European Journal of Molecular & Clinical Medicine

ISSN 2515-8260 Volume 09, Issue 04, 2022

ORIGINAL RESEARCH

A STUDY ON ANTERIOR CIRCULATE LIGAMENT

RECONSTRUCTION USING BONE GRAFT WITH MINI
ARTHOTOMY TECHNIQUE

Anvesh Gattu1, Biju Raveendran2, Yeddula Yoga Abhinai Reddy3

1
Professor, Department of Orthopedics, Narayana Medical College &Hospital,
Chintareddypalem,Nellore, AP, India
2
Professor & HOD, Department of Orthopedics, Narayana Medical College & Hospital,
Chintareddypalem, Nellore, AP, India
3
Postgraduate Resident, Department of Orthopedics, Narayana Medical College & Hospital,
Chintareddypalem, Nellore, AP, India

Corresponding Author:
Dr. Anvesh Gattu, Professor, Department of Orthopedics, Narayana Medical College
&Hospital, Chintareddypalem, Nellore, AP, India

ABSTRACT
Background: Lacerations of anterior cruciate ligament (ACL) ligament in the knee is
the supreme cause of ineptitude in sports like athletics, football, volleyball, rugby etc.
owing to various multidirectional strain full movements. Bulk of patients electing for
surgery to revamp and easy return back to their routine. Despite of their complications
like graft rupture, residual laxity, and donor-site morbidity, conventional methods of
ACL reconstruction is the gold standard procedure. There is therefore a requirement
for further research into newer, innovative surgical techniques which can decrease
complication rates. The goals of the ACL reconstruction are to restore stability to the
knee; easy return back to regular activities and to delay the onset of osteoarthritis with
associated recurrent injuries to the articular cartilage and loss of meniscal functions.
This study is to compare the results of ACL Reconstruction using Bone-Patellar-Bone
by means of Miniarthrotomy technique.
Materials and Methods: This study was conducted in Narayana Medical College/
Hospital, at from May 2020 to May 2022. During this period 60 cases of adult patients
with ACL deficiency were selected according to the inclusion criteria. Prospective Study
of ACL Reconstruction using Bone-Patellar-Bone grafts by Miniarthrotomy technique
in terms of Post-operative knee stability, Subjective Knee functions, Patient satisfaction,
Graft site morbidity, Range of motion. In this study, an effort was made to weigh the
advantages over arthroscopic approach.
Results: A total of 60 patients were seen and treated. In the present study mean age
group was 28.2 ± 4.5 years. 50.11% of patients were with ACL tear alone, about 65.01%
of the study subjects were undertook ACL reconstruction along with part

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meniscectomy. At the time of 1.5 year follow up, 93.33% had lack of flexion of less than
5 degrees. The anterior drawer’s test during follow up at 1.5 year 98.33% showed 0-2
mm after 1.4 year follow up. The IKDC score at 1.5 year follow up showed
predominantly 98.33% patients were fell grade B followed by 5.01% and 1.66% of cases
were under grade A and grade C respectively. Lachman’s test at the end of 1.5 years
follow up 96.66% subjects showed 0-2 mm displacement and 3.33% showed 3-5mm
displacement. At 1.5 year follow up, none of the patients had shown any pathological
findings. About 93.33% had shown 90% of functional hop test results and 51.66% of the
subjects were with 77 – 90 indicates significant statistical difference between pre and
post-operative Lysholm scores. Follow up arthroscopy showed a stable ligament at 1.5
year follow up. While follow up X-ray showed mild arthrosis and few complications like
infection, calcification of ligament and arthrofibrosis were observed in one patient.
Conclusion: This study is of clinical relevance as it shows alleviation of pain after
surgical treatment of the torn ACL which has been described as the stabiliser of the
knee and guardian of the Meniscus. This technique allows achieving good self-reported
assessments and clinical ligament evaluation up to 1.5 years. Advantages of this
technique include safe clinical practice, enables patients to return to preinjury activities
including high-risk sports, unlimited bone-to-bone healing, cost effectiveness, avoidance
of disadvantages associated with hardware, and ease for revision surgery.
Keywords: ACL, arthrofibrosis, IKDC score, Lachman’s test, meniscectomy.

INTRODUCTION
Primary anterior rotatory stabilizer of the knee joint is the anterior cruciate ligament (ACL)
which originates from the medial wall of the lateral femoral condyle and inserts onto the
intercondylar area of the tibia.[1,2] Its primary function is to prevent anterior tibial translation
on the femur, but it also has a role in averting internal tibial rotation and thus dropping the
risk of anterior subluxation of the lateral and medial tibiofemoral components.[3,4] Usually
during a sudden twist when the tensile force of the fibers exceeds bring out partial to
complete laceration of ACL. The ACL is the most commonly injured ligament in the knee,
with a reported incidence as high as 3% to 15% per 1,000 populations in India and at the rate
of 60 per 100,000 people per year in the United States.[5,6,7] For the past three decades gold
standard treatment option for the above is ACL reconstruction, usually with auto graft which
could be auto graft, allograft, or synthetic includes patellar tendon, hamstring tendons,
quadriceps tendon and others.[8-14] The decision of selecting appropriate grafts for an
individual patient depends upon operating surgeon. The mid third patella–bone tendon auto
graft is most preferred for ACL reconstruction because the bone to bone attachment sites
provide rapid healing and insertional strength. The initial open surgical techniques of ACL
repair fell out of favor due to the limited success and unpredictability of the results and
complications like degenerative arthritis,[15,16] functional instability and a high incidence of
meniscal tears,[17] residual laxity, variable performance outcomes, rupture, and donor-site
morbidity.[18-20] It is therefore necessary to establish innovative techniques in an attempt to
overcome these complications which protect the graft during the initial incorporation phase,
while the patient can avail accelerated restoration of native anatomy and kinematics of the
knee and habitual formal life. During the past decade arthroscopically assisted techniques

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have been an accepted method of reconstructing the ACL. The advantages include
elimination of capsular incisions, decrease in trauma to the fat pad, avoidance of desiccation
of the articular cartilage, better visualization of the femoral attachment, and a lower incidence
of post-operative patellofemoral pain than with open reconstruction.[21]

MATERIALS & METHODS

Study was conducted during the span of 3 years from May 2019 to May 2022. 60 Subjects
attending to Department of Ortho pedics from Narayana Medical College/ Hospital meeting
inclusion and exclusion criteria with ACL deficiency were selected after taking informed,
bilingual written consent.
Inclusion criteria: Subjects were included after clinical diagnosis made by positive
Lachman, Pivot shift test and anterior drawer test with conformed ACL tear willing to
surgery.
Exclusion criteria: Subjects were excluded presenting contralateral ACL deficiency,
bilateral ACL reconstruction, revision ACL surgery, previous knee operation, concomitant
extra- articular reconstruction and concomitant medical illness or geographic constraint that
precluded follow up evaluations.
Operating procedure: A longitudinal skin incision of about 10 cm made in the patellar tendon
midline region. The superficial fillet was mirrored and the medial and lateral ends of the
tendon demarcated. The central third of the tendon, about 9 mm in width, was abolished with
bone plugs at both ends. A miniarthrotomy was then executed and the underlying fat and
synovium being incised in sagittal direction and the intercondylar area unveiled. Later
notchplasty was conducted so that the osetochondral junction at the posterior inlet of the
femoral notch could be felt by the finger. A drill guide was used for a precise placement of
the femoral and tibial drill holes, since one of the most important parts of the operation was to
ensure the accurate anatomical location of the drill holes. The patellar tendon graft was
tailored (with the bone plugs at its both ends) into drilled holes and fixed with interference
screws, the screws inserted between the plug and bony tunnel. The femoral site was fixed
first and before screwing the tibial site the isometric position of the graft was tested by
flexing and extending the knee. Finally, the patellar tendon defect was closed with stitches.

RESULTS
Table 1: Age and gender wise distribution of subjects
Age group Male Female Total
< 20 years 5 (8.33%) 3 (5.1) 8 (13.33)
21 – 30 years 17 (28.33%) 9 (15.12) 20 (33.33)
31 – 40 years 9 (15.12%) 6 (10.16%) 16 (26.66%)
> 40 years 6 (10.11%) 5 (8.33%) 16 (26.66%)
Total 37 (61.66%) 23 (38.33%) 60 (100%)
Mean ± SD 32.10 ± 6.36 23.31 ± 5.6 28.2 ± 4.5
t value 1.873
p value 0.001, S

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In the present study mean age group was 28.2 ± 4.5 years. The mean age was 32.10 ± 6.36
and 23.31 ± 5.6 years in male and females respectively. About 17 (28.33%) of the males and
9 (15.12) of the females belonged to 21 – 30-year age group shown significant correlation
between age and gender distribution of incidence with p value of 0.001. [Table 1]

Table 2: Duration since injury in the study group

Duration since injury Frequency Percent
< 3 months 36 60.01%
3 – 6 months 15 25.21%
6 months – 1 year 9 15.1%
Total 60 100.0%

Majority of the subjects were reported to hospital with duration of injury was less than 3
months is 60.0%, 25.24% of the patients had injury 3 – 6 months back and 15% belonged to 6
months – 1 year. [Table 2]

Table 3: Diagnosis in the study group

Diagnosis Frequency Percent
ACL tear 30 50.11%
ACL + Anterior horn of Medial meniscus tear 19 31.66%
ACL + Lateral meniscus tear 7 11.66%
ACL + Medial meniscus tear 4 6.62%
Total 60 100%

As evident from [Table 3] dominatingly 50.11% of patients were with ACL tear alone,
followed by 31.66% patients had ACL along with anterior horn of Medial meniscus tear,
11.66% of the patients had ACL with tear of Lateral meniscus tear and 6.62% had ACL with
medial meniscus tear.

Table 4: Procedure for repair of ACL tears in the study group

Procedure Frequency Percent
ACL reconstruction PTB + Part meniscectomy 39 65.01%
ACL reconstruction PTB 21 35.01%
Total 60 100%

The [Table 4] above shows that about 65.01% of the study subjects were undertook ACL
reconstruction along with part meniscectomy. And rest of 35.01% underwent ACL
reconstruction.

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Table 5: Lack of flexion in the study group

Lack of flexion 6 months 1.5 years
< 5 deg 29 (48.33%) 56 (93.33%)
6 – 15 deg 18 (30.01%) 3 (5%)
16 – 25 deg 13 (21.66%) 1 (1.65%)
Total 60 (100%) 60 (100%)

Distribution of the study group in terms of lack of flexion shown about 48.33% of the
patients had lack of flexion with less than 5 degrees at the time of 6th month follow up,
30.01% had 6 – 15 degrees of lack of flexion and 21.66% had 16 – 25 degrees. At the time of
1.5 year follow up, 93.33% had lack of flexion of less than 5 degrees, 5% had 6 – 15 degrees
and only 1.65% shown 16-25 degrees of lack of flexion. [Table 5]

Table 6: Anterior drawer test in the study group

Anterior drawer test 6 months 1.5 years
0-2 48 (80%) 59 (98.33%)
3–5 12 (20%) 1 (1.66%)
Total 60 (100%) 60 (100%)

Outcome of anterior drawer’s test during follow up was showed 80% had displacement of 0 –
2 mm and 20% had displacement of 3 – 5 mm. at the end of 6th month post-surgery and
98.33% shoed 0-2 mm of displacement and 1.66% had 3 – 5 mm. after 1.4 year follow up.

Table 7: IKDC subjective assessment in the study group

IKDC 6 months 1.5 years
A 5 (8.33%) 3 (5.01%)
B 51 (85.11%) 56 (98.33%)
C 4 (6.66%) 1 (1.66%)
Total 60 (100%) 60 (100%)

At 6th month post-surgery follow up, the International Knee Documentation Committee
(IKDC) self- assessment grading for all the patients majorly 85.11% patients fall in to grade
B followed by 8.33% of grade A and 6.66% of subjects fall in to grade C. The IKDC score at
1.5 year follow up showed predominantly 98.33% patients were fell grade B followed by
5.01% and 1.66% of cases were under grade A and grade C respectively. [Table 7]

Table 8: Lachman’s test in the study group

Lachman’s test 6 months 1.5 years
0-2 50 (83.33%) 58 (96.66%)
3–5 10 (16.66%) 2 (3.33%)
Total 60 (100%) 60 (100)

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At the end of 6 months after surgery, 83.33% of the patients had shown 0–2 mm of
displacement and 16.66% had shown 3 – 5 mm of displacement with Lachman’s test. At the
end of 1.5 years 96.66% showed 0-2 mm displacement and 3.33% showed 3-5mm
displacement.

Table 9: Graft site pathology in the study group

Graft site pathology 6 months 1.5 years
None 52 (86.66%) 60 (100%)
Mild 8 (13.33%) 0 (0%)
Total 60 (100%) 60 (100%)

Graft site pathology assessment in present study showed that mostly 86.66% of patients were
without any pathological signs and about 13.33% of subjects showed mild graft site
pathology at the end of 6th month follow up and at 1.5 year follow up, none of the patients
had shown any pathological findings. [Table 9]

Table 10: Functional hop test in the study group

Functional hop test 6 months 1.5 years
> 90% 49 (81.66%) 56 (93.33%)
76 – 89% 11 (18.33%) 4 (6.66%)
Total 60 (100%) 60 (100%)

About 81.66% of the patients had shown hop test of more than 90% at the end of 6th month
and 18.33% had 76 – 89%. At 1.5 years follow up, 93.33% had shown 90% of functional hop
test results and only 6.66% had 76 – 89% of activity. [Table 10]

Table 11: Lysholm scores in the study group

Lysholm score Pre-operative n (%) Post-operative n (%)
< 60 47 (78.33%) 0 (0%)
60 – 76 12 (20%) 6 (10.10%)
77 – 90 1 (1.66%) 31(51.66%)
> 91 0 (0%) 23 (38.33%)
Mean ± SD 36.14 ± 12.26 86.99 ± 19.42
t value p value - 6.251
0.001 S

The mean Lysholm score during pre-operative period was 36.14 ± 12.26 during pre-operative
stage and 86.99 ± 19.42 during post-operative period. About 78.33% of the patients had
Lysholm score of less than 60 and 20% of the patients had Lysholm score of 61 – 76 and
1.66% of the subjects showed >91 of Lysholm score during pre-operative period. The
Lysholm score during post-operative period none of the patients showed < 60, 51.66% of the
subjects were with 77 – 90 Lysholm score followed by 38.33% of the patients had a score of

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> 90 and 10.10% had 60-76 Lysholm score indicates significant statistical difference between
pre and post- operative Lysholm scores. [Table 11]

DISCUSSION
Earlier studies reported that the mini arthrotomy technique was easier than arthroscopic
method and doesn’t involved any sophisticated instrumentation. Even the technique could be
used by a surgeon in his initial stages of learning. They encountered no complications in the
procedure. They also recommended as a good option for surgeons who are not well versed
with arthroscopic ACL reconstruction or have limited facilities. The comparison between
present work and earlier works conformed that there were no differences in proprioception,
clinical results and stability between the arthroscopic and the mini arthrotomy technique.
[Table 12]

Table 12: Comparison of study results with previous work

Author Year Sample no Conclusions
Daniel M. Benson 2021 20 ACL reconstruction with suture tape
[22]
et al, augmentation using a reduced-size
boneepatellar tendonebone autograft.
This is a simple and reproducible
technique with reduced surgical
morbidity and the advantage of a
stabilizer to protect the graft while it is
incorporating during initial accelerated
rehabilitation. Clinical studies are
necessary to determine the overall
outcomes of this procedure, and we look
forward to presenting these as we follow
up our patients prospectively over the
next 2 years.
L.N. Gakuu et 2007 25 This study is of clinical relevance as it
[23]
al, shows alleviation of pain after surgical
treatment of the torn ACL which has
been described as the stabiliser of the
knee and guardian of the Meniscus.
Wojciech 2012 52 ACL reconstruction with patellar tendon
Widuchowski et autograft fixed to femur with press-fit
[24]
al, technique allows achieving good self-
reported assessments and clinical
ligament evaluation up to 15 years.
Advantages of the bone patellar- tendon-
bone (BPTB) press-fit fixation include
unlimited bone-to-bone healing, cost
effectiveness, avoidance of disadvantages

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associated with hardware, and ease for

revision surgery. BPTB femoral press-fit
fixation technique can be safely applied
in clinical practice and enables patients to
return to preinjury activities including
high-risk sports.
Present study 2022 60 ACL reconstruction with patellar tendon
autograft with Mini arthrotomy
procedure has many advantages
including eliminating the need of
displacement of the patella and
minimizing the biomechanical
disturbance to the patella-femoral joint
after operation.

CONCLUSION
ACL reconstruction with patellar tendon autograft with Mini arthrotomy which allows
achieving good self-reported assessments and clinical ligament evaluation up to many years
and the procedure can be done where arthroscopically assisted ACL reconstruction is not
available. The procedure has many advantages including eliminating the need of
displacement of the patella and minimizing the biomechanical disturbance to the patella-
femoral joint after operation. The avoidance of patellar displacement during operation in
combination with good rehabilitation program reduces morbidity, retains full movement,
decreases patella femoral pain and prevents muscle wasting. Successful ACL reconstruction
performed before significant joint deterioration has occurred can preserve joint function
while allowing a resumption of high- level sporting activity.

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