Optimizing position of patellar tendon graft in anterior cruciate ligament reconstruction

Background. ACL graft may take a non-optimal position even in correctly drilled tunnels, being one of the possible causes of residual instability. Aim: to study the possibility and evaluate the efficiency of the graft position improvement directly in the ACL footprints. Material and methods. Prospective study of 30 patients, divided in 2 equal groups, who have undergone two-incised ACL reconstruction with BTB autograft. The first group of patients received traditional surgical technique, while in the second group a cortical bony fragment from anterior tibial margin was fixed to graft to create tight contact with medial margin of tibial aperture. Graft and tunnels length parameters, interarticular distance were measured intraoperatively. Postoperative radiographs and CT, 6 months follow-up CT, and 12 months follow-up MRI were performed. Median follow-up with IKDC score was 23.5 months (Q1=18; Q3=25). Results. Graft axis in the first study group was more vertically with mean deviation from native ACL axis 6,2 ̊ (SD=1.8) in anteroposterior view, and 6,7 ̊ (SD=2.1) in lateral view. In the second group ax-es difference was minimal in both anteroposterior view (M=0.7 ̊; SD=0.4) and lateral view (M=2,1 ̊; SD=0,6). Intergroup differences were statistically significant (p <0,05). Tunnels, graft bone blocks and additional bony fragment position remained unchanged; bone healing was observed in 6 months. In the second group tibial tunnel aperture with graft lying next to medial wall had anatomical “C”-shape. Patients in both study groups had normal range of motion. There were 6 patients with “glide” and 1 with “clunk” positive pivot-shift tests in the first study group, and only one with “glide” test in the second study group (p=0.045). Conclusion. Creation of fulcrums for patellar tendon graft and its firm fixation at the ACL attachment sites promotes better anatomical and functional treatment outcomes.