1. Introduction

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In the naval field, patients with anterior cruciate ligament lesion are active military, with demandant physical activities every day, the reason why is so important to incorporate them as soon as possible to their work and daily activities, with the minimal functional sequelae, diminishing the life quality and adequate service activities develop. This study is a retrospective one, reviewing the files of each patient and do not need additional studies.

The rupture of the anterior cruciate ligament (ACL) is a common lesion around the world. The incidence is about 35 for every 10,000 people of all ages. This rupture frequently results in knee instability, increased articular laxity and activity reduction, with an increased risk of knee osteoarthrosis at long-term[1].

The patients with the diagnosis of secondary articular instability after ACL rupture suffer from knee functional limitation, and an arthroscopic intervention is needed to reconstruct the ligament with a graft[2]. In the Hospital Regional Naval de Mazatlan, Mexico, the isquiotibial grafts (semitendinous and internal rectus) are the most used, for his reason is necessary to evaluate the obtained functional results to determine the effectivity of those procedures.

This work seems to evaluate if there exists a functional difference between the use of isquiotibial grafts after ACL reconstruction.

2. Material And Methods

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A non-experimental, observational, transversal, comparative and retrospective study was carried on in the Hospital Regional Naval de Mazatlan, Mexico. For the functional evaluation after ACL plasty the test of LACHMAN and PIVOT-SHIFT was used to evaluate articular stability, the LYSGHOLM test was used to evaluate the knee functionality and the SF-36 test was used to estimate the perception of health by the patients.

The Lysholm test was used to evaluate the knee functionality in a subjective manner by the patient. The qualification under 65 points was considered poor; between 66 to 83 regular; from 84 to 94 good and above 95 points excellent.

The SF-36 test was used to evaluate the health state of the patients in 8 areas, according to the patient perception. A punctuation is between 0 to 100, and a higher punctuation represents a better health The data was collected from the patient's files and introduced in the Excel program for their statistic analysis. The positive or negative results in the Lachmann and Pivot-Shift test were registered too.

2.1. Studied Population
The patients with surgery for ACL plasty with isquiotibial graft treated in the Hospital Regional Naval de Mazatlán in the period between June 2017 and June 2018 were included. A total of 45 patients were studied from which 20 patients were treated with semitendinous internal rectus graft and 25 patients with semitendinous graft.

2.2. General Objective
To elucidate if there is a functional difference between the use of ST+IR graft or ST graft only in the treatment of ACL rupture.

3. Results

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For the analysis of the results, the program Excel of Microsoft office with Windows 10 was used for descriptive data, with stratification according to the used graft. From a total of 54 patients, 9 were excluded for incomplete files. In total 45 patients were analyzed, 20 from the ST+IR group and 25 from the ST group (Figure 2). The ST graft has a total of 55.6% vs the ST+IR with 44.4%.

Figure 2

The general distribution by sex was 39 men and 6 women (Table 5, figure 3). The age range was from 16 to 51 years, with an average of 30.9 years and a standard deviation of 8.5 years, the median of 32 years, mode of 32 years and a male: female ratio of 3.6:1 (Table 6).

Figure 3    Table 5    Table 6

DH: With access to hospital service, SAIN: Administration Service of Naval Intendency, CG: General Marine Corps, IM: Marine Infantry, SSN: Naval Sanity Service. From Clinical Files of the HOSNAVTLA From the total studied patients, 3 are from the Naval Sanity Service, 21 from the Marine Infantry, 3 from the general marine corps, 7 from the Administration Service of Naval Intendency, and 11 with access to hospital services (figure 4).

Figure 4

All patients go through rehabilitation, 27 had a left knee injury and 18 right knee injury (Figure 5). A total of 29 patients presented meniscal associated injury (Figure 6), and from the total 13 are marine infantry (48.8% of the associated meniscal injuries).

Figure 5    Figure 6

The articular stability test of Lachmann and Pivot-Shift in the pre and post-surgery time using the ST+IR graft in 20 patients were registered and shows the significant improvement in the stability after ACLR (Figure 7).

The same analysis with the mentioned tests with the use of ST graft only shows improvement in the stability too (Figure 8).

Figure 7    Figure 8

The 20 patients with ST+IR graft presents a median in the Lysholm test of 89.7 points with a standard deviation of 7.7 points and the 25 patients with ST graft obtain a median in Lysholm test of 90.84 points and a standard deviation of 7.7. Both Lyshom test were compared by Student T-test obtaining a p= 0.206, without significant differences between grafts, and in the Sf-36 test, the P was .241, without significant difference neither (Table 7).

Table 7

In the Lysholm test, the results were grouped by range. The results under 65 points were considered poor, between 66 and 83 regular, from 84 to 94 good and over 95 excellent (See figure 9).

Figure 9

4. Discussion

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This is the first study carried out in a Regional Naval Hospital about the functional results after anterior cruciate ligament reconstruction with isquiotibial grafts using the semitendinous and semitendinous and internal rectus. There exist many studies worldwide but none of them present a similar population, with Mexican military personnel with a high grade of physical activity. However, a bigger sample and follow up for better and significant results are mandatory.

In this study, we did not find significant differences in the use of one or other graft, although the internal rectus preservation can increase the time to recovery and preadaptation of the patients. According to other studies about the same topic but in different populations, the results are very similar to the presented in this study.

Actually, the gold standard in lesions of the ACL is the surgical reconstruction with plasty or graft[20]. The selection of graft type must be individualized according to the advantages of each one, surgeon experience and patients preference after discussion of pros and cons. The ideal graft is the one who mimics the anatomy and ACL properties, capable to support the needed pressure, follow the anatomic path, guarantee an initial safe fixation and integration[2]. There is no significant clinical differences between autograft or allograft; however, the allograft with sterilization techniques with radiation could present high failure indexes[21].

The complete treatment included rehabilitation for the adequate mobility and normal strength in the knee joint, the critical step is the fast recovery of the complete extension[7].

The complications after ACL reconstruction are divided in the directly related to the surgical procedure and the medical ones. The surgical complications include: infection (0.14% to 5.7% ), articular rigidity (4% to 35%), graft failure and osteoarthritis (50 to 70 %). The most frequent medical complications are the Deep venous thrombosis and pulmonary embolism[12,22,24].

In consequence, the preservation of muscular strength of isquiotibial muscles is particularly important in sportsman and sportswoman with ACL injury. Gobbi, A et al. [39]presents a work questioning the necessity of using the internal rectus in the isquiotibial reconstruction, showing good functional results with the use of semitendinous only and similar results in patients using semitendinous and internal rectus for ACL reconstruction.

Considering the literature about the use of the mentioned grafts and the similar functional results we found that both techniques offer excellent results for the patients. It must be considered that the use of semitendinous only in the triple band we can diminish the associated morbidity in the donor site, with less affection in the strength and flexion grades that with the use of semitendinous plus internal rectus.

With the analyzed data from military patients and rightful owners of the HOSNAVTLAN, we confirm that the rupture of ACL is more frequent in men than women with a relation of 6.5:1, with the IM service being the one with greater incidence of this pathology with a relation of 7:15, the median age was 30.9 +/- 8.5 years, and the meniscal associated injury was present in 67% of the cases, and from the total of those injuries 48% were in IM service. Those associations are related to the population in the study, the intense and constant physical activity.

The good functionality of this kind of grafts with the functional test was confirmed, with Lachman test negative in 89% of patients for both grafts and negative Pivot-shift test in 95%. With the functional test of Lysholm with 90.27 points in average, the initial hypothesis was accepted, with an adequate articular and functional recovery independent of the use of ST or ST+IR.

5. Conclusion

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We could identify with this study a risk group in the MI service, where the preventive medicine could be a good option to reduce the incidence of this injury in the military personnel. With the actual tendency to better surgical techniques, fast and functional recovery after surgery reduced damage and comorbidity, the present study suggests that the use of ST graft only is a better option than ST+IR to diminish the donor site comorbidity with less grade of flexion, increased post-surgical pain and longtime of recovery.

Advice

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From this paper we can continue the research in multiple fields like the risk factors conditioning the ACL rupture in the MI personnel, to implement preventive measures for the ACL rupture and meniscal injury, and the economic impact of this diseases comparing the use of isquiotibial graft and other grafts.

Ethical Cons Iderations

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According to NOM-012-SSA3-2012, “that establish the criteria for the execution of research projects in human beings", this is a research protocol for human health, observational, comparative, transversal, retrospective, comparing the functional results of 2 different surgical techniques, both extensively described in the literature with good results. The nature of this study does not place the patient integrity in any risk and only the functional results are analyzed and compared with the hospital files.

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