Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage

A Comparison of Results in Older, Middle-aged, and Younger Patients after Primary Anterior Cruciate Ligament Reconstruction: Minimum 10-Year Follow-up

Background

Anterior cruciate ligament (ACL) reconstruction is commonly performed to prevent decreased knee function and restore stability in middle-aged and even older patients. However, few studies have compared the long-term clinical outcomes of ACL reconstruction between older, younger, and middle-aged patients. The purpose of this study was to compare the long-term clinical outcomes of ACL reconstruction in older patients with those in younger and middle-aged patients.

Methods

A total of 352 patients who underwent primary ACL reconstruction between January 2003 and March 2008 were retrospectively reviewed and classified into three groups (group A: 246 [age, 20-29 years], group B: 72 [age, 40-49 years], group C: 34 [age, 50-65 years]). The mean follow-up period was 14.2 ± 1.6 years. Clinical outcomes were evaluated and compared between groups.

Results

The differences in the range of motion, clinical scores, and stability tests were not statistically significant among the three groups. The difference in the graft failure rate among the three groups was significant (group A: 16 [6.5%], group B: 7 [9.7%], group C: 6 [17.6%]; p = 0.040). In particular, when compared between the two groups, there was a significant difference between group A and group C (p = 0.036). The 10-year survival rates were 93.5%, 90.3%, and 82.4% for groups A, B, and C, respectively (p = 0.048).

Conclusions

Although graft failure rates were higher in older patients than younger and middle-aged patients, clinical outcomes of ACL reconstruction in older patients were comparable to those of younger and middle-aged patients in terms of the range of motion, clinical scores, and stability tests at a minimum follow-up of 10 years.

Outcomes of Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years and Younger Than 30 Years

Background:

Few studies have compared the outcomes of anterior cruciate ligament (ACL) reconstruction between older patients and younger patients.

Purpose:

To evaluate the clinical and functional outcomes of ACL reconstruction with autologous hamstring tendon in patients >50 years and <30 years. It was hypothesized that the outcomes would be comparable between these age groups.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients >50 years (older group) or <30 years (younger group) who underwent ACL reconstruction surgery with autologous hamstring tendon between 2012 and 2015 at the authors’ hospital were retrospectively enrolled in this study. All patients had a minimum of 2 years of follow-up. Intraoperative findings, including cartilage and meniscal injury, were recorded, and clinical and functional outcomes were evaluated using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores. We used the paired-samples t test for statistical analysis between the 2 age groups.

Results:

A total of 67 patients and 459 patients were included in the older and younger groups, respectively. Both groups achieved significant preoperative to postoperative improvement in IKDC (older group, from 41.4 to 88.9; younger group, from 49 to 91.2), Lysholm (older group, from 49.8 to 86.1; younger group, from 50.2 to 91.8), and Tegner (older group, from 2.7 to 4.4; younger group, from 4.6 to 6.9) (P < .05 for all) scores. The change in Tegner score from preinjury to postoperatively was not statistically significant in the older group (from 4.5 to 4.4; P = .471), although it was significant in the younger group (from 7.5 to 6.9; P < .05). No between-group differences were noted in preoperative or postoperative IKDC or Lysholm scores. Both age groups reached a high rate of return to sports activity, and no major complications or ACL retears were noted in either group.

Conclusion:

Comparable results after ACL reconstruction were achieved in patients >50 years compared with patients <30 years, with a high rate of return to sports activity and a low rate of complications at the 2-year follow-up. The younger group returned to a higher Tegner score, while the older group did not.

Is There a Role for Cartilage Imaging in Athletes?

This article reviews implications for cartilage imaging in athletes in the setting of (1) acute chondral injury diagnosis, (2) evaluation and follow-up of conservative and surgical therapy, and (3) evaluation of cartilage as a surrogate for meniscal function and joint stability. Focal knee cartilage defects are common in athletic populations. Athletes with articular cartilage injury may initially be able to return to sport with conservative therapy; however, a reduction of athletic ability and progression to osteoarthritis is expected in athletes with untreated severe chondral injury. For diagnostic and pre- and postsurgical evaluation purposes, morphological magnetic resonance (MR) assessment of the articular cartilage with high-resolution protocols is crucial. Although not widely implemented for clinical use, compositional MR techniques have great potential for monitoring the development and progression of biochemical and microstructural changes in cartilage extracellular matrix before gross morphological changes occur.

Comparable clinical and functional outcomes after anterior cruciate ligament reconstruction over and under 40 years of age

PURPOSE

The aim of the present meta-analysis was to update the literature on the outcomes and complications of ACL reconstruction in patients aged 40 years and older. It has been hypothesized that patients older than 40 years of age may have comparable clinical outcomes to those of younger patients.

METHODS

A systematic review of articles from 1996 to 2018 was completed using Pubmed, Medline, Cochrane Reviews, and Google Scholar databases using the keyword terms "anterior cruciate ligament reconstruction" and "middle-aged OR elderly OR over 40 OR age factors." Functional and clinical outcomes (International Knee Documentation Committee, Lysholm and Tegner score and KT-1000 arthrometer), complication and graft failure rate were evaluated.

RESULTS

Eleven articles met inclusion criteria. In total, 306 middle-aged patients and 566 younger patients were included in this study. The mean age of patients > 40 was 49 ± 7 (range 40-75) years with a mean follow-up of 25 ± 9 months (range 12-68). The mean age of younger patients was 26 ± 2.7 (range 15-39) years with a mean post-operative follow-up of 26.7 ± 11.5 months (range 3-64). The results were slightly higher (but no significantly different) towards the younger group in terms of objective IKDC (P = n.s.), Lysholm (P = n.s.) and Tegner (P = n.s.) scores and knee laxity assessment (P = n.s.). Complication rate (P = n.s.) and graft failure (P = n.s.) were low even in this cohort.

CONCLUSIONS

The present meta-analysis shows that patients older than 40 years achieve comparable clinical outcomes to those of younger patients following primary ACL reconstruction. This evidence may push the surgeons toward a more aggressive approach in this specific cohort of patients.

LEVEL OF EVIDENCE

III.

One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures.

OBJECTIVE

To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates.

DATA SOURCES

A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases.

STUDY SELECTION

Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS.

CONCLUSION

A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.

Delayed ACL Reconstruction in Patients ≥40 Years of Age Is Associated With Increased Risk of Medial Meniscal Injury at 1 Year

BACKGROUND

Anterior cruciate ligament (ACL) tears in the pediatric and young adult ACL-deficient knee are often associated with meniscal or chondral injury with delayed time to surgery. The incidence of ACL reconstruction performed in patients aged ≥40 years is rising, and it is unclear if delayed surgery in this cohort similarly affects the health of the meniscus and cartilage.

PURPOSE

To evaluate whether delayed reconstruction in a cohort of patients aged ≥40 years is associated with an increased risk of meniscal or chondral injury.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Records of patients aged ≥40 years who underwent primary arthroscopic ACL reconstruction between 2012 and 2016 at an academic hospital were retrospectively reviewed. Patient characteristic data and time to surgery were recorded. Operative reports were analyzed for meniscal and chondral injuries as well as treatment. Patients were grouped according to time to surgery, defined as early (<90 days) or delayed (≥90 days). Logistic regression modeling was used to form associations between elapsed time to surgery and patient characteristics to meniscal and chondral damage. Additionally, risks for meniscal and chondral injury were analyzed at time points of 180 days and 1 year from injury to surgery.

RESULTS

A total of 227 patients met the study criteria: 106 patients underwent early surgery, and 121 underwent delayed surgery. The authors identified 127 medial meniscal tears and 106 lateral meniscal tears. Medial, lateral, and patellofemoral compartment chondral injury was reported in 127, 82, and 130 patients, respectively. Delayed surgery (≥90 days) was not associated with increased risk of medial or lateral meniscal tears or any chondral injury at 90 days. Each year of increased age was associated with an increased odds ratio: 1.09 ( P = .001) for medial meniscal tears, 1.06 ( P = .014) for lateral meniscal tears, 1.10 ( P = .001) for medial compartment chondral injuries, and 1.07 ( P = .007) for patellofemoral compartment chondral injuries. Additionally, each unit of increased body mass index was associated with an increased odds ratio: 1.09 ( P = .039) for medial meniscal tears and 1.14 ( P = .003) for medial compartment cartilage injury. Analysis of 180-day and 1-year time points revealed an increased risk (odds ratio, 3.47; 95% CI, 1.55-7.77; P = .002) for medial meniscal injury when surgery was delayed for >1 year.

CONCLUSION

Delayed ACL reconstruction (≥90 days) among patients aged ≥40 years was not associated with an increased risk of meniscal or chondral injury. Increasing age and body mass index were associated with higher risks of meniscal and chondral injuries in this cohort. Delay in surgery for >1 year was associated with increased risk of medial meniscal tear.

Does the Chronicity of Anterior Cruciate Ligament Ruptures Influence Patient-Reported Outcomes Before Surgery?

BACKGROUND

The time between an anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) may influence baseline knee-related and general health-related patient-reported outcome measures (PROMs). Despite the common use of PROMs as main outcomes in clinical studies, this variable has never been evaluated.

PURPOSE

To compare baseline health-related quality of life measures and the prevalence/pattern of meniscal and articular cartilage lesions between patients who underwent acute and chronic ACLR so as to provide clinicians with benchmark PROMs in 2 different patient populations with ACL injuries.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 1192 patients from the MOON (Multicenter Orthopaedic Outcomes Network) cohort who underwent primary ACLR were eligible. "Acute" ACLR was defined as <3 months (n = 853; 71.6%) and "chronic" ACLR as >6 months (n = 339; 28.4%) from injury. Patient demographics, surgical characteristics (articular cartilage injury, medial meniscal [MM] and lateral meniscal [LM] tears), and baseline PROM scores (Marx activity rating scale, International Knee Documentation Committee [IKDC] subjective form, Knee injury and Osteoarthritis Outcome Score [KOOS], and Short Form-36 Health Survey [SF-36]) were collected to determine whether the time from injury to ACLR influences (1) baseline PROMs and (2) the pattern and prevalence of concurrent articular cartilage and meniscal injuries. Analysis of covariance models were used to adjust for confounders on baseline outcome scores (age, sex, body mass index [BMI], smoking status, competition level, education).

RESULTS

The median patient age was 23 years (interquartile range [IQR], 17-35 years), 530 (44.5%) were female, and the median BMI was 25.0 kg/m² (IQR, 22.3-27.9 kg/m²); however, the chronic group was older, had a higher BMI, and consisted of fewer collegiate athletes. A significantly greater number of partial LM tears were seen in the acute group versus the chronic group (14.2% vs 6.5%, respectively; P < .001), but there were more meniscal tears overall (73.5% vs 63.2%, respectively; P = .001), complete MM tears (49.0% vs 22.5%, respectively; P < .001), and articular cartilage injuries (54.0% vs 32.8%, respectively; P < .001) in the chronic group versus the acute group. After controlling for confounders, patients in the chronic ACLR group reported a significantly lower baseline Marx score (7.75 vs 12.10, respectively; P < .001) but higher baseline IKDC, SF-36 physical functioning, and all KOOS subscale scores except the KOOS-quality of life subscale score compared to those in the acute ACLR group; however, only the KOOS-sports and recreation subscale exceeded the minimum clinically importance difference of 8 points (62.30 vs 48.26, respectively; P < .001).

CONCLUSION

After controlling for age, sex, competition level, smoking, and BMI, patients in the chronic ACLR group participated in less pivoting and cutting sports but reported better pain/function. Whether decreased activity is deliberate after an ACL injury or patients who undergo chronic ACLR are simply less active and may be treated successfully without surgery warrants further investigation. Nonrandomized studies that utilize PROMs should consider time from injury in study design and data interpretation.

Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors

BACKGROUND

The aim of this study was to update our original systematic review of return to sport rates following anterior cruciate ligament (ACL) reconstruction surgery.

METHOD

Electronic databases were searched from April 2010 to November 2013 for articles reporting the number of patients returning to sport following ACL reconstruction surgery. Return to sport rates, physical functioning and contextual data were extracted and combined using random-effects meta-analyses. Data from the original review (articles published up to April 2010) were combined with data from the updated search.

RESULTS

Sixty-nine articles, reporting on 7556 participants, were reviewed. On average, 81% of people returned to any sport, 65% returned to their preinjury level of sport and 55% returned to competitive level sport after surgery. Symmetrical hopping performance (d=0.3) and the contextual factors of younger age (d=-0.3), male gender (OR=1.4), playing elite sport (OR=2.5) and having a positive psychological response (d=0.3) favoured returning to the preinjury level sport. Receiving a hamstring tendon autograft favoured returning to competitive level sport (OR=2.4), whereas receiving a patellar tendon autograft favoured returning to the preinjury level sport (OR=1.2).

CONCLUSIONS

Returning to sport varied according to different physical functioning and contextual factors, which could warrant additional emphasis in postoperative rehabilitation programmes to maximise participation.

Knee stability after anterior cruciate ligament reconstruction in patients older than forty years: comparison between different age groups

PURPOSE

The aim of this study was to compare clinical and arthrometrical results of a series of patients older than 40 years with those of younger patients following anterior cruciate ligament (ACL) reconstruction. The hypothesis of this study was that certain biological and biomechanical factors related to middle-aged patients, ACL reconstruction would provide different results compared with younger patients.

METHODS

Thirty-six patients >40 years operated for ACL reconstruction between 2002 and 2010 were selected for this retrospective study, and results were compared with patients in two other age groups (<30 years and 30-40 years). At a minimum follow-up of two years, patients were reviewed and clinically examined subjectively and objectively according to Tegner, International Knee Documentation Committee (IKDC) classification and Lysholm evaluation scales. An arthrometric evaluation with KT-1000 was also performed.

RESULTS

No statistically significant difference was found among the three different age groups at the subjective and objective evaluations. However, the KT-1000 arthrometric study showed a statistically significant mean side-to-side difference at 30 lb with 1.8 mm [standard deviation (SD) 2.4] for patients >40 years, 2.7 mm (SD 1.8) for patients aged 30-40 years and 2.6 mm (SD 1.8) for patients <30 years.

CONCLUSIONS

Our results seem to show that ACL reconstruction is a safe and valid option for patients of all age groups, even for those >40 years. Moreover, in that group, greater knee stability was found when compared with the younger patient groups.

Isolated anterior cruciate ligament reconstruction in patients aged fifty years: comparison of hamstring graft versus bone-patellar tendon-bone graft

PURPOSE

Anterior cruciate ligament (ACL) deficiency contributes to symptomatic functional instability of the knee, regardless of age. We evaluated patient-reported clinical outcome, instrumental stability and prevalence of radiological osteoarthritis based on two homogenous patient samples aged 50 years, an average of three years after isolated ACL reconstruction.

METHODS

ACL reconstruction using a bone-patellar tendon-bone (BPTB) autograft was done in 19 patients and a four-stranded semitendinosus tendon (ST) autograft in 22 patients. Clinical and functional follow-up assessment was performed an average of 32 months after surgical treatment. Clinical and functional follow-up assessment included the International Knee Documentation Committee (IKDC) score, Tegner score and Lysholm score. Instrumental stability testing was carried out using the KT-1000™ arthrometer. The degree of degenerative changes and prevalence of osteoarthritis was based on the Kellgren-Lawrence classification.

RESULTS

Mean follow-up was 32 months (range, 28-36). Mean age was 49.4 years in both groups. The median pre-injury Tegner score was 5.5 (range, 2-8) and the median preoperative Lysholm score was 35 (range, 15-69). At two years, all variables improved significantly for both groups compared to the preoperative values (P < 0.05), with no significant intergroup differences. Approximately 76 % of patients were graded A or B according to the IKDC score in both groups. Activity level according to the scores of Tegner and Lysholm was 4.9/5.3 and 83.4/82.5 on two-year-follow up in both groups. Radiological assessment reported degenerative changes of grade I Osteoarthritis (OA) in 36 % of patients. Grade-II OA was found in 31 % of patients. Grade-III OA and grade-IV OA were found in about 24 % and 7 % of all patients, respectively. Correlation analyses showed significant relationships between conservation of knee-joint stability and clinical outcome according to the IKDC score, and activity level according to the Lysholm score (p < 0.05).

CONCLUSION

Arthroscopic ACL reconstruction using either BPTB graft or hamstring graft in appropriately selected middle-aged patients results in patient satisfaction and good clinical results, with return to a reasonable level of activity regardless of surgical method and graft choice.

[Ligament ruptures of the lower extremity in the elderly]

There is an increasing incidence of ligament ruptures of the lower extremities in older patients. This higher incidence is caused by the typical current demographic changes in the population and the higher level of activity and athletic motivation of the older people in our society. In this review we address the most important ligament ruptures of the lower extremity in the old patient. Quadriceps tendon and Achilles tendon ruptures are mostly the result of degenerative and abrasion changes. The ACL rupture on the other hand occurs spontaneously after adequate trauma and without former degenerative changes especially in highly active patients. For a differentiated treatment of the older patient with tendon ruptures, secondary diseases, an increased risk and complication profile and a potentially decreased compliance during rehabilitation must be taken into consideration before indicating operative or conservative therapy. There are no strict age-related limitations for indication of an operative treatment of tendon ruptures in the older patient. In this patient group a differentiated treatment decision is recommended.

Management of anterior cruciate ligament rupture in patients aged 40 years and older

The aim of anterior cruciate ligament (ACL) reconstruction is essentially to restore functional stability of the knee and to allow patients to return to their desired work and activities. While in the young and active population, surgery is often the best therapeutic option after an ACL tear, ACL reconstruction in middle-aged people is rather more controversial due to concerns about a higher complication rate. The purpose of our article is to establish, through a systematic review of the literature, useful decision-making criteria for the management of anterior cruciate ligament rupture in patients aged 40 years and older, guiding surgeons to the most appropriate therapeutic approach. Various reports have shown excellent results of ACL reconstruction in patients over the age of 40 in terms of subjective satisfaction, return to previous activity level, and reduced complication and failure rates. Some even document excellent outcomes in subjects of 50 years and older. Although there are limited high-level studies, data reported in the literature suggest that ACL reconstruction can be successful in appropriately selected, motivated older patients with symptomatic knee instability who want to return to participating in highly demanding sport and recreational activities. Deciding factors are based on occupation, sex, activity level of the subject, amount of time spent performing such highly demanding activities, and presence of associated knee lesions. Physiological age and activity level are more important than chronological age as deciding factors when considering ACL reconstruction.

Single-stage anterior cruciate ligament revision with bone-patellar tendon-bone: a case-control series of revision of failed synthetic anterior cruciate ligament reconstructions

PURPOSE

The purpose of this study was to investigate the clinical results of single-stage revision anterior cruciate ligament reconstruction (ACLR) after synthetic ligament failure.

METHODS

The subjects comprised 20 patients who underwent revision ACLR after synthetic ligament failure. All revisions were performed with bone-patellar tendon-bone graft, and bone tunnel expansion after removal of synthetic materials was treated with bone plugs sized and trimmed as necessary to fill the bone tunnels. Clinical results were assessed at a mean of 2.8 years postoperatively, followed by comparison with the results of 20 primary ACLRs selected as case-matched controls. Assessment included the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, instrumented laxity testing, and radiologic examination.

RESULTS

Bone tunnel enlargement to 11 mm in diameter or greater was found in 10 of 20 revision ACLRs. However, favorable anteroposterior stability was obtained at final follow-up (1.4 +/- 2.0 mm in revision ACLR group and 1.5 +/- 1.5 mm in primary ACLR group). The overall Lysholm score improved significantly from preoperatively to final follow-up, but the revision ACLR group showed significantly worse results for the pain parameter than the primary ACLR group. The final IKDC results also showed significant postoperative improvement, but the number of cases with grade C was significantly higher in the revision ACLR group than in the primary ACLR group, which was attributed to radiologically confirmed osteoarthritis in the revision ACLR group.

CONCLUSIONS

Single-stage revision ACLR with bone-patellar tendon-bone graft after synthetic ligament failure yielded favorable results in terms of IKDC grade, Lysholm score, and anteroposterior stability, despite enlarged bone tunnels after removal of synthetic material. Inferior results for the radiologic and pain parameters of the IKDC and Lysholm scores were attributed to osteoarthritic changes inherent to the revision ACLR group.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Anterior cruciate ligament reconstruction improves activity-induced pain in comparison with pain at rest in middle-aged patients with significant cartilage degeneration

BACKGROUND

Recent reports revealed that outcomes of anterior cruciate ligament (ACL) reconstruction in middle- or old-age patients are comparable with those of young patients. However, in case of concomitant arthrosis in the affected knee, there has been a paucity of literature regarding the outcomes of ACL reconstruction. We studied the level of improvement in pain originating from significant cartilage degeneration in middle-aged ACL-deficient patients after ACL reconstruction. We divided the pain into pain at rest and activity-induced pain.

HYPOTHESIS

The activity-induced pain would be more improved by ACL reconstruction than the pain at rest.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We studied 36 patients who had undergone arthroscopic isolated ACL reconstruction for functional instability with significant cartilage degeneration grade III or IV without mensical injury. All patients had activity-induced pain; 20 of these patients also had pain at rest. To assess the pain level, the visual analog scale (VAS) was employed, in addition to radiologic and clinical evaluations such as the Lachman test, KT-2000 arthrometer, and pivot shift test. The mean age of the patients was 48.6 years (range, 41-61 years); mean follow-up was 46.7 months (range, 27-74 months).

RESULTS

The preoperative mean VAS of the activity-induced pain (4.1 +/- 1.0; range, 2-6) showed significant improvement at the most recent follow-up (2.0 +/- 1.0; range, 0-4; P < .0001). However, the preoperative mean VAS of the pain at rest (2.9 +/- 0.9; range, 2-5) did not improve significantly at the most recent follow-up (2.5 +/- 0.8; range, 1-4; P = .149). The Lachman test, KT-2000 arthrometer, andpivot shift test showed significant improvement compared with preoperative outcomes (P < .0001). There was no significant difference in radiologic assessment between preoperative and postoperative outcomes (P = .082).

CONCLUSION

Anterior cruciate ligament reconstruction in middle-aged patients with significant cartilage degeneration is effective in reducing activity-induced pain and instability. Even though all patients had less than severe arthritic changes on preoperative radiographs, the pain at rest did not improve after ACL reconstruction.

Anterior cruciate ligament reconstruction and concomitant articular cartilage injury: incidence and treatment

PURPOSE

Articular cartilage injuries commonly occur in conjunction with anterior cruciate ligament (ACL) injury. The exact incidence of this combined injury pattern, as well as the optimal treatment for it, has not been well studied in the literature. The purpose of this study was to systematically review the literature regarding the incidence of concomitant articular cartilage and ACL injury and the results of combined surgical treatment of these injuries.

METHODS

We performed a systematic review of studies investigating the incidence of articular cartilage injury in conjunction with ACL injury and the results of combined surgical treatment for these injuries.

RESULTS

On the basis of 5 studies in the literature, the incidence of severe articular cartilage injury in acute ACL tears is between 16% and 46%. On the basis of 3 studies on combined osteochondral autografts and ACL reconstruction and 2 studies on combined autologous chondrocyte implantation and ACL reconstruction, patients can have reasonable short-term outcomes after combined surgery.

CONCLUSIONS

Articular cartilage injury is often encountered at the time of ACL reconstruction, and combined surgery can result in reasonable outcomes. Additional studies are needed to better define both the incidence of combined injury and the outcome, particularly in the long term, after these procedures.

Volumetric injury of the physis during single-bundle anterior cruciate ligament reconstruction in children: a 3-dimensional study using magnetic resonance imaging

PURPOSE

To determine the volume of injury to the physis during anterior cruciate ligament (ACL) reconstruction in pediatric patients.

METHODS

Magnetic resonance imaging scans of 10 pediatric knees were converted into 3-dimensional models. Computer-aided design/computer-aided manufacturing software placed drill holes (6, 7, 8, and 9 mm in diameter) in these models, simulating tunnels used for ACL reconstruction. The software was used to calculate total physeal volume and volume of physis removed by the tunnel. The ratio of physeal volume removed to the total physeal volume was determined.

RESULTS

For 6-, 7-, 8-, and 9-mm-diameter drill holes, the mean percent of physeal volume removed/total physeal volume was 1.6%, 2.2%, 2.9%, and 3.8%, respectively, for the tibia and 2.4%, 3.2%, 4.2%, and 5.4%, respectively, for the femur. For all subjects, the volume removed was less than 7.0% for the tibia and 9.0% for the femur by use of drill holes from 6 to 9 mm. The tibial drill hole was centrally placed in all cases compared with a more peripheral drill hole placement of the femur.

CONCLUSIONS

Drill hole placement during ACL reconstruction produces a zone of physeal injury. The overall volume of injury is relatively low, which reduces the risk of physeal arrest. With careful drill hole placement, the region of injury is central on the tibia, and the total volume of injury can be less than 5.0% of the physeal volume. For the femur, the total volume can be less than 5.0% as well. However, the region of injury is peripheral, which carries a higher risk of physeal arrest.

CLINICAL RELEVANCE

A better understanding of the relation between the ACL and physis may guide the placement of drill holes, which have a lower risk of producing physeal arrest.

Effects of articular cartilage and meniscus injuries at the time of surgery on osteoarthritic changes after anterior cruciate ligament reconstruction in patients under 40 years old

INTRODUCTION

The development of osteoarthritis (OA) after anterior cruciate ligament (ACL) reconstruction is an unsolved problem. Articular cartilage and meniscus injuries are particularly important factors that contribute to OA progression.

AIM

The purpose of this study was to investigate how articular cartilage and meniscus injuries at the time of surgery affected the development of OA under limited conditions retrospectively. Exclusion criteria of this study were (1) age 40 years or over, (2) previous surgery, (3) another combined knee ligament injury, and (4) unstable reconstructed knees.

MATERIAL

This study included 49 knees in 46 patients (average 26 years; range, 13-39 years) who had undergone isolated ACL reconstruction. Mean follow-up period was 3.9 years (range, 2-8 years). We classified patients into two groups, cartilage-damaged and non-damaged. Patients were also classified into two groups on the basis of treatment for meniscus: meniscectomy group and meniscus intact group. OA changes were investigated using weigh-bearing anteroposterior radiographs taken before surgery and at evaluation. OA changes were evaluated in terms of joint space narrowing, atrophy, sclerosis, cysts, spurs, flattening of the femoral condyle, concavity of the tibial condyle, and sharpening of the eminence. Each parameter was scored, and the total number of points was recorded as the OA score.

RESULTS

Differences between the preoperative OA score and that at evaluation were defined as the increase of the OA score. OA progressed in 28 knees (57%). OA score was higher at evaluation than before surgery (P < 0.001). In the cartilage-damaged group, the Lysholm score at evaluation was lower (P < 0.05) and the increase in the OA score was higher than in the non-damaged group (P < 0.05). The increase in the OA score was higher in the meniscectomy group (P < 0.05).

CONCLUSION

We concluded that patients with cartilage damage and who had undergone meniscectomy show more progression of OA. These patients require long-term follow-up.

LEVEL OF EVIDENCE

Level 4, case series, therapeutic studies, investigating the results of treatment.

Anterior cruciate ligament reconstruction after 10 to 15 years: association between meniscectomy and osteoarthrosis

PURPOSE

To evaluate the stability and arthrosis of the knee 10 to 15 years after arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction with patellar tendon graft.

METHODS

From July 1986 to March 1991, 82 patients underwent arthroscopic-assisted ACL reconstruction with patellar tendon graft. Of these, 62 returned for follow-up evaluation between November 2000 and April 2001. Four different physicians, blinded to each other's examination findings, evaluated the radiologic as well as surgical results according to the International Knee Documentation Committee criteria and the Lysholm knee scoring scale.

RESULTS

There were 47 male and 15 female patients. The mean period between injury and surgery was 16 months (range, 2 weeks to 8 years). Results of radiographs were compared with the finding of meniscal lesions during surgery and with International Knee Documentation Committee test results. A statistically significant association (P < .0001) was found between medial or lateral arthrosis of the knee and meniscal injury. In all patients the presence of tears in both menisci was associated with osteoarthrosis in both compartments (medial and lateral).

CONCLUSIONS

In patients who underwent arthroscopic-assisted ACL reconstruction with patellar tendon graft who also had medial or lateral meniscectomy (or both), arthrosis of the respective compartments developed by 10 to 15 years after reconstruction. Meniscectomy was also associated with poorer results on objective tests of knee function, even with a stable knee joint.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft

We studied 58 knees that underwent anterior cruciate ligament (ACL) reconstruction using a patella tendon autograft. The mean age at reconstruction was 30.4 (18-58) years, and the average follow-up was 11.2 (8.6-13.8) years. The presence of osteoarthritis was assessed radiographically using Kellgren and Lawrence's classification. Osteoarthritis was detected in the medial compartment in 25 cases and in the lateral compartment in 14 cases. Significant independent predictors of osteoarthritis were: accompanying meniscal injury [odds ratio (OR) 9.19), p<0.001], an interval of more than 6 months from injury to reconstruction (OR 4.77, p=0.021), and age more than 25 years at reconstruction (OR 3.37, p=0.034). However, no statistically significant correlation was found between the development of osteoarthritis and clinical outcome or radiological stability.

Treatment of anterior cruciate ligament injuries, part I

Anterior cruciate ligament injuries are common among athletes. Although the true natural history remains unclear, anterior cruciate ligament injuries are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. This article, the first in a 2-part series, was initiated with the use of the PubMed database and a comprehensive search of articles that appeared between January 1994 to the present, using the keywords anterior cruciate ligament. A total of 3810 citations were identified and reviewed to determine the current state of knowledge about the treatment of these injuries. Articles pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of anterior cruciate ligament injury, the natural history of the anterior cruciate ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, risk factors for anterior cruciate ligament injury, indications for treatment of anterior cruciate ligament injuries, and nonoperative and operative treatments were obtained, reviewed, and served as the basis for part I. Part II, to be presented in another issue of this journal, includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after reconstruction, and the effect of sex, age, and activity level on the outcome of surgery. Our approach was to build on prior reviews and to provide an overview of the literature for each of the before-mentioned areas of study by summarizing the highest level of scientific evidence available. For the areas that required a descriptive approach to research, we focused on the prospective studies that were available; for the areas that required an experimental approach, we focused on the prospective, randomized controlled trials and, when necessary, the highest level of evidence available. We were surprised to learn that considerable advances have been made during the past decade regarding the treatment of this devastating injury.

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

PURPOSE

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

TYPE OF STUDY

Case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, Case Series.

Functional tissue engineering parameters toward designing repair and replacement strategies

Abnormal joint kinematics and loads induced after soft tissue injuries are assumed to contribute to long-term degenerative joint disease and osteoarthritis. Controlling abnormal kinematics after repair and reconstruction of these injured structures would seem to be important for limiting wear of the articular cartilage surfaces. In this paper, we propose to expand the paradigm of functional tissue engineering to more fully characterize normal joint function and to establish design parameters for soft tissue repair and reconstruction to ultimately protect joint surfaces after surgery. Structure-function relationships are examined for tissues of increasing complexity, from tendons to menisci. Emphasis is placed on understanding normal in vivo function of tissues by conducting biomechanical experiments in vitro that better mimic in vivo conditions. This process yields nine classes of functional tissue engineering parameters: differential fiber length, in vivo force and displacement, variations in relative attachment site locations, loading from adjacent structures, fiber interactions, types of insertion, regional variations in material properties, nonparallel fiber orientations, and complex loading within the structure. These functional tissue engineering parameters are useful not only for understanding the function of normal tissues but for more effectively designing their repair and replacement. This paper concludes with a discussion of research directions that investigators might take to establish tissue-specific functional tissue engineering parameters for improving joint function and reducing articular surface degradation and osteoarthritis.

Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. A new and innovative procedure

BONE--PATELLAR TENDON: The "no hardware" technique for ACL reconstruction is a new method that offers many advantages and is straightforward to perform. Its main innovative feature is that it does not require bone-block harvesting from the patella. This reduces donor site morbidity and prevents patellar fractures. The bone tunnels are made using tube harvesters and compaction drilling. This minimizes trauma and obviates the risk of bone necrosis. The articular entrance of the tibial tunnel is completely occupied by the grafts. This prevents a windshield-wiper effect and synovial fluid ingress into the tunnel, and enhances graft incorporation. The fact that no hardware is used with both patellar tendon or hamstring grafts significantly reduces the overall cost of the operation and facilitates revision surgery. The quadriceps tendon is also a very good graft. It is thick and has good biomechanical properties and low donor site morbidity. Its disadvantages are: weakness of quadriceps after the operation, an unsightly scar, and some difficulty in graft harvesting [58]. Also, postoperative MRI is not fraught with the problem of metal artifacts. It is difficult to decide which of the methods currently available for ACL reconstruction is the best because most of them give satisfactory results. In the future, assessments of knee ligament reconstruction techniques should look at long-term stability combined with low complication rates. Ease of revision surgery and low cost should also be taken into consideration, given the large annual volume of knee ligament reconstructions (50,000 in the United States alone) [59]. We believe that our technique addresses most of these issues, and that it constitutes a useful alternative method for ACL reconstruction. SEMITENDINOSUS--GRACILIS: This technique, which was used with 915 patients from June 1998 to February 2002, shows a particularly low rate of postoperative morbidity. The reason is probably to be found in the "waterproofing" of the bone tunnels, which lead to less postoperative bleeding and swelling. No drains were used. Rehabilitation follows the same protocol as used for the reconstruction using patellar tendon grafts (accelerated/functional). As expected, there was no widening of the femoral tunnels and little widening of the tibial tunnels. Interestingly, tibial tunnel enlargement was significantly less in a nonaccelarated rehabilitation group than in the accelerated group [60] without affecting stability. The measured internal torque of the hamstrings, as well as their flexion force, already had returned to normal 12 months postoperatively. In a prospective randomized (unpublished) study comparing this technique with ACL reconstruction with BPT grafts with medial or lateral third with only one bone plug (from the tibial tuberosity, see technique described above), we found no significant difference between both groups in subjective scores, stability, KT-1000 values, Tegner activity score, and IKDC at 1-year follow-up. Only the results of kneeling and knee walking testing were significantly better in the hamstring group [61]. In summary, the advantages of this presented technique are: (1) the knot of the graft is close proximally to the anatomic site of the insertion of the ACL, thus avoiding the Bungee effect.; (2) the press-fit tunnel fixation prevents synovial fluid entering the bone tunnels, windshield-wiper effect, and longitudinal motion within the tunnel; the intensive contact between the bony wall of the tunnel and graft collagen over a long distance without any suture material results in quick and complete graft incorporation; and (3) no fixation material means no hardware problems, facilitates revision surgery, and lowers overall costs.

Meniscal and Chondral Loss in the Anterior Cruciate Ligament Injured Knee

Rupture of the anterior cruciate ligament (ACL) of the knee is a commonly occurring injury in the athletic population. Associated meniscal and chondral injury is well recognised. This occurs both at the time of index injury and also secondarily over time in the ACL-deficient knee as a result of several related pathways culminating in osteoarthritis. ACL reconstruction is a well established surgical technique for treatment of symptomatic instability in ACL-deficient knees but the role of ACL reconstruction in the prevention of osteoarthritis remains unclear. This article reviews the contemporary literature on the pathophysiology of chondral and meniscal loss in ACL-injured knees and the role of current treatment techniques, including surgical reconstruction of ligamentous, meniscal and chondral pathology, in altering the natural history of the ACL-deficient knee.

Anterior cruciate ligament reconstruction in patients with or without accompanying injuries: A re-examination of subjects 5 to 9 years after reconstruction

PURPOSE

The purpose of this study was to compare the clinical and radiologic results of an anterior cruciate ligament (ACL) reconstruction in patients with an isolated ACL tear and patients with an ACL tear and accompanying injuries.

TYPE OF STUDY

A retrospective investigation.

METHODS

Seventy-two patients who did not have previous knee surgery or surgery of the contralateral knee were re-examined 5 to 9 years after the primary ACL reconstruction. The clinical assessment was made using the International Knee Documentation Committee (IKDC) evaluation system, and the Lysholm and the Marshall knee scores. Also, radiographic evaluation and isokinetic strength testing were performed. There were 34 patients (25 men and 9 women) with an isolated ACL tear (group A), and 38 patients (23 men and 15 women) with an ACL tear and accompanying injuries (group B). The mean age was 29 years (SD 9; range, 15 to 49 years) in group A, and 34 years (SD 12; range, 15 to 61 years) in group B. Bone-patellar tendon-bone autograft with mini-arthrotomy technique and screw fixation was used in all patients. Postoperative rehabilitation was also similar in both groups. In group B, 10 medial and 12 lateral (partial or subtotal) arthroscopic meniscectomies were performed at the same time as the ACL reconstruction. Also, 18 of the 19 medial collateral ligament ruptures, the 2 lateral collateral ligament ruptures, and the 1 posterior cruciate ligament rupture were treated surgically at this operation.

RESULTS

Subjectively (overall assessment, pain, swelling, and giving way of the knee) and objectively (range of motion, stability, crepitation, isokinetic strength testing, and radiological changes of the knee), the groups did not have any significant differences in the 5- to 9-year results. Also, the final evaluation results using the IKDC and the Lysholm and the Marshall knee scores were similar in both groups. However, there were significantly more subsequent knee surgeries in the injured knee in group B than in group A.

CONCLUSIONS

Our results show no large differences between patients with an isolated ACL tear and those with an ACL tear with accompanying injuries 5 to 9 years after an ACL reconstruction with a bone-patellar tendon-bone autograft. Tibiofemoral osteoarthritis was quite rare, and this may be partly attributable to the fact that the ACL reconstructions were successful, so that all the knees were stable at the re-examination. However, the future will show the final outcome for the patients.

Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts

BACKGROUND

A prospective study was done to determine the functional results, patient satisfaction, and graft failure rate after fifty-seven consecutive revision replacements of the anterior cruciate ligament with use of a bone-patellar tendon-bone autogenous graft.

METHODS

Fifty-four patients (fifty-five operations) were followed in this study. Concurrent operative procedures were performed during the revision procedure in thirty-seven knees (67%). These procedures included repair of a meniscal tear in twenty knees (36%) and reconstruction of deficient posterolateral or medial ligament structures in seventeen knees (31%). Nine knees (16%) had a high tibial osteotomy to correct varus malalignment before the revision operation. The results were evaluated with the Cincinnati Knee Rating System.

RESULTS

There were significant improvements in the scores for pain (p < 0.0001), activities of daily living (p < 0.01), sports participation (p < 0.001), patient satisfaction (p < 0.0001), and overall rating of the knee (p < 0.0001). Thirty-three (60%) of the replaced ligaments were functional, nine (16%) were partially functional, and thirteen (24%) had failed.

CONCLUSIONS

Many knees (93%) had compounding problems, including articular cartilage damage, prior meniscectomy, loss of secondary ligament restraints, varus malalignment, and concomitant ligament replacement or meniscal repair. Therefore, the results were generally less favorable than those following primary operations. The rate of graft failure was three times higher than our previously reported failure rate after primary replacements of the anterior cruciate ligament with a bone-patellar tendon-bone autogenous graft. Even so, symptoms and functional limitations with regard to daily and sports activities were found to have decreased and patient satisfaction improved. We advocate correction of varus malalignment prior to anterior cruciate procedures. Associated posterolateral ligament deficiencies should be surgically corrected during anterior cruciate procedures to prevent excessive loading on the graft from abnormal lateral tibiofemoral joint opening. Meniscal tears, including complex tears that extend into the avascular zone, can be concurrently repaired successfully during the revision.

Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon

We studied patients who underwent primary anterior cruciate ligament reconstruction using either the contralateral (N = 434) or ipsilateral (N = 228) autogenous patellar tendon graft to determine the difference between groups for the return of range of motion, quadriceps muscle strength, and return to sports. The contralateral group had statistically significantly more flexion than the ipsilateral group at 1 week and 2 weeks postoperatively. The contralateral group had statistically significantly greater quadriceps muscle strength in the reconstructed knee at 1, 2, and 4 months postoperatively and in the donor knee at 1 and 2 months postoperatively. Mean KT-1000 arthrometer results were 1.9 +/- 1.3 mm for the contralateral group and 2.2 +/- 1.1 mm for the ipsilateral group. The mean time to return to sports at full capability in a competitive subgroup was 4.1 months for contralateral patients and 5.5 months for ipsilateral patients. Overall, 49% of patients in the contralateral group and 12% of patients in the ipsilateral group returned to their preinjury levels of activity by 4 months postoperatively. Our results indicate that the contralateral patellar tendon can be used to restore range of motion and strength sooner than an ipsilateral patellar tendon graft. Patients can also have a faster return to full capability in sports without compromising ultimate stability.

Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations

We sought to determine how the status of the meniscus and articular cartilage observed at the time of anterior cruciate ligament reconstruction affects results at 5 to 15 years after surgery. Objective follow-up was obtained on 482 patients at a mean of 7.6 years after surgery. Subjective follow-up was obtained on 928 patients at a mean of 8.6 years after surgery. Patients with both menisci present had significantly better KT-1,000 arthrometer scores than did patients with any part of the medial or both menisci removed. Stepwise regression analyses determined that a partial or total medial or lateral meniscectomy and damaged articular cartilage significantly lowered the final subjective total score. Patients with both menisci present and normal articular cartilage had a mean subjective total score of 94, and 97% had normal or near normal radiographic ratings on a weightbearing 45 degrees posteroanterior radiographs. The overall International Knee Documentation Committee rating was normal or nearly normal for 204 of 235 patients (87%) with both menisci present, 52 of 74 patients (70%) with partial or total lateral meniscectomies, 71 of 113 patients (63%) with partial or total medial meniscectomies, and 36 of 60 patients (60%) with both menisci removed. We concluded that the long-term subjective and objective results of a successful anterior cruciate ligament reconstruction are affected by the status of the menisci and articular surface.

Technical pitfalls of anterior cruciate ligament surgery

Anterior cruciate ligament (ACL) reconstruction is extremely common. Although the number of primary reconstructions is increasing, failures and revision procedures continue to occur at approximately the same frequency. ACL reconstruction is a technically difficult procedure, and many failures can be attributed to surgical error. This article addresses the causes for failure of primary ACL reconstruction that lie within the surgeon's control. Preoperative assessment, surgical technique, and rehabilitation are addressed.

The anterior cruciate ligament and arthritis

In this article, the authors assess the natural history of osteoarthritis in the anterior cruciate ligament deficient knee, and examine the factors which may influence its progression: meniscal resection, osteochondral lesions, malalignment, concomitant ligamentous pathology, biological factors, and surgery. The role of anterior cruciate reconstruction, high tibial osteotomy in the coronal and sagittal plane, meniscal allografts, and combined procedures will be reviewed. Finally, the authors' approach to this increasingly common problem is presented.

The effect of exercise and rehabilitation on anterior-posterior knee displacements after anterior cruciate ligament autograft reconstruction

We studied the effect of rehabilitation strength training and return to activities on anterior-posterior knee displacements after patellar tendon autogenous anterior cruciate ligament reconstruction. A total of 938 measurements were sequentially collected for 142 patients with the KT-2000 arthrometer. Rehabilitation included immediate knee motion and early weightbearing, light sports at 6 months, and competitive sports at 8 months or later. At a minimum of 2 years after surgery, 121 patients (85%) had normal displacements (less than 3 mm of increase at 134 N), 14 (10%) had 3 to 5.5 mm of increase (partial function), and 7 (5%) had more than 5.5 mm of increase (failed). There was no association found between the initial onset of the abnormal displacements in the 21 knees and either the amount of time after surgery or the rehabilitation program. Six of the seven grafts that failed did so in the 1st postoperative year. Serial displacement measurements allow early detection of graft stretching and subsequent modification of rehabilitation or delay in return to strenuous activities. These measurements showed that the rehabilitation program used in this study was not itself injurious and resulted in an acceptable failure rate of 5%.