Long-term prognosis of nonoperatively treated acute knee distortions having primary hemarthrosis without clinical instability

Effect of tibial drill angles on bone tunnel aperture during anterior cruciate ligament reconstruction

BACKGROUND

Anatomic reconstruction of the anterior cruciate ligament has received greater attention as patient outcome assessment has become increasingly sophisticated. A goal during anatomic reconstruction should be the creation of a tibial tunnel aperture that is similar in size and orientation to the native anterior cruciate ligament insertion. Aperture morphology depends primarily on three factors: (1) drill-bit diameter, (2) the angle at which the tunnel intersects the tibial plateau (drill-guide angle), and (3) the tibial tunnel orientation in the transverse plane (transverse drill angle). We evaluated the influence of the aforementioned factors on tibial bone-tunnel aperture size and orientation.

METHODS

With use of various drill-bit diameters at different drill-guide angles, tunnel aperture areas were calculated on the basis of an elliptical shape. The change in tunnel aperture orientation within the transverse plane (along the tibial plateau surface) was quantified by calculating the change in anteroposterior and mediolateral lengths of the aperture.

RESULTS

Use of a 9-mm drill-bit at a 45 degrees drill-guide angle created a 90-mm(2) bone-tunnel aperture area. Decreasing the drill-guide angle from 65 degrees to 30 degrees resulted in an increase in area of 81%. An aperture oriented 45 degrees relative to the orientation of the native insertion of the anterior cruciate ligament in the transverse plane fell short of the anatomic anteroposterior distance by 2.3 mm and exceeded the mediolateral distance by 1.4 mm on the basis of a 9-mm drill-bit at a drill-guide angle of 45 degrees.

CONCLUSIONS

During anterior cruciate ligament reconstruction, the drill-bit diameter, sagittal drill angle, and transverse drill angle can all affect tibial tunnel aperture size and orientation. An improperly sized and oriented tunnel aperture may increase the risk of damaging surrounding structures. An optimal combination of these parameters should be chosen during anatomic reconstruction of the anterior cruciate ligament.

Rupture of the anterior cruciate ligament in children: early reconstruction with open physes or delayed reconstruction to skeletal maturity?

The purpose of this study was to compare two different strategies of management for ACL rupture in skeletally immature patient. In group 1, patients were treated in a children hospital by ACL reconstruction with open physis. In group 2, patients were treated in an adult hospital by delayed reconstruction at skeletal maturity assessed radiologically. Fifty-six consecutive patients were included in this retrospective study. Mean time from injury to surgery in group 1 and 2 was, respectively, 13.5 and 30 months. Patients from group 2 exhibited a higher rate of medial meniscal tears (41%) compare to group 1 (16%) and higher rate of meniscectomy. Both groups had the same rate of lateral meniscal tears. A temporary tibial valgus deformity was reported which was subsequently spontaneously resolved. No definitive growth disturbance was noticed. At 27 months mean follow-up, a best subjective IKDC score was found in group 1. Objective IKDC and radiological results were similar in both groups. Early ACL reconstruction is therefore a recommended option.

A systematic review of the femoral origin and tibial insertion morphology of the ACL

Transtibial single bundle anterior cruciate ligament (ACL) reconstruction has been the gold standard for several years. This technique often fails to restore native ACL femoral origin and tibial insertion anatomy of the ACL. Recently, there is a strong trend towards a more anatomical approach in single and double bundle ACL reconstruction. Using the anatomic double bundle structure of the ACL as a principle, the entirety of both tibial insertion and femoral origin of both bundles, the posterolateral and anteromedial, may be restored. Reflected by recent publications over the past two years, there is an increasing interest in the anatomy of the ACL. In the current study, a PubMed literature search was performed looking for measurements of the ACL femoral origin and tibial insertion. These studies show a large variability in the size and the anatomy of the femoral origin and tibial ACL insertion using different methods and specimens. The diversity of reported measurements makes clinical application of these data difficult at best. Thus, it is of paramount importance to understand the individual variations in size and shape of the ACL femoral origin and tibial ACL insertion. This study is a systematic review of the morphology of the ACL femoral origin and tibial insertion as reported in the literature.

The Kinematic Basis of ACL Reconstruction

The goals of anterior cruciate ligament (ACL) reconstruction are to restore knee stability and function and to preserve joint health. Static tests for antero-posterior laxity (e.g. Lachman test or KT-1000 arthrometer) have typically shown restoration of normal or near-normal laxity with a variety of modern ACL reconstruction techniques. However, ACL reconstruction has failed to prevent early onset of osteoarthritis, and there is growing evidence that traditional single-bundle ACL reconstruction does not restore normal knee mechanics under functional loading conditions. ACL reconstruction may fail to restore normal rotational stability during the pivot shift. Abnormal internal-external rotation and ab/adduction have been reported after ACL reconstruction during normal daily activities like walking and running. Recently, cadaveric studies have shown the potential superiority of ACL double bundle (DB) reconstruction for restoring anatomy and mechanical function. However, clinical data demonstrating the clear superiority of DB reconstruction is lacking, due to the absence of well-controlled clinical studies. Additionally, dynamic knee function after anatomic DB ACL has yet to be assessed comprehensively.

Managing anterior cruciate ligament deficiency in the skeletally immature individual: a systematic review of the literature

OBJECTIVE

To perform a systematic review of the literature to answer whether early ACL reconstruction for a skeletally immature individuals result in improved outcome compared with nonsurgical treatment or delaying the reconstruction until skeletal maturity in the pediatric athlete.

DATA SOURCES

Articles were restricted to the English language, and 6 databases were searched (MEDLINE, CINAHL, EMBASE, ACP Journal Club, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews). The following keywords were used: anterior cruciate ligament, ACL, child, immature, pediatric, pediatric, and young.

SELECTION CRITERIA

All studies examining the ACL reconstruction in skeletally immature individuals, including citations describing complications. Excluded were articles looking at ACL repairs and ACL avulsion injuries. All types of study design, including review articles, were included. Comparative studies were reviewed in detail and analyzed qualitatively.

DATA EXTRACTION AND SYNTHESIS

A total of 615 articles were identified. Sixty-six articles met the inclusion and exclusion criteria. There were no articles with levels of evidence better than level III. The majority of the articles represented case series and reviews with expert opinion.

RESULTS

There were 7 articles that provided comparisons between surgical and nonsurgical treatment in order to answer the question.

CONCLUSIONS

The study designs are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature individuals. Future prospective studies are required to answer the question adequately. A proposed algorithm was described to deal with the question.

The clinical diagnosis and results of conservative treatment of knee distortion injury

Distortion of the knee joint is a considerable trauma even when the knee is primarily stable. Of 50 patients, 30% displayed symptoms or signs 2 months after the injury and 36% on subsequent examination an average of 5.6 years later. In a repeat clinical examination one anterior cruciate ligament rupture was not confirmed at the primary stage (2%). For assessment of stability and extent of injury, the repeat clinical examination proved reliable. Ruptures of the meniscus were noted in 18% of the patients in connection with the primary injury. Of those who underwent a meniscus operation, 27% had further operations and, four patients of 50 had another operation as a result of a new trauma. Thus, a total of 25% of the patients required surgery. The material is biased as I sought to exclude ligament ruptures in the first instance. No patient was permanently incapacitated from work. A large portion of the later symptoms were connected with the patellofemoral joint or with the postoperative condition. Bandaging did not affect the resulting recovery rate. Regular exercise of the thigh muscles prevented the onset of quadriceps atrophy, but there was a clear deterioration in the condition of the muscles in the early stages.

Acute hemarthrosis of the knee: indications for diagnostic arthroscopy

The objective of this study was to define the role of early diagnostic knee arthroscopy for patients with an acute knee injury and hemarthrosis. Forty-five patients with an acute knee injury followed by a posttraumatic hemarthrosis during a 1-year period were prospectively reviewed. All patients were evaluated preoperatively followed by examination under anesthesia and arthroscopy of the knee. The majority of patients, 32 (71%), had an anterior cruciate ligament tear. Meniscal tears occurred in 21 patients (47%). Meniscal tears requiring surgery occurred in only 10 of 25 meniscal tears (40%). Seven patients (16%) had medial collateral ligament and/or posteromedial capsular sprain. Eight patients (18%) had an osteochondral fracture or patellar dislocation associated with an osteochondral fracture. The majority of knees with a torn meniscus or osteochondral fracture had an anterior cruciate ligament tear. Clinically, 18 of 21 knees (86%) with an acute complete anterior cruciate ligament tear were diagnosed preoperatively with the Lachman test. The Lachman test conducted with patients under anesthesia was positive for 19 of 21 knees (90%) with an acute complete anterior cruciate ligament tear. The preoperative examination correctly identified six of seven knees (86%) with a medial collateral ligament sprain. The preoperative Lachman test was positive in only two of five knees (40%) with a partial anterior cruciate ligament tear. The Lachman test with patients under anesthesia was positive for four of five knees (80%) with an acute partial anterior cruciate ligament tear. Preoperative examination yielded the correct diagnosis in only 9 of 21 knees (43%) with a meniscal tear and 1 of 6 knees (17%) with an osteochondral fracture.(ABSTRACT TRUNCATED AT 250 WORDS)