Anatomik Ön Çapraz Bağ Rekonstrüksiyonun Femoral Tünel Oblisitesi İle İlişkisinin Klinik Olarak Değerlendirilmesi

Öz

Amaç: Artroskopik ön çapraz bağ (ÖÇB) rekonstrüksiyonlarında hamstring tendon grefti, patellar tendon grefti, allogreft gibi çeşitli tendon greftleri kullanılmaktadır. Çalışmamızda, Otojen Hamstring Tendonlar kullanılarak Anatomik Ön Çapraz Bağ Rekonstrüksiyonu uygulanan hastalarda femoral tünel oblisitesinin sonuçlarını güncel literatür eşliğinde değerlendirmeyi amaçladık.

Gereç ve Yöntemler: Ocak 2013 – Haziran 2016 tarihleri arasında ön çapraz bağ rüptürü nedeniyle kliniğimizde cerrahi olarak tedavi edilen hastalar telefonla aranarak hastaneye davet edildi. Bunlar içerisinden fizik muayeneleri, grafi kontrolleri ve ölçümleri yapılan 64 hasta çalışmaya dâhil edildi.

Bulgular: Hastalarımızın 55’i erkek, 9’u bayandı. Hastaların yaş ortalaması 29.3±8.12 (14-47) idi. Ortalama takip süremiz 14.47±7.44 (6-36) aydır. Kontrol Lysholm ve Tegner skoru ameliyat öncesi değerlerle karşılaştırıldığında istatistiksel açıdan ileri derecede anlamlı farklılıklar bulundu (p<0.001). International Knee Documentation Committee (IKDC) diz bağları değerlendirme sistemine göre ameliyat öncesi 3 hasta (%4.7) B, 18 hasta (%28.12) C ve 43 hasta (%67.18) D olarak saptandı. Ameliyat sonrası yapılan son kontrol muayenesinde 41 hasta (%64.06) A, 21 hasta (%32.81) B ve 2 hasta (%3.12) C grubuna dâhil edildi. Ortalama femur tüneli oblisitesi 41.2±7.2° bulundu.

Sonuç: Ön çapraz bağ’ın rotasyonel stabilitesine oblik femoral tünel yerleşiminin daha fazla yarar sağladığı düşünülmektedir. Biz bu çalışmamızın sonucunda ön çapraz bağın otojen hamstring tendon grefti kullanarak anatomik teknikle uygulanmasının femoral tünel oblisite artışının fonksiyonel sonuca katkısının daha yararlı olduğu kanaatindeyiz.  

Anahtar Kelimeler

• Anterior cruciate ligament reconstruction,rüptür,artroskopi

Clinical Evaluation of the Relationship of Anatomical Anterior Cruciate Ligament Reconstruction with Femoral Tunnel Obliquity

Öz

Aim: Various tendon grafts such as hamstring tendon graft, patellar tendon graft, allograft are used in arthroscopic anterior cruciate ligament (ACL) reconstructions. In our study, we aimed to evaluate in the light of the updated literature, femoral tunnel obliquity results of anterior cruciate ligament (ACL) reconstruction using autogenous hamstring tendon graft.

Material and Methods: Between January 2013 and June 2016, the surgically treated patients in our clinic who had anterior cruciate ligament (ACL) rupture were called and invited to hospital by telephone. 64 patients whose physical examinations, radiographs and measurements were completed have been included in the study.

Results: 55 of our patients were male and 9 were female. The mean age of the patients was 29.3±8.12 (14-47) years. Total follow-up time was 14.47±7.44 (6-36) months. There were statistically significant difference between control and follow-up Lysholm and Tegner activity scores (p<0.001). According to the International Knee Documentation Committee (IKDC) knee ligation evaluation system, 3 patients (4.7%) were B, 18 patients (28.12%) were C and 43 patients (67.18%) were revealed as D in preoperative term. In the last postoperative examination, 41 patients (64.06%) were included in the group A, 21 patients (32.81%) B and 2 patients (3.12%) were included in the group C. The mean femoral tunnel obliquity was found as 41.2±7.2°.

Conclusion: The oblique femoral tunnel placement is thought to be of greater benefit to the rotational stability of the ACL. As a result of this study, we are of the opinion that the application of anterior cruciate ligament with an anatomical technique using an autogenous hamstring tendon graft is more beneficial to the functional outcome of femoral tunnel obliquity increase.

Anahtar Kelimeler

• Anterior cruciate ligament reconstruction,rupture,arthroscopy

Kaynakça

1. 1. Woo SLY, Fox RJ, Sakane M, Livesay GA, Rudy TW, Fu FH. Biomechanics of the ACL: Measurements of in situ force in the ACL and knee kinematics. The Knee. 1998; 5(4): 267-88.
2. 2. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: A level I systematic review comparing failure rates and functional outcomes. Orthop Clin North Am. 2010; 41(2): 249-62.
3. 3. Çetinkaya E, Mutlu H, Yavuz U, Gül M, Çetin Ü, Özkaya U. Anteromedial portal tekniği ile tek demet anatomik ön çapraz bağ rekonstrüksiyonu sonuçlarımız. Jarem. 2016; 6(2): 88-93.
4. 4. Noyes FR, Keller CS, Grood ES, Butler DL. Advances in the understanding of knee ligament injury, repair, and rehabilitation. Med Sci Sports Exerc. 1984; 16(5): 427-43.
5. 5. Calas P, Dorval N, Bloch A, Argenson JN, Parratte S. A new anterior cruciate ligament reconstruction fixation technique (quadrupled semitendinosus anterior cruciate ligament reconstruction with polyetheretherketone cage fixation). Arthrosc Tech. 2012; 1(1): e47-52.
6. 6. Darren J, Todd S, James I, Fu FH, Harner CD. Revision anterior cruciate ligament surgery: Experience from pittsburgh. Clin Orthop Relat Res. 1996; 325(2):100-9. 7. Dei Giudici L, Fabbrini R, Garro L, Arima S, Gigante A, Tucciarone A. Arthroscopic transphyseal anterior cruciate ligament reconstruction in adolescent athletes. J Orthop Surg (Hong Kong). 2016; 24(3): 307-11.
7. 8. Shelbourne KD, Patel DV. Timing of surgery in anterior cruciate ligament injured knees. Knee Surg Sports Traumatol Arthrosc. 1995; 3(3): 148-56.
8. 9. Shelbourne KD, Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations. Am J Sports Med. 2000; 28(4): 446-52.

9. 10. Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, et al. Decision making in the multiligamnet –injured knee:an evidence-based systematic review. Arthroscopy. 2009; 25(4): 430-8.
10. 11. Gupta R, Bahadur R, Malhotra A, Masih GD, Gupta P. Anterior cruciate ligament reconstruction using hamstring tendon autograft with preserved insertions. Arthrosc Tech. 2016; 5(2): e269-74.
11. 12. Darnley JE, Léger-St-Jean B, Pedroza AD, Flanigan DC, Kaeding CC, Magnussen RA. Anterior cruciate ligament reconstruction using a combination of autograft and allograft tendon: A moon cohort study. Orthop J Sports Med. 2016; 4(7): 2325967116662249.
12. 13. Vaishya R, Agarwal AK, Ingole S, Vijay V. Current trends in anterior cruciate ligament reconstruction: A Review. Cureus. 2015; 7(11): e378. doi: 10.7759/cureus.378. Review.
13. 14. Musil D, Sadovsky P, Filip L, Vodicka Z, Stehlík J. Anterior cruciate ligament reconstruction using hamstring tendon autograft with reserved ınsertions. Arthrosc Tech. 2016; 5(2): 269-74
14. 15. Luo H, Yu JK, Ao YF, Yu CL, Peng LB, Lin CY, et. al. Relationship between different skin incisions and the injury of the infrapatellar branch of the saphenous nerve during anterior cruciate ligament reconstruction. Chin Med J (Engl). 2007; 120(13): 1127-30.
15. 16. Wolf MR, Murawski CD, van Diek FM, van Eck CF, Huang Y, Fu FH. Intercondylar notch dimensions and graft failure after single-and double-bundle anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2015; 23(3): 680-6.
16. 17. Gadikota HR, Sim JA, Hosseini A, Gill TJ, Li G. The relationship between femoral tunnels created by the transtibial, anteromedial portal, and outside-in techniques and the anterior cruciate ligament footprint. Am J Sports Med. 2012; 40(4): 882-8.
17. 18. Panni AS, Milano G, Tartarone M, Demontis A, Fabbriciani C. Clinical and radiographic results of ACL reconstruction: A 5 to 7 year follow-up study of outside in versus insideout reconstruction techniques. Knee Surg Sports Traumatol Arthrosc. 2001; 9(2): 77-85.
18. 19. Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. Part II: the anterior cruciate ligament. Am J Sports Med. 1989; 17(2): 208-16.
19. 20. Shantanu K, Kushwaha SS, Kumar D, Kumar V, Singh S, Sharma V. A Comparative study of the results of the anatomic medial portal and all-inside arthroscopic ACL reconstruction. J Clin Diagn Res. 2016; 10(11): RC01-3.
20. 21. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect. 2001; 50(1): 463-74.
21. 22. Allen Cr, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. Orthop Clin North Am. 2003; 34(1): 79-98.
22. 23. Jackson DW, Gasser SI. Tibial tunnel placement in ACL reconstructıon. Arthroscopy. 1994; 10(2): 124-31.
23. 24. Takeda Y, Iwame T, Takasago T, Kondo K, Goto T, Fujii K, et al. Comparison of tunnel orientation between transtibial and anteromedial portal techniques for anatomic double-bundle anterior cruciate ligament reconstruction using 3-dimensional computed tomography. Arthroscopy. 2013; 29(2): 195-204.
24. 25. Taketomi S, Inui H, Nakamura K, Yamagami R, Tahara K, Sanada T, et. al. Secure fixation of femoral bone plug with a suspensory button in anatomical anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft. Joints. 2016; 3(3):102-8.
25. 26. Klein JP, Linter DM, Downs D, Vavrenka K. The incidence and significance of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation. Arthroscopy. 2003; 19(5): 470-76.
26. 27. Mologne TS, Friedman MJ. Anterior cruciate ligament reconstruction with bone-patella tendon-bone autograft: Indications, technique, complications, and management. In: Insall JN, Scott WN, editors. Surgery of the knee. Philadelphia: Churchill Livingstone; 2001. p. 681-93.
27. 28. van der Hart CP, van den Bekerom MP, Patt TW. The occurrence of osteoarthritis at a minimum of ten years after reconstruction of the anterior cruciate ligament. J Orthop Surg. 2008; 3: 1-9. doi:10.1186/1749-799X-3-24.
28. 29. Değirmenci E, Yücel İ, Özturan K. Hamstring tendon otogrefti ile ön çapraz bağ rekonstrüksiyonu. Bakırköy Tıp Dergisi. 2010; 6(1): 29-34.
29. 30. Howell SM, Taylor MA. Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am. 1996; 78(6): 814-25.