| Research background:The Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) are an important structure for stability of the knee joint, and they are easily injured while playing sports or in common accidents that occur in our daily lives. The difficult treatment of injured ligament and the high disability rate, bring a great burden on both individuals and society. Thus, how to rehabilitate the cruciate ligament is always a challenging topic in the orthopaedic field. At present, there is neither a method nor a material which can completely recover its anatomical structure and function after injury. Because of the poor quality of healing and the higher possibility of further looseness , the method of repairing the cruciate ligament by suturing ruptured parts has been discarded. Instead, the reconstruction and augmentation of arthroligament has been gaining its popularity. Although autogenous tissue transplatation is the standard method for ACL/PCL reconstruction, it' s at the expense of normal tissue .A part from the limitations of various conditions, it may also worsen the already disabled limb function. Artificial material restricted by its histocompatibility, biological mechanics and the complex bilogical environment do not easily adapt to the complicated and multi-axial compound movement of the knee joint. Meanwhile, common agreement has been achieved on the selection of allogenous graft, on the obtaining of appropriate material and on the conservation method as well as on the knowledge of the insignificant immune response after transplantation. The historical, biological and bio-mechanical changes after the surgery have been studied and the clinical effects has also been affirmed. Naturally, a question have been put before us concernily what the difference is between autogenous andallogenous transplantation to reconstruct a ruptured ligament. The answer is not easy to be found. There is no valuable prospective research in this field, and there' re more questions concern the therapeutic effect of allogenous transplantation and whether it' s suitable for Chinese people we can uncertain about the answers to the questions. So , to solve these questions, we performed this research through delicate and strict clinical scientific studies in the principle of randomness-. comparision> repetition and equilibrium, with the aid of advanced clinical follow-up checking measures.Our research combined with the advanced theory and knowledge on the treatment of knee joint ligament injury, verifies the real effects and feasibility of allogenous reconstruction, which will no doubt improve the clinical application of this technique and allow the procedure to develop fully. ObjectivesThrough strict experimental design, we' 11 observe both the effects and differences between allogenous and autogenous transplantation. At the same time, we' 11 observe the long-term effectiveness of allogenous tissue transplantation to reconstruct other ruptured ligaments of joints including the PCL, the Medial Collateral Ligment(MCL),the Lateral Collateral Ligment(LCL) of the knee joint and the Coracoclavicular Ligament(CL) of the shoulder joint, to ensure the clinical feasibility of allogenous transplantation. We well do this new research in China and remedy the flaws of the retrospective research worldwide. MethodsFirstly : According to AATB' s technological standards, we had set up an autogenous tissue bank.Secondly : Because the occurrence of ACL injury is more common clinically , and the research sample is larger, we can adopt a totally random groupingmethod. We randomly classified 53 ACL (HI0) patients into two groups: group A and group B. Group A patients were used for autogenous transplantation research. This group contained 25 patients and their grafts were from their own B-PT-B or semitendinous tendon or gracilis tendon. In group B, there were 28 patients undertaking allogenous transplantation with grafts from the heterogeneous B-PT-B, the semitendinous or gracilis tendon , the tibialis posterior tendon, or the calcaneus tendon-bone. These two groups were identical in age^ severty of injury and complications. All the operations were done by the same group of surgeons with the aid of arthroscopy. After the operations, we compared their general situation, including the days they spent in the hospitals, the duration of the operations, as well as post-operational fever and post-operational complications. At the same time, we fully examined their joints' function and stability using only the standard tests such as: physiological examination, the function test , IKDC and LysholnrTegner knee joint scales as well as the KT-2000 test. All patients were monitored for 12 to 31 months. The average monitoring duration was 19 months. Thirdly: Because the injury and the necessity for operation of PCL, lateral and medial collateral ligament of the keen and coracoclavicular ligament of the shoulder joint are somewhat fewer than ACL injuries, we couldn' t collect enough samples in a limited time to do clinical comparison research. As a result, we have to do retrospective research to study these outcomes (including using allogenous ACL ligament reconstruction). 43 patients have been divided into 3 groups as follows: Group A: 34 patients, ACL or ACL/MCL injured;Group B: 6 patients, PCL or PCL/LCL injured;Group C: 3 patients, complete acromio-clavicular ligament injured. The allografts are as follow: B-PTHB, semitendinous and gracilis tendon, tibialis posterior tendon and calcaneus tendon bone. The surgeons are from the same group as mentioned above. The post-operationalfollow-up period is, on average, 19 months, and the same test measures wereapplied.Results1 A prospective study of the anterior cruciate ligament reconstruction:allograft versus autograft1.1 Comparison of general situation between the two groups :In group A and B, the averaged time of staying in the hospital, the averagedoperation time, the duration of fever after operation and thecomplications in and after operaton were:15. 6 days and 17.2 days, 89. 5minutes and 60.3 minutes, 4.7days and 7.8days, 4 cases and 3cases, respectively. There are significant differences in the duration offever after operation and the average operation time between group A andB (P<0. 05). There are no differences in the other aspects betweengroup A and B (P>0. 05) (see table 1).1.2. Physiological examination1. 2.1 ROM: knee-extension examination:comparing groups A and B, the normalrate, slightly abnormal rate and moderately abnormal rate were 76% and 71%,16% and 19%, 8% and 9%, respectively. Knee—flexion examination: In groupA and B, the normal rate, slightly abnormal rate and moderately abnormalrate were 80% and 75%, 12% and 14%, 8% and 11%, respectively. There are nosignificant differences between the two groups(see table2-3).1.2.2 Lachman. ,ADT test: In group A and B, the Lachman and ADT were all IH° before operation. After operation, the Lachman measurements were 1.30 + 0.44° and 1.06 + 0.66° .And ADT test measurements were 1.48 + 0.65° and 1.17 + 0.78° in group A and group B respectively after opreation.1.2.3 Axial shift test: The preoperative axial movement degrees were 1° -3° , and the averaged degrees were 2.3 + 0.6° and 2.5 ±0.7° respectively in groups A and B. The postoperative axialmovement degrees were 0° -2° , and the averaged degrees were0. 6 + 0. 3° and 0. 8 + 0. 5° respectively in groups A and B. There is a significant difference between pre-operation and post-operation test results (P<0. 05), but no difference between the two groups (p<0. 05).1.3 Functional test: The normal rate .nearly normal rate and abnormal rate of the single leg horizontal leaping test were 28% , 25%, 64% and 61%, 8% and 11% in groups A and B, respectively. The severely abnormal rate of single leg horizontal leaping test was 3% in group B. The normal rate , nearly normal rate and abnormal rate of the vertical leaping test were 32% , 25%, 64% and 65%, 4% and 3. 5% in group A and B respecively. The severely abnormal rate of the vertical leaping test was 3% in group B. There is no significant difference between the two groups in either test according to the statistics.1.4 IKDC and lysholm-Tegner knee joint general function estimation: There are significant differences between the pre-operational and post-operational index concerned, but no distinct difference between the two groups (p>0. 5). The post-operational tibiae forward displacement of ill-side less than 3mm compared with an intact one are, respectively, 85% and 86% in group A and group B, whereas the displacement more than 5mm is respectively 4% and 7.1%.1.5 KT-2000 test: The tibiae forward displacement preoperatively and postoperatively were 9. 8 + 3. 8mm and 10. 9 + 2. 6 mm, 5. 7 + 2. 8 mm and 6.3 + 3.6 mm in groups A and B respectively. There is significant difference between pre and post-operation (p<0. 01), but no difference between the two groups (p>0. 05). In groups A and B, the average displacement of the injured side compared with the intact side after operation was1. 9 + 0. 7mm and 2. 3 + 0. 9mm. In groups A and B, 88% and 86% of the patients had a displacement of less than 3. 0mm, and 4. 0% and 7. 1% had a displacement of more than 5. 0mm. There is no differencebetween groups A and B.2 Allografts in clinical application : A primary and retrospective study The average follow-up were 19 months postoperatively. ROM test: after operation, the normal rate was 91%, with 9% for near normality for single ACL or PCL injury;for compound injury , the normal rate was 88%, with 13% for near normality, and there is no abnormal cases. The lysholm score for the two groups after ACL/PCL reconstruction surgery preoperatively and postoperatively were 63 ± 5. 6 and 89 ± 5. 9, and there are significant differences between them. There were 7. 5%, 57.5%,30% and 5% of patients respectively whose postoperative IKDC score was grade A, grade B, grade C and grade D. The tibiae forward displacement preoperatively and postoperatively were 13.1 ± 0.29mm and 4.7 + 1.37 in group A, and 10. 5 + 2. 5mm and 5.7 + 1. 3mm in group B using a KT-2000 test. There was a significant difference between pre-operation and post-operation (p<0. 01). In group A and B, the average displacement of the injured side compared with the intact side after operation was 2.4 + 0. 9mm and 2. 8 + 0. 9mm. There were 82% of them whose displacement was less than 3. 0mm, and 10% whose displacement was more than 5. 0mm. There were 90% of patients whose ADT test were 3° preoperatively and 1.32° postoperatively. X -ray examination shows that the space of acromioclavicular joint is nearly normal after the coracoclavicular ligament reconstruction. And this joint together with the shoulder joint have good mobility, which means the ill-leg has regained the proper function. Concerning complications, only one case became infected during ACL reconstruction, and there were two cases of deep venular thrombosis.Table 1 The results of the general situation between the two groupsGroups via Stay in Operation Duration ofcomplications contents hospital (d) time( min) fever(d)Group A 15.6 89.5 4.7 4/25Group B 17.2 60.3 7.8 3/28Conclusion: as the data shows, apart from the statistically significant difference in operation time and duration of fever after operation between the two groups (P<0.05) , other aspects are not significant different (P>0. 05)Table 2 Results of extension examination(%)Groups via contentsnormalitySlightly abnormalityModerate abnormalityGroup A Group B76% 71%16% 19%8% 9%Table3 resultsof flexion examination(%)Groups via contentsnormalitySlightly abnormalityModerate abnormality80% Group A 12% 8%Group B 75% 14% 11%there are no statistical significant differences between the two groups. (X2=0. 75, p>0. 05 on table 2 and X2=0.16, P>0. 05 on table 3 between the two groups) Conclusion:The reconstruction of ACL/PCL is an important procedure to maintain the keen function, and to improve the quality of life as well as toenhance the labor force. How to recover the function of ACL/PCL ruptured ligaments is one of the most popular topics in the field of orthopaedics, and it has been gaining consensus among scholars in orthopaedics. The selection of graft, surgical technique and type of rehabilitations are the 3 major factors that determine the curative effects of this operation. Among them, selecting a graft which has good histocompatibility and a comparable biological mechanism are of vital significance.First, due to the fact that autogenous tissular transplantation is at the expense of normal tissue , aside from the limitations of individual conditions, it is possible to aggravate the injuried limb funtion . Secondly, artificial materials which have been limited by their histocompatibility, biological mechanical traits as well as complex bio-environnment of knee joint are not a perfect choice for clinical usage at the present time. So, reconstruction of ACL/PCL through allogenous tissular transplantation is gaining more and more attention internationally .This research shows that: reconstruction of ACL , PCL MCL LCL and coracoclavicular ligament through allogenous transplantatiom has satisfactory therapeutic effects compared to autogenous transplantation. In post-operational arthrofunction and arthrostability, there is no significant difference between the two groups. This technique has its advantages as follows:First, there is less or no extra damage to patients;Second , it' s very convenient. The operation time is shortened and the procedure is simplified. Third, it has similar therapeutic effects to auto-transplantation. Therefore, in the near future, allogenous tissue transplantation will be a method to use instead of the autogenous transplantation in some situations .After all, allogenous tissue is heterogenous, The use of allogenous tissue has several disadvantages such as the danger of disease transmission through operation, the immune response, delayed tissue combination, insufficient loading ability, the high possibility of post-operational rupture, enlargement of the bone tunnel, its great expense and complicated sterilization (especially using auto semi-tendinous tendon or auto gracilis tendon which has less surgical complications than traditional B-PT-B method). So, the first choice is always auto-transplantation, except in these situations: (l) an injury of multi-ligaments, short of auto-grafts;(2) secondary revision surgery;(3) when autografts are not suitable to be used (such as the grafts of semitendinous tendon and gracilis tendon that are too thin or too short, as well as malalignment of knee extension apparatus such as patella alta);(4)for middle-aged patients doing insufficient sports. One thing should be emphasized that the exact and correct location of the bone marrow tunnel be found during operation. The consolidated fixation of a graft at the terminal end and of the tunnel and post-operational rehabilitation are equally important to the success of a ligament reconstruction .
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