On surgical techniques to reduce morbidity after anterior cruciate ligament reconstruction. The significance of harvesting technique, preconditioning, graft choice and the course of bone mineral in the calcaneus

Sammanfattning: The aim of the study was to reduce undesired postoperative effects, such as anterior knee pain, loss of sensitivity in the knee region and problems with knee-walking after anterior cruciate ligament (ACL) reconstructive surgery. Furthermore, prospectively to evaluate the bone mineral in the calcanei before and after ACL reconstruction.In a study of 124 consecutive patients we compared the traditional one-incision technique and the subcutaneous two-incision technique to harvest the central third bone-patellar tendon bone (BTB) autograft. The subcutaneous two-incision technique rendered less disturbance in anterior knee sensitivity and a tendency towards less discomfort during knee-walking.In a prospective randomised study of 53 patients we evaluated the effect of preconditioning the BTB autograft with 39 N for ten minutes before implantation. The preconditioning rendered no advantages in terms of less laxity or better clinical outcome at the 2-year follow-up.Thirty-four consecutive patients with a unilateral ACL injury underwent arthroscopic reconstruction using BTB autografts. The bone mineral areal mass (BMA) was assessed bilaterally in the calcaneus using a g-camera according to the Dual-energy Photon Absorptiometry technique. The BMA was measured before the operation, after six and 26 months. The BMA in the calcaneus on both the injured and non-injured side decreased by 16% and 17% respectively from the preoperative measurement to the 26-month control. The Tegner activity level, though, increased from 3 preoperatively to 7 at 26 months.In a retrospective study we compared the outcome after ACL reconstruction in 49 recreational athletes with 226 competitive athletes with a minimum follow-up of two years. The functional and objective results were similar.In a prospective randomised study of seventy-one patients we compared the results after ACL reconstruction using either the central third BTB autograft or triple/quadruple semitendinosus autografts. At the two-year follow-up, the use of semitendinosus autografts rendered less discomfort during knee-walking, otherwise the subjective and objective results were similar.In conclusion, when the BTB autograft is used for ACL reconstruction, the donor-site morbidity in terms of loss of sensitivity and impaired knee walking ability can be reduced with a two incision subcutaneous harvesting technique. Preconditioning of BTB autografts does not decrease laxity or improve function in the perspective of two years. Arthroscopic ACL reconstruction using BTB autografts renders similar results irrespective of the preoperative activity level. ACL injury followed by reconstructive surgery causes a substantial loss of bone mineral in the calcaneus in the perspective of two years, in spite of a signifcantly increased activity level. This was found on both the injured and non-injured side and could be a risk factor for osteoporosis later in life. The use of triple/quadruple semitendinosus autografts renders a better knee walking ability than the use of BTB autografts. Both grafts render equal results in terms of stability and function. We therefore recommend the semitendinosus autograft as a first choice of graft when ACL reconstructive surgery is required.