Сhanges in the donor site following bone-patellar tendon-bone graft harvesting with open or closed defects

Cover Page


Cite item

Full Text

Abstract

Background. The patellar tendon is frequently used as a graft source for anterior cruciate ligament reconstruction. The search of the factors that enhance the healing process of the donor site may contribute to improved anatomical and functional outcomes.

The aim of the study — to determine the features of the harvesting techniques for better donor site healing by examining postoperative changes in the patellar tendon following two different graft harvesting methods.

Methods. This study examined the condition of the patellar tendon after two methods of graft harvesting under the same early mobilization protocols. Group 1 (retrospective) enrolled 30 patients who underwent follow-up MRI at different times after surgery, during which ligamentous and bony defects were not closed. Group 2 (prospective) included 30 patients who received full-layer suturing of the patellar tendon and patellar and tibial bone defects plasty. Postoperatively, all patients underwent radiography and the Insall-Salvati ratio of their patellar position was evaluated. In Group 2, MRI was performed preoperatively and 12 months post-surgery, while CT scans were taken 1 day and 6 months post-surgery. MRI was utilized to measure the size and qualitatively assess the condition of the tendon, whereas bone defects were evaluated on CT scans.

Results. The Insall-Salvati ratio of patellar position was within the physiological norm and did not differ between the groups (M1 = 1.11; SD1 = 0.13 and M2 = 1.12; SD2 = 0.15; p = 0.955). In Group 2, after 12 months, the length of the tendon was 3.1% shorter (M = -1.4 mm; SD = 2.4 mm; p = 0.003). The width of the tendon in the upper third and middle third was slightly increased (M = 0.3 mm; SD = 2.4 mm; p = 0.502 and M = 0.5 mm; SD = 2.1 mm; p = 0.205), while in the lower third it was 2.7% larger (M = 0.7 mm; SD = 1.7 mm; p = 0.034). The thickness of the tendon increased by 55% (M = 2.4 mm; SD = 1.6 mm; p = 0.001). All patients in Group 1 exhibited persistent bony and ligamentous defects. In Group 2, six months after surgery, cancellous bone filled the defects and integrated with the bone bed; 12 months later, the tendon was healed, and its shape and size approximated preoperative parameters.

Conclusion. Full-layer suturing of the patellar tendon, reconstruction of defects using cancellous bone autograft, and early mobilization promote the healing of bone defects and restore the integrity, shape, and size of the tendon.

About the authors

Pavel A. Trachuk

Vreden National Medical Research Center of Traumatology and Orthopedics

Author for correspondence.
Email: trachukpav@gmail.com
ORCID iD: 0000-0002-4442-5831
Scopus Author ID: 58503543200
Россия, St. Petersburg

Aleksandr P. Trachuk

Vreden National Medical Research Center of Traumatology and Orthopedics

Email: trachukalex@mail.ru
ORCID iD: 0009-0005-5457-0003
Scopus Author ID: 6505851107

Cand. Sci. (Med.)

Россия, St. Petersburg

Oleg E. Bogopolskiy

Vreden National Medical Research Center of Traumatology and Orthopedics

Email: 9202211@gmail.com
ORCID iD: 0000-0002-4883-0543
Scopus Author ID: 58502787000
Россия, St. Petersburg

References

  1. Arnold M.P., Calcei J.G., Vogel N., Magnussen R.A., Clatworthy M., Spalding T. et al. ACL Study Group survey reveals the evolution of anterior cruciate ligament reconstruction graft choice over the past three decades. Knee Surg Sports Traumatol Arthrosc. 2021;29(11):3871-3876. doi: 10.1007/s00167-021-06443-9.
  2. Fukuda H., Ogura T., Asai S., Omodani T., Takahashi T., Yamaura I. et al. Bone-patellar tendon-bone autograft maturation is superior to double-bundle hamstring tendon autograft maturation following anatomical anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2022;30(5):1661-1671. doi: 10.1007/s00167-021-06653-1.
  3. Gabler C.M., Jacobs C.A., Howard J.S., Mattacola C.G., Johnson D.L. Comparison of Graft Failure Rate Between Autografts Placed via an Anatomic Anterior Cruciate Ligament Reconstruction Technique: A Systematic Review, Meta-analysis, and Meta-regression. Am J Sports Med. 2016;44(4):1069-1079. doi: 10.1177/0363546515584043.
  4. Gifstad T., Foss O.A., Engebretsen L., Lind M., Forssblad M., Albrektsen G. et al. Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia. Am J Sports Med. 2014;42(10):2319-2328. doi: 10.1177/0363546514548164.
  5. Frank R.M., Mascarenhas R., Haro M., Verma N.N., Cole B.J., Bush-Joseph C.A. et al. Closure of patellar tendon defect in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: systematic review of randomized controlled trials. Arthroscopy. 2015;31(2):329-338. doi: 10.1016/j.arthro.2014.09.004.
  6. Gaudot F., Leymarie J.B., Drain O., Boisrenoult P., Charrois O., Beaufils P. Double-incision mini-invasive technique for BTB harvesting: its superiority in reducing anterior knee pain following ACL reconstruction. Orthop Traumatol Surg Res. 2009;95(1):28-35. doi: 10.1016/j.otsr.2008.09.006.
  7. Hacken B.A., Keyt L.K., Leland D.P., LaPrade M.D., Camp C.L., Levy B.A. et al. A Novel Scoring Instrument to Assess Donor Site Morbidity After Anterior Cruciate Ligament Reconstruction With a Patellar Tendon Autograft at 2-Year Follow-up Using Contemporary Graft-Harvesting Techniques. Orthop J Sports Med. 2020;8(6):2325967120925482. doi: 10.1177/2325967120925482.
  8. Маланин Д.А., Сучилин И.А., Демещенко М.В., Черезов Л.Л. Формирование бедренного тоннеля при артроскопической пластике передней крестообразной связки с использованием референтных анатомических структур межмыщелковой ямки. Травматология и ортопедия России. 2013; 19(3):22-28. doi: 10.21823/2311-2905-2013--3-22-28. Malanin D.A., Suchilin I.A., Demeschenko M.V., Tscherezov L.L. Femoral tunnel formation using reference anatomical structures of the femoral intercondylar space during anterior cruciate ligament reconstruction. Traumatology and Orthopedics of Russia. 2013; 19(3):22-28. doi: 10.21823/2311-2905-2013--3-22-28.
  9. Маланин Д.А., Демещенко М.В., Краюшкин А.И., Сучилин И.А., Черезов Л.Л. Область большеберцового прикрепления передней крестообразной связки с позиций хирургической анатомии. Вестник Волгоградского государственного медицинского университета. 2015;12(1):43-46. Malanin D.A., Demeschenko M.V., Krayushkin A.I., Suchilin I.A., Cherezov L.L. Area of the tibial attachment of the anterior cruciate ligament from the perspective of surgical anatomy. Journal of Volgograd State Medical University. 2015;12(1):43-46.
  10. Iwahashi T., Shino K., Nakata K., Otsubo H., Suzuki T., Amano H. et al. Direct anterior cruciate ligament insertion to the femur assessed by histology and 3-dimensional volume-rendered computed tomography. Arthroscopy. 2010;26(9 Suppl):13-20. doi: 10.1016/j.arthro.2010.01.023.
  11. Pearle A.D., McAllister D., Howell S.M. Rationale for Strategic Graft Placement in Anterior Cruciate Ligament Reconstruction: I.D.E.A.L. Femoral Tunnel Position. Am J Orthop (Belle Mead NJ). 2015;44(6):253-258.
  12. Lameire D.L., Abdel Khalik H., Zakharia A., Kay J., Almasri M., de Sa D. Bone Grafting the Patellar Defect After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Decreases Anterior Knee Morbidity: A Systematic Review. Arthroscopy. 2021;37(7):2361-2376. doi: 10.1016/j.arthro.2021.03.031.
  13. Mishra A.K., Fanton G.S., Dillingham M.F., Carver T.J. Patellar tendon graft harvesting using horizontal incisions for anterior cruciate ligament reconstruction. Arthroscopy. 1995;11(6):749-752. doi: 10.1016/0749-8063(95)90123-x.
  14. Peebles L.A., Akamefula R.A., Aman Z.S., Verma A., Scillia A.J., Mulcahey M.K. et al. Following Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies. Arthrosc Sports Med Rehabil. 2024;6(2):1-9. doi: 10.1016/j.asmr.2024.100902.
  15. Tsuda E., Okamura Y., Ishibashi Y., Otsuka H., Toh S. Techniques for reducing anterior knee symptoms after anterior cruciate ligament reconstruction using a bone-patellar tendon-bone autograft. Am J Sports Med. 2001;29(4):450-456. doi: 10.1177/03635465010290041201.
  16. Borque K.A., Laughlin M.S., Pinheiro V.H., Jones M., Williams A. Rebranding the ‘anatomic’ ACL reconstruction: Current concepts. J ISAKOS. 2023;8(1):23-28. doi: 10.1016/j.jisako.2022.11.001.
  17. Fox M.A., Engler I.D., Zsidai B.T., Hughes J.D., Musahl V. Anatomic anterior cruciate ligament reconstruction: Freddie Fu’s paradigm. J ISAKOS. 2023;8(1):15-22. doi: 10.1016/j.jisako.2022.08.003.
  18. Musahl V., Nazzal E.M., Lucidi G.A., Serrano R., Hughes J.D., Margheritini F. et al. Current trends in the anterior cruciate ligament part 1: biology and biomechanics. Knee Surg Sports Traumatol Arthrosc. 2022;30(1):20-33. doi: 10.1007/s00167-021-06826-y.
  19. Musahl V., Engler I.D., Nazzal E.M., Dalton J.F., Lucidi G.A., Hughes J.D. et al. Current trends in the anterior cruciate ligament part II: evaluation, surgical technique, prevention, and rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2022;30(1):34-51. doi: 10.1007/s00167-021-06825-z.
  20. Mochizuki T., Fujishiro H., Nimura A., Mahakkanukrauh P., Yasuda K., Muneta T. et al. Anatomic and histologic analysis of the mid-substance and fan-like extension fibres of the anterior cruciate ligament during knee motion, with special reference to the femoral attachment. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):336-344. doi: 10.1007/s00167-013-2404-4.
  21. Siebold R., Schuhmacher P., Fernandez F., Śmigielski R., Fink C., Brehmer A. et al. Flat midsubstance of the anterior cruciate ligament with tibial “C”-shaped insertion site. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3136-3142. doi: 10.1007/s00167-014-3058-6.
  22. Śmigielski R., Zdanowicz U., Drwięga M., Ciszek B., Ciszkowska-Łysoń B., Siebold R. Ribbon like appearance of the midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111 knees. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3143-3150. doi: 10.1007/s00167-014-3146-7.
  23. Shino K., Nakata K., Nakamura N., Toritsuka Y., Horibe S., Nakagawa S. et al. Rectangular tunnel double-bundle anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft to mimic natural fiber arrangement. Arthroscopy. 2008;24(10): 1178-1183. doi: 10.1016/j.arthro.2008.06.010.
  24. Hospodar S.J., Miller M.D. Controversies in ACL reconstruction: bone-patellar tendon-bone anterior cruciate ligament reconstruction remains the gold standard. Sports Med Arthrosc Rev. 2009; 17(4):242-246. doi: 10.1097/JSA.0b013e3181c14841.
  25. Kaeding C.C., Pedroza A.D., Reinke E.K., Huston, L.J., MOON Consortium, Spindler K.P. Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort. Am J Sports Med. 2015;43(7):1583-1590. doi: 10.1177/0363546515578836.
  26. Murgier J., Hansom D., Clatworthy M. Current evidence around patellar tendon graft in ACLR for high-risk patients: current concepts. J ISAKOS. 2020;5(1):32-35. doi: 10.1136/jisakos-2019-000399.
  27. Murgier J., Powell A., Young S., Clatworthy M. Effectiveness of thicker hamstring or patella tendon grafts to reduce graft failure rate in anterior cruciate ligament reconstruction in young patients. Knee Surg Sports Traumatol Arthrosc. 2021;29(3):725-731. doi: 10.1007/s00167-020-05973-y.
  28. Tuca M., Valderrama I., Eriksson K., Tapasvi S. Current trends in anterior cruciate ligament surgery. A worldwide benchmark study. J ISAKOS. 2023;8(1):2-10. doi: 10.1016/j.jisako.2022.08.009.
  29. MOON Knee Group, Spindler K.P., Huston L.J., Zajichek A., Reinke E.K., Amendola A. et al. Anterior Cruciate Ligament Reconstruction in High School and College-Aged Athletes: Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? Am J Sports Med. 2020;48(2):298-309. doi: 10.1177/0363546519892991.
  30. Rahr-Wagner L., Thillemann T.M., Pedersen A.B., Lind M. Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the danish registry of knee ligament reconstruction. Am J Sports Med. 2014;42(2):278-284. doi: 10.1177/0363546513509220.
  31. Aglietti P., Buzzi R., D’Andria S., Zaccherotti G. Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis. Am J Sports Med. 1992;20(1):38-45. doi: 10.1177/036354659202000111.
  32. Kohn D., Sander-Beuermann A. Donor-site morbidity after harvest of a bone-tendon-bone patellar tendon autograft. Knee Surg Sports Traumatol Arthrosc. 1994;2(4):219-223. doi: 10.1007/BF01845591.
  33. Kartus J., Movin T., Karlsson J. Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy. 2001;17(9):971-980. doi: 10.1053/jars.2001.28979.
  34. Adriani E., Mariani P.P., Maresca G., Santori N. Healing of the patellar tendon after harvesting of its mid-third for anterior cruciate ligament reconstruction and evolution of the unclosed donor site defect. Knee Surg Sports Traumatol Arthrosc. 1995;3(3):138-143. doi: 10.1007/BF01565472.
  35. Brandsson S., Faxén E., Eriksson B.I., Kälebo P., Swärd L., Lundin O. et al. Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit. Knee Surg Sports Traumatol Arthrosc. 1998;6(2):82-87. doi: 10.1007/s001670050077.
  36. Cerullo G., Puddu G., Gianní E., Damiani A., Pigozzi F. Anterior cruciate ligament patellar tendon reconstruction: it is probably better to leave the tendon defect open! Knee Surg Sports Traumatol Arthrosc. 1995;3(1):14-17. doi: 10.1007/BF01553519.
  37. Muellner T., Kaltenbrunner W., Nikolic A., Mittlboeck M., Schabus R., Vécsei V. Shortening of the patellar tendon after anterior cruciate ligament reconstruction. Arthroscopy. 1998;14(6):592-596. doi: 10.1016/s0749-8063(98)70055-6.
  38. Eilerman M., Thomas J., Marsalka D. The effect of harvesting the central one-third of the patellar tendon on patellofemoral contact pressure. Am J Sports Med. 1992;20(6):738-741. doi: 10.1177/036354659202000616.
  39. Lidén M., Movin T., Ejerhed L., Papadogiannakis N., Blomén E., Hultenby K., Kartus J. A histological and ultrastructural evaluation of the patellar tendon 10 years after reharvesting its central third. Am J Sports Med. 2008;36(4):781-788. doi: 10.1177/0363546507311092.
  40. Insall J., Salvati E. Patella position in the normal knee joint. Radiology. 1971;101(1):101-104. doi: 10.1148/101.1.10.
  41. Balendra G., Jones M., Borque K.A., Willinger L., Pinheiro V.H., Williams A. Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers. Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2200-2208. doi: 10.1007/s00167-021-06765-8.
  42. Kartus J., Lindahl S., Stener S., Eriksson B.I., Karlsson J. Magnetic resonance imaging of the patellar tendon after harvesting its central third: a comparison between traditional and subcutaneous harvesting techniques. Arthroscopy. 1999;15(6):587-593. doi: 10.1053/ar.1999.v15.015058.
  43. Svensson M., Kartus J., Ejerhed L., Lindahl S., Karlsson J. Does the patellar tendon normalize after harvesting its central third?: a prospective long-term MRI study. Am J Sports Med. 2004;32(1):34-38. doi: 10.1177/0363546503258935.
  44. Coupens S.D., Yates C.K., Sheldon C., Ward C. Magnetic resonance imaging evaluation of the patellar tendon after use of its central one-third for anterior cruciate ligament reconstruction. Am J Sports Med. 1992;20(3):332-335. doi: 10.1177/036354659202000317.

Supplementary files

Supplementary Files
Action
1. JATS XML
Download

Copyright (c) 2024 Eco-Vector

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
СМИ зарегистрировано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор).
Регистрационный номер и дата принятия решения о регистрации СМИ: серия ПИ № ФС 77 - 82474 от 10.12.2021.


This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies