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CASE REPORT – OPEN ACCESS

InternationalJournalofSurgeryCaseReports76(2020)81–84

ContentslistsavailableatScienceDirect

International Journal of Surgery Case Reports

j o ur na l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Combined hamstrings and peroneus longus tendon for undersized graft in anterior cruciate ligament reconstruction: A report of two adolescence female patients

Andri M.T. Lubis

^∗

, Dina Aprilya, Kanya Tania

DepartmentofOrthopaedicandTraumatology,FacultyofMedicineUniversitasIndonesia,CiptoMangunkusumoHospital,Indonesia

a rt i c l e i nf o

Articlehistory:

Received22August2020 Accepted20September2020 Availableonline23September2020

Keywords:

ACLreconstruction Female

Unqualiﬁedgraft Hamstringtendon Peroneuslongustendon

a b s t ra c t

INTRODUCTION:Anteriorcruciateligament(ACL)ruptureisacommoninjuryinyoungandactivepopu- lationandreconstructionisthemainstaytreatmenttomaintainstabilityoftheknee.Hamstringtendon (HT)isthemostpopulargraftforACLreconstruction.Incertainpatient,particularlyinwomen,thesizeof tendongrafttoreconstructtheACLisunpredictable.Inthecaseofunqualiﬁeddonor,weneedacombined graftfromanothersourcetomatchthesizerequirement.

CASEPRESENTATION:WepresenttwocasesofACLreconstructionusingcombinationofHTandPLTgraft inadolescentfemale.Weevaluatekneefunctionalscoreandankledonorsitemorbidity.Inthesecond casewealsodidsecondlookfortheACLgraftintegrityarthroscopically.Thisstudyhasbeenreportedin linewiththeSurgicalCaseReport(SCARE)criteria.

DISCUSSION:Oneyearaftersurgery,InternationalKneeDocumentationCommittee(IKDC)scoreforboth caseswereimprovedandnoankle-donorsitemorbiditywithgoodmotoricpowerand100%American OrthopedicFootAnkleScore(AOFAS).

CONCLUSION:Additionalperoneuslongustendoncanbe consideredasanalternativeinundersized hamstringtendongraftwithoutsigniﬁcantdonorsitemorbidity.

1. Introduction

The variability of graft choices in ACL reconstruction urges clinicianstoindividualizethechoicebasedoneachpatientbycon- sideringgraftavailability,patient’spreferenceandcharacteristics suchasage,sex,anthropometricstatusandactivities[1].Hamstring tendon(HT)isthemostcommonlyusedasithaslessermorbidity regardingtokneeextensiondeﬁcitandkneelingpain[2,3].How- ever,HTgrafthasanunpredictablesizeandthuscanbeproblematic insmallertendonsize.Anothersourceofgraftisperoneuslongus tendon(PLT)graftwhichstillindebatesduetothedonorsitemor- biditydespiteofitsstrengthandstiffness,itsuseasaugmentation graftwasagoodoptionduetotheeasyaccessandlesserinfection risk[4–7].

In thisreport,wecombinedHTand PLTgraftintwoadoles- cencefemalepatientswithsimilarcharacteristicandevaluatedthe kneeandanklestabilityparameters.Writtenconsentwasobtained fromparentsforpublicationofthiscasereportandaccompanying

Abbreviations: ACL,anteriorcruciateligament;HT,hamstringtendon;PLT, peroneuslongustendon;SCARE,SurgicalCaseReport;IKDC,InternationalKnee DocumentationCommittee;AOFAS,AmericanOrthopedicFootAnkleScore.

∗Correspondingauthor.

E-mailaddress:[email protected](A.M.T.Lubis).

images.Theauthorsdeclarenoconﬂictsofinterest.Thisworkhas beenreportedinlinewiththeSCAREcriteria[8].

2. Casepresentation

Twopatientspresentedtoourcenterwithkneeinstabilityfol- lowingatwistinginjury.Thefirstpatientwas15-year-oldfemale with50kgofweightand150cminheightwithaconfirmedACL ruptureonMagneticResonanceImaging(MRI).Thesecondpatient was16-year-oldfemalewith55kgweightand155cmheightwitha confirmedACLruptureandmeniscusinjuryonMRI.Weperformed ACLreconstructiononlyinthefirstpatientandACLreconstruction withmeniscusrepairinthesecondpatient.

2.1. Surgicaltechniques

2.1.1. Hamstringtendonharvesting

Afterdrawingtheosseouslandmarkatpatellaandtibialtuber- cle,anoblique2cmincisionwasmadealongthepesanserinus betweentibial tubercleand posteromedialborder of tibia.Gra- cilisand semitendinosustendonswereidentiﬁedand harvested (Fig.1).Thedistalendofthesemitendinosustendonandgracilis tendonwereliftedupwithscissorsand graspedwitha Kocher.

Theconjoinedtendonbetweentendondistalendswasdividedand

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CASE REPORT – OPEN ACCESS

A.M.T.Lubisetal. InternationalJournalofSurgeryCaseReports76(2020)81–84

Fig.1.HamstringTendonGraftharvesting.

Fig.2. Peroneuslongustendongraftharvesting.

released.Byadvancingthetendonstripper,tendonsweredetached fromthemuscleproximally.

2.1.2. Peroneuslongustendonharvesting

PLTwasharvestedthroughanincisionalongtheposteriorbor- derofthedistalﬁbula,abovethesuperiorperonealretinaculum.

Thetendonwasexposedonitsposterolateralsurface.Thedistalend wascutandheldwithsutureandtheproximalendwasreleased bytendonstripper(Fig.2).

Intheﬁrstpatient,HTgraftbycombininggracillisandsemi- tendinosustendonwasonly5mmindiameterwith13cmlength afterquadrupled(Fig.1).This5mmdiametergraftwastoosmallto beagoodgraft.Tosalvagethisunqualiﬁedgraft,weusedPLTgraft.

The6mmdiameterand11cmlength-harvestedPLTwasadded totheunqualiﬁedHSgraftandmadean8mm×11cmsix-strand graft.

MeniscuswasrepairedinthesecondpatientandACLrecon- structionwasplannedwithPLTgraftconsideringtheactivitylevel andthesimilarityofbodycharacteristicasthepreviouspatient.

WeharvestthePLTwiththesamemanneraspreviouspatient.The tendonwassurprisinglyinsufﬁcient6mm×10cm(afterdoubled).

WedecidedtotaketheHTasaugmentationandaﬁnal7.5mm×10 cmsixstrandgraftwasobtained.

Inbothpatients, autograftswereﬁxedtothefemoraltunnel withEndo-button(Smith&Nephew)andtothetibialtunnelwith interferencescrew(Smith&Nephew).

Postoperatively,thefirstpatienthadthekneeimmobilizedin 0^◦extensioninaweekandgraduallyincreaseuntil90^◦flexionin thesecondweek.Afterwardsthebracewassetinflexiblerangeso thatpatientcouldstarttheactiveandpassiverangeofmotionexer- cise.Weightbearingwasincreasedastolerated.Thesecondpatient hadacombinedACLreconstructionandmeniscusrepairrehabilita- tionprotocol.Inbothpatients,gentleanklestretchwasencouraged sincethefirstpost-operationdaybyusingaresistanceband.Propri- oceptiveexerciseswereperformed3monthsaftersurgerywhich weregraduallyincreasedinintensityuntilanother3months.

2.2. Evaluation

Painandstabilityatkneeandanklejointsubjectivelyandobjec- tivelyevaluatedatone-yearpostoperatively.Weusedthevisual analoguescale(VAS)tomeasurepainbeforeandaftersurgery.Knee andanklestability wereevaluatedusingtheInternationalKnee DocumentationCommittee(IKDC)2000StandardEvaluationForm andAmericanOrthopedicFootandAnkleSociety(AOFAS)Ankle- HindfootScorerespectively.Thepoweroffooteversionandﬁrst rayplantarﬂexionwasexaminedusingMedicalResearchCoun- cil(MRC)scaleformusclestrengthandcomparedtothenormal sidesoncontralateralankles.Otherdonor-sitemorbiditiesatankle regionwerealsorecordedsuchasnumbnessorproximalstump irritation.InthesecondpatientACLgraftwasre-evaluatedonthe secondlook8monthsafterthereconstruction.

3. Results

3.1. KneepainandIKDCsubjectivekneeevaluation

Intheﬁrstpatient,kneepainwasVAS3–4beforesurgeryand VAS0ononeyearfollowup.IKDCScore100%atoneyearfollow up.Inthesecondcase,thekneepainwasVAS3beforesurgery,and nowonlyexperiencedmilddiscomfort.IKDCscorewas95.4%at oneyearfollowup.

3.2. Kneestabilitytest

Bothofpatientkneeswereunstablepre-operativelyasobserved bythepositivemeasurementonanteriordrawertest,pivotshift

Fig.3.FullROM(a)plantarﬂexionand(b)eversion;(c)standingontiptoeatoneyearfollowup.

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Fig.4.ACLgraft(Asterix)observedviathearthroscopicanterolateralviewingportal onsecond-lookarthroscopy.

testandLachmantest(+3).BothpatientshadnegativeLachman andanteriordrawertestinoneyearfollowup.

3.3. Anklemorbidity

Inbothpatients,nocomplaintregardingtheanklewithgood motoricpower(scale5forbothankleeversionandﬁrstrayplantar ﬂexion)andnolimitationofanklerangeofmotion(Fig.3).The100%

AOFASscorewereobservedinbothpatientsatone-yearfollowup.

3.4. Second-lookarthroscopy

Thesecondpatientagreedtoundergosecond-lookarthroscopy 8-monthsafterACLreconstruction.Graftwastautonprobing,com- pletelycoveredbysynovium,andnotearwasobserved(Fig.4).

4. Discussion

BesidesfemaleshaveamorecommonACLinjurythanmales, theyalsohavesomespecialconsiderationsregardingtotherecon- struction [9–11]. Female HTsare shorter in lengthand smaller in diameter compared to male patient. The tensile strength of thehamstringtendonisalsoweakerinfemaleaslaxityismore commonwhichisalsoplaysascontributingfactorfortheinjury itself.SomestudiesrevealedmoderatecorrelationoftheHTgraft size andanthropometric parameters,which canbevaluablefor patientcounselingandalternativegraftsourceplanning.Bothof ourpatientshadsimilaranthropometryproﬁlewhichactuallynot atriskforaninadequategraftsize[3,4,12].

Thecommonproblemregardingthereconstructioninfemale isusuallythegraftsizemismatch[12,13].Toensureappropriate graftsizeandbiomechanicalfunction,ithasbeenrecommendedto usegraftsatleast7–8mmindiametertoreplicatethenativeACL diameter[2,14].Inthisreport,ourpatientswerebothadolescence femalewithsimilarcharacteristic.Intheﬁrstpatient,wepreferred HTdespiteofthepossibilityofundersizedgraftinAsianfemale withsuchanthropometricproﬁlebecausethelesserriskofante- riorkneepain.GraftsalvagemethodhasbeenpreparediftheHT wereundersizedsuchasPLToroppositeHT.Basedontheprevious patientwiththesimilarityofcharacteristicandpreviousactivity, wechooseprimaryPLTgraftforACLreconstruction.However,due totheundersizedPLT,weharvestedHTforaugmentation.

PLTisoneoftheimportantsupportivestructuretoprovidesta- bilityofthefootandankle.Chayaninetal.[5]studynotrecommend theuseofPLTgraftastheﬁrstoptionfortheACLreconstructionbut thistendoncanserveasanalternativedonorincaseofthemulti- directionalinstabilitywhich needsseveraldonortendonsinthe reconstruction.Incontrast,otherstudiesevaluatedtheACLrecon- structionusingPLTautograftandthestudyhasshownthatmost

patientsratedasnormalornearlynormalIKDCscorewithnoeffect ongaitparameters,anklejointdysfunctionordifﬁcultyinsports activities[4–7,15].

ThisstudyusedPLTasaugmentationgraft.IKDCscoreswere improvedtonormal.TheAOFASscorewereexcellent,similarwith previousresultbyChayaninetal.[5]andRhatomyetal.[16]which investigatedanklefunctionaloutcomeafterPLTharvesting.Knee stabilityparametersinourpatientswerealsoimproved.Further- more,therewerenoanklepain,numbnessandankle-footmotion restrictionin post-operativefollow-up. Subjectively,themuscle strengthofankleplantarflexionandfooteversionwereaccessed andresultinnormalmusclestrength.Patientalsocanperformtip toewalkingbymeansthattherewasnolimitationoftheankleand footfunctionpostoperatively.Thisfindingsupportedthestudyby Kermogluetal.[7]whichfoundnodysfunctionoranydifficultyin sportsactivitiesattheirfollowupwithimprovedkneestabilitypro- file.Shietal.[17]alsoshowednodifferencesbetweenpreoperative andpostoperativeanklestrengthandrangeofmotion.

Limitationsofthisstudyincludearesmallnumberofpartici- pantsandtheneedofquantiﬁeddatafortheanklemusclepower withlongerperiod ofevaluation regarding thelong-termankle morbidityoutcome.

5. Conclusion

Uncertaintyinpredictinggraftsizeurgedthepreoperativeplan- ningtopreparegraftaugmentation.Combininghamstringstendon withperoneuslongustendoncouldbeanalternativeforundersized graftwithoutasigniﬁcantankle-donorsitemorbidity.

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest.

Funding

Theauthorsreportnoexternalsourceoffundingduringthe writingofthisarticle.

Ethicalapproval

Ethicalapprovalwasnotrequiredinthetreatmentofthepatient inthisreport.

Consent

Writteninformedconsentwasobtainedfromtheparentsfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

DinaAprilyaandKanyaTaniacontributetothestudyconcept ordesign,datacollectionandwritingthepaper.

Andri MTLubis contributes in the studyconcept or design, datacollection,analysisandinterpretation,oversightandleader- shipresponsibilityfortheresearchactivityplanningandexecution, includingmentorshipexternaltothecoreteam.

Guarantor

AndriMTLubisisthesoleguarantorofthissubmittedarticle.

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Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

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