Average International Knee Documentation Committee Score Research Articles

Outcomes of "Over the Top" Anterior Cruciate Ligament Reconstruction Associated with a Lateral Extra-Articular Tenodesis in Children.

(1) Purpose: The incidence of anterior cruciate ligament (ACL) ruptures in children and adolescents has considerably increased during the last decades due to higher levels of competitive athletic activity, and early sport specialization and professionalization. Contemporary ACL reconstruction techniques have recently been subject to renewed interest in this population. The objective of this study is to report the short- and mid-term results of our physis-sparing ACL reconstruction technique using an "over the top" technique associated with a modified Lemaire procedure. (2) Methods: A retrospective series of 12 junior soccer players who presented to our clinic with a torn ACL between January 2019 and September 2021 was reviewed. The inclusion criteria were patients under 15 years with open tibial and femoral physes, with a stable contralateral knee, a minimum follow-up of 6 months, and a time frame from injury to surgery of <3 months. Patients with previous knee surgery, structural concomitant injuries, muscular, neurological, or vascular abnormalities, or hypersensitivity to metal alloys were excluded. The functional evaluation was performed using the International Knee Documentation Committee (IKDC) rating, Lysholm score, and Tegner activity level. Moreover, clinical and radiological assessments were also performed, including KT-1000 and knee X-rays. (3) Results: We identified 1 female and 11 male patients with ACL tears, with a mean age of 13.17 ± 0.9 months. Concomitant injuries include isolated vertical and bucket-handle tears of the medial meniscus, lateral meniscus tears, bilateral tear of both menisci. The mean follow-up time was 26 ± 12.6 months. The average IKDC, Lysholm and Tegner scores were 93.29 ± 11.04, 95.08 ± 13.2 and 9 ± 0.0 points, respectively. The average KT-1000 score of the participants was 0.96 ± 1.6 points. None of the included patients reported post-surgical complications or required additional surgeries. (4) Conclusions: Our novel ACL reconstruction with LET technique is a safe procedure that resulted in good clinical outcomes, lower failure rate and return to sports in skeletally immature patients.

Paper 87: Anterior Cruciate Ligament Reconstruction in Patients Age 50 and Older: Outcomes and Tips for Success

Objectives:As people remain physically active later in life, there is an increased incidence of anterior cruciate ligament (ACL) injuries in patients 50 years of age and older. Historically, ACL reconstructions have not been recommended for patients over 50 years of age. While there is abundant literature on the outcomes of ACL reconstruciton in patients under 40 years of age, little has been published on the outcomes in this age group. The purpose of this study was to investigate whether ACL reconstruction in patients fifty years of age and older rwill esult in an improvement in function, stability, and quality of life at 5-year follow up. We also study the indications, outcomes, and tips for success.Methods:A retrospective review was performed of patients fifty years or older with a minimum follow up of two years who underwent an ACL reconstruction using a bone patellar tendon bone (BPTB) allograft by a single fellowship trained orthopedic sports medicine surgeon over a sixyear period. Patients were excluded from the study if they had significant radiographic osteoarthritic changes, or concurrent ligamentous or bony procedures performed. Patients were asked to return for an evaluation, including physical examination and KT-2000 instrumented stability measurements. Both the operative and non-operative knees were evaluated for range of motion, tenderness, stability on anterior drawer, Lachman, and pivot shift testing. Bilateral KT-2000 measurements which were taken at 10, 20, and 30 pounds as well as maximum manual testing. Each measurement was taken three times and averaged. The following scores were used pre- and post-operatively to assess function and pain: Lysholm, International Knee documentation Committee (IKDC), Tegner Activity, and SF-12. A physical examine including KT-2000 measurements was performed in a subset of these patients.Results:Fifty patients with an average follow-up of 5 years (range 2-8 years) underwent an ACL reconstruction using BPTB allograft. The average age at surgery was 55 years (range 50-68 years). Tegner scores improved from a pre-operative score of 3.3 to a post-operative score of 5.3 (p = .0001, 95% CI 2.2-3.5). The average post-operative IKDC score was 81.3 (SD 16.4), Lysholm score 88.5 (SD 16.3), SF-12 physical 54.3 (SD 6.6) and SF-12 mental 51.8 (SD 8.3). Forty (80%) patients reported good to excellent results, six (12%) patients reported fair results and four (8%) patients reported poor results. The patients that returned for a physical examinaiton had a range of motion that averaged flexion to 135 (SD 5.4), and all achieved full extension. There was one patient (2%) that had greater than 4mm translation on Lachman testing, and no patients had a positive pivot shift. There were no identified surgical complications.Conclusions:An anterior cruciate ligament reconstruction using BTB allograft successfully restores stability and allows return to pre-injury level of activity with few complications in patients 50 years or older at an average of 5 years follow-up. Our data set represents the largest case series of ACL reconstructions for this age demographic in the literature, using validated outcome tools, and complimented with a physical examination in a sub-set of the cohort. We have found no comparison that yields a clinically significant difference (based on MCID of 10 on theLysholm scale). Thus, older patients can be counseled to expect a functional return close to their pre-injury level, similar to younger patient cohorts.

Tibial Spine Repair in the Pediatric Population: Outcomes and Subsequent Injury Rates

PurposeTo evaluate short- to mid-term outcomes after arthroscopic operative fixation of tibial spine fractures in pediatric patients, to determine the incidence of further ipsilateral and contralateral knee injuries, and to describe associated meniscal pathology and intraoperative findings at the time of tibial spine repair.MethodsAll patients under age 18 with a tibial spine fracture treated arthroscopically at 1 institution by 2 surgeons from 2008 through 2019 were identified by Current Procedural Terminology codes. Patients at least 1 year from their date of surgery were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form. Questions pertained to knee function, pain, and further injury or surgery on either knee. Patient charts, preoperative imaging, and operative reports were reviewed to determine demographic information, tibial spine fracture type, concomitant injuries, and intraoperative details.ResultsSixty-six of 97 eligible patients (68%) completed questionnaires. Average age at initial surgery was 10.7 years (range, 4-17). Mean follow-up was 5.8 years (range, 1.0-11.9). Average IKDC score at follow-up was 91.4 (range, 62.1-100). Patients reported their knee as 92% of “normal” (range, 40-100). Thirty-five (53%) currently participate in sport; 6 (9%) remain limited because of instability and residual pain. Regarding pain on a visual analog scale, 94%, 95%, and 83% of patients reported less than a 3 at rest, with daily activity, and with sport, respectively. Seven patients (11%) had subsequent ACL rupture. Six patients (9%) underwent ACL reconstruction 3.1 years (range, 0.9-7) after initial repair. Fourteen patients (21%) required at least 1 additional procedure. Regarding the contralateral knee, there were no ACL or tibial spine injuries. Sixty-one (92%) patients were both satisfied and would definitely undergo the procedure again.ConclusionsAlthough many pediatric patients demonstrate excellent results after tibial spine repair at mean 5.8 years follow-up, 10.6% sustained an ipsilateral ACL rupture, and 21% required an additional procedure. No patient had a contralateral tibial spine or ACL injury. This is helpful when counseling patients regarding injury risk when returning to activity after tibial spine repair.Level of EvidenceLevel IV, therapeutic case series.

A Unified Platelet-rich Plasma Preparation Protocol Using a Customizable Concentration System for Knee Osteoarthritis

Introduction:Platelet-rich plasma (PRP) is an autologous solution of platelets, concentrated over baseline, that delivers a high dose of anti-inflammatory and anabolic proteins. High-quality data support its use for pathology like knee osteoarthritis (OA), but vast heterogeneity among PRP processing methods and product content make synthesizing clinical data very challenging. Most processing techniques rely upon centrifugation and often involve manual processing steps, such as resuspension or extraction of platelets, which can introduce further heterogeneity in the final product. The Angel cPRP device is a fully automated device that uses both centrifugation and principles of flow cytometry in its PRP processing. However, the system has a wide range of preprocessing settings that alter PRP composition and there are no recommendations or standards on which settings should be used for OA. The aims of this manuscript are to (1) describe a unified PRP processing technique using this system and (2) report preliminary outcomes using that unified protocol when treating knee OA.Methods:For the processing of PRP, all patients had whole blood drawn under aseptic conditions (104 cc whole blood for unilateral OA, 156 cc whole blood for bilateral OA) that was then processed at the unified setting of 0% hematocrit, first spin performed at 4000 rpm for 11 minutes and the second spin at 3000 rpm for 2 minutes. The device automatically separated the resulting PRP that was then injected. For the second aim of this work, 90 knees (63 patients) met the criteria for inclusion. International Knee Documentation Committee (IKDC) subjective scores completed at baseline and 3 months were collected and analyzed.Results:Overall, IKDC score improved from 42.3±14.1 preinjection to 59.7±17.5 at 3 months postinjection (P&lt;0.001). Of the 90 knees injected with PRP, 57% met the criteria for a positive response at 3 months with an average final IKDC score of 66.5±15.0 (Δ 24.7±10.9). Increased patient age (P=0.008) and body mass index (P=0.008) were associated with lower 3-month subjective IKDC scores.Discussion:A single PRP injection created with the unified preparation protocol described here resulted in significant improvement in preliminary patient-reported outcomes. There was a positive response in 57% of patients. Higher age and body mass index were associated with worse outcomes. Given the wide range of preprocessing settings available on this device, the protocol described here can serve as an initial guide for clinical and research implementation.

Functional results of allograft vs. autograft tendons in anterior cruciate ligament (ACL) reconstruction at 10-year follow-up.

The anterior cruciate ligament (ACL) tear is one of the most common sports injuries of the knee, and the arthroscopic reconstruction is the gold standard. Nevertheless, controversies about the surgical techniques and the type of graft still exist. Allografts have been considered by many surgeons as valid alternative to autografts. The aim of this study was to assess the effectiveness of allografts compared to autografts at approximately 10 years of follow-up, investigating the level of physical activity currently performed by patients of each group. Ninety-four patients, divided into two groups (allografts and autografts), have been retrospectively studied. The two groups did not significantly differ in preoperative sport activity level, age (mean 40.70years for autografts and 41.23 for allografts) and characteristics. Allograft group received a fresh-frozen graft from the musculoskeletal tissues bank. Evaluations were made using the International Knee Documentation Committee (IKDC) and Lysholm score; every patient was interviewed for complications. The mean follow-up time was approximately 10years for both groups, with a minimum of 8years. There were no statistically significant differences between the two groups. Average IKDC scores were 75.21 (SD 15.36) and 80.69 (SD 13.65) for the allograft and autograft groups, respectively. The mean Lysholm score was 87.57 (SD 9.43) for the allografts and 89.10 (SD 8.33) for the autografts. No major complications linked to the allograft tissue arose. Both groups achieved almost the same functional outcomes at an average 10years of follow-up, indicating fresh-frozen allografts as a reasonable alternative for ACL reconstruction. IV, Retrospective case-control study.

Mid-Term Patient Reported Outcomes and Return to Sport for Physeal Sparing ACL Reconstruction in Skeletally Immature Patients

Objectives: Physeal-sparing techniques for anterior cruciate ligament (ACL) reconstruction have previously been described as safe treatment for adolescent ACL tears in patients with open physes, however few studies to date have reported on return-to-sport or patient reported outcome scores for this specific patient population. This study examined patient reported outcomes in children who underwent a physeal-sparing ACL reconstruction with a minimum of two-year follow-up. Methods: Surgical logs of ACLR performed at a single pediatric/adolescent sports medicine center from 2011 to 2016 were reviewed. Patients with open physes who had ACLR with a hybrid physeal sparing or all-epiphyseal technique were identified. Patients were treated by one of two pediatric sports trained orthopedic surgeons. Their demographics, operative reports, rehabilitative course, time to return-to-play, and post-operative course were retrospectively reviewed. Prospective patient reported outcomes scores, ACL-Return to Sport after Injury (ACL-RSI) and International Knee Documentation Committee (IKDC) or Pediatric IKDC (Pedi-IKDC) and return to sport questionnaire including pre-injury primary sport and competition level, ability to return to pre-injury level of competition following ACLR and subsequent ACL injury were collected. Results: There were 49 patients who met inclusion criteria. Prospectively collected data was obtained for 25 patients at an average of 4.6 (range 2.1-8.0) years following surgery. The average chronological age of patients at time of surgery was 12.8 ± 1.4 years with an average bone age of 13.5 ± 1.3 years. At mid-term follow-up, the average chronological age was 17.2 ± 2.0 years. Average Pedi-IKDC or IKDC score was 94.2 ± 9.2 and ACL-RSI Score was 89.2 ± 18.3. There were 23 patients who considered themselves athletes prior to surgery, 8 patients identifying as recreational athletes competing in town or school leagues and 15 patients identifying as competitive athletes participating on youth travel or club leagues. All patients reported the ability to return to their primary sport following ACLR, with 74% returning to the same or higher level of competition, of which 6 were recreational athletes and 11 were competitive athletes. In addition, 6 patients did not complete outcomes data, but had suffered tear of their ipsilateral (3) or contralateral (3) side and were treated at the same facility. These patients were included in calculation of overall re-tear rate of 12.5% (5 patients) and contralateral tear of 25% (8 patients). Conclusion: Mid-term results of patients treated with a hybrid physeal-sparing or all-epiphyseal ACLR were favorable, with adolescents reporting a high level of functional ability and strong psychological readiness to engage in athletic activities. Re-tear and contralateral tear rates were equivalent to other reported studies. These physeal-sparing techniques demonstrate the ability for young athletes to successfully remain physically active and involved in their sports several years following surgery.

Comparison of Traditional Physical Therapy to Internet-Based Physical Therapy after Knee Arthroscopy: A Prospective Randomized Controlled Trial Comparing Patient Outcomes and Satisfaction

Objectives: Knee arthroscopy results in significant improvements in functional outcomes, pain and quality of life for patients suffering from meniscal tears. Traditionally, patients have undergone formal physical therapy (PT) after knee arthroscopy to regain function. Prior studies have demonstrated that patients who undergo internet-based PT after total knee arthroplasty performed as well as patients receiving traditional PT, but this has not been studied in the knee arthroscopy population. The goal of this study is to compare traditional outpatient physical therapy to internet-based physical therapy in patients undergoing knee arthroscopy for partial meniscectomy. Methods: Patients undergoing knee arthroscopy from October 2017 to September 2018 for partial meniscectomy were enrolled. Patients were randomized to either an outpatient or internet-based physical therapy program. Participants in the outpatient physical therapy were prescribed PT for 2 sessions per week for 4-6 weeks while participants in the online physical therapy group were instructed to login daily to track progress and complete their exercises a minimum of 3 times per week. Additionally, participants completed 4 questionnaires: VR-12 mental and physical health, International Knee Documentation Committee (IKDC), Modified Cincinnati Rating System (MCRS) and Lysholm pre-operatively, 1 week, 6 weeks and 6 months after surgery. The primary outcome of knee function was measured via the IKDC. Results: Of the 97 patients who met the inclusion criteria, 51 (52.6%) were in the internet-based physical therapy group and 46 (47.4%) were in the outpatient PT group. There were 57 males (58.8%) and 40 females (41.2%). Participants in the online physical therapy group logged into the platform an average of 2.74 times pre-operatively and 14.99 times post-operatively. Additionally, patients viewed their PT exercise videos, on average, 5.58 times pre-operatively and 36.71 times post-operatively. At final follow-up, there was no significant difference in the primary outcome with an average IKDC score for the online physical therapy (71.83) compared to outpatient PT group (74.23) [p = 0.699]. Additionally, there was no significant difference noted in the three secondary outcome measures between the internet-based physical therapy group and the outpatient PT group at final follow-up (Table 1). Furthermore, no significant difference was noted between the two patient cohorts pre-operatively and 1 week and 6 weeks after surgery in all four outcome measures (Table 1). Conclusion: The results of our study indicate that patients using internet-based PT had similar functional outcomes as patients using traditional outpatient PT following knee arthroscopy for partial meniscectomy. [Table: see text]

Mosaicplasty Technique in the Treatment of Isolated Knee Femoral Condyle Osteochondral Lesions - a Retrospective Study.

Objective Focal osteochondral lesions of the knee are found in two thirds of patients undergoing arthroscopy; their treatment, when isolated and especially in young individuals, remains a debating topic. The present study analyzes the results obtained by the application of the mosaicplasty technique on the treatment of isolated knee femoral condyle osteochondral lesions. Methods Retrospective study of patients submitted to mosaicplasty and to subjective analyses with pre- and postsurgery International Knee Documentation Committee (IKDC) scores. Results A total of 13 cases with an average age of 34 years old, with male patients ( n = 4; 31%) with an average age of 23 years old (range: 17–31 years old), and female patients ( n = 9; 69%) with an average age of 39 years old (range: 16–56 years old); medial versus lateral femoral ( n = 11; 85% versus n = 2; 15%); the average size of the lesion was 1.8 cm 2 (range: 0.6–4 cm 2 ); average follow-up time: 5.045 ± 3.47 years (range: 1.15–11.01 years). The average preoperative IKDC score was of 31.63 points (±20.24), the average postoperative IKDC score was of 74.18 points (±20.26). The difference between the post- and preoperative IKDC scores was of 42.55 (±21.05) points, being the minimal score increase of 8.1 points and the maximum score increase of 82.8 points. A statistically significant difference ( p < 0.001) was found between the IKDC scores before and after the surgery. A statistically significant relation ( p = 0.038) was found between the IKDC score increase (the difference between the postoperative and the preoperative scores) and the dimension of the lesion. Conclusions Mosaicplasty with osteochondral autograft transfer, when adequately used, can produce excellent results with great durability and functional impact, low morbidity rates and costs. Expansion of the indication criteria shows promising mid-term and long-term results.

Establishment of tibial tunnel via a posterior-anterior approach for all-inside posterior cruciate ligament reconstruction: short-term outcomes

Objective To introduce a new posterior-anterior approach used to establish tibial tunnel for all-inside posterior cruciate ligament (PCL) reconstruction and evaluate its short-term therapeutic effects. Methods We retrospectively analysed the 15 patients (15 knees) with PCL injury who had been treated at Department of Orthopaedics, Zhejiang Provincial People's Hospital from January 2017 to January 2018. They were 9 men and 6 women, with a mean age of 46.3 years (from 23 to 60 years). Of them, 8 left and 7 right sides were injured. The intervals from injury to surgery averaged 33.6 days (from 4 to 120 days). Their injury was complicated with medial meniscus tear in 3 cases, lateral meniscus tear in one case, lesion of medial col-lateral ligament in 2 cases and lesion of lateral medial collateral ligament in one case. After preoperative physical examination and MRI confirmed complete PLC tear in all of them, they were treated by arthroscopic all-inside PCL reconstruction in which a new posterior-anterior approach was used to establish the tibial tunnel. Lysholm scoring and International Knee Documentation Committee (IKDC) scoring were used preoperatively and postop-eratively to evaluate the knee functions. Results Their follow-ups averaged 8.3 months (from 6 to 12 months). Operation time averaged 55 minutes (from 45 to 70 minutes). All the patients got rid of the knee instability after surgery. All their posterior drawer tests and sag signs turned to be negative. At the final fol-low-up, their range of motion of the knee ranged from 110° to 130° (average, 118°); their average IKDC score was 88.1±3.3 (from 82 to 93), significantly higher than the preoperative value (52.3±2.1) (P<0.05); their average Lysholm score was 90.6±3.1 (from 84 to 96), significantly higher than the preoperative value (43.1±2.3) (P<0.05). Conclusions This new method can avoid neurovascular damage and overcome the killer turn because it provides adequate exposure of the tibial PCL footprint and accurate placement of the tibial tunnel. It is also very convenient because the new posterior-anterior approach can be used to establish the tibial tunnel in all-inside PCL reconstruction without special tools like tibial PCL guide and retrograde drill. Its short-term clinical results have proved to be satisfactory. Key words: Posterior cruciate ligament; Arthroscopy; Wounds and injuries; Tibial tunnel

Technique for partial transphyseal anterior cruciate ligament reconstruction in skeletally immature athletes: preliminary results

Background: A number of safe and successful surgical techniques to avoid physeal injury about the knee have been described, but their reported outcomes have not equaled success rates of procedures in skeletally mature patients. The purpose of this study was to determine the outcomes of an arthroscopic-assisted ACL reconstruction using a quadruple-looped hamstring graft with a synthetic graft extender and a physeal-sparing technique for partial transphyseal ACL reconstruction in skeletally immature patients. Methods: Medical record review identified skeletally immature patients who had this procedure and a minimum 6-month follow-up. A quadrupled-looped hamstring autograft and a synthetic graft extender allowed the optimal portion of the graft to be placed intra-articular and maintain sufficient length for proximal and distal fixation. Repeat physical examination included KT-1000 measurement, scanogram, and completion of a Lysholm knee scale and International Knee Documentation Committee (IKDC) evaluation. Results: Seventeen male patients 7.7 to 14.9 yr who fit the inclusion criteria were identified. All had open tibial and femoral physes at the time of ACL reconstruction. Average follow-up was 2 yr. At latest follow-up, all patients had stable Lachman tests and were able to return to sporting activities at their previous levels. Average limb-length discrepancy was 2.2 mm, with an average angular difference of 1.7 degrees, neither of which was statistically or clinically significant. Average Lysholm score was 91.5, and the average IKDC score was 92.7. Conclusions: This technique can restore motion and stability after ACL injury in skeletally immature patients while minimizing the risk of growth disturbance that might result in length or angular deformities. Level of Evidence: IV.

Efficacy of Osteochondral Allograft Transplantation in the Knee in Adults Forty Years and Older

Objectives:Fresh osteochondral allograft transplantation (FOCA) have been used successfully to treat large chondral and osteochondral defects of the knee. The purpose of the present study was to determine the efficacy of this treatment in patients older than 40, in comparison to a cohort 39 and younger.Methods:We utilized a prospective database of 107 consecutive patients, with baseline PRO data receiving osteochondral allograft transplantation to the knee from a single surgeon practice over 8 years (March 2007-July 2015). Patient and donor characteristics were routinely collected, as were patient annual PRO measures, principally International Knee Documentation Committee (IKDC) and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Table 1 summarizes cohort demographics; 68 patients completed surveys at a minimum of 24 month follow-up and were categorized into two cohorts based on age at surgery. Group A (study group) consisted of 33 patient’s forty years of age and greater, 8 women and 25 men, with a mean age of 52.8 years (40-68) and average final up of 3.5 years. Group B (control group) consisted of 35 patient’s less than forty years, 12 women and 23 men, with a mean age of 27.8 years (15-39) and average final follow up of 2.6 years.Results:Both groups showed a significant improvement in outcome KOOS and IKDC scores at 12 months, 24 months and final follow up. 11 patients (31%) in the control cohort and 8 patients (24%) in study cohort underwent a second surgery on the index knee after the OCA transplantation. A statistically significant improvement in the study group from baseline to final follow-up (p<.02) was seen for all KOOS subscores (Symptom:+ 4.83, Pain: +13.05, ADL: +17.44, Sports: +14.48, QOL: +25.3) and IKDC (+22.46). A statistically significant improvement in the control group from baseline to final follow-up (p<.02) was seen for all 5 KOOS subscores; (Symptom:+15.22, Pain: +8.68, ADL: +18.52, Sports: +30, QOL: +32.71) and IKDC (+32.9). In the study group, the maximum improvements (112% of baseline, 45% of baseline) were seen in the KOOS QOL and sports respectively. Similar changes in the control group included 138% improvement from baseline KOOS QOL and 83.3% for sports. Despite this, there was no significant difference between the two groups with respect to any average KOOS subscore or IKDC score, at any time during the observation period.Conclusion:There was no significant difference between the group’s outcomes data at final follow up. This implies the efficacy of OCA transplantation in adults forty years of age and older is similar to that of younger adults. Interestingly, we saw the greatest improvement in each of the two cohorts in the quality of life subscale of the KOOS. Significant sustained improvements in the symptom, ADL and pain subscales of the KOOS and IKDC were also observed in both groups. Overall, patients over 40 years benefit in a similar manner to younger patients after FOCA and these benefits appear greatest for Quality of Life.Clinical InformationStudy GroupControl GroupNo. of patients studied3335Mean age at time of surgery (range)52.8 (40-68)27.8 (15-39)Body Mass Index, kg/m2 (range)28.1 (22.3-38.4)26.5 (19.4-34.0)No. of knees with previous surgery (%)27 (81)33 (94)Mean No. of previous surgeries (range)1.1 (1-3)1.1 (1-3)Location of graft, No.Lateralfemoral condyle820Medial femoral condyle2111Other44

Fixation versus Excision of Osteochondral Fractures after Patellar Dislocations in Adolescent Patients: A Retrospective Cohort Study.

Background:Patellar dislocation is one of the most common knee injuries in the adolescent population. It is often combined with osteochondral fracture. The purpose of this study was to compare the outcomes between fixation and excision of osteochondral fractures not involving the bearing surface in adolescent patients with patellar dislocations.Methods:Patients who underwent surgery for osteochondral fracture following patellar dislocation in our institution from 2007 to 2014 were retrospectively evaluated. Visual analog scale (VAS) of pain and the International Knee Documentation Committee (IKDC) form were used to assess knee pain and function at follow-up. Patient satisfaction was evaluated. Differences in the values of variables among groups were assessed using t-test if equal variance or Mann–Whitney U-test if not equal variance. The Pearson's Chi-square test was applied for dichotomous variables if expected frequency was >5 or Fisher's exact test was applied if not. A value of P < 0.05 was considered statistically significant.Results:Forty-three patients were included, with the average age of 14.1 ± 2.3 (range, 9.0–17.0) years. Nineteen underwent fixation of osteochondral fractures and 24 did not. The average follow-up time was 28 ± 10 months. There was no significant difference in age, gender, follow-up time, causes of injury, times of dislocation, and location of osteochondral fracture between fixation and excision groups. The fixation group had a significantly longer surgery time (82 ± 14 min) and larger size of osteochondral fracture (2.30 ± 0.70 cm2) than the excision group (43 ± 10 min, 1.88 ± 0.62 cm2, respectively, t = 10.77, P < 0.01 and t = 0.84, P < 0.05). At the last follow-up, the average IKDC score in the fixation group (82.52 ± 8.71) was significantly lower than that in the excision group (89.51 ± 7.19, t = 2.65, P < 0.01). There was no significant difference in VAS of pain and patients' satisfaction. There were 7 (16%) patients with recurrent dislocation.Conclusion:Excision of osteochondral fractures has equivalent or better outcomes compared to fixation in adolescent patients with patellar dislocations when these fractures do not involve the bearing surface.

Weak associations between body mass index and self-reported disability in people with unilateral anterior cruciate ligament reconstruction.

Individuals with an anterior cruciate ligament reconstruction (ACLR) are susceptible to persistent disability, weight gain and the development of knee osteoarthritis. It remains unclear whether body mass index (BMI) is a factor that influences disability following ACLR. The purpose of this study was to determine the association between BMI and self-reported disability [International Knee Documentation Committee (IKDC) Index] in individuals with a unilateral ACLR. We hypothesized that lower BMI would associate with higher IKDC. BMI and IKDC were measured in 668 individuals with a unilateral ACLR (60.9% female, BMI 24.4±3.7kg/m2, IKDC 84.7±11.9%). Bivariate associations were conducted between BMI and IKDC for the entire sample and selected subsets (gender, ACLR graft type and history of meniscal injury). Multiple regression analyses were used to determine the impact of potential covariates (Tegner score, age and months since ACLR) for significant bivariate associations. After accounting for covariates, there were no significant associations between BMI and IKDC when separately evaluating the cohort based on either gender or history of a concomitant meniscal injury. The odds of achieving age- and gender-matched healthy population average IKDC scores for those with low (<25) and high (≥25) BMI were determined. Lower BMI associated with higher IKDC (r=-0.08, P=0.04). For the entire sample, BMI did not uniquely predict variance in IKDC (ΔR 2>0.001, n.s.) after accounting for covariates. BMI uniquely predicted a significant but negligible amount of variance in IKDC in individuals with a patellar tendon autograft (ΔR 2=0.015, n.s.). Individuals with low BMI demonstrated higher odds (odds ratio=1.45; 1.05-1.99) of achieving population average IKDC scores compared to participants with high BMI. There was a significant but negligible correlation between lower BMI and lesser disability in individuals with unilateral ACLR and individuals who are underweight or of normal BMI demonstrated higher odds of achieving population average IKDC scores compared to overweight or obese individuals. While an overall association was found between lower BMI and lesser disability, the magnitude of the association remains negligible; therefore, BMI was not a strong clinical predictor of successful ACLR outcomes in this cohort of patients with unilateral ACLR. Cross-sectional prognostic study, Level II.

Hospital for Special Surgery ACL Registry: 2-Year Outcomes Suggest Low Revision and Return to OR Rates.

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries. Patient outcomes, rate of subsequent operations, and rate of subsequent ACL reconstruction following primary ACL reconstruction need to be evaluated. This study was designed to answer the following questions: (1) What is the return to surgery (OR) rate following primary ACL reconstruction and (2) what is the revision ACL reconstruction rate? Data was drawn from the Hospital for Special Surgery (HSS) ACL Registry. International Knee Documentation Committee (IKDC) Subjective Knee Evaluation, Lysholm-Tegner Scales, Marx Activity Scale, and SF12 were completed by patients at baseline, 1-, and 2-year follow-up. Clinical data and intraoperative data were registered by surgeons on an intraoperative form. Subsequent surgery rates were determined by evaluating the medical records for subsequent surgery, laterality, surgeon, procedure description, and type of anesthesia. The majority of the ACL reconstructions performed were autograft (76.6%) with the most common graft being bone-patellar tendon-bone (BTB) autograft (47.2%), hamstring autograft (21.9%), and Achilles allograft (18.2%). Average IKDC score improved from 51.9 (SD 16.1) at baseline to 83.5 (SD 14.2) at 2-year follow-up. Females had a 2.5-point lower IKDC and 1.4-point Marx scores compared to males. Of the enrolled patients, 7.3% had revision ACL surgery with 70.4% being ipsilateral ACL surgery. Of the enrolled patients, 10.3% had subsequent knee surgery with 72.3% being ipsilateral knee surgery. Multivariable logistic regression analysis showed that patients less than 18years of age at the time of their index surgery were over three times more likely to undergo a revision ACL reconstruction compared to older patients and were at four times higher risk than older patients for any subsequent knee surgery. Understanding ACL surgery, patient outcomes, and risk factors for revision ACL surgery and subsequent knee surgery after primary ACL reconstruction is essential. Patients less than 18years of age have a higher risk of subsequent knee surgery and subsequent ACL surgery than older patients.

Isokinetic Strength Training Improves Knee Symptoms and Function as Evaluated with 2000 IKDC

Background: Knee pain is most common complaint in athletes which may be caused by physical activity and exercises with many other causative factors. Sports injuries may lead to decline in muscle strength. This loss of muscular strength is strongly associated with decline in athletic performance. Improvement in strength may result in improved physical functions in injured athletes. Aim of this study was to evaluate the effectiveness of isokinetic strength training in athletes with knee pain. Subjects: The average age of the athletes was 23.48 ± 4.71 years (Range: 18 - 34). Mean body mass of the athletes was 63.35 ± 15.52 kg (Range: 39 - 93.90). 25 male and 1 female athletes participated in this study. Methods: 25 athletes with knee pain completed the isokinetic strength training sessions by using Biodex Isokinetic system 10 sessions on alternate day basis. International Knee Documentation Committee (IKDC) 2000 form was used to assess the functional status and symptoms of the athletes at baseline and after completing 10 sessions. Results: The average IKDC score was 45.64 (Range20.68-62.06) at baseline and 84.08 (range 68.96- 93.1) after completion of 10th sessions. Significant improvement was there when paired sample T test was used to find out pre and post changes in individual items of IKDC. Most of the individual items improved significantly as p value is <0.001. Conclusion: Isokinetic strength training significantly improves knee symptoms, level of sports activities, and function in patients with athletic knee pain

Arthroscopic-Assisted Fixation of Tibial Plateau Fractures: Patient-Reported Postoperative Activity Levels.

Tibial plateau fractures may result in significant limitations postoperatively. Studies have described outcomes of arthroscopic-assisted percutaneous fixation (AAPF) of these injuries but have rarely reported postoperative activity levels. Between 2009 and 2013, patients who sustained a lateral split, split depression, or pure depression type tibial plateau fracture (Schatzker types I-III fractures) and underwent outpatient AAPF were eligible for the study. Outcomes were assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm score, and Marx activity score. Twenty-five consecutive patients were eligible for the study, and 22 (88%) were included in the final analysis, with average follow-up of 2.5 years (range, 1-5.2 years). Thirteen women and 9 men with an average age of 48.3 years (range, 23-65 years) comprised the study population. Average number of screws used for fixation was 2 (range, 1-4). The average depression was 8 mm preoperatively and 0.9 mm (range, 0-3 mm) postoperatively. Four patients (18%) had complications: 2 with hardware removal and 2 with postoperative deep venous thrombosis. Average postoperative Marx activity score was 5.7. Average postoperative KOOS Symptoms, Sports, and Quality of Life scores were 88 (range, 68-100), 85 (range, 45-100), and 77 (range, 50-100), respectively. Average IKDC and Lysholm scores were 81 (range, 55-97) and 87 (range, 54-100), respectively. The AAPF surgical technique, which was performed in an outpatient setting, facilitated excellent postoperative range of motion, outcomes, and activity scores with minimal complications. [Orthopedics. 2016; 39(3):e486-e491.].

Clinical and functional outcome after anterior cruciate ligament reconstruction using the LARS™ system at a minimum follow-up of 10 years

BackgroundSince the 1980's several artificial ligaments were used for reconstruction of the anterior cruciate ligament (ACL) serving different complications. The aim of this study was to assess the clinical and functional outcomes of primary ACL reconstruction using the Ligament Augmentation Reconstruction System (LARS™) with a minimum follow-up of 10-years. The LARS™ presents a synthetic material consisting of non-absorbing polyethylene terephthalate fibres used for ligament reconstruction. MethodsOutcomes of 18 patients who underwent arthroscopic ACL reconstruction using the LARS™ system between 2000 and 2004 with a minimum follow-up of 10years were observed. The International Knee Documentation Committee score (IKDC), Visual Analog Scale (VAS), Lysholm score, and Tegner Activity Scale were assessed. Clinical assessment was performed by Lachman testing, assessment of side-to-side difference on KT-2000 testing and plain radiography evaluation of osteoarthritis. ResultsThere were seven males and 11 females, mean age 29years (range, 18 to 44years) and a mean follow-up of 151.5 months. Five patients (27.8%) sustained a re-rupture of the LARS™ system and underwent revision surgery after a mean time of 23months and four patients (22.2%) presented with a re-rupture. The average IKDC score was 76.60±18.18, the average Lysholm score was 88.00±10.07 and the average Tegner activity score was five at final follow-up. ConclusionOur results indicate that the LARS™ system should currently not be suggested as a potential graft for primary reconstruction of the ACL. In special cases, however, the LARS™ system can serve as an alternative graft.Level of evidence: Level IV, retrospective study.

Half-peroneus-longus-tendon graft augmentation for unqualified hamstring tendon graft of anterior cruciate ligament reconstruction

BackgroundIn some situations, harvested hamstring tendon grafts are not qualified for anterior cruciate ligament (ACL) reconstruction. This study aimed to present a reinforcing method with additional half peroneus longus tendon (half-PLT) graft augmentation. MethodsEight cases underwent ACL reconstruction with unqualified hamstring tendon grafts (diameter <7mm) and were salvaged by additional half-PLT graft augmentation. The pivot shift test and KT-1000 tests were performed 3years after surgery. Functional evaluation of subjective International Knee Documentation Committee (IKDC) and Lysholm scores was also done. In addition, Foot and Ankle Disability Index (FADI) scores were used to evaluate the function of the ankle donor site. ResultsThe diameter of unqualified four-strand hamstring tendon grafts was 6.2mm on average (range, 6.06.5mm). The average diameter of hamstring grafts with half-PLT augmentation was 9.6mm (range, 9.5-10.0mm). The pivot shift test was negative in all patients. No significant differences between normal and abnormal knees were found by KT-1000. The average IKDC score was 86.0 (range, 83 to 89), and the average Lysholm score was 84.4 (range, 80-90). The average FADI score for the donor sites of half-PLT was 135.8 (range, 134-136). ConclusionsAdditional half-PLT can successfully and safely reinforce unqualified hamstring tendon grafts for ACL reconstruction.

Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes

Background: The treatment of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial. Current evidence supports the view that surgical techniques restore knee stability and prevent progressive articular damage. However, most of the studies on this topic are small case series or they have short- or medium-term follow-up times. Purpose: To determine the long-term functional outcomes and secondary complications of transphyseal intra-articular ACL reconstruction with hamstring graft in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: Transphyseal ACL reconstruction with autograft hamstrings was performed in 27 skeletally immature patients. The average age at surgery was 13 years (range, 12-16 years), and the average follow-up time was 10.6 years (range, 10-13 years). Clinical outcomes were assessed with preoperative and final follow-up Tegner, International Knee Documentation Committee (IKDC) subjective, and Lysholm scores. Surgery details, return to sports, and ACL reconstruction failures were collected. The anteroposterior knee laxity was assessed by arthrometry, and the presence of deformities and lower limb length discrepancies were evaluated by radiographs. The presence of degenerative signs on anteroposterior and lateral knee radiographs at final follow-up was also evaluated. Results: Transphyseal ACL reconstruction was performed with vertically oriented tunnels, 7 to 10 mm in diameter, using semitendinosus-gracilis autograft. The average preoperative Tegner, IKDC, and Lysholm scores were 7, 55, and 40, respectively. Significant differences in these scores were observed at the time of the final assessment (Tegner, 6 [P = .026]; IKDC, 94 [P < .001]; Lysholm, 92 [P < .001]). Two patients reported instability during sports activity. Three patients had a rupture of the ACL graft. No leg length discrepancy, axis malalignment, or degenerative changes were observed. Conclusion: The transphyseal ACL reconstruction in skeletally immature patients is a safe option, with high functional and satisfaction results, without significant growth plate damage in this series of patients.

Neglected ununited tibial eminence fractures in the skeletally immature: arthroscopic management.

The purpose of this study was to prospectively evaluate outcomes of arthroscopic management of neglected ununited tibial eminence fractures in skeletally immature patients. The study was conducted and cases performed by two surgeons from two centres as a prospective case series of 13 patients with neglected ununited tibial eminence fractures: nine were girls and four were boys; ten were right knees and three were left. The average age at surgery was ten [standard deviation (SD) 2.6] years. Average follow-up was 10.8 (SD 6.8) months. Primary outcome measures used for evaluation were the Objective International Knee Documentation Committee Score (IKDC), subjective IKDC and modified Lysholm knee score. Secondary outcome measures were visual analogue scales (VAS) for pain and patient satisfaction. Twelve patients had grade A objective IKDC score and one patient had grade B. Average subjective IKDC score was 80.5 (SD 16.7). Average modified Lysholm score was 91.2 (SD 8.9). Average VAS for operation satisfaction was 9.6 (SD 0.5) and for pain was 0.4 (SD 0.5). All patients showed radiological union and anatomical reduction at an average of 12.4 weeks postoperatively. At follow-up, all 13 patients showed complete range of motion (ROM). Eleven patients had negative Lachman, anterior drawer and pivot-shift tests, while two patients had grade 1 positive Lachman and negative anterior drawer and pivot-shift tests. No patient had complained of instability. Neglected ununited tibial eminence fractures in skeletally immature patients achieve good functional outcome results when treated with arthroscopic reduction and internal fixation using sutures.