Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft with Remnant Preservation: Comparison of Outcomes According to the Amount of Remnant Tissue

Abstract

There has been controversy about whether remnant tissue of anterior cruciate ligament (ACL) has to be preserved in ACL reconstruction. The purpose of the study was to compare clinical outcomes between groups of patients who underwent ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft divided according to amount of ACL remnant and investigate effect of remnant preservation on outcomes of ACL reconstruction. A total of 185 patients who underwent ACL reconstruction with BPTB autograft were retrospectively reviewed. Patients were divided into four groups according to proportion of length of remnant tissue of injured ACL covering part of reconstructed ACL to total length of reconstructed ACL: group A included 83 patients with no remnant, group B consisted of 38 patients with remnant of < 1/3, group C consisted of 35 patients with remnant of 1/3 to2/3, and group D consisted of 29 patients with remnant of > 2/3. Primary outcome was International Knee Documentation Committee (IKDC) subjective score. Secondary outcomes were stability, range of motion, patient-reported outcomes determined by Lysholm knee scoring scale and Tegner activity scale, IKDC objective grade, and single hop for distance. Return to activity and near-return to activity were investigated. A minimum follow-up duration was 24 months. There was no statistically significant difference between four groups regarding postoperative anterior translation ( = 0.731), Lysholm knee score ( = 0.599), IKDC objective grade ( > 0.999), hop test ( = 0.878), and near-return to activity ( = 0.193). However, patients of group D had significantly better outcomes in IKDC subjective score (group A = 85.0 ± 5.9, group B = 84.9 ± 8.1, group C = 87.4 ± 6.4, group D = 89.2 ± 8.1, = 0.017), Tegner activity scale (group A = 5.0 ± 1.1, group B = 5.2 ± 1.0, group C = 5.7 ± 1.3, group D = 5.9 ± 1.0, = 0.001), and return to activity (group A = 25.3%, group B = 31.6%, group C = 45.7%, group D = 55.2%, = 0.014). ACL reconstruction using BPTB autograft with remnant preservation did not provide better anterior stability compared with conventional ACL reconstruction. However, preservation of remnant of> 2/3 led to more improved activity-related clinical outcomes than no remnant preservation. In cases with substantial remnant tissue of injured ACL remaining, reconstruction of ACL while preserving as much remnant tissue as possible is recommended. This is a Level III, retrospective comparative therapeutic study.

Remnant preservation with tensioning can improve the clinical outcome after anterior cruciate ligament reconstruction

“…Remnant preservation is beneficial in preserving proprioception of the native ACL and graft maturation, including synovialization, and the amount of preserved remnant is known as the important factor. 4,5,9,12,29,30 Although our study did not show a significant difference in graft maturation on follow-up MRI, this method preserved more remnant and provided better coverage, as in the previous studies. 5,21…”

“…4,16,19,28 However, recent reports including meta-analyses showed a better clinical outcome. 7,9,13,14,21 Our current study showed a statistically significant difference in IKDC subjective score. In the Lysholm and HSS scores, although there was no significant difference, the mean scores were better in group R. Considering the ceiling effect of the Lysholm and HSS scores, our current study demonstrated that remnant preservation with tensioning was better than the classical method regarding clinical outcome.…”

Anatomical Arthroscopic Anterior Talofibular Ligament Repair and Reconstruction Using a Free Tendon

“…Remnant-preserved ACL reconstruction is gaining popularity because the remnant-preservation effect may have the advantages of synovial coverage of the graft, graft remodeling, proprioceptive recovery, stability, and better clinical outcomes, [14][15][16]29 although controversial reports exist. 30,31 However, most remnant-preserved ACL reconstructions do not repair the remnant.…”

“…Recently, remnant-preserved anterior cruciate ligament (ACL) reconstruction has gained popularity because the remnant-preservation effect may be advantageous for graft remodeling, proprioceptive recovery, and clinical outcomes. [14][15][16] We describe the technique of anatomical arthroscopic ATFL repair and reconstruction (AAARR) using a free tendon graft, which has the possible advantages of not only remnant preservation but also sharing of the ligament load by the repaired ATFL remnant and the reconstructed ATFL graft. A summary of the key steps is provided in Table 1, and a summary of the technique is shown in Video 1.…”

Effect of Anterolateral Structure Augmentation on Graft Maturity After Anterior Cruciate Ligament Reconstruction: A Clinical and MRI Follow-up of 2 Years

“…The amount of remnant ACL tissue was graded as 0 (no remnant), I (remnant <1/3), II (remnant of 1/3 to 2/3), and III (remnant >2/3) according to the length proportion covering the reconstructed ACL. 21 The hip–knee–ankle angle was measured on the preoperative weightbearing whole–leg radiograph. 14 The posterior tibial slopes were measured on preoperative MRI.…”