The anterior cruciate ligament (ACL) is the primary stabilizer of the knee joint, preventing anterior translation and controlling rotational movements of the tibia. ACL tears are one of the most frequent ligamentous injuries of the knee, accounting for over 50% of all knee ligament injuries reported in sports-related trauma [1]. The global incidence is estimated at 68.6 per 100,000 person-years, with the highest burden in young, active individuals [2]. In India, hospital-based studies have reported that ACL injuries constitute 15–20% of all knee injuries, with a rising trend due to increasing road traffic accidents and sports participation [3].

Non-operative management of complete ACL tears often leads to persistent instability, secondary meniscal damage in up to 40–60% of cases, and early-onset osteoarthritis, observed in up to 50% of patients within 10 years of untreated injury [4]. Surgical reconstruction is therefore considered the gold standard for patients with symptomatic ACL deficiency, particularly for those desiring to return to sports or heavy physical activity.

Various grafts have been employed for ACL reconstruction, including bone–patellar tendon–bone (BPTB), hamstring tendons, quadriceps tendon, and allografts. Among these, patellar tendon grafts provide excellent tensile strength (up to 2977 N, close to the native ACL strength of 2160 N) and predictable bone-to-bone healing, leading to faster graft incorporation compared to soft tissue grafts [5]. Return-to-sport rates following BPTB graft reconstruction have been reported at 75–90%, with high levels of patient satisfaction. However, donor site morbidity such as anterior knee pain and kneeling discomfort occur in up to 20–30% of cases [6].

While arthroscopic ACL reconstruction has become the standard in most tertiary centers, it requires advanced equipment, longer learning curves, and higher costs. In contrast, modified miniarthrotomy techniques provide direct visualization of the graft site, reduce operative time, and are cost-effective. Studies comparing arthroscopic and miniarthrotomy techniques have demonstrated comparable functional outcomes in terms of IKDC and Lysholm scores, with no significant difference in graft stability or long-term success [7]. This makes miniarthrotomy a suitable alternative for resource-limited settings and semi-urban hospitals where arthroscopy may not be available.

Globally, long-term success rates of ACL reconstruction using patellar tendon grafts exceed 85%, with graft survival at 10 years reported at 82–90% [8]. Indian studies, including multicentric analyses, have also documented favorable outcomes, showing significant improvement in knee function, stability, and patient-reported outcome scores after BPTB graft reconstruction [9]. However, data on medial third patellar tendon grafts harvested through modified miniarthrotomy are still limited, especially in semi-urban and rural healthcare facilities where cost and accessibility remain major concerns.

The present study was conducted at Tibra Hospital, Sikar, from April 2024 to March 2025, including 95 patients undergoing ACL reconstruction with medial third patellar tendon bone plugs through a modified miniarthrotomy approach. The study aims to evaluate functional outcomes, graft stability, complications, and patient satisfaction. The expected outcome is to provide region-specific evidence supporting this method as a cost-effective and clinically reliable option for ACL reconstruction in resource-constrained healthcare setups.

METHODOLOGY

This prospective observational study was carried out at Tibra Hospital, Sikar, from April 2024 to March 2025. A total of 95 patients with clinically and radiologically confirmed anterior cruciate ligament (ACL) injuries who underwent reconstruction using medial third patellar tendon bone plugs through a modified miniarthrotomy approach were included. Patients of both sexes, aged between 18 and 50 years, who presented with symptomatic instability, giving-way episodes, and difficulty in returning to physical activity after ACL tear were enrolled. Exclusion criteria included patients with associated posterior cruciate ligament (PCL) or multi-ligamentous knee injuries, advanced osteoarthritis, revision ACL surgeries, or systemic comorbidities precluding surgery.

Preoperative evaluation included detailed history, clinical examination, and radiological assessment using plain radiographs and magnetic resonance imaging (MRI) to confirm ACL tear and rule out associated injuries. Patients were counseled regarding the procedure, and written informed consent was obtained. Standard baseline investigations were carried out prior to surgery.

The surgical technique involved harvesting the medial third of the patellar tendon with bone plugs from the patella and tibial tuberosity. A modified miniarthrotomy approach was employed to allow graft harvesting and tunnel placement under direct visualization. Femoral and tibial tunnels were created using standard instrumentation, and the graft was fixed with interference screws to ensure rigid bone-to-bone fixation. Hemostasis was achieved, and closure was done in layers. All surgeries were performed by the same orthopedic surgical team to maintain consistency.

Postoperatively, patients were placed on a standardized rehabilitation protocol. Early mobilization was encouraged from the first postoperative day, with isometric quadriceps strengthening and gradual progression to partial weight bearing by 2 weeks, followed by full weight bearing after clinical stability was ensured. Patients were reviewed at regular intervals at 6 weeks, 3 months, 6 months, and 12 months. Functional outcomes were assessed using the International Knee Documentation Committee (IKDC) score and Lysholm knee score. Stability was evaluated by clinical tests including Lachman test and pivot shift test at follow-up visits. Complications such as anterior knee pain, graft site morbidity, infection, or instability were recorded.

Data were entered into Microsoft Excel and analyzed using SPSS version 26. Quantitative variables such as age and functional scores were expressed as mean ± standard deviation, while categorical variables such as sex distribution, complications, and stability outcomes were represented as frequencies and percentages. Paired t-tests were applied to compare preoperative and postoperative functional scores, and chi-square test was used to assess categorical variables. A p-value < 0.05 was considered statistically significant.

RESULTS

A total of 95 patients with ACL injuries underwent reconstruction using medial third patellar tendon bone plugs through the modified miniarthrotomy technique. The mean age of participants was 28.6 ± 6.4 years, with a male predominance (72%). The majority of injuries were sustained during sports activities (58%), followed by road traffic accidents (32%) and other causes such as falls (10%). The right knee was more frequently involved (61%) compared to the left (39%).

Functional outcomes improved significantly after surgery. The mean preoperative Lysholm knee score was 54.2 ± 8.5, which improved to 89.6 ± 6.3 at 12 months follow-up (p < 0.001). Similarly, the mean IKDC score increased from 47.8 ± 9.1 preoperatively to 86.4 ± 7.5 postoperatively (p < 0.001). At final follow-up, 82% of patients were graded as “normal or nearly normal” according to IKDC criteria.

Knee stability also showed marked improvement. The Lachman test was negative in 83% of cases at one year, while the pivot shift test was absent in 79% of cases, confirming satisfactory graft function. Return to pre-injury levels of sports or heavy physical activity was achieved by 72% of patients within 9–12 months postoperatively.

Postoperative complications were minimal. The most common was anterior knee pain reported in 12 patients (12.6%), followed by graft-site tenderness in 7 patients (7.4%) and superficial wound infection in 3 patients (3.2%), all of which were managed conservatively. No cases of graft failure or revision surgery were recorded during the study period.

Overall, the modified miniarthrotomy technique using medial third patellar tendon bone plugs provided excellent functional recovery, satisfactory stability, and high rates of patient satisfaction, with relatively low complication rates at one-year follow-up.

Table 1: Demographic Profile and Injury Characteristics (n = 95)

Table 2: Functional Outcomes – Lysholm and IKDC Scores

Table 3: Stability and Postoperative Complications

Figure 1: Comparison of Functional Scores Pre vs Post Surgery

Figure 2: Postoperative Complications after ACL Reconstruction

DISCUSSION

The present study demonstrated that ACL reconstruction using medial third patellar tendon bone plugs through a modified miniarthrotomy technique provides excellent functional and stability outcomes with low complication rates. At 12-month follow-up, patients showed a significant improvement in Lysholm and IKDC scores, with mean postoperative values of 89.6 and 86.4 respectively, compared to preoperative scores of 54.2 and 47.8. More than 80% of patients achieved a “normal or nearly normal” functional status, while over 70% successfully returned to pre-injury levels of sports and physical activity.

These findings are consistent with earlier studies reporting favorable outcomes of bone–patellar tendon–bone (BPTB) grafts in ACL reconstruction. Aglietti et al. observed significant improvements in IKDC and Lysholm scores following patellar tendon graft reconstructions, with 85% of patients returning to sports at one-year follow-up [10]. Similarly, Shelbourne and Gray reported long-term graft survival exceeding 85% at 10 years, with high functional stability in athletes undergoing BPTB graft ACL reconstruction [11].

Comparisons between arthroscopic and miniarthrotomy techniques have revealed no significant differences in functional outcomes. Agrawal et al. in an Indian cohort demonstrated that miniarthrotomy-based ACL reconstruction achieved IKDC and Lysholm improvements comparable to arthroscopic methods, while also being more cost-effective in secondary care centers [12]. Our findings are in agreement, indicating that miniarthrotomy can serve as a viable alternative in settings where arthroscopy facilities are limited.

Donor site morbidity remains an important concern in patellar tendon graft reconstructions. In the present study, anterior knee pain was reported in 12.6% of cases, while graft site tenderness occurred in 7.4%. These rates are slightly lower than those reported by Kartus et al., who documented anterior knee pain in 25–30% of patients after BPTB graft harvest [6]. The relatively lower complication rates in our series may be attributed to careful graft harvesting from the medial third, meticulous closure, and structured rehabilitation.

International registry data also support the long-term reliability of patellar tendon grafts. Gifstad et al. analyzed over 45,000 reconstructions from Scandinavian registries and concluded that BPTB autografts had a lower revision risk compared with hamstring grafts [8]. Similarly, Panni et al. observed better graft stability with patellar tendon grafts, though hamstring grafts showed slightly less donor site morbidity [9]. Our study adds to this body of evidence by demonstrating that medial third patellar tendon grafts, harvested through a modified miniarthrotomy, maintain functional strength with acceptable complication profiles.

Overall, the findings highlight that ACL reconstruction using this technique offers a cost-effective and clinically effective solution in resource-constrained healthcare environments. By minimizing reliance on arthroscopic equipment while delivering comparable outcomes, this approach may be especially relevant for secondary-care hospitals in semi-urban and rural India.

CONCLUSION

This study demonstrated that ACL reconstruction using medial third patellar tendon bone plugs through a modified miniarthrotomy technique provides excellent functional and stability outcomes in patients with ACL injuries. Significant improvement was observed in Lysholm and IKDC scores at 12 months, with over 80% of patients achieving near-normal knee function and more than 70% returning to pre-injury levels of activity. Complication rates were low, with anterior knee pain being the most common but manageable issue. The absence of graft failures or revision surgeries during the follow-up period further highlights the effectiveness of this approach.

The findings indicate that modified miniarthrotomy offers results comparable to arthroscopic reconstruction, with the added advantages of reduced cost, simplified instrumentation, and suitability for secondary-care hospitals where arthroscopy facilities may not be available. This technique can therefore serve as a reliable and accessible alternative for ACL reconstruction in resource-limited settings.

LIMITATIONS AND RECOMMENDATIONS

The present study was limited by its single-center design and a sample size of 95 patients, which may restrict generalizability to larger populations. The follow-up period was limited to 12 months; thus, long-term graft survival, return-to-sport sustainability, and late complications such as degenerative changes could not be fully assessed. Furthermore, the study did not compare outcomes directly with other graft choices such as hamstring tendons or quadriceps tendons, nor did it assess advanced imaging for graft incorporation.

Despite these limitations, the results strongly support the use of medial third patellar tendon bone plugs through modified miniarthrotomy as an effective surgical option. It is recommended that future multicentric studies with larger cohorts and longer follow-up be conducted to validate these findings. Comparative trials between miniarthrotomy and arthroscopic techniques may also provide further insight into their relative advantages. Incorporation of objective measures such as instrumented laxity testing and imaging-based graft integration could strengthen outcome assessments. Finally, structured rehabilitation programs should be standardized to optimize functional recovery and minimize donor-site morbidity.

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