Arthroscopically assisted anterior cruciate ligament reconstruction with the pes anserine tendons. Comparison of results in acute and chronic ligament deficiency

Anterior Cruciate Ligament Reconstruction Alone Versus With Lateral Extra-articular Tenodesis With Minimum 2-Year Follow-up: A Meta-analysis and Systematic Review of Randomized Controlled Trials

BACKGROUND

Lateral extra-articular tenodesis (LEAT) aims to improve anterolateral stability of the injured knee during anterior cruciate ligament reconstruction (ACLR) surgery. Inconclusive evidence surrounding the efficacy and safety of LEAT has propelled clinical interest and ongoing discussions.

PURPOSE

To establish level 1 evidence by assessing randomized controlled trials (RCTs) with minimum 2-year follow-up that directly compared ACLR with LEAT (LEAT group) and ACLR alone (non-LEAT group) in terms of clinical outcomes and complications.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 1.

METHODS

Meta-analysis was performed with a multidatabase search (Cochrane, EMBASE, OVID Medline, PubMed, and Web of Science) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on September 9, 2020. Data from published RCTs meeting inclusion criteria were extracted and analyzed with an inverse variance statistical model.

RESULTS

A total of 7 RCTs were included, consisting of 517 LEAT and 589 non-LEAT patients. Only autografts were used for ACLR and LEAT. A variety of LEAT techniques and autograft fixation methods were used. We found improved stability (residual positive pivot shift: risk ratio [RR], 0.59; 95% CI, 0.39-0.88; P = .01) and better clinical outcomes (International Knee Documentation Committee [IKDC] score: mean difference [MD], 2.31; 95% CI, 0.54-4.09; P = .01; and Lysholm score: MD, 2.71; 95% CI, 0.68-4.75; P = .009) in the LEAT than non-LEAT group. Graft rerupture rate was 3 times less likely (RR, 0.31; 95% CI, 0.17-0.58; P < .001) in the LEAT group than the non-LEAT group.

CONCLUSION

Good-quality evidence is available to support the efficacy of LEAT in improving anterolateral knee stability and reducing graft reruptures in primary ACLR. LEAT should be considered in patients with high risk factors. Although Lysholm and IKDC scores were statistically better in the LEAT group, these are unlikely to be clinically significant. Future studies should aim to identify patient populations that would best benefit from LEAT with ACLR.

Journey around the Notch: A Systematic Review on the History of ACL Reconstruction in the United States

The evolution of anterior cruciate ligament (ACL) surgery, seemingly circular at times, informs and provides context for past and current controversies in ACL management. The purpose of this systematic review is to objectively summarize the historical course of ACL reconstruction and repair in the United States over the last 40 years. Femoral tunnel drilling and graft selection have evolved dramatically over the last few decades. An initial focus on restoring ACL anatomy was for a period sacrificed for decreased operative morbidity. However, recent developments in operative techniques aim to restore ACL anatomy while also achieving minimal operative morbidity. Despite this historically iterative process, there remains no perfect choice for the treatment of ACL tears. Continued research on ACL repair, anatomic graft placement, graft choice, and augmentation will help our patients over the next generation.

Surgical Timing Does Not Interfere on Clinical Outcomes in Combined Reconstruction of the Anterior Cruciate Ligament and Anterolateral Ligament: A Comparative Study With Minimum 2-Year Follow-Up

PURPOSE

To compare the functional outcomes, knee stability, failure rate and complication rates of combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction with hamstrings grafts between acute and chronic cases.

METHODS

Consecutive patients who underwent combined ACL and ALL reconstruction with hamstrings grafts were evaluated. Patients operated on less than 8 weeks after injury were allocated to group 1, and the others were allocated to group 2. Demographic data, knee stability, and functional outcomes of the 2 groups were evaluated.

RESULTS

Thirty-four patients in the acute group and 96 in the chronic group were evaluated. The follow-up time was similar between the groups (28.7 ± 5.2 [24-43] months vs 29.4 ± 7.2 [24-58] months; P = 0.696). No differences were found between the groups in age, sex, trauma mechanism, presence of knee hyperextension, graft diameter, and meniscal injuries. There was no difference between the groups in the postoperative KT-1000 and in the pre- or postoperative pivot shift. The preoperative KT-1000 was higher in group 2 (7.9 ± 1.1 vs 7.4 ± 1.2; P = 0.031). There were no differences in the International Knee Documentation Committee or Lysholm. Three (2.3%) patients developed failure, 1 (2.9%) in group 1 and 2 (2.1%) in group 2. The total complication rate was 10% and did not differ between the groups.

CONCLUSIONS

Combined ACL and ALL reconstruction has similar outcomes in patients undergoing surgery in the acute and chronic phases. Patients with chronic injury have similar knee stability, functional scores, and failure rates as acute-injury patients, and patients with acute injury have no more complications than chronic patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft

PURPOSE

To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction.

METHOD

One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears.

RESULTS

Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged < 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in < 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04).

CONCLUSIONS

The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes (> 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury.

LEVEL OF EVIDENCE

III.

Impact of Surgical Timing on Clinical Outcomes in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autografts

Background:

To date, no studies have analyzed the influence on clinical outcomes of the interval between an anterior cruciate ligament (ACL) injury and double-bundle (DB) reconstruction with hamstring tendon autografts.

Hypotheses:

(1) Performing ACL reconstruction sooner after an injury will reduce postoperative anterior and rotatory knee instability, (2) postoperative range of knee motion or functional results will not be affected by different intervals between injury and surgery, and (3) preoperative isokinetic peak torque of the quadriceps and hamstring muscles will be lower in patients undergoing surgery earlier, while postoperative muscle strength will not be affected by surgery timing.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study was conducted on a total of 171 patients who had undergone anatomic DB ACL reconstruction with hamstring tendon autografts. The patients were divided into 3 groups based on the time to surgery: (1) ≤1 month after the injury (group E; n = 25), (2) between 1 and 3 months after the injury (group M; n = 72), and (3) >3 months after the injury (group D; n = 74). Patients were assessed for a minimum of 2 years after surgery.

Results:

Concerning postoperative anterior laxity, 1-way analysis of variance demonstrated a significant difference (P = .0274) among the 3 groups. Anterior laxity was significantly less in group E than in group D (P = .0206). Spearman rank correlation analysis showed a significant correlation (ρ = 0.200; P = .0327) between anterior knee laxity and time to surgery. Also, a significant correlation (P = .0461) was found between the degree of the pivot-shift phenomenon and time to surgery. There were no significant differences in loss of knee extension or flexion among the 3 groups, nor were there any differences in the Lysholm knee score or International Knee Documentation Committee grade. Postoperatively, there were no significant differences in peak torque of the quadriceps or hamstring muscles among the 3 groups.

Conclusion:

Early DB reconstruction led to significantly less anterior laxity compared with delayed reconstruction. There were no significant differences in postoperative range of knee motion or functional results among the 3 time intervals between injury and surgery in this study.

Early or delayed anterior cruciate ligament reconstruction: Is one superior? A systematic review and meta-analysis

Background

Anterior cruciate ligament (ACL) reconstruction is a rapidly developing orthopaedic field and an area of notable clinical equipoise. The optimal timing of surgery in an acute (< 3 weeks) or delayed (≥ 3 weeks) time frame remains unresolved with a 2010 meta-analysis concluding no difference between these two groups across multiple outcomes. In an era of evidence-based medicine, surgeons are still basing their decisions on when to operate on little more than anecdotal evidence and personal preference. Clear guidance is required to determine whether the timing of surgery can optimise outcomes in this largely young and active patient cohort.

Methods

A systematic literature search was performed in January 2018 of Embase, Medline and OpenGrey in accordance with (PRISMA) guidelines. A total of 658 articles were retrieved, with 6 suitable for inclusion, covering 576 ACL reconstructions. Four meta-analyses were performed assessing subjective measures of Tegner activity scale and Lysholm score, and objective measures of arthroscopically identified meniscal and chondral injury. Additional relevant outcome measures underwent narrative review. Study bias was assessed and reported using the Downs and Black checklist.

Results

A statistically significant difference of 0.39 points was found on the Tegner activity scale in favour of early surgery within 3 weeks (RR 0.39, CI 0.10, 0.67, p = 0.008). No statistically difference was found between groups for the patient-reported Lysholm score (RR − 0.18, CI − 2.40, 2.05, p = 0.17). There was no statistically significant difference between groups for intra-operative findings of meniscal lesions (RR 0.84, CI 0.66, 1.08, p = 0.17). A trend towards significance was observed for the incidence of chondral lesions in the early surgery group (RR 0.56, CI 0.31, 1.02, p = 0.06). All the studies were rated either fair or good on the Downs and Black checklist with no study excluded due to bias.

Conclusions

Although there was a statistically significant result for the Tegner activity scale in favour of early surgery, the magnitude of the effect is unlikely to translate into any clinically meaningful difference. At present, there remains no clear evidence to determine superiority of acute/early or delayed reconstruction of a ruptured anterior cruciate ligament. Further research through methodologically robust randomised controlled trials or through the UK National Ligament Registry  may help to provide clearer guidance.

The Role of Lateral Extra-articular Tenodesis in Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis and Best-Evidence Synthesis

Background

The role of lateral extra-articular tenodesis (LEAT) to augment primary anterior cruciate ligament reconstruction (ACLR) remains controversial.

Purpose

To determine whether the addition of LEAT to primary ACLR provides greater control of rotational laxity and improves clinical outcomes compared with ACLR alone and to assess the impact of early versus delayed ACLR.

Study Design

Systematic review; Level of evidence, 3.

Methods

Two reviewers independently searched 7 databases for randomized and nonrandomized clinical studies comparing ACLR plus LEAT versus ACLR alone. Animal, cadaveric, and biomechanical studies; revision or repair procedures; and studies using synthetic ligaments and multiligamentous-injured knees were excluded. Risk of bias was assessed with a modified Downs and Black checklist. The primary outcome was postoperative pivot shift. These data were pooled by use of a fixed-effects meta-analysis model. The studies were divided into delayed (>12 months) and early (≤12 months) reconstruction groups for meta-analysis. A best-evidence synthesis was performed on the remaining outcome measures.

Results

Of 387 titles identified, 11 articles were included (5 of high quality). Meta-analysis of postoperative pivot shift in 3 studies of delayed primary ACLR showed a statistically significant difference for the pivot-shift test in favor of ACLR with LEAT (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P = .008; I² = 0). Meta-analysis of 5 studies of early primary ACLR found no statistically significant difference with the addition of LEAT (OR, 0.60; 95% CI, 0.33-1.09; P = .10; I² = 33%). Insufficient evidence was available to determine whether the addition of LEAT had any effect on clinical, objective, subjective, and functional outcomes.

Conclusion

In primary ACLR, no evidence is available showing additional benefit of LEAT in reducing the postoperative pivot shift in early reconstructions (≤12 months); however, LEAT may have a role in delayed ACLR. Strong evidence exists that a combined ACLR and LEAT reduces lateral femoral translation, but there is insufficient evidence to identify any benefit for other clinical outcomes.

Preoperative patient and injury factors of successful rehabilitation after anterior cruciate ligament reconstruction with single-bundle techniques

PURPOSE

The aim of this systematic review was to determine which patient determinants and injury factors, before anterior cruciate ligament reconstruction by arthroscopic single-bundle techniques, affect postoperative rehabilitation.

METHODS

A search of PubMed, Embase, and the Cochrane Database of Clinical Trials was performed up to February 2013. After application of our inclusion criteria, a final selection was made based on studies' methodologic score assessed with the Newcastle-Ottawa Scale. Meta-analysis was planned for each prognostic factor when data were considered clinically and statistically homogeneous.

RESULTS

Meta-analysis showed that male patients have better functional outcomes. Qualitative synthesis from 18 high-quality studies showed that patients operated on before 30 years of age reach higher activity levels. Patients with high baseline body mass index have lower activity levels after surgery. Smoking results in more symptoms and lower activity levels and subjective scores. Reconstruction before 3 months results in higher activity levels. Preoperatively, a less than 20% quadriceps strength difference, 50° of tibial external rotation or less, absence of flexion deficits, low knee influence on the patient's activity level, and less anterior knee pain result in higher functional scores. Preoperative anterior laxity difference does not predict functional scores. The prognostic value of preoperative activity and competition level for postoperative functional outcome is controversial. Patients with concomitant meniscal injuries have worse functional outcomes. The prognostic value of concomitant chondral pathology for postoperative functional outcome is controversial. Collateral ligament injury could predict functional scores or activity level.

CONCLUSIONS

Male gender, patient age younger than 30 years, reconstruction before 3 months, and high baseline activity level contribute to better functional outcomes. Smoking, high body mass index, quadriceps strength, and range-of-motion deficits affect rehabilitation negatively. Preoperative anterior laxity does not influence rehabilitation. The role of preoperative prognostic injury factors remains unclear because of limited evidence.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

Time from ACL injury to reconstruction and the prevalence of additional intra-articular pathology: is patient age an important factor?

PURPOSE

Meniscus and cartilage lesions have been reported to be prevalent during delayed reconstruction of anterior cruciate ligament (ACL) injuries. Relatively, little work has been done exploring the influence of patient age on this relationship. The purpose of this study is to determine whether the effect of time from ACL injury to reconstruction on the prevalence of associated meniscal and chondral injury is influenced by patient age. It was hypothesized that patients in whom the time from ACL injury to reconstruction exceeds 12 weeks will exhibit an increased prevalence of medial compartment pathology relative to those reconstructed within 12 weeks of injury in patients of all ages.

METHODS

Data detailing time from ACL injury to reconstruction and the prevalence of intra-articular findings were obtained in 311 of 489 consecutive patients undergoing primary isolated ACL reconstruction. Patients were divided into two groups based on whether the time from ACL injury to reconstruction was <12 weeks or at least 12 weeks. The prevalence of associated intra-articular injury was then compared between the two groups. Patients were then stratified based on age (22 years and under vs. over the age of 22), and the analysis was repeated on both groups.

RESULTS

Analysis of all patients together revealed a significantly higher prevalence of medial meniscus injury (p = 0.013) and medial compartment chondral injury (p < 0.0005) in patients in whom the time from ACL injury to reconstruction exceeded 12 weeks. The prevalence of lateral meniscal injury did not increase with increasing time ACL injury to surgery. Among patients aged 22 years and under, there was no increase in the prevalence of intra-articular pathology in any compartment in the late reconstruction group. In contrast, among patients over the age of 22, there was a significant increase in the prevalence of medial chondral injury (p = 0.042) in the late reconstruction group.

CONCLUSION

The prevalence of injuries to the meniscus and articular cartilage in the medial compartment of the knee is increased with increasing time from ACL injury to reconstruction. This relationship may vary depending on patient age. Patients over the age of 22 exhibit a higher prevalence of intra-articular injury with delayed reconstruction, while no such differences are noted among younger patients.

LEVEL OF EVIDENCE

Retrospective comparative study, level III.

Immediate ACL reconstruction prevents microvascular pathophysiology in the uninjured MCL that is not fully reversed by delayed ACL reconstruction

Anterior cruciate ligament (ACL) injury induces maladaptive vascular responses that degrade medial collateral ligament (MCL) function. The purpose of this study was to determine if early or delayed ACL reconstruction can prevent or reverse the abnormal changes in vascular function that occur in the uninjured MCL after ACL injury. Twenty-four rabbits were divided into four groups (n = 6); control, ACL-deficient (ACL-X), immediate ACL reconstructed (ACL-IR) and delayed ACL reconstructed (ACL-DR). After 8 weeks, MCLs were assessed for blood flow, responses to acetylcholine (ACh) and phenylephrine (Phe) and autoregulatory responses, using laser speckle perfusion imaging. In ACL-X knees, blood flow in the MCL increased by 2.5-fold compared to control. MCL hyperemia was diminished in ACL-DR knees and was unaltered in ACL-IR knees. MCL vasculature was unresponsive to ACh and Phe in ACL-X. These responses were partially restored by ACL reconstruction. Autoregulatory responses were not significantly different between groups. ACL-DR decreased hyperemia in the MCL and partially attenuated abnormal MCL vascular responses. ACL-IR was more effective at preventing MCL hyperemia and preserving vascular responsiveness to ACh and Phe. This suggests that the vascular alterations in the uninjured rabbit MCL are largely caused by abnormal mechanical loading resulting from ACL deficiency and can be prevented through early reconstruction. Early ACL reconstruction could limit the progression of microvascular dysfunction of the MCL, and preserve physiological joint homeostasis. This might prevent joint degeneration and delay the progression of osteoarthritis.

Early versus delayed surgery for anterior cruciate ligament reconstruction: a systematic review and meta-analysis

There is no consensus in the literature regarding the optimal timing of surgical reconstruction of the ruptured anterior cruciate ligament (ACL). Previous authors have suggested that early reconstruction may facilitate an early return to work or sport but may increase the incidence of post-operative complications such as arthrofibrosis. This study systematically reviewed the literature to determine whether ACL reconstruction should be performed acutely following rupture. Medline, CINAHL, AMED, EMBASE databases and grey literature were reviewed with a meta-analysis of pooled mean differences where appropriate. Six papers including 370 ACL reconstructions were included. Early ACL reconstructions were considered as those undertaken within a mean of 3 weeks post-injury; delayed ACL reconstructions were those undertaken a minimum of 6 weeks post-injury. We found there was no difference in clinical outcome between patients who underwent early compared to delayed ACL reconstruction. However, this conclusion is based on the current literature which has substantial methodological limitations.

[Acute anterior cruciate ligament repair with combined intra- and extra-articular reconstruction using an iliotibial band with the modified MacIntosh technique: a five-year follow-up study of 50 pivoting sport athletes]

PURPOSE OF THE STUDY

Comparisons have been often made between bone-tendon-bone plasty and hamstring tendon four-strand plasty. Whether a lateral tenodesis should be associated with the intra-articular reconstruction and the appropriate time between the accident and the repair remain two topics of debate. We present results obtained in a consecutive series of 50 pivoting sport atheletes reviewed retrospectively. These patients had been treated within eight days of trauma with a modified MacIntosh technique using an iliotibial band. This technique enables lateral tenodesis and reconstruction of the central pivot with only one harvesting site. We searched for responses to two questions: are our results comparable to those in other published series? could this operation be warranted as an emergency procedure?

MATERIAL AND METHODS

Fifty patients from a consecutive retrospective series of 62 patients (eight lost to follow-up and four excluded from the analysis) were reviewed by an independent observer at mean follow-up of 5.2 years (range 54.4 to 86.4 months). The ARPEGE and IKDC scoring systems were used. An isokinetic assessment was obtained in 38 patients at one year. The reconstruction technique used an iliotibial band measuring 40-45 mm in width. The lateral reconstruction consisted in section then translation of the lateral intermuscular partition.

RESULTS

The overall outcome was scored as follows: IKDC A 38%, B 46%, C 12%, D 4%. Mean residual differential laxity (KT 1000) was 1.86+/-1.74 assessed manually with a negative Lachman in 48% of knees. 88% of the positive tests had been neutralized. Early anatomic failure was noted in two knees with recurrent traumatic tears at 25 and 38 months. Using the ARPEGE scoring system, outcome was excellent in 38%, good in 46%, fair in 12% and poor in 4%. At last follow-up, the level of sports activities was unchanged in 33 patients. Irreducible flexion measuring more than 5 degrees was noted in two patients, and a deficit in flexion greater than 20 degrees in three. One female athlete who had resumed her former sports level presented mobilization under narcosis. None of the patients complained of pain at the harvesting site. There was one case of muscle herniation proximally by wound dehiscence. Mean residual deficit of the quadriceps, measured at twelve months, was 10% at 90 degrees /s; mean residual deficit of the hamstrings at the same speed was 1.3%.

DISCUSSION

Our overall results as measured with the IKDC scoring system were comparable with those observed in series using other autologous transplants. The risk of stiffness is greater with early reconstruction, suggesting emergency repair should be considered with caution. Recovery of muscle force demonstrates one of the advantages of using the iliotibial band which does not injure the extensor-flexor system of the knee joint. The fact that none of the patients complained of pain at the harvesting site is a favorable element for rehabilitation and resumed sports activities.

Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft

PURPOSE

No graft tissue has consistently shown superiority over others for reconstruction of the anterior cruciate ligament (ACL). Bone-patellar tendon-bone (BPTB) and doubled hamstring tendon (semitendinosus and gracilis) (HT) are the most commonly used autologous grafts. We performed a meta-analysis to compare the effectiveness of ACL reconstruction using either BPTB or HT grafts.

TYPE OF STUDY

Systematic review and meta-analysis.

METHODS

We searched the MEDLINE database (1966 to April 2003) for English-language randomized or prospective studies comparing BPTB and 3- or 4-strand HT grafts used for ACL reconstruction. For inclusion, studies were required to follow identical rehabilitation protocols within each study, and provide subjective or objective outcome data after a minimum average 2-year follow-up. Comparison data between BPTB and HT for each identified outcome measure were combined using a random-effects model meta-analysis.

RESULTS

Eleven reports fulfilled the criteria for inclusion. Outcomes favoring BPTB were found in the following outcome measures: normal Lachman examination (relative risk [RR], 0.91; 95% confidence interval [CI], 0.83-0.99; P = .025), normal pivot-shift (RR, 0.94; 95% CI, 0.88-1.0; P = .067), KT-1000 manual-maximum side-to-side difference of < or = 3 mm (RR, 0.75; 95% CI, 0.55-1.01; P = .057), and fewer reconstructions resulting in flexion loss > 5 degrees (RR, 1.41; 95% CI, 1.01-1.96; P = .04). Intermediate level laxity was more common with the HT graft, as shown by higher rates of abnormal Lachman > 0 (RR, 1.22; 95% CI, 0.99-1.5; P = .06), pivot-shift > 0 (RR, 1.3; 95% CI, 0.96-1.75; P = .09), and KT-1000 manual-maximum side-to-side differences > 3 mm (RR, 1.64; 95% CI, 1.13-2.39; P = .01). Outcome measures that favored HT were absence of patellofemoral crepitance (RR, 1.08; 95% CI, 1.01-1.15; P = .03), fewer results with extension loss > 5 degrees (RR, 0.56; 95% CI, 0.3-1.03; P = .06), and kneeling pain. The incidence of instability, as defined by Lachman grade 2, pivot-shift grade 2, or KT-1000 manual-maximum side-to-side difference > 5 mm, was not significantly different between the 2 grafts. All other outcome measures were not significantly different.

CONCLUSIONS

The data presented in this meta-analysis show that the incidence of instability is not significantly different between the BPTB and HT grafts. However, BPTB was more likely to result in reconstructions with normal Lachman, normal pivot-shift, KT-1000 manual-maximum side-to-side difference < 3 mm, and fewer results with significant flexion loss. In contrast, HT grafts had a reduced incidence of patellofemoral crepitance, kneeling pain, and extension loss. The choice of graft by the patient and surgeon must be individualized, and the results of this meta-analysis can aid in the decision by clarifying the risks and benefits of each surgical approach.

LEVEL OF EVIDENCE

Level I.

Clinical evaluation of arthroscopically assisted anterior cruciate ligament reconstruction: patellar tendon versus gracilis and semitendinosus autograft

PURPOSE

To evaluate the clinical results of anterior cruciate ligament (ACL) reconstruction in patients with ACL-deficient knee in 2 similar groups of patients.

TYPE OF STUDY

A prospective randomized comparison of patellar tendon (PT) versus semitendinosus and gracilis tendon (STG) autografts for ACL reconstruction.

METHODS

Between 1994 and 1996, 85 consecutive male patients with chronic ACL-deficient knees underwent arthroscopically assisted reconstruction with either autologous PT or double-loop STG (4-strand) graft. PT grafts were used in patients with even-numbered birth dates and STG grafts for those with odd-numbered birth dates. Preoperatively, no significant differences between the 2 groups were noted with respect to age, level of activity, and degree of laxity (chi-square analysis). A standardized rehabilitation program was used for both groups postoperatively that included immediate active extension and early weight bearing and gradual flexion. Return to sports was permitted 8 months postoperatively. Assessment of the patients was carried out using a questionnaire, clinical assessment, Lysholm knee scores, the International Knee Documentation Committee scale, and radiological examination.

RESULTS

At a mean follow-up of 81 months, there was no significant difference between the 2 groups with respect to subjective complaints (recurrent giving way, functional level) or objective laxity evaluation, including KT-1000 measurement or return to sports. Loss of extension of < or =5 degrees was greater in the PT group (12 patients, 30 %) than in the STG group (8 patients, 17 %). There was loss of flexion of < or =15 degrees in 5 patients (12 %) in the PT group and 1 patient (2.2 %) in the STG group. Anterior knee pain was recorded in 10 patients (24 %) in the PT group and 3 patients (5 %) in the STG group. The Lysholm knee score was 91.6 and 92.7 for the PT and STG groups, respectively, and the Tegner activity score decreased from 8.9 preoperatively for both groups to 7.9 for the PT group and 7.8 for the STG group.

CONCLUSION

In this study, the 2 groups had comparable results in terms of patient satisfaction, activity level, and knee function. Our study showed that patellofemoral problems and loss of knee motion are more frequent in patients with PT grafts than in those with STG grafts.

LEVEL OF EVIDENCE

Level I, Randomized Controlled Trial.

Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts

BACKGROUND

The best choice of graft tissue for use in anterior cruciate ligament reconstruction has been the subject of debate.

HYPOTHESIS

Anterior cruciate ligament reconstruction with patellar tendon autograft leads to greater knee stability than reconstruction with hamstring tendon autograft.

STUDY DESIGN

Metaanalysis.

METHODS

A Medline search identified articles published from January 1966 to May 2000 describing arthroscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring tendon autograft and with a minimum patient follow-up of 24 months.

RESULTS

There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%).

CONCLUSIONS

Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain.

Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study

BACKGROUND

The purpose of this investigation was to evaluate replacement of a torn anterior cruciate ligament with either a bone-patellar tendon-bone autograft or a two-strand semitendinosus-gracilis autograft to compare the results of clinical testing, patient satisfaction, activity level, functional status, and muscle strength.

METHODS

Fifty-six patients with a torn anterior cruciate ligament were enrolled in a prospective, randomized, controlled study. Twenty-eight underwent reconstruction with a bone-patellar tendon-bone autograft, and twenty-eight were treated with a two-strand semitendinosus-gracilis autograft. Patients were followed for an average of thirty-nine months (range, thirty-six to fifty-seven months). At the time of final follow-up, twenty-two patients in each group were evaluated in terms of clinical test findings, patient satisfaction, activity level, functional status, and isokinetic muscle strength.

RESULTS

The objective outcome of replacement of the torn anterior cruciate ligament with a bone-patellar tendon-bone graft was superior to that obtained with a two-strand semitendinosus-gracilis graft. At the three-year follow-up interval, the patients in whom a hamstring graft had been used had an average of 4.4 mm of increased anterior knee laxity compared with the laxity of the contralateral, normal knee, whereas the patients in whom a bone-patellar tendon-bone graft had been used had an average of 1.1 mm of increased knee laxity. Fourteen percent (three) of the twenty-two patients with a hamstring graft had a mild pivot shift, and 27% (six) had a moderate pivot shift. Only 14% (three) of the twenty-two patients with a bone-patellar tendon-bone graft had a mild pivot shift, and none had a moderate pivot shift. At the same follow-up interval, the patients in whom a hamstring graft had been used had significantly lower peak knee-flexion strength than those who had a bone-patellar tendon-bone graft (p = 0.039). In contrast, the two treatments produced similar outcomes in terms of patient satisfaction, activity level, and knee function (ability to perform a one-legged hop, bear weight, squat, climb stairs, run in place, and duckwalk).

CONCLUSIONS

After three years of follow-up, the objective results of anterior cruciate ligament replacement with a bone-patellar tendon-bone autograft were superior to those of replacement with a two-strand semitendinosus-gracilis graft with regard to knee laxity, pivot-shift grade, and strength of the knee flexor muscles. However, the two groups had comparable results in terms of patient satisfaction, activity level, and knee function.

Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: A prospective study

PURPOSE

This prospective study was conducted to compare the single-socket and the bi-socket anterior cruciate ligament (ACL) reconstruction techniques in terms of outcome.

TYPE OF STUDY

Nonrandomized control trial.

METHODS

There were 160 consecutive patients with unilateral chronic ACL insufficiency who underwent endoscopic single- or bi-socket ACL reconstruction alternately using multiple-stranded medial hamstring tendon and EndoButton (Smith & Nephew, Andover, MD) femoral fixation. All patients underwent the same postoperative rehabilitation protocol. Of them, 106 patients (57 single, 49 bi) were available for 2-year follow-up.

RESULTS

According to the IKDC Knee Ligament Evaluation Form, 23 patients (40%) of the single-socket group were subjectively graded as normal, 30 (53%) as nearly normal, and 4 (7%) as abnormal. Twenty-six patients (53%) of the bi-socket group were graded as normal, 21 (43%) as nearly normal, and 2 (4%) as abnormal (P =.19). The mean side-to-side anterior laxity difference (KT-1000 manual maximum force) was 0.9 +/- 1.8 mm for the single-socket group and 0.7 +/- 1.2 mm for the bi-socket group (P =.44). Fifty-three of 57 patients (93%) in the single-socket group and all patients in the bi-socket group showed anterior laxity differences of +/-3 mm or less (P =.12). There were no differences in thigh muscle strength between the groups.

CONCLUSIONS

Both single- and bi-socket ACL reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton fixation provided satisfactory anterior stability, and there were no statistically significant differences in subjective results or measured restored stability between the 2 groups.

Single- versus two-femoral socket anterior cruciate ligament reconstruction technique: Biomechanical analysis using a robotic simulator

PURPOSE

Although anterior cruciate ligament (ACL) reconstruction with multistrand autogenous hamstring tendons has been widely performed using a single femoral socket (SS), it is currently advocated to individually reconstruct 2 bundles of the ACL using 2 femoral sockets (TS). However, the difference in biomechanical characteristics between them is unknown. The objective of this study was to clarify their biomechanical differences.

TYPE OF STUDY

This is a cross-over trial using cadaveric knees.

METHODS

Seven intact human cadaveric knees were mounted in a robotic simulator developed in our laboratory. By applying anterior and posterior tibial load up to +/- 100 N at 0 degrees, 15 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion, tibial displacement and load were recorded. After cutting the ACL, the knees underwent ACL reconstruction using TS, followed by that using SS, with 44 or 88 N of initial grafts tension at 20 degrees of flexion. The above-mentioned tests were performed on each reconstructed knee.

RESULTS

The tibial displacement in the TS technique was significantly smaller than that in the SS at smaller flexion angles in response to anterior and posterior tibial load of +/- 100 N, and the in situ force in the former was significantly greater than that in the latter at smaller flexion angles. Furthermore, in the TS technique, the posterolateral graft acted dominantly in extension, while the anteromedial graft mainly resisted against anterior tibial load in flexion. However, in the SS technique, the anteriorly located graft functioned more predominantly than the posteriorly located graft at all flexion angles.

CONCLUSIONS

The ACL reconstruction via TS using quadrupled hamstring tendons provides better anterior-posterior stability compared with the conventional reconstruction using a single socket.

A comparison of outcomes at 2 to 6 years after acute and chronic anterior cruciate ligament reconstructions using hamstring tendon grafts

PURPOSE

To compare short- to intermediate-term outcomes of patients in whom an acute or chronic anterior cruciate ligament (ACL) reconstruction was performed with a hamstring tendon graft.

TYPE OF STUDY

A consecutive case series of patients who had 2-incision, arthroscopically assisted ACL reconstructions with a triple-strand hamstring tendon graft was retrospectively evaluated.

METHODS

A total of 120 patients were evaluated at a mean of 44 months. The Tegner Activity Scale, individual components of the Cincinnati Knee Rating System, and the modified Lysholm Score were administered to all patients. A total of 93 patients (78%) returned for examination, instrumented ligament laxity testing, radiographs, isokinetic strength testing, and completion of the IKDC Standard Knee Ligament Evaluation Form. Data from patients undergoing reconstructions for acute and chronic ACL deficiencies were compared. The acute group was defined as reconstruction within 6 weeks of injury without recurrent episodes of instability.

RESULTS

At surgery, significantly more (P <.05) cartilage abnormalities and partial medial menisectomies were found in the chronic group. At final follow-up, no significant differences (P >.05) were found between the acute and chronic groups for instrumented laxity, muscle strength, knee motion, or sports activity level. The acute group scored significantly higher (P <.05) on the Lysholm scale, Cincinnati Function scale, IKDC subjective assessment, and IKDC rating for pain at follow-up. The final IKDC grade resulted in significantly more (P =.039) normal knees for the acute group; however, 94.1% of acute and 92.9% of chronic knees were graded normal or nearly normal.

CONCLUSIONS

Hamstring tendons are an excellent graft choice for ACL reconstruction in both acute and chronic injuries. According to the strict IKDC rating system, greater than 90% of all patients can be expected to have a normal or nearly normal knee at short- to intermediate-term follow-up; however, the chronic group will have fewer patients with a rating of normal.

A comparison of results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes. A two- to five-year follow-up of 429 patients

The aim of this study was to compare the results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes who had a pre-injury Tegner activity level of > or =7 and a non-injured contralateral anterior cruciate ligament. One hundred and thirty-three female and 296 male patients were followed at 38 (21-68) months after the index operation. All the patients were operated on by experienced knee surgeons using patellar tendon autografts and interference screw fixation. At the index operation the median age of the female patients was 23 (1645) years and the median age of the male patients was 26 (16-47) years. The reconstruction was performed a median of 10 (0-141) and 10 (0-203) months after the injury in women and men respectively. The patients were re-examined by independent observers. At the follow-up, the median Lysholm score was 89 (38-100) points in the female group and 90 (22-100) points in the male group (P=0.015). The IKDC evaluation system, subjective anterior knee pain, subjective evaluation of the results, the knee-walking test and the KT-1000 tests revealed no differences between the groups. The mean (+/-2 SD) pre-injury Tegner activity level was 8.1 (+/-1.9) (median 8 (7-10)) in the female group and 8.4 (+/-1.8) (median 9 (7-10)) in the male group (P=0.003). At the follow-up, the Tegner activity level was 6.2 (+/-3.8) in the female group and 6.8 (+/-3.6) in the male group (P=0.012). At the follow-up, the Tegner activity level had decreased by 1.9 (+/-3.8) for the women and 1.6 (+/-3.3) for the men, as compared with the pre-injury level (n.s.). The difference between the performed and the desired activity level at the follow-up was 1.1 (+/-3.2) in the female group and 0.9 (+/-3.0) in the male group (n.s.). In the female group 53/133 (40%) and in the male group 115/296 (39%) returned to the pre-injury activity level (n.s.). The median one-leg-hop quotient was 93 (0-116)% in the female group and 96 (0-130)% in the male group (P=0.006). Concomitant meniscal injuries prior to the index operation, at the index operation or during the follow-up period were found in 64/133 (48%) women and in 185/ 296 (62%) men (P<0.01). The main conclusion was that the overall results in female and male athletes were comparable two to five years after the anterior cruciate ligament reconstruction. However, concomitant meniscal injuries were more common in male than females athletes after anterior cruciate ligament injuries.

Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft

We compared the outcome of anterior cruciate ligament reconstruction using hamstring tendon autograft with outcome using patellar tendon autograft at 2 years after surgery. Patients had an isolated anterior cruciate ligament injury and, apart from the grafts, the arthroscopic surgical technique was identical. Prospective assessment was performed on 90 patients with isolated anterior cruciate ligament injury undergoing reconstruction with a patellar tendon autograft; 82 were available for follow-up. The hamstring tendon autograft group consisted of the next 90 consecutive patients fulfilling the same criteria; 85 were available for follow-up. Clinical review included the Lysholm and International Knee Documentation Committee scores, instrumented testing, thigh atrophy, and kneeling pain. These methods revealed no difference between the groups in terms of ligament stability, range of motion, and general symptoms. Thigh atrophy was significantly less in the hamstring tendon group at 1 year after surgery, a difference that had disappeared by 2 years. The KT-1000 arthrometer testing showed a slightly increased mean laxity in the female patients in the hamstring tendon graft group. Kneeling pain after reconstruction with the hamstring tendon autograft was significantly less common than with the patellar tendon autograft, suggesting lower donor-site morbidity with hamstring tendon harvest.

Intraarticular anterior cruciate ligament graft placement on the average most isometric line on the femur. Does it reproducibly restore knee kinematics?

In the past, there has been a plausible hypothesis that anterior cruciate ligament graft placement at isometric sites, such that the tibial and femoral attachment sites remain equidistant from each other throughout knee range of motion, would increase the likelihood of a satisfactory outcome. For a given tibial placement we wanted to determine whether placing the graft on the average of the most isometric femoral line, a fixed distance from the outlet of the intercondylar notch, would return normal laxity to all knees. The three-dimensional kinematics of seven cadaveric knees were measured for angles from full extension to 90 degrees of flexion at 15 degrees increments. Physiologic levels of quadriceps muscle forces were applied to the intact knee, after transection of the anterior cruciate ligament, and after ligament reconstruction with a patellar tendon graft. On average, the reconstruction was found to return anterior-posterior translation, internal-external rotation, and varus-valgus rotation to levels not significantly different from those of the intact knee. However, the ranges of the translation and rotations were large. Placing the graft on the average most isometric femoral line did not restore knee laxity to normal in all knees. This supports the need to customize graft placement in each knee at the time of surgery.

Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Five- to nine-year follow-up evaluation

We retrospectively reviewed the results of 97 patients with anterior cruciate ligament reconstructions using an arthroscopically assisted two-incision technique without extraarticular augmentation at an intermediate followup of 5 to 9 years postoperatively. Evaluation included detailed history, physical examination, functional testing, KT-1000 arthrometer measurements, multiple scoring systems, and radiographs. The results were compared with those from a previous study that evaluated a smaller patient cohort using the identical surgical technique at a 2- to 4-year followup. The postoperative physical examination and KT-1000 arthrometer results were statistically improved when compared with preoperative findings. A negative pivot shift result was noted in 83% of patients, and a 1+ result in 17% of patients. Seventy percent of patients had < 3 mm difference on manual maximum side-to-side testing. Functional testing averaged less than 2% asymmetry for vertical jump, single-legged hop, or timed 6-meter hop. The Tegner activity level was significantly improved from prereconstruction ratings and similar to preinjury ratings. The mean Lysholm score was 87. The modified Hospital for Special Surgery scores resulted in good or excellent results in 82% of the patients (mean, 87 points). The mean Noyes sports function score was 89, and the reoperation rate for a symptomatic knee flexion contracture was 12%. Ninety-seven percent of patients indicated that they would undergo the procedure again. When compared with this same population at 2 to 4 years, we saw no deterioration in scoring scale results.

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.

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.

The effects of knee reconstruction on combined anterior cruciate ligament and anterolateral capsular deficiencies

We tested the effect of intraarticular reconstructions of the anterior cruciate ligament alone and in combination with extraarticular reconstructions in 10 cadaveric knees. These knees had anterior cruciate ligament deficiency alone or in combination with anterolateral capsuloligamentous deficiencies. In the knees with combined injury, intraarticular reconstruction returned anterior stability to levels not significantly different from levels found for the knees deficient in the anterior cruciate ligament alone and treated with this procedure. After intraarticular reconstruction, rotational stability of the knee with combined injuries failed to return to the levels seen in the knee with isolated anterior cruciate ligament deficiencies that underwent the same treatment. When a tenodesis with either 0 N or 22 N of tension was added to the intraarticular reconstruction in the knee with combined injuries, we found that excessive internal rotation significantly decreased at all angles of flexion, except at full extension with 0 N of tension. In addition, the extraarticular reconstruction with 22 N of tension in the tenodesis overconstrained the knee in internal rotation between 30 degrees and 90 degrees of knee flexion. The tenodesis with 0 N of tension overconstrained the knee at only 60 degrees and 90 degrees of flexion. These results suggest extraarticular reconstruction as an adjunct to the intraarticular operation for the knee with anterior cruciate ligament and anterolateral structural injuries. The results also suggest that the surgeon can affect anterior and rotational laxity by adjusting the tension in the tenodesis.

Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. A prospective, randomized clinical trial of electrical stimulation

Immediately after reconstruction of the anterior cruciate ligament, 110 patients were randomly assigned to treatment with high-intensity neuromuscular electrical stimulation (thirty-one patients), high-level volitional exercise (thirty-four patients), low-intensity neuromuscular electrical stimulation (twenty-five patients), or combined high and low-intensity neuromuscular electrical stimulation (twenty patients). All treatment was performed isometrically with the knee in 65 degrees of flexion. All of the patients participated in an intensive program of closed-kinetic-chain exercise. After four weeks of treatment, the strength of the quadriceps femoris muscle and the kinematics of the knee during stance phase were measured. Quadriceps strength averaged 70 per cent or more of the strength on the uninvolved side in the two groups that were treated with high-intensity electrical stimulation (either alone or combined with low-intensity electrical stimulation), 57 per cent in the group that was treated with high-level volitional exercise, and 51 per cent in the group that was treated with low-intensity electrical stimulation. The kinematics of the knee joint were directly and significantly (p < 0.05) correlated with the strength of the quadriceps. There was a clinically and statistically significant (p < 0.05) difference in the recovery of the quadriceps and the gait parameters according to the type of operation that had been performed: the patients who had had reconstruction of the anterior cruciate ligament with use of an autologous patellar-ligament graft did poorly compared with the other patients.

Quantitative evaluation after arthroscopic anterior cruciate ligament reconstruction. Allograft versus autograft

We measured the anteroposterior ligamentous laxity and thigh muscle power in 92 subjects who were rated as successes after they had undergone arthroscopic anterior cruciate ligament reconstruction for unilateral anterior cruciate ligament insufficiency 18 to 36 months previously. The subjects were divided into 2 groups according to the type of graft: fresh-frozen allogenic tendon (N = 47) or central one third of the ipsilateral patellar tendon (N = 45). Instrumented drawer tests in the Lachman position were performed to measure anterior tibial displacement at 200 N (anterior laxity). Thigh muscle power was isokinetically measured with a Cybex II dynamometer. Significantly more anterior laxity was found in the reconstructed knees than in the contralateral normal knees regardless of graft material (paired t-test, P < 0.01), except for the male allograft patients. Although the mean anterior laxity difference between sides for the allograft patients was less than that for the autogenous ones, analysis of variance failed to demonstrate a statistically significant difference between the 2 groups if the comparison was strictly made within the same sex. Thigh muscle tests revealed that extension torque in the reconstructed knees was significantly less than that in the contralateral knees and analysis of variance showed that knee extension torque at 60 deg/sec for the allograft patients was significantly better than that of the autograft ones (P < 0.05). We concluded that the allograft procedure is advantageous over the patellar tendon autograft in terms of better restoration of anterior stability.