Long-term outcome of MacIntosh reconstruction of chronic anterior cruciate ligament insufficiency using fascia lata

Comparison of Revision ACL Reconstruction Using Iliotibial Band Augmented With Allograft Versus Bone-Patellar Tendon-Bone Autograft With Lateral Extra-articular Tenodesis

Background

Bone-patellar tendon-bone (BTB) anterior cruciate ligament reconstruction (ACLR) is one of the conventional techniques in the revision setting especially after a primary hamstring tendon graft. The use of the iliotibial band (ITB) augmented with allograft (AG) is an encouraging graft alternative for ACLR in terms of clinical and biomechanical data in the literature.

Purpose

To compare the clinical outcomes of BTB graft with lateral extra-articular tenodesis, modified Lemaire (BTB-LET), and an ITB graft augmented with hamstring AG (ITB-AG) in the setting of revision ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with either the BTB-LET or ITB-AG technique between 2012 and 2020 and who had a minimum follow-up of 2 years. The clinical outcomes were assessed by the Lysholm, Tegner, Anterior Cruciate Ligament-Return to Sport after Injury, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Return to sports, complications, and revisions were also analyzed.

Results

A total of 167 patients were included, with 106 patients in the BTB-LET group and 61 patients in the ITB-AG group. There were no significant group differences in sociodemographic characteristics; however, the mean follow-up was significantly longer in the BTB-LET compared with the ITB-AG group (52.0 vs 38.8 months, respectively; P = .0001). There were no significant differences in postoperative outcome scores; however, patients in the ITB-AG group had a higher rate of return to competitive pivoting sports (32.8% vs 17.9%; P = .0288) and a higher overall rate of return to preinjury sport (63.9% vs 47.2%; P = .0365). Complications, including revisions for meniscal or chondral lesions and retears (8 [8.3%] in the BTB-LET group and 2 [4.0%] in the ITB-AG group), were not significantly different. All retears were due to sports-related accidents.

Conclusion

In this study, ITB-AG was not different from BTB-LET in terms of functional outcomes scores but allowed better return to sport rate. Performing ITB-AG reconstruction in the setting of revision ACLR appears to be safe, effective, and associated with a satisfying return-to-sports rate.

Anterior cruciate ligament arthroscopic reconstruction and lateral tenodesis with iliotibial band and gracilis tendon: Technical note

While anterior cruciate ligament reconstruction using the iliotibial band is not a new technique, it still remains underdeveloped. The iliotibial band has historically been described as a thin and less resistant structure. Its harvesting has been associated with a risk of complications (hematoma, muscle hernia) and its small graft diameter increases the risk of rerupture. The addition of the gracilis tendon could potentially produce a graft with an increased diameter. In this technical note, we present a modification to the traditional technique performed on 50 patients, describing the surgical steps, graft diameter, clinical outcomes and complications at the 2-year follow-up. The mean graft diameter was 8.9±0.9 mm at the femur and 7.7±0.7 mm at the tibia. No rerupture was reported at the 2-year follow-up. LEVEL OF EVIDENCE: IV.

Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes

PURPOSE

Despite encouraging clinical, biomechanical and histological results, ACL reconstruction using the ITB was slowly abandoned. The hypothesis was that the current literature supports the use of ITB as the graft of choice for ACL reconstruction because of its good outcomes.

METHODS

A systematic search of the literature was performed in the PubMed, MEDLINE, Cochrane, and Ovid databases to identify published clinical studies relevant to ACL reconstruction with ITB autograft and studies comparing ITB autograft with bone-patellar tendon-bone (BPTB) and hamstring (HT) autografts (none were found). The results of the eligible studies were analyzed in terms of graft failure, instrumented knee laxity measurements, Lachman test, pivot-shift test, Lysholm score, objective and subjective International Knee Documentation committee (IKDC) scores, Tegner activity score, return to sports rate, return to sports at pre-injury level and complications.

RESULTS

Nineteen clinical studies including 1,210 patients with ACL reconstruction met the inclusion criteria. Graft failure occurred after ITB autograft in 4.2% of patients. Postoperative mean side-to-side laxity was 1.41 mm with 21% of patients having greater than 3 mm side-to-side difference. Lachman test and pivot-shift test were negative (grade 0) in 57% and 85%, respectively, and were grade 0 or 1 in 95% and 97%, respectively. Functional outcomes were satisfactory in 84% of patients with good to excellent results (Lysholm score > 84). Mean postoperative Lysholm score was 93.3 and 84% of patients had an objective IKDC grade of A or B. Mean postoperative Tegner score was 6.8. The return to sports rate was 89% and 61% of patients returned to their pre-injury level. A comparison of 89 ITB versus 80 BPTB autografts revealed no significant differences in graft failure (n.s.), instrumented mean side-to-side knee laxity difference (n.s.) or Tegner score (n.s.).

CONCLUSION

The graft survival rate and clinical and functional outcomes for ITB autograft are satisfactory. By allowing ACL reconstruction and lateral tenodesis to be done with a single, continuous, pedicled graft through an outside-in femoral tunnel, this technique may become the preferred alternative for primary or secondary ACL surgery.

LEVEL OF EVIDENCE

Level IV.

ACL reconstruction with lateral extra-articular tenodesis using a continuous graft: 10-year outcomes of 50 cases

BACKGROUND

Persistence of pivot shift is the main problem after isolated intra-articular anterior cruciate ligament (ACL) reconstruction. Adding lateral extra-articular tenodesis (LET) to the ACL procedure increases the knee's stability by controlling rotational laxity. The aim of this study was to evaluate the long-term clinical and radiological outcomes of combined ACL reconstruction with LET using a continuous hamstring graft as a first-line procedure.

MATERIAL AND METHODS

Fifty patients were reviewed at 10 years postoperative. Subjective outcome scores -IKDC, Lysholm, KOOS and Tegner- were collected. A clinical and radiological assessment was done. The knees' anteroposterior laxity was measured with a rollimeter.

RESULTS

The mean IKDC subjective score was 85.5, the mean Lysholm score was 90.2 and 80% of patients had a score graded as good or very good. No pivot shift was present in 94% of patients and there was a firm endpoint in the Lachman test in 86% of patients. There was a flexion deficit>5° in 5 patients and an extension deficit of 10° in one patient. Most patients (56%) had resumed their physical activities at the same level as before the surgery. Signs of osteoarthritis were found in 26% of patients (16% were Ahlback stage 1 and 10% were stage 2). There was only one graft failure. These good outcomes are consistent with other published studies on combined ACL-LET. There was neither significant stiffness, nor a higher rate of secondary osteoarthritis relative to ACL reconstruction only, particularly in the lateral tibiofemoral compartment.

CONCLUSION

Adding primary LET to ACL reconstruction improves control of rotational laxity over time without increasing the complication rate.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Comparative clinical outcomes of anterolateral ligament reconstruction versus lateral extra-articular tenodesis in combination with anterior cruciate ligament reconstruction: systematic review and meta-analysis

BACKGROUND

Anterolateral augmentation procedures can be divided into traditional lateral extra-articular tenodesis (LET) and modern anterolateral ligament (ALL) reconstruction. Nevertheless, no studies have compared the clinical results between LET and ALL reconstruction, when combined with intra-articular ACL reconstruction. This study was therefore designed to compare the clinical results, including the anterior translation, rotational laxity, and patient-reported outcomes, in a group of patients who underwent ACL reconstruction combined with LET or ALL reconstruction.

METHODS

All studies systematically searched until March 2018 without any language restriction that reported the results of a lateral extra-articular stabilization procedure using either LET or ALL reconstruction methods combined with ACL reconstruction were evaluated. Two reviewers independently recorded data from each study, including the sample size, improvement in Lysholm score, and the number of patients with each grade of knee laxity using Lachman and pivot shift tests.

RESULTS

The pooled results of ten studies showed that the postoperative proportion of knees with grade 2 or 3 on the Lachman test was significantly higher following LET compared with ALL reconstruction in combination with ACL reconstruction (10.8%, 95% confidence interval [CI]: 6.6-17.1% vs. 1.5%, 95% CI 0.5-4.5%; p = 0.001). However, the pooled results of 12 studies showed that the proportion of knees that belonged to grade 2 or 3 on the pivot shift test, indicating poor rotational stability, was similar between these two techniques (4.9%, 95% CI 2.0-11.5% vs. 2.3%, 95% CI 1.1-4.5%; p = 0.101). The pooled improvements in Lysholm scores in these two groups were also similar (32.3, 95% CI 26.8-37.9 vs. 25.7, 95% CI 16.7-34.7, p = 0.218).

CONCLUSION

LET could lead to worse anterior instability than with ALL reconstruction when these two approaches were combined with single-bundle ACL reconstruction. However, rotational stability and patient-reported outcomes were similar between the techniques.

Superior capsular reconstruction for irreparable supraspinatus tendon tears using the long head of biceps: A biomechanical study on cadavers

INTRODUCTION

The superior articular capsule complements the rotator cuff's function in shoulder stability. With irreparable rotator cuff tears, superior capsular reconstruction (SCR) improves dynamic glenohumeral (GH) joint kinematics. We present a novel method of SCR in cadaveric shoulders using the long head of bicep (LHB) tendon instead of previously explored fascia lata autograft, thereby reducing harvest site and suture anchor associated complications.

HYPOTHESIS

This novel method of SCR using the LHB is feasible biomechanically in restoring shoulder stability in irreparable supraspinatus tendon tear.

MATERIALS AND METHODS

Seven cadaveric shoulders were tested in a custom shoulder testing system. Superior translation of the humerus, subacromial contact pressure and area, and glenohumeral range of motion were tested at 0°, 30°, and 60° of glenohumeral abduction in the following conditions: (1) intact shoulder, (2) simulated complete supraspinatus tendon tear, (3) modified SCR using LHB, (4) and modified SCR using LHB and side-to-side repair augmentation.

RESULTS

The complete cuff tear shifted the humeral head superiorly as compared to the intact shoulder. Subacromial peak contact pressure was also increased at 30° and 60° while contact area was increased at 0° and 30°. The modified SCR both with and without side-to-side repair shifted the humeral head inferiorly at 30° and 60°, with contact area further reduced at 60°. Both techniques had comparable results for contact pressure and total rotational range of motion.

CONCLUSION

The LHB with appropriate distal insertion on the greater tuberosity restores shoulder stability in irreparable rotator cuff tears by re-centering the humeral head on the glenoid.

LEVEL OF EVIDENCE

Basic science study, biomechanical testing.

Lateral Augmentation Procedures in Anterior Cruciate Ligament Reconstruction: Anatomic, Biomechanical, Imaging, and Clinical Evidence

BACKGROUND

There has been an increasing interest in lateral-based soft tissue reconstructive techniques as augments to anterior cruciate ligament reconstruction (ACLR). The objective of these procedures is to minimize anterolateral rotational instability of the knee after surgery. Despite the relatively rapid increase in surgical application of these techniques, many clinical questions remain.

PURPOSE

To provide a comprehensive update on the current state of these lateral-based augmentation procedures by reviewing the origins of the surgical techniques, the biomechanical data to support their use, and the clinical results to date.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of the literature was conducted via the Medline, EMBASE, Scopus, SportDiscus, and CINAHL databases. The search was designed to encompass the literature on lateral extra-articular tenodesis (LET) procedures and the anterolateral ligament (ALL) reconstruction. Titles and abstracts were reviewed for relevance and sorted into the following categories: anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes.

RESULTS

The search identified 4016 articles. After review for relevance, 31, 53, 27, 35, 45, and 78 articles described the anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes of either LET procedures or the ALL reconstruction, respectively. A multitude of investigations were available, revealing controversy in addition to consensus in several categories. The level of evidence obtained from this search was not adequate for systematic review or meta-analysis; thus, a current concepts review of the anatomy, biomechanics, imaging, surgical techniques, and clinical outcomes was performed.

CONCLUSION

Histologically, the ALL appears to be a distinct structure that can be identified with advanced imaging techniques. Biomechanical evidence suggests that the anterolateral structures of the knee, including the ALL, contribute to minimizing anterolateral rotational instability. Cadaveric studies of combined ACLR-LET procedures demonstrated overconstraint of the knee; however, these findings have yet to be reproduced in the clinical literature. The current indications for LET augmentation in the setting of ACLR and the effect on knee kinematic and joint preservation should be the subject of future research.

Combined Anatomic Anterior Cruciate Ligament and Double Bundle Anterolateral Ligament Reconstruction

The results of arthroscopic anterior cruciate ligament (ACL) reconstruction are so far satisfactory and improving over time as a result of the improved understanding of the anatomy and biomechanics of the ACL. Rotational instability confirmed by a positive pivot shift is present in more than 15% of cases who underwent successful ACL reconstruction. Persistent rotational instability interferes with performing pivoting sports, and also may lead to meniscal and chondral injuries, or re-rupture of the reconstructed ACL. Surgeons reconsidered the anatomy and biomechanics of the ACL and introduced the double bundle ACL reconstruction technique aiming to achieve a more rotational control by reconstructing the anteromedial and anterolateral bundles of the ACL. To date, the results of double bundle ACL reconstruction are mixed and inconsistent. The improved understanding of the existence, function, and biomechanical role of the anterolateral ligament (ALL) in controlling the rotational instability of the knee has redirected and refocused attention on a supplemental extra-articular reconstruction of the ALL in conjunction with the intra-articular ACL reconstruction so as to restore normal kinematics of the knee. In this Technical Note, we describe a technique that allows for a combined ACL and double bundle ALL reconstruction using autogenous hamstring graft (semitendinosus and gracilis) tendons. This technique is an extension of our previously described technique of a combined anatomic ACL and single bundle ALL reconstruction. The improved understanding of the anatomy of the ALL makes a double bundle ALL reconstruction more anatomic than single bundle ALL reconstruction, as the native ALL is triangular or inverted Y in shape, with a narrow proximal femoral attachment and a broad distal tibial attachment between Gerdy's tubercle and the head of the fibula.

Isolated Acetabuloplasty and Labral Repair for Combined-Type Femoroacetabular Impingement: Are We Doing Too Much?

PURPOSE

To evaluate patient outcomes after isolated arthroscopic volumetric acetabular osteoplasty and labral repair for the treatment of patients with combined femoroacetabular impingement (FAI) lesions.

METHODS

A review of a prospectively collected registry identified 86 patients (106 hips) with an average age of 38.1 years (range, 17-59 years) with combined-type FAI that underwent isolated acetabular osteoplasty and labral repair. Preoperative α-angle, degree of radiographic degenerative changes, and presence of a crossover sign were recorded. Clinical outcomes were assessed with the modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and patient satisfaction score (out of 10) at a minimum 2-year follow-up.

RESULTS

Clinical follow-up was obtained at a mean follow-up of 37.2 months (range, 27.9-79.2 months). Patients with Tönnis grade 0 and I findings had significantly higher mHHS (83.5 vs 71.5, P = .01), HOS-SSS (81.3 vs 59.9, P = .02), and iHOT-12 scores (71.1 vs 58.8, P = .04) compared to patients with Tonnis grade II changes. However, patient satisfaction scores (8.0 vs 7.2, P = .45) were no different. No significant difference was noted between unilateral and bilateral hip patient outcome scores. Patient age and preoperative α-angles did not correlate with any outcome scores (all R² <0.05). There were no cases of revision surgery or progression to arthroplasty.

CONCLUSIONS

Isolated acetabular decompression may adequately address the underlying impingement in combined-type FAI while avoiding the risks associated with femoral-sided decompression. Good to excellent patient-reported outcomes and satisfaction scores were noted with significantly higher scores in patients with minimal arthritic change. Patient age and preoperative α-angle had less effect on postoperative outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Percutaneous Reconstruction of the Anterolateral Ligament of the Knee With a Polyester Tape

Recent advances in surgeons' understanding of the anatomic, biomechanical, and radiologic features of the anterolateral ligament (ALL) of the knee have led to an increased interest in reconstruction of this structure as part of the management of knee instability. Even without any technical flaws and proper positioning of the bone tunnels, there is a small subset of patients, approximately 7% of all patients, who experience some residual anterolateral rotational instability after anterior cruciate ligament reconstruction. For this reason, some researchers have turned again toward the anterolateral aspect of the knee and specifically the ALL. In this technical note, the surgical steps for percutaneous reconstruction of ALL of the knee using a polyester tape are described.

Radiographic landmarks for surgical reconstruction of the anterolateral ligament of the knee

PURPOSE

To determine the radiographic landmarks of the anterolateral ligament (ALL) on the femur and tibia to assist in intraoperative graft placement during ALL reconstruction.

METHODS

The footprints of the ALL, fibular collateral ligament (FCL), popliteus insertion, lateral gastrocnemius insertion, and Gerdy's tubercle were isolated and centrally marked with tantalum beads in thirteen fresh-frozen cadaveric knees. Measurements were taken from the true lateral fluoroscopic images. On the femur, the mean distances from the ALL origin to the FCL origin and from the ALL origin to the popliteus insertion were measured. On the tibia, the mean distances from the ALL insertion to Gerdy's tubercle and from the ALL insertion to the lateral tibial plateau were measured. Furthermore, radiographic descriptions of the ALL origin and insertion were developed.

RESULTS

The ALL origin on the femur averaged 3.3 ± 1.5 mm anterior-distal to the FCL origin in one anatomical variant and 5.4 ± 1.4 mm posterior-proximal to the FCL origin in a second variant. The ALL origin was 9.9 ± 2.7 mm from the popliteus insertion. The ALL origin is described as overlying the posterior femoral cortical line, between Blumensaat's line and a line from the posterior condylar articular edge parallel to Blumensaat's line. The ALL insertion on the tibia averaged 24.7 ± 4.5 mm posterior to Gerdy's tubercle and 11.5 ± 2.9 mm distal to the lateral tibial plateau. The tibial ALL insertion is described between the posterior tibial cortical line and a parallel line drawn down from the apex of the tibial spine, and overlying a line drawn perpendicular to the posterior tibial cortical line starting from the apex of the posterior tibial condyles.

CONCLUSIONS

Using direct lateral fluoroscopy, radiographic landmarks of the ALL origin and insertion have been described.

Surgical options for anterior cruciate ligament reconstruction in the young child

PURPOSE OF REVIEW

To review the most recent literature on the epidemiology, diagnosis, treatment, and outcomes of pediatric anterior cruciate ligament injury.

RECENT FINDINGS

There is an increasing prevalence of anterior cruciate ligament injuries in pediatric and adolescent athletes, and nonoperative management of these injuries results in worse outcomes than surgical reconstruction. Prevention exercise protocols are cost-effective in preventing this injury in adolescent athletes. A number of techniques are currently in practice that address anterior cruciate ligament injuries in the skeletally immature, but there is no consensus on the optimal technique.

SUMMARY

The reported clinical outcomes from anterior cruciate ligament reconstruction in young patients are favorable.

Anatomy and Histology of the Knee Anterolateral Ligament

BACKGROUND

Reconstruction of the anterior cruciate ligament (ACL) is one of the most common procedures in orthopaedic surgery. However, even with advances in surgical techniques and implants, some patients still have residual anterolateral rotatory laxity after reconstruction. A thorough study of the anatomy of the anterolateral region of the knee is needed.

PURPOSE

To study the anterolateral region and determine the measurements and points of attachments of the anterolateral ligament (ALL).

STUDY DESIGN

Descriptive laboratory study.

METHODS

Dissections of the anterolateral structures of the knee were performed in 20 human cadavers. After isolating the ALL, its length, thickness, width, and points of attachments were determined. The femoral attachment of the ALL was based on the anterior-posterior and proximal-distal distances from the attachment of the lateral collateral ligament (LCL). The tibial attachment point was based on the distance from the Gerdy tubercle to the fibular head and the distance from the lateral tibial plateau. The ligaments from the first 10 dissections were sent for histological analysis.

RESULTS

The ALL was found in all 20 knees. The femoral attachment of the ALL at the lateral epicondyle averaged 3.5 mm distal and 2.2 mm anterior to the attachment of the LCL. Two distal attachments were observed: one inserts into the lateral meniscus, the other between the Gerdy tubercle and the fibular head, approximately 4.4 mm distal to the tibial articular cartilage. The mean measurements for the ligament were 37.3 mm (length), 7.4 mm (width), and 2.7 mm (thickness). The histological analysis of the ligaments revealed dense connective tissue.

CONCLUSION

The ALL is consistently present in the anterolateral region of the knee. Its attachment to the femur is anterior and distal to the attachment of the LCL. Moving distally, it bifurcates at close to half of its length. The ALL features 2 distal attachments, one at the lateral meniscus and the other between the Gerdy tubercle and the fibular head.

CLINICAL RELEVANCE

The ALL may be important in maintaining normal rotatory limits of knee motion; ALL rupture could be responsible for rotatory laxity after isolated intra-articular reconstruction of the ACL.

Anatomical study on the anterolateral ligament of the knee

Objective

Describe the knee anterolateral ligament (ALL) and establish its anatomical marks of origin and insertion.

Methods

Dissection of the anterolateral aspect of the knee was performed in six cadavers. After isolation of the ALL, its lenght, width and thickness were measured as its places of origin and insertion. The ALL origin was documented in relation to the lateral collateral ligament (LCL) origin and the insertion was documented in relation to the Gerdy tubercle, fibullar head and lateral meniscus. After the first two dissections, the ligament was removed and sent to histologycal analysis.

Results

The ALL was clearly identified in all knees. Its origin in the lateral epycondile was on average 0.5 mm distal and 2.5 mm anterior to the LCL. In the tibia, two insertions were observed, one in the lateral meniscus and another in the proximal tibia, about 4.5 mm distal to the articular cartilage, between the Gerdy tubercle and the fibullar head. The average measures obtained were: 35.1 mm lenght, 6.8 mm width and 2.6 mm thickness. In the ligament histological analysis, dense connective tissue was observed.

Conclusion

The ALL is a constant structure in the knee anterolateral region. Its origin is anterior and distal to the LCL origin. In the tibia, it has two insertions, one in the lateral meniscus and another in the proximal tibia between the Gerdy tubercle and the fibullar head.

Anterior cruciate ligament reconstruction with fascia lata using a minimally invasive arthroscopic harvesting technique

Anterior cruciate ligament (ACL) reconstruction using the fascia lata has undergone a number of technical modifications since the work of Hey-Groves, MacIntosh, and Jaeger. Arthroscopy has simplified this technique, notably in the positioning of the tunnels. Minimally invasive harvesting through two lateral proximal and distal approaches considerably reduces cosmetic problems. The femoral tunnel is made from the outside to the inside using a specific targeting device, and the transplant harvest site is closed using the Jaeger procedure so as not to weaken lateral knee stabilizing structures. This procedure consists in opening the lateral intermuscular septum 1cm from the femur to let it shift laterally and allow the transplant harvesting area to be closed. This technique uses a fascia lata transplant, the harvesting of which has shown few iatrogenous complications but requires rigorous adherence to certain rules.

Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.

Anterior cruciate ligament reconstruction using quadriceps tendon autograft for adolescents with open physes- a technical note

Background

One major concern in the treatment of ACL lesions in children and adolescents with open physes is the risk of iatrogenic damage to the physes and a possibly resulting growth disturbance.

Purpose

The primary purpose of this article is to describe our technique of a transphyseal ACL reconstruction using quadriceps tendon-bone autograft in children and adolescents with open growth plates. The secondary aim is to report our early results in terms of postoperative growth disturbances which are considered to be a major concern in this challenging group of patients. It was our hypothesis that with our proposed technique no significant growth disturbances would occur.

Methods

From January 1997 to December 2007 49 consecutive children and adolescents with open growth plates were treated for a torn ACL using the aforementioned surgical technique. The patients (28 males and 21 females) with a median age at surgery of 13 (range 8-15) years were retrospectively evaluated. Outcome measures were follow-up radiographs (weight-bearing long leg radiographs of the injured and uninjured knee, anteroposterior and lateral views, a tangential view of the patella and a tunnel view of the injured knee) and follow-up notes (6 weeks, 3, 6, 12 months and until closing of physes) for occurrence of any tibial and/or femoral growth changes.

Results: All of the 49 patients had a sufficient clinical and radiological follow-up (minimum 5 years, rate 100%). 48 cases did not show any clinical and radiological growth disturbance. One case of growth disturbance in a 10.5 years old girl was observed. She developed a progressive valgus-flexion deformity which was attributed to a malplacement of the autograft bone block within the femoral posterolateral epiphyseal plate leading to an early localized growth stop. None of the patients were reoperated due to ACL graft failure. Five of the patients underwent revision ACL surgery due to another adequate sports trauma after the growth-stop. The tibial fixation screw had to be removed under local anaesthesia in 10 patients.

Conclusions

The described ACL reconstruction technique represents a promising alternative to previously described procedures in the treatment of children and adolescents with open growth plates. Using quadriceps tendon future graft availability is not compromised, as the most frequently used autograft-source, ipsilateral hamstring tendons, remains untouched.

The effect of skeletal maturity on the regenerative function of intrinsic ACL cells

Anterior cruciate ligament (ACL) injuries are an important clinical problem, particularly for adolescent patients. The effect of skeletal maturity on the potential for ACL healing is as yet unknown. In this study, we hypothesized that fibroblastic cells from the ACLs of skeletally immature animals would proliferate and migrate more quickly than cells from adolescent and adult animals. ACL tissue from skeletally immature, adolescent, and adult pigs and sheep were obtained and cells obtained using explant culture. Cell proliferation within a collagen-platelet scaffold was measured at days 2, 7, and 14 of culture using AM MTT assay. Cellular migration was measured at 4 and 24 h using a modified Boyden chamber assay, and cell outgrowth from the explants also measured at 1 week. ACL cells from skeletally immature animals had higher proliferation between 7 and 14 days (p<0.01 for all comparisons) and higher migration potential at all time points in both species (p<0.01 for all comparisons). ACL cells from skeletally immature animals have greater cellular proliferation and migration potential than cells from adolescent or adult animals. These experiments suggest that skeletal maturity may influence the biologic repair capacity of intrinsic ACL cells.

Knee osteoarthritis after anterior cruciate ligament injury: a systematic review

BACKGROUND

This is a systematic review of studies on the prevalence of osteoarthritis in the tibiofemoral joint more than 10 years after an anterior cruciate ligament injury, the radiologic classification methods used, and risk factors for development of knee osteoarthritis.

METHODS

A systematic search was performed in PubMed, EMBASE, and AMED. Inclusion criteria were studies involving patients with anterior cruciate ligament injury, either isolated or combined with medial collateral ligament or meniscal injury and either surgically or nonsurgically treated, and a minimum 10-year follow-up with radiologic assessment. Methodological quality was evaluated using a modified version of the Coleman methodology score.

RESULTS

Seven prospective and 24 retrospective studies were included. The mean modified Coleman methodology score was 52 of 90. Reported prevalence of knee osteoarthritis for subjects with isolated anterior cruciate ligament injury was between 0% and 13%. For subjects with anterior cruciate ligament and additional meniscal injury, the prevalence varied between 21% and 48%. Seven different radiologic classification systems were used in the studies. Only 3 studies reported reliability results for the radiologic assessments. The most frequently reported risk factor for development of knee osteoarthritis was meniscal injury.

CONCLUSION

This systematic review suggests that the prevalence rates of knee osteoarthritis after anterior cruciate ligament reconstruction reported by previous reviews have been too high. The highest rated studies reported low prevalence of knee osteoarthritis for individuals with isolated anterior cruciate ligament injury (0%-13%) and a higher prevalence of knee osteoarthritis for subjects with combined injuries (21%-48%). Overall, the modified Coleman methodology score was low for the included studies. No universal methodological radiologic classification method exists, making comparisons of the studies and stating firm conclusions on the prevalence of knee osteoarthritis more than 10 years after anterior cruciate ligament injury difficult.

Long term results of anterior cruciate ligament reconstruction with iliotibial tract: 6-, 13-, and 24-year longitudinal follow-up

Many studies have reported successful outcomes less than 10 years after anterior cruciate ligament (ACL) reconstruction. However, longer-term outcomes have not been analyzed. We assessd outcomes 24 years after anterior cruciate ligament reconstruction with iliotibial tract and compared them with shorter-term results in the same patients. Between 1979 and 1981, 45 patients underwent combined intra- and extra-articular ACL reconstruction with iliotibial tract. Follow-up evaluations of these patients were performed at 6, 13, and 24 years after surgery, which included manual and instrumental laxity testing, functional assessments, and radiography. Twenty-six (60%) patients of the original ACL reconstruction cohort participated in all three follow-up assessments. Three patients had undergone meniscectomy prior to ACL reconstruction and 18 underwent meniscectomy together with ACL reconstruction. Eleven patients underwent subsequent meniscectomy. The mean Lysholm score was 96.2, 93.8, and 87.8 at 6-, 13-, and 24-year follow-up, respectively. A significant decrease in mean Lysholm score was found between 13- and 24-year follow-up. The mean KT-1000 side-to-side difference was 3.5 mm at 24-year follow-up. Overall knee laxity did not change significantly during the follow-up period. At 24-year follow-up, 17 (71%) patients had moderate or severe degenerative changes on radiographs although about 50% of the patients participated in regular sports activities and no patient required regular clinical intervention.

Treatment of anterior cruciate ligament injuries, part I

Anterior cruciate ligament injuries are common among athletes. Although the true natural history remains unclear, anterior cruciate ligament injuries are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. This article, the first in a 2-part series, was initiated with the use of the PubMed database and a comprehensive search of articles that appeared between January 1994 to the present, using the keywords anterior cruciate ligament. A total of 3810 citations were identified and reviewed to determine the current state of knowledge about the treatment of these injuries. Articles pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of anterior cruciate ligament injury, the natural history of the anterior cruciate ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, risk factors for anterior cruciate ligament injury, indications for treatment of anterior cruciate ligament injuries, and nonoperative and operative treatments were obtained, reviewed, and served as the basis for part I. Part II, to be presented in another issue of this journal, includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after reconstruction, and the effect of sex, age, and activity level on the outcome of surgery. Our approach was to build on prior reviews and to provide an overview of the literature for each of the before-mentioned areas of study by summarizing the highest level of scientific evidence available. For the areas that required a descriptive approach to research, we focused on the prospective studies that were available; for the areas that required an experimental approach, we focused on the prospective, randomized controlled trials and, when necessary, the highest level of evidence available. We were surprised to learn that considerable advances have been made during the past decade regarding the treatment of this devastating injury.