Locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency

Meniscal Tear Management Associated with ACL Reconstruction

Meniscal lesions often occur in association with anterior cruciate ligament (ACL) tears at the moment of the injury or, secondarily, as a consequence of knee instability. Both ACL and meniscus lesions are associated with a higher risk of osteoarthritis. Adequate treatment of these lesions reduces the rate of degenerative changes in the affected knee. Meniscal tears should be addressed concomitantly with ACL reconstruction and the treatment must be oriented towards preserving the meniscal tissue anytime this is possible. Several options for approaching a meniscus tear are available. The meniscal suture should always be considered, and, if possible, meniscectomy should be the last choice. “Masterly neglect” is a valuable option in selected cases.

Single-stage repair of displaced bucket-handle meniscal tears with anterior cruciate ligament reconstruction leads to good meniscal survivorship : a retrospective cohort study

AIMS

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

METHODS

We reviewed the data for a consecutive series of 88 patients (mean age 27.1 years (15 to 49); 65 male (74%) and 23 female (26%)) who underwent single-stage repair of a displaced BH meniscal tear (67 medial (76%) and 21 lateral (24%)) with concomitant hamstring autograft ACLR. The patient-reported outcome measures (PROMs) EuroQol visual analogue scale (EQ-VAS), EuroQol five-dimension health questionnaire (EQ-5D), Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), and Tegner score were recorded at final follow-up. A Kaplan-Meier survival analysis was performed to estimate meniscal repair survivorship. Analyses were performed with different cut-offs for meniscal and ACL injury-to-surgery time (within three weeks, three to ten weeks, and more than ten weeks).

RESULTS

Meniscal repair survivorship at a median final follow-up of 55 months (interquartile range (IQR) 24 to 91) was 82% (95% confidence interval 70 to 89). A total of 13 meniscus repairs failed (12 requiring meniscectomy and one requiring a further meniscal repair). At final follow-up, median PROMs were: EQ-VAS 85 (IQR 75 to 90), EQ-5D Index 0.84 (IQR 0.74 to 1.00), KOOS Pain 89 (IQR 80 to 94), KOOS Symptoms 82 (IQR 71 to 93), KOOS Activities of Daily Living 97 (IQR 91 to 100), KOOS Sport and Recreation 80 (IQR 65 to 90), KOOS Quality of Life 69 (IQR 53 to 86), IKDC 82.8 (IQR 67.8 to 90.8), and Tegner 6 (IQR 4 to 7). Two patients underwent revision ACLR following further injuries. One patient had an arthroscopic washout for infection at 11 days post-BH meniscal repair/ACLR. Four patients (4.5%) required a further procedure for stiffness, reduced ROM, and pain, and all were operated on within three weeks of meniscal injury. There was no difference in the interval between meniscal injury and surgery between repairs that failed and those that survived.

CONCLUSION

These data suggest that concomitant ACLR with repair of displaced BH meniscal tears, even if they have been displaced for some time, appears to afford satisfactory PROMs and good survivorship. Repairs within three weeks of meniscal injury may be associated with higher rates of postoperative reintervention for stiffness. Cite this article: Bone Joint J 2022;104-B(6):680-686.

Significant risk of arthrolysis after simultaneous anterior cruciate ligament reconstruction and treatment of dislocated bucket-handle meniscal tear

INTRODUCTION

Postoperative stiffness is a feared complication after anterior cruciate ligament (ACL) reconstruction. In case of associated dislocated bucket-handle meniscal tear (BHMT), reduction is urgent, with ligament reconstruction in the same surgical step.

HYPOTHESIS

Treatment of associated dislocated BHMT in ACL reconstruction incurs increased risk of arthrolysis for stiffness in flexion and/or extension.

MATERIAL AND METHODS

A retrospective exposure/non-exposure study included 208 patients undergoing ACL reconstruction between January 2009 and December 2018. Those showing dislocated medial or lateral BHMT at surgery (group A) were compared versus those free of meniscal lesions (group B). The main objective was to assess the risk of surgical revision for arthrolysis within 12 months. Group A included 69 patients: 40 male (58%), 29 female (42%); mean age, 29.0±11.2 years. Group B included 139 patients: 68 male (49%), 71 female (51%); mean age, 30.0±10.4 years. Patients were classified according to age of ACL tear, as acute (<6 weeks), subacute (6 weeks to 6 months), or chronic (>6 months).

RESULTS

Risk of revision surgery for arthrolysis was greater in Group A than in Group B, with 7 (10.1%) and 4 (2.9%) cases respectively (p=0.044), with 12-month arthrolysis-free survival of 89.7% (95% CI, 82.7-97.2) and 97.1% (95% CI, 94.3-99.9) respectively (p=0.023). Stiffness in flexion and extension was more frequent in Group A at 6 weeks and at 6 months (p>0.05). Risk of arthrolysis did not significantly differ according to accident-to-surgery time in the overall series (p=0.421) or specifically in Group A (p=0.887). The BHMT was sutured in 39 cases (56.5%), including 3 failures (7.7%) at 12 months' follow-up. Arthrolysis was required in 6 patients treated by meniscal suture (15.4%) and just 1 patient treated by meniscectomy (3.3%) (p=0.128).

CONCLUSION

The present study confirmed increased risk of surgical revision for arthrolysis after ACL reconstruction in case of dislocated BHMT treated in the same surgical step. Age of ACL tear and type of BHMT treatment (suture or meniscectomy) showed no impact on postoperative stiffness.

LEVEL OF EVIDENCE

IV, retrospective exposure/non-exposure cohort study.

What Is the Failure Rate After Arthroscopic Repair of Bucket-Handle Meniscal Tears? A Systematic Review and Meta-analysis

BACKGROUND

Meniscal repair has become the treatment of choice for meniscal tears, especially in the subset of bucket-handle meniscal tears (BHMTs). However, a comprehensive estimate of the corresponding failure rate is not available, thus maintaining doubts about the healing potential of these tears. Furthermore, a wide range of factors to predict high failure rates have been reported but with conflicting evidence.

PURPOSE

To determine the failure rate after arthroscopic repair of BHMTs as reported in the literature, compare this with the failure rate of simple meniscal tears extracted from the same studies, and analyze the influence of factors previously reported to be predictive of meniscal repair failure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic search was conducted by 2 independent reviewers using principal bibliographic databases (PubMed, Scopus, Cochrane Library, and EMBASE). After a stepwise exclusion process, 38 articles met the inclusion criteria. Failure rate data were analyzed with a random-effects proportional meta-analysis (weighted for individual study size), and forest plots were constructed to determine any statistically significant differences between BHMTs versus simple tears (longitudinal, radial, or horizontal), medial versus lateral BHMTs, isolated procedures versus repairs with concomitant anterior cruciate ligament reconstruction, and tears in red-red versus red-white zones. Moreover, a meta-regression analysis was conducted to evaluate the effect of patient age and sex, suture technique (in-out or all-inside), time from injury to surgery, mean number of stitches, and length of follow-up on failure rates.

RESULTS

The pooled failure rate was 14.8% (95% CI, 11.3%-18.3%; I² = 77.2%). A total of 17 studies provided failure rates of both BHMT repairs (46/311 repairs) and simple tear repairs (54/546 repairs), demonstrating a significantly higher failure rate for BHMT repairs (risk ratio [RR] = 1.50; 95% CI, 1.05-2.15; I² = 0%; P = .03). Medial BHMT repairs (RR = 1.94; 95% CI, 1.25-3.01; I² = 0%; P = .003) and isolated repairs (RR = 1.77; 95% CI, 1.15-2.72; I² = 0%; P = .009) had statistically higher risk of failure, but no statistically significant difference was found between tears in red-red versus red-white zones. Among the other factors evaluated with meta-regression, only the mean number of stitches showed a statistically significant effect on failure rates.

CONCLUSION

Based on the currently available literature, this systematic review provides a reasonably comprehensive analysis of failure rate after arthroscopic BHMT repair; failure is estimated to occur in 14.8% of cases. Medial tears and isolated repairs were the 2 major predictors of failure.

Bicompartmental Bucket Handle Meniscal Tear with Chronic ACL Deficiency Causing a Rare Triple PCL and Triple Cruciate Sign: A Case Report

CASE

A 16-year-old football player presented with chronic ACL deficiency along with bicompartmental bucket handle meniscal tears.

CONCLUSION

We present a "triple cruciate" sign in addition to the triple posterior cruciate ligament (PCL) sign seen on Magnetic Resonance Imaging (MRI) to aid in diagnosing this injury.

Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus

PURPOSE

The importance of meniscus integrity in the prevention of early osteoarthritis is well known, and preservation is accepted as the primary goal. The purpose of the ESSKA (European Society for Sports Traumatology, Knee Surgery and Arthroscopy) European consensus on traumatic meniscus tears was to provide recommendations for the treatment of meniscus tears based on both scientific evidence and the clinical experience of knee experts.

METHODS

Three groups of surgeons and scientists elaborated and ratified the so-called formal consensus process to define the recommendations for the management of traumatic meniscus tears. A traumatic meniscus tear was defined as a tear with an acute onset of symptoms caused by a sufficient trauma. The expert groups included a steering group of eight European surgeons and scientists, a rating group of another nineteen European surgeons, and a peer review group. The steering group prepared twenty-seven question and answer sets based on the scientific literature. The quality of the answers received grades of A (a high level of scientific support), B (scientific presumption), C (a low level of scientific support) or D (expert opinion). These question and answer sets were then submitted to and evaluated by the rating group. All answers were scored from 1 (= totally inappropriate) to 9 (= totally appropriate) points. Thereafter, the comments of the members of the rating group were incorporated by the steering group and the consensus was submitted to the rating group a second time. Once a general consensus was reached between the steering and rating groups, the finalized question and answer sets were submitted for final review by the peer review group composed of representatives of the ESSKA-affiliated national societies. Eighteen representatives replied.

RESULTS

The review of the literature revealed a rather low scientific quality of studies examining the treatment of traumatic meniscus tears. Of the 27 questions, only one question received a grade of A (a high level of scientific support), and another received a grade of B (scientific presumption). The remaining questions received grades of C and D. The mean rating of all questions by the rating group was 8.2 (95% confidence interval 8.1-8.4). A general agreement that MRI should be performed on a systematic basis was not achieved. However, MRI was recommended when arthroscopy would be considered to identify concomitant pathologies. In this case, the indication for MRI should be determined by a musculoskeletal specialist. Based on our data, stable left in situ lateral meniscus tears appear to show a better prognosis than medial tears. When repair is required, surgery should be performed as early as possible. Evidence that biological enhancement such as needling or the application of platelet-rich plasma would improve healing was not identified. Preservation of the meniscus should be considered as the first line of treatment because of an inferior clinical and radiological long-term outcome after partial meniscectomy compared to meniscus repair.

DISCUSSION

The consensus was generated to present the best possible recommendations for the treatment of traumatic meniscus tears and provides some groundwork for a clinical decision-making process regarding the treatment of meniscus tears. Preservation of the meniscus should be the first line of treatment when possible, because the clinical and radiological long-term outcomes are worse after partial meniscectomy than after meniscus preservation. The consensus clearly states that numerous meniscus tears that were considered irreparable should be repaired, e.g., older tears, tears in obese patients, long tears, etc. LEVEL OF EVIDENCE: II.

Arthroscopically Repaired Bucket-Handle Meniscus Tears: Patient Demographics, Postoperative Outcomes, and a Comparison of Success and Failure Cases

OBJECTIVE

To define patient demographics, preoperative, and intraoperative surgical variables associated with successful or failed repair of bucket-handle meniscal tears.

DESIGN

All patients who underwent arthroscopic repair of a bucket-handle meniscus tear at a single institution between May 2011 and July 2016 with minimum 6-month follow-up were retrospectively identified. Patient demographic, preoperative (including imaging), and operative variables were collected and evaluated. A Kaplan-Meier curve was generated to demonstrate meniscus repair survivorship.

RESULTS

In total, 75 patients (78 knees) with an average age of 26.53 ± 10.67 years met inclusion criteria. The average follow-up was 23.41 ± 16.43 months. Fifteen knees (19.2%) suffered re-tear of the repaired meniscus at an average 12.24 ± 9.50 months postoperatively. Survival analysis demonstrated 93.6% survival at 6 months, 84.6% survival at 1 year, 78.4% survival at 2 years, and 69.9% survival at 3 years. There was significant improvement from baseline to time of final follow-up in all patient-reported outcome (P < 0.05) except Marx score (P = 0.933) and SF-12 Mental Subscale (P = 0.807). The absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively was the only variable significantly associated with repair failure (P = 0.024). Concurrent anterior cruciate ligament reconstruction (vs. no concurrent anterior cruciate ligament reconstruction) trended toward significance (P = 0.059) as a factor associated with successful repair.

CONCLUSIONS

With the exception of the absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively, no other variables were significantly associated with re-tear. The results are relatively durable with 84.6% survival at 1 year. Surgeons should attempt meniscal repair when presented with a bucket-handle tear.

Outcomes After the Operative Treatment of Bucket-Handle Meniscal Tears in Children and Adolescents

Background:

Bucket-handle meniscal tears (BHMTs), which we define as vertical longitudinal tears of the meniscus with displacement of the torn inner fragment toward the intercondylar notch region, are a well-recognized tear pattern. Optimizing the management of BHMTs in younger patients is important, as preserving meniscal tissue may limit future joint degeneration.

Purpose/Hypothesis:

The purpose of this study was to review the patient demographics, clinical presentation, operative details, outcomes, and risk factors for a reoperation associated with operatively treated BHMTs in a pediatric population. We hypothesized that the repair of BHMTs in adolescents would yield a higher reoperation rate than meniscectomy in our population.

Study Design:

Case-series; Level of evidence, 4.

Methods:

A departmental database was queried to identify all patients 19 years or younger who presented with a BHMT and underwent surgery between October 2002 and February 2013. Clinical, radiological, and surgical data were retrospectively collected, and risk factors for a reoperation and persistent pain were assessed in all patients with longer than or equal to 6 months of follow-up.

Results:

A total of 280 BHMTs were treated arthroscopically by 1 of 8 sports medicine fellowship–trained surgeons. The mean age at surgery was 15.5 ± 2.5 years (range, 2.1-19.2 years), and most patients were male (177/280; 63%). Most injuries occurred during sports (203/248; 82%) and involved the medial meniscus (157/280; 56%). Concurrent anterior cruciate ligament (ACL) surgery was performed in 103 cases (37%). Meniscal repair was performed in 181 cases (65%) and was more common in younger patients (P = .01) and for the lateral meniscus (P < .001). Among 185 (66%) cases with longer than or equal to 6 months of adequate follow-up data (which included 126 meniscal repairs [68%]), a meniscus-related reoperation occurred in 45 (24%) cases. A reoperation related to the original BHMT injury or surgery was more common after meniscal repair than after meniscectomy (40/126 [32%] vs 5/59 [8%], respectively) (P = .001) and less common with concurrent ACL surgery (P = .07), although this was not statistically significant. Among patients injured during sports and with adequate follow-up, all but 1 patient (176/177; 99%) returned to sports; a slower rate of return was seen in those undergoing meniscal repair (P = .002) and concurrent ACL surgery (P < .001). At final follow-up, 170 of 185 patients (92%) were pain free. For the 15 patients with persistent pain at final follow-up, no identifiable risk factors for persistent pain were identified.

Conclusion:

Most BHMTs in younger patients occurred in males and during sports and affected the medial meniscus. Concurrent ACL surgery was indicated in approximately one-third of cases and was associated with a lower reoperation rate and slower return to sports. Two-thirds of patients underwent meniscal repair, over two-thirds of whom did not require a reoperation during the study period, despite the high activity levels in this age group.

Outcome of meniscal repair prior compared with concurrent ACL reconstruction

Meniscal tears are commonly associated with traumatic rupture of the anterior cruciate ligament (ACL). At our centre, if a patient presents with locked knee in conjunction with an ACL injury we perform an initial arthroscopy to remove the cause of locking and schedule ACL reconstruction once a full range of motion has returned. The aim of this study was to assess the outcome of meniscal tears stabilised prior to ACL reconstruction. We identified 24 patients who underwent repair of a torn meniscus before having their ACL reconstruction (group 1). As a comparison group we identified 148 patients who underwent meniscal repair at the time of ACL reconstruction (group 2). Twelve of the patients in group 1 underwent meniscectomy, seven at the time of reconstruction and five subsequently. This gives a success rate of 50% (12/24) in the ACL deficient patients. In comparison forty two of the patients in group 2 went on to have a meniscectomy representing a success of 72% (106/148). The odds ratio for meniscectomy in an ACL deficient meniscal repair is 2.52 (95% CI 1.07-5.97) and there is a relative risk of 1.76 (95% CI 1.05-2.63). The difference in success of the meniscal repair between the groups was significant (Fisher's exact test p=0.05). Meniscal repair and delayed ACL reconstruction is more likely to fail than a combined repair and ACL reconstruction.

Surgical repair of meniscal tears with concomitant anterior cruciate ligament reconstruction in patients 18 years and younger

BACKGROUND

There are sparse data available regarding outcome of meniscal repair performed at the time of ACL reconstruction in the pediatric and adolescent population.

PURPOSE

To review the results of meniscal repair performed at the time of ACL reconstruction in pediatric and adolescent patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The records of all patients age 18 years or younger who underwent meniscal repair at the time of ACL reconstruction between 1990 and 2005 were reviewed. Ninety-nine patients (56 female, 43 male) with an average age of 16 years (range, 13-18) were included. Average injury to surgery interval was 107 days (range, 2-1109). Clinical outcomes were assessed at a mean of 8 years postoperatively (range, 2-19). A multivariate model was used to compare this cohort with a previously published cohort of patients with isolated meniscal tears.

RESULTS

The clinical success rate of meniscal repair was 84% for simple tears, 59% for displaced bucket-handle tears, and 57% for complex tears (74% overall). Twenty-six menisci (26% overall) failed repair and 25 patients underwent repeat arthroscopic surgery (19 partial meniscectomies, 6 re-repairs). The average Tegner and International Knee Documentation Committee scores were 6.2 (range, 2-10) and 90.3 (range, 52-100), respectively. Risk factors for failure included complex and bucket-handle tear (P = .01), medial meniscal tears (P = .03), and skeletal immaturity (P = .01). Compared with isolated meniscal repairs in a similar pediatric and adolescent population, complex tears repaired in combination with ACL reconstruction did significantly better (57% vs 13%; P = .004).

CONCLUSION

Clinically successful repair of meniscal tears treated at the time of ACL reconstruction in patients 18 years or younger depends on tear type, with complex and bucket-handle tears being negative prognostic factors. Complex tears have a higher rate of clinical success when repaired at the time of ACL reconstruction versus when repaired in isolation.

Second-look arthroscopic evaluation of bucket-handle meniscus tear repairs with anterior cruciate ligament reconstruction: 67 consecutive cases

PURPOSE

To evaluate arthroscopic second-look bucket-handle meniscus tear (BHMT) repairs using different suturing techniques.

METHODS

Between May 2002 and September 2006, 122 consecutive cases underwent arthroscopic repair surgery, including 40 males and 24 females (63 with concurrent anterior cruciate ligament [ACL] injury and 1 isolated BHMT) having 67 (60 medial and 7 lateral) repairs available for second-look arthroscopy evaluation. Inclusion criteria for reparability included reducible tears involving red-red and red-white zone without obvious additional complex tears and tissue degeneration, and concurrent ACL injury and/or isolated BHMT. Patients were excluded if they had combined ligaments injuries other than ACL. The arthroscopic suturing techniques, classified according to different involvement of meniscus zones, consisted of typical inside-out and all-inside suture repair with suture hook.

RESULTS

In a series of 64 second-look cases with 67 repairs, which showed healing after an average of 26 months (range, 14 to 66 mos), 55 repairs (82.1%) were completely healed (and clinically asymptomatic) in 53 cases; 5 cases (5 repairs; 7.5%) had joint line tenderness (incompletely healed and clinically asymptomatic); and 7 repairs (6 medial, and 1 lateral; 10.4%) failed, with recurrent locking or catching in 4 cases (and clinically asymptomatic in 2 cases). The overall success rate, including completely healed and incompletely healed cases, was 89.6%. Four failures occurred in failed ACL-reconstructed knees.

CONCLUSIONS

For large bucket-handle meniscus tears involving red-red and red-white zones, an arthroscopic hybrid suture technique with ACL reconstruction achieves high anatomic healing results, with an overall meniscal healing rate of 89.6%, including 82.1% completely healed and 7.5% incompletely healed. The failure rate was 10.4% in the average 26-month follow-up period.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Anterior cruciate ligament injury with simultaneous locked bucket-handle tears of both medial and lateral meniscus in a 19-year-old female professional ski racer: a case report

Acute anterior cruciate ligament deficiency combined with simultaneous locked bucket-handle tears of both medial and lateral menisci have rarely been observed. This case report describes the first case of such a combined knee injury in an athlete including injury mechanism, clinical symptoms, specific signs on MRI, and treatment options.

Changes in arthroscopic findings in the anterior cruciate ligament deficient knee prior to reconstructive surgery

We retrospectively compared the arthroscopic findings of 75 patients at the time of diagnosis of ACL rupture and the findings at the time of ACL reconstruction. We found that in the ACL deficient knee the deterioration in meniscal tears and osteochondral lesions was statistically greater with increased interval between diagnosis of ACL rupture and reconstruction. This study implies that in those patients where ACL reconstruction is indicated, a delay in reconstructive surgery can have a deleterious effect on the articular surface of the knee.

Repair of locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency

BACKGROUND

Large bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency have been considered avascular and, thus, irreparable.

HYPOTHESIS

The rate of meniscal healing is higher than previously reported.

STUDY DESIGN

Prospective cohort study.

METHODS

Fifty-nine patients underwent staged surgical procedures of meniscal repair followed at an average of 77 +/- 58 days by ligament reconstruction once full range of motion was obtained.

RESULTS

Fifty-two patients with 55 meniscal repairs were available for follow-up. At reconstruction, 30 menisci (55%) appeared healed; 19 (34%), partially healed; and 6 (11%) showed no healing (only 4 were removed). Of 43 tears in the white-on-white zone, 21 appeared healed; 17, partially healed; and 5 showed no healing. Of 11 in the red-on-white zone, 8 appeared healed; 2, partially healed; and 1 showed no healing. One meniscal tear in the red-on-red zone appeared healed. At an average follow-up of 4.3 +/- 3.1 years, 36 of the 43 (83.7%) white-on-white meniscal repairs remained asymptomatic; all repairs in the other zones remained asymptomatic.

CONCLUSION

Locked bucket-handle meniscal tears heal at a high rate when repaired as an isolated procedure, even when full weightbearing and activity before reconstruction is allowed and when the tear is in the white-on-white zone.

Approach to meniscal tears in anterior cruciate ligament reconstruction

It is generally accepted that meniscus repair in a knee with persistent anterior cruciate ligament (ACL) insufficiency leads to a higher retear rate, and that meniscal repair in conjunction with ACL reconstruction is associated with a higher rate of meniscal healing compared with patients who do not undergo ACL reconstruction. In this article, we will review the background of thses concepts and present treatment strtegies for meniscal tears in ACL-insufficient knees, with particular attention to meniscal repair and meniscal allograft transplanatation.

Meniscal injury: II. Management

Meniscal repair is a viable alternative to resection in many clinical situations. Repair techniques traditionally have utilized a variety of suture methods, including inside-out and outside-in techniques. Bioabsorbable implants permit all-inside arthroscopic repairs. The success of meniscal repair depends on appropriate meniscal bed preparation and surgical technique and is also influenced by biologic factors such as tear rim width and associated ligamentous injury. Successful repair in >80% of cases has been reported in conjunction with anterior cruciate ligament reconstruction. Success rates are lower for isolated repairs. Complications related to repair include neurologic injury, postoperative loss of motion, recurrence of the tear, and infection. Meniscal allograft transplantation may provide a treatment option when meniscus salvage is not possible or when a previous total meniscectomy has been done.

Return of motion after simultaneous repair of displaced bucket-handle meniscal tears and anterior cruciate ligament reconstruction

Patients with displaced bucket-handle (DBH) meniscal tears in anterior cruciate ligament (ACL)-deficient knees are prone to flexion contracture following meniscal repair and simultaneous ACL reconstruction. It has been suggested that ACL reconstruction be delayed until full range of motion has returned after the meniscal repair. A retrospective analysis was performed comparing the return of extension in patients undergoing simultaneous ACL reconstruction and repair of DBH tears (group A) versus a control group of patients with non-DBH tears (group B). Age, sex, body mass index, duration of time from injury to surgery, and preoperative extension were also compared between groups and evaluated for their significance as risk factors. Patients in group A achieved recovery to -5 degrees and 0 degrees of extension 22% and 35% more slowly, respectively, when compared with group B. These differences were not statistically significant. Female patients tended to heal more rapidly in both groups. We conclude that a one-stage procedure is sufficient in allowing patients with DBH tears in ACL-deficient knees to regain a functional knee to within 5 degrees of full extension.

Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup

We sought to determine the long-term results of 1057 consecutive patients who underwent an anterior cruciate ligament reconstruction with an autogenous patellar tendon graft from 1987 through 1993 and who followed an accelerated rehabilitation program. The patients were followed prospectively and objective physical examination data were obtained on 806 patients at a mean of 4.0 years postoperatively. Subjective follow-up data were obtained on 948 patients at a mean of 4.4 years postoperatively. The mean final range of motion was 5 degree/0 degrees/140 degrees. The mean manual maximum KT-1000 arthrometer score was 2.0 +/- 1.5 mm. Isokinetic quadriceps muscle strength testing revealed a mean of 94% strength after acute reconstructions and 91% strength after chronic reconstructions. International Knee Documentation Committee evaluation after acute reconstruction rated 42% of knees as normal, 47% as near normal, 10% as abnormal, and 1% as severely abnormal. The same evaluation after chronic reconstruction rated 41% of knees as normal, 44% as near normal, 14% as abnormal, and 1% as severely abnormal. Radiographically, 94% of acute knees and 89% of chronic knees had no joint space narrowing. Subjective modified Noyes questionnaire results showed a mean score of 93.2 +/- 7.9 points. The mean time for patients to return to sport-specific activities was 6.2 weeks and to athletic competition at full capacity was 6.2 months postoperatively. In the long-term, patients exhibited full range of motion, excellent stability, good strength, and a return of full function in most cases.

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.

Vascular anatomy of the ovine anterior cruciate ligament. A macroscopic, histological and radiographic study

Sheep are being extensively utilized in animal models for orthopaedic research, but the vascular anatomy of their anterior cruciate ligament (ACL) has not yet been thoroughly described. This study demonstrates the blood supply to the ACL. Vascular injection with plastogen G, lead oxide and India ink was performed in 12 back limbs of Styrian mountain sheep, and gross observations, microradiography and routine histology were done. The large vessel and the microvascular anatomy are similar to those described for humans. The middle genicular artery and the descending genicular artery contribute vessels that supply the ACL. Epiligamentous vascular plexuses give off capillaries which penetrate the ligament substance and supply numerous, longitudinally oriented intraligamentous vessels. These findings make the Styrian mountain sheep a potential animal model for biologic investigations of ACL pathology.

Preventing anterior knee pain after anterior cruciate ligament reconstruction

We studied a group of 602 patients who had anterior cruciate ligament reconstructions between 1987 and 1992. An autogenous patellar tendon graft was used, regardless of preexisting patellofemoral pain or chondromalacia. The surgeon and rehabilitation protocol were the same for all patients, with emphasis on obtaining full knee hyperextension postoperatively. All patients were evaluated by a questionnaire designed to determine the incidence and severity of anterior knee pain as it relates to sporting or daily living activities, prolonged sitting, stair climbing, and kneeling. Range of motion for the study group was recorded during physical examination. We compared the findings with those from a control group of 122 patients who had no previous knee injury. The study group reported a mean score of 89.5 +/- 12.5, compared with 90.2 +/- 12.3 in the control group. Both the operative and control groups reported little or no symptoms during sporting activities (94% and 92%, respectively). No differences were noted with respect to the other activities surveyed. These results demonstrate that anterior knee pain after anterior cruciate ligament reconstruction is not an inherent complication associated with patellar tendon harvesting. We suggest that the increased incidence of anterior knee pain with an autogenous patellar tendon graft can be prevented by obtaining full knee hyperextension postoperatively. This goal can be achieved through preoperative rehabilitation and a postoperative protocol emphasizing early restoration of full knee hyperextension.

Accelerated rehabilitation after arthroscopic meniscal repair: a clinical and magnetic resonance imaging evaluation

Twenty-two patients who underwent meniscal repair using the outside-in technique combined with anterior cruciate ligament (ACL) reconstruction were submitted to an accelerated rehabilitation protocol that included immediate full range of motion and weightbearing. The patients were reviewed postoperatively by means of clinical assessment and magnetic resonance imaging (MRI) after an average of 28 months. Clinical evaluation was performed according to the International Knee Documentation Committee form, and sagittal knee laxity was measured with a KT-2000 arthrometer (MedMetric Corp, San Diego, CA). The MRI scans were obtained using a 0.2-T high-resolution MRI unit dedicated to the study of limbs, and the meniscal signal was graded according to a modified Crues classification. Overall, 77.3% of patients reported clinically good results. Loss of extension of < 5 degrees was detected in only 2 patients (9.1%). Three out of 22 patients showed clinical signs of meniscal retear. One of these patients had a second operation for a bucket-handle tear. The presence of a full-thickness rim at MRI evaluation, present in 10 patients (45.5%), did not correlate with the presence of clinical symptoms of retear. Instead, the 3 symptomatic patients presented a complete rim with a gap > 1 mm between the meniscal wall and the fragment of the posterior horn. This finding is believed to be a more reliable indicator for retear following meniscal repair. The low failure rate in this series suggests that an aggressive rehabilitation regimen may be prescribed without deleterious effects in subjects undergoing ACL reconstruction and concomitant meniscus repair.

Arthroscopic meniscal repair in conjunction with anterior cruciate ligament reconstruction: factors affecting the healing rate

Ninety-eight of 121 consecutive patients who underwent arthroscopy-assisted meniscal repair in combination with anterior cruciate ligament reconstruction were evaluated by second-look arthroscopy with an average interval of 16 months (range, 6 to 63 months). Of the 98 meniscal repairs, 73 had completely healed, 13 had incompletely healed, and 12 had not healed. Six possible factors that may have affected the healing of the repaired menisci were statistically analyzed. There were no statistically significant differences between the three groups with respect to sex, age, tear site on the medial or lateral meniscus, or residual anterior laxity as measured using the KT-1000. The factors that had a statistically significant impact on healing rate were the rim width and meniscal locking. Negative correlations with the healing rate were observed in menisci that were repaired in the central third zone and that had been locked or could be locked by probing at the time of surgery.

Anterior instability of the knee despite an intensive rehabilitation program

To investigate if an intensive rehabilitation program has a positive influence on the late course of an old, isolated anterior cruciate ligament rupture, patients were evaluated at an average of 8 years after injury. Seventy-five percent had acquired the injury during sporting activities. After diagnostic arthroscopy, which was done at an average of 163 days after the injury, the patients immediately were assigned to an intensive rehabilitation program. At the followup examination, none of the patients had an excellent result as determined by the Swiss Knee Group Score; 6 patients had a good result; 13 had a fair result; and 8 had a bad result. Fourteen patients had a partial meniscectomy during the followup period, and 4 had positive signs for meniscal lesions at the followup examination. In 52% of the patients gonarthrosis had advanced 2 stages, and in 26% it had advanced 3 stages. There was a significant correlation between worsening of gonarthrosis and previous meniscectomy, poor evaluation scores, and clinical signs of instability. Even an intensive rehabilitation program cannot prevent secondary lesions of the meniscus with ensuing joint degeneration. Thus, immediate operative reconstruction of old ruptured anterior cruciate ligaments is recommended.

Timing of surgery in anterior cruciate ligament-injured knees

Despite recent advances in the surgical techniques of anterior cruciate ligament (ACL) reconstruction in the past two decades, there is no consensus of opinion as to the ideal timing for ACL surgery. Based on the evolution of management of patients with ACL injuries over the period 1982-1994, we have found that various factors need to be considered in order to provide the best possible long-term result to the patient with minimal or no complications. In this review, we discuss the perioperative factors that one must consider to determine optimum timing for ACL surgery. Factors such as mental preparation of the patient; school, work, family, and social schedules; preoperative condition of the knee [i.e., minimal or no swelling, good strength, good leg control, and full range of motion (ROM) including full hyperextension]; and associated ligamentous and/or meniscal injuries must be considered before undertaking ACL surgery. With careful consideration of the above-mentioned factors and with our preoperative and postoperative rehabilitation program, we have been able to obtain predictable, successful, long-term results following ACL reconstruction in our athletic population. We emphasize that every patient should be treated on his or her own merit, and treatment decisions must be individualized.