Primary stability of single-stage revision reconstruction of the anterior cruciate ligament in case of failure of dynamic intraligamentary stabilization depends on implant position during ACL repair

Introduction The object of this study was to evaluate the primary stability of tibial interference screw (IFS) fixation in single-stage revision surgery of the anterior cruciate ligament (ACL) in the case of recurrent instability after ACL repair with dynamic intraligamentary stabilization (DIS), dependent on the implant position during DIS. Materials and methods Tibial aperture fixation in ACL reconstruction (ACL-R) was performed in a porcine knee model using an IFS. Native ACL-R was performed in the control group (n = 15). In the intervention groups DIS and subsequent implant removal were performed prior to single-stage revision ACL-R. A distance of 20 mm in group R-DIS1 (n = 15) and 5 mm in group R-DIS2 (n = 15) was left between the joint line and the implant during DIS. Specimens were mounted in a material-testing machine and load-to-failure was applied in a worst-case-scenario. Results Load to failure was 454 ± 111 N in the R-DIS1 group, 154 ± 71 N in the R-DIS2 group and 405 ± 105 N in the primary ACL-R group. Load-to-failure, stiffness and elongation of the group R-DIS2 were significantly inferior in comparison to R-DIS1 and ACL-R respectively (p < 0.001). No significant difference was found between load-to-failure, stiffness and elongation of R-DIS1 and the control group. Conclusion Primary stability of tibial aperture fixation in single-stage revision ACL-R in case of recurrent instability after DIS depends on monobloc position during ACL repair. Primary stability is comparable to aperture fixation in primary ACL-R, if a bone stock of 20 mm is left between the monobloc and the tibial joint line during the initial procedure.

Combined Suspensory and Aperture Fixation of Posterior Tibialis Tendon Anterior Transfer for Dropfoot

Category: Other; Trauma Introduction/Purpose: Anterior transfer of the tibialis posterior tendon (TPT) can restore ankle dorsiflexion in patients with foot drop. A limitation of this procedure is the need for postoperative ankle immobilisation. We present the results of a novel dual method of TPT docking which infers immediate stability, allowing early weightbearing. Methods: 8 patients underwent 9 tendon transfers,age range of 28-52 years. 3 patients had dropfoot from common peroneal nerve injury, 6 cases were part of a complex cavovarus or spastic equinovarus correction. The TPT is passed to the dorsum of the foot through the interosseous membrane. The docking site is prepared with a bicortical pilot hole followed by unicortical overreaming. The TPT is whipstitched and an Arthrex biceps button is threaded to the sutures. The button is passed bicortical and flipped using a tension slide technique give stable suspensory fixation. Additional stability is conferred by overpassing an Arthrex biotenodesis screw giving aperture fixation. Patients are immobilised in a boot and allowed to weightbear immediately. Results: Follow up was 6 months. There was difficulty in docking of suspensory fixation in two of the early cases. These patients had aperture fixation and were immobilised non weightbearing in a cast for 6 weeks. With technical modifications, all subsequent patients had dual fixation. At 6 months there were no radiological or clinical failures of fixation. Patients without other underlying issues were able to mobilise splint free at 6 months. All patients were satisfied with their procedure. Conclusion: Aperture fixation with an interference screw has become the gold standard for TPT transfer, however, patients still need a prolonged period of immobilisation. Combined suspensory and aperture fixation is technically straightforward and seems to give more initial stability allowing early weightbearing. Further prospective studies and biomechanical studies are needed to validate this technique.

Aperture and Suspensory Fixation Equally Efficacious for Quadriceps Tendon Graft Fixation in Primary ACL Reconstruction: A Systematic Review

This review is aimed to compare suspensory and aperture quadriceps tendon autograft femoral and tibial fixations in primary anterior cruciate ligament reconstruction (ACL-R), and the clinical outcomes and complication profiles of each fixation method. Greater understanding of the optimal graft fixation technique for quadriceps tendon (QT) autografts may assist surgeons in improving outcomes after ACL-R. PubMed, Embase, and Medline were searched from database inception to September 2017, and again to July 2018, and identified 3,670 articles, 21 studies of which satisfied inclusion/exclusion criteria. Across included studies, 1,155 QT ACL-R patients (mean age, 28.7 years [range, 15–59 years], with mean postoperative follow-up of 36.1 months [range, 3.4–120 months]), were analyzed. Suspensory fixation on both sides demonstrated a higher percentage of patients (81.7%) achieving the highest rating of “A or B” on the International Knee Documentation Committee (IKDC) knee ligament examination form compared with aperture fixation on both sides (67.7%). Moreover, suspensory fixation had a lower side-to-side difference in anterior laxity (1.6 mm) when compared with aperture fixation (2.3 mm). Among studies which reported graft failure, all of which employed aperture fixation, the rate was 3.2%. Across available data, primary ACL-R using QT grafts appears to have successful short-term outcomes with a short-term graft failure rate of 3% independent of fixation method. While there is limited data regarding the comparison of aperture and suspensory soft-tissue quadriceps tendon (SQT) fixation in ACL-R, the findings of this systematic review suggest that suspensory fixation and aperture fixation in both the femoral and tibial tunnels are equally efficacious based on clinical outcome data on IKDC grade and measured laxity. This is a level IV, systematic review study.