Summary

Clinico-radiological outcomes of arthroscopic all inside anterior cruciate ligament reconstruction by single tibial and double femoral socket technique using autogenous semitendinosus graft: - A Novel Approach

Abstract

Introduction

Many clinical and biomechanical studies have showed improved kinematic restoration using double bundle anterior cruciate ligament (ACL) reconstruction techniques. But the conventional double bundle is criticized for its issues of intraoperative complexity, limiting knee flexion strength due to use of semitendinosus and gracilis for which Trilink technique was described. We present a novel 3 socket ‘’Modified Trilink Technique’’ which tackles these issues of the conventional technique by utilizing only semitendinosus and confronts problem of tunnel confluencing faced by previously described trilink technique.

Methodology

It was a prospective study done in 15 patients with a follow up of 1 year. For functional scoring IKDC, Tegner score, KOOS score, Lysohlm score was evaluated. Radiological parameters included MRI, CT scan for assessment of ligamentisation and tunnel widening was done at 6 months. Semitendinosus alone is harvested and two separate bundles of ACL are prepared (AM and PL). Anatomic placement of femoral sockets is performed via inside out method and single socket is made over tibia using all inside technique. 2 pro-cinch were used for suspensory fixation on femoral side and fixation on tibial side was done by free endobutton. Both grafts were passed according to anatomical orientation and were differentially tensioned.

Results

The mean Tegner Scale (pre-operative) was 3.60 ± 1.55 which increased to 7.40±1.50 (range: 5-10) at 1 year post surgery. KT-1000 examination showed that the mean side-to-side difference in anterior knee laxity was 11.20±3.03 (range: 2- 15) mm pre-operatively and 2.80±0.77 (range: 2-4) mm post operatively at 1 year. The mean of IKDC score was 49.20%±3.88 (range: 42-55) in pre-operative period which increased to 72.87±5.59 (range: 63-82) at 3 months post-operatively. The mean further increased to 81.67%±3.87% (range: 76-90) at 1-year post-surgery. 93.3% of the subjects showed excellent Lysholm’s outcome whereas 6.7% showed good outcome at 1 year post ACL reconstruction. There was no significant widening of femoral and tibial tunnels at 6 months as compared to the literature as assessed on CT scan. MRI done at 6 months was evaluated to assess healing of the graft. 26.5% of the subjects had 5 as the Figueroa score whereas 73.3% had 4 which give indirect evidence of good ligamentization in 15 subjects. None cases had synovial fluid at graft tunnel interface.

Conclusion

This Modified Trilink Technique maximizes bone preservation, mimic native functional anisometry and improves femoral footprint coverage while avoiding complexity and pitfalls of conventional double bundle and Trilink technique of ACL reconstruction.