Anterior cruciate ligament reconstruction with the patellar ligament comparative analysis of the autologous versus homologous ligament

ARTIGO ORIGINAL

Anterior cruciate ligament reconstruction with the patellar ligament comparative analysis of the autologous versus homologous ligament

Cleber Antonio Jansen Paccola^I; Mauricio Kfuri Junior^II; Paulo Sergio Arre Cunha^III; Fabricio Fogagnolo^IV

^IProfessor Titular do Deptº de Cirurgia, Ortopedia e Traumatologia, Faculdade de Medicina de Ribeirão Preto-USP

^IIDoutor em Ortopedia e Traumatologia

^IIIMédico Assistente do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto-USP

^IVPós-graduando em Ortopedia e Traumatologia

INTRODUCTION

The anterior cruciate ligament is an important element of knee stabilization.¹ Patellar and chondral lesions are related to rupture of the anterior cruciate ligaments, with possible functional implications for the joint.^2,3

The main objective of treating the anterior cruciate ligament lesion, conservatively or surgically, is functional knee stabilization.⁴ The patients' physiological age, sports activities level and associated articular lesions are critical elements in choosing the therapeutic approach.

The conservative treatment is founded on changing the physical activities, on avoiding contact sports and on muscular strenghtening.⁵ Surgical treatment is the consensus for individuals who wish to resume their normal level of practicing sports.⁶

The most employed surgical technique to treat lesions of the anterior cruciate ligament consists of using the central third of the patellar ligament as a substitute.^7,8 This preference is due to the biomechanical and fixation characteristics of this graft.⁹

Although the functional results of the autologous grafts are quite satisfactory, the aggression to the donor area is discussed. Complications as patellar tendinitis, patellar fracture, weakening of the knee extensor apparatus and low patella can result from patellar tendon graft removal.¹⁰

The ideal substitute for the anterior cruciate ligament would restore articular stability with no adittional harm due to graft removal. The use of prosthetic ligaments was idealized having this in mind. However, complications as mechanical collapse and synovitis disencouraged its utilization.¹¹

The homologous grafts constitute an atractive alternative in the knee ligament surgery. The main advantages of this surgical technique are less morbidity, shorter surgical procedure, better cosmesis and less pain after surgery. The controversial aspects are the risk of immunological reactions and the potential to transmit infectious diseases.^12,13

The aim of our study was to compare the use of homologous and autologous patellar ligaments in the anterior cruciate ligament reconstruction.

Casuistic and Methods

From March, 1993, to August, 1998, a group of 40 patients submitted to the anterior cruciate ligament surgical reconstruction was evaluated according to the International Knee Documentation Committee protocol¹⁴. The patients were allocated into two groups with 20 subjects each, quite comparable but differentiated according to the type of patellar tendon graft used, autologous or homologous. Table 01 illustrates the profile of the two groups of study.

Initially, the patients were asked about their level of playing sports in three different moments: before the lesion, after the lesion but before surgery and, finally, after surgery. The sports activities were categorized in four classes: vigorous, involving rotation, corte and jumping onto the knee, moderate, related to practice involving jogging, light, activities of low impact, as walking , and absent, in sedentary individuals. When a change in the sports practice level was documented, its relation with the operated on knee or other factors such as professional and familial activities was investigated. Previous surgeries, patellar status during surgery and articular alignment were data which completed the patients' profile.

Protocol evaluation included eight variables categorized in four indices each: normal (A), almost normal (B), abnormal (C) and very abnormal (D). The first variable involved the subjective evaluation of the patients concerning knee function in the daily life activities. The second variable concerned occurrence of the symptoms pain, swelling, partial falseio or total falseio in different levels of activity. The patient was always questioned concerning the higher level of activity that he could attain when a particular symptom was absent. The third variable evaluated amplitude of movement documenting loss of extension and loss of flexure. The ligament evaluation using clinical examination and instrumental quantification (KT 1000 MEDmetric, San Diego, CA) of the anterior-posterior displacement of the tibia in relation to the femur constitutes the fourth variable. Manual perception during the articular crepitation exam characterized the fifth variable defined as compartment findings. The sixth variable was related to problems in the local the graft was removed. The search of reductions in the articular spaces using radiographic findings constitutes the seventh variable. The eighth variable involved functional tests in which the individual was stimulated to jump onto the operated on leg and the amplitude of this movement was compared with the contralateral member. Since each of the variables had its own index, the final results were equivalent to the lower index obtained in any of the analyzed variables.

Results

Tables 02 and 03 present the results for autologous and homologous patellar tendon, respectively, in each of the IKDC protocol evaluated categories

The variables subjective evaluation, symptoms, ligament examination, radiographic findings showed that 80% were in the normal or almost normal indices. For the variables movement amplitude and functional test, 80% of the patients presented normal indices. In the variables radiographic findings and ligament examination, 10% of the patients were considered abnormal. The final result, considering the worst index for each patient, was 70% almost normal, 20% abnormal, and 10% normal.

In the subjective evaluation, 65% of the patients of this group were considered normal. According to our protocol, there was an at least 85% index of results considered normal or almost normal in all the studied variables. One patients in this group presented unsuccessful ligament surgery and very abnormal functional tests. The final result for this group was 80% almost normal results, 15% abnormal results, and 5% very abnormal results.

Figure 01 compares the final functional results in the two groups of patients, showing that most of the cases were categorized as almost normal in the two groups.

The ligament examination by instrumental quantification (KT1000) was analyzed under the statistical point of view comparing the operated on knee with the normal knee and, then, the autologous and the homologous patellar tendon receiving knees.

No statistical difference between the knee operated on with the autologous patellar tendon and the normal side was observed in measurements with 15 pounds (p=0.6609), 20 pounds (p=0.3945), and 30 pounds (0.2824).

The comparison between the operated on knee with the homologous patellar tendon and the normal side also did not show statistical differences with 15 pounds ( p=0.5604), 20 pounds (p=0.4091), and 30 pounds (p=0.1734).

When the knees operated on with autologous patellar tendon and homologous patellar tendon were compared, no statistical differences were observed with 15 pounds (p=0.8938), 20 pounds (p=0.8938), and 30 pounds (p=0.6141).

DISCUSSION

Although the surgical treatment of the anterior knee instability has significantly evolved with arthroscopy, controversial aspects persist.

The choice of the ideal graft to substitute the anterior cruciate ligament is discussed concerning capacity of integration and donor area morbidity.¹⁵

The autologous grafts used to reconstruct the anterior cruciate ligament are free grafts, which will present revascularization weeks after articular implantation.¹⁶ This reality opened perspectives to use homologous free grafts whose main advantage is less morbidity to the patients, since there are not additional agressions to the knee due to graft removal.

The utilization of homologous grafts in the knee ligament surgery implies in a shorter surgical procedure, less time with a tourniquet, lower indices of peroperative pain and better cosmesis.¹⁷

In our group of patients treated with homologous grafts we observed that the immediate post-operative behavior, concerning pain and capacity to restore amplitude of the articular movements, was superior to that observed in patients treated with autologous grafts. Preservation of potential areas to donate grafts, as the extensor apparatus and the knee flexor tendons, was responsible for better cosmesis. In the late post-operative period no significant differences were found concerning morbidity between the two groups of study.

One of the debatable aspects of using homologous grafts is the possible occurrence of immunological reactions, as the transmission of infectious diseases.¹⁸ However, the graft preservation technique used in our study, freezing to –80º C, seems to reduce graft antigenicity with no significant alteration of the mechanical properties.¹⁹

Immunological reactions characterized by reactional synovitis of the knee were not observed in our homologous graft treated patients. The study of the articular stability has shown that autologous and homologous grafts presented the same mechanical behavior.

Experimental studies in dogs have shown that one year after the implant, patellar ligament homologous grafts presented macroscopical and histological maturation, assuming an aspect similar to the original anterior cruciate ligament.^20,21

Clinical studies comparing ligament reconstruction with homologous and autologous grafts, clinically followed-up from 3 to 5 years on average, point out similar functional results also observed in our study.^17,22

The use of homologous grafts is particularly interesting in the cases of surgical revision, reducing surgical morbidity in the knee that has already undergone previous removal of the graft.

CONCLUSION

The comparative study between homologous and autologous patellar ligament grafts to surgically reconstruct the anterior cruciate ligament revealed that there are not significant differences between the two groups of study.

The homologous patellar ligament constitutes a grafting option to substitute the anterior cruciate ligament.

Referências

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Publication Dates

• Publication in this collection
  28 June 2006
• Date of issue
  Dec 2000