Summary
Knee injuries are very common, especially in sports medicine, and can have severe consequences for the patient, limiting their movements and impeding daily routines. There are four ligaments connecting the thigh and shin bones: medial collateral (MCL), lateral collateral (LCL), posterior cruciate (PCL), and anterior cruciate ligament (ACL) (National Library of Medicine (NLM)). The last one is the focus of the current study. The ACL is located in the middle of the knee joint and keeps the shin bone in its place behind the end of the thigh bone (NLM). When one overextends a knee joint, receives a hit at the side of it, or quick stops and changes direction while running or landing from a jump, the ACL can be overstretched or torn (NLM). An ACL injury can also occur with other knee injuries, such as a torn MCL or knee cartilage-meniscus (NLM). ACL injuries most frequently occur in the middle of the ligament or when it is pulled out of the thigh bone (NLM). Thus, the ACL is an important but vulnerable part of the human body.
Most patients with ACL injuries require professional medical help and surgery. When an ACL injury occurs, the gap between torn edges prevents them from healing on their own (NLM). Therefore, patients undergo ACL reconstruction (ACLR) – the replacement of the torn ligament with a graft (Fineberg et al., 2000). Grafts can be taken from the patient’s body (autografts) or a cadaver (allografts) (Johnson et al., 1992; Frank & Jackson, 1997). These grafts are commonly harvested from a patellar tendon or a hamstring tendon (Johnson et al., 1992; Frank & Jackson, 1997). Other allografts sources include Achilles, tibialis anterior, and quadriceps tendons (Shino et al., 1986). However, a bone-patellar tendon-bone (BPTB) autograft is widely accepted as the most suitable and reliable (Kurosaka et al., 1987; Noyes et al., 1984). Despite other kinds of grafts gaining popularity, it is still the most common choice for ACLR (Lee et al., 2008). Thus, a bone-patellar tendon-bone (BPTB) autograft as a method of anterior cruciate ligament reconstruction (ACLR) was chosen as the object of study.
Although BPTB grafts are widely used for ACLR, little research was conducted to identify and study all of its possible complications. According to Almazan et al. (2006), intraoperative incidents and complications during ACLR with a BPTB autograft are quite frequent due to the procedure’s complexity. However, the researchers concluded that all of them occur due to technical errors during graft harvesting, tunnel placement, or graft fixation and are preventable (Almazan et al., 2006). Serious intra- or post-operative incidents and complications, such as a patella fracture or a late patellar tendon rupture, are very rare (Marumoto et al., 1996). Moreover, Stein et al.’s research (2002) demonstrated that even such incidents caused minimal changes in patients’ outcomes when they followed post-operative rehabilitation guidelines. As Milankov et al. (2012) noted, it did not affect their mobility, and most of the patients continued to engage in sports activities at the same or even higher level after nine months since ACLR. In brief, ACLR with a BPTB autograft is a complex procedure with several risk factors, but intraoperative incidents are preventable and generally have short-term complications.
However, some researchers registered certain long-term complications after ACLR with a BPTB autograft. They include the high incidence of anterior knee pain and kneeling pain (Feller & Webster, 2003). It affects patients’ lifestyles, limiting their mobility and the variety of available activities. The incidence of anterior kneeling pain in Saudi Arabia might be even higher than the one registered in international studies. Therefore, the aim of the study is to know and determine the incidence of anterior knee pain following anterior cruciate ligament reconstruction using bone-patellar tendon-bone grafts among the Saudi Arabia population.
Discussion
Anterior knee pain is a frequent postoperative complication after ACL reconstruction with a BPTB graft. It is often combined with the difficulty of kneeling, which disrupts patients’ daily routines (Breitfuss et al., 1996). Several studies identified a high incidence of long-term anterior knee pain and kneeling pain among 25-60% of the patients (Breitfuss et al., 1996; Feller & Webster, 2003; Ibrahim et al., 2005; Pinczewski et al., 2007). The patients continue to suffer from it up to three years after ACLR, preventing their full recovery (Feller & Webster, 2003; Ibrahim et al., 2005). The presented data prove the relevance and acuteness of the problem.
Many studies were conducted to identify means to reduce or mitigate post-ACLR complications, including anterior knee pain. Tsuda et al. (2001) identified two risk factors for anterior knee pain: anterior instability (side-to-side difference of more than 3 mm) and residual patellar bony defect with a depth of more than 2 mm. The experts suggested using different surgical techniques to mitigate these risk factors and reduce the incidence of anterior knee pain (Tsuda et al., 2001). Their study has shown a decrease in anterior knee pain rate to 17% (Tsuda et al., 2001). Some of the researchers focused on graft choice and studied its influence on the incidence of kneeling pain. Ibrahim et al. (2005) and Pinczewski et al. (2007) emphasized the higher level of anterior knee pain and other post-operative complications among patients with BPTB grafts compared to those with semitendinosus and gracilis (STG) grafts. It makes one question whether BPTB grafts are the optimal choice for ACL reconstruction or an additional risk factor for anterior knee pain and kneeling pain.