Extensor Mechanism Disruption After Contralateral Middle Third Patellar Tendon Harvest for Anterior Cruciate Ligament Revision Reconstruction

doi:10.1016/j.arthro.2005.07.010

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 21, Issue 10, October 2005, Pages 1268.e1-1268.e6

https://doi.org/10.1016/j.arthro.2005.07.010 Get rights and content

Abstract

The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.

Section snippets

Case 1

A 5-ft 5-in, 150-lb 40-year-old woman presented with symptoms of left anteromedial and medial knee pain. Previous orthopaedic surgeries included a left ACL reconstruction with ipsilateral middle third patellar tendon graft in 1989 after a skiing injury. She ruptured her reconstructed left ACL in 1998 in another skiing accident. Arthroscopy was performed in 2000 and confirmed a ruptured ACL graft. Debridement of a cyclops lesion was also performed. The patient sustained another knee injury 2

Case 2

A 5-ft, 120-lb 39-year-old woman presented with right knee instability after undergoing a right ACL reconstruction with ipsilateral bone–patellar tendon–bone autograft in 1997. She continued to experience knee instability and significant medial knee pain that precluded cycling. On presentation 2 years postoperatively, physical examination revealed a 1-2+ Lachman test, 2+ pivot-shift, and a 2+ Losee test. There was a 7.5-mm difference measured by the Knee Laxity Tester (OSI, Union City, CA) with

Discussion

Very few complications have been reported for central third patellar tendon harvest from the contralateral knee despite the well-documented donor-site morbidity for the ipsilateral knee harvest for ACL reconstruction. One of the main arguments against using a contralateral patellar tendon autograft harvest for ACL reconstruction is that it violates the otherwise normal knee and traumatizes the primary postoperative weight-bearing pillar.¹ However, Shelbourne and Urch³ suggest that contralateral

References (16)

J.R. Ritchie et al.
Graft selection in anterior cruciate ligament revision surgery
Clin Orthop
(1996)
J.W. Uribe et al.
Revision anterior cruciate ligament surgeryExperience from Miami
Clin Orthop
(1996)
K.D. Shelbourne et al.
Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon
Am J Sports Med
(2000)
K.D. Shelbourne et al.
Revision anterior cruciate ligament reconstruction using the contralateral bone–patellar tendon–bone graft
Instr Course Lect
(2002)
K.D. Shelbourne
Accelerated rehabilitation after anterior cruciate ligament reconstruction
Am J Sports Med
(1990)
R. Allum
Aspects of current management—Complications of arthroscopic reconstruction of the anterior cruciate ligament
J Bone Joint Surg Br
(2003)
B. Graf et al.
Complication of intra-articular anterior cruciate ligament reconstruction
Clin Sports Med
(1988)
J. Kartus et al.
Ipsi- or contralateral patellar tendon graft in anterior cruciate ligament revision surgery—A comparison of 2 methods
Am J Sports Med
(1998)

There are more references available in the full text version of this article.

Cited by (21)

Acute effects of ipsilateral semitendinosus and gracilis autograft anterior cruciate ligament reconstruction on lower limb muscle activation
2024, Apunts Sports Medicine
There is little information regarding the acute repercussions of anterior cruciate ligament (ACL) reconstruction on muscle activation, especially on the proximal hip muscles. Thus, this study analyzed the acute effects of ACL reconstruction with doubled semitendinosus/gracilis (ST/G) autografts on lower limb muscle activation. Fourteen male recreational athletes that presented a primary unilateral ACL rupture and underwent the ACL reconstruction with an ST/G graft. Surface electromyographic (sEMG) signal were recorded from each participant during the maximal voluntary isometric contraction (MVIC) of the gluteus maximus and gluteus medius, vastus lateralis and vastus medialis, semitendinosus, biceps femoris, and medial gastrocnemius muscles and also during bipodal mini-squatting with open and closed eyes, before surgery and 15 days postoperatively. (sEMG) signal were normalized to isometric peak electromyography.
The postoperative assessment showed reduced muscle activation in the gluteus maximus (p = 0.013, d:0.48) in non-operated limb and also in the muscle gluteus medius (p = 0.013, d:0.79), vastus medialis (p = 0.035, d:0.63) semitendinosus (p = 0.001, d:2.46), biceps femoris (p<0.001, d:1.5), and medial gastrocnemius (p = 0.001, d:1.45) during MVIC in the operated limb. The postoperative assessment also revealed alterations in the sEMG activity of the hip and local thigh muscles in the operated and non-operated limbs during mini-squatting with opened eyes and closed eyes (p<0.05). ACL reconstruction surgery with a doubled ST/G autograft may promote immediate changes in lower limb muscle activation of the operated and non-operated limb.
Emerging Topics in ACL Graft Selection: Best Evidence for the Use of Quadriceps Tendon Graft
2021, Operative Techniques in Sports Medicine
Citation Excerpt :
Several studies, including a meta-analysis by Xie et al.,40 have reported no significant differences between BTB and 4-strand HT in terms of instrumented laxity measurements, Lachman test, objective IKDC scores, graft failure, extension deficit, and flexion deficit,5,46,47 while both metanalyses and randomized controlled trials have reported BTB grafts to be superior in terms of the pivot shift test and return to preinjury activity level.48-52 Despite advantages in knee stability and clinical outcomes, using BTB can be associated with donor site morbidity including anterior knee pain (46%), kneeling pain,53,54 anterior knee numbness (13%), patella fracture (1.3%),55,56 and patellar tendon rupture.57,58 There have also been some controversial claims of increased osteoarthritis (OA) after ACLR after BTB compared to HT.54,59
Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures in orthopaedic sports medicine. Despite this, graft selection remains controversial with various regional, institutional, and individual preferences and trends. The traditional autograft options for reconstruction have been hamstring tendon and bone-patellar tendon-bone (BTB) autografts. Recently, quadriceps tendon (QT) autografts have garnered significant interest and appear promising because of their biomechanical properties and stability on clinical outcomes, and have less donor site morbidity compared with BTB. In this review, recent developments in QT autograft research are discussed and future directions which may clarify the appropriate role of quadriceps grafts in ACL reconstruction are explored.
Fracture Complications after Anterior Cruciate Ligament Reconstruction
2018, The Anterior Cruciate Ligament: Reconstruction and Basic Science: Second Edition
The Case for the Bone-Patellar Tendon-Bone Autograft with Anterior Cruciate Ligament Reconstruction
2018, The Anterior Cruciate Ligament: Reconstruction and Basic Science: Second Edition
Comparison of grafts for anatomical reconstruction of the ACL: Patellar versus semitendinosus/gracilis
2015, Revista Brasileira de Ortopedia
Comparar o resultado funcional do tratamento cirúrgico da reconstrução anatômica do ligamento cruzado anterior (LCA) com banda única com o uso de dois tipos de enxerto autólogos.
Foram avaliados prospectivamente 27 pacientes, submetidos à reconstrução anatômica do LCA pela técnica de Chambat, divididos em dois grupos: A, com 14 e uso como enxerto dos tendões flexores; e B, com 13 e uso como enxerto do tendão patelar. Em ambos os grupos foi feita fixação com parafuso de interferência absorvível.
Com base no escore de Lysholm, o grupo A apresentou pontuação média de 71,6 no primeiro mês, enquanto o B apresentou 75. Já no fim do sexto mês ambos apresentaram 96,6. A avaliação do IKDC total mostrou que no primeiro mês a maioria dos pacientes, tanto no grupo A (85,7%) no grupo B (76,9%), apresentava uma avaliação do joelho próximo do normal e no sexto mês o grupo A apresentou 92,9% como normal e o grupo B, 100%.
Os resultados, segundo avaliação funcional de Lysholm e subjetiva do IKDC, não apresentaram diferenças estatisticamente significantes entre os grupos e foram melhores no sexto mês.
To compare the functional results from surgical treatment for anatomical reconstruction of the anterior cruciate ligament (ACL) with a single band, using two types of autologous grafts.
Twenty‐seven patients who underwent anatomical reconstruction of the ACL by means of the Chambat technique were evaluated prospectively. They were divided into two groups: A, with 14 patients, using grafts from flexor tendons; and B, with 13 patients, using grafts from the patellar tendon. In both groups, fixation was performed using an absorbable interference screw.
Based on the Lysholm score, group A presented a mean score of 71.6 in the first month, while B presented 75. At the end of the sixth month, both groups presented 96.6. Evaluation of the total IKDC showed that in the first month, the majority of the patients, both in group A (85.7%) and in group B (76.9%), presented a knee assessment that was close to normal. In the sixth month, 92,9% of group A had normal presentations, and 100% of group B.
According to the Lysholm functional evaluation and the IKDC subjective assessment, there was no statistically significant difference in the results between the groups, and the results were better in the sixth month.
Reconstruction of patellar tendon rupture after anterior cruciate ligament reconstruction: A case report
2008, Knee
Citation Excerpt :
In our series of 1300 ACL reconstructions, we know of only one case of patellar tendon rupture. Almost all of the reported cases of knee extensor mechanism complications were on the same side as the ACL injury, except in the cases of contralateral patellar tendon rupture, where the BTB was harvested for ACL reconstruction in the other knee [1,6]. Patellar tendon rupture after ACL reconstruction may occur during the first month after the operation, usually as a result of trauma [1,6,7].
Patellar tendon rupture following use of its central third for anterior cruciate ligament (ACL) reconstruction is a rare disabling injury that is technically difficult to repair. We report one case of patellar tendon rupture after harvesting the mid-third for ACL reconstruction. A number of different surgical methods exist for reconstructing patellar tendon ruptures. Here we report a case using a bone–tendon–bone (BTB) allograft, followed by a multiple-wire loop reinforcement with no postoperative immobilisation. One year after operation, our patient had regained full knee extension and flexion. Insall Salvati index on the operated side was identical to the uninjured side. The patient had good quadriceps strength, and isokinetic muscle testing showed no deficit in his right leg. He was able to return to professional handball without limitation.

View all citing articles on Scopus

: Cite this article as: Busfield BT, Safran MR, Cannon WD. Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction. Arthroscopy 2005;21:1270.e1-1270.e6 [doi:10.1016/j.arthro.2005.07.010].

View full text

Case reportExtensor Mechanism Disruption After Contralateral Middle Third Patellar Tendon Harvest for Anterior Cruciate Ligament Revision Reconstruction

Abstract

Section snippets

Case 1

Case 2

Discussion

Graft selection in anterior cruciate ligament revision surgery

Clin Orthop

Revision anterior cruciate ligament surgeryExperience from Miami

Clin Orthop

Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon

Am J Sports Med

Revision anterior cruciate ligament reconstruction using the contralateral bone–patellar tendon–bone graft

Instr Course Lect

Accelerated rehabilitation after anterior cruciate ligament reconstruction

Am J Sports Med

Aspects of current management—Complications of arthroscopic reconstruction of the anterior cruciate ligament

J Bone Joint Surg Br

Complication of intra-articular anterior cruciate ligament reconstruction

Clin Sports Med

Ipsi- or contralateral patellar tendon graft in anterior cruciate ligament revision surgery—A comparison of 2 methods

Am J Sports Med

Case report
Extensor Mechanism Disruption After Contralateral Middle Third Patellar Tendon Harvest for Anterior Cruciate Ligament Revision Reconstruction