Contralateral Normal Knee Research Articles

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.

The effect of the Oxford uncemented medial compartment arthroplasty on the bone mineral density and content of the proximal tibia

We studied the bone mineral density (BMD) and the bone mineral content (BMC) of the proximal tibia in patients with a well-functioning uncemented Oxford medial compartment arthroplasty using the Lunar iDXA bone densitometer. Our hypothesis was that there would be decreased BMD and BMC adjacent to the tibial base plate and increased BMD and BMC at the tip of the keel. There were 79 consecutive patients (33 men, 46 women) with a mean age of 65 years (44 to 84) with a minimum two-year follow-up (mean 2.6 years (2.0 to 5.0)) after unilateral arthroplasty, who were scanned using a validated standard protocol where seven regions of interest (ROI) were examined and compared with the contralateral normal knee. All had well-functioning knees with a mean Oxford knee score of 43 (14 to 48) and mean Knee Society function score of 90 (20 to 100), showing a correlation with the increasing scores and higher BMC and BMD values in ROI 2 in the non-implanted knee relative to the implanted knee (p = 0.013 and p = 0.015, respectively). The absolute and percentage changes in BMD and BMC were decreased in all ROIs in the implanted knee compared with the non-implanted knee, but this did not reach statistical significance. Bone loss was markedly less than reported losses with total knee replacement. There was no significant association with side, although there was a tendency for the BMC to decrease with age in men. The BMC was less in the implanted side relative to the non-implanted side in men compared with women in ROI 2 (p = 0.027), ROI 3 (p = 0.049) and ROI 4 (p = 0.029). The uncemented Oxford medial compartment arthroplasty appears to allow relative preservation of the BMC and BMD of the proximal tibia, suggesting that the implant acts more physiologically than total knee replacement. Peri-prosthetic bone loss is an important factor in assessing long-term implant stability and survival, and the results of this study are encouraging for the long-term outcome of this arthroplasty.

Biomechanical Comparison Of Double Bundle Versus Single Bundle Anterior Cruciate Ligament Reconstruction Using Three Dimensional Gait Analysis

No differences were detected between anatomic SB and DB ACL reconstructed patients with regard overall tibio-femoral rotation and adduction moments. There has been a recent focus on surgical techniques that more closely approximate the anatomy of the anterior cruciate ligament (ACL). Double bundle techniques have gained popularity but are more surgically demanding, costly and may lead to more complex revision procedures. Outcome measures used in clinical studies may not be sensitive enough to detect a difference between the techniques, therefore more accurate in vivo studies are required. This study utilizes three dimensional gait analysis to compare two groups of patients having undergone either an anatomical single or double bundle ACL reconstruction. It is hypothesised that there will be no significant difference between the two groups with regard tibio-femoral rotation and knee adduction moments. Twenty-eight patients (14 SBACLR, 14 DBACLR) were assessed using a ten-camera Vicon system allowing three dimensional gait analysis. They were each required to perform four tasks: level walking, step descent and immediate pivot, jog and cut and hop and dodge The overall range of tibial rotation and knee adduction moments were recorded for the reconstructed and normal contralateral knee. Other outcome measures including KT-1000, IKDC score and functional hop tests were recorded and clinical tests such as a Lachman and pivot shift were performed. Patient demographics were similar for both groups and all patients were clinically stable and satisfied with their reconstructed knee (IKDC A or B). There were no significant differences for range of tibial rotation between the reconstructed and ACL intact limbs for either the DB or SB groups. Similarly there were no differences between DB and SB groups regarding adduction moments. This paper demonstrates that an anatomical single bundle ACL reconstruction, when compared to the normal contralateral knee, is able to control tibio-femoral rotation and adduction moments as well as a double bundle procedure. The key may be anatomical graft position, not the number of bundles.

Relationship between isokinetic strength and tibiofemoral joint space width changes following ACL reconstruction

Purpose: Following anterior cruciate ligament (ACL) injury and reconstruction (ACL-R), quadriceps muscle weakness and low hamstring-to-quadriceps muscle strength ratios have been associated with post-traumatic osteoarthritis (PTOA) as well as primary OA. However, this relationship has not been examined using tibiofemoral joint space width difference (JSW-D) as a measurement of PTOA onset. JSW-D is a measurement technique that is sensitive to PTOA changes prior to the clinical manifestation of the disease. It is important to determine risk factors associated with the onset and progression of PTOA at the earliest time point in the disease process when intervention can alter the progression of the disease. Consequently, the focus of this study was to examine the relationship between isokinetic knee strength and JSW-D at one and four years post-ACL-R compared to a group of healthy, non-injured subjects of similar sex, age, BMI, and activity level. Methods: A secondary analysis of data collected during a longitudinal study of biomarkers of PTOA following ACL-R was utilized for this exploratory study. Entry criteria for injured subjects included: age at time of ACL-R = 14-55; BMI = 18.5-30; Tegner activity score > 4; < 2/3 meniscectomy; < grade IIIa articular cartilage lesions; no history of joint surgeries, knee injections, or other knee pathologies; no abnormal knee laxity or evidence of radiographic OA at baseline. Additional criteria for controls included: no knee pain/dysfunction, and normal clinical evaluation and baseline MRI. At 1- and 4-years post ACL-R, standing, bilateral metatarsal phalangeal (MTP) view knee x-rays were obtained for JSW assessment. Subjects were considered to have significant narrowing if their injured minus normal (contralateral) knee JSW difference (JSW-D) fell below the 95% confidence interval of controls. At the same time point, isokinetic knee strength was assessed at 60, 180, and 300 deg/sec, and normalized to body weight. Relationships between strength and JSW-D were evaluated between ACL subgroups (normal and narrowed) and controls using analysis of covariance adjusted for age, sex, BMI, and time since surgery. Post-hoc group comparisons were made using Fisher's LSD. Results: Of the 34 ACL-R patients included, 6 had significant JSW-D narrowing at 1-year follow-up, and 8 had narrowing at 4-year follow-up. The mean strength values for all ACL-R subjects (“normal” and “narrowed JSW-D” groups combined) were found to be significantly less than the control group at both time points. However, ACL-R subjects with narrowed JSW-D did not differ from normal JSW-D subjects (all p > 0.20) with one exception: extension at 60 degrees/second at four-year follow-up (p = 0.005). The pattern of knee extension strength at 60 deg/sec at 1-year follow-up was similar to changes observed at 4-year follow-up. Extension to flexion strength ratios were not found to have a significant association with JSW-D at any speed. Conclusions: Strength deficits present as early as one year following ACL-R and persist at 4-years post. In general, ACL-R group subjects were not found to have significantly different strength values within JSW subgroups. In contrast to previous studies, the current investigation did not reveal an association between PTOA and low extension to flexion strength ratios. It should be noted that no subjects in this study reported appreciable pain/dysfunction or reduced physical activity, which is indicative of the clinical manifestation of OA. However, subjects with narrowed JSW-D had significantly lower extension strength at 60 degrees/second than controls and injured subjects with normal JSW-D. It may be that individuals that loose a significant amount of knee extension strength are at greater risk for tibiofemoral JSW narrowing following ACL trauma.

Dynamic Electromyography After Cruciate-retaining Total Knee Arthroplasty Revealed A Threefold Quadriceps Demand Compared With The Contralateral Normal Knee

Quadriceps functional impairment accounts for a considerable amount of morbidity after knee replacement. Cruciate-retaining total knee arthroplasty (CR-TKA) may predispose to increased quadriceps demand. We compared bilateral relative quadriceps effort in seven patients with successful unilateral CR-TKA at least 2years after surgery. Dynamic electromyography (EMG) recorded quadriceps activity during walking recorded simultaneously with gait analysis using IDEEA. There was greater EMG activity for the operated knees, both in amplitude (43.08±26.47 vs. 16.02±5.38, P=.0355), and the area under the curve (7231.1±3869.8 vs. 2547.3±1007.9, P=.0267). The onset and duration of muscle activity were similar for both knees (P=.74). CR-TKA demonstrated threefold EMG activity and muscle effort during normal walking. The study suggested that quadriceps functional deficiency is associated with CR-TKA.

A novel approach for evaluating acceptable intra-operative correction of lower limb alignment in femoral and tibial malunion using the deviation angle of the normal contralateral knee

BackgroundA simple and appropriate approach for evaluating an acceptable alignment of bone around the knee during operation has not yet been reported. MethodsThirty-five men and 35 women presenting with nonunion or malunion of the unilateral femoral shaft were included in the first study. Using the standing scanograph, the contralateral normal lower extremity was measured to determine the normal deviation angle (DA) of the medial malleolus when the medial aspect of the knee was placed in the midline of the body. In the second study, the normal DA from individual patients was used as a reference to evaluate knee alignment during operation in 40 other patients presenting with distal femoral or proximal tibial nonunion or malunion. The clinical and knee functional outcomes of these 40 patients were investigated. ResultsThe average normal DA was 4.2° in men and 6.0° in women (p<0.001). Thirty-four of the 40 patients presenting with disorders around the knee were followed up for an average of 3.6years (range, 1.1–6.5years). Thirty fractures healed with a union rate of 88% and an average union period of 4.2months (range, 2.5–6.5months). Ideal knee alignment was maintained in all 30 patients with fracture union. Satisfactory function of the knee was achieved in 28 patients (82%, p<0.001). ConclusionsUsing a normal DA as a reference may be a feasible and effective technique for evaluating an acceptable alignment of bone around the knee during operation. Levels of evidenceLevel IV, Case series.

Normal sagittal of the anterior cruciate ligament can be reproduced using accessory anteromedial portal technique: a magnetic resonance imaging study

Over time, the need for anatomic anterior cruciate ligament (ACL) to restore normal kinematics and postoperative function of the knee has been accepted. The purpose of this study was to compare the sagittal alignment of reconstructed ACL, which is performed between transtibial (TT) technique and accessory anteromedial (AAM) portal technique and between the reconstructed and the normal side in the same patient. In addition, we used the head of a metallic femoral interference screw as a reference to measure the femoral tunnel position. This was a retrospective study with 15 patients in each group: accessory anteromedial portal technique (n=15), TT technique (n=15) and contralateral normal side of each technique group (15 knees per technique). Magnetic resonance images of the ACL sagittal angle and radiographs of the coronal screw angle were used for comparing the two groups. The paired t test was used to compare operated and contralateral normal knee and independent t test was used to compare the TT and the AAM groups. The sagittal angle of ACL of AAM technique (51.6±3.3°) was not different from the normal side (50.8±2.1°) (P=0.270), however that of the TT technique (59.9±5.7°) was significantly different from the normal side (50.9±2.4°) (P<0.001). The sagittal angle of AAM technique was significantly lower than that of the TT technique (P<0.001). The coronal angle of the screw to axis of the femur in AAM technique (51.7±3.8°) was more horizontal than that of the TT technique (24.4±8.9°) (P<0.001). The center of the screw head of the AAM technique was 30.7±3.1% of the Blumensaat line and 39.2±5.2% of the condylar height. The anatomic sagittal angle of ACL can be achieved using the AAM technique compared with the TT technique. In addition, the angle of the screw in coronal plane was more horizontal using the AAM technique than with use of the TT technique. Level III, diagnostic study.

Malalignment and subchondral bone turnover in contralateral knees of overweight/obese women with unilateral osteoarthritis: Implications for bilateral disease

To explore whether the risk of incident tibiofemoral (TF) osteoarthritis (OA) in the radiographically normal contralateral knee of overweight/obese women with unilateral knee OA is mediated by malalignment and/or preceded by increased turnover of subchondral bone. We used data of post hoc analyses from a randomized controlled trial. Cross-sectional analyses evaluated the baseline association between frontal plane alignment and bone turnover in the medial TF compartment in 78 radiographically normal contralateral knees. Longitudinal analyses ascertained whether incident radiographic OA (TF osteophyte formation within 30 months) was associated with malalignment and/or increased bone turnover at baseline. Alignment subcategories (varus/neutral/valgus) were based on the anatomic axis angle. (99m)Tc-methylene diphosphonate uptake in a late-phase bone scan was quantified in regions of interest in the medial tibia (MT) and medial femur (MF) and adjusted for uptake in a reference segment of the ipsilateral tibial shaft (TS). MF and MT uptake in varus contralateral knees was 50-55% greater than in the TS. Adjusted MT uptake in varus contralateral knees was significantly greater than that in neutral and valgus contralateral knees (mean 1.55 versus 1.38 and 1.43, respectively; P < 0.05). Among 69 contralateral knees followed longitudinally, 22 (32%) developed TF OA. Varus angulation was associated with a marginally significant increase in the odds of incident OA (adjusted odds ratio 3.98, P = 0.067). While the small sample size limited our ability to detect statistically significant risk factors, these data suggest that the risk of developing bilateral TF OA in overweight/obese women may be mediated by varus malalignment.

Surgical Technique: Development of an Anatomic Medial Knee Reconstruction

The main static stabilizers of the medial knee are the superficial medial collateral and posterior oblique ligaments. A number of reconstructive techniques have been advocated including one we describe here. However, whether these reconstructions restore function and stability is unclear. This anatomic reconstruction technique consisted of reconstruction of the proximal and distal divisions of the superficial medial collateral and the posterior oblique ligament using two separate grafts. We prospectively followed all 28 patients (19 male, nine females) who had this new reconstruction between 2007 and 2009. The average age was 32.4 years (range, 16-56 years). There were eight acute and 20 chronic injuries. All patients presented with side-to-side instability with activities of daily living and other higher level activities. Minimum followup was 6 months (average, 1.5 years; range, 0.5-3 years). No patients were lost to followup. Preoperative International Knee Documentation Committee subjective outcome scores averaged 43.5 (range, 14-66) and final postoperative values averaged 76.2 (range, 54-88). Preoperative valgus stress radiographs averaged 6.2 mm of medial compartment gapping compared with the contralateral normal knee, whereas postoperative stress radiographs averaged 1.3 mm. Early observations suggest this anatomic reconstruction technique improves overall patient function and restores valgus instability.

9 RELATIONSHIP BETWEEN ARTHROSCOPIC FINDINGS AT THE TIME OF ACL RECONSTRUCTION AND TIBIOFEMORAL JOINT SPACE WIDTH

Purpose: Little is known about the initial onset and early progression of post-traumatic OA (PTOA) following severe knee trauma such as that associated with anterior cruciate ligament (ACL) disruption. The purpose of this investigation was to study subjects following ACL injury with and without associated injuries to the cartilages (meniscal and articular cartilages) and determine the relationship between these concomitant injuries and tibiofemoral joint space width (JSW) compared to healthy, matched controls at 3–4 year follow-up. Methods: This investigation was designed as a prospective cohort study with a nested case-control analysis. Thirty-eight ACL-injured (20 women) and 32 healthy control subjects (18 women) matched for age, sex, race, BMI, and activity level were evaluated and followed over 3–4 years. Entry criteria for ACL-R subjects included: Age 14–55 yrs; BMI = 18.5–30, Tegner activity score >4; no relevant knee pathologies other than what was produced by the index injury; normal anatomic alignment; less than 2/3 menisectomy; and Gr IIIa articular cartilage lesions or less. All reconstructions occurred within 6 months of injury, and all subjects participated in a standardized rehabilitation program. Similar entry criteria were utilized for controls, with the exception of: no history of knee pain or dysfunction; no abnormal findings with clinical knee examination; and no abnormal findings on baseline MRI. Articular cartilage and meniscus lesions were identified via arthroscopic visualization at the time of ACL-R and graded by an experienced orthopedic surgeon. This information was recorded on the 2000 International Knee Documentation Committee (IKDC) Surgical Documentation Form, and included characterization of meniscus and articular cartilage lesion location, size, and severity. Bilateral, weight bearing tibiofemoral radiographs were obtained at baseline and 3–4 year follow-up intervals and JSW assessed using previously validated techniques. Subjects were considered to have significant JSW differences of their injured knee if the injured minus normal (contralateral) knee difference fell outside the calculated 95% confidence interval (CI) of bilateral differences measured in controls. Logistic regression (controlled for subject age, sex, BMI, and time between injury and ACL-R) was used for group comparisons and calculation of corresponding odds ratios. Results: Statistical analyses revealed two distinct groupings of JSW differences for the ACL-R subjects. Those with a grade IIb articular cartilage lesion or less and “intact” menisci in both the medial and lateral compartments (the “low-risk” group); or those with grade IIIa femoral articular cartilage lesions and/or menisectomy in either compartment (“high-risk” group). The low risk group was comprised of 25 subjects, and 72% (18/25) of these individuals had JSW values that fell within the normal 95% CI of control values. The high-risk group was comprised of 13 subjects, with only 38% (5/13) having normal JSW at follow-up. Subjects in the high risk group were significantly more likely to have JSW difference values that fell outside the 95% CI of controls in comparison to those in the low risk group (OR: 4.11; 95% CI: 1.01 to 39.55; p = 0.05). Conclusions: Suffering ACL injury in combination with either a grade IIIa articular cartilage lesion, or meniscus injury requiring surgical resection resulted in ACL-R subjects that were more than 4 times more likely to display abnormal JSW changes in comparison to ACL-R subjects without these concomitant injuries at 3–4 year follow-up. These dramatic changes occurred over a relatively short time interval following the injury and reconstruction in subjects with normal knee function and no symptoms of OA and this demonstrates the importance of these articular structures on what appears to be some of earliest changes associated with the initial onset of PTOA.

Gait analysis comparison of cruciate retaining and substituting TKA following PCL sacrifice

The role of the posterior cruciate ligament (PCL) remains controversial in total knee arthroplasty (TKA), with some surgeons who believe in PCL sacrifice and substitution and others who believe in PCL preservation for stability. Manufacturers have developed both cruciate-substituting/posterior stabilized (PS) implants typically used when the ligament is sacrificed and cruciate retaining (CR) implants designed for ligament preservation. However, studies demonstrate excellent clinical results with CR implants despite PCL sacrifice. This study sought to determine functional stability differences between PS and CR TKAs following PCL sacrifice. Eighteen (9 matched pairs) subjects with either a PS or CR TKA and sacrificed PCL and a normal contralateral knee were subjected to physical exam and gait analysis (walking, stair ascent and descent) using a staircase model, passive reflective arrays and an optoelectric system. No differences were detected between the two groups among any of the measured parameters (knee flexion angle, knee flexion moment, knee power absorption, pelvic tilt). PCL sacrifice in a well-balanced cruciate retaining TKA did not result in instability during stair descent based on gait parameters. The decision to use a posterior stabilized design when faced with an incompetent PCL intraoperatively should be based on factors other than anticipated instability.

All-Arthroscopic Repair of Arcuate Avulsion Fracture With Suture Anchor

Arcuate avulsion fractures are very rare but present pathologic posterolateral rotation instability. Untreated instability may lead to overload of the reconstructed posterior cruciate ligament (PCL) graft. Surgical treatment and clinical results have not yet been reported to our knowledge. This study presents the case of a 45-year-old man with PCL injury and an arcuate avulsion fracture of the fibular head. The dial test was positive preoperatively, and magnetic resonance imaging showed an “arcuate” sign. The avulsed bone fragment was reduced and fixed with a suture anchor by an all-arthroscopic technique. At the 1-year follow-up, the patient had resumed all his normal activities, including sports. He scored 1+ on the posterior drawer test, and external rotation was 1° less than that in his contralateral normal knee. Compared with the values in the contralateral normal knee, the posterior tibial translation was reduced from 15.5 mm preoperatively to 6.3 mm postoperatively. The postoperative magnetic resonance imaging and computed tomography scans showed that the reconstructed PCL graft and the osseous fragment of the styloid process of the fibular head attached to the popliteofibular ligament were reduced. This technical note describes an all-arthroscopic reduction and fixation technique of arcuate avulsed fracture of the fibular head.

Proprioception following partial meniscectomy in stable knees

to investigate the proprioceptive function of patients with isolated meniscal tears of the knee before and after arthroscopic partial meniscectomy. one hundred subjects (50 patients who underwent a knee arthroscopy and 50 normal controls) were evaluated using single-leg dynamic postural stabilometry. All participants were assessed clinically and radiologically. Knee outcome scores were obtained for all subjects. of the 50 patients arthroscoped, 34 were found to have meniscal tears. Twenty-nine of these patients were reassessed 3 months post-operatively. There was a significant proprioceptive deficit in subjects with meniscal tears when compared to their normal contra-lateral knee (P < 0.001) and the control group (P < 0.001). Partial meniscectomy resulted in a significant improvement in knee outcome scores but not proprioception measurements (n.s.). patients with isolated meniscal tears were found to have a significant proprioceptive deficit which persisted following arthroscopic partial meniscectomy despite an otherwise successful clinical outcome.

A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system

We conducted a prospective randomised study of anatomical single-bundle (A-SB group) versus double-bundle (A-DB group) anterior cruciate ligament (ACL) reconstruction using the hamstrings tendons. Twenty patients with unilateral ACL deficiency were randomised into two groups. We created the bone tunnels at the position of the original insertion of the anteromedial bundle footprint and posterolateral bundle footprint in the A-DB group and at the central position between these two bundles in the A-SB group. All of the patients were tested before ACL reconstruction and one year after surgery. The KT-1000 measurements, isokinetic muscle peak torque and heel-height difference were evaluated and the general knee condition was assessed by Lysholm score. For pre- and postoperative stability assessment, we used the six-degrees-of-freedom of knee kinematic measurement system using an electromagnetic device (the EMS) for quantitative assessment during the Lachman test and the pivot shift test. There were no significant differences in the KT-1000 measurements, isokinetic muscle peak torque, heel-height difference, and Lysholm score at one-year follow-up between these two groups. The EMS data showed there were significant differences in the acceleration of the pivot shift test between the operated knee and the contralateral normal knees in the A-SB group. In conclusion, clinical outcomes were equally good in both groups. However, the EMS data showed the anatomical double-bundle ACL reconstruction tended to be biomechanically superior to the single-bundle reconstruction.

Anterior Cruciate Reconstruction Using Bone-patellar Ligament – Bone Autograft

Background: Injuries to ligaments of knee are common in our society especially in the young athletes and sports men participating in football, volleyball, rugby etc. Tears of the anterior cruciate ligament (ACL) leads to knee instability which leads to inability to participate in sports. In the none athletes ACL injury tends to decline in their level of daily activity. This is a study of ACL tears seen and managed by the author over a long period along with scientific data of clinical presentations, diagnosis, associated injuries, the ACL repair, rehabilitation protocol and the overall outcome. Objective: To review the authors experience of patients with anterior cruciate ligament tears who have been treated by bone-patellar tendon-bone autografts. That was to be achieved through clinical, radiological, athroscopy and extensive rehabilitation programme and arthroscopic review after one year follow-up. Setting: Menelik Hospital and the Nairobi Hospital. Methods: Thirty five patients with anterior cruciate ligament tear in one knee and a normal contralateral knee were evaluated and followed up for six years. Clinical history, physical evaluation, X-ray and athroscopies were done to rule out concomitant meniscal lesions and facilitate their treatment accurately. Follow up arthroscopy; physical examinations by Lachman test, pivot test and anterior drawer test were done. Subjective and objective data were obtained and reviewed to assess final outcome. Results: A total of 35 patients were seen and treated. Only 25 patients were available having been followed up fully. There were 18 males and seven females giving a male to female ratio of 2:1. The injuries were unilateral 18 (72%) on the right and seven (28%) on the left. Initial Lachman”s test was graded at 2 and 3 while anterior drawers test and pivot test at 2 and 3 respectively in all patients. Post operatively these improved to grade zero with negative pivot test in all patients. The subjective results were excellent and good in 80% of the patients, while the objective were 68% . Follow up arthroscopy showed a stable ligament at one year while follow up X-ray showed mild arthrosis. A few complications occurred with one infection and calcification of ligament in two patients, arthrofibrosis in two patients. Conclusion: This study is of clinical relevance as it shows alleviation of pain after surgical treatment of the torn ACL which has been described as the stabiliser of the knee and guardian of the Meniscus.

Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft: Intermediate-Term Outcome

The purpose of this study was to compare the intermediate-term outcomes of anterior cruciate ligament (ACL) reconstruction by use of bone-patellar tendon-bone (BPTB), quadriceps tendon with a bone plug (BQT), and quadriceps tendon without a bone plug (QT). We evaluated 198 primary ACL reconstructions in 191 patients at a mean of 55.6 months postoperatively. Assessment included side-to-side comparison of range of motion, arthrometer values, presence of effusion, anterior knee pain, and numbness. Comparisons were made between QT and BQT patients and between men and women. The results were compared with data from 30 patients in a previous study who had undergone ACL reconstruction by the same surgeon (W.R.S.) with BPTB. Range of motion averaged -3.2 degrees +/- 2.2 degrees of extension to 134.3 degrees +/- 10.2 degrees of flexion for the operative extremity compared with -3.6 degrees +/- 2.07 degrees to 134.2 degrees +/- 10.6 degrees for the contralateral extremity at final follow-up. KT-1000 manual maximum measurements (MEDmetric, San Diego, CA) of the operative extremity averaged 0.94 mm more than those of the normal contralateral knee. When compared with BPTB autograft, the quadriceps tendon autograft showed significantly better results, with less anterior knee pain (4.56% v 26.7%), less anterior numbness (1.5% v 53.3%), a higher percentage of arthrometer measurements showing a side-to-side difference of 0 to 3 mm (88% v 68%), and better extension (mean loss, 0.55 degrees v 2.77 degrees ). There was no significant difference between the 2 groups with regard to loss of flexion, Lachman test, pivot-shift test, presence of effusion, or number of failures. Central quadriceps tendon autograft, QT or BQT, produces equivalent results when compared directly with BPTB autograft in arthroscopically assisted ACL reconstruction. There was no difference in results between men and women with a quadriceps tendon autograft, either with or without the use of a bone plug. ACL reconstruction using quadriceps tendon autograft is an effective surgical option that reduces donor-site morbidity. Level IV, therapeutic case series.

Incidence of Subsequent Injury to Either Knee within 5 Years after Anterior Cruciate Ligament Reconstruction with Patellar Tendon Autograft

Background The risk of subsequent anterior cruciate ligament injury to either knee after surgery based on sex, age, and activity has not been extensively studied. Hypotheses Women have a higher incidence of anterior cruciate ligament injury to the contralateral knee after surgery than men but do not have a difference in injuries to the reconstructed knee. Young, competitive athletes have a higher incidence of injury than older patients. The time to return to full activities does not affect injury rate. Study Design Cohort study (prognosis); Level of evidence, 2. Methods The authors prospectively followed 1820 patients after primary anterior cruciate ligament reconstruction to determine if patients suffered an injury to either knee within 5 years after surgery. Subsequent injury was evaluated based on sex, age, and activity level. Results Minimum 5-year follow-up was obtained on 1415 patients (78%). Seventy-five patients (5.3%) had an injury to the contralateral knee, and 61 patients (4.3%) suffered an injury to the reconstructed knee (P =. 2185). Women suffered more injuries (7.8%) to the contralateral normal knee than men (3.7%; P <. 001) but not more injuries to the reconstructed knee (4.3% vs 4.1%; P =. 5543). The risk of subsequent injury to either knee was 17% for patients <18 years old, 7% for patients aged 18 to 25 years, and 4% for patients older than 25 years. There was no difference in injury rate between patients who returned before and after 6 months postoperatively. Conclusion Women have a higher incidence of anterior cruciate ligament injury to the contralateral knee than men after reconstruction. The incidence of injury to either knee after reconstruction is associated with younger age and higher activity level, but returning to full activities before 6 months postoperatively does not increase the risk of subsequent injury.

Proprioception of the knee joint in patellofemoral pain syndrome

The importance of proprioception in the etiology, treatment, and prevention of sports injuries and joint diseases has become increasingly clear. The purpose of this study was to investigate knee proprioception in patients with patellofemoral pain syndrome (PFPS). The study included 28 patients (18 females, 10 males; mean age 28 years; range 16 to 48 years) with a clinical diagnosis of unilateral PFPS and 27 normal volunteers (13 females, 14 males; mean age 26 years; range 19 to 32 years) without any complaint related to the knee. The mean duration of complaints was 35.8 weeks (range 2 weeks to 3 years). In both patient and control groups, proprioception of the knee was measured by means of active joint position sense at four different target angles (15 degrees , 30 degrees , 45 degrees , 60 degrees ) with the use of a digital goniometer and the results were compared. Proprioceptive errors were greater at all target angles in the affected knees compared to those measured in the contralateral knees and both knees of the controls. Differences between affected knees and contralateral knees ranged from 1.01+/-0.25 degrees to 1.65+/-0.43 degrees and were significant at three target angles (15 degrees , 30 degrees , 60 degrees ; p<0.05). Comparisons between the affected knees and both knees of the controls also showed significant differences at all target angles ranging from 2.48+/-0.92 degrees to 3.87+/-2.46 degrees (p<0.001). Errors obtained in the normal knees of the patients were also significantly greater compared to those seen in both knees of the controls, exceeding 2.7 degrees at some target angles (p<0.001). Our results show that patients with PFPS have impaired proprioception in the affected knee accompanied by significant losses in the proprioception of the contralateral normal knee. Based on these findings, proprioceptive rehabilitation techniques should be incorporated into the treatment of PFPS.

Risk of Tearing the Intact Anterior Cruciate Ligament in the Contralateral Knee and Rupturing the Anterior Cruciate Ligament Graft during the First 2 Years after Anterior Cruciate Ligament Reconstruction

Background The risk of tear of the intact anterior cruciate ligament in the contralateral knee after anterior cruciate ligament reconstruction of the opposite knee and the incidence of rupturing the anterior cruciate ligament graft during the first 2 years after surgery have not been extensively studied in a prospective manner. Clinicians have hypothesized that the opposite normal knee is at equal or increased risk compared with the risk of anterior cruciate ligament graft rupture in the operated knee. Hypothesis The risk of anterior cruciate ligament graft rupture and contralateral normal knee anterior cruciate ligament rupture at 2-year follow-up is equal. Study Design Cohort study; Level of evidence, 2. Methods The Multicenter Orthopaedic Outcome Network (MOON) database of a prospective longitudinal cohort of anterior cruciate ligament reconstructions was used to determine the number of anterior cruciate ligament graft ruptures and tears of the intact anterior cruciate ligament in the contralateral knee at 2-year follow-up. Two-year follow-up consisted of a phone interview and review of operative reports. Results Two-year data were obtained for 235 of 273 patients (86%). There were 14 ligament disruptions. Of these, 7 were tears of the intact anterior cruciate ligament in the contralateral knee (3.0%) and 7 were anterior cruciate ligament graft failures (3.0%). Conclusion The contralateral normal knee anterior cruciate ligament is at a similar risk of anterior cruciate ligament tear (3.0%) as the anterior cruciate ligament graft after primary anterior cruciate ligament reconstruction (3.0%).

MR imaging of antigen‐induced arthritis with a new, folate receptor‐targeted contrast agent

The purpose of this study was to investigate if the new folate receptor-targeted Gd-chelate P866 may enhance immune-mediated arthritis. A monoarthritis was induced in the right knee of 15 Sprague-Dawley rats. MR imaging of both knees was performed at 2 T before and up to 2 h and 24 h after injection (p.i.) of P866 (n = 3 dose finding study and n = 6, 0.02 mmol Gd/kg), the non-FR targeted P866 analog P1001 (n = 3 at 24 h after P866-administration, 0.02 mmol Gd/kg) or Gd-DOTA (n = 6, 0.1 mmol Gd/kg). Pulse sequences comprised T(1)-SPGR 80 degrees /50 ms/1.7 ms (flip angle/TR/TE) and inversion recovery 10 degrees /3000 ms/1500 ms/50-3050, 10 000 ms (flip angle/TR/TE/TI) sequences. DeltaSI-data and T(1)-relaxation times of arthritic knees and contralateral normal knees were determined. Folate receptor expression was confirmed with histopathology. All three contrast agents showed an initial perfusion effect with significantly higher DeltaSI-data of arthritic knees compared with normal knees (p < 0.05). In addition, P866, but not P1001 or Gd-DOTA, showed a prolonged enhancement of the synovitis. Compared with precontrast values, the T(1)-relaxation times of inflamed synovia were significantly decreased at 2 h p.i. of P866 (p < 0.05), but not P1001 or Gd-DOTA (p > 0.05). Histopathology confirmed the presence of folate receptors in the inflamed joints, but not normal joints. Thus, results suggest a specific accumulation of the folate receptor-targeted Gd-chelate P866 in this arthritis model.