no. 17
    
18.
Gohil S, Annear PO, Breidahl W. Anterior cruciate ligament reconstruction using autologous double hamstrings: a comparison of standard versus minimal debridement techniques using MRI to assess revascularisation − a randomised prospective study with a one-year follow-up. J Bone Jt Surg 2007; 89:1165–1171.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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