Long term results after LARS reconstruction for ACL tears

96 Pages·2017·3.44 MB·English

by  Windows User

Diplomarbeit

Long term results after LARS reconstruction for ACL
tears: A prospectively planned 12-years follow-up study

eingereicht von
Anna Verena Kiegerl

zur Erlangung des akademischen Grades
Doktor(in) der gesamten Heilkunde

(Dr. med. univ.)

an der
Medizinischen Universität Graz

ausgeführt an der
Universitätsklinik für Orthopädie und Traumotologie

unter der Anleitung von
PD Dr. Gerwin A. Bernhardt, MBA, FACS
PD Dr. Gerald Gruber, MBA

Graz, am 13.12.2017
Eidesstattliche Erklärung

Ich erkläre ehrenwörtlich, dass ich die vorliegende Arbeit selbstständig und ohne fremde
Hilfe verfasst habe, andere als die angegebenen Quellen nicht verwendet habe und die den
benutzten Quellen wörtlich oder inhaltlich entnommenen Stellen als solche kenntlich
gemacht habe.
Graz, am 13.12.2017 Anna Verena Kiegerl eh

i
Abstract

Introduction: The reconstruction of the anterior cruciate ligament (ACL) is a
frequent operation. A lot of research has been conducted in order to detect the ideal
graft for the ACL reconstruction. This study evaluated long-term results after
reconstruction of the ACL with an artificial ligament.
Methods: We invited forty-one patients who underwent reconstruction of the ACL
with LARS (Ligament Advanced Reinforcement System or Ligament Augmentation
and Reconstruction System) ligament between August 2001 and March 2005 to a
follow-up evaluation at the Department of Orthopaedics and Traumatology of the
Medical University of Graz. The outcome was assessed by physical examination,
X-rays of both knees, Magnetic Resonance Imaging (MRI) and four questionnaires
(SF-36, IKDC Subjective Knee Evaluation Form, Lysholm Score and Tegner Score).
Results: Twenty-seven patients were available for a long-term follow-up evaluation.
The mean follow-up period was 12.4 years. The mean Lysholm Score was 91.1 ±
9.3 and the mean IKDC Score was 85.6 ± 11.5. The result of the Tegner Score was
4. The mean MCS Score of the SF-36 was 48.6 ± 13.1 and the mean PCS Score
was 50.7 ± 9.6. Definite osteoarthritic changes of the operated knee were present
in 50.0% of the patients. This rate was significantly higher compared to the
contralateral knee. The overall complication rate was 48.8% including a revision rate
of 14.6%.
Discussion: Long-term results after reconstruction of the ACL with LARS ligament
are less encouraging than the short-term results. The results of the Lysholm score
and the subjective IKDC score as well as the quality of life, assessed by the SF-36,
show good average results. However, we found a far too high overall complication
rate in the long term. We cannot recommend LARS ligament for primary ACL
reconstruction.

ii
Zusammenfassung

Einleitung: Die Rekonstruktion des vorderen Kreuzbandes ist eine häufig
durchgeführte Operation. Es wurde viel Forschungsarbeit betrieben, um
herauszufinden, welches das ideale Transplantat zur Rekonstruktion des vorderen
Kreuzbandes darstellt. Diese Studie erhob Langzeitergebnisse nach der
Rekonstruktion des vorderen Kreuzbandes mit einem Band aus synthetischem
Material.
Methoden: Wir luden einundvierzig Patienten, bei denen zwischen August 2001
und März 2005 eine Rekonstruktion des vorderen Kreuzbandes mittels LARS
(Ligament Advanced Reinforcement System oder Ligament Augmentation and
Reconstruction System) Band durchgeführt wurde, zu einer Nachuntersuchung an
der Universitätsklinik für Orthopädie und Traumatologie der Medizinischen
Universität Graz ein. Die Ergebnisse wurden mittels klinischer Untersuchung,
Röntgenbildern beider Knie, Magnetresonanztomographie (MRT) und vier
Fragebögen (SF-36, IKDC Subjective Knee Evaluation Form, Lysholm Score und
Tegner Score) erhoben.
Resultate: Siebenundzwanzig Patienten nahmen an der Nachuntersuchung zur
Erhebung der Langzeitergebnisse teil. Die durchschnittliche Nachbeobachtungszeit
betrug 12,4 Jahre. Der durchschnittliche Lysholm Score betrug 91,1 ± 9,3, der
durchschnittliche IKDC Score betrug 85,6 ± 11,5 und der Tegner Score betrug 4.
Die durchschnittlichen Ergebnisse der MCS und PCS Scores des SF-36 betrugen
48,6 ± 13,1 und 50,7 ± 9,6. Definitive arthrotische Veränderungen des betroffenen
Knies wurden bei 50.0% der Patienten gefunden. Im Vergleich zur kontralateralen
Seite war dieser Prozentsatz signifikant höher. Die totale Komplikationsrate betrug
48.8% mit einer Revisionsrate von 14,6%.
Diskussion: Langzeitergebnisse nach der Rekonstruktion des vorderen
Kreuzbandes mittels LARS Band sind weniger vielversprechend als
Kurzzeitergebnisse. Der Lysholm Score, der IKDC Score und auch die
Lebensqualität, die mithilfe des SF-36 erhoben wurde, zeigten gute
durchschnittliche Ergebnisse. Jedoch fanden wir eine viel zu hohe

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Komplikationsrate, weshalb wir das LARS Band nicht zur primären Rekonstruktion
des vorderen Kreuzbandes empfehlen können.

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Table of Contents

Abstract ................................................................................................................... ii
Zusammenfassung ................................................................................................. iii
Abbreviations ........................................................................................................ viii
Legend of Figures ................................................................................................... x
Legend of Tables .................................................................................................... xi
GENERAL PART .................................................................................................... 1
1 Introduction ...................................................................................................... 1
2 Background ...................................................................................................... 2
2.1 Anatomy of the knee ................................................................................. 2
2.1.1 Osseous Structures ............................................................................ 2
2.1.2 Joint capsule ....................................................................................... 3
2.1.3 Ligaments ........................................................................................... 4
2.1.3.1 The cruciate ligaments .................................................................... 5
2.1.4 Menisci ............................................................................................... 6
2.1.5 Bursae ................................................................................................ 6
2.1.6 Functional anatomy .......................................................................... 10
2.2 Histology of Ligaments ............................................................................ 12
2.3 The anterior cruciate ligament ................................................................. 13
2.3.1 Structure ........................................................................................... 13
2.3.2 Ligament insertions ........................................................................... 13
2.3.3 Blood supply ..................................................................................... 13
2.4 Injury of the anterior cruciate ligament .................................................... 15
2.4.1 Risk factors ....................................................................................... 15
2.4.1.1 Gender differences ........................................................................ 15
2.4.1.2 Knee kinetics ................................................................................. 15
2.4.1.3 Hormones and menstrual cycle ..................................................... 16
2.4.1.4 Anatomical factors ......................................................................... 17
2.4.2 Mechanisms of injury ........................................................................ 17
2.4.3 Diagnosis .......................................................................................... 18
2.4.3.1 Clinical tests .................................................................................. 18
2.4.3.2 Magnetic resonance imaging ......................................................... 19
2.4.4 Treatment ......................................................................................... 20
2.4.4.1 Conservative treatment ................................................................. 20

v
2.4.4.2 Rehabilitation in conservative treatment ........................................ 21
2.4.4.3 Operative treatment ....................................................................... 22
2.4.4.4 Autografts ...................................................................................... 22
2.4.4.5 Allografts ....................................................................................... 23
2.4.4.6 Synthetic grafts .............................................................................. 24
2.4.4.6.1 LARS ligament ......................................................................... 26
2.4.4.7 Rehabilitation after ACL reconstruction ......................................... 27
SPECIAL PART .................................................................................................... 29
3 Methods ......................................................................................................... 29
3.1 Study design ........................................................................................... 29
3.2 Patients ................................................................................................... 29
3.3 Associated injuries .................................................................................. 30
3.4 Surgery and Surgical technique .............................................................. 30
3.5 Outcome assessment at the final follow-up ............................................. 30
3.5.1 Numeric Rating Scale ....................................................................... 31
3.5.2 Questionnaires.................................................................................. 31
3.5.2.1 SF-36 ............................................................................................. 31
3.5.2.2 IKDC .............................................................................................. 32
3.5.2.3 Lysholm Score ............................................................................... 33
3.5.2.4 Tegner Activity Scale ..................................................................... 33
3.5.3 Kellgren-Lawrence Score ................................................................. 33
3.6 Magnetic Resonance Imaging ................................................................. 36
3.7 Statistical analysis ................................................................................... 37
4 Results ........................................................................................................... 38
4.1 Outcome assessment .............................................................................. 39
4.1.1 Numeric Rating Scale ....................................................................... 40
4.1.2 Subjective Feelings of Instability and Giving Way Attacks ................ 40
4.1.3 Clinical examination .......................................................................... 40
4.1.3.1 Joint effusion ................................................................................. 40
4.1.3.2 Range of Motion ............................................................................ 40
4.1.3.3 Medial and lateral instability .......................................................... 41
4.1.3.4 Lachman test ................................................................................. 41
4.1.3.5 Anterior drawer test ....................................................................... 42
4.1.4 Questionnaires.................................................................................. 42
4.1.4.1 SF-36 ............................................................................................. 42

vi
4.1.4.2 IKDC Subjective Knee Evaluation Form ........................................ 44
4.1.4.3 Lysholm Score ............................................................................... 44
4.1.4.4 Tegner Activity Scale ..................................................................... 44
4.1.5 X-rays ............................................................................................... 44
4.1.6 MRI ................................................................................................... 46
4.1.7 Complications ................................................................................... 46
5 Discussion ..................................................................................................... 49
5.1 Conclusion .............................................................................................. 56
6 Literature ........................................................................................................ 57
Appendix I ............................................................................................................ 68
CRF ................................................................................................................... 68
SF-36 ................................................................................................................ 71
IKDC Subjective Knee Evaluation Form ............................................................ 78
Lysholm Score .................................................................................................. 81
Tegner Activity Scale ........................................................................................ 82
Appendix II ........................................................................................................... 83
Presentations of this work ................................................................................. 83

vii
Abbreviations

ACL Anterior cruciate ligament
ALL Anterolateral ligament
BP Bodily Pain
BPTB Bone-patella tendon-bone
CRF Case Report Form
FCL Fibular collateral ligament
GH General Health
IKDC International Knee Documentation Committee
LAD Ligament Augmentation Device
LARS Ligament Advanced Reinforcement System or
Ligament Augmentation and Reconstruction System
LCL Lateral collateral ligament
LK Leeds-Keio
MCL Medial collateral ligament
MCS Mental Component Summary Measure
MH Mental Health
MRI Magnetic resonance imaging
nb norm-based
NRS Numeric Rating Scale
PCL Posterior cruciate ligament
PCS Physical Component Summary Measure
PF Physical Functioning

viii
RE Role – Emotional
RF Role – Physical
ROM Range of Motion
SD Standard deviation
SF Social Functioning
SF-36 Short Form-36
TCL Tibial collateral ligament
VT Vitality

ix