Manipulation Under Anesthesia and/or Lysis of Adhesions After Anterior Cruciate Ligament Reconstruction in Female Basketball Players: Does Race Play a Role?

BACKGROUND

Arthrofibrosis can limit function and return to sport after anterior cruciate ligament (ACL) reconstruction. Previously reported risk factors for developing arthrofibrosis after ACL reconstruction include female sex, age <18 years, time from injury to surgery <28 days, concomitant meniscal repair, prolonged immobilization, and genetic factors. There is a lack of evidence regarding whether race plays a significant role.

HYPOTHESIS

The risk of undergoing manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA) after primary ACL reconstruction with bone-patellar tendon-bone (BTB) autograft in female basketball players is higher in African American players than in White players.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Using a computerized relational database, the authors identified competitive female basketball players who underwent primary ACL reconstruction with BTB autograft by the senior author over a 13-year period. Data previously entered from examinations and surgical findings were reviewed retrospectively. Univariate statistics and multivariable logistic regression were used to assess the relationship between undergoing subsequent MUA and/or LOA and study predictors.

RESULTS

A total of 186 knees (114 African American knees and 72 White knees) met inclusion criteria. The overall rate of MUA and/or LOA was 8.6%. Thirteen African American knees (11.4%) and 3 White knees (4.2%) underwent MUA and/or LOA for treatment of arthrofibrosis. No study predictor was found to have a statistically significant relationship with the rate of MUA and/or LOA on univariate analysis. However, when controlling for body mass index and previously described risk factors (age <18 years, time from injury to surgery ≤28 days, and concomitant meniscal repair) in the logistic regression model, the authors found that MUA and/or LOA was more likely in African American (odds ratio, 4.01 [95% CI, 1.01-15.92]; P = .049) than in White female players and in patients who underwent ACL reconstruction within 28 days of injury (odds ratio, 4.01 [95% CI, 1.18-13.57]; P = .026) compared with those with surgery delayed beyond 28 days.

CONCLUSION

In female basketball players, the present study found a statistically significantly increased risk for undergoing MUA and/or LOA after primary ACL reconstruction with BTB autograft in African American females compared with White females and in patients who underwent ACL reconstruction within 28 days of injury.

An Analysis of Symptomatic Meniscal Re-Tear Incidence in Two Age Populations: Differences in Older versus Younger Adults

A symptomatic meniscal tear is one of the most common problems treated by an orthopaedic surgeon. Treatment ranges from observation to complete meniscectomy. Prior research has shown that contact stresses increase within the joint compartment after partial meniscectomy, thus leading to arthritis of the compartment. The purpose of the current study was to determine the incidence of meniscal re-tears in two populations of patients and identify potential factors predisposing to re-tear. A retrospective review of our relational database identified 1,930 arthroscopic partial meniscectomies from 1993 to 2003. Meniscectomies were divided into two groups, 430 patients < 45 years of age (YOUNG) and 712 patients ≥ 45 (OLD). Age, onset date, Lysholm, Tegner, tear type, radial and circumferential location, as well as degree and location of chondromalacia, were analyzed. Of the YOUNG group, 1.16% experienced re-tears, versus 0.42% of the OLD group. From the younger re-tear group, 80% were chronic and 20% had grade 2 chondromalacia in one compartment. The YOUNG re-tear group was slightly more active with higher Tegner (5.6 vs. 4.3) and Lysholm (66.2 vs. 60) scores than the rest of the YOUNG group. The OLD re-tear group was less active with a lower Tegner (2.5 vs. 4.1) and Lysholm (62 vs. 66) score compared with the rest of the older group. In this study, patients under 45 years and with chronic tears had slightly higher incidence of re-tears. Results indicated that the lateral meniscus is more likely to re-tear.

A Meta-Analysis of Arthroscopic Meniscal Repair: Inside-Out versus Outside-In versus All-Inside Techniques

Meniscal repair has been introduced to preserve knee function and limit the accelerated degenerative changes associated with meniscal tissue resection. Arthroscopic techniques have evolved to improve morbidity. However, there are few clinical outcome studies in the peer-reviewed literature that compare the use of these approaches. Therefore, our purpose was to perform a meta-analysis of the existing literature on arthroscopic meniscal repair techniques. Specifically, we evaluated differences in: (1) operating time; (2) incidence of postoperative meniscal healing; (3) functional outcomes, using various scoring systems; and (4) incidence of complications. We searched the peer-reviewed literature using SCOPUS, Medline, EMBASE, and Web of Science. Eight studies were eligible for the meta-analysis. These included one prospective, randomized trial (level I), three prospective, comparative studies (level II), and four retrospective, comparative studies (level III). There were a total of 476 patients who had a mean follow-up between 3 and 156 months. When evaluating objective outcomes, the inside-out technique had a significantly higher mean operating time than the all-inside technique. The inside-out and all-inside techniques had comparable meniscal healing rates, but the outside-in repair had a significantly higher rate of meniscal healing than the all-inside repair. Upon assessment of functional outcomes, the inside-out and all-inside methods had comparable International Knee Documentation Committee and Tegner activity scores, but the all-inside method had greater improvements in Lysholm scores. The inside-out and all-inside repairs had similar overall complication rates. All-inside repair may demonstrate lower operating times, but the outside-in repair may have superior meniscal healing rates. Functional outcomes are overall comparable between the techniques. However, there are limited clinical data on the outcome differences between these procedures, and further comparative studies with longer follow-up are needed.

Efficacy of Two Techniques in Anterior Cruciate Ligament Reconstruction

The purpose of this study is to compare failure rate and functional outcome in young, active patients (< 25 years) with two-incision (rear-entry) versus transtibial (all-endoscopic) anterior cruciate ligament (ACL) reconstructions.Utilizing a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA), 480 patients were identified that underwent ACL reconstruction, using a bone-patellar-tendon-bone autograft, by a single surgeon between January 2000 and December 2010 via a transtibial or two-incision technique. Totally, 377 (78.6%) of these patients were less than 25 years of age. Data for each patient were collected at their initial clinic visit, at the time of surgery, and at each follow-up clinic visit and entered into the computerized relational database. Overall, 274 patients (72.7%) underwent ACL reconstruction with a transtibial technique, and 103 patients (27.3%) underwent reconstruction with a two-incision technique. Failures were identified as a 2+ Lachman, 1+ or greater pivot shift, or a KT-1000 arthrometer difference of five or more.In patients < 25 years of age, there were 10 failures (9.7%) out of 103 patients undergoing a two-incision reconstruction and 28 failures (10.2%) out of 274 patients undergoing a transtibial reconstruction (p = 1.000). There was no statistical significance between the failure rate in the two different groups in regards to gender, meniscal tear, activity level, or any other factor that was analyzed.Our study showed no statistical difference between the two-incision technique and the transtibial technique for ACL reconstruction using bone-patellar-tendon-bone autograft with an overall 10.1% failure rate in young, active patients (< 25 years of age). The level of evidence is level IV.

Relationship Between Posterior-Inferior Tibial Slope and Bilateral Noncontact ACL Injury

Is there a correlation between increased posterior-inferior tibial slope angle and noncontact anterior cruciate ligament (ACL) injury? Does increasing the posterior-inferior tibial slope angle increase the risk of bilateral ACL injury? A computerized relational database (Access 2007; Microsoft Inc, Redmond, Washington) was used to conduct a retrospective review of patients undergoing bilateral or unilateral ACL reconstruction surgery or treatment by a single surgeon between 1995 and 2013. Included in the study were patients with bilateral and unilateral ACL injuries and patellofemoral pain syndrome with no associated ACL deficiency. Exclusion criteria included concomitant ligament injury, previous ACL reconstruction, and previous knee surgery. Also excluded were patients who did not have plain lateral radiographs. Fifty patients were randomly selected from each group. After controlling for age and Tegner activity level, the authors found that the posterior-inferior tibial slope angle was a significant predictor (P=.002) of noncontact ACL injury. Mean posterior-inferior tibial slope angle for the bilateral, unilateral, and control groups was 11.8°±2.3°, 9.3°±2.4°, and 7.5°±2.3°, respectively. In the group with unilateral ACL injury vs the group without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle (P=.03) was associated with a 20% increase in unilateral ACL injury. In those with bilateral ACL injury vs those without ACL deficiency, a 1° increase in posterior-inferior tibial slope angle (P=.001) increased bilateral knee injury by 34%. The difference between the mean angles of the control group without ACL deficiency and both the bilateral injury and unilateral injury cohorts was statistically significant (P=.003). Increased posterior-inferior tibial slope angle is associated with an increased risk of noncontact bilateral and unilateral ACL injury. [Orthopedics. 2017; 40(1):e136-e140.].

Body Mass Index as an Indicator of Associated Intra-articular Injuries in Patients With Anterior Cruciate Ligament Tears

This study assessed the relationship between body mass index (BMI), anterior cruciate ligament (ACL) injury, and associated meniscal and cartilage injury. Age, ACL classification, and Tegner activity score were considered. A total of 1968 ACL reconstruction patients (2/1/1996 to 5/1/2012) were analyzed. All graft types, age groups, and activity levels were included. A BMI ≥30 correlated with a significant likelihood of medial meniscus tears (p = .022). Patients with a BMI ≥30 were 21.6% more likely to have a medial meniscus tear with an ACL injury. Grade III and IV chondral lesions correlated with a BMI ≥30 (p = .029). Patient's age predicted medial meniscus outcome (p = .013). Patients whose age was >25 had a 25.7% higher risk of medial meniscus tear. Chronic ACL patients were 52.6% more likely to have a meniscus injury. BMI, age, Tegner activity score, and ACL classification are good predictors of medial meniscus injury. Patients with a BMI ≥30 exhibit a greater risk of medial meniscus tear with ACL instability; however, BMI does not significantly contribute to increased chondral damage in ACL-deficient patients.

Age, graft size, and Tegner activity level as predictors of failure in anterior cruciate ligament reconstruction with hamstring autograft

BACKGROUND

Patient age, Tegner activity level, and graft size could be factors that influence the outcome of anterior cruciate ligament reconstruction (ACLR) with hamstring autografts.

HYPOTHESIS

Decreased graft size, higher Tegner activity score, and younger age are associated with an increased failure rate of ACLR, represented by continued knee laxity and revision surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 98 patients who had undergone ACLR with hamstring tendon autografts between 2000 and 2007 were identified from a computerized relational database. Inclusion criteria consisted of a minimum of 2 years of follow-up, all age groups, and all activity levels. Exclusion criteria consisted of treatment with other grafts or previous ligament surgery, previous ACL repairs, bilateral ACL injuries, and associated ligament tears. Failure was defined as a 2+ Lachman result, positive pivot shift, and 5-mm difference or more on KT-1000 arthrometer measurement.

RESULTS

Fifteen of the 98 ACLRs (15.3%) were defined as failures. Of the failures, 12 of 48 (25%) occurred in patients aged 25 years and younger, whereas 3 of 50 (6%) occurred in patients older than 25 years. There was a statistically significant association when comparing failure rate and age groups (P = .009); however, a significant association was not found between graft size and failure rate in the entire study population (P = .135) or within the different age groups (age ≤25 years vs. >25 years) based on failure rate (P = .390 and P = .165, respectively). No statistical significance was found when Tegner activity level and failure rate were compared in the overall study population (P = .463) or within age groups (≤25 years, P = .707; >25 years, P = .174).

CONCLUSION

In this study population, younger patients (≤25 years) demonstrated a higher failure rate compared with the over-25 age group. A statistically significant difference was not found in terms of graft size and activity level correlating with failure rate in ACL reconstruction with hamstring autograft.

Anterior cruciate ligament graft failure: a comparison of graft type based on age and Tegner activity level

BACKGROUND

When reviewing anterior cruciate ligament instability, age, gender, activity level, associated injury, and type of graft should all be considered.

HYPOTHESIS

The authors hypothesized that patients under 25 years of age will have higher failure rates with anterior cruciate ligament reconstruction than those older than 25 years, and that in the patients younger than 25 years, bone-patellar tendon-bone autograft will have the lowest failure rate.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

With use of a computerized relational database, all patients having primary anterior cruciate ligament reconstruction at 1 institution between January 2000 and July 2007 with allograft, bone-patellar tendon-bone, and hamstring grafts were evaluated.

RESULTS

A significant association was found between age group and graft failure (P = .012). Patients 25 years and younger had a significantly higher failure rate (16.5%) than patients older than 25 years (8.3%). Pairwise comparisons indicated that both allograft (29.2%) and semitendinosus/gracilis (25.0%) grafts resulted in significantly higher failure rates than bone-patellar tendon-bone grafts (11.8%) in the age group of patients 25 years and younger.

CONCLUSION

Autograft hamstrings and allografts had a significantly higher failure rate in the age group of patients 25 years and younger compared with the bone-patellar tendon-bone autograft. These data suggest that bone-patellar tendon-bone autografts may be a better graft source for young, active individuals.

Femoral tunnel defect filled with a synthetic dowel graft for a single-staged revision anterior cruciate ligament reconstruction

Bone defects are a common obstacle to successful revision anterior cruciate ligament (ACL) reconstruction. We describe the use of a synthetic bone graft plug to fill a cylindric defect after femoral interference screw removal. During revision ACL reconstruction performed through a 2-incision technique, we placed an outside-in guidewire for a new femoral tunnel that converged with the femoral screw from the primary ACL reconstruction. The screw was removed, and the resultant defect appeared very similar to the cylindric bone defect left after an osteochondral graft harvest. The confluence of the defect and the planned femoral tunnel would have allowed a "windshield wiper" effect of the graft at the lateral wall of the notch. We filled the screw defect with a synthetic bone graft plug to limit the aperture size of the femoral tunnel and to buttress the tendinous portion of the revision ACL graft, while maintaining proper anatomic graft position. In this article, we present a readily available all-arthroscopic option for repairing cylindric bone defects without the risk of an allograft or the morbidity of an autograft for a single-stage revision ACL reconstruction.

The association between posterior-inferior tibial slope and anterior cruciate ligament insufficiency

PURPOSE

The purpose of this study was to determine whether an increased posterior-inferior tibial slope (PITS) is associated with anterior cruciate ligament (ACL) rupture and whether an increased PITS results in worse pivot-shift grades in ACL-insufficient patients. This study also examined the difference in PITS between men and women.

METHODS

We radiographically measured the PITS angle of 100 ACL-insufficient patients and 100 patients with patellofemoral pain (control patients). The mean PITS of male and female cases and control patients was compared to determine whether sex had an influence on the mean PITS angle. The measured PITS was compared with the pivot-shift grade with patients under anesthesia in a subgroup of 87 isolated ACL-insufficient patients with no other knee injury.

RESULTS

Female ACL-insufficient patients had a significantly greater PITS (12.0 degrees +/- 3.5 degrees ) than their negative controls (8.6 degrees +/- 2.7 degrees ) (P < .001). Male ACL-insufficient patients had a significantly greater PITS (10.8 degrees +/- 3.9 degrees ) than their negative controls (8.4 degrees +/- 3.4 degrees ) (P < .001). In the isolated ACL-insufficient patients, the high-grade pivot-shift patient group had a statistically significantly greater PITS (11.10 degrees +/- 3.85 degrees ) than the low-grade pivot-shift patient group (9.19 degrees +/- 3.58 degrees ) (P = .03).

CONCLUSIONS

An increased PITS is associated with ACL rupture. A higher pivot-shift grade is associated with an increased degree of PITS. Female patients did not have a significantly greater mean PITS angle than male patients.

LEVEL OF EVIDENCE

Level III, prognostic case-control study.

Prospective evaluation of 1485 meniscal tear patterns in patients with stable knees

BACKGROUND

Despite emphasis on classifying meniscal tears based on healing potential of the tear, research has concentrated on unstable knees, and few reports have provided information regarding associated clinical variables in stable knees.

PURPOSE

To report on a large series of meniscal tears in stable knees that have been carefully mapped by tear shape and tear zones to allow comparison with meniscal tears in unstable knees.

STUDY DESIGN

Prospective case series, reviewed retrospectively.

METHODS

A total of 1485 meniscal tears in stable knees were evaluated. Preoperatively, each patient underwent a standardized assessment. Each tear was carefully mapped at arthroscopy. Statistical analysis was performed to determine factors that may be associated with peripheral meniscal tears.

RESULTS

The distribution and shape of tears varied significantly within the radial and circumferential zones in this stable knee population. Five prospective variables were associated with peripheral tears: gender, presence of an effusion, positive McMurray test, varus alignment, or a loss of extension more than 5 degrees.

CONCLUSIONS

Patient demographic information and physical examination can be useful in identifying patients who may have a peripheral meniscus tear.

Reconstruction of the anterior cruciate ligament in females: A comparison of hamstring versus patellar tendon autograft

PURPOSE

To compare the clinical results of anterior cruciate ligament reconstruction in female patients using quadruple-looped hamstring autograft versus patellar tendon autograft at minimum 2-year follow-up.

TYPE OF STUDY

Case series.

METHODS

A prospective clinical review was performed to compare the results of ACL reconstruction with hamstring versus patellar tendon autograft in a group of female patients. Exclusion criteria included chronic injuries (greater than 3 months), associated collateral ligament injuries, Workers' Compensation or litigation cases, and bilateral anterior cruciate ligament injuries. There were 39 female patients in the hamstring group (average follow-up, 40.9 months) and 37 female patients in the patellar tendon group (average follow-up, 52 months). Both types of grafts were fixed with an EndoButton proximally and with sutures tied over a post or button distally. The postoperative rehabilitation regimen was identical for both groups. Objective parameters evaluated included preinjury and postoperative Tegner and Lysholm scores, side-to-side KT-1000 maximum-manual arthrometer differences, and clinical examination including Lachman and pivot-shift tests. Graft failure was defined by any one of the following: a KT-1000 difference of greater than 5 mm, a 2+ Lachman, a 1+ or greater pivot shift, or revision surgery.

RESULTS

The failure rate in the hamstring group was 23% versus 8% in the patellar tendon group, which was not statistically significant (P >.1). Comparison of preinjury Tegner activity scores to postoperative scores revealed that patients in the hamstring group did not return to their preinjury level of activity (preinjury 6.54 v postoperative 5.17) as well as patients in the patellar tendon group (preinjury 6.20 v postoperative 6.59). Patients in the hamstring group had a significant increase in pain compared with the patellar tendon group (P =.034).

CONCLUSIONS

Although not statistically significant, the hamstring group had more failures, more laxity on clinical examination, and more patients with larger KT-1000 arthrometer differences. These results indicate a trend toward increased graft laxity in female patients undergoing reconstruction with hamstring autograft compared with patellar tendon when evaluated by a single surgeon using similar fixation techniques at short- to medium-range follow-up. More studies with larger patient numbers using current fixation techniques are necessary to confirm these findings.

Medial and lateral meniscal tear patterns in anterior cruciate ligament-deficient knees. A prospective analysis of 575 tears

We used our database to evaluate the locations of meniscal tears associated with anterior cruciate ligament injuries. Five hundred seventy-five meniscal tears were seen in 476 patients. Each tear was categorized prospectively according to the side (medial/lateral), the radial zone of the tear, and the circumferential zone of the tear. The different tear locations were then compared for the medial and lateral menisci and evaluated for statistical significance. We found a nearly equal number of tears on the medial (305) and lateral (270) sides. A significantly greater number of tears on the medial side as compared with the lateral side were posterior (99.4% versus 87.8%) and peripheral (75.4% versus 44.1%). Peripheral posterior horn tears of the medial meniscus were the most common type of tear (230 of 575, 40%) by a statistically significant amount.

The effect of Workers' Compensation on clinical outcomes of arthroscopic-assisted autogenous patellar tendon anterior cruciate ligament reconstruction in an acute population

PURPOSE

To assess the effect of Workers' Compensation (WC) benefits on subjective outcomes of patients following anterior cruciate ligament (ACL) reconstruction.

TYPE OF STUDY

Prospective study of ACL reconstruction with bone-patellar tendon-bone in an acute population.

METHODS

From October 1991 through June 1997, 1,015 patients underwent ACL reconstruction, 769 with bone-patellar tendon-bone autografts; 235 met the criteria for this study. All chronic injuries, failed and/or bilateral reconstructions were excluded making the total population 139. The final populations included 115 patients in a non-WC group and 24 patients in a WC group. Average follow-up for was 34.5 months for the WC group and 33.6 months for the non-WC group. All patients had equal objective evaluations, which allowed the subjective criteria to be analyzed.

RESULTS

The results revealed a significant difference in the subjective data of patients with WC benefits. Uniformly, WC patients rated subjective criteria as far worse than the non-WC group in postoperative stages. The average of the 15-item visual analog scale showed statistically significant (P <.01) differences between the WC and non-WC groups. Average postoperative Tegner scores were 3.05 for the WC group and 6.02 for the non-WC group, which was statistically significant. The WC group did not return to their preinjury Tegner score.

CONCLUSIONS

The data show that the patients' perception of their knee function drastically differs from the objective findings on examination; therefore, it should be anticipated that the WC patient might have lower subjective outcomes from surgical treatment when compared with their non-WC counterparts.

Clinical comparison of intraarticular anterior cruciate ligament reconstruction using autogenous semitendinosus and gracilis tendons in men versus women

Reconstruction of the anterior cruciate ligament using a hamstring tendon autograft has often been recommended for female athletes. We compared the results of acute, isolated, intraarticular anterior cruciate ligament reconstructions using quadruple-looped hamstring autografts in 39 female and 26 male patients. All reconstructions were performed by the same surgeon using a similar surgical technique and the same postoperative management. In each case, patients had Endobutton femoral fixation and either post or button fixation for the tibial side. The average follow-up was 40.9 months for women and 39.0 months for men. Objective analysis of results included examination for the presence of effusion and crepitus, Lachman and pivot shift testing, and KT-1000 arthrometer testing for side-to-side differences. Subjective analysis consisted of a 15-item visual analog scale completed by patients postoperatively, and pre- and postoperative Tegner and Lysholm scores. The clinical failure rate was 23% (9 of 39) for the female patients and 4% (1 of 26) for the male patients, which was statistically significant. There was also a trend toward increased laxity in female patients. Subjectively, the women also reported a higher frequency and intensity of pain. Based on Tegner activity levels, more of the men returned to their preinjury level of activity than did the women. When compared with the male patients, female patients had a significantly higher failure rate after reconstruction.

Clinical results of meniscus repair in patients 40 years and older

The critical role that the meniscus plays in the knee along with the advantages of preserving as much of the meniscus as possible have both been well documented. Whenever possible, meniscus repair has become the procedure of choice for treatment of meniscal tears. However, some researchers have reported less favorable results in older patients. To determine the results of meniscus repair in older patients, patients 40 years and older who underwent arthroscopically assisted meniscus repair were prospectively followed up. Thirty-seven patients were included in the study, all of which had a minimum 2-year follow-up (average, 26.5 months). The average age of the patients at the time of the repair was 44.2 years (range, 40 to 52 years); 26 were males and 11 were females. There were 19 left knees and 18 right knees included in the study. Twenty-two patients had associated anterior cruciate ligament reconstructions. Physical examination at follow-up included swelling, joint line tenderness, locking, and McMurray testing and radiographs. Five of 37 menisci repaired (13.5%) were symptomatic at latest follow-up. All of these patients had joint line tenderness and two had a positive McMurray test. Three of these patients had repeat arthroscopy confirming that the meniscus had not healed. Because of the small number of patients with symptoms at follow-up, the authors feel that meniscus repair in patients 40 years and older is an effective treatment for peripherally located meniscus tears. With 86.5% of the patients having good clinical results, these findings are comparable with other studies with a younger population and signify that repair of peripheral tears is indicated in this age group especially in conjunction with anterior cruciate ligament reconstruction. The findings suggest that the location and meniscal tear, rather than the age of the patient, determine the potential for successful repair.

The effect of partial lateral meniscectomy in patients > or = 60 years

To determine the benefit, if any, of meniscectomy in an older population, all patients > or = 60 years who underwent partial lateral meniscectomy were evaluated. Thirty-five patients (36 knees) were available for follow-up. The average patient age was 64.9 years. Patients were divided into two groups based on the degree of articular cartilage damage. Patients in group 1 had no damage worse than grade II and underwent arthroscopic partial meniscectomy only, while patients in Group 2 had grade III or IV damage and underwent arthroscopic debridement as well as partial meniscectomy. With an average follow-up of 36.8 months, the overall failure rate was 13.9%. Eighty-six percent of the patients reported the overall assessment of their knee as improved (94% and 80% in groups 1 and 2, respectively). While patients in group 2 tended to have less favorable results than patients in group 1, these results indicate that this procedure is warranted and that both groups benefited significantly from partial meniscectomy.

The effect of anterior cruciate ligament reconstruction on symptoms of pain and instability in patients who have previously undergone meniscectomy: a prereconstruction and postreconstruction comparison

To determine the effect of anterior cruciate ligament (ACL) reconstruction on symptoms of pain and instability in patients with chronic ACL insufficiency who had previously undergone meniscectomy, we reviewed a series of 21 symptomatic, previously meniscectomized patients with chronic ACL deficiency (average age, 31 years). Arthroscopically assisted intra-articular ACL reconstruction using a middle, one-third patella-tendon autograft was performed in all cases. All patients had radiographic evidence of degenerative changes before ACL reconstruction. The average time from meniscectomy to ACL reconstruction was 6.6 years. Preoperative and postoperative range of motion, stability, and subjective evaluations were compared. Follow-up averaged 37.4 months (range, 24 to 67 months). Physical examination and postoperative KT-1000 side-to-side measurements revealed three patients (14%) with pathological ligament laxity. One patient had a 2+ Lachman, a 2+ pivot shift, and > 5 mm difference on KT-1000 maximum manual test, and two patients had a 1+ Lachman and a 1+ pivot shift. Range of motion measurements taken at follow-up were not significantly different from preoperative measurements (extension, P = .14; flexion, P = .46). Subjectively, all items on a panel of 15 visual analog scales were improved, but intensity of pain and instability were significantly improved after statistical analysis (P < .05). This review suggests that symptoms of pain and instability in patients with chronic ACL deficiency who have previously undergone meniscectomy can be improved by ACL reconstruction if objective stability is obtained.

Early season anterior cruciate ligament tears. A treatment dilemma

An anterior cruciate ligament tear before or early in an athlete's season presents a treatment dilemma: surgically repair the ligament and end the season, or use rehabilitative exercises and bracing to quickly return the athlete to play. We conducted a prospective study of 43 athletes (44 acute tears) over 44 months to determine criteria for early return to play and if an early return is safe. All patients had an acute injury in a previously normal knee, a positive Lachman test, and KT-1000 arthrometry indicating ligament abnormalities. Magnetic resonance imaging of each injured knee showed an interior cruciate ligament tear but no meniscal tear. Thirty patients (31 tears) returned to play with rehabilitation and a brace at an average of 5.7 weeks after injury: Only 12 patients returned to their sports without recurrent buckling of their injured knees; 18 patients (19 knees) had recurrent buckling during play. Thirteen patients could not return to play. Patients were observed until they 1) had ligament reconstruction (29 patients, 29 tears), 2) gave up their sports because of instability but did not elect surgery (3 patients), or 3) returned to play in a brace and declined surgery (11 patients, 12 tears). All who elected reconstruction experienced recurrent knee buckling. We found 23 meniscal tears (17 knees) in the 29 patients undergoing reconstruction.

Preliminary results of the T-fix endoscopic meniscus repair technique in an anterior cruciate ligament reconstruction population

In a study to evaluate the preliminary results of endoscopic meniscus repair using the T-fix suture anchor (Acufex Microsurgical Inc, Mansfield, MA), 21 mensiscus repairs in 20 patients were prospectively followed-up for a minimum of 1 year. There were 11 medial and 10 lateral tears; 14 were in the peripheral third (zones 0-1) and 7 were in the central third (zone 2) of the meniscus. All patients had associated anterior cruciate ligament reconstructions. At follow-up, 4 patients were symptomatic, 3 of whom had tears that were complex and in zone 2. Radiographic follow-up showed that 3 patients had a mild progression Fairbank's change. One patient required removal of all sutures because of infection. Second-look arthroscopy on 4 cases revealed that 3 had healed and 1 had not healed. Meniscus healing can be accomplished with T-fix endoscopic technique if principals of meniscus repair are adhered to (i.e., blood supply, synovial rasping, stable fixation).

The effect of suture type on meniscus repair. A clinical analysis

To test the hypothesis that use of permanent suture for meniscus repair allows longer, more stable fixation and more complete healing than absorbable suture, 89 patients (90 meniscus repairs) undergoing repair between 1990 and 1993 were evaluated. Eight patients were lost to follow-up, leaving 81 patients with 82 meniscal repairs. All patients underwent meniscus repair with either absorbable or permanent suture and were re-evaluated at an average of 24.1 months follow-up. The tears were within 5 mm of the peripheral meniscal rim and communicated with the peripheral blood supply (either red-red or red-white zone). Group 1 (absorbable suture) was comprised of 50 patients (38 males and 12 females; 19 right and 31 left knees). There were 36 medial and 14 lateral repairs. Group 2 (permanent suture) was comprised of 31 patients with 32 meniscus repairs (23 males and 8 females; 17 right knees and 14 left knees). There were 23 medial and 9 lateral meniscus repairs. Follow-up consisted of objective (clinical examination, range of motion, McMurray test, detectable swelling, locking, and joint-line tenderness) and subjective evaluations (15 question series of visual analog scales). Success or failure of the meniscal repair was based on the degree of symptoms present at follow-up. Group 1 had 9 failures, while Group 2 had none. All of the failures were rescoped and required additional surgical procedures. Group 1 had higher scores on all subjective questions. Data were analyzed using the two-sample t-test and the chi-squared test. The absolute failure rate was statistically significant. In this study, menisci repaired with permanent sutures had a lower incidence of clinical symptoms and a much lower failure rate. Thus, permanent suture is recommended for meniscus repair as it appears to allow for longer and more stable fixation, permitting more complete maturation and remodeling of the meniscus.

The effect of intraoperative isometric measurement on the outcome of anterior cruciate ligament reconstruction: a clinical analysis

The concept of isometry is based on the measurement of displacement between potential femoral and tibial anterior cruciate ligament (ACL) graft attachment sites while the knee is taken through a range of motion. To evaluate the clinical benefit of intraoperative isometry measurements in ACL reconstruction, we prospectively compared 59 patients (58% acute) in whom isometry was tested (group I) with 35 patients (77% acute) in whom isometry was not tested (group II). All patients underwent arthroscopically assisted ACL reconstruction using autogenous bone-patella tendon-bone graft and interference screw fixation, and were followed-up for a minimum of 24 months (mean, 30 months). With 88% follow-up, no significant differences were found in objective testing, which included the pivot shift test, the Lachman test, KT-1000 arthrometer measurements, and range of motion. A significant difference was found between the two groups when Lysholm scores (P = .04) and Tegner Scores (P = .02) were compared, with group II having higher scores. In addition, one of 15 visual analog scales, "gives way," showed a significant difference between the two groups (P = .01). On a scale of 1 to 10 with 1 being "no giving way" and 10 being "very frequent giving way", group I had an average of 1.68 and group II had an average of 0.58. These differences were related to the greater percentage of chronic cases in group I. Analysis of only those patients with acute injuries from each group showed no significant differences in any objective or subjective measurement. Group I had an overall failure rate of 13%, and group II had a failure rate of 6.7% (chi 2 = .848). These results indicate that, in the hands of a surgeon experienced in ACL reconstruction, intraoperative assessment of isometry has little effect on the clinical outcome.

Use of the T-fix suture anchor in fascial sheath reconstruction of complex meniscal tears

The importance of preserving meniscal tissue has become increasingly apparent as studies have demonstrated early arthritic changes in the knee. To increase the healing rate of complex tears, the use of a fascial sheath to encapsulate the exogenous clot around the tear has previously been proposed. This report describes the placement of a fascial sheath over a repaired meniscal tear using a T-fix anchor suture. With the increased use of fascial sheaths in combination with an exogenous blood clot, meniscal repair rates in complex tears can be increased.

Deltoid and syndesmosis ligament injury of the ankle without fracture

Ankle diastasis without fracture is a rare injury with few examples reported. We report on four male patients, aged 16 to 18 years, who sustained this injury playing football. Swelling and tenderness over both the deltoid and syndesmosis ligaments are the most common physical findings. Plain ankle radiographs demonstrated lateral talus subluxation in three patients, and a stress radiograph demonstrated subluxation of the talus in one patient. Treatment consisted of reduction and fixation of the syndesmosis with a screw followed by 6 weeks of cast immobilization. Using the scale developed by Edwards and DeLee, three patients had excellent results and one had a good result. Diagnosis of tears of the deltoid and syndesmosis ligaments without fracture requires a high index of suspicion on the physician's part. In patients whose mortise is more than 1 mm subluxated, reduction and screw fixation will produce good results.

Endoscopic anterior cruciate ligament reconstruction. Endobutton/button--a method of endoscopic fixation

1. Reconstruction of the anterior cruciate ligament may be accomplished in many ways using a variety of autologous as well as allograft tissue. 2. A method of fixation uses an Endobutton for femoral fixation and a 19 mm Hewson Ligament Button for the tibial fixation of the graft. 3. This method of fixation will permit the surgeon to choose the graft best suited to the patient's needs while allowing endoscopic reconstruction of the anterior cruciate ligament, regardless of the choice of graft. Fixation of the graft need no longer be a variable in anterior cruciate ligament reconstruction.

Endobutton button endoscopic fixation technique in anterior cruciate ligament reconstruction

The surgical technique of Endobutton (Acufex Microsurgical, Inc, Mansfield, MA) button fixation for anterior cruciate ligament reconstruction is described. This technique avoids the potential pitfalls of interference screw fixation, avoids a second incision, and is adaptable to a variety of graft materials (autograft or allograft bone-patellar tendon-bond and hamstring).

T-Fix endoscopic meniscal repair: technique and approach to different types of tears

Endoscopic meniscus repair using the T-Fix suture device (Acufex Microsurgical, Inc, Mansfield, MA) allows ease of suture placement for meniscus stability without the problems associated with ancillary incisions such as neurovascular compromise. It is ideal for the central posterior horn tears that are difficult using conventional techniques. Vertical tears, bucket handle tears, flap tears, and horizontal tears can be approached using a temporary "anchor stitch" to stabilize the meniscus before T-Fix repair. The basic method of repair and our approach to these different types of tears is presented.

Comparison of patella tendon versus patella tendon/Kennedy ligament augmentation device for anterior cruciate ligament reconstruction: study of results, morbidity, and complications

In a study designed to evaluate the efficacy of supplementing patellar tendon bone-tendon-bone intraarticular anterior cruciate ligament (ACL) reconstructions with the polypropylene braid ligament augmentation device (Kennedy LAD; 3M, Minneapolis, MN), 75 consecutive patients treated between July 1988 and January 1990 with isolated ACL disruptions in whom no associated ligament injury was present were offered the LAD as part of their preoperative consent. Interference screws at both bone plugs were used. Group I was composed of 25 patients (10 acute, 15 chronic) with ACL disruptions who had the LAD added to their reconstruction. Group II was composed of 50 patients (24 acute, 26 chronic) who underwent an identical surgical procedure except that the LAD was not used. Objective and subjective assessments were made throughout the postoperative course, with the longest follow-up an average of 24 months postoperatively. Statistical analysis of these findings failed to show any statistically significant differences between the groups. Complications that occurred among the augmented group included infection, synovitis, effusion, and recurrence of instability, intraarticular adhesions, hemarthrosis, and painful hardware. This study demonstrates that the LAD added to the morbidity and severity in this series. It does not seem to improve results and is therefore not recommended for use in this manner.

The Dacron ligament prosthesis in anterior cruciate ligament reconstruction. A four-year review

We studied 40 patients who underwent reconstruction for chronic anterior cruciate ligament deficiency with a Dacron ligament prosthesis using a modified MacIntosh over-the-top technique, augmented with iliotibial band. Thirty patients had undergone at least 1 prior surgical procedure on the affected knee, but only 7 patients had previous anterior cruciate ligament reconstruction. All patients were followed for a mean of 47.5 months. The results at final followup demonstrated an average side-to-side arthrometer difference of 1.0 mm. The Lysholm score improved from 65 preoperatively to 89 at the end of the review; the Tegner activity level score improved from 3 to 5. Objectively, 75% of the patients had a negative Lachman test result and 95.1% of the subjects had negative or trace pivot shift results at review. Mild knee pain was still present with day-to-day activity in 87.7% of the patients. Complications occurred in 27.5% of patients, including five who had implant ruptures and two who had their grafts removed. Synovitis was a significant problem. Based on our failure criteria, 47.5% (19) of the subjects had failed results. In this study, radiologic evidence of tracer separation greater than 1 cm was a criterion of failure. With inclusion of tracer separation, the failure rate increased to 60.0% (24). Multiple previous surgeries of any type had an adverse effect on results. Damage to secondary stabilizers in these cases increased failure rate. Based on the high complication and failure rates, and relatively poor end result in this retrospective review, we cannot recommend this procedure.

Maisonneuve fracture dislocation of the ankle

Ligamentous injuries of the ankle are usually benign and may be managed satisfactorily by nonoperative measures. This is not true, however, of the Maisonneuve variant. In this paper we present a case report of a high school athlete who sustained a Maisonneuve fracture dislocation of the ankle. The diagnosis was missed initially, because of an incomplete examination. The subsequent physical and radiographic examination revealed the proper diagnosis. Guidelines for the evaluation and appropriate treatment are discussed.

Rib fractures in athletes

Rib fractures are the most common serious injury of the chest. They occur most commonly in the middle and lower ribs with blunt trauma, and also with direct force to a small area of the chest wall and violent muscle contractions. Diagnosis is generally not difficult. The athlete should have a chest x-ray to confirm the diagnosis. Differential diagnosis includes severe rib contusion, costochondral separations, muscle strains and pneumothorax. If no internal problems exist, treatment consists of ice, NSAIDs, analgesics and a rib belt or tape. Healing should be well on its way before a return to sports. Fractures of the first 4 ribs or the last 2 ribs, multiple fractures and flail segments are less benign than other fractures, and may result in injury to surrounding structures. First rib and floating rib fractures are uniquely athletic fractures; they are avulsion fractures caused by a sudden vigorous contraction in different directions of pull.

Operative management of acute PCL injuries with associated pathology: long-term results

Eighteen consecutive patients with posterior cruciate ligament injury and associated pathology were reviewed. All were re-examined with an average follow up of 5.4 years (range: 3.5 to 7.5). Six posterior cruciate ligaments were repaired to the femur with multiple #2 nonabsorbable suture, and one "mop end" mid-substance tear was repaired with sutures in each stump. Seven mid-substance tears were repaired and augmented with the semitendinosus tendon, while four additional mid-substance tears were repaired and augmented with the semitendinosus tendon and a Dacron stent (Meadox). One medial meniscus was repaired and one was partially excised, and one lateral meniscus tear was partially excised. The anterior cruciate ligament was repaired to the tibia in two knees, left alone (interstitial tear) in two, and excised with extraarticular iliotibial band tenodesis augmentation in five. At follow up, arthrometer readings (Stryker) correlated well with clinical examination. The four knees with Dacron stent had a 0 to 1 mm difference at 90 degrees, while the failures had greater than 5 to 6 mm. Six of these were in the repair alone group and two were in the repair with semitendinosus augmentation group. Eight knees (44.5%) had radiographic changes primarily in the medial compartment. Using Hughston's perimeters to evaluate the results, objective 55.5% were rated good, 27.8% were rated fair, and 16.7% were rated poor or failures. Using Clancy's criteria, 22.2% were excellent, 22.2% were good, 44.5% were fair, and 11.1% were rated failures.(ABSTRACT TRUNCATED AT 250 WORDS)

A multicenter study on the results of anterior cruciate ligament reconstruction using a Dacron ligament prosthesis in "salvage" cases

A multicenter study is presented on 80 patients who underwent ACL reconstruction using a Dacron (E.I. Du Pont de Nemours and Co., Wilmington, DE) ligament prosthesis. Patient selection was based on a history of a failed autologous reconstruction and/or primary repair of the ACL. These selection criteria are unique and have not been previously reported in the literature. The frequency of prior intraarticular ACL surgery was 1.24 procedures per patient and 1.68 when combined with prior extraarticular reconstructions. Forty-one patients had a mean followup of 28 months (24 to 42 months). The mean followup for all of the patients was 21 months. The graft was augmented with autologous tissue in 59 cases and used as a pure prosthesis in the rest. Functionally, the mean Lysholm score improved from 40 to 81 points. The percentage of a combined excellent/good Lysholm rating increased from 6% to 60%. The Tegner activity rating level improved from 2 to 4. The percentage of a negative Lachman sign, anterior drawer, and pivot shift was approximately 75% at followup. There was no significant difference between the results of augmentation and nonaugmentation cases, indicating that the graft acts as a permanent prosthesis rather than as a scaffold or stint. The patients showed a significant improvement considering their preoperative global instability.

Correction of abduction. Deformity of the small finger caused by avulsion of the insertion of the third volar interosseous muscle

Wartenberg described the clinical sign of the abducted extended small finger that can result from ulnar nerve palsy. When this sign occurs in ulnar nerve palsy, it is a result of imbalance created by paralysis of the third volar interosseous muscle allowing the extensor digiti minimi to abduct the small finger as the finger is extended. If the third volar interosseous muscle is traumatically avulsed at its insertion and the ulnar nerve is intact, the abductor digiti minimi manus is an additional deforming force.

Foam bones. Experimental teaching aid

The teaching of surgical anatomy is an important aspect of an orthopedic training program. The fabrication of polyurethane bones by the authors' staff has proved to be a simple, inexpensive, and rapid means of duplicating bones, permitting the orthopedic surgeons to experiment with new surgical techniques as well as to teach surgical skills. Polyurethane bones may be purchased commercially but are much less costly and more instructive when made by staff members.

Pantalar arthrodesis: a long-term follow-up

Eighty-three pantalar arthrodeses in 69 patients performed at the Shriners Hospital for Crippled Children, Greenville, South Carolina, between 1941 and 1977 were evaluated. Follow-up was from 1 to 33 years. Diagnoses included poliomyelitis, myelodysplasia, arthrogryposis, clubfeet, and extremity or spinal cord trauma. Methods of fusion were one-stage pantalar arthrodesis, two-stage triple ankle fusion, one-stage completion of prior tarsal fusion, and one-stage denudation of the talus. Pantalar arthrodesis is successful in the paralytic sensitive foot with a stable knee and there is no greater incidence of nonunion in the one-stage (Hunt-Thompson) procedure than in the two-stage procedure. Complications and failure of fusion are common in the insensitive foot.