OUTCOME OF ACL RECONSTRUCTION: A COMPARISON BETWEEN BIOTRANSFIX SCREW ...

24 Pages·2017·0.64 MB·English

OUTCOME OF ACL RECONSTRUCTION: A
COMPARISON BETWEEN BIOTRANSFIX SCREW
AND ALL-INSIDE TECHNIQUE

BY

NIK ALYANI NIK ABDUL ADEL

A dissertation submitted in fulfillment of the requirement for
the degree of Master of Orthopaedic Surgery

Kulliyyah of Medicine
International Islamic University Malaysia

MAY 2017
ABSTRACT
This is a cross sectional study of 40 patients with Anterior Cruciate Ligament (ACL)
injury treated with ACL reconstruction surgery in Hospital Sultanah Nur Zahirah,
Kuala Terengganu and Hospital Kemaman, Kemaman, Terengganu. The aim of this
study is to compare outcomes of patient after an ACL reconstruction between two
techniques: biotransfix screw or all inside technique. 20 patients in each group of
technique were selected and agreed to participate in this study. They were evaluated
for the functional outcome with IKDC score, quality of life SF-36 questionnaire and
time taken to return to normal activities at 18-24 months post-operative. There were
32 patients from HSNZ and another 8 from Hospital Kemaman. 37 patients were male
and all of them were Malay. Mean age was 25.03 years old, range from 17 to 41 years
old. 25 of them were working as office worker and the rest were a field worker. 37.5%
were smoker at the time of surgery, while another 62.5% were nonsmoker. Right knee
involved in 27 patients. Patients in biotransfix screw operated at mean of 21.3 months
after the injury while in all inside technique was at mean of 17.65 months. Mean BMI
was 24.58 with 42.5% of them were normal, 40% were overweight, 10% were
underweight and 7.5% were obese. The biotransfix screw technique scored slightly
better in all categories except for physical function, body pain and role emotional in
SF 36 questionnaires compare to all inside technique but they were not statistically
significant. Both groups have mean IKDC score of 82.99. Time taken to return to
normal activity level was at mean of 46.3 weeks which was about similar in both
groups. Re rupture rate were 10% in biotransfix screw technique and 5% in all inside
technique. None of them has any form of infection. There were also no correlation in
between outcome with age, tobacco use, BMI, duration of injury until operation and
occupation of the patient in both techniques. As a conclusion, the functional outcome,
quality of life and time return to normal activity were not statistically has a significant
difference between biotransfix screw and all inside technique. There were also no
correlations between factors study with outcome in both groups.

ii
APPROVAL PAGE
I certify that I have supervised and read this study and that in my opinion, it
conforms to acceptable standards of scholarly presentation and is fully adequate, in
scope and quality, as a dissertation for the degree of Master of Orthopaedic Surgery

……………………………….
Mohd Shukrimi bin Awang
Supervisor

……………………………….
Mohd Ariff Bin Sharifudin
Co-Supervisor

This dissertation was submitted to the Department of Orthopaedic and is accepted
as a fulfillment of the requirements for the degree of Master of Orthopaedic Surgery

………………………………...
Mohd Shukrimi bin Awang
Head, Department of
Orthopaedics, Traumatology
and Rehabilitation

This dissertation was submitted to the Kulliyyah of Medicine and is accepted as a
fulfillment of the requirements for the degree of Master of Orthopaedic Surgery

………………………………
Azmi bin Md Nor
Dean, Kulliyyah of Medicine

iii
DECLARATION
I hereby declare that this thesis is the result of my own investigation, except where
otherwise stated. I also declare that it has not been previously or concurrently
submitted as a whole for any other degrees at IIUM or other institutions.

Nik Alyani Nik Abdul Adel

Signature…………………. Date …..................

iv
INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

DECLARATION OF COPYRIGHT AND AFFIRMATION OF
FAIR USE OF UNPUBLISHED RESEARCH

OUTCOME OF ACL RECONSTRUCTION: A COMPARISON BETWEEN
BIOTRANSFIX SCREW AND ALL-INSIDE TECHNIQUE

I declare that the copyright holders of this dissertation are jointly owned by the
student and IIUM.

Copyright ©2017 Nik Alyani Nik Abdul Adel and International Islamic University Malaysia. All
rights reserved.

No part of this unpublished research may be reproduced, stored in a retrieval
system, or transmitted, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise without prior written permission
of the copyright holder except as provided below.
1. Any material contained in or derived from this unpublished research
may be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print
or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieval system
and supply copies of this unpublished research if requested by other
universities and research libraries.

By signing this form, I acknowledged that I have read and understand the IIUM
Intellectual Property Right and Commercialization policy.

Affirmed by Nik Alyani Nik Abdul Adel

……..……..…………… …………………..
Signature Date

v
ACKNOWLEDGEMENTS
First of all, Alhamdulillah I was able to complete the thesis. I am deeply grateful to
my supervisor, Assoc. Prof. Dr. Mohd Shukrimi bin Awang who had always guide me
from the beginning of this research until completion of the report. I am heartily
thankful to Dr Atikah Amirah Suzanna bt Abdullah, Dr Suzanah bt Kamaluddin and
Dr Isnoni bt Ismail from Hospital Sultanah Nur Zahirah for all the support given
throughout the completion of the thesis. My appreciation also to all patient who
participated in this study.

Special thanks to my husband, siblings and collegues for their continuous
support and help throughout my study and completion of this thesis.

Lastly, I would like to send my regard and blessings to all of those who
supported me in any aspect during the completion of the project.

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TABLE OF CONTENTS
Abstract .......................................................................................................................... ii
Approval page ............................................................................................................... iii
Declaration .................................................................................................................... iv
Copyright Page ............................................................................................................... v
Acknowledgements ....................................................................................................... vi
List of Tables ................................................................................................................ ix
List of Figures ................................................................................................................ x

CHAPTER ONE: INTRODUCTION ........................................................................ 1
1.1 Background of Study .................................................................................... 1
1.2 Objectives and Hypothesis ........................................................................... 2
1.2.1 General Objective............................................................................... 2
1.2.2 Specific Objective .............................................................................. 2
1.2.3 Hypothesis .......................................................................................... 3

CHAPTER TWO: LITERATURE REVIEW ........................................................... 4
2.1 History and Embryology Of ACL ................................................................ 4
2.2 Anatomy of ACL .......................................................................................... 6
2.3 Histology of ACL ....................................................................................... 10
2.4 Biomechanisc and Functions of ACL ........................................................ 12
2.5 Epidemiology if ACL Injury ...................................................................... 13
2.6 Mechanisms of Injury ................................................................................ 15
2.7 Clinical Evaluation and Treatment Options ............................................... 16
2.8 ACL Reconstruction Surgery ..................................................................... 17
2.8.1 History .............................................................................................. 17
2.8.2 Evaluation of ACL Reconstruction Surgery .................................... 18
2.8.3 Graft Fixation Method...................................................................... 21
2.8.4 Single Bundle and Double Bundle Reconstruction .......................... 22
2.8.5 Type of Graft .................................................................................... 23
2.8.6 Graft Incorporation........................................................................... 23
2.9 Acl Outcome Measurement ........................................................................ 25
2.9.1 IKDC Subjective Knee Score........................................................... 26

CHAPTER THREE: MATERIALS AND METHODS ......................................... 28
3.1 Study Design .............................................................................................. 28
3.2 Methodology .............................................................................................. 29
3.3 Outcome ..................................................................................................... 30
3.3.1 Short Form 36 .................................................................................. 30
3.3.2 International Knee Documentation Committee (IKDC) Subjective
Knee Score ......................................................................................... 31
3.4 Data Analysis ............................................................................................. 31

CHAPTER FOUR: RESULTS AND FINDINGS ................................................... 33
4.1 Demographic Analysis ............................................................................... 33
4.2 Outcome ..................................................................................................... 28
vii
4.2.1 SF 36 ................................................................................................ 36
4.2.2 IKDC Score ...................................................................................... 37
4.3 Time Return To Normal Activity Level ..................................................... 38
4.4 Factors Contributing To Outcome ............................................................. 38
4.4.1 Correlation in between age, BMI and duration since injury until
operation with SF 36 scores .............................................................. 38
4.4.2 Relationship in between tobacco use and occupation with SF 36
scores and IKDC scores ..................................................................... 40
4.5 Complications ............................................................................................ 45

CHAPTER FIVE: DISCUSSION ............................................................................. 46
5.1 Discussion Of Result .................................................................................. 46
5.1 Study Limitations ....................................................................................... 53
5.1 Conclusion .................................................................................................. 53

REFERENCES ........................................................................................................... 55

APPENDIX ................................................................................................................. 60

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LIST OF TABLES

Table 4.1 Occupation, tobacco use and site of reconstruction 35
Table 4.2 Compare mean of duration of injury and BMI by technique 35
Table 4.3 Comparison between mean of SF 36 with technique 36
Table 4.4 Comparison of mean IKDC score with technique 37
Table 4.5 Comparison of time return to normal activity with technique 38
Table 4.6 Correlation SF 36 with BMI, age and duration since injury 39
until operation in biotransfix screw technique
Table 4.7 Correlation SF 36 with BMI, age and duration sine injury 40
until operation in all inside group
Table 4.8 Comparison mean SF 36 and IKDC with tobacco use in 41
biotransfix screw
Table 4.9 Comparison mean SF 36 and IKDC score with tobacco use 42
in all inside group
Table 4.10 Comparison mean SF 36 and IKDC score with occupation in 43
biotransfix screw group
Table 4.11 Comparison mean SF 36 and IKDC score with occupation in 44
all inside group

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LIST OF FIGURES
Figure 2.1 Histology slide on early organization of ACL between 5
femur and tibia at 10th week gestation.
Figure 2.2 Magnified view of ACL of a fetus at tenth week of gestation 5
showing fibroblasts in the ligament is aligned to its axis.
Figure 2.3 The ACL’s AM and PL bundle origin and insertion. 7
Figure 2.4 The position of AM and PL bundle during knee extension 8
and flexion. The AM bundle will always be anterior in all
position of the knee
Figure 2.5 The histological section of ACL at physiological 11
impingement site, where the below pictures shows larger
view. Chondrocyte-like cells and tenocytes clearly seen
(with metachromatic staining)
Figure 2.6 Schematic diagram showing mechanism of ACL injury 16
usually occurs in sports activity
Figure 2.7 Schematic diagram diagram of all inside ACL 20
reconstruction using sockets creation and suspensory type of
graft fixation
Figure 2.8 Schematic diagram of single bundle (left) and double bundle 22
(right) ACL reconstruction
Figure 4.1 Number of patients based on technique 33
Figure 4.2 Gender 34
Figure 4.3 Body Mass Index (BMI) 36

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