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Evaluation of the results of arthroscopic anterior cruciate ligament reconstruction by quadruple semitendinosus and gracilis tendon autograft fixation with biodegradable interference tibial screw and endobutton for femur

Introduction: Anterior cruciate ligament is often injured in physical activities especially contact sports and road accidents. ACL injury is a debilitating condition which may result pain, swelling and instability especially during activities involving side stepping and pivoting. Arthroscopic reconstruction of the ACL with central one-third of the patellar ligament and the hamstring tendon construct are most commonly used for reconstruction of ACL. Hamstring tendon graft using semitendinosus or semitendinosus-gracilis tendons either tripled for quadrupled form has evolved as an alternative for ACL reconstruction. Materials and Methods: This was a quasi-experimental study (Prospective Study). This study was done from January 2015 to December 2016 at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Sher-E-Bangla Nagar, Dhaka. Patients presented with unilateral knee complaints and clinically diagnosed as ACL injury of both sexes at OPD of NITOR were included in this study. Due to time limitation and financial constrain 30 cases were selected during the study period. Purposive sampling (nonrandomized) was done according to availability of the patients and strictly considering the inclusion and exclusion criteria. Results: Post operatively Lachman test improved significantly, 95% cases of grade I and grade II was in 5% patients. Anterior drawer was positive in 10% cases. Pivot shift test was negative in all cases. McMurry test negative in all cases. After operation 80% had 135 o knee flexion and 20% had less than 130 o flexion. Preoperative versus post operative Lysholm knee score in this series shows significant improvements ( p< 0.05). Preoperative and postoperative Lysholm score were 67.57±11.458 and 9427±5.656 respectively. Regarding final outcome, out of 30 patients, 29 (96.67%) had satisfactory (excellent + good), 1 (3.3%) had unsatisfactory (fair) outcome. Confidence interval (CI) at 95% confidence level is 87.21% – 102.79%. Conclusion: Anterior cruciate ligament injury most commonly occurs in young adult especially during sporting activity. It hampers their daily activity and causes financial loss so early reconstruction is necessary for their return to daily activity.


Introduction
Anterior cruciate ligament is an intra-articular structure in the central knee joint complex. It acts in concert with the other intra-articular structure to control and limit motion of the knee joint. Thus maintain both static and dynamic equilibrium. Anterior cruciate ligament is often wounded in physical activities especially contact sports and motorbike accidents [1] . ACL injury is a debilitating condition which may result pain, swelling and instability especially during activities involving side stepping and pivoting. So ACL reconstruction is advised to athletes for an active and competitive life without experiencing episodes of instability [2] . Surgical techniques for ligament injuries of knee have developed years. Now-a-days, ACL arthroscopic reconstruction with autogenous graft is commonly used.
The central portion of patellar ligament and the hamstring tendons construct are most commonly used for reconstruction of ACL [3] . The outcomes of ACL reconstruction using different grafts are debatable. Clinical and radiographic outcomes of ACL reconstruction using these grafts fixed with modern devices and proper surgical techniques and postoperative rehabilitation, those two grafts are an equivalent option for ACL reconstruction [4] . The bone-patellar tendon bone autograft is thought to be the "Gold standard" as because of direct bone to bone healing. This healing allows the patient for early rehabilitation with significant long term results [5] . But there are some problems with the BPTB graft such as donor site morbidity, anterior knee discomfort and pain on kneeling. Hamstring tendon graft using semitendinosus or semitendinosus-gracilis tendons either tripled for quadrupled form has evolved as an alternative for ACL reconstruction [6] . The fixation methods used in bone tunnels are mainly two types, aperture fixation and suspensory fixation. In aperture fixation graft fixed at the start of the bone tunnel as interference screws and in suspensory fixation sutures are attached to a femoral fixation tool as endobutton.
The clinical results using biodegradable screws or metal screws are statistically similar for ACL reconstruction [7] . These devices are used to provide secure fixation helping early motion exercise and weight bearing.

Materials and methods
This was a quasi experimental study (Prospective Study). This study was done from January 2015 to December 2016 at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Sher-E-Bangla Nagar, Dhaka. Patients presented with unilateral knee complaints and clinically diagnosed as ACL injury of both sexes at OPD of NITOR were included in this study. Due to time limitation and financial constrain 30 cases were selected during the study period. Purposive sampling (nonrandomized) was done according to availability of the patients and strictly considering the inclusion and exclusion criteria.

Inclusion criteria
 Clinically diagnosed unilateral ACL injury which was symptomatic after conservative treatment of adequate duration (4-6 weeks).  Age between 15 to 50 years.  In doubtful cases diagnosis confirmed by MRI.

Exclusion criteria
 Bilateral anterior cruciate ligament deficiency.  Multiple ligament injury of the knee.  Presence of fractures around the knee (tibial plateau, patella, femoral condyles).  Patient previously operated for knee injuries.  Age before 15 and after 50 years.  Loss of knee motion due to acute injury/Stiffness.  Osteoarthritis.

Ethical Issue
Prior approval of protocol was taken by Ethical Review Committee NITOR, Dhaka. The patients were informed about purpose and design of the study and right for withdrawing themselves from the study according to Helsinki declaration. Patients were informed about the procedure of treatment, anticipated results, possible advantages, disadvantages, complications etc. Individuals who gave informed written consent voluntarily were involved in this research.

Data Collection
A data collection sheet was structured with the variables. Data was gathered by interview, observation, physical examination and radiological findings. In my study I had evaluated the results by using Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) knee examination and evaluation form.

Analysis
According to Lysholm knee score pre and postoperative (at 24 weeks) score was calculated. Comparison of mean preoperative and postoperative value was done to determine whether significant improvement was achieved or not. Again on the basis of individual postoperative value final outcome categorization was done. According to International Knee Documentation Committee (IKDC) knee examination and evaluation form subjective and objective outcome of the patient was evaluated.

Results
This prospective study was carried out from December 2014 to June 2013 at NITOR. The advantages of arthroscopy in the diagnosis and treatment of ACL injuries has been accepted for a decade now. A total of 30 cases were selected for the study. Follow up given for 6 months to 12 months and final outcome was recorded at 6 months. The following results were obtained.  Out of 30 patients male was 27 and female patient 3. This bar chart describes the distribution of the subjects by occupation. None of them were sportsman, service holder 43.3%, 36.7% were student, and other were 20%. Right side involvement was 57% and left side involvement was 43%. The cause of injury was sporting activity (Football & Cricket) 83.3%, RTA 10% and others 6.7% cases.    In this series 96.7% patients had uneventful post operative period one (3.3%) had infection at knee. Preoperative clinical evaluation showed that all patients had abnormal knee function, mild to moderate pain. All patients complained of swelling and giving way.
Postoperatively 100% patients regained normal to near normal knee function and knee stability. Significant improvement of pain and swelling also occurred.

Discussion
This prospective study was carried out from January 2015 to December 2016 at NITOR. In our study mean age was 25.8 (±5.261) years, age range was 18-36 years. Majority of the patients (60%) were from age 20 to 30 years. We had 30 patients, among them 27 was male and 3 female patient. None of the patients were sportsman, 43.3% were service holder, 36.7% were student, cultivator3.3%, lawyer 3.3%, housewife 6.7%, none of the patients was professional sportsman. Right side involvement was 56.7% and left side involvement was 43.3%. The cause of injury was sporting activity in 83.3%, RTA 10% and accidental fall and others in 6.7% cases. Forty seven percent patients had Isolated ACL injury, 26.7% had ACL with lateral meniscus injury and rest are ACL with medial meniscus injury. In this series Quadrupled Semitendinosus and Gracilis Autograft mean diameter was 7.07 with SD(± 0.691) and mean length 25.23with SD(±1.331). Mean duration was 17.37 months with SD (±11.072) months. In this study 63.3% patient stayed in hospital after operation less than 5 days. Preoperative versus post operative Lysholm knee score in this series shows significant improvements (p<0.05). Preoperative and postoperative Lysholm score were 67.57±11.458 and 9427±5.656respectively. Regarding final outcome, out of 30 patients, 29 (96.67%) had satisfactory (excellent + good), 1 (3.3%) had unsatisfactory (fair) outcome. Confidence interval (CI) at 95% confidence level is 87.21% -102.79%. So, among the population we will found satisfactory result by this procedure. It is quite acceptable outcome.

Conclusion
Anterior cruciate ligament injury most commonly occurs in young adult especially during sporting activity. It hampers their daily activity and causes financial loss so early reconstruction is necessary for their return to daily activity.