Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. A new and innovative procedure.

BONE--PATELLAR TENDON: The "no hardware" technique for ACL reconstruction is a new method that offers many advantages and is straightforward to perform. Its main innovative feature is that it does not require bone-block harvesting from the patella. This reduces donor site morbidity and prevents patellar fractures. The bone tunnels are made using tube harvesters and compaction drilling. This minimizes trauma and obviates the risk of bone necrosis. The articular entrance of the tibial tunnel is completely occupied by the grafts. This prevents a windshield-wiper effect and synovial fluid ingress into the tunnel, and enhances graft incorporation. The fact that no hardware is used with both patellar tendon or hamstring grafts significantly reduces the overall cost of the operation and facilitates revision surgery. The quadriceps tendon is also a very good graft. It is thick and has good biomechanical properties and low donor site morbidity. Its disadvantages are: weakness of quadriceps after the operation, an unsightly scar, and some difficulty in graft harvesting [58]. Also, postoperative MRI is not fraught with the problem of metal artifacts. It is difficult to decide which of the methods currently available for ACL reconstruction is the best because most of them give satisfactory results. In the future, assessments of knee ligament reconstruction techniques should look at long-term stability combined with low complication rates. Ease of revision surgery and low cost should also be taken into consideration, given the large annual volume of knee ligament reconstructions (50,000 in the United States alone) [59]. We believe that our technique addresses most of these issues, and that it constitutes a useful alternative method for ACL reconstruction. SEMITENDINOSUS--GRACILIS: This technique, which was used with 915 patients from June 1998 to February 2002, shows a particularly low rate of postoperative morbidity. The reason is probably to be found in the "waterproofing" of the bone tunnels, which lead to less postoperative bleeding and swelling. No drains were used. Rehabilitation follows the same protocol as used for the reconstruction using patellar tendon grafts (accelerated/functional). As expected, there was no widening of the femoral tunnels and little widening of the tibial tunnels. Interestingly, tibial tunnel enlargement was significantly less in a nonaccelarated rehabilitation group than in the accelerated group [60] without affecting stability. The measured internal torque of the hamstrings, as well as their flexion force, already had returned to normal 12 months postoperatively. In a prospective randomized (unpublished) study comparing this technique with ACL reconstruction with BPT grafts with medial or lateral third with only one bone plug (from the tibial tuberosity, see technique described above), we found no significant difference between both groups in subjective scores, stability, KT-1000 values, Tegner activity score, and IKDC at 1-year follow-up. Only the results of kneeling and knee walking testing were significantly better in the hamstring group [61]. In summary, the advantages of this presented technique are: (1) the knot of the graft is close proximally to the anatomic site of the insertion of the ACL, thus avoiding the Bungee effect.; (2) the press-fit tunnel fixation prevents synovial fluid entering the bone tunnels, windshield-wiper effect, and longitudinal motion within the tunnel; the intensive contact between the bony wall of the tunnel and graft collagen over a long distance without any suture material results in quick and complete graft incorporation; and (3) no fixation material means no hardware problems, facilitates revision surgery, and lowers overall costs.