Contrast On Clinical Efficacy Of Different Autologous Materials For Arthroscopic Anterior Cruciate Ligament Reconstruction

Background and objectivesAnterior cruciate ligament (ACL) is one of the most important ligament in the knee, which plays an important role in the joint stability. ACL rupture is a common injury with an increasing incidence. According to information statistics, an estimated incidence of 85 cases per 100 000 people yearly occurred among 16 to 39 years old people. ACL injuries cannot self-healing, and delayed treatment can lead to significant instability of the knee and sequentially accelerate meniscus and articular degeneration, even result in high-degree dislocation of the knee.Early reconstruction is of great importance to restore the stability of knee and prevent, delay and relieve secondary injury. In recent 20 years, with the rapid development of arthroscopy, most of the doctors recommon arthroscopic ACL reconstruction. Though there are still some reports of open reduction and internal fixation(ORIF) for ACL injury in recent years, auxiliary and all arthroscopy reconstruction are becoming the main treatment option.National and international basic and clinical researches on the ACL injuries and its treatment had been studied, focusing on the reconstruction of anatomy, reconstruction of biomechanics, improvement of the materials and fixation methods, varieties of graft, arthroscopic reconstruction and rehabilitation. Among the upon researches, which is the best graft is related with clinical outcomes of reconstruction and so that it is of great concern in the field of ACL reconstruction. Therefore, recently the researches about graft are focus on the field of biological engineering and organize material science.Recently, it has reached a consensus in the aspect of indications and technique of anterior cruciate ligament reconstruction. However, which is best graft in the anterior cruciate ligament reconstruction is still controversial. At present, there has a wide selection of grafts, include auto-graft, heterogeneous allograft, biological material, artificial material and tissue engineering graft. Because of the advantage of no immune rejection, less infection chance, biomechanical stability and close physiological situation, the autogenous semitendinosus gracilis graft and the autogenous bone-patellar-bone graft have been widely used clinically.The autogenous bone-patellar-bone graft has the following advantages. First, it has good tensile, tensile strength and can be shaped into the graft that has similar maximum fracture strength with the normal one. Second, the bones at the two end of graft make it easy to fixed firmly and reach osseous healing. Finally, the graft has on elasticity that it can against various kinds of abnormal activities that is harmful to the knee stability. All those advantages provide bone-patellar-bone graft good biological foundation and make it become the gold standard of the anterior cruciate ligament reconstruction in the past. However, because of the local complications caused by material affect the clinical outcome, researchers try to find other grafts that can overcome the disadvantage of the bone-patellar-bone graft.Because the autogenous semitendinosus gracilis graft have less local complications caused by material, it has thought to be the alternative of bone-patellar-bone graft and become the focus research. The material of semitendinosus gracilis auto-graft is relatively simple, have no harm to the medial collateral ligament and don’t need to repair. What is more, the four bundle tendons after the semitendinosus gracilis auto-graft fold have a bigger cross sectional area(10mm2) and provide an initial strength of 4589N, which is stronger than the maximum tear strength of the normal ACL(1730N). All those advantages make the semitendinosus gracilis auto-graft can completely meet the tensile strength of the first cruciate ligament reconstruction and benefit for early rehabilitation activities. However, it has the following disadvantages. First, it takes more time for tendon bone healing that early rehabilitation activity is unprocurable. Second, it has poor postoperative stability and long external fixation time, therefore it cause knee adhesion easily and have bad recovering effect.In this study, the range of motion, muscle strength recovery and knee joint instability after two different autologous materials for arthroscopic anterior cruciate ligament (ACL) reconstruction were recorded to evaluate their clinical efficacy. The finally goal of this study is to provide clinical basis for the choice of graft in the anterior cruciate ligament reconstruction and therefore further improve the recovery of knee joint function in patients.Materials and methods1. Study subjects:46 cases of patients with ACL injury register in chaozhou hospital from January 2011 to July 2013 were recruited in our study. All the patents check the knee MRI to make sure the ACL injury. Patient with blood system diseases, cardiac arrhythmias, and severe liver and kidney dysfunction were excluded.2. Grouping:According to different grafts, all 46 patients were randomly divided into 2 groups, the hamstring group and the B-PT-B group. The hamstring group was treated with double-stranded semitendinosus gracilis tendon autograft materials reconstruction. In two groups of patients age, gender, duration, cause of injury and illness there was no statistically significant difference (P>0.05), comparable. All patient underwent arthroscopic resconstruction of acl by the same surgeon3. Surgery methods:All patients were actively perfect preoperative preparation, routine fasting for solids and liquids, and perform combined spinal epidural analgesia until the level of anesthesia is satisfied. The limb routine application of pneumatic tourniquet, the pressure around is about 300 mmHg. First, perform the knee joint diagnostic examination, further defined the injury, and check the complications and deal with other injuries. Second, material for transplantation, the hamstring group use double-stranded semitendinosus gracilis tendon as autograft materials, and the B-PT-B group use 1/3 of the patellar ligament as autograft materials. Under the Arthroscopic, the anterior cruciate ligament stumps is clean regularly and reshape the fossa intercondyloideaas the circumstances may require. After the anterior cruciate ligament tibial and femoral bone sites were determined using special locator respectively, establish and reconstruct the material size to matches the femoral tunnel and tibial tunnel. In the hamstring group, the femoral end fix with endo-button, the tibial end with interface screw. In the B-PT-B group, all the tendon ends were fixed with interface screw. Place the knee in 20-30° flexion location and adjust the tension, after the tension was appropriate, all the tendon ends were fixed. Run the Pivot Shift test and Lachman test to check the stability of the knee joint, using probe to test the tension of the reconstructed ligament.4. Rehabilitation Program:all patients followed the standard rehabilitation program of ACL reconstruction.5. Observe Index:(1) The range of motion, muscle strength recovery, knee joint instability, and Lysholm knee score of two groups were compared. The diameter of the quadriceps 10cm above the patellar was measured to estimate the muscle recovery degree. The pivot shift test and the Lachman test were used to estimate the knee stability. The Lysholm knee score were used to compare the outcomes of the two groups. (2) The results of isokinetic test of quadriceps and hamstrings in 60deg/sec before reconstruction and 3,12 months after reconstruction in two groups were recorded, including peak torque and agonist/antagonist ratio. (3) The difference of knee proprioception following ACL reconstruction between two groups was evaluated.6. Statistical method:The software spss19.0 was used for statistics. T test is used in measurement data and chi-square test used in qualitative data. Inspection level is defined as a=0.05.Results1. Comparison of patient demographics the two groups:the age, gender, Time from injury to surgery and between the B-PT-B group and the Hamstring group had no significant difference (P>0.05), so that it is comparable (Table 1).2. Comparison of the mean time of surgery the two groups:the mean surgery time of the B-PT-B group and the Hamstring group was 96±22 and 93±15. No significant difference was found between two groups (P>0.05) (Table 2)3. Comparison of the range of motion and muscle strength recovery of the two groups:the two groups have no significant difference in the range of motion (P>0.05). And the two groups have no significant difference in muscle strength recovery (P>0.05) (Table 3).4. Comparison of knee stability of the two groups:After treatment, knee joint instability of B-PT-B group was significantly better than hamstring group (P<0.05) (Table 4).5.1 Comparison of peak torque (PT) of the two groupsPT of uninjured limb between two groups have no significant difference in 60deg/sec before reconstruction and 3,12 months after reconstruction (P>0.05). Comparison of PT in 60deg/sec before reconstruction and 3,12 months after reconstruction in two groups were significantly different (P<0.05). PT of B-PT-B group was significantly higher than the Hamstring group.(Table 5).5.2 Comparison of H/Q of the two groupsH/Q of two groups in 60deg/sec before reconstruction and 3 months after reconstruction were significantly different (P<0.05). But H/Q of two groups have no significant difference 12 months after reconstruction.(Table6).6. Comparison of Lysholm knee score of the two groups:The Lysholm knee score of Hamstring group improves from 53.22±1.46 to 84.78±1.04, while the score of B-PT-B group improves from 54.24±1.60 to 84.77±1.48. The comparison of preoperative and postoperative of the two groups both have significance difference (P<0.05).But the postoperative comparison of the two groups has non-statistics significance (p>0.05) (Table.7).7. Comparison of joint position sense of two groups:The joint position sense of the Hamstring group and B-PT-B Group before operation were 5.21±2.68° and5.89±1.10°, respectively. The joint position sense of the Hamstring group 3 months and 12 months post-operatively were4.44±1.56° and 3.77±1.52°, while B-PT-B group were 2.45±1.13° and 2.04±1.22° respectively. The comparison of preoperative and postoperative of the two groups both have no significance difference (P>0.05) (Tab.8)The time threshold to detection of passive motion of the Hamstring group and B-PT-B Group at 15°efore operation were 2.06±0.61° and 2.04±0.83°, respectively. The joint position sense of the Hamstring group 3 months and 12 months post-operatively were 2.14±0.34° and 1.52±0.72°, while B-PT-B group were 2.08±0.55 and 1.46±0.23°,respectively. The comparison of preoperative and postoperative of the two groups both have no significance difference (P>0.05) (Tab.9).ConclusionThis study indicate that the arthroscopic anterior cruciate ligament reconstruction using the 1/3 B-PT-B auto-graft has exact effect. It can effectively restore knee function in patients and promote proprioception reconstruction. It can also promote better stability. This study indicates that the B-PT-B auto-graft is an effective method for ACL reconstruction.