International Journal of Orthopaedics Sciences 2020; 6(4): 867-871

E-ISSN: 2395-1958
P-ISSN: 2706-6630
IJOS 2020; 6(4): 867-871 Study of functional outcome following arthroscopic
© 2020 IJOS
www.orthopaper.com anatomical ACL reconstruction using autologous
Received: 01-08-2020
Accepted: 05-09-2020 hamstring graft
Dr. Avinash Gundavarapu
Yashoda Superspeciality Dr. Avinash Gundavarapu, Dr. Santhosh Kumar M, Dr. Vishal Singh and
Hospital, Rajbhavan road,
Hyderabad, Telangana, India Dr. Prashant Kumar Mishra
Dr. Santhosh Kumar M DOI: https://doi.org/10.22271/ortho.2020.v6.i4m.2430
Yashoda Superspeciality
Hospital, Rajbhavan road, Abstract
Hyderabad, Telangana, India. Background: Our study aim is to assess the functional outcome of arthroscopy assisted anatomical
reconstruction of ACL with autologous hamstring graft using IKDC score.
Dr. Vishal Singh
Dhanwantri Hospital, Jaipur,
Methodology: Our study is a prospective observational study conducted in 40 patients, all patients
Rajasthan, India between age group of 20-40 yrs, both male and females with ACL injury, admitted to Yashoda
Superspeciality hospital, between April 2016 and May 2017 (14 months) and fulfilling inclusion and
Dr. Prashant Kumar Mishra exclusion criteria, treated surgically with Arthroscopic anatomic ACL reconstruction using autologous
Yashoda Superspeciality hamstring graft were included as the subjects for study. Case selection was done according to.
Hospital, Rajbhavan road, Results: A total of 40 patients, 32 male and 8 female with 26 right knee and 14 left knee involvement
Hyderabad, Telangana, India. with ACL tear were operated. The IKDC score reflected highly significant improvement in the stability,
mainly rotational and anterior stability when preoperative score were compared with the score of most
recent follow up i.e. 6 months. Pre-operative mean of 44.43+3.630 SD and Post-operative mean was
88.53+3.994 SD. The average Pre-operative mean was 44.525 and average Post-operative mean was
88.525, with an average mean increase in score was 44, with significant P value < 0.01 using IKDC
score.
Interpretation and conclusion: Anatomical ACL reconstruction is excellent technique for treating
patients with ACL tear who are especially involved in the activities which involve pivoting most of the
times in their life time for e.g. Athletes.

Keywords: Arthroscopy, anatomical ACL reconstruction, IKDC score

1. Introduction
Anterior cruciate ligament (ACL) is one of the common sports injuries seen by orthopedic
surgeons and is the most common complete ligamentous injury in the knee. The anterior
cruciate ligament is a band of dense connective tissue which runs from the posteromedial
aspect of the intercondylar notch on the lateral femoral condyle towards anteriorly, medially
and distally [1]. The narrowest part of the ACL is at midsubstance level (35 mm2). It is a major
knee ligament to stabilize the joint movement against anterior tibial translation and rotational
loads [1, 2]. A recent systemic review by Hwang et al. showed that the ACL tibial foot print is
15 mm anterior to the ACL and two-fifth of medial-lateral width of the interspinous distance
with the majority of the ACL fibres attaching anterior to the posterior margin of lateral
meniscus [3]. The purpose of ACL reconstruction is to restore normal stability, and to protect
the knee from further injury [5]. Anatomic ACL reconstruction can be defined as the functional
restoration of the ACL to its native dimensions, collagen orientation, and insertion sites [4].
Anatomic placement of an anterior cruciate ligament (ACL) graft is critical to the success and
clinical outcome of ACL reconstruction. Non-anatomic ACL graft placement is the most
common technical error leading to recurrent instability following ACL reconstruction [5, 6]
results in limited range of motion, higher than physiologic graft tension, and ultimately graft
Corresponding Author:
failure [7, 8]. A vertically oriented ACL graft may resist the motion of anterior tibial translation,
Dr. Avinash Gundavarapu but may fail to control the combined motions of anterior tibial translation and internal rotation
Yashoda Superspeciality which occur during the pivot-shift phenomenon [9]. The purpose of this study is to assess the
Hospital, Rajbhavan road, function of arthroscopy assisted anatomical ACL reconstructed knee in patients who
Hyderabad, Telangana, India underwent autologous hamstring graft reconstruction.
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The functional outcome is measured using International Knee test (for collateral ligaments), McMurray’s test (for menisci),
documentation committee (IKDC). Posterior drawer test (for posterior cruciate ligament),
Reverse pivot shift test (for Posterolateral complex). Routine
2. Material and Methods skiagram of both knees in standing position in antero-
Our study is a Prospective Observational Study conducted in posterior view and lateral view of the affected knee were
Yashoda Superspeciality Hospital, Rajbhavan road, taken and lateral view in 450 of flexion of the affected knee
Hyderabad. A total of 40 patients (both male and female) with was also done. MRI of the knee was done in cases with
ACL injury between age group of 20-40yrs admitted to equivocal clinical findings. Diagnostic arthroscopic
Yashoda Superspeciality hospital, between April 2014 and examination of the knees was used as last resort for patients
May 2015 (14 months) were treated surgically with with negative or equivocal clinical and radiological findings
Arthroscopic anatomic ACL reconstruction using autologous but consistent symptoms suggesting anterior cruciate ligament
hamstring graft after obtaining informed consent. deficiency. After obtaining written informed consent, patients
with established ACL injury were taken up for Arthroscopic
2.1 Inclusion Criteria Anatomic ACL reconstruction using autologous hamstring
1. Clinical / radiological / arthroscopic evidence of anterior graft. Functional evaluation of the reconstructed ACL will be
cruciate Ligament injury/deficiency, which is done using IKDC score.
symptomatic even after conservative therapy of adequate
duration. Post –Operative Care and Follow Up
2. Young and middle aged, active, motivated patients with Post-operatively patients were placed in knee brace. Partial
future interest in professional / recreational sports aiming weight bearing with crutches (50% of the body weight) was
for active life style. allowed for one month. Mobilization was started immediately,
3. The acute inflammatory phase of the injury has subsided giving priority to the recovery of full extension. CPM was
and full range of motion and good quadriceps strength used to help flexion. Active static quadriceps exercises and
has been regained with no extensor lag (usually after 4-6 ankle pumps were started as soon as the patient recovered
weeks of injury) from anesthesia. The crutches are maintained until quadriceps
4. Patients with regular follow-up visits to outpatient control was reestablished typically about 4-6 weeks. Standard
department. ACL reconstruction rehabilitation protocol was then followed.
Non cutting, Non-pivoting sports was allowed after 3 months.
2.2 Exclusion Criteria Cutting and pivoting sport activities were started by 6 months.
1. Patients with bilateral ACL tear or associated All knees were examined before surgery, in the operating
periarticular fractures or fractures of lower limb and room, immediately after the procedure and at one, two, four,
spine. six months. Ability to bear weight (graded as full, partial, or
2. Patients with any other associated ligament injuries of the impossible) was assessed postoperatively and at two, four and
Knee (tear of posterior cruciate ligament, medial and six months. Difficulty with squatting (assessed as no problem
lateral collateral ligament requiring treatment) flexing the knees greater than or equal to 90 degrees, ability to
3. Patients with open physis. flex the knees greater than or equal to 90 degrees with slight
4. Patients with local skin infections. difficulty, unable to flex the knees greater than or equal to 90
degrees, or unable to squat) will be assessed at the
2.3 Study Procedure preoperative, four and six month visits. Results were
Fourty Patients with Complete ACL injury, treated surgically documented at two weeks, one, two, four and six months. In
with Autologous hamstring graft Arthroscopically, and with our study we used IKDC Score in order to evaluate the
regular follow-up visits were included in this study. The study rehabilitation progress of patients with ACL reconstruction.
period was of 14 months. A detailed history and clinical
examination was be done. The following specific tests were 3. Results
performed for diagnosing anterior cruciate ligament Out of 40 patients with ACL tear in our study, 32 were males
deficiency: Lachman test, Anterior drawer test, Pivot shift test (80%) and 8 were females (20%). All the patients were
and followed by preoperative IKDC Subjective Evaluation. between 20-40 yrs of age.
Injuries to the associated structures were assessed by
performing the following clinical tests:- Valgus / Varus stress

Graph 1: Age and Sex Distribution

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In our study 40% of cases were in the age group of 20-25 ranged from day 0 to 11 months, Out of which 45% of the
years, followed by 27% cases in 25-30 years. Both Males and patients were operated between 2 to 6 months. Road traffic
females predominantly belonged to age group 20-25 years. accidents accounted for 30% (12 cases) of patients while 60%
The mean age of patients in our study was 28.4 years. The (24 cases) were due to sports injury. Injury sustained during
Ratio of male to female patients was 4: 1 With right to left activities of daily living accounted for 10% (4 Cases).
ratio of 1.86: 1. The duration of symptoms in our study Graph 2 -

Graph 2: Injury sustained during activities of daily living accounted

Majority of the patients 60% (24 cases) presented with a The results of Pre-operative and Post-operative Anterior
feeling of giving way of the knee, during routine work and Drawer test were statistically analyzed and the mean of pre-
guarded walking due to apprehension, usually without pain. operative Anterior Drawer Test was 2.40 + 0.672 SD and
40% (16 cases) patient had a feeling of giving way during Post-operative was 0.20 + 0.516 SD with significant p value
heavy laborer or playing usually with pain. The most common <0.01. Similarly the results of preoperative Pivot shift test
clinical finding associated in the patients of ACL tear was (PST) and Post-operative Pivot shift test were statistically
effusion, which was present in 70% (28 patients) of cases. analysed. The mean preoperative PST was 2.10 + 0.632 SD
The joint line tenderness was present in 60% (16 patients) of and post-operative was 0.35 + 0.622 with significant p value
the cases. There were 30% cases (12 patients) with flexion < < 0.01. The results of IKDC Score were statistically analyzed
100 degrees. There were only two cases (5%) who had using the paired-t test at 5% level of significance, the mean
Flexion < 10 degrees. Manual knee laxity test were performed preoperative score was 44.53 + 3.630 SD and post- operative
in all cases before ACL reconstruction in which Anterior mean score was 88.53 + 3.994 SD with significant p value <
Drawer Test, Lachman test and Pivot shift test were positive 0.01.
in 100% of cases. Results of Manual knee laxity test after
anatomical ACL reconstruction showed 82.5% cases were
Lachman test negative, 12.5% were Grade 1 and only 5%
were Grade 2. Results of Anterior Drawer Test after ACL
reconstruction were 85% were negative, 10% were Grade 1
and 5% were Grade 2. Results of Pivot shift test after double
bundle ACL reconstruction were 72.5% were negative, 20%
were Grade 1 and 7.5% were Grade 2. There were no cases of
severe instability in our series with Grade 3 for Lachman test,
Anterior drawer test and Pivot shift test.
The results of Pre-operative and Post-operative Lachman test
were statistically evaluated and the mean of pre-operative
Lachman test was 2.43 + 0.675 SD and post-operative
lachman test has 0.23 + 0.530 SD with significant p value<
0.01.
Graph 3: Range of Motion.
Table 1: Pre-operative findings.
No major complications were seen in our series except
S. No. Test Negative Grade 1 Grade 2 Grade 3 superficial infection in 3 cases (7.5%). 3 cases (7.5%) had
1 Lachman test 0 5 12.5% 15 37.5% 20 50% difficulty in regaining the motion. There were no cases in our
2 Anterior Drawer Test 0 5 12.5% 15 37.5% 20 50%
series which had graft avulsion, Graft impingement. There
3 Pivot shift 0 6 15% 24 60% 10 25%
were 3 cases (7.5%) of superficial infection which were all
treated and responded well to intravenous antibiotics.
Table 2: Post-operative findings
S. NO Test Negative Grade 1 Grade 2 Grade 3 4. Discussion
1 Lachman Test 33 82.5% 05 12.5% 02 5% 00 0% Most of our patients in our series - 16 cases (40%) were in the
2
Anterior Drawer
34 85% 04 10% 02 5% 00 0% age group 20 – 25 years followed by 27% (11 cases) in 25 –
Test 30 years age group. Brig VP Pathania, Lt Col GR Joshi et al.
3 Pivot shift test 29 72.5% 08 20% 03 7.5% 00 0% [10]
in there series showed the maximum number of patients

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10 cases (40%) were grouped between 25 – 30 years of the laxity test, positive Lachman test were found in 4 patients
age. The age of the patients ranged from 20 – 40 years with (7.01%), all were evaluated as + and none was evaluated as
the mean age of 28.4years in our study and A.J. Johnson, E. ++, Positive pivot shift test were detected in only one patient
Eriksson, T. Haggmark and M.H. Pope (1984) in their series (1.7%). Kazunori Yasuda, M.D., Phd. D. et al. [15] In their
had patients whose age ranged from 17 to 48 years with the series regarding pivot shift test 9 (37.5%) patients were
mean age of 26.3 years. evaluated as + and 3 patients (12.5%) were evaluated as ++ in
Takeshi Muneta et al. [11] in their study indicated that double the single bundle group while 3 (12.5%) patients were
bundle ACL reconstruction via 4 stranded ST is superior to evaluated as +, and no patient was evaluated as ++ in the
the single bundle technique with regard to anterior and double bundle group. Masayoshi Yagi, Ryosuke Kuroda,
rotational stability. Freddie Fu and Christian letterman et al 12 M.D., et al. [16] in their series the Lachman test revealed
suggest that anatomical ACL double bundle reconstruction positive results in two (10%) and three (15%) patients in the
may result in better restoration of in vivo kinematics of knee anteriomedial group and Posterolateral reconstruction group
joint and can improve clinical outcomes in ACL surgery. respectively, while no (0%) patient in double bundle group
The ratio of the right knee to left knee in this series was 1.8:1 showed positive instability. Muneta T, koga H, Morito T,
and A.J. Johnson, E. Eriksson et al. (1984) in their study had Yagishita K. (2006) [17] In their series post-operative results of
right to left knee involvement ratio of 1.2: 1. manual knee laxity tests. A statistically greater number of
Sports injuries (60%) predominates as mode of injury in our patients in the single bundle group were positive based on the
series and William G Clancy, Jr Devon A. Nelson, Bruce Lachman test (34% in the single bundle group and 13% in the
Reider and Rajesh G Narechania (1982) had 88% of sports double bundle group, respectively).
related injuries. No major complications were seen in our series except
The major presenting complaint was guarded walking. 50% superficial infection in 3 cases (7.5%). 3 cases (7.5%) had
(20 cases) presented with a feeling of giving way of the knee difficulty in regaining the motion. There were no cases in our
during routine work with no or minimal pain or guarded series which had graft avulsion, Graft impingement. There
walking. In rest of the cases 30% (12 cases) patient had a were 3 cases (7.5%) of superficial infection which were all
feeling of giving way with pain during heavy labor or sports treated and responded well to intravenous antibiotics. The
activity. However, they all had various associated complaints average tourniquet time in our series was 1 hour 10 minutes
like Effusion (70%), Joint line tenderness (40%), difficulty in and here were no case of tourniquet palsy in our series.
climbing staircase and difficulty in squatting. R.J. Johnson, E. Yasuda et al. [15] in their series, no major complication were
Eriksson, T. H. Haggmrk and M.H. Pope (1994) [13] in their recorded at a minimum follow up of 24 months, and they
study 73 patients (83.9%) complained of a feeling of giving suggested that anatomical double bundle ACL reconstruction
way of the knee, associated with joint effusion (92%). appears to be a safe and practicable technique. Kazunori
All the patients were evaluated symptomatically by IKDC Yasuda, M.D., Phd. D. Eiji Kondo, M.D., Hiroki Ichiyama,
score, clinically and radiologically at 2 weeks, one month, 3 M.D. et al. (DEC.2004) [15] in their series they did not
months, 6 months, and statistical analysis was done. The experience Any intraoperative problems concerning tunnel
average preoperative IKDC score was 44 (39 – 52). Average positioning, the graft placement, or the graft fixation. There
post-operative Lysholm score at 6 months follow up was 88 were no post- operative complication, such as infection,
(80 – 94). The average increases in points were 44. After the neurovascular injury, cartilage injury, injuries in other knee
average follow up of 6 months above 90% patients were structures or delayed wound healing. T muneta M.D., Ph. D
satisfied with their result. H. Koga, M.D. et al. (2007) [14] in their series there were no
In our study 82.5% (33 cases) were negative Lachman test, problematic loss of knee motion in either the single bundle or
The mean of pre-operative Lachman test was 2.43 + 0.675 SD double bundle group. Prolonged joint inflammatory reaction
and post-operative lachman test was 0.23 + 0.530 SD with that continued for more than 3 months after the surgery or that
highly significant p value < 0.01 suggesting that stability was occurred at more than 3 months postoperatively was found in
significantly improved after double bundle ACL 4 (11%) patients in the single bundle group and 2 (5.5%)
reconstruction. Results of anterior drawer test after double patients in double bundle group.
bundle ACL reconstruction were 85% (34cases) were
negative. The mean of pre-operative ADT was 2.40 + 0.672 5. Conclusion
SD and post-operative mean 0.2 + 0.516 with significant p Most of patient who underwent double bundle ACL
value < 0.01. Results of Pivot shift test after double bundle reconstruction were satisfied with the results and achieved
ACL reconstruction were 72.5% (29 cases) were negative. pre-injury status in our study. Reconstructed ACL (AM and
The mean preoperative PST was 2.10 + 0.632 SD and post- PL bundles) in anatomic ACL reconstruction recreates normal
operative was 0.35 + 0.622 with highly significant p value < anatomy and similar biomechanical properties as native ACL.
0.01 suggesting that there was highly significant improvement Double bundle ACL reconstruction provides anterior and
in the stability after double bundle ACL reconstruction. T. rotational stability. This Anatomical ACL reconstruction is a
muneta M.D., PhD H. Koga, M.D. et al. (2007) [14] in their good technique for the ACL reconstruction in athlete and high
series manual knee laxity testing revealed that negative demanding patients who has to undergo pivoting most often
Lachman and Pivot shift test results in more patient in double in their life time.
bundle group than in single bundle group. Post operatively
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