Results of Anterior Cruciate Ligament Injuries by Arthroscopic Reconstruction Using Semitendinosus Tendon

Objectives: This study was designed to evaluate the surgical management of anterior cruciate ligament injuries by arthroscopic reconstruction using semitendinosus grafts. Methodolgy: This study was conducted by Dibba Hospital Fujairah, United Arab Emirates from March 2017to March 2020. A total of 40 patients were selected for this research. In our study, we used arthroscopy assisted ACL reconstruction technique with single bundle quadrupled semitendinosus tendon autograft. This autograft was inserted from the ipsilateral limb with the help of endobutton femoral side of graft was fixed and with bioabsorbable screw tibial side of graft was stabilized. A single surgeon performed all the surgeries. Original Research Article Valecha et al.; JPRI, 33(28B): 142-148, 2021; Article no.JPRI.67727 143 Results: In our observations, we reported that the majority of the patients had exposure of ACL injury in their middle adult age (32-38 years old) due to high engagement in physical activities (67.8%) like biking, playing sports and many others. The ratio of right knee injury site was comparatively high (53.5%) than the left one (46.4%). Conclusion: From the results, we concluded that the younger age group is more prone to anterior Cruciate ligament injury. ACL reconstruction with Semitendinosus tendon autograft helps in maintaining knee movement and assist in early knee stability.


INTRODUCTION
Anterior Cruciate ligaments are considered the best method to prevent the knee from anterior translation and act as a knee stabilizer [1]. It also helps to reduce valgus stress and rotational stress. The Anterior Cruciate ligament is the most prone part of the human body for injuries [1]. In recent years 0.24 to 0.34 ACL incidents were reported and labelled as the knee's most prevalent injury [2]. ACL injuries also induce cartilage damage and knee arthrosis which need proper management. Management of these injuries relies upon the intrinsic (physical strength of patient) and extrinsic risk factors (environmental factors) of ACL injuries. Intrinsic factors are also based on the Q-angle of the knee, ACL size, intercondylar notch, and tibia slope [1]. Whereas extrinsic factors involved friction of the ground, climate factor (especially dry climate enhance the torsional factors of patients if they engaged in any sports activities like a football) [2][3]. Due to the high frequency of ACL incidents, many authors were interested in studying ACL surgery outcomes in past years. Reconstruction of Anterior Cruciate ligament is considered as the most appropriate method for decreasing the ACL morbidity ratio [2]. This method has a high efficacy ratio due to optimal activation of knee joint surrounding muscles. ACL injuries directly affect the pattern of surrounding muscles, only the reconstruction method can resolve the activity of rupture muscles. The proper muscles activity can be achieved through technical factors of ACL reconstruction, including fixation method, graft choice and by practising complete rehabilitation protocol [3].
Advance arthroscopic techniques play a vital role in ACL reconstruction surgery, especially in anterior and posterior cruciate ligaments [4]. These advanced arthroscopic techniques provide better results for small incisions. This method helps in the examination of the intercondylar notch for the placing of tunnel and attachment sites [5]. Arthroscopic assisted ACL reconstruction provides less postoperative pain and helps in regain early motion. Tendon bone autograft is a widely used arthroscopic assisted ACL reconstruction method in recent years [6]. In recent years this method gains attention after observing fewer chances of a posterior blow out and a massive improvement in femoral tunnel placement [7]. This method is best suitable for those patients who were engaged in aerobic activities [7]. Nowadays, physicians prefer ACL reconstruction with soft grafts like semitendinosus [8]. These semitendinosus grafts have superiority over the bone-patellar tendonbone graft due to their mechanical resistance [9]. Another reason for its dominance is due to less anterior knee pain. In the past, many studies reported a high proficiency ratio of this method with more minor postoperative complications [10]. This study was designed to evaluate the surgical management of anterior cruciate ligament injuries by arthroscopic reconstruction using semitendinosus grafts. We formulate a hypothesis that females have high tendency of ACL injuries as compared to men.

METHODOLOGY
This study was conducted by Dibba Hospital Fujairah, United Arab Emirates from March 2017to March 2020. A total of 40 patients were selected for this research. During follow up, six patients required revision in ACL reconstruction, and six patients were lost in followup after surgery, so these 12 patients were excluded from the study. The rest 28 patients were observed in a minimum of two years of s follow up. We include 18-45 years old patients who were suffering from grade 1, 2 meniscal injuries. All the patients with associated articular condylar fractures and multi ligamentous damages were excluded from this research. Patients with a knee infection, congenital diseases, and previous surgery history were also excluded from this research. Those who fulfilled inclusion criteria were further undergone through complete clinical examination. We asked about the history of injury, were concerned with the mode of injury and trauma severity. Later on, patients were further observed by the Lachman knee scoring system. Radiography examinations were proceeded before and after surgery. MRI of their knee evaluated all the patients. For surgery, we used the anteromedial portal technique. In our study, we used arthroscopy assisted ACL reconstruction technique with single bundle quadrupled semitendinosus tendon autograft. This autograft was inserted from the ipsilateral limb with the help of endobutton femoral side of graft was fixed and with bioabsorbable screw tibial side of graft was stabilized. A single surgeon performed all the surgeries. All the patients were hospitalized for two days after surgery and after discharge, they were not allowed to engage in any activity for six weeks. After release, patients were observed at two weeks, six weeks, three months, six months, nine months and two years of surgery to analyse the surgical outcomes. We followed pre and post-operative symptoms and assessed patients with the Lachman test after surgery.

RESULTS
In Table 1, we mentioned patient age, mode of injury, and site of injury. We observed majority of the patients had exposure in their middle adult age (32-38 years old) due to high engagement in physical activities (67.8%) like biking, playing sports and many others. The ratio of right injury site was comparatively high (53.5%) than the left one (46.4%).
In Table 2, we presented the surgical information of all patients, including duration of injury to surgery, symptoms, graft site, knee flexion and post-operative complications. In the majority of the cases, surgery was executed after six months of damage, with an 8mm graft due to severe pain and swelling. After surgery, wound infection and knee pain were highly observable.
In Table 3, we mentioned the Lachman score, and in Table 4 Lachman test score according to performance was noted. In half cases, good outcomes were observed.   Recently the study of Padya et al.
[16] observed a high prevalence of injury in female, but in our results, we observed that male are more prone to injury due to their increased exposure to the environment. Furthermore, Brown et al. claim that the limb's sidedness does not affect the damage and recovery period. In our study, we observed that 46.4% of patients had right side injury, and 53.5% of patients were reported with a left side injury.
In our study, the majority of the patients injured due to increased engagement in sports activities (67.8%). Patients were more engaged in jumping, running, basketball, volleyball. We observed 17.8% of cases arises due to traffic accidents. Comparing these results with D Chaudhary et al., our results are parallel by his research. In his study, he observed 66.7% of injured cases due to sports activities, 30.8% due to traffic accidents, and 2.2 % reported due to household injuries.
In many studies, researchers claim that ACL surgery has better outcomes if it proceeds after three weeks of injury. In our research, we treat patients with bracing for reducing swelling [17][18][19]. After the examination of symptoms, patients were sent to the surgery. In many patients, we observed that perioperative edema, ROM and hyperaemia restricted the postoperative outcomes.
A recent systematic review conducted by Conte EJ et al. [20] observed that ACL reconstruction with 8mm or larger quadrupled hamstring decreases surgery's failure. These results are also reported in a previous study of Mariscalco MW et al. [21], in which he observed failure of ACL reconstruction in 263 patients treated with <8mm graft. Another study reported that graft length size depends on the patient BMI, and its diameter depends on the thickness of the patient thigh. In our research, we used an 8mm diameter graft in 53.5% of patients; in 17.8%, we used less than 7 mm graft, and in 28.5% cases, graft size was above 9mm. After the surgery, we get 96% positive outcomes in average follow up of 25.4 months-this high ratio of positive effects observed due to the strict protocol of rehabilitation. Patients were not allowed to engage in further sports activities for six months. During this period, the Lysholm score was constantly recorded at six months, one year and two years after surgery. We observed improvement in Lysholm score after surgery. The mean Lysholm score before surgery was reported as 66±5.2, and after surgery, we kept a mean 88.70±5.54 lysholm score of patients with significant statistical value (p<0.01). During the two years follow up, our study examined 42.8% of cases with excellent outcomes, 50% with good results. With an overall 95% success rate, all patients regain their preinjury activity level. . In their study; they observed 91-93% improvement in Lysholm score during pre and post-operative duration. Discussing the post-operative compliactions, we observed wound infection in 3 cases; in nine patients, we observed severe swelling, and in 4 cases, we observed knee pain. On the other hand, we record >120 degrees ROM in all patients.

CONCLUSION
From the results, we concluded that the younger age group is more prone to anterior Cruciate ligament injury. ACL reconstruction with Semitendinosus tendon autograft helps in maintaining knee movement and assist in early knee stability. ACL injuries required proper pre and post-operative management to minimize complications.
Adequate planning and radiological assessment are needed before surgical intervention.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s