Final International Knee Documentation Committee Research Articles

Comparison of femoral tunnel position and knee function in anterior cruciate ligament reconstruction: a retrospective cohort study using measuring-fluoroscopy method versus bony marker method

BackgroundPrevious studies have shown that surgical technique errors especially the wrong bone tunnel position are the primary reason for the failure of anterior cruciate ligament (ACL) reconstruction. In this study, we aimed to compare the femoral tunnel position and impact on knee function during the ACL reconstruction using measuring combined with fluoroscopy method and bony marker method for femoral tunnel localization.MethodsA retrospective cohort study of patients undergoing ACL reconstruction using the bony marker method or measuring combined with fluoroscopy for femoral tunnel localization was conducted between January 2015 and January 2020. A second arthroscopic exploration was performed more than 1 year after surgery. Data regarding patient demographics, the femoral tunnel position, results of the Lysholm score, the International Knee Documentation Committee (IKDC) score, KT-1000 side-to-side difference, pivot shift grade, and Lachman grade of the knee were collected.ResultsA total of 119 patients were included in the final cohort. Of these, 42 cases were in the traditional method group, and 77 cases were in the measuring method group. The good tunnel position rate was 26.2% in the traditional method group and 81.8% in the measuring method group (p < 0.001). At the final follow-up, the Lysholm and IKDC scores were significantly greater in the measuring method group than the traditional method group (IKDC: 84.9 ± 8.4 vs. 79.6 ± 6.4, p = 0.0005; Lysholm: 88.8 ± 6.4 vs. 81.6 ± 6.4, p < 0.001). Lachman and pivot shift grades were significantly greater in the measuring method group (p = 0.01, p = 0008). The results of KT-1000 side-to-side differences were significantly better in the measuring method group compared with those in the traditional method group (p < 0.001).ConclusionsThe combination of the measuring method and intraoperative fluoroscopy resulted in a concentrated tunnel position on the femoral side, a high rate of functional success, improved knee stability, and a low risk of tunnel deviation. This approach is particularly suitable for surgeons new to ACL reconstructive surgery.

Satisfactory Outcomes and Improved Range of Motion With Arthroscopic Lysis of Adhesions and Manipulation for Arthrofibrosis After Multiligamentous Knee Reconstruction

To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient-reported outcomes at mid- to long-term follow-up. We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side. In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5-9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°-129°), mean extension of 3.2° ± 5.2° (range, 0°-12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°-117°). At a mean follow-up of 7.0±3.9 years (range, 2.4-16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° (P= .003), a significant increase in arc of motion of 51° (P= .002), and an increase in extension of 3° (P= .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow-up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery. At mid-term follow-up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA. Level IV, therapeutic case series.

Arthroscopic treatment of the symptomatic discoid lateral meniscus improves the knee function in the long-term: a ten-year follow-up study.

Discoid lateral meniscus (DLM) is a common meniscal anatomic disorder and can cause irreversible knee consequences. The long-term clinical outcomes of DLM management remain unclear. Moreover, several potential factors would influence the long-term functional outcomes. The factors also remain unclear. This study aims to evaluate the long-term clinical outcomes of the arthroscopic management of the DLM and to identify the patients' factors affecting the long-term results. Medical records were retrospectively examined for patients with symptomatic unilateral DLM who underwent arthroscopic procedures between January 2004 and August 2011. The characteristics of DLM, the preoperative and the long-term postoperative visual analog scale (VAS), the International Knee Documentation Committee (IKDC) score, Lysholm, and Yulish scores were evaluated. Data were collected, processed, and analyzed using SAS software version 9.2. Univariate and multivariate analyses were performed to identify the factors influencing the long-term outcomes of the DLM arthroscopy. A total of 128 patients were included, most of whom were females (68.7%). The median age of the included participants was 24 (16-31) years old. The median duration of symptoms was 23.3 (10, 31) months, and the median follow-up duration was 126.2 (113, 140) months. The functional scores significantly improved postoperatively compared to the preoperative scores; VAS (1.65 ± 1.17 vs. 6.08 ± 1.31), Lysholm (91.39 ± 5.05 vs. 77.51 ± 10.19), and IKDC (84.63 ± 7.69 vs. 67.89 ± 9.56), respectively; p<0.05. Multivariate analysis revealed that gender, the status of self-reported instability, preoperative VAS, Yulish MR cartilage grade, and Lysholm score had a significant correlation with the worsening of the final follow-up IKDC scores. Arthroscopic procedure significantly improved the long-term joint function of the DLM patients, as evidenced by the sustained improvement of the VAS, Lysholm, and IKDC scores. These clinical outcomes were greatly influenced by gender, the status of self-reported instability, preoperative Yulish MR cartilage grade, VAS, and Lysholm score.

Achilles Tendon-Bone Allograft is Advantageous for Chronic Patellar Tendon Ruptures Using a Modified Fixation Technique

Objectives: A patellar tendon rupture is an extremely disabling extensor mechanism injury. This follow-up study describes the clinical and radiologic outcomes of a new modified technique for reconstructing chronic patellar tendon ruptures. Materials and Methods: From 2014 to 2018, we reconstructed 15 chronic patellar tendon ruptures using Achilles tendon-bone allograft. Clinical and radiologic outcomes were evaluated preoperatively and during the final follow-up, 2 to 7 years after reconstruction. Assessments involved the International Knee Documentation Committee (IKDC), Lysholm, and Kujala scores, as well as quadriceps muscle strength and extension lag. Radiologic results were evaluated using the Insall-Salvati index on plain radiography and allograft integration through magnetic resonance imaging. Results: At the final follow-up, the Lysholm, IKDC, and Kujala scores improved by 57, 58, and 54 points, respectively (P&lt;0.001). The average quadriceps muscle strength improved from 2.6 (2 to 3) before the operation to 4.6 (4 to 5) at the final follow-up (P&lt;0.001). The extension lag also improved significantly from 31.7 degrees (25 to 40) to 0.6 degrees (0 to 10). The preoperative Insall-Salvati index was 1.6 (1.5 to 1.9), which improved significantly to 1.2 (1 to 1.3) postoperatively (P&lt;0.001). Two years after the operation, magnetic resonance imaging showed good allograft integration in all pateints. Conclusion: Combining an Achilles tendon-bone allograft with a robust fixation method led to favorable clinical and radiologic outcomes. Level of Evidence: Level IV.

Suture Anchor-Based Quadriceps Tendon Repair May Result in Improved Patient-Reported Outcomes but Similar Failure Rates Compared to the Transosseous Tunnel Technique

The purpose of this study was to compare failure rates and patient-reported outcomes between transosseus (TO) suture and suture anchor (SA) quadriceps tendon repairs. Following institutional review board approval, patients who underwent primary repair for quadriceps tendon rupture with TO or SA techniques between January 2009 and August 2018 were identified from an institutional database and retrospectively reviewed. Patients were contacted for satisfaction (1-10 scale), current function (0-100 scale), failure (retear), and revision surgeries; International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were also collected to achieve a minimum of 2-year follow-up. Sixty-four patients (34 SA, 30 TO) were available by phone or e-mail at a mean of 4.81 ± 2.60 years postoperatively. There were 10 failures, for an overall failure rate of 15.6%. Failure incidence did not significantly differ between treatment groups (P= .83). Twenty-seven patients (47% of nonfailed patients) had completed patient-reported outcomes. The SA group reported higher subjective function (SA: 90 [85-100] vs TO: 85 [60-93], 95% CI of difference: -19.9 to -2.1× 10-5, P= .042), final IKDC (79.6 [50.0-93.6] vs 62.1 [44.3-65.5], 95% CI of difference: -33.0 to -0.48, P= .048), KOOS Pain (97.2 [84.7-97.2] vs 73.6 [50.7-88.2], 95% CI of difference: -36.1 to -3.6× 10-5, P= .037), Quality of Life (81.3 [56.3-93.8] vs 50.0 [23.4-56.3], 95% CI of difference: -50.0 to-6.2, P= .026), and Sport (75.0 [52.5-90.0] vs 47.5 [31.3-67.5], 95% CI of the difference: -45.0 to -4.1× 10-5, P=.048). There is no significant difference in failure rate between transosseus and suture anchor repairs for quadriceps tendon ruptures (P= .83). Most failures occur secondary to a traumatic reinjury within the first year postoperatively. Despite the lack of difference in failure rates, at final follow-up, patients who undergo suture anchor repair may report significantly greater subjective function and final IKDC, KOOS Pain, Quality of Life, and Sport scores. III, retrospective cohort study.

Comparative Outcomes Occur After Superficial Medial Collateral Ligament Augmented Repair vs Reconstruction: A Prospective Multicenter Randomized Controlled Equivalence Trial

Background: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. Purpose/Hypothesis: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. Results: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group (P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) (P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] (P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) (P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) (P = .184). Conclusion: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

Lateral Meniscal Tears in Young Patients: A Comparison of Meniscectomy and Surgical Repair.

Background:Meniscal tears are common in active patients, but treatment trends and surgical outcomes in young patients with lateral meniscal tears are lacking.Purpose:To evaluate treatment trends, outcomes, and failure rates in young patients with lateral meniscal tears.Study Design:Cohort study; Level of evidence, 3.Methods:Patients aged ≤25 years treated surgically for isolated lateral meniscal tears from 2001 to 2017 were identified. Treatment trends were compared over time. International Knee Documentation Committee (IKDC) scores and failure rates were compared by treatment modality (meniscectomy vs meniscal repair). Failure was defined as reoperation, symptomatic osteoarthritis, or a severely abnormal IKDC score. Univariate regression analyses were performed to predict failure and IKDC scores based on treatment, type and location of tear, or extent of meniscectomy.Results:Included were 217 patients (226 knees) with a mean age of 17.4 years (range, 7-25 years); of these patients, 144 knees (64%) were treated with meniscectomy and 82 knees (36%) with meniscal repair. Treatment with repair increased over time compared with meniscectomy (P < .001). At a minimum 2-year follow-up (mean, 6.1 ± 3.9 years), 107 patients (110 knees) had IKDC scores, and analysis indicated that although scores in both groups improved from pre- to postoperatively (repair: from 69.5 ± 13.3 to 97.4 ± 4.3; meniscectomy: from 75.7 ± 9.0 to 97.3 ± 3.9; P < .001 for both), improvement in IKDC score was greater after repair (27.9 ± 13.9) versus meniscectomy (21.6 ± 9.4) (P = .005). Included in the failure analysis were 184 patients (192 knees) at a mean follow-up of 8.4 ± 4.4 years. The rates of reoperation, symptomatic osteoarthritis, and failure were not significantly different between the meniscectomy and repair groups.Conclusion:An increase was seen in the rate of isolated lateral meniscal tear repair in young patients. IKDC score improvement was greater after repair than meniscectomy, although postoperative IKDC scores were similar. Symptomatic arthritis, reoperation, and failure rates were similar between groups; however, there was a trend for increased arthritis symptoms in patients treated with meniscectomy, especially total meniscectomy. Treatment modality, type and location of tear, and amount of meniscus removed were not predictive of final IKDC scores or failure.

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.

The outcomes of one-stage treatment for multiple knee ligament injuries combined with extensor apparatus rupture

BackgroundMultiple knee ligament injuries combined with extensor apparatus rupture are serious and complex knee injuries that are rare in clinical practice. The management is extremely challenging and controversial.The aim of this study is to describe a patient collective with multiple knee ligament injuries combined with extensor apparatus injuries in detail and to report the mid-term outcomes of a one-stage surgical treatment regarding subjective outcome scores, complications, knee instability, and ROM.MethodsEleven of 425 patients with multiple knee ligament injuries combined with extensor apparatus injuries admitted to our hospital were reviewed from July 2008 to May 2017. All patients underwent one-stage repair and reconstruction of multiple knee ligaments and extensor apparatus. The Lysholm knee score and the International Knee Documentation Committee (IKDC) score were adopted to evaluate the surgical effect preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at the final follow-up.ResultsTen patients were followed up with a mean time of 40 (range, 24–60) months. At the last follow-up, 8 patients had joint flexion range of motion greater than or equal to120 degrees, 2 patients had joint flexion range of motion of 100–120 degrees, and 1 patient had active knee extension limitation of 5 degrees. Stress radiographs showed that the mean differences in posterior displacement were reduced from 10.8 ± 3.0 mm preoperatively to 2.0 ± 2.5 mm at the last follow-up. There were significant improvements in stress radiographs from pre- to postoperative states for all patients with multiple knee ligament injuries. The Lysholm score ranged from 85 to 96, with a mean of 92.1 (compared with 33 before surgery, P < 0.05). The final IKDC scores were A in 2 patients (20%), B in 7 (70%), and C in 1 (10%). Nine of the 10 patients (90%) returned to their former activity level.ConclusionMultiple knee ligament injuries combined with extensor apparatus rupture are rare. Single-stage management of the repair and reconstruction of multiple knee ligaments and extensor apparatus with proper rehabilitation is an effective and reliable procedure to restore knee stability and function.Level of evidenceLevel IV, therapeutic case series.

Root Repair Versus Partial Meniscectomy for Medial Meniscus Posterior Root Tears: Comparison of Long-term Survivorship and Clinical Outcomes at Minimum 10-Year Follow-up

Background: The importance of repair in medial meniscus posterior root tears (MMPRTs) has been increasingly recognized because it restores hoop tension. However, no study has compared the long-term outcomes between meniscectomy and repair. Hypothesis: Survivorship and clinical outcomes of repair would be better than those of meniscectomy after long-term follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Between 2005 and 2009, patients with MMPRTs who had been followed up for at least 10 years after partial meniscectomy (n = 18) or pullout repair (n = 37) were recruited. Clinical assessments, including the Lysholm score and International Knee Documentation Committee (IKDC) subjective score, were evaluated preoperatively and at the final follow-up. The final results in each group were compared with the preoperative results, and the final results of the groups were compared. Clinical failure was defined as conversion to total knee arthroplasty (TKA), and the final clinical scores were assessed just before TKA. Kaplan-Meier survival analysis was used to investigate the survival rates of surgical procedures. Results: Mean ± SD follow-up period was 101.4 ± 45.9 and 125.9 ± 21.2 months in the meniscectomy and repair groups, respectively (P = .140). The mean Lysholm and IKDC scores, respectively, in the meniscectomy group were 50.8 ± 7.7 and 37.6 ± 7.0 preoperatively and 58.2 ± 22.1 and 44.4 ± 19.0 postoperatively (P = .124; P = .240). In the repair group, the mean Lysholm score and IKDC score, respectively, significantly increased from 52.3 ± 10.9 and 41.0 ± 9.6 preoperatively to 77.1 ± 24.0 and 63.7 ± 20.6 postoperatively (P < .001; P < .001). The final Lysholm and IKDC scores in the repair group were significantly better than those in the meniscectomy group (P = .004; P = .003). In cases of clinical failure, 10 patients (56%) in the meniscectomy group and 8 patients (22%) in the repair group converted to TKA in the follow-up period (P = .016). According to Kaplan-Meier analysis, the 10-year survival rates for the meniscectomy and repair groups were 44.4% and 79.6%, respectively (P = .004). Conclusion: In MMPRTs, root repair was superior to partial meniscectomy in terms of clinical results for at least 10 years of follow-up. From a long-term perspective, repair with restoration of hoop tension is more effective management than meniscectomy.

Understanding the Implications of the Meniscal Ossicle: Patient Presentation, Treatment, and Outcomes.

The meniscal ossicle is observed in clinical practice, yet there currently is limited information on its potential clinical significance. The purpose of this study was to assess the clinical presentation, imaging findings, and clinical treatment and outcomes of a series of patients identified as having a meniscal ossicle. An institutional database was reviewed to identify knees with a meniscal ossicle. Clinical presentation, magnetic resonance imaging (MRI), treatment, and outcomes were analyzed. Radiographs were graded using Kellgren-Lawrence (KL) scores. MRIs were reviewed for the presence and location of meniscal ossicles and additional knee pathology. Knee arthroplasty rates were recorded with the remaining patients contacted to obtain final International Knee Documentation Committee (IKDC) and Tegner's scores. Failure was defined as conversion to arthroplasty or failing IKDC score (< 75.4). Forty-five meniscal ossicles in 45 patients (26 males and 19 females) with a mean age of 51 years (standard deviation [SD] = 19.0) were included. Pain was the most common presenting symptom (89%). Forty-two patients (93%) had an associated meniscus root tear on MRI. Eighteen percent of patients that did not have an ossicle on initial imaging subsequently developed an ossicle. Mean KL grades progressed significantly from baseline of 1.84 (SD = 1.0) to 2.55 (SD = 0.93 p < 0.01) on final follow-up. Thirty-nine percent of baseline radiographs showed KL grades of less than 2 compared with only 15% of follow-up radiographs (p = 0.04). Mean IKDC score obtained for patients ≤ 60 at an average follow-up of 3.1 years (SD = 3.2) was 65.2 (SD = 19.0). Eight out of 45 patients (18%) had progressed to total knee arthroplasty (TKA) by latest available follow-up. Sixty-two percent of patients met failure criteria at latest available follow-up. The meniscal ossicle is most commonly found in the posterior horn or root of the medial meniscus and is highly suggestive to be sequelae of a posterior root tear. Therefore, the presence of a meniscal ossicle should alert the orthopaedic surgeon to the high likelihood of the patient having a meniscus root tear. These patients have shown to have poor clinical outcomes and worsening arthritis.

Long-term Outcomes of Primary Repair of the Anterior Cruciate Ligament Combined With Biologic Healing Augmentation to Treat Incomplete Tears

Background: Surgical treatment to repair partial anterior cruciate ligament (ACL) injury without reconstruction has demonstrated inconsistent clinical success. Purpose: To examine the long-term clinical outcomes of primary ACL repair combined with biologic healing augmentation in patients with symptomatic partial ACL tears. Study Design: Case series; Level of evidence, 4. Methods: 50 patients (mean age, 29.5 years) with a partial ACL tear and symptomatic knee instability were treated with primary ligament repair in conjunction with marrow stimulation and followed prospectively for a mean duration of 10.2 years (range, 5.3-14.3 years). Comparative analysis of preinjury, preoperative, and postoperative scores using patient-reported assessment instruments was performed to examine clinical outcomes. Correlation of final outcome scores with patient age, type of ACL tear, side-to-side difference in ligamentous laxity, and body mass index (BMI) was performed through use of Spearman rank analysis. Results: 44 patients were available for assessment at final follow-up. The median Tegner Activity Scale score of 7 at final follow-up was the same as the preinjury median score of 7 (P = .128). The mean Marx Activity Scale, International Knee Documentation Committee (IKDC) Subjective, and Lysholm Knee Questionnaire scores were 10.8, 90.4, and 96.2, respectively, at final follow-up. Mean final Knee injury and Osteoarthritis Outcome Score (KOOS) subset assessments of Pain, Symptoms, Activities of Daily Living, Sports, and Quality of Life were 98.6, 97.5, 99.7, 94.3, and 95.6, respectively. Secondary ACL insufficiency occurred in 27% of patients. Clinical outcome scores were similar for all scoring instruments between patients treated for an associated diagnosis of meniscal or articular cartilage injury. No significant correlations of age, BMI, ACL tear type, or laxity and final IKDC Subjective, Lysholm, or KOOS scores were found. Analysis revealed a negative correlation of patient age and Tegner score at preinjury (rs = −0.333, P = .022) and at final follow-up (rs = −0.376, P = .013). The mean side-to-side difference in ligamentous laxity of 3.4 mm at short-term follow-up in those patients who developed secondary ACL insufficiency over the duration of follow-up was significantly greater than the mean of 0.9 mm in those who did not (P = .010). Conclusion: Primary ACL repair combined with biologic healing augmentation to treat select cases of knee instability secondary to incomplete ACL rupture demonstrated good to excellent long-term outcomes in this cohort for those patients who did not experience secondary ACL insufficiency, with high rates of restoration of knee stability and return to preinjury athletic activities. The rate of secondary treatment for recurrent ACL insufficiency over the course of long-term follow-up was greater than would be expected for primary ACL reconstruction. Greater side-to-side differences in objective findings of ligamentous laxity were identified at shorter term follow-up in the patients who later went on to experience symptomatic secondary ACL insufficiency, compared with those who maintained stability long term.

Clinical outcome of arthroscopic management of isolated posterior cruciate ligament injuries

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Isolated posterior cruciate ligament&lt;strong&gt; (&lt;/strong&gt;PCL) injuries are considered as benign and treated conservatively. But studies have shown the long term outcomes of these patients are poor. Aim of this study is to determine the functional outcomes, efficacy, and complication of isolated PCL injuries treated by arthroscopic PCL reconstruction or fixation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 24 patients, each with an isolated PCL injury, (17 with complete PCL tear and 7 with PCL avulsion fracture) were enrolled in this prospective study. Patients with complete tear underwent PCL reconstruction with hamstring tendon autograft and patients with displaced avulsion fractures underwent arthroscopic fixation with suture bridge technique. Average age at time of surgery was 33 years. Average time from injury to surgery was 1 month. Average follow-up period was 18 months. Patients underwent regular follow-up postoperatively with clinical and radiographic evaluation. Follow-up examinations comprised the Lysholm knee score, the International Knee Documentation Committee (IKDC) score.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean preoperative Lysholm score for 24 knees was 41; mean postoperative Lysholm score was 90. Eighteen of 24 patients had excellent results, and 4 patients had good results and 2 patients have fare result at final assessment. IKDC ratings showed significant improvements on subsequent follow ups. In final IKDC ratings, 21 patients were assessed as normal or near normal (grade A or B).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The short-term follow-up, analytical results showed good function after arthroscopic management in isolated PCL injuries. Hence we recommend surgical intervention in isolated PCL injuries.&lt;/p&gt;

Isolated posterior cruciate ligament injuries: Results of arthroscopic management

Aim: Isolated posterior cruciate ligament (PCL) injuries are considered as benign and treated conservatively. Aim of this study is to determine the functional outcomes, efficacy of isolated PCL injuries treated by arthroscopic PCL reconstruction or fixation. Materials and Methods: A total of 24 patients, each with an isolated PCL injury, (17 with complete PCL tear and 7 with PCL avulsion fracture) were enrolled in this prospective study. Patients with complete tear underwent PCL reconstruction with hamstring tendon autograft and the patients with displaced avulsion fractures underwent arthroscopic fixation with suture bridge technique. The patients underwent regular follow-up postoperatively with clinical and radiographic evaluation. Follow-up examinations comprised the Lysholm knee score, International Knee Documentation Committee (IKDC) score. Results: Mean pre-operative lysholm score for 24 knees was 41; mean post-operative lysholm score was 90. 18 of 24 patients had excellent results, 4 patients had good results, and 2 patients had fare result at final assessment. In final IKDC ratings, 21 patients were assessed as normal or near normal (Grade A or B). Conclusions: The short-term follow-up showed good function after arthroscopic management in isolated PCL injuries. Hence, we recommend surgical intervention in isolated PCL injuries.

Posterior Cruciate Ligament Reconstruction Using Single-Bundle Achilles Allograft with Open Tibial Inlay Fixation

Objectives:PCL reconstruction research has shown that the tibial inlay and transtibial tunnel procedures offer similar biomechanical results. The purpose of this study was to evaluate the early results of PCL reconstruction using a single-bundle Achilles allograft and tibial inlay fixation.Methods:We retrospectively studied 14 patients who had undergone PCL reconstruction using the direct tibial inlay fixation technique from 2009 to 2013, with a mean follow-up of 13.4 months. (6-28 months). The patients were 11males and 3 females with an average age of 29.2 years (17-41 years). Ipsilateral femoral shaft fractures were determined in 2 cases, ipsilateral trochanteric fracture in 1 case and popliteal artery injury in 1 case. Surgery was performed within 2-4 weeks. Spanning-joint external fixation was applied to 2 patients because of gross instability with failure to maintain reduction in a brace. Combined reconstructions involving the posterolateral corner (9/14), anterior cruciate ligament (ACL (11/14)), or medial collateral ligament (MCL (1/14)) were performed. All PCL reconstructions were performed with Achilles allograft. In 1 case with arterial injury, the repair was made by a cardiovascular surgeon. In 2 case, deep infection developed, which was controlled with debridement and antibiotic treatment. Superficial peroneal nerve injury in 1 case was treated with tenolysis in the 6th month, then partial healing was seen at 18 months. In all patients, the preoperative posterior drawer (PD) examination was positive. All patients were evaluated with preoperative and postoperative examination and x-rays. The International Knee Documentation Committee (IKDC) evaluation was applied to all patients at the final follow-up.Results:Postoperative PD examination demonstrated the following: 0 (normal) in 4 patients, 1+ in 7 patients, and 2+ in 3 patients, compared to the preoperative PD of 3+ or greater in all patients. Preoperative IKDC objective evaluation rated all knees as severely abnormal based on instability. The final follow-up objective IKDC evaluation distribution was as follows: A, 4 knees; B, 6 knees; C, 3 knees and D, 1 knee, compared to D in all 14 knees preoperatively. The average final follow-up IKDC subjective score was 74.1 (20-100).Conclusion:Despite transtibial PCL reconstruction being advocated by several authors, it has technical difficulties of the arthroscopic approach to the posterior compartment of the knee. In the open inlay technique, posterior arthrotomy allows accurate placement of the tibial PCL insertion, avoiding the killer curve and more closely duplicating the normal PCL anatomy. Based on our initial experience with this technique at early follow-up, we continue to use the tibial inlay technique as our preferred technique for isolated or combined reconstruction of the PCL.

Ön Çapraz Bağ Yırtıklarının Dört Katlı Otojen Hamstring Tendon Grefti İle Artroskopik Rekonstrüksiyonu

Objective: The aim of this study was to determine the results of arthroscopic reconstruction of anterior cruciate ligament with hamstring tendon graft. Method: Thirty-eight patients with a mean age of 27.35 years were analyzed. Functional evaluation was made with Lysholm knee score, IKDC (International Knee Documentation Committee) score, Modified Cincinnati knee score and Tagner Activity score, clinical evaluation was made with stability tests, range of motion of the joint and thigh atropy measurements at the final control (mean 18, range 8 - 28 months). Results: The Lysholm scores were excellent for 27 patients, good for 11 patients and Modified Cincinnati knee scores were excellent for 31 patients, good for 7 patients. The final functional results were significantly better than pre-operative results according to the Lysholm scores, Modified Cincinnati knee scores and Tagner Activity scores. Pre-operative activity results were achieved after operation. The final IKDC scores were significantly better than pre-operative scores. There was not significantly difference between pre-injury and final results. Lachman, Pivot-shift tests were measured as 1 (+) in 8 patients at final control. Compared with the normal side, the thigh circumferences were measured as equal in 24 patients, < 10 mm difference in 10 patients and 10 – 20 mm difference in 4 patients. No flexion or extension losses occurred in the affected knees; mean flexion was measured as 124° (range 115°- 130°). Conclusion: We conclude that arthroscopic reconstructions of anterior cruciate ligament with use of Hamstring tendon autograft which revealed both satisfactory functional results and high personal satisfaction

Arthroscopic reconstruction of the posterior cruciate ligament with a quadruple hamstring tendon graft

Background This study prospectively evaluated 21 patients treated consecutively to determine patient outcomes, efficacy, and possible complications of arthroscopically assisted posterior cruciate ligament (PCL) reconstruction performed with hamstring tendon grafts. Patients and methods Twenty-one patients (18 men and three women), each with an isolated PCL injury, underwent PCL reconstruction with a hamstring tendon autograft and were enrolled in this prospective study. The average age of the patients at the time of surgery was 26 years (range, 21-30 years). The average follow-up period was 21 months (range, 12-30 months). Patients underwent regular follow-up after clinical and radiographic preoperative and postoperative evaluation. Follow-up examinations included the International Knee Documentation Committee score, thigh muscle assessment, and radiographic evaluation. Results In the final International Knee Documentation Committee ratings, 85.7% of patients (18 of 21) were assessed as normal or near normal (grade A or B). A statistically significant improvement was observed in thigh girth difference, extensor strength ratio, and flexor strength ratio before and after reconstruction. Conclusion Analytical results showed satisfactory function after PCL reconstruction with the use of hamstring tendon autografts. We suggest that the hamstring tendon autograft is a safe, effective, and acceptable choice for PCL reconstruction, and that it affords good ligament reconstruction.

Surgical Management of Traumatic Knee Dislocation With Posterolateral Corner Injury

To evaluate the results of our method of surgical treatment of traumatic knee dislocation with injury to the posterolateral corner by use of a standardized protocol. Twenty-five consecutive patients presented with a grossly dislocated or reduced knee. Five of these patients were not included in this series. The remaining 20 patients were treated by primary arthroscopic reconstruction. The anterior cruciate ligament (ACL) was reconstructed using gracilis tendon reinforced with artificial ligament (Ligament Augmentation and Reconstruction System [LARS] ligament); the posterior cruciate ligament (PCL) was reconstructed with semitendinosus tendon and reinforced with LARS ligament; and the posterolateral corner was treated using the gracilis and semitendinosus tendons from the uninjured knee. Twenty patients returned for subjective and objective evaluation at a minimum of 24 months after surgery. Early mobilization through continuous and active exercise was started on the fourth day postoperatively. At a mean follow-up of 44 months, the mean Lysholm score was 90 points, the mean score on the survey of daily activities was 90 points, and the sports activities score on the knee outcome survey averaged 80 points. By the rating of Meyers etal. the results were excellent in 6 patients, good in 10 patients, fair in 3 patients, and poor in one patient. The final International Knee Documentation Committee (IKDC) rating was not normal in any knee. The mean loss of extension was 2° (range, 0° to 3°) and loss of flexion was 12° (range, 10° to 15°). By using the described method of arthroscopically assisted reconstruction of the cruciate ligaments and the posterolateral corner, 80% of the patients had good subjective results and functional stability, and according to the IKDC scale, 45% of knees were nearly normal, 45% were abnormal, and 10% were severely abnormal. No patient's rating returned to normal. Level IV, therapeutic case series.

Paper 273: Posterior Cruciate Ligament Reconstruction with Stent Operation for Remnant augmentation

Although, recently, it has been reported that posterior cruciate ligaments(PCLs) have spontaneous healing potential and can heal by conservative treatment, despite good early functional results, the posterior laxity of the knee is not completely eliminated after conservative treatment. The PCL can retain the normal tension only when the injured ligament is maintained anatomically. The purpose of this study was to develop and evaluate a technique of PCL reconstruction with stent operation for remnant PCL augmentation. Between September 2003 and March 2006, 23 patients who had a tear of the PCL underwent reconstruction with stent operation using hamstring tendon graft(20cases) or tibialis posterior allograft(4 cases) for remnant PCL augmentation. 20 patients were evaluated after a minimum duration of follow-up 24 months. The remnant PCL and the synovium were preserved, and the augmentation was performed using transtibial technique. Femoral tunnel was created at near the foot-print of anterolateral bundle. Stability was measured on posterior stress radiographs and with a maximal manual displacement test performed with a KT-1000 arthrometer. Clinical evaluation was carried out with use of the scoring systems of the international Knee Documentation Committee(IKDC) and the Orthopadische Arbeitsgruppe Knie Score(OAK). The mean side-to-side differences in displacement was reduced from 9.9 ± 4.0 mm preoperatively to 3.0 ± 2.6 mm at last follow-up on the stress radiographs, and it was reduced from 6.9 ± 2.1 mm preoperatively to 2.7 ± 1.5 mm as measured with the KT-1000. The final IKDC score was A in 7(35%), B in 10(50%), C in 2(10%) and D in 1(5%) patients. The average OAK score improved from 61.6 ± 13.1 to 88.2 ± 9.5. The group in which tibialis posterior allografts were used for augmentation showed worse results than hamstring autograft group in clinical result. In one case, posterior instability was recurred more than 10mm compare to contralateral side, PCL revision was performed as a double bundle reconstruction using achilles allograft. Excellent posterior stability and relatively good clinical results were achieved with the stent operation for remnant PCL augmentation. This technique is technically feasible and the PCL remnants and synovium may be beneficial to ligament healing and proprioception. However, other combined injuries seem to affect clinical results. The short-term results are encouraging, but long –term results are needed to confirm the value of this technique for alternative operative method of acute or subacute PCL injuries.

Single-bundle transtibial posterior cruciate ligament reconstruction using a bioabsorbable cross-pin tibial back side fixation

The purpose of this study was to examine a developed surgical technique by performing a mid-term evaluation of clinical and stability results and complications. Thirty patients who underwent transtibial posterior cruciate ligament (PCL) reconstruction using a bioabsorbable cross-pin tibial back side fixation method were enrolled in this prospective study. Lysholm and International Knee Documentation Committee (IKDC) knee scales were used to evaluate clinical outcomes. Stability was evaluated using a Telos device with a 150N force at 90 degrees of knee flexion. Follow-up magnetic resonance imaging (MRI) was also performed in 20 (66.7%) patients, and complications were evaluated. Those with complication by MRI were assigned to an abnormal MRI group. The follow-up period was 47 (range, 25-62) months. On comparing preoperative and final follow-up clinical results, Lysholm and IKDC knee scale scores were found to have improved significantly (P<0.001). The mean side-to-side difference in posterior translation measured using a Telos device was 13.4±3.1mm (range 10-20mm) preoperatively and 3.2±1.5mm (range 1-7mm) at last follow-up, which represented a significant improvement in stability (P<0.001). Five patients showed cyst formation in the tibial tunnel and two patients showed a significant signal increase at the anterior portion of the tibial tunnel, which was believed to indicate a pro-cystic status. The normal and abnormal MRI groups had similar Lysholm and IKDC knee scale scores and stress radiographs (P>0.05). Single-bundle transtibial PCL reconstruction using a bioabsorbable cross-pin tibial back side fixation was found to produce satisfactory clinical and stability results. However, despite these satisfactory results, a potential complication of tibial cyst formation was observed. Case series, Level IV.