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Evaluation of Efficacy of Surgical Management for Treatment of Chondral Defects of the Knee in Adults
Vol 10 | Issue 1 | January-June 2024 | page: 66-69 | Shaunak Pathwardhan, Parag Sancheti, Kailas Patil, Sunny Gugale, Sahil Sanghavi, Yogesh Sisodiya, Obaid UL Nisar, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2024.v10.i01.230
Author: Shaunak Pathwardhan [1], Parag Sancheti [1], Kailas Patil [1], Sunny Gugale [1], Sahil Sanghavi [1], Yogesh Sisodiya [1], Obaid UL Nisar [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Shaunak Patwardhan,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and
Rehabilitation, Pune, Maharashtra, India.
E-mail: patwardhanshaunak@gmail.com
Abstract
Background: Articular cartilage defects of the femoral condyles cause pain and functional decline; untreated full-thickness lesions predispose to early osteoarthritis. This study compared short-term outcomes after three surgical strategies—arthroscopic microfracture, two-stage autologous chondrocyte implantation (ACI) and single-stage bone marrow aspirate concentrate (BMAC)—for full-thickness femoral condyle defects ≥2.0 cm².
Methods: In this prospective single-centre cohort (Oct 2019–Oct 2021) 66 adults meeting inclusion criteria were enrolled; 53 completed one-year follow up. Treatment selection was individualized. Primary outcomes were IKDC and KOOS scores measured preoperatively and at 6 and 12 months. Secondary outcomes included MOCART MRI appearance and complication rates. Standard rehabilitation and statistical analysis were applied.
Results: All three techniques produced clinically meaningful improvements in IKDC and KOOS at one year. Greater gains correlated with younger age, lower BMI and shorter symptom duration. Between-group differences at one year were not statistically significant in this cohort. MRI (available for 23 patients) generally showed defect fill and integration. Complications were few and minor.
Conclusion: Arthroscopic microfracture, single-stage BMAC and two-stage ACI each provided meaningful short-term functional improvement with low complication rates. Individualized technique selection is recommended; longer randomized studies are needed to assess durability.
Keywords: Cartilage defect, Microfracture, Autologous chondrocyte implantation, BMAC, IKDC, KOOS.
Introduction
Articular cartilage is a highly specialized, avascular and aneural tissue with limited intrinsic capacity for repair. Its zonal architecture and sparse cellularity confer excellent load-bearing and low friction properties but hinder meaningful regeneration after full-thickness injury.[1] Full-thickness chondral and osteochondral defects of the femoral condyles frequently produce pain, mechanical symptoms and functional impairment and are encountered commonly at diagnostic arthroscopy of symptomatic knees.[2,3] Epidemiological series indicate that focal cartilage lesions are prevalent among patients undergoing knee arthroscopy and can produce morbidity comparable to more advanced degenerative disease in selected populations.[4,5 ]The aetiology of focal defects is heterogeneous — acute trauma, repetitive overload, axial malalignment, meniscal deficiency and ligamentous instability are common contributors — and the lesion characteristics (size, depth, location) together with patient factors (age, activity level, body mass index) largely determine therapeutic choice and prognosis.[3,6]
Surgical approaches for symptomatic full-thickness defects range from palliative arthroscopic debridement to marrow-stimulation techniques (microfracture), osteochondral autograft transfer (OATS/mosaicplasty), two-stage cell-based restorative techniques such as autologous chondrocyte implantation (ACI), and contemporary one-stage biologic augmentations that combine concentrated marrow elements (BMAC) with scaffolds.[7,8] Microfracture has been widely used for small to moderate defects because it is technically straightforward and cost-effective, but it produces predominantly fibrocartilaginous fill that may be biomechanically inferior to hyaline cartilage.[9–11] ACI and matrix-augmented ACI aim to regenerate hyaline-like tissue through chondrocyte expansion and implantation but require two procedures and greater resource allocation.[12–14] Single-stage BMAC approaches are attractive in resource-constrained settings because they concentrate marrow-derived progenitor cells and growth factors in one operation, but standardisation of preparation and robust long-term comparative evidence remain limited.[15–18]
Systematic reviews and meta-analyses demonstrate heterogeneity across studies in patient selection, lesion characteristics and outcome reporting; therefore, firm universal recommendations regarding a single superior technique are difficult to make.[6,19] This study therefore sought to evaluate short-term functional and radiological outcomes following microfracture, two-stage ACI and single-stage BMAC in a prospective cohort treated at a tertiary orthopaedic centre, with the goal of informing surgeon decision-making in similar clinical and resource settings.[20]
Literature overview
Large arthroscopic cohorts and registry data highlight the frequency and clinical burden of focal cartilage lesions.[3,4] Microfracture has been associated with reliable short-term symptomatic relief, particularly in younger patients with smaller lesions, but durability may decline over time, especially for larger defects.[9–11] Mosaicplasty transfers hyaline cartilage plugs but is constrained by donor site morbidity and size limitations.12 ACI and matrix-assisted cell therapies have demonstrated favourable medium-term outcomes in many series but at the cost of two-stage procedures and greater expense.[13–16] Contemporary interest centers on single-stage biologic augmentation (eg, BMAC with scaffolds) which offers logistical advantages and encouraging early imaging and functional results, though preparation protocols and long-term data are variable.[6,14,17,18 ]Systematic reviews emphasise patient selection and lesion characteristics as key determinants of success, supporting individualized treatment planning.[6,19]
Materials and Methods
This prospective single-centre cohort was conducted from October 2019 to October 2021. Adults aged 15–55 years with symptomatic ICRS/Outerbridge grade 4 full-thickness chondral defects of the femoral condyles measuring ≥2.0 cm² on MRI or arthroscopic assessment were considered. Patients with advanced degenerative knee disease, systemic metabolic or neoplastic illness, intra-articular fractures, prior ipsilateral major knee surgery or defects <2.0 cm² were excluded. Institutional ethics approval and informed consent were obtained for all participants.
Baseline evaluation included a standardized history, physical examination, IKDC and KOOS questionnaires, weight and BMI measurement, plain radiographs and MRI to document lesion size, depth and associated meniscal or ligamentous pathology. Sixty-six consecutive eligible patients were enrolled; surgical strategy selection (microfracture, two-stage ACI or single-stage BMAC) was individualized based on defect size and location, associated pathology, patient preferences and resource considerations. Concomitant meniscal repair or ligament reconstruction was performed when indicated.
Surgical techniques followed standardized protocols. Microfracture was performed arthroscopically with stable borders debrided and multiple perforations into the subchondral plate created using an awl to allow marrow element ingress. ACI comprised arthroscopic harvest of cartilage for chondrocyte expansion followed by mini-open implantation of the cell-seeded scaffold in the second stage. Single-stage BMAC involved iliac crest aspiration, bedside centrifugation to concentrate marrow elements and implantation beneath a collagen matrix via a mini-arthrotomy. Perioperative care included prophylactic antibiotics, regional or general anaesthesia and a standardised rehabilitation regimen tailored to the procedure: early controlled range of motion with protected weight bearing and progressive strengthening over weeks.
Follow up occurred at routine intervals with detailed clinical examination and patient-reported outcomes at six months and one year. Postoperative MRI with MOCART scoring and second-look arthroscopy were obtained when clinically indicated and feasible. Outcome measures included change in IKDC and KOOS (primary endpoints), MOCART MRI appearance and complication rates (secondary endpoints). Statistical analysis used paired comparisons for within-group changes and ANOVA for between-group comparisons with significance set at p<0.05. Data were analysed using standard statistical software.
Results
Of the 66 eligible patients, 53 (80.3%) completed the one-year follow up and were included in the final analysis. The cohort comprised 34 males and 19 females with a mean age of 32.7 years (SD 8.9) and mean BMI 24.44 kg/m². Mean defect area was 5.6 cm² (range 2.2–10.4 cm²); 69.8% of lesions exceeded 4.0 cm². Procedures performed were arthroscopic microfracture in 33 patients (62.3%), single-stage BMAC in 15 (28.3%) and two-stage ACI in 5 (9.4%). Concurrent pathology requiring treatment (eg, meniscal tears, ACL injuries) was present in 54.7% and was addressed during the index procedure as appropriate.
At six months and one year, all three groups demonstrated statistically significant improvements in IKDC and KOOS relative to baseline (p<0.05 for within-group comparisons). Mean improvements were greater in younger patients and those with lower BMI. Between-group differences in mean IKDC and KOOS gains at one year did not reach statistical significance in this cohort, though subgroup sample sizes (particularly for ACI) were small. Postoperative MRI enabling MOCART scoring was available for 23 patients and generally indicated acceptable defect fill and integration across procedures. Complications were few and minor; there were no reported major procedure-related adverse events within the one-year follow up.
Discussion
This prospective single-centre series demonstrates that arthroscopic microfracture, single-stage BMAC and two-stage ACI each produced meaningful symptomatic and functional improvement at one year for symptomatic full-thickness femoral condyle defects. The clinical improvements observed align with prior epidemiological and cohort data indicating that appropriately selected patients derive benefit from both marrow-stimulation and restorative biologic techniques.3–8 Age, BMI and timing of surgery emerged as important correlates of outcome in this cohort, consistent with published series that identify younger patients and those treated earlier as more likely to experience substantial gains.[8,11,15]
Microfracture remains a pragmatic, cost-effective option that delivers reliable short-term relief for many patients, particularly for smaller defects and lower-demand individuals, but it typically yields fibrocartilaginous repair tissue whose long-term biomechanical properties may be inferior to native hyaline cartilage.[9–11] Mosaicplasty and osteochondral grafting provide immediate hyaline cartilage restoration but are limited by donor site morbidity and size constraints.[12–14 ]ACI and matrix-assisted chondrocyte implantation have shown promising medium-term outcomes in multiple series but require two-stage procedures, cell expansion facilities and greater resources.[13,16]
Single-stage BMAC with a collagen matrix offers logistical advantages in a single operation and in this cohort produced early functional gains comparable to other techniques; however, variability in marrow concentrate preparation and lack of standardisation complicate cross-study comparisons and long-term efficacy remains to be established.[15–18] MRI assessment using standardized scoring such as MOCART provided useful non-invasive information about defect fill and integration in those patients imaged, but routine postoperative imaging and histological verification were not feasible for all participants in this series. Limitations of this study include non-randomised technique allocation influenced by surgeon preference and resource considerations, incomplete imaging for the entire cohort, small subgroup sizes (notably for ACI), and relatively short follow up of one year — all of which limit definitive between-technique comparisons and long-term inference.[6,19,20]
Taken together with the broader literature, these findings support individualized treatment selection that balances lesion characteristics, patient factors, surgeon expertise and resource availability. Prospective randomized trials with standardized imaging protocols, second-look arthroscopy and histological assessment are required to determine technique-specific durability, cost-effectiveness and activity-related outcomes over the longer term.[6,17,19]
Conclusion
In this prospective cohort of adults with symptomatic full-thickness femoral condyle defects ≥2.0 cm², arthroscopic microfracture, single-stage BMAC with collagen matrix and two-stage ACI each produced significant improvements in IKDC and KOOS scores at one year with low complication rates. Patient factors — especially younger age, lower BMI and shorter interval from injury to surgery — were associated with greater functional gains. Radiological assessment where obtained demonstrated acceptable defect fill and early repair integration. Within the limitations of non-randomised allocation, incomplete imaging and short follow up, no single technique proved clearly superior at one year. Individualised, evidence-informed decision-making and longer randomized studies with standardized imaging and histology are recommended to guide optimal management and resource allocation.
References
1. Kim J, Cho H, Young K, Park J, Lee J, Suh D. In vivo animal study and clinical outcomes of autologous atelocollagen-induced chondrogenesis for osteochondral lesion treatment. J Orthop Surg Res. 2015; 10. Doi: 10.1186/s13018-015-0212-x.
2. Chubinskaya S, Haudenschild D, Gasser S, Stannard J, Krettek C, Borrelli J. Articular Cartilage Injury and Potential Remedies. J Orthop Trauma. 2015; 29(Suppl):S47–S52.
3. Curl WW, Krome J, Gordon ES, Rushing J, Smith BP, Poehling GG. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy. 1997 Aug; 13(4):456–60. Doi: 10.1016/S0749-8063(97)90124-9.
4. Widuchowski W, Widuchowski J, Trzaska T. Articular cartilage defects: Study of 25,124 knee arthroscopies. Knee. 2007; 14:177–82. doi:10.1016/j.knee.2007.02.001.
5. Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH. Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc. 2010 Oct; 42(10):1795–801.
6. Migliorini F, Eschweiler J, Schenker H, Baroncini A, Tingart M, Maffulli N. Surgical management of focal chondral defects of the knee: a Bayesian network meta-analysis. J Orthop Surg Res. 2021; 16:543. Doi: 10.1186/s13018-021-02684-z.
7. Seo SS, Kim CW, Jung ADW. Management of Focal Chondral Lesion in the Knee Joint. Knee Surg Relat Res. 2011; 23(4):185–96.
8. Løken S, Heir S, Holme I, Engebretsen L, Årøen A. 6-year follow-up of 84 patients with cartilage defects in the knee. Acta Orthop. 2010 Oct; 81(5):611–8. doi:10.3109/17453674.2010.519166.
9. Heir S, Nerhus TK, Røtterud JH, Løken S, Ekeland A, Engebretsen L, et al. Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: knee injury and osteoarthritis outcome score in patients scheduled for knee surgery. Am J Sports Med. 2010 Feb; 38(2):231–7. Doi: 10.1177/0363546509352157.
10. Messner K, Maletius W. The long-term prognosis for severe damage to weight-bearing cartilage in the knee: a 14-year clinical and radiographic follow-up in 28 young athletes. Acta Orthop Scand. 1996 Apr; 67(2):165–8. Doi: 10.3109/17453679608994664.
11. Widuchowski W, Lukasik P, Kwiatkowski G, Faltus R, Szyluk K, Widuchowski J, et al. Isolated full thickness chondral injuries. Prevalence and outcome of treatment. A retrospective study of 5233 knee arthroscopies. Acta Chir Orthop Traumatol Cech. 2008 Oct; 75(5):382–6.
12. Willers C, Wood DJ, Zheng MH. A current review on the biology and treatment of articular cartilage defects (Part I & II). J Musculoskelet Res. 2003; 7:157–81. Doi: 10.1142/S0218957703001125.
13. da Cunha Cavalcanti FMM, Doca D, Cohen M, Ferretti M. Updating on diagnosis and treatment of chondral lesion of the knee. Rev Bras Ortop. 2012 Jan; 47(1):12–20. Doi: 10.1016/S2255-4971(15)30339-6.
14. Camp CL, Stuart MJ, Krych AJ. Current concepts of articular cartilage restoration techniques in the knee. Sports Health. 2014 May; 6(3):265–73. Doi: 10.1177/1941738113508917.
15. Moyad TF. Cartilage Injuries in the Adult Knee: Evaluation and Management. Cartilage. 2011 Jul;2(3):226–36. Doi: 10.1177/1947603510383973.
16. Bedi A, Feeley BT, Williams RJ 3rd. Management of articular cartilage defects of the knee. J Bone Joint Surg Am. 2010 Apr; 92(4):994–1009. doi:10.2106/JBJS.I.00895.
17. Robinson PG, Williamson T, Murray IR, Al-Hourani K, White TO. Sporting participation following the operative management of chondral defects of the knee at mid-term follow up: a systematic review and meta-analysis. J Exp Orthop. 2020 Oct 6; 7(1):76. Doi: 10.1186/s40634-020-00295-x.
18. Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013 Jul; 4(3):193–203. Doi: 10.1177/1947603513481603.
19. Litchfield RB, Kirkley A, Brimingham T, Giffin R, Willits K, Feagan B, et al. A randomized trial comparing arthroscopic surgery to non-surgical care for knee osteoarthritis. Arthroscopy. 2009.
20. Steadman JR, Rodkey WG, Briggs KK. Microfracture to treat full-thickness chondral defects: surgical technique, rehabilitation, and outcomes. J Knee Surg. 2002; 15(3):170–6.
| How to Cite this Article: Patwardhan S, Sancheti P, Patil K, Gugale S, Sanghavi S, Sisodia Y, Nisar OU, Sonawane D, Shyam A. Evaluation of Efficacy of Surgical Management for Treatment of Chondral Defects of the Knee in Adults. Journal of Medical Thesis. 2024 January-June; 10(1):66-69. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
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Optimizing ACL Reconstruction: The Role of Precise Footprint Restoration and Adequate Graft Size for Knee Stability
Vol 7 | Issue 2 | July-December 2021 | page: 9-12 | Rohan Bhargava, Parag Sancheti, Kailas Patil, Sunny Gugale, Sahil Sanghavi, Yogesh Sisodia, Obaid UI Nisar, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2021.v07.i02.164
Author: Rohan Bhargava [1], Parag Sancheti [1], Kailas Patil [1], Sunny Gugale [1], Sahil Sanghavi [1], Yogesh Sisodia [1], Obaid UI Nisar [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Anterior cruciate ligament (ACL) rupture significantly reduces activity and quality of life in active individuals. This prospective study assesses whether tailoring hamstring graft diameter and restoring the patient’s native tibial insertion footprint during individualized anatomic single-bundle reconstruction improves early clinical outcomes.
Methods: Two hundred and one consecutive patients with symptomatic ACL tears underwent arthroscopic reconstruction with intraoperative measurement of native tibial footprint area and calculation of restored aperture using an ellipsoid formula. Graft diameters were recorded, and patients followed a standardised rehabilitation protocol. Outcomes included subjective IKDC and Lysholm scores and instrumented KT-1000 laxity at 6 and 12 months.
Results: Mean native tibial footprint area was 97.68 ± 18.86 mm2 and mean restored area was 76.1 ± 12.1 mm2, corresponding to a mean restoration of 79.25 ± 14.61%. The majority of patients received 9 mm grafts. Patients with >70% footprint restoration achieved superior IKDC and Lysholm scores at one year. Complication rates were low.
Conclusion: Individualized restoration of the tibial footprint with appropriately sized hamstring grafts correlates with favorable early outcomes after ACL reconstruction.
Keywords: ACL reconstruction, Tibial footprint, Graft size, IKDC, Lysholm.
Introduction:
Anterior cruciate ligament (ACL) rupture represents a common and functionally significant injury in young and active populations. Over the past century, treatment evolved from open repair and extra-articular tenodesis to arthroscopic intra-articular reconstructions as our understanding of ACL anatomy and biomechanics advanced. These historical and technical shifts are well documented and mark the progression toward less invasive and more anatomic procedures.[1–5] Contemporary practice has shifted the emphasis from simply re-establishing continuity to reproducing the native ACL insertion sites and restoring physiological knee kinematics[.6–10] The concept of anatomic reconstruction therefore focuses on placing tunnels and grafts to match individual patient morphology so as to reproduce native tensioning patterns of the anteromedial and posterolateral fibers and to restore rotational stability.[11–13] Individualized anatomic ACL reconstruction further adapts tunnel position and graft selection to the measured dimensions of the patient’s tibial and femoral footprints rather than applying a single standard technique to all knees.[7,8,11]Biomechanical and clinical studies have raised awareness that graft diameter and footprint coverage each affect knee stability and the risk of revision: smaller hamstring grafts appear linked to higher early revision rates while excessively large grafts risk impingement and damage to adjacent structures.[14–16] Given these considerations, precise intraoperative measurement and calculation of percentage footprint restoration have practical relevance for surgical planning. The present prospective cohort therefore investigates intraoperative footprint measurements, percentage of restored area, graft diameters commonly used, and their association with objective and patient-reported outcomes at one year after individualized single-bundle hamstring ACL reconstruction.[17]
Aims and objectives:
To determine (1) the native tibial ACL insertion site area using intraoperative measurements;
(2) the percentage of that footprint restored by the harvested hamstring graft and tunnel aperture;
(3) the association between percentage restoration, graft diameter, and early functional outcomes measured at 6 and 12 months.
Review of literature:
The evolution of ACL treatment reflects incremental improvements in understanding anatomy, graft biology and fixation.[1–5 ]The arthroscopic era allowed less invasive intra-articular reconstructions and a variety of autograft options emerged.[6–10] Comparative studies of single-bundle and double-bundle reconstructions have reported mixed results but have driven the field toward an anatomic philosophy that aims to reproduce native footprints and kinematics.[11–13] Investigators described practical methods to estimate insertion site area based on elliptical assumptions, establishing that individualized reconstructions commonly restore a substantial proportion of the tibial footprint.[17,18] Subsequent anatomical and cadaveric studies have highlighted population variability in tibial and femoral footprint dimensions, the ribbon-like morphology of the ACL midsubstance, and the need for classification of tibial insertion shapes to guide reconstruction.[12,19] Biomechanical studies and registry analyses reveal that graft diameter influences local knee mechanics and may affect clinical failure rates: smaller hamstring graft sizes have been associated with increased anterior translation and higher revision risk in younger patients, while larger grafts reduce meniscal stress and cartilage contact pressures.[14,15] Nevertheless, clinical outcomes depend on both accurate tunnel placement and sufficient graft size; increased graft diameter cannot fully compensate for malpositioned tunnels.[11,13 ]Recent work also emphasizes preoperative MRI as a useful adjunct to predict insertion dimensions and aid surgical planning.[17,20 ]Overall, the literature supports an individualized anatomic approach combining accurate footprint restoration and appropriate graft sizing to optimize early outcomes after ACL reconstruction.
Relevant anatomy: The knee’s osseous and soft tissue anatomy underlies ACL function and reconstructive strategy. The ACL is a flat, ribbon-like structure with two functional components that demonstrate differential tensioning through knee motion, with anteromedial fibers remaining taut during flexion and posterolateral fibers tightening near extension.[12,19] The primary blood supply derives from the middle geniculate artery with accessory supply from genicular branches; osseous attachments contribute little to intra-ligamentous vascularity.[12,19] Tibial and femoral insertion sites vary in size and shape across individuals and populations; these dimensions, measured as length and mid-width, allow estimation of insertion area by an ellipsoid formula.[17 ] Variation in tibial insertion shape has clinical relevance because different configurations may require modified tunnel trajectories or graft choices to avoid iatrogenic meniscal or root damage.[19]
Materials and methods:
This prospective single-center cohort included 201 patients admitted for primary arthroscopic hamstring ACL reconstruction. Inclusion required clinical and MRI confirmation of ACL rupture; patients with multiligament injuries, previous ipsilateral knee surgery, or contraindications to surgery were excluded. Preoperative workup included demographic data and anthropometric measurements. Semitendinosus harvest was performed, with gracilis added when additional graft bulk was required; grafts were quadrupled and sized. Intraoperative measurements of tibial insertion length and mid-width were taken using an arthroscopic ruler and used to calculate native insertion area by the ellipsoid formula ((length × mid-width) × π/4). Tunnel apertures were measured after reaming to compute restored graft aperture area; percentage restoration was calculated as (aperture area/native insertion area) × 100. Tibial and femoral tunnels were positioned to match the measured native insertion sites where permitted by anatomy and notch dimensions. Graft diameter was recorded (8, 9 or 10 mm most commonly). Postoperative rehabilitation followed a standardised protocol emphasizing early range of motion and graduated muscle strengthening. Outcomes were assessed by IKDC and Lysholm subjective scores and KT-1000 instrumented laxity testing at 6 and 12 months. Statistical analysis used ANOVA and unpaired t-tests to explore associations between graft size, percentage restoration and outcomes with p70% footprint restoration constituted 73.1% of the series. At 12 months, mean IKDC and Lysholm scores were higher in the >70% restoration group (IKDC mean ≈ 89.2; Lysholm mean ≈ 93.7) compared with the ≤70% group (IKDC mean ≈ 79.2; Lysholm ≈ 88.0). Objective KT-1000 measurements showed small, non-significant differences across graft sizes at 12 months. Overall complication rate was low (2.48%), including one deep infection, one DVT, two cases of impingement and one graft re-tear.
Discussion:
This series supports the concept that individualized anatomic ACL reconstruction — tailoring tunnel placement and graft selection to native footprint dimensions — can achieve high percentages of tibial footprint restoration and favorable early functional outcomes. Patients in whom >70% of the native tibial footprint was restored reported superior subjective scores at one year and most commonly received a 9 mm hamstring graft. These clinical observations are consistent with biomechanical data showing that larger grafts reduce anterior translation and articular contact stresses, and with registry studies linking small hamstring graft diameters to higher revision rates.[14,15] However, restoring footprint anatomy remains paramount; increasing graft size cannot fully compensate for non-anatomic tunnel placement.[11,13] The low complication and failure rates in this cohort suggest that individualized single-bundle reconstruction, when performed with careful intraoperative measurement and standardized rehabilitation, provides reliable short-term outcomes. Strengths of the series include prospective recruitment, consistent surgical technique and near-complete follow-up at one year; limitations are single-center design, surgeon-dependent intraoperative measurements and follow-up limited to the early postoperative period. Late outcomes such as osteoarthritis and medium- to long-term re-injury rates require longer observation. Future studies should examine whether the early benefits of footprint restoration translate into durable clinical advantages across broader populations and activity levels.[16–20]
Result
Two hundred and one patients completed one-year follow-up. The cohort was predominantly male (76%) with mean age 29.5 years; 90% were aged 21–40. Injury mechanisms were sports (43%), falls (36%) and road-traffic accidents (22%). Mean native tibial insertion area measured intraoperatively was 97.68 ± 18.86 mm². Mean restored graft aperture area after reaming was 76.1 ± 12.1 mm², yielding a mean percentage footprint restoration of 79.25 ± 14.61%. Seventy-three point one percent of patients achieved >70% footprint restoration. Graft diameters were most commonly 9 mm (62.7%), followed by 8 mm (26.4%) and 10 mm (10.9%). At 12 months, patients with >70% restoration demonstrated higher subjective scores (mean IKDC ≈ 89.2; mean Lysholm ≈ 93.7) compared with those with ≤70% restoration (mean IKDC ≈ 79.2; mean Lysholm ≈ 88.0). Instrumented KT-1000 laxity measurements showed only small, non-significant differences across graft sizes at one year. Overall complication rate was low (2.48%), comprising one deep surgical site infection, one deep vein thrombosis, two cases of graft impingement and one graft re-tear. Mean follow-up adherence was high and return-to-sport rates improved from preoperative baseline levels. No additional surgeries were performed during the follow-up other than the single documented graft re-tear revision within one year.
Conclusion:
In conclusion, individualized anatomic single-bundle hamstring ACL reconstruction that restores a substantial proportion of the native tibial footprint — most commonly achieved with a 9 mm graft in this cohort — is associated with improved early patient-reported outcomes and acceptable objective stability. Accurate intraoperative measurement and tailored graft selection appear to be practical strategies to optimize short-term results after ACL reconstruction. Longer-term studies are required to confirm durability and to evaluate implications for osteoarthritis and late re-injury.
References
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2. Engebretsen L, Benum P, Fasting O, Mølster A, Strand T. A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate ligament. Am J Sports Med. 1990 Nov; 18(6):585–90.
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6. Middleton KK, Muller B, Araujo PH, Fujimaki Y, Rabuck SJ, Irrgang JJ, Tashman S, Fu FH. Is the native ACL insertion site “completely restored” using an individualized approach to single-bundle ACL-R? Knee Surg Sports Traumatol Arthrosc. 2015 Aug; 23(8):2145–50.
7. Hofbauer M, Muller B, Murawski CD, van Eck CF, Fu FH. The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction. Knee Surg Sports Traumatol Arthrosc. 2014 May; 22(5):979–86.
8. Van Eck CF, Lesniak BP, Schreiber VM, Fu FH. Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy. 2010 Feb; 26(2):258–68.
9. Siebold R. The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011 May; 19(5):699–706.
10. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Individualized anterior cruciate ligament surgery: a prospective study comparing anatomic single- and double-bundle reconstruction. Am J Sports Med. 2012 Aug; 40(8):1781–8.
11. Magnussen RA, Lawrence JTR, West RL, et al. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012; 28(4):526–31.
12. Conte EJ, Hyatt AE, Gatt CJ, Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014; 30(7):882–90.
13. Bedi A, Maak T, Musahl V, Citak M, O’Loughlin PF, Choi D, Pearle AD. Effect of tibial tunnel position on stability of the knee after anterior cruciate ligament reconstruction. Am J Sports Med. 2011 Feb; 39(2):366–73.
14. Zantop T, Diermann N, Schumacher T, Schanz S, Fu FH, Petersen W. Anatomical and nonanatomical double-bundle ACL reconstruction: importance of femoral tunnel location on knee kinematics. Am J Sports Med. 2008; 36(4):678–85.
15. Tashman S, Kopf S, Fu FH. The kinematic basis of anterior cruciate ligament reconstruction. Oper Tech Sports Med. 2012 Mar; 20(1):19–22.
16. Rabuck SJ, Middleton KK, Maeda S, Fujimaki Y, Muller B, Araujo PH, Fu FH. Individualized anatomic anterior cruciate ligament reconstruction. Arthrosc Tech. 2012 Sep; 1(1):e23–9.
17. Granan LP, Forssblad M, Lind M, Engebretsen L. The Scandinavian ACL registries 2004–2007: baseline epidemiology. Acta Orthop. 2009 Oct 1; 80(5):563–7.
18. Gottlob CA, Baker JC, Pellissier JM, Colvin L. Cost effectiveness of anterior cruciate ligament reconstruction in young adults. Clin Orthop Relat Res. 1999 Oct ;( 367):272–82.
19. Yu B, Garrett WE. Mechanisms of non-contact ACL injuries. Br J Sports Med. 2007 Aug 1; 41(suppl 1):i47–51.
20. Van der Bracht H, Bellemans J, Victor J, Verhelst L, Page B, Verdonk P. Can a tibial tunnel in ACL surgery be placed anatomically without impinging on the femoral notch? A risk factor analysis. Knee Surg Sports Traumatol Arthrosc. 2013; 22(2):291–297.
| How to Cite this Article: Bhargava R, Sancheti P, Patil K, Gugale G, Sanghavi S, Sisodia Y, UI Nisar O, Sonawane D, Shyam A | Optimizing ACL Reconstruction: The Role of Precise Footprint Restoration and Adequate Graft Size for Knee Stability | Journal of Medical Thesis | 2021 July-December; 7(2): 09-12. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
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A Comparative study of Clinical and Functional Outcomes of ACL reconstruction: Remnant Preserving versus Remnant Sacrificing Techniques.
Vol 7 | Issue 1 | January-June 2021 | page: 1-4 | Nilay Kumar, Parag Sancheti, Kailas Patil, Sunny Gugale, Sahil Sanghavi, Yogesh Sisodia, Obaid UI Nisar, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2021.v07.i01.150
Author: Nilay Kumar [1], Parag Sancheti [1], Kailas Patil [1], Sunny Gugale [1], Sahil Sanghavi [1], Yogesh Sisodia [1], Obaid UI Nisar [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Keeping the remaining anterior cruciate ligament (ACL) tissue during reconstruction is thought to help graft healing by preserving blood supply and nerve endings that support proprioception. However, whether this practice improves clinical outcomes remains debated.
Methods and materials: We conducted a prospective cohort study of primary arthroscopic ACL reconstructions performed at a tertiary centre between June 2016 and December 2017. Patients with prior ipsilateral knee surgery, multi-ligament injuries, infection, or inability to complete follow-up were excluded. Hamstring autografts were used for all cases. The decision to preserve the remnant was made intra-operatively if the stump was viable and did not obstruct accurate tunnel placement. Outcomes recorded at 3, 6 and 12 months included IKDC and Lysholm scores, Lachman and anterior drawer grades, range of motion and KT-1000 arthrometry.
Result: Both remnant-preserving and remnant-sacrificing groups showed large functional improvements by one year. Remnant preservation was associated with better early arthrometric stability at 3 and 6 months; by 12 months outcomes were similar between groups. Complication rates were low and comparable.
Conclusion: Selective remnant preservation can offer transient early mechanical benefit without increasing complications when it does not compromise anatomic tunnel placement. Larger randomized, imaging-based studies with longer follow-up are required.
Keywords: ACL reconstruction, Remnant preservation, Hamstring autograft, KT-1000, IKDC.
Introduction
Tearing the anterior cruciate ligament (ACL) is one of the most common and life-changing knee injuries for active people. It causes instability, limits sports participation and can accelerate joint degeneration. Modern ACL reconstruction aims for anatomic restoration using autograft tissue and reliable fixation, but grafts require time to revascularize and remodel, and some patients experience lingering laxity or loss of joint sense (proprioception) that can impair full recovery [1–4].
A debated technique is to preserve whatever viable native ACL tissue remains at reconstruction. The remnant may carry blood vessels and nerve endings that speed graft revascularization and help maintain proprioception; it could also provide some mechanical restraint early after surgery [5–8]. On the other hand, leaving the remnant can make arthroscopic visualization and precise tunnel placement harder and, if neglected, might contribute to impingement or formation of a cyclops lesion that limits extension [9–11].
Clinical studies offer mixed messages. Some series report earlier graft revascularization or modest early stability benefits with remnant preservation, while larger comparative studies and meta-analyses often find no durable functional advantage at medium-term follow-up [12–15]. Because of this, many surgeons take a selective approach: preserve the remnant when it looks suitable and will not interfere with anatomic reconstruction; otherwise debride it. This study compares short-term clinical and objective outcomes between remnant-preserving and remnant-sacrificing ACL reconstruction to see whether the theoretical benefits translate into meaningful patient improvement. [1–8]
Materials and Methods
We ran a prospective cohort at a tertiary orthopaedic centre including consecutive primary arthroscopic ACL reconstructions from June 2016 to December 2017. Exclusion criteria were revision ACL surgery, prior major ipsilateral knee operations, and multi-ligament injury necessitating altered protocols, active joint infection and inability to follow up. Preoperative evaluation included history, clinical exam, radiographs and MRI for tear characterization and remnant appearance.
Hamstring autograft (semitendinosus ± gracilis) were harvested and prepared as multi-strand constructs. The intra-operative decision to preserve the remnant followed defined criteria: the stump had to appear viable, be amenable to retraction or tensioning that would allow accurate tibial and femoral tunnel placement, and pose no clear impingement risk. When the remnant blocked anatomic tunnel positioning or risked impingement, partial or complete debridement was performed. Femoral tunnels were drilled via an anteromedial portal with cortical button fixation; tibial fixation used interference screw techniques. Final graft position and absence of impingement were confirmed arthroscopically.
All patients followed a standardized postoperative rehabilitation program. Outcomes measured at 3, 6 and 12 months included IKDC and Lysholm scores, Lachman and anterior drawer testing, KT-1000 arthrometry and range of motion. Data were recorded prospectively on standardized forms and analyzed to compare the two groups. [7, 8]
Literature Review
The ACL contains distinct fiber bundles with differing tension patterns, receives vascular contribution mainly from the middle geniculate artery, and includes neural elements that contribute to proprioception. Histologic studies sometimes show persistent mechanoreceptors and vascular channels in ruptured stumps months after injury, lending biological plausibility to remnant preservation [5, 7, and 13]. Animal and in-vitro work emphasizes that tendon-to-bone healing depends on vascular ingrowth and formation of a fibrocartilaginous interface—processes that could theoretically be aided by preserving viable native tissue [3, 4].
Clinically, several preservation techniques have been described: traction sutures on the stump, careful posterior tibial drilling, partial debridement when needed, and meticulous notch work to prevent impingement [11–14]. Smaller series and second-look arthroscopy/MRI studies sometimes show earlier graft revascularization and less tibial tunnel widening when remnants are conserved, but larger clinical comparisons and meta-analyses generally report that early imaging or arthrometric advantages do not consistently translate into better patient-reported function or durable stability [12–15]. Concerns about cyclops lesions and loss of extension exist, but larger comparative series do not uniformly show higher complication rates when preservation is performed judiciously [16–18].
Overall, the literature supports a selective preservation strategy guided by remnant quality, timing from injury and intra-operative feasibility rather than universal conservation for all ACL tears. [9–15]
Results
During the study period, 508 patients met inclusion criteria and underwent primary arthroscopic ACL reconstruction. Fifty-two procedures (10.2%) involved intentional remnant preservation and 456 (89.8%) underwent standard remnant debridement. Patients chosen for preservation were typically younger and had a shorter time from injury to surgery. Both groups showed large improvements in patient-reported scores by one year; mean Lysholm and IKDC scores rose substantially and were similar between groups at 12 months. Range of motion recovered well in most patients. KT-1000 arthrometry showed better anterior translation values for the preservation group at three and six months, but differences were no longer significant at twelve months. Overall complication incidence was low (under 5%) and included stiffness and wound problems; two patients required intervention for deep infection. There was no significant difference in complication frequency between groups. In short, remnant preservation produced a transient early stability benefit, but one-year functional outcomes were comparable across cohorts.
Discussion
This series indicates that selective remnant preservation can provide a modest early mechanical advantage, which shows on arthrometric testing during the first months after surgery. That finding fits the biologic idea that preserved tissue may offer immediate restraint and possibly speed revascularization in the early remodeling window. The disappearance of this advantage by one year suggests that long-term graft function is mainly governed by correct anatomic reconstruction, graft selection and rehabilitation rather than remnant status alone.
Selection bias is an important caveat: surgeons favored preservation in younger patients and when surgery occurred earlier, so the observed early benefits may partly reflect patient selection. Concerns that preservation increases cyclops lesions or arthrofibrosis were not realized in this cohort when surgeons preserved stumps carefully and prioritized anatomic tunnel placement—if the remnant threatened correct positioning, partial or full debridement was preferred. Thus, remnant preservation is a reasonable option when it can be performed without compromising tunnel accuracy; it should not override the technical imperatives of anatomic reconstruction.
Limitations include nonrandomized allocation with possible selection bias, lack of routine MRI or second-look arthroscopy to quantify graft ligamentization and neural recovery, and a one-year follow-up that does not address long-term graft survival or osteoarthritis risk. Randomized trials with imaging biomarkers and formal proprioception testing would more definitively determine whether remnant preservation confers durable biological or functional benefits. [16–20]
Conclusion
In this prospective cohort, selectively preserving the ACL remnant during reconstruction produced a modest early improvement in objective anterior stability but did not deliver superior patient-reported outcomes or objective measures at one year. Complication rates were low and comparable when preservation was undertaken carefully without compromising anatomic tunnel placement. Therefore, remnant preservation is appropriate when it does not hinder accurate reconstruction, but inability to preserve the stump does not preclude excellent outcomes with standard anatomic techniques and structured rehabilitation. Larger randomized and imaging-driven studies with longer follow-up are needed to determine whether remnant preservation has durable benefits for graft biology, proprioception and long-term joint health.
References
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| How to Cite this Article: Kumar N, Sancheti P, Patil K, Gugale S, Sanghavi S, Sisodiya Y, Ul Nisar O, Sonawane D, Shyam A| A Comparative Study of Clinical and Functional Outcomes o ACL reconstruction: Remnant Preserving Versus Remnant Sacrificing Techniques | Journal of Medical Thesis | 2021 January-June; 7(1): 01-04. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
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