Arthroscopic-assisted Anterior Cruciate Ligament Reconstruction Research Articles

Postoperative Pain Control After ACL Reconstruction With Semitendinosus Tendon Graft: A Randomized Controlled Trial Comparing Adductor Canal Block to Local Infiltration Analgesia

Background: Both adductor canal block (ACB) and local infiltration (LI) are effective for postoperative pain management after arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction (ACLR). While LI is a more straightforward procedure, its effectiveness remains debated. Purpose: To evaluate morphine consumption within 48 hours after ACLR with a semitendinosus tendon graft, comparing ACB and LI; secondary objectives: to evaluate pain levels, patient satisfaction, quadriceps strength, range of knee motion, and complications. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients undergoing primary ACLR with a semitendinosus tendon graft were randomized to receive either ACB (0.25% bupivacaine; 20 mL) or LI at the surgical wound, graft harvest area, and intra-articular injection. The LI group received morphine (3 mg), ketorolac (30 mg), and tranexamic acid (1 g). Morphine consumption within 48 hours was monitored using an intravenous patient-controlled analgesia device. Results: A total of 48 patients were analyzed (n = 24 in each group); baseline characteristics were similar between groups. The LI group consumed significantly less morphine than the ACB group at 6 hours (median [interquartile range, IQR], 3 mg [0-4.8 mg] for the LI group vs 5.5 mg [2-9] for the ACB group; P = .003). However, no significant differences were observed in morphine consumption at other time points. Additionally, no significant difference was found in cumulative morphine consumption at 48 hours between the groups (median [IQR], 21.5 mg [11-34.5 mg] for the ACB group vs 16.5 mg [8.5-21.8 mg] for the LI group; P = .137). Postoperative pain scores, quadriceps strength, and patient satisfaction were similar between the 2 groups. Conclusion: Morphine consumption at 48 hours postoperatively was comparable between the LI and ACB groups, and no significant group differences were found in postoperative pain, quadriceps strength, or patient satisfaction. Registration: TCTR20190320003 (Thai Clinical Trial Registry).

Press-Fit-Hybrid Technique for Anterior Cruciate Ligament Reconstruction With Autologous Hamstring Tendons

Arthroscopic-assisted anterior cruciate ligament reconstruction follows standardized protocols. Multiple fixation techniques are known. Discussion has been raised about osseus fixation and integration. To improve a biological osseous fixation of the anterior cruciate ligament transplant, a Press-Fit-Hybrid technique has been developed. The basic principle is to recycle bony cylinders obtained from the femoral and tibial tunnel to fix the transplant in the femoral and tibial tunnel. In addition to the biological advantage, there are additional economic benefits, such as no extra fixation material is necessary compared with common fixation techniques, and the overall surgical procedure requires minimal effort.

Poster 256: The "N+10 Rule" to Avoid Graft Tunnel Mismatch in Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction Using Independent Femoral Tunnel Drilling

Objectives: To determine the amount of tibial graft tunnel mismatch during application of the “N+10” rule in arthroscopic assisted anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BTB) graft using independent femoral tunnel drilling.To compare actual (measured) tibial tunnel length and desired (calculated) tibial tunnel length when using the “N+10” rule for independent femoral tunnel drilling. Methods:Twenty paired knees from 10 fresh frozen cadaveric specimens (5 female and 5 male specimens) underwent arthroscopic assisted bone-patellar tendon-bone ACL reconstruction using independent femoral tunnel drilling with either a hyperflexion accessory anteromedial portal (n=10) or flexible reamer technique (n=10). The prepared patellar tendon graft bone blocks were trimmed to 10 x 20mm for all specimens and the intertendinous distance (N) between the bone blocks was measured. The “N+10 Rule” was used to set the angle of the ACL tibial tunnel guide to the appropriate degree setting for drilling. The amount of excursion or recession of the tibial bone plug in relation to the anterior tibial cortical aperture was measured in both flexion and extension. A +/-6mm threshold was used to assess this strategy based on prior biomechanical aperture fixation studies. As a secondary outcome, the intraarticular distance (IAD) and the actual tibial tunnel length (TTL) were measured and compared to the planned TTL based on the equation: IAD + TTL = N + 20 (size of bone plug in millimeters)Results:The average BTB ACL intertendinous distance (N) was 47.5mm (SD =5.5mm). The average measured IAD was 27.2mm (SD=3.0mm). Using the “N+10 Rule”, the average mismatch of the tibial tunnel was 4.9mm (SD=3.6mm) and 3.8mm (SD=3.5mm) in flexion and extension, respectively. Both values fall within the +/- 6mm threshold. When comparing the actual measured tibial tunnel length (TTL) to the desired TTL, there was an average difference of 5.4mm (SD=3.9mm)Conclusions:The “N+10” rule resulted in an acceptable average mismatch in both flexion and extension using the threshold of +/- 6mm for 20 cadaveric knees. Measured actual TTL compared to the desired calculated TTL were acceptable 61% of the time using the same threshold. The “N+10” is a simple and effective intraoperative strategy for achieving desired tibial tunnel length to avoid excessive graft tunnel mismatch.Figure 1:Derived formula for calculating ideal tibial tunnel length (TTL) using intraarticular distance (IAD), and the known values of the intertendinous distance (N) and lengths of the bone blocks (20mm).Figure 2:Intraoperative photo of BTB ACL graft measuring intertendinous distance between the bone plugs (N=55mm). Following the "N+10" ruleFigure 3:Intraoperative photo of tibial ACL guide measurement of tibial tunnel length at 50mm with guide set to 65 degrees.Figure 4:Intraoperative photo of the ACL tibial tunnel guide positioned on the anatomic tibial footprint set to 65 degrees (N=55mm). Using this setting for the guide, the tibial tunnel measured 50mm as seen in the zoomed in photo, as per the formula.

Minimally invasive treatment of portal pseudoaneurysm in a haemophiliac after knee arthroscopy

The formation of a pseudoaneurysm or ‘false’ aneurysm is a rare vascular complication of arthroscopic surgery. Its occurrence is even more uncommon in the background of a clotting disorder. We present a case of a recreational athlete with a history of haemophilia, who developed a pseudoaneurysm over an arthroscopic portal site following arthroscopic-assisted anterior cruciate ligament reconstruction. The lesion was treated successfully with image-guided thrombin injection. We discuss the association between haemophilia and pseudoaneurym formation as well as prevention methods and treatment options.

Effect of drains on dynamic proprioception after arthroscopically assisted anterior cruciate ligament reconstruction

<p class="abstract"><strong>Background:</strong> Decrease in proprioception and kinesthesia occurs after ACL injury. Changes occurring within the joint following injury affect normal recruitment and firing patterns of the surrounding musculature. There are little data in the literature with reference to drain use after arthroscopic procedures on the knee or ACL reconstruction. The objective of the study was to determine the effect of postoperative drain use on proprioception after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring graft.</p><p class="abstract"><strong>Methods:</strong> In this study, 54 arthroscopic ACL reconstruction patients were randomized for either intra-articular suction drain group or non-drain group. Outcome Assessment was done at 1 month, 3, 6 and 12 months after the surgery in which patients were assessed using Star excursion balance test by measuring excursion distances in each of the 8 directions.<strong></strong></p><p class="abstract"><strong>Results:</strong> Excursion distances in eight directions showed more increment in drainage tube (DT) group compared to no DT group. However it was found to be statistically significant only for posteromedial (p =0.018) and medial directions (p <0.001).</p><p><strong>Conclusions:</strong> Postoperative drain should be used after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring graft for improving the deficits in dynamic posture control.</p>

Return to Sports and Functional Outcome after Primary Anterior Cruciate Ligament Reconstruction in Jamaica

Objective: The aim of this study was to assess the function and number of patients who returned to sports after undergoing primary anterior cruciate ligament reconstruction. Methods: The study consisted of two arms, a retrospective and a prospective arm. For the retrospective arm, the medical records of patients who underwent primary anterior cruciate ligament reconstruction between January 1, 2005 and December 31, 2010 were reviewed. For the prospective arm: patients seen between January 1st, 2011 and December 31st, 2011 were reviewed. The subjects were then contacted and evaluated by the Tegner-Lysholm Score, the International Knee Documentation Committee (IKDC) score, clinical knee examination and KT-1000 arthrometer. The patient’s ability to return to sports was documented. The data was analyzed using EXCEL 2008 and SPSS version 20 for Mac. Results: Seventy three (73) patients were identified, of which 46 were included in the study. Thirty two (32) patients participated in competitive sports. Majority of the patients were males (32/46), average age was 27 years (range 16 -51) at the time of surgery. All patients underwent single bundle arthroscopic-assisted anterior cruciate ligament reconstruction with ipsilateral patella bone-tendon bone autograft. After surgery 36 (78%) patients returned to sports. The majority of patients had good knee-impairment function. Patients took approximately 9 months (range 2-19) to return to sports. 24 (66%) patients returned to their pre-injury level and 12 (34%) patients returned to a lower level. Ten (10) patients did not return to sports. Fear of re-injury was the most common reason. Conclusion: Despite good short and long-term knee outcome scores, athletes were still fearful of re-injury and this prevented them from returning to their previous level of sports.

Effect of drainage tube on knee function after arthroscopically assisted anterior cruciate ligament reconstruction

Background: There is a paucity of literature evaluating the use of intra-articular drains after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction and their effects on knee function. Objective: The aim of this study is to determine the effect of postoperative drain use on knee function after ACL reconstruction with quadrupled hamstring graft. Materials and Methods: In this study, 44 arthroscopic ACL reconstruction patients were randomized for either intra-articular suction drain group or nondrain group. Outcome assessment was done on postoperative day 4, day 10, 1 month, 3, 6, and 12 months after the surgery in which patients were asked to complete a visual analog pain scale. They were assessed for a range of motion (ROM) in flexion and extension with a universal goniometer, knee effusion, and knee stability by Lachman's test. Results: Both treatment and control groups showed no statistical significant difference in flexion of the knee through the ROM (P = 0.116). The percentage reduction in knee effusion was found to be statistically significant at 4 th (P < 0.001), 10 th (P < 0.001) 16, and 1 month (P = 0.012) in between treatment and control group. The overall pain difference between the two groups was not found to be statistically significant (P = 0.198). Conclusion: Clinically, the drain group showed faster pain relief, lesser effusion, and early return to motion compared to the no-drain group but was not statistically significant.

Tobacco Use Is Associated With Increased Complications After Anterior Cruciate Ligament Reconstruction

Background: The use of tobacco is a well-established cause of preventable morbidity and mortality. There have been few studies examining the effect of tobacco use on outcomes and complications after arthroscopic knee procedures such as anterior cruciate ligament (ACL) reconstruction. Purpose: To investigate the relationship between tobacco use and rates of postoperative infection, venous thromboembolism (VTE), arthrofibrosis, and subsequent ACL reconstruction after primary ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A national insurance database was queried for patients who underwent arthroscopic-assisted ACL reconstruction using Current Procedural Terminology code 29888. Patients underage for tobacco use in all regions of the United States (age <20 years), those with prior ACL reconstruction, and those with the following concomitant procedures were excluded: open cruciate or collateral ligament reconstruction, open or arthroscopic cartilage procedures, patellar stabilization, extra-articular ligamentous reconstruction, and posterior cruciate ligament reconstruction. Tobacco use and non–tobacco use cohorts were queried using International Classification of Diseases–9th Revision coding. The non–tobacco use patients were then matched to the patients with coded tobacco use by age, sex, obesity, diabetes, meniscal repair, and meniscectomy. Complications within 90 days postoperatively were assessed for both cohorts, including infection, VTE, arthrofibrosis, and subsequent ipsilateral or contralateral ACL reconstruction after the index procedure. Results: A total of 13,358 patients who underwent ACL reconstruction met inclusion and exclusion criteria, including 1659 patients with documented tobacco use and 11,699 matched controls. The incidence of infection was significantly higher in patients who use tobacco (2.0%) versus matched controls (0.9%; odds ratio [OR], 2.3; P < .0001). The rate of VTE was also significantly higher in patients who use tobacco (1.0%) compared with matched controls (0.5%; OR, 1.9; P = .035). The rate of subsequent ACL reconstruction was significantly higher in the tobacco use cohort (12.6%) compared with matched controls (7.8%; OR, 1.7; P < .0001). There was no significant difference in the rate of postoperative stiffness after ACL reconstruction between patients who use tobacco (2.0%) and matched controls (2.3%; OR, 0.9; P = .656). Conclusion: ACL reconstruction in patients who use tobacco is associated with significantly increased rates of infection, VTE, and subsequent ACL reconstruction compared with controls. There was no association between tobacco use and postoperative arthrofibrosis after primary ACL reconstruction.

Effect of drainage tube on muscle strength &amp; knee function after arthroscopically assisted anterior cruciate ligament reconstruction

Background: There is a paucity of literature evaluating the use of intra-articular drains after arthroscopic procedures. The aim of this study is to determine the effect of postoperative drain use on muscle strength and knee function after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring graft. Method: 44 arthroscopic ACL reconstruction patients were randomized for either intra-articular suction drain group or non-drain group. All arthroscopic ACL reconstructions using a four strands hamstrings graft as auto graft were included in the trial. Assessment was done on postoperative day 4, day10, 1 month, 3, 6 and 12 months after the surgery in which patients were asked to complete a visual analogue pain scale, were assessed for range of motion, knee effusion, measurement of quadriceps and hamstrings using dynamometer. Result: Comparison of quadriceps strength between the two groups showed no statistical significant difference at 30 degrees. (p <0.167) and 90 degrees (0.115) of knee flexion. Statistically significant difference was seen at 60 degrees knee flexion. (p = 0.036). Both groups showed no statistical significant difference in knee flexion. (p = 0.116) The reduction in knee effusion was found to be statistically significant at 4th (p <0.001), 10th (p <0.001)16 and one month (p = 0.012) ) in between treatment and control group. The overall pain difference between the two groups was not found to be statistically significant. (p = 0.198) Conclusion: This study showed that following surgery, clinically the increment in the muscle strength was more in the drain group compared to the no drain group but was statistically significant only for quadriceps at 60 degree flexion in drain group. Clinically the drain group showed faster pain relief, lesser effusion and early return to motion compared to the no drain group.

One-incision versus two-incision techniques for arthroscopically-assisted anterior cruciate ligament reconstruction in adults

One-incision versus two-incision techniques for arthroscopically-assisted anterior cruciate ligament reconstruction in adults

Electrophysiological Assessment of Injury to the Infra-patellar Branch(es) of the Saphenous Nerve during Anterior Cruciate Ligament Reconstruction Using Medial Hamstring Auto-grafts: Vertical versus Oblique Harvest Site Incisions

BackgroundIt was suggested that the direction of incision for medial hamstring tendons harvesting influences the incidence of injury to the infrapatellar branch of the saphenous nerve (IPBSN), a common complication following arthroscopically-assisted anterior cruciate ligament reconstruction (ACLR).ObjectivesThe main purpose of current study was to compare the incidence of IPBSN injury between vertical and oblique incisions utilizing electrophysiological evaluation.Patients and MethodsThere were 60 patients underwent arthroscopically-assisted ACLR assigned to two equal vertical or oblique incision groups, randomly. One year postoperatively, the patients were electrophysiologically examined to detect whether IPBSN is injured. The Lysholm score was completed. The patients' satisfaction with surgical outcomes determined utilizing visual analogue scale (VAS). Finally, two groups were compared and the effect of IPBSN injury on function and satisfaction was investigated.ResultsThe incidence of IPBSN injury was higher in the vertical group (4 patients vs. 10 patients), but the difference was not statistically significant. The mean of Lysholm and VAS scores were the same. Also, the mean of Lysholm score was the same in patients with and without IPBSN injury. However, patients without IPBSN injury were more satisfied (8.9 ± 9 vs. 7.4 ± 1.1; P < 0.001).ConclusionsIPBSN injury is a common complication following arthroscopically-assisted ACLR and, if not significant, oblique direction of the incision is associated with decreased incidence of the injury. IPBSN injury has no effect on the function but because of the disturbance with patients' satisfaction, authors believe the oblique incision is preferable to avoid the nerve injury during medial hamstring tendons harvesting.

Irreducible dislocation of the knee joint

Posterolateral knee dislocations are very rare and generally irreducible by closed reduction. It is due to interposition of various portions of medial capsule-ligamentous structure in the knee joint space. In such cases, open reduction is recommended. Only a few cases have been reported in the literature. This article presents an unusual case of irreducible knee dislocation, in which the medial femoral condyle buttonholed through the medial retinaculum and capsular structure. Closed reduction attempt was unsuccessful. Open joint reduction was performed. Direct repair of the medial collateral ligament and retinaculum, and arthroscopic assisted posterior cruciate ligament reconstruction were also performed. Arthroscopic-assisted anterior cruciate ligament reconstruction was carried out in staged operation.

The Incidence of Deep Venous Thrombosis After Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction

The purpose of our study was to retrospectively assess and analyze the incidence of deep venous thrombosis (DVT) after arthroscopically assisted anterior cruciate ligament reconstruction (ACLR) at our institution. We conducted a retrospective analysis of 249 arthroscopic ACLRs performed in our hospital between February 2009 and February 2012. The surgical procedure was standardized in all the patients and was conducted by the same 2 surgeons. Quadrupled hamstring autograft was used in all the patients. No patient was given nonsteroidal anti-inflammatory drugs for the first 2 weeks after surgery. A unilateral contrast venography examination was performed on the third postoperative day. Patients were confined to bed once DVT was confirmed, followed by therapeutic doses of batroxobin. The proportion of patients with DVT was calculated. The significance of the association between clinical factors and postoperative DVT was determined. This study included 171 patients (123 men and 48 women), with a mean age (±SD) of 30.1 ± 10.0 years. DVT was detected in 24 patients (14.0%; 95% confidence interval, 8.8% to 19.3%). Body mass index (BMI), operative time, operator, and duration of tourniquet application were not significant risk factors for DVT. The risk of DVT was significantly higher in patients aged 35 years or older (P < .01). Higher risk for DVT was also identified in female patients (P < .05). Pulmonary embolism did not develop after thrombolytic therapy in any of the 24 patients with DVT after ACLR. The incidence of DVT in patients who underwent arthroscopic ACLR was 14% in this study. Female patients and those aged 35 years or older have a significantly higher risk of DVT developing after ACLR; thus thromboprophylaxis is advocated in these patients. Level IV, therapeutic case series.

Navigated Anterior Cruciate Ligament Reconstruction: Radiographic Validation of a Nonimage-based System

The authors compared the intraoperative navigated measurements of the location of the tibial and femoral tunnels during arthroscopic-assisted anterior cruciate ligament reconstruction to the postoperative measurements performed on standard plain radiographs in 56 patients. The position of the center of the tibial and femoral tunnels was measured intraoperatively with the OrthoPilot (B. Braun Aesculap, Tuttlingen, Germany) and postoperatively on plain anteroposterior and lateral radiographs. The center of the tibial tunnel was located at 43% of the mediolateral tibial dimension intraoperatively and at 41% of the mediolateral tibial dimension postoperatively (P=.14). The center of the tibial tunnel tibial was located at 40% of the anteroposterior tibial dimension intraoperatively and at 35% of the anteroposterior tibial dimension postoperatively (P=.01). The center of the femoral tunnel was located at 85% of the anteroposterior femoral dimension intraoperatively and at 76% of the anteroposterior femoral dimension postoperatively (P<.001). A significant correlation was found between intraoperative navigated and postoperative radiographic measurements only at the femur. Good agreement existed between all navigated and radiographic measurements. The OrthoPilot navigation system allows an accurate measurement of the location of the tibial and femoral tunnels during anterior cruciate ligament reconstruction.

Anterior cruciate ligament recostruction with bone-patellar tendon-bone autograft in Tanner 3 stage patients with open physes

Ten skeletally immature patients were treated with an arthroscopic-assisted anterior cruciate ligament reconstruction with bone-patellar tendon bone autograft (compass, 50-55°; holes, 7-9 mm). Radiological assessments (standard radiograph), Orthopädische Arbeitsgruppe Knie (OAK) score and KT 1000, were conducted on all patients, 1 year after surgery. Skeletal maturity had been reached by all patients and no complications were observed. All patients returned to their preinjury sport level. Drilling more vertical tunnels when bone-tendon-bone autograft was chosen to avoid partial epiphysiodesis and offers good functional and isometric results.

What’s new on ACL surgery horizon?

The history of the treatment of anterior cruciate ligament (ACL) injuries is fascinating and filled with interesting anecdotes and sharp turns. Regrettably, it turned out that primary repair is not an option for the ruptured ACL due to its incapacity to heal [1]. Reconstruction with different augmentations devices has also only presented disheartening results. This has led orthopaedic surgeons to perform ACL reconstruction instead of repair. Initially ACL reconstruction was performed using arthrotomy with the goal to reproduce the native anatomy of the ACL. As with all modern surgery, minimally invasive surgical techniques were introduced in knee surgery and with it the start of arthroscopically-assisted ACL reconstruction [2]. In the beginning, arthroscopic ACL reconstruction was performed using a two-incision technique in which the femoral bone tunnel was drilled from outside-in. Over time this changed to one-incision technique in which the femoral bone tunnel is drilled inside-out through the tibial tunnel. Recent studies found that this traditional single-bundle reconstruction fails to reproduce native ACL anatomy and does not fully restore the rotational stability of the knee joint and a more anatomic approach to ACL reconstruction was proposed [3]. The double-bundle technique brought the focus of ACL reconstruction back to restoring anatomy. It has shown superior results in terms of rotational stability in both biomechanical [4] and clinical studies [5]. However, it is vital to differentiate between anatomic and double-bundle ACL reconstruction. The latter is merely a step closer to reproduce the native anatomy of the ACL; however, it can still be done non-anatomically. Moreover, anatomic ACL reconstruction can also be performed using a single-bundle technique. Non-anatomic tibial and femoral tunnel placement represents one of the most important causes of ACL graft failure [6]. When the tibial tunnels are placed too anteriorly, it may lead to roof impingement, which is associated with loss of extension and abrasion of the graft [7]. To prevent this, some surgeons move their tibial tunnel more posteriorly. However, this approach creates tunnel mismatch [8]. Often, a tibial tunnel positioned at the PL insertion site is combined with an (high) AM femoral tunnel. It results in tunnel placement outside of the native insertion site, which can result in abnormal knee kinematics [9]. Multiple studies have demonstrated that non-anatomic tunnel placement results in limited range of motion, higher than physiologic graft tension, and ultimately graft failure [10, 11]. Biological healing of the graft-bone interface may also be affected [12]. Anatomic ACL reconstruction can be defined as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites [13]. Use of a three-portal technique with a medial viewing portal facilitates a true anatomic ACL reconstruction. Anatomic ACL reconstruction can be performed in both single- and double-bundle reconstruction, and in primary, revision and augmentation surgery [14]. However, when different aspects of the surgery are compared, such as single- versus double-bundle techniques, it is necessary that both procedures are performed in an anatomic fashion. Most of the clinical studies comparing single-bundle to double-bundle reconstruction do not present a fair comparison since often one or both surgical techniques were not performed anatomically [15, 16]. In addition, associated injuries such as cartilage injuries, meniscus tears and osteoarthritic changes should be taken into account when conducting comparative clinical studies. Another future consideration is the further improvement of our outcome measures for ACL reconstruction. For example, in the office setting it is difficult to quantify differences in rotational stability in absolute terms [17]. New tools should be reliable, accurate, precise and valid. Examples of such tools that currently used for research purposes are dynamic stereo radiography, T2 MRI mapping of cartilage and quantification of graft healing on MRI [3, 18, 19]. Furthermore, there is a need of consensus on which outcome measures should be used, to facilitate homogeneous reporting of outcome amongst authors. For example, currently important outcome measures such as range of motion are underreported [20], even though it provides important clues to accuracy of tunnel placement and the presence of impingement. In addition, patient reported outcomes, such as the IKDC Subjective Knee Form, KOOS, Tegner Activity Scale and Marx Activity Scale, should be reported in all studies. The use of more accurate and standardized outcome measures could demonstrate the benefits of anatomic ACL reconstruction with regard to the restoration of normal structure and function of the knee. Anatomic ACL reconstruction intends to replicate normal anatomy, restore normal kinematics and protect long-term knee health. The road to anatomic ACL reconstruction has been long and winding. It is a detailed surgical procedure with a steep learning curve and many pitfalls. In the future, more reliable, accurate, precise and validated outcome measures are needed to evaluate its results.

The Safe Zone for Femoral Cross-Pin Fixation –An Anatomical Study

Femoral cross-pin fixation in anterior cruciate ligament (ACL) reconstruction has a potential for neurovascular injury, thus a "safe zone" must be defined for safe pin passage with this technique. In this anatomic study, femoral-sided, arthroscopic-assisted ACL reconstruction using the TransFix system (Arthrex, Naples, Fla) was performed on five fresh extended thigh and lower leg cadavers. Using a goniometer, five cross-pin guidewires were sequentially drilled at 0 degrees, -20 degrees, -40 degrees, +20 degrees, and +40 degrees, using the parallel to floor line as 0 degrees. Negative was defined as starting the pin more posteriorly, and positive was defined as starting the pin more anteriorly. Distance from the pin to the peroneal nerve, saphenous nerve, and femoral artery was measured after pin placement, and measurements were averaged. The peroneal nerve was at minimal risk with average distance to the guide pin of 1.87, 2.13, 2.45, 2.74, and 3.05 cm at -40 degrees, -20 degrees, 0 degrees, +20 degrees, and +40 degrees, respectively. The saphenous nerve was an average distance of 2.19, 1.98, 1.41, 1.42, and 1.29 at -40 degrees, -20 degrees, 0 degrees, +20 degrees, and +40 degrees, respectively. The femoral artery was an average distance of 1.81, 1.51, 0.78, 0.46, and 0.08 cm at -40 degrees, -20 degrees, 0 degrees, +20 degrees, and +40 degrees, respectively. Based on this anatomical study, the absolute neurovascular safe zone during cross-pin guidewire placement is from +20 degrees (0 degrees parallel to floor line) and -40 degrees (lowering guide more posterior).

Arthroscopic Anterior Cruciate Ligament Reconstruction Using Fresh-Frozen Bone Plug–Free Allogeneic Tendons: 10-Year Follow-up

To evaluate the long-term outcomes following arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction using fresh-frozen allogeneic tendon. Sixty-one athletically active patients (mean age at surgery, 20.9 years) who had arthroscopic-assisted ACL reconstruction using fresh-frozen free tendon allograft underwent physical examination, instrumented laxity measurement, radiographs, and thigh muscle strength at 10 to 14 years (mean, 11.5) postoperatively, and these data were compared with results of similar measurements obtained at 2 years postoperatively. Lachman test and pivot shift test were maintained as negative in 53 (87%) and 52 (85%) patients at follow-up, respectively. Quantitative measurements using the KT-2000 knee arthrometer showed 1.6 +/- 1.3 (mean +/- SD) mm in the side-to-side difference, and no more than 3 mm in 56 patients (92%) at final follow-up. All but one was assessed as normal or nearly normal by International Knee Documentation Committee score. Patient activity level was decreased at the long-term follow-up, but this change was mainly associated with changes in social context (e.g., graduation from school) rather than with knee limitations. None of the patients experienced deep infection or graft rejection. Degenerative joint disease on radiographs was seen in 13 out of 15 patients (87%) whose menisci had been excised, whereas it was observed in 12 out of 46 (26%) whose menisci had been preserved. A series of 61 patients with fresh-frozen bone plug-free tendon allografts using a 2-incision technique for arthroscopic ACL reconstruction results in long-term knee stabilization and functioning among young active individuals while simultaneously avoiding graft harvest site morbidity. Level IV, therapeutic case series.

Anterior Cruciate Ligament Reconstruction After 10 to 15 Years: Association Between Meniscectomy and Osteoarthrosis

To evaluate the stability and arthrosis of the knee 10 to 15 years after arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction with patellar tendon graft. From July 1986 to March 1991, 82 patients underwent arthroscopic-assisted ACL reconstruction with patellar tendon graft. Of these, 62 returned for follow-up evaluation between November 2000 and April 2001. Four different physicians, blinded to each other's examination findings, evaluated the radiologic as well as surgical results according to the International Knee Documentation Committee criteria and the Lysholm knee scoring scale. There were 47 male and 15 female patients. The mean period between injury and surgery was 16 months (range, 2 weeks to 8 years). Results of radiographs were compared with the finding of meniscal lesions during surgery and with International Knee Documentation Committee test results. A statistically significant association (P < .0001) was found between medial or lateral arthrosis of the knee and meniscal injury. In all patients the presence of tears in both menisci was associated with osteoarthrosis in both compartments (medial and lateral). In patients who underwent arthroscopic-assisted ACL reconstruction with patellar tendon graft who also had medial or lateral meniscectomy (or both), arthrosis of the respective compartments developed by 10 to 15 years after reconstruction. Meniscectomy was also associated with poorer results on objective tests of knee function, even with a stable knee joint. Level IV, therapeutic case series.

Postoperative evaluation of femoral tunnel position in ACL reconstruction: plain radiography versus computed tomography

Inaccurate femoral tunnel placement has been identified as one of the most frequent errors in failed anterior cruciate ligament reconstructions. Most surgeons evaluate the femoral tunnel position on plain radiographs but in a lot of cases it is difficult to detect the femoral tunnel. The goal of this study was to compare plain digital radiographs and multiplanar computed tomography (CT) scans for the evaluation of femoral tunnel position. We examined 50 patients 24-60 months postoperatively, following an arthroscopically-assisted anterior cruciate ligament reconstruction with central third bone-patellar tendon-bone graft. Endobutton fixation was used on the femoral side and titanium interference screws on the tibial side. Standard antero-posterior and lateral X-rays and a CT scan were obtained from each patient. Sagittal and frontal reconstructions of the CT scan were used for the evaluation. We measured the height of the center of the tunnel in the notch in the frontal plane, and the position of the tunnel along Blumensaat's line (BL) in the lateral plane. Measurements are reported as percentages of total notch height and of the length of BL. On plain X-rays the tunnel was invisible in 46 cases in the anterior-posterior plane and in eight cases on the lateral plane. The average position in the frontal plane was 89.8%, and in the lateral plane 38.6%. In the CT scans, measurements were able to be done in 48 patients. The frontal-plane position averaged 90.5% and the lateral-plane position 34.1%. Pearson's correlation coefficient for the values in the lateral plane for CT and X-rays was low at 0.22, with p>0.05. In our group of 50 patients we were able to detect the femoral tunnel on both plains of standard X-rays in only four patients, whereas it was possible to take accurate measurements in 48 patients on reconstructed CT scans. We advocate the use of CT technology for the evaluation of femoral position whenever precise measurements are needed.