Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon

Difference of Knee Strength Recovery Between Revision and Primary ACL Reconstruction

Different grafting procedures are available to restore knee stability after revision anterior cruciate ligament (ACL) reconstruction. We compared knee strength recovery between ACL revision surgery and primary reconstruction. One hundred and ten patients with ACL revision surgery were matched with 110 patients with primary reconstruction based on the graft procedure. The isokinetic knee strength had been assessed for the first 9 months post-surgery. Knee laxity, function, and activity score were also evaluated. Limb symmetry index for knee extensor and flexor strength was not different at 4-, 6- and 9-months post-surgery between revision surgery and primary reconstruction. These results depended on ipsilateral or contralateral graft choice. Ipsilateral hamstring tendon (HT) and contralateral bone-patellar-tendon-bone (BPTB) graft procedures were similar for a revision of a BPTB graft failure. Contralateral HT procedure was better than ipsilateral BPTB procedure for a revision of a HT graft failure. The early recovery of isokinetic knee strength after ACL revision surgery regardless of the HT or BPTB procedures, was similar to the recovery after primary ACL reconstruction with the same graft technique. These results apparently depended on a temporary quadriceps arthrogenic muscle inhibition and on a persistent donor site morbidity, concerning the new and the previous grafts, respectively.

Contralateral grafts have comparable efficacy to ipsilateral grafts in anterior cruciate ligament reconstructions: a systematic review

PURPOSE

To perform a systematic review of the clinical outcomes of anterior cruciate ligament reconstruction using either contralateral or ipsilateral tendon autografts.

METHODS

A systematic review of literature published from inception to December 9, 2022, in multiple databases (PubMed, Embase, Scopus, and the Cochrane Library) was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews) guidelines. Two reviewers independently screened the literature, extracted the data, performed the risk of bias assessment and assessed the study quality. At least one of the following outcomes was evaluated for each study: muscle strength (isometric strength of the quadriceps or hamstring muscles, isokinetic peak flexion torque of the hamstring, or isokinetic peak extension torque of the hamstring), knee laxity examination, Lysholm score, pivot shift, International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lachman test result, return to sports time, or incidence of complications. A random effects model was used for all analyses.

RESULTS

Four hundred scientific manuscripts were recovered in the initial search. After screening, 12 studies (2 randomized controlled trials, 9 cohort studies, and 1 case- control study) met the search criteria for the qualitative analysis. Among them, 9 cohort studies were used for the quantitative analysis. The results showed few statistically significant differences in terms of muscle strength (contralateral group versus ipsilateral group or donor site group versus ipsilateral group or donor site group versus nonoperative group), Lysholm score, and return to sports time. A comparison showed no significant differences in knee laxity, IKDC score, Tegner activity score, Lachman test score, or incidence of complication, or contralateral rupture.

CONCLUSIONS

In anterior cruciate ligament reconstruction, the contralateral autologous tendon has a similar effect as the ipsilateral autologous tendon.

Range of Motion, Strength, and Function After ACL Reconstruction Using a Contralateral Patellar Tendon Graft

BACKGROUND

Regaining preinjury levels of activity and progressing rehabilitation factors after anterior cruciate ligament (ACL) reconstruction have shown mixed results.

PURPOSE

To evaluate the timing and rate of return for knee range of motion (ROM), stability, strength, and subjective scores after ACL reconstruction with contralateral patellar tendon graft (PTG).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Included were 2148 patients (1238 male patients, 910 female patients) who underwent primary ACL reconstruction with a contralateral PTG between 1995 and 2017 and had complete objective data through 3 months of follow-up. All patients participated in a rehabilitation program specific to goals for each knee. Patients were evaluated objectively with goniometric measurement of ROM, isokinetic quadriceps strength testing, and laxity with a KT-2000 arthrometer. Subjective data were collected at 2 and 5 years.

RESULTS

Normal extension on the reconstructed knee was attained for 95% of patients at 1 week postoperatively; normal flexion on the reconstructed knee was reached by 77% of patients by 3 months. At 3 months postoperatively, mean limb symmetry index strength was 104%, and the strength on the ACL-reconstructed and graft-donor knees was 87% and 86% of their respective preoperative strength. Mean manual maximum side-to-side difference in laxity was 2.0 mm at 1 month. Most patients (90%) returned to level 8 sports or higher and did so at an average of 5.7 months. Mean International Knee Documentation Committee scores for the ACL-reconstructed and graft-donor knees were 89 and 91 at 2 years (n = 1015 patients) and 84 and 90 at 5 years (n = 1275 patients), respectively. Mean Cincinnati Knee Rating Scale scores for the ACL-reconstructed and graft-donor knees were 92 and 96 at 2 years (n = 1184) and 88 and 94 at 5 years (n = 1236), respectively.

CONCLUSION

For patients who underwent ACL reconstruction with a contralateral PTG, postoperative ROM and strength were restored quickly by splitting the rehabilitation into different goals between the two knees. Using a contralateral PTG, this structured rehabilitation plan can lead to a relatively quick return to sport and good subjective long-term outcomes.

Is contralateral autogenous patellar tendon graft a better choice than ipsilateral for anterior cruciate ligament reconstruction in young sportsmen? A randomized controlled trial

AIM

The aim of this study was to compare the peak extensor torque (primary outcome), sensory-motor capacity and Lysholm questionnaire score up to the fourth postoperative month post-primary anterior cruciate ligament reconstruction (ACLR) with bone-patellar-tendon-bone (BPTB) graft using either ipsilateral or contralateral technique in young sportsmen.

METHODS

We performed a randomized controlled trial from 2018 to 2019. The same preoperative protocol, surgical technique and postoperative protocol were used in both groups. Eighty-eight young adult male patients were randomized, and 44 of each group completed the trial.

RESULTS

After the follow up analysis, the contralateral receptor and donor limb demonstrated a statistically significant increase in peak extension torque compared with the ipsilateral operated limb (effect size (ES) = 0.99, power = 0.99, P < 0.0001; ES = 0.46, power = 0.56, P < 0.04). The symmetry between limbs was compared between groups. In the contralateral group, there was a significant decrease in the recipient limb (after surgery), compared with the donor limb (before surgery) (ES = 0.87, power = 0.99, P < 0.0001). In the ipsilateral group, the operated limb demonstrated a significant decrease in peak extension torque compared with the non-operated limb after surgery (ES = 1.88, power = 0.99, P < 0.0001). The comparison between groups in sensory-motor capacity and Lysholm score demonstrated a non-significant group effect postoperatively.

CONCLUSION

The use of contralateral BPTB is more effective in increasing peak extension torque when compared with ipsilateral technique in young sportsmen. Furthermore, patients achieved greater symmetry (side to side) in quadriceps muscle performance after the 4-month follow up with a contralateral graft.

Complication after the reconstruction of the old patellar tendon rupture

Introduction. Chronic patellar tendon rupture (PTR) occurs rarely; its frequency and prevalence are unknown. There are very little data on the late patellar tendon reconstruction in rheumatoid arthritis and its complications. Case report. We presented a surgical repair of a PTR with early postoperative rupture of the contralateral patellar tendon for a 21-year-old woman with a past medical history of juvenile rheumatoid arthritis (treated with corticosteroids) who sustained initial injury 11 months prior to the presentation. The contralateral side was used for autograft harvesting. We used bone-tendon-bone (BTB) autograft and allografts followed by double-wire loop reinforcement and immediate postoperative mobilization. The patient was followed for 2 years, and the function of both knees was re-stored completely, with a full active range of motion. In this case, reconstruction of an 11-month-old chronic PTR (with complete resorption of the tendon and completely separated infrapatellar pads, complicated by the contralateral PTR) with BTB autograft and allografts and double wire loop reinforcement gave an excellent functional result. Two years after the surgical treatment, the extensor function of both knees was completely restored with a full range of movements. The patient reported satisfying outcomes and was able to return to all pre-injury activities without the assistance of orthopedic devices. Conclusion. This case report highlights the importance of the early diagnosis and describes operative techniques used in chronic PTR repair and treatments of the early postoperative complications such as rupture of the contralateral tendon.

Muscle strength after the anterior cruciate ligament reconstruction via contralateral bone-tendon-bone autograft

Purpose

The anterior cruciate ligament (ACL) reconstruction via a contralateral bone-tendon-bone (C-BTB) autograft was introduced to encourage early return to sports. The purpose of this study is to evaluate whether primary contralateral BTB ACL reconstruction can be adapted for early return-to-sports modification by investigating the chronological changes of muscle strength after surgery.

Methods

Fifteen patients who had underwent C-BTB ACL reconstruction were compared with a matched group of 15 patients of ipsilateral BTB (I-BTB) ACL reconstruction. The clinical outcomes of the time of return-to-sports, Tegner activity scale and the rate of second ACL injuries, the tibial anterior translation measurement, and knee extension and flexion muscle strength were assessed.

Results

Within 12 months after surgery, 14 of 15 patients from both groups returned to preinjury sports. The median time to return to sports after surgery was 6.5 months in the C-BTB group and 8.0 months in the I-BTB group (p = 0.021). No significant difference was noted with regard to the Tegner activity scale, reinjury rate or mean instrumental anterior tibial translation. The quadriceps muscle strength in the ACL-reconstructed knee compared with the opposite knee in both groups at 5 months after surgery was 120.6% in the C-BTB group and 70.0% in the I-BTB group (p < 0.001). However, the quadriceps muscle strength of the non-reconstructed limb, which instructed the graft harvested knee in the C-BTB and the intact knee in the I-BTB group, compared with that of the preoperative uninjured limb, was 74.5% in the C-BTB group and 118.7% in the I-BTB group (p = 0.0021) 5 months after surgery. Moreover, the quadriceps muscle strength of the reconstructed knee compared with the preoperative normal limb was 88.8% and 81.5% in the C-BTB and I-BTB groups, respectively (p = 0.38).

Conclusions

ACL reconstruction via the C-BTB autograft indicated better quadriceps muscle strength from early stage after surgery compared with I-BTB ACL reconstruction. However, the ostensible rapid symmetrical muscle strength recovery was attributed to strength deficits compared to the preoperative condition at the donor site limb and ACL-reconstructed limb.

Level of evidence

Level: Level: 4.

Tibial slope and medial meniscectomy significantly influence short-term knee laxity following ACL reconstruction

PURPOSE

To determine demographic, anatomic, and surgical factors associated with static and dynamic Anterior Tibial Translation (ATT) following ACL reconstruction. The hypothesis was that both static and dynamic ATT would be greater in knees with high tibial slope or that required meniscectomy.

METHODS

The authors prospectively enrolled 280 consecutive patients that had primary ACL reconstruction using hamstring autografts at one center for which preoperative tear type, meniscal tears, and medial tibial slope were documented. A total of 137 were excluded due to concomitant extra-articular tenodesis or surgical antecedents on either knee, and 18 were lost to follow-up, leaving 125 that were evaluated at a minimum of 6 months including: static ATT on monopodal weight-bearing radiographs, and dynamic ATT on differential stress radiographs using the Telos™ device.

RESULTS

Both postoperative static and dynamic ATT were strongly associated with preoperative static and dynamic ATT (respectively, β = 0.068 and β = 0.50, p < 0.001). Multivariable regression confirmed that postoperative static ATT increased with tibial slope (β = 0.24; CI 0.01-0.47; p = 0.042) and in knees that had partial medial meniscectomy (β = 2.05; CI 0.25-3.84; p = 0.025), while dynamic ATT decreased with age (β = - 0.11; CI - 0.16 to - 0.05; p < 0.001), and increased with tibial slope (β = 0.27; CI 0.04-0.49; p = 0.019) and in knees that had partial medial meniscectomy (β = 2.20; CI 0.35-4.05; p = 0.019).

CONCLUSION

Both static and dynamic ATT following ACL reconstruction increased with tibial slope and in knees that had partial medial meniscectomy. These findings could help surgeons tailor their techniques and 'à la carte' rehabilitation protocols, by preserving the menisci and sometimes delaying full weight-bearing and return to sport in patients at risk, and hence improve outcomes and prevent graft failures.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

V.

Effect of Physical Therapy Visits on Clinical Outcomes Following Anterior Cruciate Ligament Reconstruction With and Without Concurrent Meniscal Repair

BACKGROUND

Health care payment reform has increased employers and health insurance companies' incentive to take measures to control the rising costs of medical care in the United States. To date, limited research has investigated the influence outpatient physical therapy (PT) visits have on clinical outcomes following anterior cruciate ligament reconstruction (ACLR) with and without a concurrent meniscal repair.

OBJECTIVE

To examine the relationship between the number of PT visits and patient-reported outcome scores following ACLR outpatient rehabilitation.

STUDY DESIGN

Retrospective cohort.

LEVEL OF EVIDENCE

2b.

METHODS

Patients following ACLR with (n = 62) and without (n = 328) meniscal repair were identified through an electronic medical record database.

RESULTS

Patients with more PT visits had higher knee outcome survey-activities of daily living (KOS-ADL) change scores (P = .01) following ACLR without meniscal repair. Younger patients yielded significantly higher KOS-ADL change scores (P = .05) in the same cohort. Patients in the semisupervised PT visit strata recorded an 11.1 higher KOS-ADL change score compared with patients within the unsupervised PT visit stratum (P = .02). Younger patients also yielded significantly larger reductions in numeric pain (P = .01) following ACLR without meniscal repair. No significant differences were found between PT visits and either patient-reported outcome following ACLR with meniscal repair.

CONCLUSIONS

Our findings suggest that younger patients and those in a semisupervised PT visit model have superior patient-reported outcomes following ACLR without meniscal repair. Preliminary findings indicate no relationship with PT visits and patient-reported outcomes in patients after ACLR with meniscal repair surgery.

CLINICAL RELEVANCE

These findings promote an alternative model to outpatient PT following ACLR without meniscal repair that may be more clinically effective and value based. There appears to be a need for patients to undergo a balanced regimen of supervised PT and effective interventions that can be conducted independently.

CONTRALATERAL PATELLAR TENDON AUTOGRAFT IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

OBJECTIVE

To conduct a systematic review of literature about the use of contralateral patellar tendon autograft in anterior cruciate ligament reconstructions and present the results.

METHODS

The LILACS, MEDLINE, Cochrane, PubMed, Scielo and Google Scholar databases were searched without date restrictions for the keywords "anterior cruciate ligament reconstruction" combined with "contralateral" in the article title. After the studies were identified, two independent evaluators collected the qualitative characteristics of the studies and classified them according to clinical outcomes of these grafts as positive, neutral, or negative.

RESULTS

A total of 755 articles were found initially, and after detailed evaluation of all references, followed by a screening process and assessment of quality, a total of 11 studies were determined to be eligible for inclusion in this systematic review. Of these, 72.72% were level II studies, the most common level of evidence among the results. Positive results for this type of graft were found in 63.63% of the studies.

CONCLUSION

Based on the literature review, most of the included articles (63.63%) presented positive results for the use of contralateral patellar tendon grafts. Level of Evidence III; Systematic review.

Chronicity of Anterior Cruciate Ligament Deficiency, Part 2: Radiographic Predictors of Early Graft Failure

BACKGROUND

Accumulating evidence suggests that long-term anterior cruciate ligament (ACL) deficiency can give rise to an abnormal tibiofemoral relationship and subsequent intra-articular lesions. However, the effects of chronic ACL deficiency (ACLD) on early graft failure after anatomic reconstruction remain unclear.

HYPOTHESIS

We hypothesized that patients with long-term ACLD lasting more than 5 years would have a greater rate of early graft failure due to insufficient intraoperative reduction of the tibia and that the preoperative and immediately postoperative abnormal tibiofemoral relationship in the sagittal plane, such as anterior tibial subluxation (ATS), would correlate with the graft status on postoperative magnetic resonance imaging (MRI).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 358 patients who had undergone anatomic ACL reconstruction with hamstring grafts were divided into 5 groups based on chronicity of ACLD: (1) 0 to 6 months, (2) 6 months to 1 year, (3) 1 to 2 years, (4) 2 to 5 years, and (5) longer than 5 years. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken in all patients to evaluate the tibiofemoral relationship, specifically with regard to ATS, space for the ACL (sACL), and extension angle. All patients underwent MRI at 6 months to reveal graft status. Groups with a high rate of graft failure were further analyzed to compare demographic and radiographic factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors.

RESULTS

Graft failure without trauma was observed in 4 (1.8%), 0 (0%), 1 (3.7%), 3 (9.7%), and 8 patients (17.7%) in groups 1, 2, 3, 4, and 5, respectively. Of the 76 patients in groups 4 and 5, significant differences were noted between the failure and intact subgroups in preoperative ATS (4.9 vs 2.4 mm, respectively; P < .01), side-to-side differences in sACL (sACL-SSD) (4.7 vs 1.9 mm, respectively; P < .01), extension deficit (4.4° vs 1.3°, respectively; P < .01), and chondral lesions (P = .02), while postoperative ATS and sACL-SSD showed no differences. Multivariate logistic regression analysis revealed that of these factors, preoperative sACL-SSD could be a risk factor for early graft failure (odds ratio, 3.2; 95% CI, 1.37-7.46).

CONCLUSION

Early graft failure at 6 months increased in patients with ACLD longer than 2 years. In this population, preoperative sACL-SSD was the most significant risk factor for early graft failure on MRI. However, immediately postoperative radiographic measurements had no effect on graft failure rates.

Reconstruction of chronic patellar tendon rupture with contralateral bone-tendon-bone autograft

PURPOSE

To evaluate the clinical and functional outcome following the reconstruction of chronic patellar tendon ruptures using the contralateral bone-tendon-bone (BTB) autograft.

METHODS

The records of seven patients who underwent reconstruction of chronic patellar tendon rupture with contralateral patellar BTB were retrospectively reviewed. Chronic tears were defined as a minimum of 3 months from injury to initial clinical evaluation. Clinical assessments included range of motion of the knee, Tegner, Lysholm and International Knee Documentation Committee (IKDC) score and a radiographic analysis of patellar height (Caton-Deschamps index). Postoperative complications and quadriceps strength at last follow-up were reported.

RESULTS

The mean age of the patients undergoing surgery was 33 (±10.5) years with a mean follow-up of 41.3 (±29.7) months. Reconstruction surgery was performed at an average of 16 months (3-60 months) after the injury. 86 % of the patients had a normal patella height with mean of patellar height of 1.5 (±0.2) in preoperative radiographs and of 1.2 (±0.07) on postoperative evaluation (p = 0.0136). The mean IKDC was 45.5 (±10.8) before surgery and 64.5 (±12.4) at the last follow-up (p = 0.0001), and Lysholm score was 45.4 (±11.3) and 79 (±11.8), respectively (p = 0.0001). The median Tegner activity scale preinjury was 6 (range 5-7), preoperatively was 1 (range 1-2) and 4 (range 2-5) postoperatively (p = 0.0001). All patients had quadriceps wasting with a difference in thigh girth between the injured side and healthy side of 3.6 ± 0.7 cm (ns). No surgical complications were encountered.

CONCLUSIONS

In this limited cohort, surgical reconstruction of chronic patellar tendon ruptures using contralateral bone-tendon-bone graft was a safe and viable option that improves clinical and functional outcomes compared to presurgical function. However, despite the restoration of a normal patellar height, function did not return to preinjury level.

Return to Play and Player Performance After Anterior Cruciate Ligament Injury in Elite Australian Rules Football Players

Background:

Australian Rules football is a highly aerobic and anaerobic game that at times requires players to perform cutting or pivoting maneuvers, potentially exposing them to anterior cruciate ligament (ACL) injury. At present, there are limited data available addressing the impact of ACL injury on return to play and preinjury form after ACL reconstruction.

Purpose:

To determine the prevalence of ACL injury and the incidence of further ACL injury, and to consider player return to play and return to preinjury form after ACL reconstruction. It was hypothesized that elite-level Australian Football League (AFL) players do not return to preinjury form until, at minimum, 2 years after returning to play.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective analysis was undertaken on a cohort of elite AFL players who injured their ACL between 1990 and 2000. Return to play after ACL reconstruction was determined by the mean number of ball disposals, or release of the ball by the hand or foot, at 1, 2, and 3 years after return to play and compared with preinjury form. Associations between player and injury characteristics, method of reconstruction, and outcomes (return to play, preinjury form, and further ACL injury) were examined.

Results:

During the included seasons, a total of 2723 AFL players were listed. Of these, 131 (4.8%) sustained an ACL injury, with 115 players eligible for inclusion. Of 115 players, 26% did not return to elite competition, while 28% of those who did return experienced further ACL injury. The adjusted mean number of disposals (± standard error of the mean) was significantly lower at 1 year (12.21 ± 0.63; P = .003), 2 years (12.09 ± 0.65; P = .008), and 3 years (11.78 ± 0.77; P = .01) after return to play compared with preinjury (14.23 ± 0.67). On average, players did not return to preinjury form by 3 years (P < .01). Players aged 30 years or older were less likely to return to play compared with younger players (P = .0002), moderate-weight players were more likely to return to play compared with lighter-weight players (P = .007), and there were significantly increased odds of not returning to play if the dominant side was injured (odds ratio, 0.10; 95% CI, 0.03-0.34; P = .0002).

Conclusion:

On average, AFL players do not return to their preinjury form after ACL injury and reconstruction, a common injury in this sporting population. This along with the high occurrence of reinjury highlights the career-threatening nature of ACL injury for elite AFL players.

Timing of anterior cruciate ligament reconstruction within the first year after trauma and its influence on treatment of cartilage and meniscus pathology

PURPOSE

Anterior cruciate ligament (ACL) ruptures are often associated with primary meniscal and cartilage lesions. Late reconstruction of ACL-deficient knees may increase the risk of developing secondary meniscal and cartilage lesions; hence, the timing of ACL repair is of the utmost importance. Because meniscus outcome is also a potential predictor for osteoarthritis (OA), this study compared ACL repair within the first 6 months after injury to that of surgery conducted 7-12 months after injury with regard to the incidence of meniscal and cartilage lesions.

METHODS

This prospective cross-sectional study included all complete isolated primary ACL ruptures treated in our institution within 1 year after trauma over a 12-month period. Exclusion criteria were revision ACL, complex ligament injuries, previous knee surgery, and missing injury data. Cartilage lesions were classified according to the score established by the International Cartilage Repair Society (ICRS score) and meniscal tears according to their treatment options.

RESULTS

Two hundred and thirty-three of 730 patients (162 men, 71 women) with ACL repair met the inclusion criteria. 86.3 % of surgical interventions were conducted within 6 months and 13.7 % after 6 months of trauma. Severe cartilage lesions grade III-IV did not significantly differ between the different time points of ACL repair (<6 months 39.9 %; >6 months 31.3 %; p = n.s.). Medial meniscus lesions received significantly higher meniscal repair in early compared to delayed ACL repair. Significantly higher rate of meniscal repair of the medial meniscus was seen in cases of early ACL repair compared to delayed (<6 months 77.2 %, >6 months 46.7; p = 0.022). The rate of medial meniscal repair in early ACL repair was significantly higher for women (89.5-0 %; p = 0.002), however, not for men (73.3-53.8 %; p = n.s.). No differences were found for lateral meniscal lesions, with regard to neither the different time points (p = n.s.) nor the sex (p = n.s.).

CONCLUSIONS

Because of the significantly higher rate of prognostically advantageous meniscal repair, the recommendation for an ACL reconstruction within 6 months after trauma was made to preserve the meniscus and reduce the risk of developing OA.

LEVEL OF EVIDENCE

Prospective cross-sectional cohort study, Level II.

Does meniscal pathology alter gait knee biomechanics and strength post-ACL reconstruction?

PURPOSE

Individuals following anterior cruciate ligament reconstruction (ACLR) with concomitant meniscal pathology have a higher risk of developing knee osteoarthritis (OA) compared to those with isolated ACLR. Knee extensor weakness and altered dynamic knee joint biomechanics have been suggested to play a role in the development of knee OA following ACLR. This study investigated whether these factors differ in people following ACLR who have concomitant meniscal pathology compared to patients with isolated ACLR.

METHODS

Thirty-three patients with isolated ACLR and 34 patients with ACLR and meniscal pathology underwent strength and gait assessment 12-24 months post-operatively. Primary measures were peak isometric knee extensor torque and knee adduction moment (peak and impulse). Secondary measures included peak knee flexion moment and knee kinematics (sagittal and transverse).

RESULTS

There were no between-group differences in knee extensor strength [mean difference (95 % CI) 0.09 (-0.23 to 0.42) Nm/kg, n.s.], peak knee adduction moment [-0.02 (-0.54 to 0.49) Nm/(BW × HT) %, n.s.] or knee adduction moment impulse [0.01 (-0.15 to 0.17) Nm/(BW × HT) %, p = n.s.]. No between-group differences were found for any secondary measures.

CONCLUSIONS

No evidence was found to suggest that the higher prevalence of OA in patients with ACLR and meniscal pathology compared to patients with isolated ACLR is attributed to reduced knee muscle strength or altered knee joint biomechanics assessed 1-2 years post-surgery. Given that there is a higher incidence of knee OA in patients with concomitant meniscal pathology and ACLR, further investigation is needed so that population-specific rehabilitation protocols can be developed.

LEVEL OF EVIDENCE

III.

Reconstruction of chronic patellar tendon rupture using graft from contralateral patella graft together with reinforcement from flexor tendons. Case report

Chronic patellar tendon rupture is a rare disabling injury that is technically difficult to repair. The true prevalence of this injury is unknown. Delayed reconstruction of chronic patellar tendon rupture has yielded suboptimal clinical and functional results. Many different surgical methods for reconstruction of chronic patellar tendon injury have been reported. In this report, we present a case with chronic patellar tendon injury that was addressed using a technique that had not previously been described in the literature, through combining procedures that had been described separately. The reconstruction method presented in this article has the advantages of being easy and reproducible, without a requirement of allografts.

Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction

PURPOSE

The aim of this study was to evaluate the incidence of failure of anterior cruciate ligament (ACL) reconstruction and to assess the prognostic factors for such an outcome.

METHODS

A prospective inception cohort of patients undergoing ACL reconstruction was analysed for failure (patient reported symptoms of rotational instability, a clinically positive pivot shift, MRI or arthroscopy showing ACL graft rupture). Risk factors evaluated included medial and lateral meniscal deficiency, medial and lateral meniscal repair, age, gender, BMI, graft size and time to surgery. Survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed using the Cox proportional hazard model to investigate whether covariate risk factors influenced graft survival.

RESULTS

One hundred and twenty-three patients were available for final analysis at a follow-up of 2 years. Eighteen patients satisfied the criteria of failure (15.4 %). Risk factors for failure were medial meniscal deficiency (hazard ratio 4.5; 95 % CI 1.8-11.5; p = 0.002), or lateral meniscal deficiency (hazard ratio 3.5; 95 % CI 1.3-9.3; p = 0.01). At 2-year follow-up, ACL survival was 94.5 % (95 % CI 89-100) for patients with intact menisci and 69 % (95 % CI 56-86) for those with deficiency of the medial or lateral meniscus (log-rank test p = 0.017). Patients were 4.9 times more likely to fail if they had a deficient medial or lateral meniscus. Those patients who underwent meniscal repair did not demonstrate any increased risk of failure.

CONCLUSION

Medial and lateral meniscal tears are important prognostic factors that influence the survival of ACL reconstruction. Surgeons should endeavour to repair all meniscal tears associated with ACL reconstruction.

LEVEL OF EVIDENCE

II.

Long-term outcomes of medial CMI implant versus partial medial meniscectomy in patients with concomitant ACL reconstruction

PURPOSE

To compare the clinical, objective and radiographic long-term results of patients with anterior cruciate ligament (ACL) lesion and partial medial meniscus defects, treated with ACL reconstruction and partial medial meniscectomy or medial CMI implant.

METHODS

Seventeen patients treated with combined ACL reconstruction and medial CMI and 17 patients treated with ACL reconstruction and partial medial meniscectomy were evaluated with mean follow-up 9.6 years with Lysholm, Tegner, objective and subjective International Knee Documentation Committee scores, and VAS for pain. Arthrometric evaluation was performed with KT 2000. Weigh-bearing radiographs, antero-posterior and Rosenberg view, were also performed and evaluated with Kellgren-Lawrence score, Ahlback score and joint space narrowing.

RESULTS

Pre-operative demographic parameters and clinical scores between patients treated with CMI and partial medial meniscectomy revealed no significant differences. A significant improvement of all the clinical scores was detected in both groups from pre-operative status to final follow-up. No significant difference between groups were found for clinical and radiographic scores; however, the chronic subgroup of patients treated with CMI showed a significantly lower level of post-operative knee pain compared to patients treated with partial medial meniscectomy and the acute subgroup of medial CMI showed better arthrometric scores.

CONCLUSION

Good long-term clinical results in terms of stability, subjective outcomes and objective evaluation were reported both for medial CMI implant and partial medial meniscectomy, combined with ACL reconstruction for the treatment of partial medial meniscus tears combined with ACL lesions. Chronic meniscal tears treated with medial CMI reported lower levels of post-operative pain compared to meniscectomy, while acute lesions treated with medial CMI showed less knee laxity. Therefore, the use of the collagen meniscus implant in the case of anterior knee instability with a meniscal defect appears justified and able to improve clinical outcomes in the long term.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Impaired Quadriceps Rate of Torque Development and Knee Mechanics After Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft

BACKGROUND

Rate of torque development (RTD) measures the ability of a muscle to produce torque quickly. Decreased quadriceps RTD may impair performance of sporting tasks after surgery. Currently, little is known about variations in quadriceps RTD between anterior cruciate ligament (ACL)-reconstructed and noninjured limbs.

PURPOSE

To determine the differences in RTD of the quadriceps, the rate and timing of knee extensor moment (KEM) development, and knee flexion excursion during running after ACL reconstruction with patellar tendon autograft.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

This study involved 21 patients (11 female) 6 months after ACL reconstruction with patellar tendon autograft (median [IQR]: age, 18 [16-20] years; mass, 68.18 [61.34-75] kg; height, 1.74 [1.66-1.78] m). Patients performed four 5-second maximal voluntary isometric strength trials of both limbs on an isokinetic dynamometer. RTD was calculated as the mean slope of the torque-time curve between 20% and 80% of total time to peak torque. Then, patients underwent 3-dimensional motion analysis while running on an instrumented treadmill at a self-selected running speed (mean ± SD, 2.68 ± 0.28 m/s). The rate of knee extensor moment (RKEM) was calculated as the mean slope of the moment curve between 10% and 30% of stance phase. Between-limb comparisons were determined with a paired t test for peak KEM, RKEM, knee flexion excursion during 10% to 30% of stance, and time to generate KEM.

RESULTS

In the reconstructed limb, deficits in the peak rate of quadriceps torque development compared with the noninjured limb existed both isometrically (RTD, 257.56 vs 569.11 Nm/s; P < .001) and dynamically (RKEM, 16.47 vs 22.38 Nm/kg·m·s; P < .001). The reconstructed limb also generated a KEM later in the stance phase compared with the noninjured limb (11.37% vs 9.61% stance; P < .001) and underwent less knee flexion excursion (15.5° vs 19.8°; P < .001).

CONCLUSION

After ACL reconstruction with patellar tendon autograft, patients have lower RTD and RKEM in the reconstructed limb. Deviations in RTD and the timing of the KEM can change the way the knee is loaded and can potentially increase injury risk and future development of posttraumatic osteoarthritis. Rehabilitation should consider exercises designed to improve RTD and prepare the limb for the demands of sport performance.

Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery

CONTEXT

A recently updated meta-analysis of return-to-sport rates after anterior cruciate ligament (ACL) reconstruction demonstrated that 65% of athletes returned to their preinjury level of sport after surgery. The aim of this clinical review was to explore contextual factors associated with returning or not returning to the preinjury level after ACL reconstruction.

EVIDENCE ACQUISITION

Data were obtained from peer-reviewed literature via a search of the electronic databases Medline, Embase, CINAHL, and SPORTDiscus from database inception to January 2015. The keywords anterior cruciate ligament and return to sport were used. Additional literature was identified via hand-searching of the reference lists of relevant articles and the ePublication lists of key scientific journals. Random effects meta-analyses were used to pool the results of modifiable contextual factors and to examine their association with returning or not returning to the preinjury level of sport after surgery.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 2.

RESULTS

Lower fear of reinjury (standardized mean difference, 0.7), greater psychological readiness to return to sport (standardized mean difference, 1.0), and a more positive subjective assessment of knee function (standardized mean difference, 0.9) favored return to the preinjury level after surgery.

CONCLUSION

Returning or not returning to the preinjury level after ACL reconstruction is complex and multifactorial. Screening for potentially modifiable contextual factors, particularly psychological factors, early after ACL injury may help clinicians identify athletes who could be at risk of not returning to the preinjury level of sport and institute interventions that could improve returning to sport.

Anterior cruciate ligament reconstruction with contralateral autogenous patellar tendon graft: evaluation of donor site strength and subjective results

BACKGROUND

Few surgeons use a contralateral patellar tendon autograft for primary anterior cruciate ligament (ACL) reconstruction because of concern for donor site morbidity.

HYPOTHESIS

There will be no difference in quadriceps muscle strength or International Knee Documentation Committee (IKDC) subjective scores in patients with contralateral grafts compared with patients with ipsilateral grafts.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2007 and 2009, a total of 279 patients who underwent primary ACL reconstruction with autogenous patellar tendon graft from the contralateral knee met the inclusion criteria of unilateral knee involvement, no arthritic changes preoperatively, and minimum 2-year follow-up objective and subjective evaluations. A control group was obtained of 58 patients who had the same inclusion criteria and were of the same age but who underwent surgery with ipsilateral graft. Patients underwent a goal-directed and sequential postoperative rehabilitation program that first emphasized controlling a hemarthrosis and obtaining full knee range of motion immediately after surgery, followed by increasing leg strength and performing functional activities. The rehabilitation for the contralateral donor site emphasized high-repetition/low-resistance exercises beginning the day after surgery. The IKDC subjective data were compared between surgery groups. Quadriceps muscle strength was evaluated in both knees compared with the preoperative values obtained in the noninvolved knee and between knees at 2 years postoperatively.

RESULTS

Quadriceps muscle strength compared with the preoperative normal value (mean ± SD) was 105% ± 29% in the ipsilateral ACL-reconstructed knee versus 114% ± 28.4% in the contralateral donor knee (P < .01) and 116% ± 25% in the contralateral ACL-reconstructed knee (P = .0339). Mean side-to-side strength (ACL-reconstructed knee/opposite knee) was 98.4% ± 13.6% in the contralateral group versus 92.9% ± 13.0% in the ipsilateral group (P < .01). The mean total IKDC score was 92.4 ± 9.6 for the contralateral donor knee. The mean IKDC total score for the ACL-reconstructed knee was 88.8 ± 12.3 in the contralateral group and 88.9 ± 11.2 in the ipsilateral group (P = .626).

CONCLUSION

After ACL reconstruction with contralateral patellar tendon graft, patients can achieve strength symmetry between legs after surgery without experiencing adverse subjective symptoms after graft harvest. Furthermore, strength return can be superior with a contralateral graft than with an ipsilateral graft.

Ipsilateral versus contralateral hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized trial

BACKGROUND

Benefits of graft harvest from the side contralateral to the anterior cruciate ligament (ACL)-deficient leg have been identified when using bone-patellar tendon-bone autografts in ACL reconstruction (ACLR). As hamstring tendon autografts are becoming more commonly used, a study examining the effect of contralateral graft harvest of semitendinosus gracilis (STG) tendons on patient quality of life was conducted.

PURPOSE

To evaluate if ACLR using a hamstring tendon autograft results in better patient quality of life if the graft is harvested from the leg contralateral to the ACL rupture compared with the ipsilateral leg.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 100 participants between 16 and 50 years of age with a complete ACL tear were randomly assigned to undergo ACLR using either the ipsilateral or contralateral leg as the STG graft donor. Primary outcome measures were the ACL Quality of Life questionnaire (ACL-QOL), concentric knee flexion and extension strength at 60 and 240 deg/s, International Knee Documentation Committee (IKDC) knee assessment form, early postoperative pain and diary of analgesic use, and rate of reruptures. Outcome measures were evaluated before surgery and at 3, 6, 12, and 24 months after surgery.

RESULTS

The ACL-QOL score improved over time for both groups (P < .001), and there were no significant differences between groups at any time point (P = .528). Significant differences in knee flexion and extension strength were found at 3 months after surgery. There were no differences between groups in IKDC knee assessment scores or rerupture rates.

CONCLUSION

There does not appear to be any measurable benefit or drawback in quality of life to the use of an STG graft from the unaffected limb. In light of this finding, further research to examine other possible effects on agility and balance as well as time and ability to return to sport should be conducted. Longer term follow-up beyond 2 years would allow for a more thorough evaluation of the risk of reruptures or contralateral reruptures using this novel approach.

Return to basketball and soccer after anterior cruciate ligament reconstruction in competitive school-aged athletes

BACKGROUND

Little is known about the return to sports after anterior cruciate ligament reconstruction and whether sex differences exist regarding the level and timing at which athletes return.

HYPOTHESES

Compared to school-aged girls, boys return to full sports earlier and at a higher frequency after surgery (1). Athletes who return to sports earlier will not have a higher incidence of subsequent injury to either knee after surgery (2).

STUDY DESIGN

Cohort.

METHODS

The patient population comprised 413 consecutive school-aged athletes who were injured while competing in basketball or soccer. Patients were enrolled prospectively, and activity levels were obtained through follow-up visits, surveys, phone calls, and e-mail.

RESULTS

Follow-up was obtained for 402 patients (basketball: 58 boys, 242 girls; soccer: 25 boys, 77 girls). Eighty-seven percent of girls and boys returned to high school basketball after surgery: the mean time to return to full participation in basketball was 5.2 ± 2.1 months for girls and 5.3 ± 2.2 months for boys (P = .92). Similarly, 93% of girls and 80% of boys returned to compete in high school soccer after surgery (P = .13); the mean time to return to full participation in soccer was 5.1 ± 1.9 months for girls and 5.1 ± 2.0 for boys (P = 1.00). About 20% of athletes went on to compete in their sport in college. The time of return to sports was not a statistically significant factor for the incidence of subsequent anterior cruciate ligament injury.

CONCLUSION

Of 402 athletes competing in basketball and soccer, women and men returned at the same rate and same level of sport after surgery. Athletes who returned to sports at earlier times after surgery did not have a higher incidence of subsequent anterior cruciate ligament injury than patients who returned at later times.

Femoral press-fit fixation in ACL reconstruction using bone-patellar tendon-bone autograft: results at 15 years follow-up

Background

If anterior cruciate ligament (ACL) reconstruction is to be performed, decision regarding graft choice and its fixation remains one of the most controversial. Multiple techniques for ACL reconstruction are available. To avoid disadvantages related to fixation devices, a hardware-free, press-fit ACL reconstruction technique was developed.

The aim of this study was to evaluate clinical outcome and osteoarthritis progression in long term after ACL reconstruction with central third patellar-tendon autograft fixed to femur by press-fit technique.

Methods

Fifty two patients met inclusion/excusion criteria for this study. The patients were assessed preoperatively and at 15 years after surgery with International Knee Documentation Committee Knee Ligament Evaluation Form, Lysholm knee score, Tegner activity scale and radiographs.

Results

Good overall clinical outcomes and self-reported assessments were documented, and remained good at 15 years. The mean Lysholm and Tegner scores improved from 59.7 ± 18.5 and 4.2 ± 1.0 preoperatively to 86.4 ± 5.6 (p = 0.004) and 6.9 ± 1.4 (p = 0.005) respectively at follow-up. The IKDC subjective score improved from 60.1 ± 9.2 to 80.2 ± 8.1 (p = 0.003).

According to IKDC objective score, 75% of patients had normal or nearly normal knee joints at follow-up. Grade 0 or 1 results were seen in 85% of patients on laxity testing. Degenerative changes were found in 67% of patients. There was no correlation between arthritic changes and stability of knee and subjective evaluation (p > 0.05).

Conclusions

ACL reconstruction with patellar tendon autograft fixed to femur with press-fit technique allows to achieve good self-reported assessments and clinical ligament evaluation up to 15 years. Advantages of the bone-patellar-tendon-bone (BPTB) press-fit fixation include unlimited bone-to-bone healing, cost effectiveness, avoidance of disadvantages associated with hardware, and ease for revision surgery. BPTB femoral press-fit fixation technique can be safely applied in clinical practice and enables patients to return to preinjury activities including high-risk sports.

Anterior cruciate ligament tears: conservative or surgical treatment? A critical review of the literature

PURPOSE

Is it rational to recommend surgical reconstruction of the torn anterior cruciate ligament to every patient? Is conservative management still a valid option?

METHOD

Through a literature review, we looked for the arguments from each side and checked their validity.

RESULTS

Unfortunately results of most studies cannot be compared because of the following reasons not exhaustively cited: studied populations differed with respect to age, sex, professional and sports activity level, lesions associated with ACL rupture, patient recruitment methods, time from injury to treatment and different therapeutic modalities. Furthermore, various methods were used to evaluate the clinical and radiological results and there was no consensus of their interpretation. Some authors assumed that the incidence of further meniscus lesions could probably be reduced if the torn ACL was surgically reconstructed. But, we have no evidence to believe that this would be due to the surgical repair rather than to a decrease of involvement in strenuous activities. At present it is not demonstrated that ACL-plasty can prevent osteoarthritis. Numerous factors could explain evolution to arthrosis whatever the treatment for the ACL-ruptured knee. Studies comparing surgical and conservative treatments confirm that ACL reconstruction is not the pre-requisite for returning to sporting activities. More recent and scientifically well-designed studies demonstrate that conservative treatment could give satisfactory results for many patients. They suggest some methods to help them choose the best treatment.

CONCLUSION

At present there are no evidence-based arguments to recommend a systematic surgical reconstruction to any patient who tore his ACL. Knee stability can be improved not only by surgery but also by neuromuscular rehabilitation. Whatever the treatment, fully normal knee kinematics are not restored. While the patients wish to go back to their sport and want everything possible done to prolong their ability to perform these activities, they should be informed that the risk of further knee lesions and osteoarthritis remains high, whatever the treatment, surgical or conservative.

LEVEL OF EVIDENCE

Systematic review of Level I, II, III and IV studies, Level IV.

Infections and patellar tendon ruptures after anterior cruciate ligament reconstruction: a comparison of ipsilateral and contralateral patellar tendon autografts

BACKGROUND

No studies document the incidence or results of infections and patellar tendon ruptures after anterior cruciate ligament reconstruction with a contralateral patellar tendon autograft.

PURPOSE

To determine the results of patients who have infections and patellar tendon ruptures after anterior cruciate ligament reconstruction with a patellar tendon autograft and compare the results between ipsilateral and contralateral grafts.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors determined the incidence of infections requiring surgical intervention and complete patellar tendon ruptures after surgery. Data were analyzed in 2 groups based on the graft source: ipsilateral (n = 2553) or contralateral (n = 2811). Data reviewed included range of motion, quadriceps strength, and subjective evaluations.

RESULTS

Infections occurred in 9 ipsilateral patients (0.35%) and 4 contralateral patients (0.14%) (P = .12). At final follow-up, less than normal knee extension was found in 4 ipsilateral patients and 1 contralateral patient; less than normal flexion was found in 4 ipsilateral patients and 2 contralateral patients. Patellar tendon ruptures occurred in 6 ipsilateral patients (0.24%) and 7 contralateral patients (0.25%) (P = .92). At 1 month after patellar tendon repair, mean motion (degree of hyperextension-degree short of 0° extension-degree of flexion) in the contralateral group was 5-0-137 in the reconstructed knee and 5-0-118 in the graft-donor knee, which was greater than 5-0-98 found in the ipsilateral group for the reconstructed knee (P < .05). The mean Noyes subjective score at a mean of 4 years postoperatively for the tendon-ruptured knee was 87 points in the ipsilateral group and 93 points in the contralateral group (P = .32), which is comparable with the published normative data for the Noyes score reporting a mean score of 93.6 ± 8.3 points.

CONCLUSION

There were no significant differences in the incidence of infection or patellar tendon rupture between the ipsilateral and contralateral groups. Patients with complications after anterior cruciate ligament reconstruction with a patellar tendon autograft may have less difficulty obtaining full knee motion when the graft is harvested from the contralateral knee.

Double-bundle ACL reconstruction demonstrated superior clinical stability to single-bundle ACL reconstruction: a matched-pairs analysis of instrumented tests of tibial anterior translation and internal rotation laxity

PURPOSE

To compare objective measures of in vivo joint laxity between patients treated with single-bundle (SB) or double-bundle (DB) anterior cruciate ligament (ACL) reconstructions.

METHODS

Sixty-four patients matched by age, height, weight, and that had undergone unilateral SB or DB hamstring ACL reconstruction participated in this study. Bilateral anterior tibial translation (ATT) was recorded using the KT1000 arthrometer, and a robotic testing system was used to assess side-to-side differences in rotational characteristics. Each reconstruction was evaluated to determine how well it mimicked the anteroposterior (AP) and rotational biomechanics of the normal knee. A reconstruction was defined as mimicking the normal knee if ATT and internal rotation (IR) were within 3 mm and 3.5°, respectively.

RESULTS

Side-to-side differences in ATT were significantly higher for the SB group (2.2 ± 1.4 mm) than the DB group (1.1 ± 1.0 mm, P = 0.001). While relative side-to-side differences in IR did not differ between the SB (1.3°) and DB groups (1.1°, P = 0.82), absolute IR differences were significantly less with the DB reconstruction (2.1° vs. 4.7°, P = 0.001). A significantly greater percentage of DB patients (81%, P = 0.0003) had both ATT and IR similar to the normal knee, compared to 34% of the SB patients; however, IKDC subjective scores did not differ between groups. Regardless of technique, patients with the greatest rotational laxity of their non-operative knee demonstrated significantly worse IKDC scores.

CONCLUSION

DB reconstruction resulted in reduced side-to-side differences in both ATT and IR. The DB technique more consistently reproduced the biomechanical profile of the uninjured limb than did the SB technique without increasing the risk of over-constraining the knee.

Autologous patellar tendon and quadrupled hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized multicenter review of different fixation methods

ACL reconstruction with bone patellar tendon bone (BPTB) grafts has been shown to produce dependable results. Recently, reconstructions with double-looped semitendinosus gracilis (DLSG) grafts have become common. The prevailing opinion is that ACL reconstruction with patellar tendon graft produces a more stable knee with more anterior knee pain than DLSG grafts, while the functional results and knee scores are similar. The present study evaluates BPTB grafts fixed with metallic interference screws and DLSG grafts fixed with Bone Mulch Screw on the femur and WasherLoc fixation on the tibia. All else being the same, there is no difference in the outcome between the two grafts and fixation methods. This is a prospective randomized multicenter study. A total of 115 patients with isolated ACL ruptures were randomized to either reconstruction with BPTB grafts fixed with metal interference screws (58 patients) or DLSG grafts (57 patients) fixed with Bone Mulch Screws and WasherLoc Screws. Follow-up was at one and two years; the latter by an independent observer. At two years, one ACL revision had been performed in each group. Eight patients in the DLSG group and one in the BPTB group underwent meniscus surgery in the follow-up period (P = 0.014). Mean Lysholm score at the two year follow-up was 91 (SD +/- 10.3) in the DLSG group and also 91 (SD +/- 10.2) in the BPTB group. Mean KT-1000 at two years was 1.5 mm in the BPTB group and 1.8 mm in the DLSG group (n.s.). At two years, four patients in the BPTB group and three in the DLSG group had a Lachman test grade 2 or 3 (n.s.). More patients in the BPTB group had pain at the lower pole of the patella (P = 0.04). Peak flexion torque and total flexion work were lower in the DLSG group at one year (P = 0.003 and P = 0.000) and total flexion work also at two years (P = 0.05). BPTB ACL reconstruction fixed with interference screws and DLSG fixed with Bone Mulch Screws on the femur and WasherLoc Screws on the tibia produce satisfactory and nearly identical outcomes. Among our patients in the DLSG group, flexion strength was lower, and more patients underwent meniscus surgery in the follow-up period. The BPTB group has more anterior knee pain.

Anterior cruciate ligament reconstruction: outcome using a patellar tendon bone (PTB) autograft (one bone block technique)

OBJECTIVE

The aim of this study was to determine the outcome of anterior cruciate ligament (ACL) reconstruction using a patellar tendon bone autograft (one bone block technique).

METHOD

We retrospectively evaluated a case series of patients who had received arthroscopic ACL reconstructions using patellar tendon bone autograft. Fifty-four (54) ACL reconstructions were evaluated at a mean of 38 months (range 25-62 months). Clinical assessment was made using a modified Lysholm score, documentation of International Kappanee Documentation Committee (lKappaDC), the anterior knee pain questionnaire of Shelbourne and Trumper, and by KappaTau-Rolimeter arthrometric analysis. Radiographic assessments were also performed.

RESULTS

Arthrometric analysis showed that 51 knees (94%) were graded Alpha or Beta with a median laxity of 2 mm, postoperatively. The Lysholm score improved postoperatively from 70 to 89. The patellar position in terms of congruence angle did not show any significant change, and the final shortening of the patellar tendon using the Insall-Salvati ratio was 6.07%. Only three patients complained of moderate pain on kneeling, one patient was unable to participate in strenuous works and one patient complained of harvest-site tenderness.

CONCLUSION

It is concluded that the use of patellar tendon autograft with a single tibial-tubercule bone block and a strip of patellar periosteum have the advantages of being available and comparable in terms of graft size and strength and shows satisfactory results with reduced anterior knee pain.

Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation, and harvest

Increased stability has been reported with both autografts and allografts for anterior cruciate ligament (ACL) reconstruction. However, meta-analysis has shown significantly lower overall knee stability rates and more than double the abnormal stability rate with allografts. Some issues surrounding allograft sterilization (ie, risk of disease transmission) are unresolved, and cost is also a concern. Single-bundle ACL reconstruction can produce high stability rates when tunnels are properly placed, but there is evidence that double-bundle repair may offer greater rotatory stability. Cortical fixation has been associated with increased stability owing to the high stiffness of cortical bone. Anterior and posterior approaches are both recommended. The controversy related to single-bundle versus double-bundle ACL reconstruction remains unresolved.

Anterior cruciate ligament reconstruction : quadriceps versus patellar autograft

The bone-patellar tendon-bone has been widely used and considered a good graft source. The quadriceps tendon was introduced as a substitute graft source for bone-patellar tendon-bone. We compared the clinical outcomes of anterior cruciate ligament reconstructions using central quadriceps tendon-patellar bone and bone-patellar tendon-bone autografts. We selected 72 patients who underwent unilateral anterior cruciate ligament reconstruction using bone-patellar tendon-bone between 1994 and 2001 and matched for age and gender with 72 patients who underwent anterior cruciate ligament reconstruction using quadriceps tendon-patellar bone. All patients were followed up for more than 2 years. We assessed anterior laxity, knee function using the Lysholm and International Knee Documentation Committee scores, and quadriceps strength, the means of which were similar in the two groups. More patients (28 or 39%) in the bone-patellar tendon-bone group reported anterior knee pain than in the quadriceps tendon-patellar bone group (six patients or 8.3%). Anterior cruciate ligament reconstruction using the central quadriceps tendon-patellar bone graft showed clinical outcomes comparable to those of anterior cruciate ligament reconstruction using the patellar tendon graft, with anterior knee pain being less frequent in the former. Our data suggest the quadriceps tendon can be a good alternative graft choice.

LEVEL OF EVIDENCE

Level III Therapeutic study.

Reconstruction of chronic patellar tendon rupture with contralateral BTB autograft: a case report

Chronic patellar tendon rupture is a rare disabling injury that is technically difficult to repair. Many different surgical methods have been reported for the reconstruction of chronic patellar tendon ruptures. We are reporting the use of contralateral bone-tendon-bone (BTB) autograft for chronic patellar tendon rupture reconstruction followed by double-wire loop reinforcement and without postoperative immobilization. One year after the operation, our patient had full knee extension and up to 130 degrees of flexion. He had good quadriceps strength, and isokinetic muscle testing showed no deficit comparing to his right leg. Patient returned to playing basketball in his spare time, without having any limitation.

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.

Changes in muscle strength and EMG median frequency after anterior cruciate ligament reconstruction

The purpose of this study was to monitor neuromuscular changes in quadriceps femoris muscle at 1 and 3 months after anterior cruciate ligament reconstruction (ACLR). Changes in isometric muscle strength (MVC), voluntary activation and surface electromyogram (EMG) parameters were examined in relation to knee stability, pain and swelling in 31 patients (25 M, 6 F) mean (SD) 30(8) years. Physically inactive (RC) and sports participants (SC) acted as controls. Median frequency (Hz) and amplitude (mV) of rectus femoris using Fast Fourier Transform (FFT) 2(11) was calculated during 5-s isometric contractions at 100, 75, 50 and 25% of MVC. One month after surgery, a significant correlation (P < 0.01) was found between activation (%) and MVC of injured knee extensors. By 3 months, most patients were pain free and had achieved full activation but still had muscle weakness. At 1 and 3 months post-surgery and for all levels of MVC contraction, the median frequencies of the injured limbs were significantly lower (P < 0.05) compared to the SC group as were those of the RC group. There was a significant lowering of the median frequencies of the uninjured limbs compared to the SC group at 75 and 100% of MVC. The EMG amplitude of the uninjured and injured limbs mirrored those of the SC and RC groups, respectively. These results support the view that muscle activation patterns were altered following ACL injury and surgical repair and may contribute to subsequent changes in muscle fibre properties during detraining and subsequent retraining.

What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction

Anterior cruciate ligament surgery and rehabilitation have changed drastically during the past 30 years. The patellar tendon autograft fixed with buttons provides tight bone-to-bone placement of the graft and quick bony healing, which allows accelerated rehabilitation to obtain full range of motion and strength. Although surgical stability is easily reproducible, long-term patient satisfaction is difficult to guarantee. Full knee range of motion should be compared to that of the contralateral normal knee, including full hyperextension. We followed the progress of all patients to gauge the utility of our rehabilitation program. In order of importance, the lack of normal knee range of motion (within 2 degrees extension and 5 degrees of flexion compared with that of the normal knee), partial or total medial meniscectomy, partial or total lateral meniscectomy, and articular cartilage damage were related to lower subjective scores. Rehabilitation after ACL reconstruction must first strive to achieve full symmetrical knee range of motion before aggressive strengthening can begin. Our current perioperative rehabilitation starts at the time of injury and preoperatively includes aggressive swelling reduction, hyperextension exercises, gait training, and mental preparation. Goals after surgery are to control swelling while regaining full knee range of motion. After quadriceps strengthening goals are reached, patients can shift to sport-specific exercises. When using a graft from the contralateral knee, the conflicting goals of strengthening the donor site and achieving full knee range of motion are divided between the knees. Thus, normal range of motion and strength can be achieved more easily and more quickly than when using an ipsilateral graft. Regardless of the graft source, a systematic rehabilitation program that emphasizes the return to symmetrical knee motion, including hyperextension, is necessary to achieve the optimum result.

Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction

The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.

Graft selection in anterior cruciate ligament reconstruction

The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high-performance athletes, and hamstring autografts and allografts have some relative advantages for lower-demand individuals. No current indications exist for synthetic ligaments.

Stability results of hamstring anterior cruciate ligament reconstruction at 2- to 8-year follow-up

PURPOSE

The purpose of this study was to test the hypothesis that hamstring (HS) anterior cruciate ligament (ACL) reconstructions using EndoButton (Smith & Nephew, Andover, MA) femoral and whipstitch/screw tibial fixation can produce a high rate of objective stability in a population of reconstructed patients with low morbidity.

TYPE OF STUDY

Case series.

METHODS

We retrospectively reviewed 153 consecutive primary HS ACL reconstructions in skeletally mature patients without other ligament reconstructions. All knees had EndoButton femoral and whipstitch/screw tibial fixation; 139 patients were located and 133 were tested. Thirteen were geographically distant and tested subjectively only. Evaluations included KT-1000 testing; radiographs; and Noyes, Lysholm, and Single Assessment Numeric Evaluation (SANE) ratings. Follow-up was 24 to 104 months (mean, 54.4 months).

RESULTS

There were no graft failures. No patient had rupture of an implanted graft. No patient had repeat surgery for instability; 96.9% of reconstructions had maximum manual side-to-side differences of < or =3 mm, 85.7% had < or =2 mm; 3% of the knees had a 4-mm difference; none had > or =5-mm difference. There was no objective stability difference between male and female patients and no deterioration in results with increasing follow-up time. Median ratings were: Noyes, 94; Lysholm, 94.5; and SANE, 90. Radiographs showed that no EndoButtons had migrated. No EndoButton or tibial screw had to be removed due to symptoms from the implant. One hundred eighteen of 120 patients had full extension; the other 2 patients had a 2 degrees flexion loss. One patient required repeat arthroscopy for arthrofibrosis but had full range of motion at follow-up. There were no deep knee infections. One patient had a superficial wound infection requiring intravenous antibiotics. One patient had a calf deep vein thrombosis that resolved with treatment.

CONCLUSIONS

Hamstring ACL reconstructions can produce (1) reliable, durable stability in both males and females with no graft failures, (2) good clinical ratings, (3) excellent range of motion, and (4) low morbidity, without hardware problems.

LEVEL OF EVIDENCE

Level IV, Case Series.

Donor site morbidity and return to the preinjury activity level after anterior cruciate ligament reconstruction using ipsilateral and contralateral patellar tendon autograft: a retrospective, nonrandomized study

AIM

To compare the donor site morbidity after anterior cruciate ligament reconstruction using ipsilateral and contralateral bone-patellar tendon autograft.

STUDY DESIGN

Cohort study; Level of evidence, 2 PATIENTS AND METHOD: Between 1997 and 1999, 100 patients underwent anterior cruciate ligament reconstruction with autologous bone-patellar tendon graft. The reconstructions were performed using ipsilateral bone-patellar tendon graft in 52 patients (group Ip) and contralateral bone-patellar tendon graft in 48 patients (group Co). Group Co consisted of 2 subgroups: group CoD consisted of the donor knees (n=48) and group Co-ACL consisted of the anterior cruciate ligament-reconstructed knees (n=48). Mean follow-up was 39.2 months. Donor site morbidity was evaluated with a questionnaire, computerized historical data, KT-2000 arthrometer measurements, the Cincinnati score, and the Tegner score.

RESULTS

KT-2000 arthrometer evaluation showed a mean side-to-side difference of 0.6 mm in both groups. There were no significant differences between the 2 groups concerning the Cincinnati and Tegner scores. With regard to local tenderness, a significantly higher rate was found in group Ip (59.6%) and group Co-D (58.3%) compared with group Co-ACL (6.3%). In groups Ip and Co-D, high statistically significant differences were also found according to kneeling pain (69.2% and 70.8%, respectively) and knee-walking pain (76.9% and 70.8%, respectively) compared with group Co-ACL (6.3% and 10.4%, respectively). With regard to numbness, there was no statistical significance between the rates of all 3 groups: group Ip=75%, group Co-D=85.4%, and group Co-ACL=64.6%. There was one rupture of the patellar tendon and one patient with chronic patellar tendinitis, both in the donor knee of group Co-D.

CONCLUSION

The contralateral bone-patellar tendon graft appears to present no advantage over the ipsilateral graft, as all symptoms concerning donor site morbidity are shifted from the injured into the healthy knee, and return to activity is not more rapid.