Miniarthrotomy versus arthroscopic-assisted anterior cruciate ligament reconstruction with autogenous patellar tendon graft

Return to Play and Long-term Participation in Pivoting Sports After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Rupture of the anterior cruciate ligament (ACL) is a common and feared injury among athletes because of its potential effect on further sports participation. Reported rates of return to pivoting sports after ACL reconstruction (ACLR) vary in the literature, and the long-term consequences of returning have rarely been studied.

PURPOSE

To examine the rate and level of return to pivoting sports after ACLR, the duration of sports participation, and long-term consequences of returning to pivoting sports.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

All primary ACLRs with a bone-patellar tendon-bone autograft between 1987 and 1994 (N = 234) in athletes participating in team handball, basketball, or soccer before injury were selected from a single-center quality database. A long-term evaluation (median, 25 years; range, 22-30 years) was performed using a questionnaire focusing on return to pivoting sports, the duration of sports activity after surgery, later contralateral ACL injuries, revision surgery, and knee replacement surgery. Participants were stratified into 2 groups depending on the time between injury and surgery (early, <24 months; late, ≥24 months).

RESULTS

A total of 93% of patients (n = 217) responded to the questionnaire. Although 83% of patients returned to pivoting sports after early ACLR, only 53% returned to preinjury level. Similar return-to-sport rates were observed in males and females (P > .05), but males had longer sports careers (median, 10 years; range, 1-23 years) than females (median, 4 years; range, 1-25 years; P < .001). The incidence of contralateral ACL injuries was 28% among athletes who returned to sports versus 4% among athletes who did not return (P = .017) after early ACLR. The pooled reinjury rate after return to preinjury level of sports was 41% (30%, contralateral injuries; 11%, revision surgery). The incidence of contralateral ACL injuries was 32% among females versus 23% among males (P > .05) and, for revision surgery, was 12% among females versus 7% among males (P > .05) after returning to sports. Having a late ACLR was associated with an increased risk of knee replacement surgery (9% vs 3%; P = .049) when compared with having an early ACLR.

CONCLUSION

ACLR does not necessarily enable a return to preinjury sports participation. By returning to pivoting sports after ACLR, athletes are also facing a high risk of contralateral ACL injuries. Long-term evaluations in risk assessments after ACLR are important, as a significant number of subsequent ACL injuries occur later than the routine follow-up.

The Effects of Bone Marrow-Derived Mesenchymal Stem Cells and Fascia Wrap Application to Anterior Cruciate Ligament Tissue Engineering

After an anterior cruciate ligament (ACL) injury, surgical reconstructions are necessary in most cases, either with autografts, allografts, or artificial ligaments. Potential tissue-engineered ligaments would circumvent the disadvantages apparent in these methods. While seeding of mesenchymal stem cells (MSCs) and fascia wrap could potentially improve tissue regeneration and mechanical properties, their exact roles were evaluated in the current study. Knitted biodegradable scaffolds of poly-L-lactic acid (PLLA) and poly-glycolic-lactic acid (PGLA) yarns were used to reconstruct ACL in 48 rabbits. These were divided into four equal groups: only knitted scaffolds were used in group I; knitted scaffolds and mesenchymal stem cells were used in group II; knitted scaffolds, MSCs, and fascia lata were used in group III; knitted scaffolds and fascia lata were used in group IV. Carboxyfluorescein diacetate (CFDA)-labeled MSCs were used to trace the fate of seeded cells in groups II and III. Histology, Western blot analysis, and mechanical properties of reconstructed ACL were analyzed after 20 weeks. Fibroblast ingrowths were seen in all four groups while CFDA-labeled MSCs could be found after 8 weeks of implantation in groups II and III. Both the amount of collagen type I and collagen type III in groups III and IV were significantly higher than in group II, which was much higher than in group I. Both maximal tensile loads and stiffness of the reconstructed ACLs in groups I, II, III, and IV were significantly lower than normal controls after 20 weeks of implantation. It is concluded that MSCs could promote synthesis of collagen type I and collagen type III in tissue-engineered ligaments, while fascia wraps have stronger effects. Both MSC seeding and fascia wrap could not enhance ultimate tensile load and stiffness.

Post-operative complications following primary ACL reconstruction using allogenic and autogenic soft tissue grafts: increased relative morbidity risk is associated with increased graft diameter

BACKGROUND

The purpose of this study is to compare the risk of peri-operative complication events associated with allogenic and autogenic grafts during routine follow-up for six months after primary arthroscopic anterior cruciate ligament (ACL) reconstruction surgery.

METHODS

A retrospective cohort study identified patients that underwent ACL reconstruction via an arthroscopically assisted single tunnel technique. Fixation was primarily cortical suspension (endobutton) from the femora and bicortical fixation (Washer-loc) in the tibia. Patients were monitored for six months following surgery. Morbidity was defined as complications during this period requiring medical or surgical intervention. Risk of complications was compared according to tissue type and patient characteristics. The Cochran-Mantel-Haenszel method was applied to estimate risk ratios (RR) and confidence intervals (CI) as the measure of association between graft type and morbidity risk.

RESULTS

The cohort included 413 eligible patients. Sixty six percent received allograft tissue, while the remainder received autograft tissue. Morbidity risk was 7.0% among patients receiving allograft tissue and 2.8% among patients receiving autograft tissue. Allograft demonstrated elevated risk of complication versus autograft (RR=2.3 (95% CI: 0.9-7.2)), though the data are of borderline significance (p=0.11). Complications were associated with larger graft diameter in comparison to patients who experienced no complication (9.0+/-1.2 mm v. 8.4+/-1.0mm, p=0.005).

CONCLUSION

The relative morbidity risk was about two-fold greater among patients receiving allograft tissue. Regardless of tissue type, graft size was larger among patients who experienced a complication.

LEVEL OF EVIDENCE

Level III.

[Minimally invasive surgery versus conventional surgery. A review of the scientific evidence]

The concept that small incisions lead to a better outcome in many procedures has extended into most surgical areas, orthopaedic surgery among them. However, in some cases there is not enough scientific evidence to recommend these procedures. This article attempts to provide an updated review of the works published with sufficient scientific evidence on the advantages of minimally invasive surgery (MIS) compared to conventional access approaches. The published articles, meta-analyses and systematic literature reviews with level I or II evidence are reviewed in topographic order. Wherever possible, the information available on the costs-benefits of this type of surgery is also reviewed.

Biomechanics of the anterior cruciate ligament and implications for surgical reconstruction

Injury to the anterior cruciate ligament (ACL) is regarded as critical to the physiological kinematics of the femoral-tibial joint, its disruption eventually causing long-term functional impairment. Both the initial trauma and the pathologic motion pattern of the injured knee may result in primary degenerative lesions of the secondary stabilisers of the knee, each of which are associated with the early onset of osteoarthritis. Consequently, there is a wide consensus that young and active patients may profit from reconstructing the ACL. Several factors have been identified as significantly influencing the biomechanical characteristics and the functional outcome of an ACL reconstructed knee joint. These factors are: (1) individual choice of autologous graft material using either patellar tendon-bone grafts or quadrupled hamstring tendon grafts, (2) anatomical bone tunnel placement within the footprints of the native ACL, (3) adequate substitute tension after cyclic graft preconditioning, and (4) graft fixation close to the joint line using biodegradable graft fixation materials that provide an initial fixation strength exceeding those loads commonly expected during rehabilitation. Under observance of these factors, the literature encourages mid-to long-term clinical and functional outcomes after ACL reconstruction.

Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients

Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabilitation protocols have decreased the duration of hospitalization and subsequent length of recovery following elective total hip arthroplasty. We assessed the feasibility and safety of outpatient total hip arthroplasty in 150 consecutive patients. A comprehensive perioperative anesthesia and rehabilitation protocol including preoperative teaching, regional anesthesia, and preemptive oral analgesia and antiemetic therapy was implemented around a minimally invasive surgical technique. A rapid rehabilitation pathway was started immediately after surgery and patients had the option of being discharged to home the day of surgery if standard discharge criteria were met. All 150 patients were discharged to home the day of surgery, at which time 131 patients were able to walk without assistive devices. Thirty-eight patients required some additional intervention outside the pathway to resolve nausea, hypotension, or sedation prior to discharge. There were no readmissions for pain, nausea, or hypotension yet there was one readmission for fracture and nine emergency room evaluations in the three month perioperative period. This anesthetic and rehabilitation protocol allowed outpatient total hip arthroplasty to be routinely performed in these consecutive patients undergoing primary total hip arthroplasty. With current reimbursement approaches the modest savings to the hospital in length of stay may be outweighed by the additional costs of personnel, thereby making this outpatient system more expensive to implement.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Primary anterior cruciate ligament reconstruction using contralateral patellar tendon autograft

Primary ACL reconstruction using a contralateral patellar tendon autograft is an effective means of achieving symmetrical range of motion and strength after surgery. When the graft is harvested from the ipsilateral knee, the rehabilitation for the ACL graft and for the graft-donor site are different and have opposing goals. Rehabilitation for the ACL graft involves obtaining full range of motion, reducing swelling, and providing the appropriate stress to achieve graft maturation. Rehabilitation for the graft-donor site involves performing high-repetition strengthening exercises to regain size and strength, best achieved when begun immediately after surgery.

Evaluation of tibial bone-tunnel changes with X-ray and computed tomography after ACL reconstruction using a bone-patella tendon-bone autograft

Thirteen patients who underwent anterior cruciate ligament (ACL) reconstruction with bone-patella tendon-bone autografts (BTB) using interference screws were the subjects of this study. We analysed the relationship between bone-tunnel changes and clinical results 2 years after ACL reconstruction. To investigate changes, X-ray images were used to evaluate bone-tunnel enlargement, and computed tomography (CT) was used to evaluate the sclerotic area around the bone tunnel. The KT-2000 was used to measure the discrepancy of tibial anterior displacement between the affected and nonaffected sides (DTAD). There was no correlation between bone-tunnel enlargement and DTAD. On the other hand, in the CT evaluation, there was a significant correlation between the sclerotic area and DTAD. Our results suggest that it is more significant to analyse the area of sclerotic change than bone-tunnel enlargement for clinical evaluation. We cannot evaluate bone-tunnel changes correctly with two-dimensional X-rays and cannot analyse the sclerotic area using X-rays. Therefore, we recommend that CT, with which it is possible to analyse the sclerotic area, be used to evaluate bone-tunnel changes and clinical results.

Outpatient total knee arthroplasty with a minimally invasive technique

Fifty consecutive patients were enrolled in this prospective study. This was 37% of the 135 patients undergoing primary total knee arthroplasty (TKA) by one surgeon. The average patient age was 68 years (50-79 years). A comprehensive perioperative management pathway was developed and was implemented, which combined regional anesthesia with a minimally invasive, TKA technique in which the only incision in the capsule and extensor mechanism is a capsular incision from the joint line to the superior pole of the patella. Postoperatively, patients received oral analgesia. After specific discharge criteria were met, 48 patients (96%) chose to go home the day of surgery. No intraoperative complications occurred. There were 3 readmissions, none related to early discharge: gastrointestinal bleed at 8 days, superficial irrigation and debridement at 21 days, and a closed manipulation at 9 weeks. This study demonstrates that, in these selected patients, outpatient TKA was safe with no short-term readmission or complications related to early discharge. This comprehensive pathway may make it possible for this minimally invasive TKA to be done as an outpatient in specialized surgicenters in the future.

Vordere Kreuzbandplastik mit proximaler Endobutton-Fixation eines Lig.-patellae-Transplantats

BACKGROUND

Interference screw fixation in ACL reconstruction with bone-patellar tendon-bone graft (BPTB) is a potential source of intraoperative complications such as graft laceration. Further problems are artifacts on MRI and screw removal in revision surgery. These problems can be avoided by using distant fixation with the EndoButton. We designed this study to evaluate the clinical as well as the subjective outcome of ACL reconstruction with BPTB graft and femoral fixation with the EndoButton.

METHODS

A total of 51 patients (7 female, 44 male) were examined 2-5 years after ACL reconstruction with BPTB graft and femoral fixation with the EndoButton. We used the IKDC form, Lysholm score, Tegner activity score, and digital radiographs (AP, lateral, axial) for the evaluation.

RESULTS

Of all the patients included in the study, 87% showed a "normal" or "nearly normal" knee function according to the IKDC score, Lysholm score 94.2+/-7.9, Tegner score 6.4+/-1.2, and subjective IKDC 89.9+/-11.9. Radiological signs of arthritic changes could be seen in ten cases.

CONCLUSION

The clinical outcome of ACL reconstruction with EndoButton fixation is comparable to other studies on ACL reconstruction with interference screw fixation. However, since the EndoButton avoids potential problems of the interference screw fixation, we recommend this fixation technique for ACL reconstruction with BPTB graft.

Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty

To assess the potential recovery rate of a minimally invasive total hip replacement technique with minimal soft tissue disruption, an accelerated rehabilitation protocol was implemented with weightbearing as tolerated on the day of surgery. One hundred consecutive patients were enrolled in this prospective study. Ninety-seven patients (97%) met all the inpatient physical therapy goals required for discharge to home on the day of surgery; 100% of patients achieved these goals within 23 hours of surgery. Outpatient therapy was initiated in 9% of patients immediately, 62% of patients by 1 week, and all patients by 2 weeks. The mean time to discontinued use of crutches, discontinued use of narcotic pain medications, and resumed driving was 6 days postoperatively. The mean time to return to work was 8 days, discontinued use of any assistive device was 9 days, and resumption of all activities of daily living was 10 days. The mean time to walk (1/2) mile was 16 days. Furthermore, there were no readmissions, no dislocations, and no reoperations. Therefore, a rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty.

Patellar tendon autograft harvesting using a mini vertical incision

Patellar tendon autograft is a commonly used graft for anterior cruciate ligament reconstruction. Harvesting the patellar tendon graft typically entails using a longer incision than other graft options. We describe a technique for harvesting bone-patellar tendon-bone autograft using a smaller more cosmetic incision.

Current trends in anterior cruciate ligament reconstruction. Part II. Operative procedures and clinical correlations

Surgical management of the anterior cruciate ligament-deficient knee has evolved from primary repair to extracapsular augmentation to anterior cruciate ligament reconstruction using biologic tissue grafts. The technique of anterior cruciate ligament reconstruction has improved over the last few decades with the aid of knowledge gained from basic science and clinical research. The biology and biomechanics of anterior cruciate ligament reconstruction were analyzed in the previously published first part of this article. In this second part, current operative concepts of anterior cruciate ligament reconstruction as well as clinical correlations are discussed. The latest information regarding anterior cruciate ligament reconstruction is presented with a goal of demonstrating the correlation between the application of basic science knowledge and the improvement of clinical outcomes.

Current trends in anterior cruciate ligament reconstruction. Part 1: Biology and biomechanics of reconstruction

With today's increasing emphasis on sporting activities, the incidence of anterior cruciate ligament injuries has also increased. Epidemiologic studies estimate that the prevalence of anterior cruciate ligament injuries is about 1 per 3000 Americans. Management of these injuries has evolved from nonoperative treatment to extracapsular augmentation and primary ligament repair to anterior cruciate ligament reconstruction. Treatment of these injuries has significantly improved over the last few decades with the application of knowledge gained from both basic science and clinical research. This article is composed of two parts. The first part reviews the biology and biomechanics of the injured anterior cruciate ligament and the basic science of reconstruction. In the second part, to be published later, current operative concepts of reconstruction, as well as clinical correlations, are reviewed. Summarizing the latest information on basic scientific as well as clinical studies regarding the anterior cruciate ligament, this article intends to demonstrate the correlation between the application of basic science knowledge and improvement of clinical outcomes.

Comparison of arthroscopic one-incision and two-incision techniques for reconstruction of the anterior cruciate ligament

The purpose of this study was to assess the outcome of arthroscopic anterior cruciate ligament reconstruction performed using either the 'one-incision' technique or the rear-entry 'two-incision' technique. A series of 221 consecutive patients who underwent anterior cruciate ligament reconstruction was reviewed retrospectively. In the study population, two subgroups were defined. Group A consisted of 118 patients who underwent reconstruction using the one-incision transtibial endoscopic technique and Group B consisted of 103 patients who underwent reconstruction using the two-incision technique. The groups were comparable in terms of age, sex and activity level. The follow-up was performed after 47 (40-68) months in Group A and 55 (40-68) months in Group B. The Lysholm score at the final follow-up was significantly lower in Group A (90, 38-100) than in Group B (94, 34-100) (P = 0.002). The median KT-1000 total side-to-side difference was 1.5 (-6 to 7.5) mm in Group A, and 2.0 (-3.5 to 9) mm in Group B (n.s.). No significant difference between the groups was found when the IKDC evaluation system was used. Four intra-operative complications were registered in Group A and none in Group B (P = 0.06). No significant difference was found in terms of anterior knee pain, the one-leg-hop quotient or the activity level at the final follow-up. In this study the two methods gave similar and satisfactory results. Serious intraoperative complications were, however, recorded in four cases when the one-incision technique was used.

Single-incision endoscopic anterior cruciate ligament reconstruction using patellar tendon autograft. Minimum two-year follow-up evaluation

We conducted a retrospective, minimum 2-year follow-up study to evaluate the effectiveness of a single-incision endoscopic anterior cruciate ligament reconstruction technique using patellar tendon autograft without extraarticular augmentation and followed by accelerated rehabilitation. One hundred three patients were evaluated (mean followup, 36 months; range, 24 to 55). There were significant improvements in physical examination test results (Lachman, anterior drawer, and pivot shift) postoperatively, and 94 patients (91%) had negative pivot shift results. KT-1000 arthrometric testing showed a significant reduction in manual maximum anterior translation and side-to-side differences at followup. Good range of motion was achieved. Patients with asymmetric prone heel heights usually had hyperextension in the contralateral knee. Functional tests showed 4% to 6% differences in side-to-side comparisons for a timed single-legged hop, single-legged hop for distance, and vertical jump. Postoperatively, the results of the Tegner scale were similar to preinjury scores. The mean results of the Hospital for Special Surgery scale (90), Lysholm score (89), and Noyes sport function score (90) were all excellent or good. Only 5 patients (5%) required reoperations for flexion contractures. Ninety-six patients (93%) reported they were "mostly" or "completely" satisfied, and 98 (95%) would recommend the procedure to others. These results demonstrated encouraging outcome using this single-incision technique.

Arthroscopically assisted reconstruction of the anterior cruciate ligament: initial clinical experience and minimal 2-year follow-up comparing endoscopic transtibial and two-incision techniques

The purpose of this study was to determine the outcome of endoscopic Anterior Cruciate Ligament (ACL) reconstruction and assess whether this technique modification offers any significant advantages over arthroscopically assisted reconstruction. A consecutive series of 90 athletically-active patients (67 males, 23 females) who underwent reconstruction for ACL deficiency using a patellar tendon autograft was retrospectively reviewed. The study group consisted of two treatment subgroups: Group 1-EA (Endoscopic-Assisted technique using no lateral femoral condylar incision) consisted of 45 patients with a mean age of 25 years (range 15 to 43 and Group 2-AA (Arthroscopic-Assisted technique using both anterior and lateral femoral condylar incisions) consisted of 45 patients with a mean age of 25 years (range 16 to 37). The study groups were evaluated at specific postoperative intervals with a mean follow-up in Group 1-EA of 30 months (range 24-37) and in Group 2-AA, 41 months (range 24 to 77). Serial KT-1000 results averaged 2 mm in both groups with 75% of Group 1-EA and 78% in Group 2-AA patients noted to have < or = 3 mm side-to-side differences. No statistically significant differences were noted for complications including patellofemoral pain, arthrofibrosis, harvest site pathology, or painful hardware. At ultimate follow-up however, this study suggests that both methods may result in similar and reproducible satisfactory outcome.

Arthroscopic anterior cruciate ligament reconstruction

Significant advances in arthroscopic techniques have led to wide-spread performance of arthroscopically assisted ACL reconstruction. Properly performed reconstruction has proved to be successful clinically. The surgeon who undertakes ACL reconstruction must be familiar with techniques for both autograft hamstring augmentation and bone-patellar tendon-bone ACL reconstruction for the ACL-deficient knee. The arthroscopic techniques discussed in this article will allow successful treatment of most acute and chronic ACL injuries. Arthroscopic ACL reconstruction is a highly demanding procedure, with the possible risk of significant knee disability if the ACL graft is placed improperly. Proper patient selection, surgical technique, and postoperative rehabilitation remain the foundations for successful ACL reconstruction.

Pain after use of the central third of the patellar tendon for cruciate ligament reconstruction. 33 patients followed 2-3 years

We performed reconstruction of the anterior cruciate ligament in 33 patients using the central third of the patellar tendon. In 20 patients we did an arthroscopically-assisted procedure, while 13 patients had an additional mini-arthrotomy through the gap in the patellar tendon. After 2-3 years the subjective knee function, according to the Lysholm score, was excellent or good in 18 knees and fair or poor in 15 knees, mainly due to anterior knee pain. Although 18 patients complained about anterior knee pain, only 1 patient required further surgery. After the operation the patella had a lower position. A flexion contracture was found in 7 patients, and 13 had heterotopic bone formation at the apex of the patella. Although stability was restored in 31 of the 33 reconstructed knees, anterior knee pain was a frequent complication. There were no correlations between the anterior knee pain and patellar height, flexion contracture or heterotopic bone formation.