Endoscopic Anterior Cruciate Ligament Reconstruction Research Articles

The "N+10 Rule" to Avoid Graft-Tunnel Mismatch in Bone-Patellar Tendon-Bone ACL Reconstruction Using Independent Femoral Tunnel Drilling.

Graft-tunnel mismatch (GTM) is a common problem in anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-patellar tendon-bone (BPTB) grafts. Application of the "N+10 rule" in endoscopic ACLR with BPTB grafts will result in acceptable tibial tunnel length (TTL), minimizing GTM. Controlled laboratory study. Endoscopic BPTB ACLR was conducted on the paired knees of 10 cadaveric specimens using 2 independent femoral tunnel drilling techniques-accessory anteromedial portal and flexible reamer. The graft bone blocks were trimmed to 10 × 20 mm, and the intertendinous distance (represented by "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 number of degrees 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 GTM threshold of ±7.5 mm was set based on prior studies. The mean BPTB ACL intertendinous distance was 47.5 ± 5.5 mm. The mean measured intra-articular distance was 27.2 ± 3 mm. Using the N+10 rule, the mean total (flexion plus extension) GTM was 4.3 ± 3.2 mm (GTM in flexion, 4.9 ± 3.6 mm; GTM in extension, 3.8 ± 3.5 mm). In 18 of 20 (90%) cadaveric knees, the mean total GTM fell within the ±7.5-mm threshold. When comparing the actual measured TTL to the calculated TTL, there was a mean difference of 5.4 ± 3.9 mm. When comparing femoral tunnel drilling techniques, the total GTM for the accessory anteromedial portal technique was 2.1 ± 3.7 mm, while the total GTM for the flexible reamer technique was 3.6 ± 5.4 mm (P = .5). The N+10 rule resulted in an acceptable mean GTM in both flexion and extension. The mean difference between the measured versus calculated TTL using the N+10 rule was also acceptable. The N+10 rule is a simple and effective intraoperative strategy for achieving desired TTL regardless of patient-specific factors to avoid excessive GTM in endoscopic BPTB ACLR using independent femoral tunnel drilling.

CORRELATION BETWEEN MORPHOMETRY OF PATELLAR LIGAMENT AND PATELLA-AN AID TO TOTAL KNEE ARTHROPLASTY

Background: Patellar ligament is of surgical importance in procedures pertaining to total knee arthroplasty. It is extensively used as an autogenous graft for endoscopic anterior cruciate ligament reconstruction. Patellar ligament is the most preferred autograft owing to sufcient load to failure strength and stiffness. Purpose of the study: Dimensions of patella have been shown to be of anthropometric importance and is also used for personal identication as the bone is resistant to postmortem changes. There is paucity of literature on studies correlating the dimensions of patellar ligament and patella bone in Indian population. This study is the rst of its kind to provide data on the same. 53 prosected lower limbs were used to study the morphome Material and Methods: try of Patellar ligament and Patella using digital vernier calipers. The mean length, width and thickness values of Patellar ligament and bone were recorded. Pearson correlation coefcient was used to test the strength of association between the two variables. It was seen that there was negative correlation between Results: patella length and ligament length and thickness. There was positive correlation between patella length and ligament width. Patella width correlated positively with ligament length and ligament width but negatively with ligament thickness. Patella thickness correlated negatively with ligament length and thickness but positively with ligament width. This Conclusion- study will provide valuable anthropometric data and aid the orthopaedic surgeons performing knee surgeries.

Femoral Footprint Visualization Using a Transtibial Portal in Anterior Cruciate Ligament Reconstruction.

In traditional endoscopic anterior cruciate ligament (ACL) reconstruction, inadequate visualization of the femoral footprint through a lateral portal frequently causes surgical errors. Although various portal locations have been reported, no study has identified ideal locations for specific portals in relation to ACL reconstruction. This article presents the new transtibial portal technique (ie, the use of an existing tibial tunnel). This technique provides excellent direct visualization of the femoral ACL footprint without the need to create additional portals. It allows dynamic visualization of the relationship of the future graft with posterior cruciate ligament and bone structures. [Orthopedics. 2021;44(5):e691-e693.].

Graft-Tunnel Mismatch in Endoscopic ACL Reconstruction: Reliability of Measuring Tunnel Lengths and Intra-articular Distance.

Background:A continued technical challenge for surgeons performing bone–patellar tendon–bone anterior cruciate ligament (ACL) reconstruction with endoscopic techniques is graft-tunnel mismatch. If tibial tunnel and intra-articular distances could be reliably estimated, surgeons could adjust the length of the femoral tunnel to minimize graft-tunnel mismatch.Purpose/Hypothesis:To determine whether arthroscopic measurement of the following was reliable: femoral tunnel distance (FTD), tibial tunnel distance (TTD), intra-articular distance (IAD), and total distance (TD; sum of these 3 measurements). It was hypothesized that intraoperative measurement of these distances would be reliable.Study Design:Controlled laboratory study.Methods:Eight sports fellowship–trained orthopedic surgeons independently performed arthroscopic measurements of the FTD, TTD, IAD, and TD in 7 cadaveric knees in which femoral and tibial tunnels had been drilled. Each surgeon performed the measurements twice using an EndoButton depth gauge. Following this, each parameter was measured open with a medial parapatellar approach. Finally, a computed tomography (CT) scan of each knee was performed, with the FTD, TTD, and IAD measured by a musculoskeletal radiologist. Inter- and intrarater reliability of the arthroscopic measurements was calculated, as well as the correlation between arthroscopic measurements and open and CT measurements.Results:Interrater reliability for the arthroscopic measurements was 0.8 for FTD, 0.89 for TTD, 0.61 for IAD, and 0.76 (range, 0.54-0.93) for TD. Intrarater reliability was 0.94 for FTD, 0.97 for TTD, 0.83 for IAD, and 0.93 for TD. The correlation between arthroscopic and open measurements was 0.9 for FTD, 0.94 for TTD, 0.4 for IAD, and 0.84 for TD. The correlation between arthroscopic and CT measurements was 0.85 for FTD, 0.92 for TTD, and 0.71 for IAD.Conclusion:The results of this study show that arthroscopic measurement of FTD and TTD has a high degree of intra- and interrater reliability, while that of IAD and TD demonstrates high intrarater reliability but moderate interrater reliability.Clinical Relevance:Reliable measurement of the TTD and IAD can potentially allow adjustment of the FTD, minimizing graft-tunnel mismatch in endoscopic ACL reconstruction.

20-Year Outcomes of Anterior Cruciate Ligament Reconstruction With Hamstring Tendon Autograft: The Catastrophic Effect of Age and Posterior Tibial Slope

Background: No well-controlled studies have compared the long-term outcome of anterior cruciate ligament (ACL) reconstruction with hamstring tendon autograft between adolescents and adults. Increased posterior tibial slopes (PTSs) have been reported in the ACL-injured versus controls, but the effect of PTS on the outcome after reconstruction is relatively unexplored. Purpose: To compare the prospective longitudinal outcome of “isolated” ACL ruptures treated with anatomic endoscopic ACL reconstruction using hamstring tendon autograft over 20 years in adolescent and adult cohorts and to examine factors for repeat ACL injury. Study Design: Case-control study; Level of evidence, 3. Methods: A single-surgeon series of 200 consecutive patients undergoing isolated primary ACL reconstruction with hamstring tendon autograft were prospectively studied. Subjects were assessed preoperatively and at 2, 7, 15, and 20 years postoperatively. Outcomes included International Knee Documentation Committee (IKDC) Knee Evaluation, IKDC subjective scores, KT-1000 instrumented laxity testing, and radiological evaluation of degenerative change and medial tibial slope. Twenty-year outcomes were compared between those who underwent surgery at the age of 18 years or younger (adolescent group, n = 39) and those who underwent surgery when older than 18 years (adult group, n = 161). Results: At 20 years, 179 of 200 subjects were reviewed (89.5%). ACL graft rupture occurred in 37 subjects and contralateral ACL injury in 22 subjects. Of those with intact ACL grafts at 20 years, outcomes were not statistically different between adolescents and adults for the variables of IKDC subjective score (P = .29), return to preinjury activity level (P = .84), current activity level (P = .69), or degree of radiological degenerative change at 20 years (P = .51). The adolescent group had a higher proportion of grade 1 ligamentous laxity testing compared with the adult group (P = .003). Overall, ACL graft survival at 20 years was 86% for adults and 61% for adolescents (hazard ration, 3.3; P = .001). The hazard for ACL graft rupture was increased by 4.8 in adolescent males and 2.5 in adolescent females compared with adults. At 20 years, the ACL survival for adolescents with a PTS of ≥12° was 22%. The hazard for ACL graft rupture was increased by 11 in adolescents with a PTS of ≥12° (P = .001) compared with adults with a PTS <12°. Conclusion: Repeat ACL injury after isolated ACL reconstruction is common, occurring in 1 in 3 over 20 years. In the absence of further injury, isolated ACL reconstruction using this technique was associated with good long-term outcomes with respect to patient-reported outcomes and return to sports, regardless of age. However, mild ligament laxity and ACL graft rupture after ACL reconstruction are significantly more common in adolescents, especially adolescent males, compared with adults. PTS of 12° or more is the strongest predictor of repeat ACL injury, and its negative effect is most pronounced in adolescents.

5 year survival of endoscopic ACL reconstruction with living donor hamstring tendon allograft in juveniles and adolescents

Introduction: Repeat Anterior Cruciate Ligament (ACL) injury is common in juveniles and adolescents following ACL Reconstruction. This has led the authors to consider alternative graft material for young people with an ACL injury. This is the first study to examine the survival and contributing factors of further ACL injury in juveniles and adolescents after ACL reconstruction utilising a living donor hamstring tendon allograft.

Twenty-year comparison outcome data of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring autograft

Twenty-year comparison outcome data of a longitudinal prospective evaluation of isolated endoscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring autograft

Twenty-Year Outcome of a Longitudinal Prospective Evaluation of Isolated Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon or Hamstring Autograft

Background: Long-term prospective studies of isolated endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors. Purpose: This study aimed to compare the outcomes of isolated ACL reconstruction using the patellar tendon (PT) autograft and the hamstring (HT) autograft in 180 patients over 20 years. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 180 participants undergoing isolated ACL reconstruction between 1993 and 1994 were prospectively recruited. Evaluation was performed at 1, 2, 5, 7, 10, 15, and 20 years after surgery and included the International Knee Documentation Committee (IKDC) knee ligament evaluation with radiographic evaluation, KT-1000 arthrometer side-to-side difference, and subjective scores. Results: Over 20 years, there were 16 patients (18%) and 9 patients (10%) with an ACL graft rupture in the HT and PT groups, respectively (P = .13). ACL graft rupture was associated with male sex (odds ratio [OR], 3.9; P = .007), nonideal tunnel position (OR, 3.6; P = .019), and age <18 years at the time of surgery (OR, 4.6; P = .003). The odds of a contralateral ACL rupture were increased in patients with the PT graft compared with patients with the HT graft (OR, 2.2; P = .02) and those aged <18 years at the time of surgery (OR, 3.4; P = .001). The mean IKDC scores at 20-year follow-up were 86 and 89 for the PT and HT groups, respectively (P = .18). At 20 years, 53% and 57% of the PT and HT groups participated in strenuous or very strenuous activities (P = .55), kneeling pain was present in 63% and 20% of the PT and HT groups (P = .018), and radiographic osteoarthritic change was found in 61% and 41% of the PT and HT groups (P = .008), respectively. Conclusion: Compared with patients who received the HT graft, patients who received the PT graft had significantly worse outcomes with regard to radiologically detectable osteoarthritis, kneeling pain, and contralateral ACL injury. At 20-year follow-up, both HT and PT autografts continued to provide good subjective outcomes and objective stability. However, further ACL injury is common, particularly in male individuals, younger patients, and those with tunnel malposition.

Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger

Background: The current body of literature surrounding anterior cruciate ligament (ACL) survival and the variables contributing to further ACL injuries after primary ACL reconstruction in children and adolescents is limited, with no long-term evidence examining the incidence and contributing factors of further ACL injuries in this younger patient population. Purpose: To determine the long-term survival of the ACL graft and the contralateral ACL (CACL) after primary reconstruction in patients aged ≤18 years and to identify the factors that increase the odds of subsequent ACL injuries. Study Design: Case series; Level of evidence, 4. Methods: Patients having undergone primary ACL reconstruction at age ≤18 years between 1993 and 1998 who were included in a prospective database by a single surgeon were considered for this study. Single-incision endoscopic ACL reconstruction was performed with either an autologous bone–patellar tendon–bone graft or a hamstring tendon graft. At a minimum of 15 years after ACL reconstruction, patients completed a subjective survey involving the International Knee Documentation Committee (IKDC) questionnaire in addition to questions regarding current symptoms, further ACL injuries, family history of ACL injury, and current level of activity. Results: A total of 288 adolescents (age range, 13-18 years) met the inclusion criteria, of whom 242 (84%) were reviewed at a mean of 16 years and 6 months after ACL reconstruction. Of these patients, 75 (31%) sustained a further ACL injury: 27 (11.2%) suffered an ACL graft rupture, 33 suffered a CACL injury (13.6%), and 15 sustained both an ACL graft rupture and a CACL injury (6.2%) over 15 years. Survival of the ACL graft was 95%, 92%, 88%, 85%, and 83% at 1, 2, 5, 10, and 15 years, respectively, and survival of the CACL was 99%, 98%, 90%, 83%, and 81%, respectively. Survival of the ACL graft was less favorable in those with a family history of ACL injury than in those without a family history (69% vs 90%, respectively; hazard ratio [HR], 3.6; P = .001). Survival of the CACL was less favorable in male patients than in female patients (75% vs 88%, respectively; HR, 2.1; P = .03) and in those who returned to competitive team ball sports than in those who did not (78% vs 89%, respectively; HR, 2.3; P = .05). Conclusion: After ACL reconstruction in patients aged ≤18 years, a further ACL injury occurred in 1 in 3 patients over 15 years. The 15-year survival rate of the ACL graft was 83%, and the 15-year survival rate of the CACL was 81%. The ACL graft and CACL were most vulnerable within the first 5 years after index surgery. A family history of ACL rupture significantly increased the risk for ACL graft ruptures, and a CACL injury was more common in male patients and those who returned to team ball sports. High IKDC scores and continued participation in sports were maintained over the long term after ACL reconstruction in the adolescent population.

Twenty-Year Outcomes of a Longitudinal Prospective Evaluation of Isolated Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts

Background: Long-term prospective follow-up studies of single-incision endoscopic anterior cruciate ligament (ACL) reconstruction are limited and may include confounding factors. Purpose: This longitudinal prospective study reports the outcomes of isolated ACL reconstruction using middle-third patellar tendon autografts in 90 patients over 20 years. Study Design: Case series; Level of evidence, 4. Methods: Between January 1993 and April 1994, a total of 90 patients met study inclusion criteria: evaluation at 1, 2, 3, 4, 5, 7, 10, 15, and 20 years after surgery. Exclusion criteria were associated ligamentous injuries requiring surgery, previous meniscectomy or meniscal injuries requiring more than one-third meniscectomy, chondral injuries, and an abnormal contralateral knee. Results: At 20 years, 32 (36%) patients had sustained another ACL injury: 8 (9%) to the index limb and 27 (30%) to the contralateral limb (3 injuring both knees). The mean International Knee Documentation Committee (IKDC) score was 86. Of the patients, 50% participated in strenuous/very strenuous activities, and kneeling pain was present in 63%. Radiographic degenerative change was found in 61%; 20% had IKDC grade C, and 0% had grade D. The IKDC clinical examination revealed that 95% had a normal/nearly normal knee. Significant sex differences existed: when compared with male patients, female patients were less likely to reinjure the reconstructed ACL (18% vs 2%, respectively; P = .01), reported poorer IKDC subjective scores (90 vs 83, respectively; P = .03), had more activity-related pain (20% vs 57%, respectively; P = .02), and were less likely to participate in strenuous activities (66% vs 35%, respectively; P = .009). ACL graft survival was not related to age. Patients <18 years old had an increased odds ratio (3.2) for rupturing the contralateral ACL. A coronal graft angle <17° increased the risk of failure compared with an angle >17° (77% vs 96% survival, respectively) by a factor of 8.5. Conclusion: Injuries more commonly occurred in the contralateral ACL than in the reconstructed ACL graft, and the most significant predictor of a contralateral ACL injury was age <18 years. The most significant predictor of an ACL graft rupture was a coronal graft angle <17°. Female patients had lower rerupture rates, poorer subjective scores, and decreased participation in strenuous activities, putting the graft at a lower risk of failure. Kneeling pain remained persistent over 20 years. Radiographic osteoarthritis was evident in 61% of patients, but symptomatic osteoarthritic symptoms were rarely reported.

Endoscopic Anterior Cruciate Ligament Reconstruction in Children Using Living Donor Hamstring Tendon Allografts

Background: The incidence of anterior cruciate ligament (ACL) injuries in children is increasing, but ACL reconstruction with traditional autograft sources is associated with high rates of further ACL injury when compared with adult populations. The outcome of ACL reconstruction using an alternative graft source, the living donor hamstring tendon (HT) allograft, has not been reported. Purpose: To determine the outcome of endoscopic transphyseal single-tunnel ACL reconstruction using living donor HT allografts. Study Design: Case series; Level of evidence, 4. Methods: Between 2007 and 2008, 32 children underwent endoscopic transphyseal single-tunnel ACL reconstruction using living donor HT allografts. The HT allograft was harvested from a parent. At a minimum 2 years’ follow-up, full International Knee Documentation Committee (IKDC) knee ligament examination was performed on the children including instrumented testing using the KT-1000 arthrometer. Donors underwent subjective review at a minimum 2 years’ follow-up. Results: Thirty-one children (97%) were able to be contacted for review. Of these, 2 (6%) sustained an ACL graft rupture within 2 years after surgery. Twenty-nine children completed clinical and subjective review. The mean age at ACL reconstruction was 13 years (range, 8-16 years). The mean HT graft size was 7.2 mm (range, 6-8 mm). The mean IKDC subjective score was 97 (range, 84-100). Twenty-eight patients (97%) had a normal or nearly normal IKDC ligament grade. At 2 years after surgery, 27 patients (93%) reported regularly participating in very strenuous or strenuous activities. There were no cases of limb malalignment. Twenty eight (97%) of the donors reported that they would undergo the same procedure again under the same circumstances. Conclusion: Excellent clinical and subjective outcomes were achieved with high levels of return to desired activities. This technique allows a more predictable size of the HTs compared with an autograft from the child and maintains an intact neuromuscular hamstring structure in the child. Finally, the child’s own HTs are reserved for future use. Anterior cruciate ligament reconstruction using living donor allografts should be considered a viable choice in children.

The influence of electromyographic biofeedback therapy on knee extension following anterior cruciate ligament reconstruction: a randomized controlled trial

BackgroundLoss of knee extension and a deficit in quadriceps strength are frequently found following anterior cruciate ligament (ACL) reconstruction. The aim of this study was to investigate whether the addition of Eletromyographic Biofeedback (EMG BFB) therapy for the vastus medialis muscle to the in the early phase of the standard rehabilitation programme could improve the range of knee extension and strength after ACL reconstruction more than a standard rehabilitation programme. The correlation between EMG measurement and passive knee extension was also investigated.MethodSixteen patients, all of whom underwent endoscopic ACL reconstruction using patellar tendon autograft, were randomly assigned to two groups:• Control group (8 patients): standard rehabilitation protocol; with full weight-bearing postoperative, knee brace (0° extension, 90° flexion), electrical stimulation, aquatics and proprioceptive training.• The EMG BFB group (8 patients): EMG BFB was added to the standard rehabilitation protocol within the first postoperative week and during each session for the next 6 weeks.Each patent attended a total of 16 outpatient physiotherapy sessions following surgery. High-Heel-Distance (HHD) Test, range of motion (ROM) and integrated EMG (iEMG) for vastus medialis were measured preoperatively, and at the 1, 2, 4 and 6-week follow ups. Additionally, knee function, swelling and pain were evaluated using standardized scoring scales.ResultsAt 6 weeks, passive knee extension (p < 0.002) and the HHD Test were significantly (p < 0.01) better in the EMG BFB group compared to controls. Integrated EMG (vastus medialis) of the EMG BFB group also showed a significant increase after 2 (p < 0.01) and 6 (p < 0.01) weeks. At the 6-week follow up, no significant (p > 0.01) differences were found between the two groups for the assessment of knee function, swelling and pain.ConclusionThe results indicate that EMG BFB therapy, in the early phase of rehabilitation after ACL reconstruction, is useful in enhancing knee extension. Improved innervation of the vastus medialis can play a key role in the development of postoperative knee extension. EMG BFB therapy is a simple, inexpensive and valuable adjunct to conventional therapeutic modalities.

Interval Arthrometric Comparison of Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft Versus Allograft

Background: There is little information regarding the incremental changes in the postoperative laxity of patellar tendon (PT) autografts versus allografts in anterior cruciate ligament (ACL) reconstruction. Hypotheses: (1) There would be no significant increase in laxity between 6 weeks and 1 year postoperatively with PT autografts or allografts, (2) there would be no significant difference in laxity between PT autografts and allografts, (3) there would not be a significant difference in laxity between nonirradiated and low dose–irradiated PT allograft tissues, and (4) the physical examination findings would correlate with the instrumented laxity outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of 238 ACL-deficient patients who underwent single-incision endoscopic ACL reconstruction with a PT autograft (n = 132) or allograft (n = 106; 58 irradiated and 48 nonirradiated) from a single surgeon was made looking at data from preoperatively and from 6 weeks to 1 year postoperatively. The objective measurements of ligament integrity included range of motion, Lachman test, pivot-shift test, and KT-1000 arthrometer instrumented laxity examination. Failure was defined as arthrometric side-to-side differences (maximum manual difference) ≥3 mm or a positive pivot shift. Statistical significance was defined as P < .05. Results: There were no differences in postoperative examination findings or instrumented laxity between PT autografts and allografts (irradiated or nonirradiated) in either subgroup. The postoperative improvement based on the Lachman examination, pivot-shift test, and arthrometric data in all study groups was significant (P < .001) in 98% (autograft: n = 130; allograft: n = 104) of patients, and arthrometric failure correlated with failure by physical examination. There was no significant change in graft laxity, as measured by KT-1000 arthrometer, from 6 weeks to 1 year postoperatively for 98% of patients. Finally, there was no statistical correlation in instrumented laxity results for either the autograft or allograft group with reference to age, gender, concurrent meniscectomy, meniscal repairs, interval to surgery, postoperative patellar pain, time to surgery, or irradiated versus nonirradiated allograft. Conclusion: Laxity is not increased after the initial 6 weeks for either PT allograft or autograft constructs during the first postoperative year. There was no correlation between age, gender, concomitant injury, interval to surgery, or radiation of the graft with instrumented laxity results. Furthermore, our arthrometric data paralleled our clinical findings of stability at follow-up.

Long-term follow-up of patellar tendon grafts or hamstring tendon grafts in endoscopic ACL reconstructions

Several studies compare the short- and long-term results of anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) graft or double-looped semitendinosus and gracilis (DLSG) graft. However, no studies evaluate the long-term results of BPTB grafts fixed with metal interference screws and DLSG grafts fixed with the Bone Mulch Screw and the Washer Loc. This prospective randomized multicentre study has the null hypothesis that there is no difference in long-term outcome between the two procedures. A total of 114 patients with a symptomatic ACL rupture were randomized to reconstruction with either a BPTB graft (N=58) or a DLSG graft (N=56). Follow-up was conducted after one, two and sevenyears. At the seven-year follow-up, 102 of the 114 patients (89%) were available for evaluation; however, 16 of these by telephone-interview only. Ten patients in the BPTB group and 19 patients in the DLSG group underwent additional knee surgery (P=0.048), two and three, respectively, of these were ACL revisions (n.s.). The total flexion work was lower in the DLSG group (P=0.001). The mean peak flexion torque and extension work, however, showed no difference between the groups. No significant differences were found between the groups regarding the Tegner activity score, the Lysholm functional score, the Knee injury and osteoarthritis outcome score (KOOS), subjective knee function, anterior knee pain or mobility. There was no significant difference in laxity between the groups on the Lachman test or the KT-1,000 maximum manual force test. Both grafts and fixation methods resulted in satisfactory subjective outcome and objective stability. Both these methods can therefore be considered as suitable alternatives for ACL reconstructions. II.

Clinical Results and Risk Factors for Reinjury 15 Years After Anterior Cruciate Ligament Reconstruction

Background: There is a lack of prospective studies comparing the long-term outcome of endoscopic anterior cruciate ligament (ACL) reconstruction with either a patellar tendon or hamstring tendon autograft. Purpose: This prospective longitudinal study compared the results of isolated endoscopic ACL reconstruction utilizing a 4-strand hamstring tendon (HT) or patellar tendon (PT) autograft over a 15-year period with respect to reinjury, clinical outcomes, and the development of osteoarthritis. Study Design: Cohort study; Level of evidence, 2. Methods: Ninety consecutive patients with isolated ACL rupture were reconstructed with a PT autograft, and 90 patients received an HT autograft, with an identical surgical technique. Patients were assessed at 2, 5, 7, 10, and 15 years. Assessment included the International Knee Documentation Committee (IKDC) knee ligament evaluation including radiographic evaluation, KT-1000 arthrometer testing, and Lysholm knee score. Results: Patients who received the PT graft had significantly worse outcomes compared with those who received the HT graft at 15 years for the variables of radiologically detectable osteoarthritis (grade A: 46% in PT and 69% in HT; P = .04), motion loss (extension deficit <3°: 79% in PT and 94% in HT; P = .03), single-legged hop test (grade A: 65% in PT and 92% in HT; P = .001), participation in strenuous activity (very strenuous or strenuous: 62% of PT and 77% of HT; P = .04), and kneeling pain (moderate or greater pain: 42% of PT and 26% of HT; P = .04). There was no significant difference between the HT and PT groups in overall IKDC grade (grade A: 47% of PT and 57% of HT; P = .35). An ACL graft rupture occurred in 17% of the HT group and 8% of the PT group (P = .07). An ACL graft rupture was associated with nonideal tunnel position (odds ratio [OR], 5.0) and male sex (OR, 3.2). Contralateral ACL rupture occurred in significantly more PT patients (26%) than HT patients (12%) (P = .02) and was associated with age ≤18 years (OR, 4.1) and the PT graft (OR, 2.6). Conclusion: Anterior cruciate ligament reconstruction using ipsilateral autograft continues to show excellent results in terms of patient satisfaction, symptoms, function, activity level, and stability. The use of HT autograft does, however, show better outcomes than the PT autograft in all of these outcome measures. Additionally, at 15 years, the HT graft–reconstructed ACLs have shown a lower rate of radiological osteoarthritis.

Patellar tendon autograft versus 4-strand hamstring autograft for endoscopic reconstruction of anterior cruciate ligament:a Meta-analysis

Objective To compare clinical outcomes of patellar tendon and 4-strand hamstring au- tografts in single-bundle endoscopic reconstruction of anterior cruciate ligament （ACL） . Methods The digital databases （PubMed, Embase, Cochrane Central Register of Controlled Trials, CBM）were searched for randomized controlled trials （RCTs） comparing patellar tendon with hamstring autografls for reconstruction of ACL. In addition, the reference lists from related original studies and review articles were hand-searched. The Coehrane Collaboration＇ s tool for assessing risk of bias and Cochrane collaboration＇s RevMan 5.0 software were used for assessing trial methodological quality and data analyses. Results Fourteen RCTs were included. There were 1232 participants who met inclusion criteria in all studies. Meta-analyses showed that no statistically significant differences were found in graft failure rate after single-bundle reconstruction of the ACL at mean follow-ups of 2 to 3 years （ RR = 0.69, 95% CI O. 34 to 1.38, P = 0. 29, of 5 years （ RR = 0. 37, 95% C]0.09 to 1,55, P=0. 18）, of 10 years （P=0.94） or when 3 subgroups combined （RR=0.71, 95% CI O. 39 to 1.31, P =0.28） . The difference in ~〉 5~ extensor deficit was not statistically significant between the 2 groups （ RR = 1.63, 95% CI O. 85 to 3.16, P = 0. 14）. Anterior knee pain and kneeling pain or discomfort showed significantly differences between the 2 groups at a mean follow-up of 2 years （ P 〈 0. 05）, but did not at follow-ups of 5 years and 10 years （ P 〉 0. 05）. Conclusions In single-bundle endoscopic ACL reconstruction, patellar tendon and 4-strand hamstring autografts have similar rates of graft failure and knee motion deficits. The patellar tendon autograft may have higher rates of anterior knee pain and kneeling pain or discomfort at an early stage after operation than the 4-strand hamstring autograft, but there may be no such differences on a long-term basis. Key words: Patella ligament; Anterior erueiate ligament; Meta-analysis; Hamstring

Fifteen-Year Outcome of Endoscopic Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft for “Isolated” Anterior Cruciate Ligament Tear

Background: Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries. Purpose: To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft. Study Design: Case series; Level of evidence, 4. Methods: Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment. Results: Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle <17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age <18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C). Conclusion: Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization.

Preliminary Clinical Results of Two Techniques for Addressing Graft Tunnel Mismatch in Endoscopic Anterior Cruciate Ligament Reconstruction

This study reports the initial clinical results of 540 degrees of graft rotation or free tibial bone block to address graft tunnel mismatch in endoscopic anterior cruciate ligament (ACL) reconstruction. The operative reports of patients who underwent endoscopic ACL reconstruction between 1999 and 2001 were reviewed. Nine of 11 patients treated with a free tibial bone block and 14 of 17 patients treated with 540 degrees of graft rotation were evaluated. Mean follow-up was 20 months (range: 13-40 months) for the bone block group and 34 months (range: 18-48 months) for the 540 degrees group. There were statistically significant improvements in physical examination test results postoperatively, and only one patient in the 540 degrees group had a grade one positive pivot shift test. KT-1000 arthrometer testing demonstrated a statistically significant decrease in manual maximum and side-to-side differences at final follow-up. Mean Lysholm and Noyes sports function scores were excellent or good for all patients. One patient required reoperation for flexion contracture, one patient required an arthroscopic irrigation and debridement for a minor infection, and one patient required arthroscopic subtotal medial meniscectomy for failed meniscal repair. No difference was noted between these results and previous results of patients undergoing conventional endoscopic ACL reconstruction. These results demonstrate graft rotation and free bone block techniques are effective in addressing graft tunnel mismatch in endoscopic ACL reconstruction.

An Alternative Solution to Graft-tunnel Mismatch Using Patellar Tendon Autograft During ACL Reconstruction

Graft-tunnel mismatch is a common technical difficulty that can complicate endoscopic anterior cruciate ligament reconstruction with bone-patella tendon-bone autograft. When this situation arises, interference fixation in both the femoral and tibial tunnels is not possible. Several techniques have b

Single-Bundle Anterior Cruciate Ligament Reconstruction

Background Conventional endoscopic single-bundle transtibial anterior cruciate ligament (ACL) reconstruction from the posterolateral tibial footprint to the anteromedial femoral footprint results in a vertical graft. A more oblique horizontal graft from the anteromedial tibial footprint to the posterolateral femoral footprint may offer a better alternative for all endoscopic ACL reconstruction. Hypothesis When compared with a conventional ACL single-bundle position, the horizontal graft ACL position has more obliquity and so undergoes a greater change in length during anterior translation and internal rotation. Study Design Controlled laboratory study. Methods A computer navigation system was used to acquire kinematic data during a flexion-extension cycle and outline the anteromedial and posterolateral aspects of the tibial and femoral footprints on 5 fresh-frozen cadaveric knees. Three virtual graft positions were defined: conventional (posterolateral tibia—anteromedial femur), central, and horizontal (anteromedial tibia— posterolateral femur). After transection of the ACL, the obliquity, anisometry, absolute length change, and apparent strain were computed for each graft position during the Lachman test, the anterior drawer test, and internal rotation at 0° and 30° of flexion. Results The horizontal position was more oblique than the other positions (P < .05). There were no differences in anisometry. The horizontal position elongated more than the other positions during the Lachman test (P < .05) and more than the conventional position during the anterior drawer test (P = .009). During internal rotation at 30° flexion, the horizontal position elongated more than the other positions (P < .05). The central and horizontal positions had more apparent strain than that of the vertical position during the Lachman test and internal rotation (P < .05); no significant difference was found during the anterior drawer test. Conclusion In ACL-deficient cadaveric knees, the horizontal graft position has greater obliquity and so undergoes greater elongation without increased apparent strain when compared to the central graft position, in response to anterior translation and internal rotation maneuvers. Clinical Relevance Horizontal graft placement of a single-bundle ACL may result in greater control of translation and rotation.