Anterior cruciate ligament reconstruction using autologous double hamstrings: a comparison of standard versus minimal debridement techniques using MRI to assess revascularisation

Abstract

Animal studies have shown that implanted anterior cruciate ligament (ACL) grafts initially undergo a process of revascularisation prior to remodelling, ultimately increasing mechanical strength. We investigated whether minimal debridement of the intercondylar notch and the residual stump of the ruptured ACL leads to earlier revascularisation in ACL reconstruction in humans. We undertook a randomised controlled clinical trial in which 49 patients underwent ACL reconstruction using autologous four-strand hamstring tendon grafts. Randomised by the use of sealed envelopes, 25 patients had a conventional clearance of the intercondylar notch and 24 had a minimal debridement method. Three patients were excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee (IKDC) evaluation. All observations were made by investigators blinded to the surgical technique. Signal intensity was measured in 4 mm diameter regions of interest along the ACL graft and the mid-substance of the posterior cruciate ligament. Our results indicate that minimal debridement leads to earlier revascularisation within the mid-substance of the ACL graft at two months (paired t-test, p = 0.002). There was a significant reduction of mid-substance signal six months after the minimal debridement technique (paired t-test, p = 0.00007). No statistically significant differences were found in tunnel placement, incidence of Cyclops lesions, blood loss, IKDC scores, range of movement or Lachman test between the two groups.

Anterior Cruciate Ligament Reconstruction and Preservation: The Single–Anteromedial Bundle Biological Augmentation (SAMBBA) Technique

“…6 Matsumoto et al 7 noted that the area around the ACL septum contains a population of vascular-derived stem cells that may contribute to ligament regeneration and repair at the rupture site. In a canine model, they elucidated that transplantation of ACL-ruptured tissue contributed to early tendon-bone healing.…”

Anterior Cruciate Ligament Reconstruction With Preservation of Femoral Anterior Cruciate Ligament Stump

“…3 Gohil et al 13 reported a 59% incidence of cyclops formation after ACL reconstruction with minimal debridement of the notch tissue compared with 37.5% in patients with standard debridement (although the difference did not reach statistical significance). However, the flap of soft tissue that we have described lies posterosuperior to the proximal part of the graft; thus it cannot cause any impingement.…”

“…3,13 In our technique, we elevate the available thin layer of tissue including the remnant of the ACL with gentle dissection over the femoral condyle, leaving it attached at the back, and then the tunnel or socket is made directly on the bone and not through the soft tissues. On the other hand, on the tibial side, the tunnel is made through the ACL remnant itself.…”

Preoperative assessments completed for anterior cruciate ligament reconstructions with remnant preservation

“…2 Gohil et al used MRI scans to assess differences in revascularization after the use of standard vs minimal debridement techniques. 23 They indicated that minimal debridement leads to earlier revascularization within the midsubstance of the ACL graft at two months. There was a significant reduction of the mid-substance signal six months after use of the minimal debridement technique.…”