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 Table of Contents  
Year : 2022  |  Volume : 37  |  Issue : 2  |  Page : 70-75

Functional outcome of arthroscopic anterior cruciate ligament reconstruction using variable loop cortical suspensory fixation

Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), Dr. Ram Manohar Lohia Hospital, New Delhi, India

Date of Submission12-Sep-2022
Date of Acceptance14-Sep-2022
Date of Web Publication19-Oct-2022

Correspondence Address:
Sarvesh Kumar Pandey
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), Dr Ram Manohar Lohia Hospital, New Delhi 110001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_23_22

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Anterior cruciate ligament (ACL) injury is more common in men than women. Variable loop cortical suspensory fixation is an excellent graft fixation device, which provides an option for further tightening the graft even after the tibial end fixation is done if the surgeon feels it is needed. At 3-month follow-up, ACL reconstruction using the novel variable loop cortical suspensory fixation device granted an improvement in mean LYSHOLM score from 19.91 preoperatively to 85.59 at 3-month follow-up, which is a statistically very significant clinical and functional outcome. The principal advantage of the ACL reconstruction using variable loop cortical suspensory fixation is that it uses the ability to re-tension the graft after tibial fixation. A taut ACL construct is crucial during postoperative rehabilitation to reduce the risk of knee instability and re-rupture of the ACL graft. We conclude that the technique described here is a simple, robust, and effective approach to minimize graft laxity, and thereby leave a snug ACL construct. In addition, re-tensioning of the graft after tibial fixation eliminates the need for a posterior drawer on the knee, as the resulting laxity will be removed with re-tensioning.

Keywords: ACL, cortical, loop, suspensory, variable

How to cite this article:
Pandey SK, Khare R, Yadav AK, Deswal D, Jaiswal S. Functional outcome of arthroscopic anterior cruciate ligament reconstruction using variable loop cortical suspensory fixation. J Bone Joint Dis 2022;37:70-5

How to cite this URL:
Pandey SK, Khare R, Yadav AK, Deswal D, Jaiswal S. Functional outcome of arthroscopic anterior cruciate ligament reconstruction using variable loop cortical suspensory fixation. J Bone Joint Dis [serial online] 2022 [cited 2023 Apr 2];37:70-5. Available from: http://www.jbjd.in/text.asp?2022/37/2/70/358801

  Introduction Top

Anterior cruciate ligament (ACL) is one of the most common injured knee ligaments and at the same time, one of the most frequent injuries seen in sports orthopedic practice. Arthroscopic evaluation of knees with hemarthrosis following injury has shown ACL injury in 60%–70% of cases.[1] There are a lot of controversies related to the management of this injury and numerous scientific papers focusing on this topic, including biomechanical, basic science, clinical, or animal studies were published. Treatment options range from nonoperative strategies including physiotherapy, bracing, and modification of physical activity to surgical reconstruction of the ligaments. The operative treatment seems to be the procedure of choice, especially for sports active patients and athletes, as well as for patients with ligament injuries. Various implants are used for graft fixation. A suspensory graft ligament fixation device is shown to be particularly suitable for maximizing the contact between a soft-tissue graft and the bone tunnel prepared to receive the graft. Suspensory femoral fixation of ACL grafts with fixed-loop endo button and variable loop button devices has gained popularity for ACL reconstruction. However, suspensory femoral cortical fixation for ACL reconstruction has evolved from a fixed-loop device to an adjustable-loop device. Our study aims to evaluate the outcome of arthroscopic anterior cruciate ligament reconstruction using variable loop cortical suspensory fixation.

  Materials and Methods Top

This study was conducted in the Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), Dr. Ram Manohar Lohia Hospital, New Delhi from November 1, 2017 to March 31, 2019. A total of 22 patients were included in the study as per the following criteria.

Inclusion criteria

  • All patients with ACL tear (18–50 years of age).

  • Exclusion criteria

  • Bony avulsions of ACL.

  • ACL tear with associated other ligament injuries, cartilage lesions, meniscal injuries, and intra-articular fractures.

  • ACL tear in osteoarthritic knee: Detailed history of the patients was taken and patients were clinically examined. Patients were assessed with the LYSHOLM II scores recorded preoperatively with postoperative scores. Detailed written bilingual informed consent was taken. All routine investigations were done for pre-anesthetic checkup. A radiograph of the involved knee was done, anteroposterior, lateral view, and magnetic resonance imaging (MRI) of the affected knee was done if needed (in doubtful cases). Follow-up was done at 2 weeks, 1 month, 2 months, and 3 months. Patients were assessed clinically and functionally with LYSHOLM II score. Descriptive statistics such as mean, median, and proportion were used to describe the study results, and appropriate statistical tests were applied. All patients were operated on under spinal anesthesia. The basic steps of arthroscopic ACL reconstruction were diagnostic arthroscopy, graft harvesting and preparation, notch debridement and notchplasty (if required), making of femoral and tibial tunnels, graft insertion, graft fixation, and closure. The gracilis and semitendinosus tendons were harvested through an incision centered approximately 4 cm medial and just distal to the tibial tubercle. The graft size was measured with a sizer. Next, the ACL remnant was shaved off and notchplasty (if required) was done with a shaver to avoid impingement of the graft in the femoral tunnel.

  • Femoral tunnel preparation

    A femoral tunnel guide with an offset of 4 or 5 mm (next size of the graft thickness in mm divided by 2) was inserted through the tibial tunnel and placed over the top position. The femoral guide pin was then placed at the femoral footprint and slightly advanced to make a starting point. Then the knee was hyper-flexed and the guide pin was advanced through both the cortices of the distal femur. After this 4 mm was calibrated, cannulated reamer was passed to drill both cortices of the distal femur over the femoral guide pin. Femoral tunnel length was measured by a femoral tunnel measuring depth gauge. Then tunnel length of 25–30 mm was kept for the hamstring graft. Then the femoral tunnel was reamed by cannulated reamer (graft diameter size) on the femoral guide pin. Prepared tunnel was checked with a probe, for blowout of the wall. The tunnel ends were cleaned of any bony debris with a curette and shaver. Next, the tibial tunnel was prepared.

    Tibial tunnel preparation

    The pretibial periosteum was incised longitudinally with electrocautery, beginning at the margin of the sartorius insertion and the medial margin of the patellar tendon. This incision was extended 2 cm to 3 cm proximally toward the joint line. Limited subperiosteal elevation was performed with a periosteal elevator at this anteromedial incision. The endoscopic aimer for the tibial tunnel was adjusted to the 55° position, and the guide tip was positioned intra-articularly through the anteromedial portal.

    The 55° orientation produces an ovoid intraarticular aperture that more closely approximates the anatomic ACL footprint of the tibia was 7 mm anterior to posterior cruciate ligament. The guide in, typically, was angulated 55° to the anterior cortex of the tibia when viewed laterally placing the tibial tunnel. Approximately 3.5 cm below the joint line, a more vertically oriented tibial tunnel may preclude optimal femoral access and produces a more circular, less anatomic aperture in the tibia. The guide tip was positioned with the tip impaling the posterior fibers of the tibial ACL stump. A cannulated reamer corresponding to the size of the graft was used to drill the tibial tunnel; the surgeon stopped when the reamer just broke through the intra-articular cortex. Finally, a 5.5 mm synovial resector was placed through the tibial tunnel to remove debris.

      Graft Passage and Fixation Top

    Before passage of the graft and variable loop suspensory button [Figure 1], the lateral condylar width measured was marked from the button to indicate when the button should flip on the cortex. The measured femoral socket depth should be marked on the graft minus 5 mm. This marking indicated when the graft had sunk into the socket 5 mm short of the socket terminus. The passing suture was used to pass the variable loop and variable loop suspensory button through the tibial tunnel and the femoral socket. Under arthroscopic visualization through the anteromedial portal, the variable loop suspensory button is advanced through the femoral tunnel. Tension on the tibial end of the graft, while advancing the graft, was maintained until the button has exited onto the lateral femoral cortex. Sterile mini-fluoroscopy was used to confirm that the button was flush on the lateral femoral cortex. To advance or “dunk” the graft into the femoral socket, each of the white tensioning sutures was pulled, alternating both sides [Figure 2]. This was done until the graft has dunked to the graft marking, which left the graft approximately 5 mm short of the proximal femoral socket terminus, which remained for the final tensioning of the graft. The knee was then cycled approximately 20 times to remove graft creep. With the knee in 20° of flexion and a constant posterior drawer force applied to the knee. A biodegradable interference screw, two size greater than tunnel diameter was selected and then inserted.
    Figure 1: Photograph showing the graft and variable cortical suspensory button assembly

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    Figure 2: Pulling the variable loop and graft

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    The ACL graft was re-examined under direct arthroscopic visualization and probed to evaluate laxity [Figure 3]. The ACL was examined in flexion and extension to determine the presence of femoral notch impingement. The blue passing sutures were unloaded from the button and the white tensioning strands were cut below the skin surface. Lachman and pivot shift tests were performed to examine knee stability. The excess ACL graft was then excised so that it was flush with the tibial tunnel cortex. The wounds were then irrigated and closed in the standard fashion. The knee was placed in a functional brace locked in extension. The brace was worn for a total of 3–4 weeks postoperatively and held in extension immediately after surgery. The brace was unlocked to a maximum 90° of knee flexion with a gradually increased range of motion over the next 48 to 72 h postoperatively. Like most orthopedic procedures ACL reconstruction cannot have a successful outcome without appropriate rehabilitation. Physiotherapy was done according to the following protocol:
    Figure 3: Reconstructed anterior cruciate ligament

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    For the first 2 weeks, there was pain relief and swelling control, wearing a knee brace and non-40weight bearing for 1 week. From weeks 3 to 6, partial weight bearing was allowed and range of movement exercises was stressed upon. From weeks 7 to 12, full mobilization [Figure 4] and strengthening exercises were followed. Follow-up was done at 15 days, 1 month, 2 months, and 3 months. X-ray was done in the immediate postoperative period. LYSHOLM score was checked at 15 days, 1 month, 2 months, and 3 months. Complications if any were also looked for.
    Figure 4: Three-month postoperative result

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      Results Top

    The age of the patients ranged from 18 years to 44 years with the mean age being 26.82 (standard deviation [SD] ± 9.27) years. In our study, 17 cases are men and 5 cases are women. All patients had giving way sensation of their knees and the Lachman and Anterior Drawer test was positive in all of them. Approximately 100% of the patients had a poor LYSHOLM’s score preoperatively. LYSHOLM’s score improved significantly over the 3 months postoperative period. At the end of 3 months, 4 patients (18.2%) had a fair results, 15 patients (68.2%) had a good results, and 3 patients (13.6%) had excellent results [Table 1].
    Table 1: Preoperative and 3-month post-op LYSHOLM’s score

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      Discussion Top

    ACL reconstruction surgery has progressed considerably in the last decade with many recent advances and new developments. A lot of studies explored many factors involved in the different technical aspects of ACL fixation. ACL tear usually leads to torsional instability of the knee joint, which can cause secondary progressive degenerative meniscal and chondral lesions.[1],[2] Reconstruction of ACL with quadrupled hamstrings autograft is a popular procedure. The goal of treatment is to return the injured patient to the desired level of function. This study comprised 22 patients who underwent single-bundle ACL reconstruction using quadrupled hamstring graft in ABVIMS and Dr. Ram Manohar Lohia Hospital, New Delhi for a period of one and half years. All patients were operated on for the reconstruction using an endo button on the femoral side and bioabsorbable interference screw on the tibial side. ACL injuries are fairly common in younger generations. Giving way of the knees as a result of instability is the most common symptom in ACL deficient for which the patients seeks advice. Locking is present in those patients having meniscal tears. It is also very important to make an accurate diagnosis of ACL injury. This can be achieved by detailed history (including the exact mechanism of the injury), clinical examination including tests for rotatory instability, and proper investigations. These are essential for an accurate diagnosis of these injuries and to determine the severity of instability. Anterior drawer test was positive in all the cases of ACL insufficiency. Management of ACL still remains an enigma to the orthopedic surgeon. ACL reconstruction using quadrupled hamstring autograft offers an excellent knee function, knee stability, and restoration of preoperative functional status with minimal complications. There is no clear consensus on the timing of surgery, although much has been studied so far in the literature. Most authors have opined on waiting for at least 3 weeks before ACL reconstruction from the time of injury. In our study, we treated acute injuries with bracing and rehabilitation and restricted activity until swelling reduced and the patient regained functional range of motion in the knee. In our study, the age of the patient ranged from 18 years to 44 years with the mean age being 26.82 (SD ± 9.27 years). The average patients included in the age group 11–20 years, 21–30 years, and 31–40 years, respectively, were 36.4%, 27.3%, and 36.4%. In the study conducted by Chodavarapu et al.,[3] the mean age was 29 years, whereas in our study patients were between 15 and 45 years of age, out of which 17 cases were men and 5 cases were women. In the study conducted by Chodavarapu et al.,[3] 96% were men and 4% were women, all aged between 15 and 45 years of age; whereas in another study by Azees et al.,[4] of the 20 patients, all were men (95%]) except one woman (5%0 in the age group of 16–53. The women in the age group 11–20 years were predominantly affected (80%), whereas rest 20% of them were in the 21–30 years age group; however, 47.1%, 29.1%, and 23.5% of total men were in age group (>30 years), 21–30 years, and 11–20 years, respectively.

    As far as the side of the limb is considered, it was found that both clinically and radiologically 12 patients (54.5%) had a grade 3 tear in the right knee, 9 patients (45.5%) had a grade 3 tear in the left knee, and only 1 (4.5%) patient had partial ACL tear in the left knee. In the study conducted by Chodavarapu et al.,[3] 60% were injured in the left knee and 40% were injured in the right knee; whereas in another study by Azeej et al.,[4] 70% were right side knee only and 30% were left side knee. An analysis of the efficiency of MRI in diagnosing internal derangement of the knee by Nikolaou et al.[5] reported accuracy for tears of medial-lateral meniscus, anterior, and posterior cruciate ligaments, and articular cartilage was 81%, 77%, 86%, 98%, and 60%, respectively. They also stated a lower reliability for accuracy in clinical examination andavoid the surgical risks of a diagnostic arthroscopy. Our study had an MRI accuracy of more than 90%. MRI is preferable to arthroscopic diagnosis before surgery. Brown et al.[6] studied the incidence of the sidedness of limb injury and sex incidence and stated that although their study pointed out that women are more prone to this injury; the incidence is yet more in men due to their increased exposure to work in a strenuous.[6] They also hypothesized that limb-sidedness has no influence either during environmental injury or the recovery period. Our study did not find any significance in the sidedness or the gender to the recovery during rehabilitation. If we consider the symptoms in our study, 100% of patients had a sense of giving away in our study, whereas the Lachman test was also positive in all of the cases (100%). Although in the study conducted by Chodavarapu et al.,[3] the most common symptom presented was instability (88%) followed by pain (80%), in our clinical study the anterior drawer test in neutral position was grade 3 in 95.5% and grade 2 in 4.5% of patients, respectively. We also conducted the same test in the medial and lateral positions, where 95.5% and 100% of patients had grade 3 assessments, respectively. All the patients had positive anterior drawer test at grade 3. Lachman’s test was positive in 96%, and the pivot shift test was positive in 72%. In a study conducted by Chodavarapu et al,[3] there were 80% of Grade C and 20% of Grade B, preoperatively. In a study conducted by Sharma et al.,[7] there were no significant differences in Lachman and pivot shift grading in both groups postoperatively. There was Grade B, uniplanar laxity by Lachman test in five (15%) cases, postoperatively and 10% had Grade 2+ anterolateral rotator laxity. Kocher et al. evaluated the relation between an objective assessment of knee laxity and the subjective assessment of symptoms and function. He opined that the pivot shift test was a better correlator of functional stability than the Lachman’s test or instrumented knee laxity.[8] The outcome of the study has been objectively analyzed using the LYSHOLM II score. In our study, the mean preoperative LYSHOM score average was 19.91, at 2 weeks was 25.82, at 1 month was 55.82, at 2 months was 67.73, and at 3 months was 85.59, respectively. In the study conducted by Chodavarapu et al.,[3] the preoperative LYSHOLM score was fair (65–83) in 56% and poor (<65) in 44%; it is improved to excellent (>90%) in 72% and 24% had a good[9] mean TEGNER, LYSHOLM score preoperatively outcome (84–90). In a study by Negi et al., mean TEGNER LYSHOLM knee score preoperatively was 60.2 + 6.02, and mean TEGNOR LYSHOLM knee score after 6 months surgery was 91.72 + 3.17. Whereas Azeej et al. study had the mean LYSHOLM knee score was 74, 74, 94, and 98 at preop, 3-, 6-, and 12-month follow-up, respectively. The LYSHOM knee score was excellent in 50% cases, good in 40% cases, and fair in 10% cases in the study conducted by Sharma et al.,[5] whereas in our study it was good in 68.2%, fair in 18.2% cases, and excellent in 13.6% cases at 3-month follow-up. As shown by Chen et al.,[10] at 3-month intervals LYSHOLM score increased from 19.91 to 85.59.

    A taut ACL construct is crucial during postoperative rehabilitation to reduce the risk of knee instability and re-rupture of the ACL graft. Graft fixation devices are important for the success of ACL reconstruction with hamstring tendon autografts. Fixed-length cortical suspensory fixation (CSF) devices are frequently used but are associated with tunnel widening, induced by micromotion at the bone–graft interface. Adjustable CSF devices aim to solve these problems and because the device is adjustable, the loop can be re-tensioned to remove that dynamic elongation, thus allowing for improved knee stability until sufficient healing has occurred. In 2017, meta-analysis found that compared with aperture fixation, suspensory fixation is more reliable for laxity correction offering comparable clinical score and lower failure rates.[11] reported 2-year revision. In 2018, a study using the Scandinavian knee ligament registries reported 2 years revision rates for CSF devices of approximately 2.7% for the femur and 2.8% for the tibia. Eysturoy et al.[11] reported the failure rates of ACL reconstruction with hamstring tendon grafts in the Danish registry for using all major fixation devices. They found that adjustable CSF devices lower the relative failure risk (hazard ratio [HR], 0.96) at 2 years compared with nonadjustable CSF devices (HR, 1.24) and interference screw fixation (HR, 1.28). Therefore, our comparisons with the literature are consistent with the conclusions of recent reviews and[12] registry studies.

    Financial support and sponsorship

    Not applicable.

    Conflicts of interest

    There are no conflicts of interest.

      References Top

    Andersson C, Gillquist J Treatment of acute isolated and combined ruptures of ACL-A long term follow-up study. Am J Sports 1992;20:7-12.  Back to cited text no. 1
    Tenuta JJ, Arciero RA Arthroscopic evaluation of meniscal repairs: Factors that affect healing. Am J Sports Med 1994;22:797-802.  Back to cited text no. 2
    Chodavarapu LM, Asif Hussain KS, Kumar KKK, Patnala C, Yadoji H Analysis of functional outcome of anterior cruciate ligament reconstruction using quadruple hamstring graft. Int J Res Orthop 2017;3:877-82.  Back to cited text no. 3
    Ajeej MQA, Prasad GS A comparison of functional outcome between titanium interference screw and on loop: Endobutton fixation on femur in arthroscopic anterior cruciate ligament reconstruction. J Evolution Med Dent Sci 2018;7:5474-8.  Back to cited text no. 4
    Nikolaou VS, Chronopoulos E, Savvidou C, Plessas S, Giannoudis P, Efstathopoulos N, et al. MRI efficacy in diagnosing internal lesions of the knee: A retrospective analysis. J Trauma Manag Outcomes 2008;2:4.  Back to cited text no. 5
    Brown TN, Palmieri-Smith RM, McLean SG Sex and limb differences in hip and knee kinematics and kinetics during anticipated and unanticipated jump landings: Implications for anterior cruciate ligament injury. Br J Sports Med 2009;43:1049-56.  Back to cited text no. 6
    Sharma B, Parmar RS Early outcome analysis of arthroscopic anterior cruciate ligament reconstruction using fixed closed loop and adjustable loop techniques: A prospective case series. J Orthop Allied Sci 2018;6:74-8.  Back to cited text no. 7
    Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med 2004;32:629-34.  Back to cited text no. 8
    Negi VS, Pawar U, Pangwane S Functional outcome of arthroscopic reconstruction of anterior cruciate ligament using quadrupled semitendinosis autograft. MVP J Med Sci 2016;3:101-9.  Back to cited text no. 9
    Chen J, Gu A, Jiang H, Zhang W, Yu X A comparison of acute and chronic anterior cruciate ligament reconstruction using Lars artificial ligaments: A randomized prospective study with a 5-year follow-up. Arch Orthop Trauma Surg 2015;135:95-102.  Back to cited text no. 10
    Eysturoy NH, Nissen KA, Nielsen T, Lind M The influence of graft fixation methods on revision rates after primary anterior cruciate ligament reconstruction. Am J Sports Med 2018;46:524-30.  Back to cited text no. 11
    Persson A, Gifstad T, Lind M, Engebretsen L, Fjeldsgaard K, Drogset JO, et al. Graft fixation influences revision risk after ACL reconstruction with hamstring tendon autografts. Acta Orthop 2018;89:204-10.  Back to cited text no. 12


      [Figure 1], [Figure 2], [Figure 3], [Figure 4]

      [Table 1]


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