Update On Surgical Technique for Anterior Cruciate Ligament RepairFor years, surgeons have used the tried and tested bone-patellar tendon-bone graft repair for anterior cruciate ligament (ACL) repairs. But more and more there are an increasing number of other repair options available.
In this update, surgeons from the University of Maryland review the autograftchoices. Autograft means the tendon harvested and used as a graft to replace the torn ligament comes from the patient. The four main types of autograft include 1) bone-patellar tendon-bone, 2) hamstring, 3) quadriceps, and 4) bone-hamstring tendon-bone.
Type of graft is important but so is graft fixation. Fixation refers to the method used to hold the donor tissue in place until healing occurs. Most of the fixation methods involve the use of tissue bundles. For example, there's the double-bundle technique and the four-stranded and eight-stranded techniques.
Other graft fixation options include femoral press-fit, femoral cross-pin, screws, and endobutton femoral fixation. The authors describe each of these and review when surgeons are most likely to use each one. The results of recent research using any of these fixation methods is also summarized.
After looking over all of the recent publications, there wasn't a clear number-one-best-choice for ACL graft repair. Little difference was seen in results between the hamstring tendon and bone-patellar tendon-bone autografts. Not enough studies have been done using the single- or double-stranded technique to form a clear decision.
Other areas that remain unclear include the best type of bundle technique to use. Likewise, it's not possible to measure rotary stability of the knee after surgery. This makes it difficult to compare results from method to method. It was possible to see that several of the fixation methods (e.g., metal screw, bioabsorbable screw, endobutton femoral fixation, trans-fix femoral fixation) are equal in results.
It seems at the present time that there are more unanswered questions than answers to the dilemma of choosing the best repair and fixation techniques for ACL injuries. More studies are needed to come to some firm conclusions in this area of surgery.
Craig H. Bennett, and Ian M. Loper. Graft Choices and Fixation Types in Anterior Cruciate Ligament Reconstruction. In Current Orthopaedic Practice. May/June 2008. Vol. 19. No. 3. Pp. 288-292.
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