Research and Publication Ethics: This research received approval from the Fırat University Ethics Committee of Animal Experiments under the reference number 2014/2. The study involved a sample of 12 female Anatolian Black Goats, with an average weight of 38 kg, and ages ranging between 3 to 4 years. The study subjects were housed at the Animal Hospitalization Unit of Fırat University Animal Hospital throughout the research period. Approximately one month prior to the commencement of the experimental phase, the goats were randomly allocated into two groups. Internal and external parasitic treatments were administered using Okzan oral tablets (Ceva, Turkey) and Dektomax (Pfizer, Brazil). General health examinations and observations were conducted during the adaptation period. At times, the goats were allowed to graze in designated areas on the university campus. Prior to and following the surgical intervention, assessments encompassing physical, radiographic (Canon CXDI-50G, Japan), and arthroscopic (Karl- Storz as a set of arthroscopy; 2.7 mm diameter, 175 mm long 30 ° arthroscope, Tutlingen, Germany) examinations were conducted. Facilities such as Fırat University Large Animal Hospitalization Unit, Large Animal Clinic, Arthroscopy Unit, X-ray, and Imaging Center were utilized for the duration of the study.
In this investigation, specially crafted acrylic (Polymethyl Methacrylate) buttons were employed for the fixation of tendons in lieu of the CCL, and subsequent results were assessed. The acrylic button patterns, measuring 2 mm in thickness with an outer diameter of 16 mm and an inner diameter of 12 mm, were lubricated with light machine oil and positioned on a slide for experimentation. These acrylic buttons were positioned on a single slide, covering patterns filled with cold acrylic. Once the acrylic had solidified, the buttons were carefully removed from their patterns. Subsequently, two holes, each measuring 2 mm in diameter and spaced 4 mm apart, were drilled at the center of the buttons. The acrylic (Polymethyl Methacrylate) buttons, once obtained, underwent a meticulous cleaning process followed by sterilization.
Anesthesia: General anesthesia was induced through intramuscular (IM) injections, commencing with 0.1 mg/kg xylazine hydrochloride (Rompun®; 23.32 mg/ml, Bayer, Istanbul, Turkey) premedication, followed by 11 mg/kg ketamine hydrochloride (Ketasol; 10%, 100 mg/ml, Richterpharma, Austria). Postoperatively, all subjects received intramuscular administration of flunixin meglumine (Vet-Fulin®, 82.95 mg/ml, Turkey) at a dosage of 2 mg/kg for three days. Additionally, ceftiofur (Sefakim®, 50 mg/ml, Topkim, Turkey) was administered intramuscularly at a dose of 1 mg/kg for a duration of seven days during the postoperative period. Subsequent to the induction of general anesthesia, the right knee joint and the associated graft area underwent a shaving procedure. Following the shaving process, the subjects were positioned on the operating table. The surgical site was then thoroughly disinfected using 10% povidone iodine (Batticon; Adeka, Turkey).
Preparation of Graft: MTC tendon graft access and preparation involved making an incision through the parapatellar approach, distally from the medial side of the tibia. Once the skin incision was performed, the tendon was accessed in the region guided by an elevator. The identified MTC tendon was excised at a distal location near the tarsi joint using scissors (Figure 1). Subsequently, the graft was reshaped proximally, and the distal portion of the graft was intricately knitted using a special technique with Polyglactin 910 USP: 0 (Vicryl, No: 0, Ethicon, Johnson & Johnson, USA) (Figure 1). Saline solution (0.9%) was added during the knitting process. Upon completion of the knitting operation, the graft was maintained under a moist gas hydrophilic environment.
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Figure 1: a. Detection Process of MTC Tendon. b. One-Sided Cutting of the MTC Tendon. c, d, f. Unilateral Knitting Process of MTC Tendon. g. Detecting and cutting the MPL Tendon. h. Image of Two-Sided Cut-Out MPL Tendon. i. Knitting Process of MPL Tendon, which is cut out on both sides, and moistened with serum physiological. |
MPL tendon graft access and preparation followed a similar procedure, where an incision was made laterally through the skin to reach the MPL tendon The MPL tendon graft was excised both proximally and distally, followed by thorough washing with saline. Subsequently, the entirely free distal and proximal parts of the MPL tendon graft were intricately knitted using the same technique with Polyglactin 910 USP: 0 (Vicryl, No: 0, Ethicon, Johnson & Johnson, USA) (Figure 1).
Surgical Protocol: The excision of CCL was performed through a lateral parapatellar approach, with the incision extended down to the distal aspect of the tibia. Prior to initiating the experimental study, it was observed, based on experience gained from preliminary arthroscopic studies on cadavers, that the corpus adiposum infrapatellare (fat pad) tissue in the region posed challenges to the arthroscopic procedure. Consequently, a portion of the fat pad tissue was excised during the operation (Figure 2). Post-removal, there was notable bleeding in the area, and to mitigate this risk, 1 mL of adrenaline was injected before cutting the tissue.
The joint was brought into a flexion position, and the CCL was identified and subsequently cut. Great care was taken to ensure the complete removal of the CCL without any residual tissue (Figure 2). The Paatsama technique was used in the study. The Paatsama technique is one of the first developed and still applied intracapsular operation techniques. Holes were drilled into the anatomical connection points of the CCL in the femur and tibia without damaging the CaCL and the grafts were placed. To facilitate the passage of the prepared graft, a 4-millimeter diameter tunnel was drilled into the tibia (Figure 3). Subsequently, the tunnel was opened from the femoral condyle using the same drill, delineating the path for the graft passage (Figure 3). An intraarticular tunnel, opening towards the right medial aspect of the proximal articular face of the tibia (i.e., towards the insertion point of the CCL on the tibia), was established with a drill. Additionally, a second tunnel in the lateral femoral condyles, directed towards the insertion point of the CCL, was created.
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Figure 2: a. Removal of Fat Pad Tissue During Operation b.Discontinuation of the CCL. c. Image of CCL cut away. |
The MPL and MCT tendons from the right hind legs of the subjects were utilized as substitutes for the excised cruciate ligaments. The grafts underwent reinforcement through a knitting process and were threaded through tunnels in both the tibia and femur. The knitted graft, whether MTC or MPL, was extracted from the tibial tunnel using a 4 mm diameter hook. Simultaneously, the graft, having passed through the tibial tunnel, was further advanced into the distal femoral tunnel within the same procedure. The grafts retrieved from the tunnels were meticulously stretched to prevent any potential slack (Figure 4 and 5) Subsequently, prior to the fixation procedure, the knee joint underwent flexion and extension maneuvers.
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Figure 4: The Transition of the MTC Tendon Knitted with Polyglactin 910 Through the a. Tibia Tunnel and b. Femur Tunnel |
In six goats, the MTC graft (secured with a single button on the femur), and in another six goats, the MPL graft (secured with two acrylic (polymethyl methacrylate) buttons, one on the tibia and one on the femur) were affixed utilizing acrylic buttons in lieu of the CCL (Figure 6). Specially crafted buttons, modeled after the Endobutton used in human medicine, were employed in the study for graft fixation. The findings suggested that acrylic buttons can be a viable option in the treatment of CCL rupture.
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Figure 6: Placement of Acrylic (Polymethyl Methacrylate) Buttons: a. The appearance of a sterilized operation ready acrylic button, b. Placement of the acrylic button on the tibia |
Postoperative Care: After the fixation, joint movements, including flexion-extension, were applied to assess the strength of the graft. The joint was closed once deemed sufficiently durable, and the operative site was closed following standard procedural methods. Locally, Penicillin G vial (1,000,000 IU) was applied to the region, and a 10% povidone iodine dressing was applied to the incision site. Postoperatively, PVC-supported bandages were applied to the subjects for a duration of 20 days. In the postoperative period, intramuscular administration of ceftiofur at 1 mg/kg and flunixin meglumine at a dose of 2 mg/kg was carried out. Antibiotic applications continued for seven days, and analgesic applications were administered for three days.
Six months postoperatively, the goats underwent euthanasia. The findings from physical examination, radiographic analysis, arthroscopic evaluation, and histopathological examinations of the goats observed over the six-month period were documented and subsequently analyzed in this study.
The tissue graft section outside the tunnel and the tissue surrounding the button were immersed in a 10% neutral formalin solution alongside the graft bone tissue within the tunnel. Subsequently, the graft tissue affiliated with the bone tissue underwent decalcification post formalin fixation. All tissues underwent standard processing procedures, leading to the preparation of paraffin blocks. Microphotographs (DP 72) were captured through staining techniques utilizing Hematoxylin Eosin (H.E), Masson's Trichrome, and Safranin O methods under a light microscope (Olympus BX43).
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