Anterior cruciate ligament patellar tendon reconstruction: it is probably better to leave the tendon defect open!

Abstract

The purpose of our prospective study was to establish whether or not in anterior cruciate ligament (ACL) patellar tendon reconstruction the tendon defect has to be closed. In 50 consecutive ACL patellar tendon reconstructions, the tendon defect was randomly closed (group I) or left open (group II). The following data were recorded from all patients on the 4th and 14th days post operation: range of motion (ROM), pain at rest, pain and validity at isometric contraction, ability of bent leg raising (at 4th day) and straight leg raising (at 14th day). All the patients underwent ultrasonographic examination after 3 months and X-ray scanning at 6 months post operation. Forty patients underwent a CT-scan examination at 6 months. Thirty patients underwent isokinetic testing between 10 and 12 months post operation. Evaluating the immediate post operation data, no statistically significant differences emerged between the two groups. Ultrasonography showed in 68% of the knees of group I (defect closed) a thickened patellar tendon (PT), while in 60% of group II it was of normal thickness. No patients of either group developed patella infera by X-ray evaluation 6 months post operation. CT scans at 6 months showed that 100% of the knees of group I had a thickened PT in toto (nearly twice as thick as normal). Scar tissue was present not only in its central third but also in more than half of the cases in the medial and lateral third. In group II 75% of the patients had a normal thickness PT and 25% presented with only a minimal thickening. Scar tissue was distinguished only at its central third.(ABSTRACT TRUNCATED AT 250 WORDS)

Healing of the patellar tendon donor defect created after central-third patellar tendon autograft harvest

“…Aggressive versus non-aggressive rehabilitation protocol In our experimental model, the scar tissue was present only in the central-third of the tendon (donor site defect), and not in the medial and lateral thirds (remaining tendon). This finding is in agreement with that reported by other authors [7]. Cerullo et al [7], using CT and ultrasonography, compared extension of the scar tissue in two different situations: (1) the PTDD was left open (25 cases) and (2) the gap was closed reapproximating the medial and lateral remaining patellar tendon (25 cases).…”

“…Only a few studies have investigated the healing of the PTDD in humans [1,3,7,8,18,20,22,23] as well as in animals [6,11,14,19], and they have been primarily focused on the use of ultrasonography, CT, MRI, and biomechanical testing, rather than on histology. Moreover, little is known about the histologic healing pattern in the PTDD following PTA harvest, above all in the initial stages of the healing process; likewise, the source of recellularization of the defect has not yet been fully investigated.…”

Closing patellar tendon defects after anterior cruciate ligament reconstruction: absence of any benefit

“…However, painful bone spurs developed at the apex of the patella in some of their patients. In another study, Cerullo et al [9] found that if the patellar tendon was sutured, a scar process involving the entire patellar tendon and not only the central defect developed. In the present study, the remaining parts of the patellar tendon showed signs of a hypertrophic response to the poor healing of the donor site.…”

Translation from Research to Applications

“…Defects in the PT are not completely healed for months. [54][55][56] Lessening the severity of these complications by enhancing healing of the PT should lead to improved patient outcome. [57][58][59][60] The MCL, on the other hand, can heal but with a significantly different biochemical composition and matrix organization, resulting in inferior biomechanical properties even 2 years after injury.…”