Arthrometer Measurements Research Articles

Better 4-year outcomes for anterior cruciate ligament reconstruction with double-layer versus single-layer bone-patellar tendon-bone allografts.

To evaluate the results of anterior cruciate ligament reconstruction using a double-layer bone-patellar tendon-bone (DBPTB) graft. Between 2010 and 2011, 98 patients underwent anterior cruciate ligament reconstruction with an allograft. Forty-seven of these patients received a DBPTB allograft and 51 received a traditional monolayer BPTB graft. Outcomes were evaluated at the end of a minimum 4-year follow-up in both groups using KT 1000 arthrometer measurements, Lachman and pivot-shift tests, the International Knee Documentation Committee form, and Lysholm scores. One patient (1/47, 2%) in the DBPTB allograft group and six patients (6/51, 12%) in the traditional monolayer BPTB graft were lost during follow-up because of graft rupture (n.s.). The mean side-to-side differences in the DBPTB and monolayer BPTB graft groups 4years post-operatively were significantly different at 1.4±1.3 and 1.7±1.6mm, respectively (p<0.05). The DBPTB group performed significantly better than the BPTB group on the Lachman test, International Knee Documentation Committee knee score, and Lysholm scores (p<0.05). The DBPTB allograft group achieved better outcomes than the traditional BPTB allograft group regarding success rate, anterior stability, and knee function. Level II.

Surgical Reconstruction in Chronic Posterior Cruciate Ligament Injuries of the Knee

Introduction: This is a cross-sectional study to evaluate the outcome of posterior cruciate ligament reconstruction in chronic injuries using ipsilateral Bone-patella tendon-Bone graft in nine patients, between January 2000 and January 2003 at our institution. Methods: Eight male and one female patient; their ages ranged from 18 to 36 years old. The surgery was done at an average of 17.2 months (range from 3 and 40 months) post injury. All patients were followed up for a minimum of two years period. The assessment was done at twelve and twenty-four months using Lysholm knee score, IKDC knee examination evaluation score and arthrometric measurement with KT-2000. Results: The result showed only moderate success in restoration of ligament stability with 73.4% satisfactory objective results. However, the functional improvement and patient satisfaction is only 55%. The incidences of degenerative changes were 89% at the time of operation. Conclusion: Surgical reconstruction of chronic Posterior Cruciate Ligament restored satisfactory stability of the knee but the functional outcome was only moderate.

Arthroscopic Transtibial Tunnel Posterior Cruciate Ligament Reconstruction

The goals leading to successful posterior cruciate ligament (PCL) reconstruction surgery include identification and treatment of associated pathology such as posterolateral instability, posteromedial instability, and lower extremity malalignment. The use of strong graft material, properly placed tunnels to as closely as possible approximate the posterior cruciate ligament insertion sites, and the minimization of graft bending also enhance the probability of the PCL reconstruction success. In addition, mechanical graft tensioning, primary and backup PCL graft fixation, and the appropriate postoperative rehabilitation program are also necessary ingredients for PCL reconstruction success. Both single- and double-bundle PCL reconstruction surgical techniques are successful when evaluated with stress radiography, KT-1000 arthrometer measurements, and knee ligament rating scales. Indications for double-bundle PCL reconstruction as of this writing include severe hyperextension of the knee and revision PCL reconstruction. About 2–18-year postsurgical results in combined PCL, ACL, and medial- and lateral-side knee injuries (global laxity) revealed very successful PCL reconstruction using the arthroscopic transtibial tunnel surgical technique. The purpose of this chapter is to describe the arthroscopic transtibial tunnel PCL reconstruction surgical technique and present results with this surgical procedure.

Short-Term Study of the Outcome of a New Instrument for All-Inside Double-Bundle Anterior Cruciate Ligament Reconstruction

The purpose of this study was to evaluate the short-term clinical results and location of the bone tunnel with a new surgical procedure for all-inside double-bundle anterior cruciate ligament (ACL) reconstruction. The double-bundle ACL reconstruction procedure was performed in 24 patients (13 male and 11 female patients) with a mean age of 31.0 years. Anterior and posterior tibial translation using an arthrometer (KT-1000; MEDmetric, San Diego, CA) and the Lysholm score were measured before surgery and at a mean of 24.8 months (range, 13 to 45 months) postoperatively. Computed tomography scans were taken to evaluate the bone tunnel positions using 3-dimensional images with the quadrant method for the femoral tunnel and Stäubli's technique for the tibial tunnel. Three-dimensional computed tomography scans showed that the anteromedial and posterolateral tunnels were placed in anatomically appropriate positions. Arthrometric measurements showed that the mean side-to-side differences were 5.3 mm (SD, 1.6mm) preoperatively and 0.05 mm (SD, 0.7 mm) at a mean of 24.8 months postoperatively, indicating a remarkable improvement (P < .00001). The mean Lysholm score was 56.3 points (SD, 14.8 points) preoperatively and 95.5 points (SD, 3.8 points) at final follow-up and was significantly improved after the operation (P < .00001). The all-inside double-bundle ACL reconstruction technique used in this study resulted in the creation of tunnels in an anatomically appropriate position. Short-term clinical follow-up showed improvement in patient-reported outcomes and knee stability. This technique may provide an alternative option for all-inside ACL reconstruction. Level IV, therapeutic case series.

Effect of Posterolateral Bundle Graft Fixation Angles on Clinical Outcomes in Double-Bundle Anterior Cruciate Ligament Reconstruction

Background: In double-bundle (DB) anterior cruciate ligament (ACL) reconstruction, no consensus exists on an optimal setting for the posterolateral bundle (PLB) graft fixation angles. Hypothesis: Different PLB fixation angles would affect clinical outcomes in DB ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This study prospectively included 90 patients who underwent primary DB ACL reconstruction with an autologous semitendinosus tendon. The PLB fixation angles were randomly set as follows: 0° of flexion (P0; n = 30), 20° (P20; n = 30), and 45° (P45; n = 30). In all groups, the anteromedial bundle was fixed at 20° of flexion. The following evaluation methods were used at the preoperative period and at 3, 6, and 9 months and 1 and 2 years after the surgery: clinical examination, KT-1000 arthrometer measurement, muscle strength, Tegner score, Lysholm score, and subjective rating scale regarding patient satisfaction and sports performance levels. Graft retear, contralateral ACL tear, and additional meniscus surgery were also recorded. Results: Seventy-five patients (P0, n = 25; P20, n = 26; P45, n = 24) who were followed for 2 years were evaluated. Preoperatively, there were no differences among the groups. Postoperatively, pivot-shift test results in the P0 and P20 groups were better than those in the P45 group (P0, n = 23 graded negative and 2 graded 1+; P20, n = 23 and 2; P45, n = 15 and 7, respectively; P0 vs P45: P = .038 and P20 vs P45: P = .038). Average KT-1000 arthrometer laxity measurements were better in the P20 group than in the P45 group (P0, 0.4 mm; P20, 0.3 mm; P45, 1.3 mm; P20 vs P45: P = .048), and there were more patients with graft failure (KT-1000 measurement, ≥4 mm) in the P45 group (n = 3) than the P0 and P20 groups (each, n = 0). There were no significant differences in range of motion, other laxity tests, muscle strength, Tegner score, Lysholm score, subjective rating scale, or additional surgery. Conclusion: In DB ACL reconstruction, when the anteromedial bundle was fixed at 20° of flexion, fixation of the PLB at 45° was worse than fixation at 0° and 20° with respect to anterior and rotational stability during the 2-year follow-up. KT-1000 arthrometer measurements and pivot-shift test results were significantly worse, and there were more patients with graft failure in the P45 group. There were no differences among groups in other findings.

Posterior cruciate ligament reconstruction via tibial inlay technique in multiligament knee injuries.

The aim of this study is to report our institution's experience regarding the use of open tibial inlay technique in patients undergoing single-stage combined posterior cruciate ligament (PCL) reconstruction. Records of 17 patients who underwent PCL reconstruction with tibial inlay technique were retrospectively reviewed. Patients with ipsilateral femoral or tibial osteochondral avulsion fractures or ipsilateral concomitant tibia and femur shaft fractures were excluded. Out of these 17 patients, six cases underwent anterior cruciate ligament (ACL) + PCL reconstruction, nine cases underwent ACL+ PCL + posterolateral corner reconstruction, one case underwent ACL + PCL + MCL reconstruction and one case underwent ACL+ PCL + posterolateral corner + MCL reconstruction. Mean follow-up was 14.27±6.77 (range: 6-30) months. In preoperative assessments, all patients had 3+ posterior laxity in posterior drawer test; at final follow-up, 6 patients had 0 laxity, 7 patients had 1+ laxity, and 4 patients had 2+ laxity (p<0.001). International Knee Documentation Committee (IKDC) objective evaluation showed severe disability in all patients preoperatively, whereas 5 knees were grade A, 8 knees were grade B, 3 knees were grade C, and 1 knee was grade D at final follow-up. Mean IKDC subjective score was 75.22±7.53 at final follow-up. Postoperatively, mean side-to-side difference in KT-1000 arthrometer measurement was 2.45±1.80 mm. At final follow-up, mean range of motion (ROM) was 0º on extension and 123.56±6.31º on flexion. Open tibial inlay approach is beneficial during PCL reconstruction. Further study is warranted to establish its effectiveness on functional outcomes and prevention of complications.

Modified Transtibial Versus Anteromedial Portal Technique in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction

Background: Although several studies have compared a conventional transtibial technique with an anteromedial (AM) portal technique for single-bundle (SB) anterior cruciate ligament (ACL) reconstruction, no study to date has investigated whether the modified transtibial technique results in the femoral tunnel being in a similar anatomic position and produces similar clinical outcomes with those of the AM portal technique. Purpose: To compare the clinical outcomes and femoral tunnel position of SB ACL reconstruction using a modified transtibial technique (creating a femoral tunnel with varus and internal rotation of the tibia as well as modification of the tibial tunnel orientation) with those of SB ACL reconstruction using an AM portal technique. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 40 patients (40 knees) who underwent arthroscopic SB ACL reconstruction were included in this study. Patients were randomized using a computer-generated sequence into 2 groups: 20 patients by the modified transtibial technique (group 1) and 20 patients by the AM portal technique (group 2). Clinical evaluations included the 2000 International Knee Documentation Committee (IKDC) subjective knee score, Lysholm knee score, Tegner activity scale, Lachman test, pivot-shift test, 2000 IKDC knee examination, and KT-1000 arthrometer measurement. Three-dimensional computed tomography scans were analyzed according to the quadrant method, and the obliquity of the femoral tunnels in the coronal and sagittal planes and the size of the tunnel orifice were measured. Results: All clinical parameters improved significantly after SB ACL reconstruction, with no between-group differences. The mean distance of the femoral tunnel center location from the posterior condylar surface (0.8% difference; P = .167) and from the Blumensaat line (2.1% difference; P = .067) was similar in groups 1 and 2. The mean coronal obliquity of the femoral tunnel was significantly lower in group 1 than in group 2 (42.5° ± 6.1° vs 49.3° ± 7.2°, respectively; P = .001), but the mean sagittal obliquity was similar between the 2 groups (41.9° ± 6.1° vs 43.3° ± 5.4°, respectively; P = .303). The mean area of the tunnel orifice was significantly greater in group 1 than in group 2 (11.6 ± 1.4 × 9.2 ± 1.6 mm vs 10.3 ± 1.1 × 9.1 ± 1.4 mm, respectively; P = .013). Conclusion: The modified transtibial technique for SB ACL reconstruction showed good clinical results and anatomic placement of the femoral tunnel, similar with those of the AM portal technique.

Mid- to Long-term Results of Single-Bundle Versus Double-Bundle Anterior Cruciate Ligament Reconstruction: Randomized Controlled Trial

To evaluate the mid-to long-term results of a randomized controlled trial of single-bundle (SB) versus double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a semitendinosus tendon. Seventy-eight patients who underwent primary ACL reconstruction with an autologous semitendinosus tendon were prospectively randomized into 2 groups: SB reconstruction (n = 39) and DB reconstruction (n = 39). In both groups, grafts were fixed at 30° of flexion with a total tension of 80 N. The following evaluation methods were used: clinical examination, KT-1000 arthrometer (MEDmetric, San Diego, CA) measurement, muscle strength, Tegner activity score, Lysholm score, subjective rating scale regarding patient satisfaction and sports performance level, graft retear, contralateral ACL tear, and additional meniscus surgery. Fifty-three patients (25 in SB group and 28 in DB group) who were followed up for a minimum of 3 years (mean, 69 months; range, 36 to 140 months) were evaluated. Preoperatively, there were no differences between the groups. Postoperatively, the Lachman and pivot-shift test results were better in the DB group (P = .024 and P < .0001, respectively). KT measurements were better in the DB group (mean, 1.4 mm v 2.7 mm; P = .0023). The Tegner score was also better in the DB group (P = .033). There were no significant differences in range of motion, muscle strength, Lysholm score, subjective rating scale, graft retear, and secondary meniscal tear. In ACL reconstruction using the transtibial approach, DB reconstruction was significantly better than SB reconstruction regarding anterior and rotational stability during the 3- to 12-year follow-up. The results of KT measurements and the Lachman and pivot-shift tests were significantly better in the DB group, whereas there was no difference in the anterior drawer test results. The Tegner score was also better in the DB group; however, there were no differences in the other subjective findings. Level II, lesser-quality prospective randomized trial.

Associations between isolated bundle tear of anterior cruciate ligament, time from injury to surgery, and clinical tests.

To evaluate the associations between isolated anteromedial (AM) or posterolateral (PL) bundle tear of the anterior cruciate ligament (ACL), the time from injury to surgery, and various clinical tests. 36 women and 189 men aged 16 to 52 (mean, 26.4) years underwent ACL reconstruction of the right (n=107) and left (n=118) knees. Patients were evaluated for the International Knee Documentation Committee Subjective Knee Score, Cincinnati Knee Rating System Score, anterior drawer test, Lachman test, pivot shift test, KT1000 arthrometer measurement, isokinetic muscle tests of the extensors, and functional tests (single leg hop and timed hop test). Examination under anaesthesia (EUA) was also performed, followed by diagnostic arthroscopy. The integrity of the ACL bundles was tested using a probe. The AM and PL bundles were morphologically intact if structurally present, and functionally intact if not lax on probing. Of the 225 patients, 8 had isolated AM bundle tears, 2 had isolated PL bundle tears, and 215 had complete ACL tears in terms of function. The corresponding numbers were 30, 13, and 182 in terms of morphology. Compared with patients with complete ACL tear, the mean time from injury to surgery was significantly shorter in patients with isolated AM or PL bundle tear in terms of function (17.5 vs. 5.6 months, p<0.001) and morphology (17.5 vs. 8.8 months, p<0.001). Compared with patients with complete ACL tear, those with a functionally intact PL bundle had a higher rate of negative pivot shift test in preoperative evaluation (1% vs. 17%, p=0.002) and EUA (1% vs. 63%, p<0.001), and had a higher rate of negative Lachman test in EUA (1% vs. 25%, p=0.02). The time from injury to surgery was shorter in patients with isolated bundle ACL tear. In patients with ACL deficiency, the pivot shift test was useful in detecting an intact PL bundle.

Long-term followup of surgically treated knee dislocations: stability restored, but arthritis is common.

Surgical treatment of knee dislocations is intended to correct the anatomic injury and restore knee stability and patient function. Several studies have shown successful results with surgical treatment of knee dislocations with up to 10 years of followup, but longer-term studies are uncommon. We evaluated patients treated surgically for knee dislocations at 10-year followup to assess (1) knee stability; (2) return to preinjury level of function; (3) development of arthrosis; and (4) range of motion (ROM) loss. This study was a retrospective review of 127 combined PCL, ACL, and medial and/or lateral side reconstructions performed by a single surgeon (GCF) between 1990 and 2008. Of these, 44 were available for clinical and functional evaluation (35%) at a minimum 5-year followup. Inclusion criteria were combined PCL/ACL plus medial and/or lateral side reconstruction. Evaluation methods included arthrometer measurements, stress radiography, knee ligament rating and activity scales (Lysholm and Tegner), plain radiographs with osteoarthritic assessment, and physical examination. Of the 44 patients, there were nine ACL/PCL medial, 22 ACL/PCL lateral, and 13 ACL/PCL mediolateral reconstructions. Followup was at a minimum of 5 years (mean, 10 years; range, 5-22 years). The mean age at the time of injury was 31 years with a range of 13 to 65 years. The mean arthrometer-measured side-to-side differences were as follows: PCL screen, 1.9 mm; corrected posterior, 2.4 mm; corrected anterior, 0.8 mm; and anterior displacement at 30° of knee flexion, 1.7 mm. Stress radiographic measurements at 90° of knee flexion revealed a mean side-to-side difference of 1.9 mm. Mean Lysholm, and Tegner scores were 84 of 100 and 4.1 of 9, respectively. Ninety-three percent (41 of 44) of patients returned to their preinjury level of activity or one Tegner grade lower. Ten of the 44 knees (23%) developed degenerative joint disease. The mean flexion loss was 12.5°, and flexion contractures were not seen in any of the patients. We found that a high proportion of patients treated for these severe injuries achieved static and functional stability, allowing the return to physically demanding work and recreational activities, but that nearly one-fourth of them will develop arthritis at a mean of 10 years. We cannot extrapolate our results to an elite athlete population, but our results probably apply well to working class populations. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Effect of Notchplasty in Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction

Background: The effects of notchplasty on the clinical outcome after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction remain unclear. Hypothesis: Anatomic ACL reconstruction with notchplasty would result in less risk of loss of extension and would provide adequate space for better graft healing, leading to better knee stability compared with anatomic ACL reconstruction without notchplasty. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 137 patients who underwent anatomic double-bundle ACL reconstruction were included. Seventy-three patients without notchplasty were classified as the control group, and 64 patients with 2-mm notchplasty were classified as the notchplasty group. The following evaluation methods were used: loss of extension, patient’s subjective feeling of limited extension and pain at passive full extension, muscle strength, manual laxity tests, KT-1000 arthrometer measurement, patellofemoral joint findings, Tegner score, Lysholm score, subjective scores, and time to return to sports. Tearing of the reconstructed ACL and additional synovectomy were recorded. Both tibial and femoral tunnel positions were measured using 2-view radiographs: a Rosenberg and a lateral view. Results: Loss of extension was larger in the notchplasty group compared with controls (at 6 months: 0.8° vs 1.4°, P = .012; at 2 years: 0.4° vs 0.9°, P = .0053). The number of patients with a feeling of limited extension was also larger in the notchplasty group (at 6 months: 13 patients graded 1+ [somewhat limited] and 2 patients graded 2+ [very limited] vs 18 graded 1+ and 6 graded 2+, P = .015; at 2 years: 2 graded 1+ and 0 graded 2+ vs 4 graded 1+ and 5 graded 2+, P = .011). Six patients in the notchplasty group required additional synovectomy because of the prolonged loss of extension, whereas no patient in the control group required additional synovectomy. There were no differences between groups regarding muscle strength, patellofemoral findings, Lysholm score, Tegner score, subjective scores, or time to return to sports. The KT-1000 arthrometer measurement was better in the notchplasty group (1.2 vs 0.4 mm, P = .0017). However, 6 patients in the notchplasty group showed an overconstrained knee (KT-1000 measurement ≤–2 mm), compared with only 1 patient in the control group. There were no differences between groups in the other manual laxity tests or the tunnel positions. Conclusion: In anatomic double-bundle ACL reconstruction, anterior stability was improved and there were no harmful effects on patellofemoral joint findings by 2-mm notchplasty; however, notchplasty likely caused overconstrained knee, leading to a need for additional synovectomy in some patients. In contrast, anatomic double-bundle ACL reconstruction without notchplasty did not increase the incidence of loss of extension or of graft failure.

Biomaterials in the Arthroscopic Anterior Cruciate Ligament Reconstruction

We conducted this clinical study in order to compare the quality of graft fixation with a bioabsorbable screw, as compared to a metal screw, in the anterior cruciate ligament reconstruction. A number of 124 patients were submitted to the surgical intervention and 113 out of them were kept under medical survey up to 1 year after the surgery. This included: anamnesis, physical examination, IKDC evaluation and the knee arthrometric measurements. After 1 year, there was no significant difference between the two groups, from the IKDC evaluation point of view. The final IKDC evaluation was normal or almost normal in 92% out of the patients in the group with absorbable screws and in 90% out of the patients making part of the control group. The incidence of post surgery complications was similar in both of the groups. The study shows that the absorbable screw is an efficient alternative to the fixation with a metal screw in the anterior cruciate ligament reconstruction.

Surgical Treatment of Knee Dislocations: 5 to 22 Year Results

The purpose of this paper is to present the results of surgical treatment of knee dislocations with 5 to 22 year follow up in 44 patients in this retrospective case series. Inclusion criteria are a combined PCL ACL plus medial and or lateral side reconstruction in patients with 5 to 22 year follow up. The surgery was performed by one surgeon for all patients. The mean follow up was 9.8 years with a range of 5 to 22 years. The patient age at the time of surgery was 30.9 years, with an age range of 13 to 65 years. The diagnosis were 9 ACL PCL medial (20.5%), 22 ACL PCL lateral (50.0%), and 13 ACL PCL medial lateral (29.5%). Mechanisms of injury included 26 motor vehicle related (59.1%), 9 sports injuries (20.5%), 6 industrial/farming (13.6%), and 3 pedestrian automobile encounters (6.8%). Evaluation methods included KT 1000 arthrometer measurements, stress radiography, knee ligament rating scales, physical examination, and plain radiographs. The KT 1000 arthrometer mean side to side difference measured in millimeters are: PCL screen 1.9 mm, corrected posterior 2.4 mm, corrected anterior 0.8 mm, and the anterior displacement at 30 degrees of knee flexion 1.7 mm. The combined mean side to side difference measurement for all parameters was 1.7 mm. Stress radiographic measurements at 90 degrees of knee flexion to evaluate the PCL reconstruction revealed a mean 1.9 mm side to side difference. Mean Lysholm knee ligament score was 84.4/100. Mean Hospital for Special Surgery score was 82.8/100. Mean Tegner score was 4.1/9. 65.1% of patients returned to their pre-injury level of activity, and 92.8% of postoperative patients returned to their pre-injury level of activity or one Tegner grade lower level of function. Post reconstruction physical examination for the PCL revealed 97.8% of knees had symmetrical or less than grade one posterior drawer (43 of 44 knees). Post ACL reconstruction 39 knees had symmetrical Lachman test (86.6%) and 40 knees had symmetrical (negative) pivot shift (90.9%). Symmetrical varus was present in 41 knees (93.2%), and symmetrical valgus was present in 43 knees (97.7%). Axial rotation was symmetrical to the normal knee in 38 knees (86.4%) and tighter than the normal knee in 6 (13.6%). There were 10 of the 44 knees developed degenerative joint disease (22.7%), and 3 of the 44 knees required total knee replacement (6.8%). There was no loss of terminal extension in any of the knees, but the mean flexion loss was 12.5 degrees compared to the normal knee. Static stability is achieved and documented with KT 1000 arthrometer measurements (mean 1.7 mm side to side difference), and stress radiography (1.9 mm side to side difference), and these results do not deteriorate with time. Functional stability is achieved with 92.8% of patients returning to physically demanding work and/or recreational activities. Post traumatic degenerative joint disease occurs in 22.7% of the knees in this series, and the incidence increases as the time from injury increases.

Single-bundle modified patellar tendon versus double-bundle tibialis anterior allograft ACL reconstruction: a prospective randomized study

The purpose of this study was to prospectively compare the outcomes of single-bundle (SB) anterior cruciate ligament (ACL) reconstruction with modified bone-patellar tendon-bone (BPTB) allograft and double-bundle (DB) reconstruction with tibialis anterior allograft. With 94 patients enroled in the study, 43 subjects who had SB ACL reconstruction with modified BPTB allograft (group S) and 41 subjects of DB ACL reconstruction with tibialis anterior allograft (group D) were followed up for a minimum of 2years. Clinical outcomes including Lachman and pivot-shift tests, KT-1000 arthrometer measurements, and the International Knee Documentation Committee (IKDC) classification, Lysholm and Tegner activity scores were compared between the two groups at the last follow-up. The mean graft size of the group S, the anteromedial bundle and posterolateral bundle in group D were 9.9±0.2, 7.5±0.4 and 6.6±0.4mm, with statistically significant difference between the group S graft to either bundle of group D grafts (p<0.001). At the last follow-up, there was no statistical difference between the two groups for the Lachman test, pivot-shift test and side-to-side difference. Substantial improvements in the subjective knee function scores were achieved in both groups, but without significant difference between the two groups. After a 2-year minimum follow-up, SB ACL reconstruction based on modified BPTB allograft achieved similar clinical outcomes to DB reconstruction with tibialis anterior allograft in knee stability, both anterior-posterior and rotational, as well as knee function. The modified BPTB allograft was recommended as an ideal graft option for the SB ACL reconstruction. Therapeutic, randomized controlled study, Level II.

Short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction

This study aims to analyse the short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction surgery. Clinical outcomes of 19 patients who had partial medial meniscectomy and anterior cruciate ligament reconstruction during the same surgery (Group 1) were compared with the outcomes of 25 patients who had also reconstruction but did not have any meniscal lesion (Group 2). Median follow-up time was 29 months (range 12-67 months) in Group 1 and 27 months (range 12-70 months) in Group 2. Feeling of apprehension in sports activities, International Knee Documentation Committee (IKDC) score, KT-2000 Arthrometer(®) measurements and post-operative time to return to sports activity were the criteria for data analysis. Eight patients (42%) in Group 1 and 5 patients (20%) in Group 2 stated feeling of apprehension in sports activities. IKDC score improved to A in 11 patients (58%) from Group 1, and 18 patients (72%) from Group 2. Mean anterior translation according to KT-2000 arthrometer measurements was 5.2 ± 1.3 mm in Group 1, and 4.6 ± 1.3 mm in Group 2. Post-operative time to return to sports activity was 8.5 ± 3.0 months in Group 1, and 6.5 ± 2.2 months in Group 2. Partial meniscectomy for irreparable medial meniscal tears, applied during the same surgery with anterior cruciate ligament reconstruction, negatively affects the clinical outcomes in the short-term follow-up. This study may be a reference for long-term clinical trials and also future investigations of new methods in the treatment of similar cases. IV.

Joint Stability Characteristics of the Ankle Complex in Female Athletes With Histories of Lateral Ankle Sprain, Part II: Clinical Experience Using Arthrometric Measurement

This is part II of a 2-part series discussing stability characteristics of the ankle complex. In part I, we used a cadaver model to examine the effects of sectioning the lateral ankle ligaments on anterior and inversion motion and stiffness of the ankle complex. In part II, we wanted to build on and apply these findings to the clinical assessment of ankle-complex motion and stiffness in a group of athletes with a history of unilateral ankle sprain. To examine ankle-complex motion and stiffness in a group of athletes with reported history of lateral ankle sprain. Cross-sectional study. University research laboratory. Twenty-five female college athletes (age = 19.4 ± 1.4 years, height = 170.2 ± 7.4 cm, mass = 67.3 ± 10.0 kg) with histories of unilateral ankle sprain. All ankles underwent loading with an ankle arthrometer. Ankles were tested bilaterally. The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness. Anterior displacement of the ankle complex did not differ between the uninjured and sprained ankles (P = .37), whereas ankle-complex rotation was greater for the sprained ankles (P = .03). The sprained ankles had less anterior and inversion end-range stiffness than the uninjured ankles (P < .01). Changes in ankle-complex laxity and end-range stiffness were detected in ankles with histories of sprain. These results indicate the presence of altered mechanical characteristics in the soft tissues of the sprained ankles.

Joint Stability Characteristics of the Ankle Complex After Lateral Ligamentous Injury, Part I: A Laboratory Comparison Using Arthrometric Measurement

The mechanical property of stiffness may be important to investigating how lateral ankle ligament injury affects the behavior of the viscoelastic properties of the ankle complex. A better understanding of injury effects on tissue elastic characteristics in relation to joint laxity could be obtained from cadaveric study. To biomechanically determine the laxity and stiffness characteristics of the cadaver ankle complex before and after simulated injury to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) during anterior drawer and inversion loading. Cross-sectional study. University research laboratory. Seven fresh-frozen cadaver ankle specimens. All ankles underwent loading before and after simulated lateral ankle injury using an ankle arthrometer. The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness. Isolated ATFL and combined ATFL and CFL sectioning resulted in increased anterior displacement but not end-range stiffness when compared with the intact ankle. With inversion loading, combined ATFL and CFL sectioning resulted in increased range of motion and decreased end-range stiffness when compared with the intact and ATFL-sectioned ankles. The absence of change in anterior end-range stiffness between the intact and ligament-deficient ankles indicated bony and other soft tissues functioned to maintain stiffness after pathologic joint displacement, whereas inversion loading of the CFL-deficient ankle after pathologic joint displacement indicated the ankle complex was less stiff when supported only by the secondary joint structures.

Clinical outcomes following anterior cruciate ligament reconstruction utilizing hamstring tendon autografts

Background: A case series demonstrating functional outcomes of 36 patients 2 years following anterior cruciate ligament (ACL) reconstruction utilizing hamstring autografts is presented here. We employed a quadruple bundle technique with cortical endobutton fixation. Materials and Methods: The methods of evaluation comprised of the 2000 International Knee Documentation Committee (IKDC) knee forms, clinical hamstring and quadriceps muscle strength testing in guidance with the Medical Research Council (MRC) grading, single leg triple hop assessment for distance, and the 'Aircast Rolimeter' arthrometer for objective joint laxity. Results: Mean IKDC score was 84.05 ± 14.37. A clinical final evaluation of normal or nearly normal was obtained by 97.2% (35/36) the participants. Passive motion deficit measured clinically using a goniometer was also found to be normal or nearly normal in 97.2% (35/36). One hundred percent of patients had normal or near normal grades for clinical manual knee ligament tests, 94.4% (34/36) patients had normal or near normal compartmental findings, and 100% of patients had normal or near normal harvest site findings. Hamstring muscle strength of the operated knee was clinically assessed to be 5/5 in 86.11% of candidates, while quadriceps muscle strength measured 5/5 in 100% of the subjects. The triple leg hop for distance demonstrated optimal performance with a limb symmetry index of 95.3 ± 13.3%. Arthrometric measurements revealed a mean side to side difference of + 0.70 ± 1.78 mm with Lachman's test and + 0.67 ± 1.43 mm with the anterior drawer test between the operated knee and the normal contralateral knee. Conclusion: We conclude that at 18 months following ACL reconstruction with hamstring auto grafts, our subject group displayed exceptionally satisfactory functional outcomes.

Use of quadriceps tendon versus hamstring tendon autograft for arthroscopic anterior cruciate ligament reconstruction: a comparative analysis of clinical results

This study aims to evaluate midterm clinical results of the use of two autogenous graft types. Between June 2005 and November 2010, clinical data of 44 patients who were operated were retrospectively analyzed. Quadriceps tendon-patellar bone autograft was used for reconstruction surgery in 23 patients (QT-PB group), while quadrupled hamstring tendon autograft was used in 21 patients (HT group). The Tegner's activity scale, Lysholm scoring system, single-leg-hop test and KT-2000 arthrometric measurements were used for data collection. The mean length of follow-up was 37.6 months. Although the mean Lysholm score increased in both groups, excellent results in HT group were two-fold higher compared to QT-PB group. The mean laxity for the operated knee joint was 5.65 mm (3.5 to 8.0 mm) in QT-PB group and 3.67 mm (3.0 to 5.5 mm) in HT group. Head-to-head analysis using KT-2000 arthrometer demonstrated that 12 patients (52.1%) in QT-PB group and two patients (9.6%) in HT group had more than 3 mm of anterior laxity difference. Quadrupled hamstring tendon autograft is superior to central quadriceps tendon-patellar bone in arthroscopic anterior cruciate ligament reconstruction surgery.

Comment on Li et al.: Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis

Dear Editor, In International Orthopaedics, Xue Li and his colleagues published a meta-analysis conducted to compare the efficacy of arthroscopic single-bundle and double-bundle anterior cruciate ligament reconstruction, and they did very well [1]. However, the meta-analysis has brought a few questions to our minds that we would like to convey to the authors: Publication language was limited to English in the meta-analysis. Therefore, the authors should mention the potential importance of language bias in the limitations of their meta-analysis. In the article, the authors used the odds ratio (OR) for dichotomous outcomes to report the risk value rather than relative risk (RR). As there are 17 randomised controlled trials (RCTs) included, RR can report the real risk value better than OR. Therefore, we suggest that RR should be used to report the risk value in this article. It is not sufficient that publication bias was only assessed by visual examination of a funnel plot. Funnel plot symmetry should be further assessed by statistical tests (e.g. Egger’s linear regression test or Begg’s rank correlation test). Moreover, in the meta-analysis, publication bias was only assessed for KT1000 arthrometer measurements. Actually, publication bias should be assessed for other comparisons (such as Lysholm score, objective International Knee Documentation Committee score, negative pivot-shift test). Therefore, publication bias may be present, distorting the meta-analysis. It is not appropriate that summary OR and standard mean difference (SMD) estimates with corresponding 95 % confidence intervals were derived by using the method of Mantel-Haenszel (M-H) or inverse variance (IV) with the assumptions of a random effects model. However, studies should be combined by using the DerSimonian and Laird random effects model, which considers both within- and between-study variations [2]. The difference in the follow-up periods between studies was large, which may cause heterogeneity. Subgroup analysis was performed by stratifying the available data according to follow-up periods. To make the article more credible, the authors should analyse the effect of single-bundle versus double-bundle anterior cruciate ligament reconstruction according to different ages and sexes on account of the limitation of the studies included. Moreover, further high-quality RCTs based on larger sample sizes are still needed. Evidence indicated that only the larger study should be included for analysis when some publications contained the same or overlapping data. There are two studies performed by Jarvela et al. [3, 4] containing overlapping data. In the two studies, all patients were recruited from Hatanpaa Hospital, Tampere, Finland. Concerning patients with anterior cruciate ligament reconstruction, the study by Jarvela et al. [3] carried out in 2005 included 52 single-bundle and 25 double-bundle reconstructions, and the second study by Jarvela et al. [4] included 25 single-bundle and 35 double-bundle reconstructions. Therefore, the larger group of single-bundle reconstructions and the larger group of double-bundle reconstructions by Jarvela et al. [3, 4] should be included in this meta-analysis. Moreover, further high-quality RCTs based on larger sample sizes are still needed to compare arthroscopic single-bundle and double-bundle anterior cruciate ligament reconstructions. We believe that our remarks will contribute to more accurate elaboration of the results presented by Li et al.