Summary

After ACL reconstruction, adhesion occurs between the transverse ligament and the ACL graft in varying degrees. Surgical release of adhesion resulted in subjective improvement of the symptom by regaining normal mobility of the transverse ligament.

Abstract

Objectives)
Satisfactory outcomes of anatomical anterior cruciate ligament (ACL) reconstructions based have been recently reported. However, patients often complaint of various subsequent symptoms after the surgeries even if appropriate graft placement such as slight pain or discomfort in the anterior part of the knee during sports activities or activity of daily living. One of the potential causes could be adhesion of the grafts to the surrounding normal tissue or newly generated scar tissue. Thus, the objective of this study is to examine adhesion focusing on between the graft and the transverse ligament of the menisci, which is located adjacent to the tibial attachment area of the native ACL, by 2nd-look arthroscopy (AS) and to evaluate symptomatic improvement by arthroscopic release of the adhesion.

Materials)
One hundred ninety patients were received anatomical ACL reconstruction with a bone-patellar tendon –none (BTB) graft or hamstring tendon (HST) grafts from Jan. 2016 to Dec. 2018 in Kansai Rosai Hospital. Among these patients, 2nd -look AS was performed in 40 patients at x and X months after ACL reconstruction. Three knees were excluded due to extension loss more than 5 degree. As a result, 37 knees are included in this study. No patient complained instability or extension loss more than 5 degree. The reasons for 2nd-look AS were as follows: 10 requested hardware removal (no symptom), 15 different feeling than the normal side and 12 discomfort feeling when knee is extended. Arthroscopic evaluation was performed and surgical release was done in case of adhesion between the graft and transverse ligament. To evaluate symptomatic improvement by arthroscopic release of the adhesion, changes of the symptom after the surgery were evaluated by interview in patients without other abnormal lesion except the adhesion when all the patients returned to the individual pre-operative activity level.

Results

In 31 out of 37 patients, adhesion between the ACL graft and the transverse ligament was confirmed in varying degrees. Adhesion restricted normal mobility of the transverse ligament which was above the ACL at near full extension and moved anteriorly to the posterior margin of the fat pad at near full extension. However, surgical release regained it. This was particularly apparent at near full extension and the transverse ligament moves anteriorly independently from ACL. In 31 patients with adhesion, 11 have no other abnormal lesion like a cyclops, scarring of infrapatellar fat pad and outgrowths of synovial membrane. Adhesion was the only abnormal finding in these 11 patients. After arthroscopic release for adhesion, all of 5 patients with uncomfortable feeling in the operated knees preoperatively had improvement in symptoms. Four of other 6 patients achieved improvement in uncomfortable feeling when compared with preoperative status, although these 6 patients just requested hardware removal and complained no symptom before 2nd look AS. In total, surgical release of adhesion was effective in 9 of 11 knees.

Conclusion

After ACL reconstruction, adhesion occurs between the transverse ligament and the ACL graft in varying degrees. Surgical release of adhesion resulted in subjective improvement of the symptom by regaining normal mobility of the transverse ligament.