Final International Knee Documentation Committee Research Articles

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.

Combined Posterolateral Corner Reconstruction With Remnant Tensioning and Augmentation in Chronic Posterior Cruciate Ligament Injuries: Minimum 2-Year Follow-Up

To evaluate functional results and knee stability after tensioning of remnant posterior cruciate ligament (PCL) with anterolateral (AL) bundle reconstruction and posterolateral corner (PLC) reconstruction in chronic PCL and PLC injuries. Between March 2001 and March 2007, 95 patients with chronic PCL injuries combined with PLC injuries underwent tensioning of the remnant PCL with AL bundle reconstruction and PLC reconstruction. Among these 95 patients, 70 who were satisfied with our inclusion were reviewed. The mean follow-up period was 40.1 months (range, 24 to 96 months). Tensioning of remnant PCL fibers was performed by distal transfer of the posterior tibial attachment. The AL bundle of the PCL was reconstructed by use of the modified inlay technique. The PLC reconstructive procedure was performed with a single sling through fibular tunnel. Stability was measured on posterior stress radiographs and by use of a maximal manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee and Orthopädishe Arbeitsgruppe Knie scoring systems were used for clinical evaluation. Stress radiographs showed that the mean side-to-side difference (posterior tibial translation compared with that of the contralateral knee) was reduced from 10.3 ± 2.4 mm preoperatively to 2.2 ± 1.5 mm at the last follow-up (P < .001), whereas the KT-1000 tests showed that this difference was reduced from 8.4 ± 2.2 mm preoperatively to 2.0 ± 1.4 mm (P < .001). The final International Knee Documentation Committee objective score was A in 30 patients (42.8%), B in 34 (48.6%), and C in 6 (8.6%). The mean Orthopädishe Arbeitsgruppe Knie score improved from 63.5 ± 10.4 to 88.9 ± 7.6 (P < .001). Excellent posterior stability and relatively good clinical results were achieved with tensioning of the remnant PCL and AL bundle and PLC reconstruction by use of fibular tunnel for patients with chronic combined PCL-PLC injuries. Level IV, case series.

Arthroscopic Posterior Cruciate Ligament Reconstruction Using LARS Artificial Ligament: A Retrospective Study

The aims of this study were to analyze the preliminary clinical effects of arthroscopic reconstruction of posterior cruciate ligament (PCL) using Ligament Advanced Reinforcement System (LARS) artificial ligament. It is hypothesized that LARS artificial ligament is a safe and effective choice for PCL reconstruction, providing good knee stability. Forty-one patients who underwent PCL reconstruction using LARS artificial ligament were enrolled in this retrospective study. Average age at time of surgery was 34 y (range, 23-57 y). Average time from injury to surgery was 15 d (range, 5-45 d). Average follow-up period was 44 mo (range, 36-54 months). Follow-up examinations included the Lysholm Knee Score and the International Knee Documentation Committee (IKDC) score. The average Lysholm knee score was 64.9 ± 8.8 preoperatively (range, 47-75) versus 92.1 ± 3.3 three years after operation (range, 79-100). Thirty-six of 41 patients (88%) showed good or excellent results at final assessment. The final IKDC score at 3 y postoperatively rated as normal in 21 patients (51%), nearly normal in 17 patients (42%), abnormal in three patients (7%). The results shows that LARS artificial ligament appears to be an effective device for PCL reconstruction leading to good ligamentous stability and knee function. Long-term follow-up should be performed to confirm the durable stability of the knee and the tolerance of the knee to the LARS artificial ligament.

Single-Stage Anterior Cruciate Ligament Revision With Bone–Patellar Tendon–Bone: A Case-Control Series of Revision of Failed Synthetic Anterior Cruciate Ligament Reconstructions

The purpose of this study was to investigate the clinical results of single-stage revision anterior cruciate ligament reconstruction (ACLR) after synthetic ligament failure. The subjects comprised 20 patients who underwent revision ACLR after synthetic ligament failure. All revisions were performed with bone-patellar tendon-bone graft, and bone tunnel expansion after removal of synthetic materials was treated with bone plugs sized and trimmed as necessary to fill the bone tunnels. Clinical results were assessed at a mean of 2.8 years postoperatively, followed by comparison with the results of 20 primary ACLRs selected as case-matched controls. Assessment included the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, instrumented laxity testing, and radiologic examination. Bone tunnel enlargement to 11 mm in diameter or greater was found in 10 of 20 revision ACLRs. However, favorable anteroposterior stability was obtained at final follow-up (1.4 +/- 2.0 mm in revision ACLR group and 1.5 +/- 1.5 mm in primary ACLR group). The overall Lysholm score improved significantly from preoperatively to final follow-up, but the revision ACLR group showed significantly worse results for the pain parameter than the primary ACLR group. The final IKDC results also showed significant postoperative improvement, but the number of cases with grade C was significantly higher in the revision ACLR group than in the primary ACLR group, which was attributed to radiologically confirmed osteoarthritis in the revision ACLR group. Single-stage revision ACLR with bone-patellar tendon-bone graft after synthetic ligament failure yielded favorable results in terms of IKDC grade, Lysholm score, and anteroposterior stability, despite enlarged bone tunnels after removal of synthetic material. Inferior results for the radiologic and pain parameters of the IKDC and Lysholm scores were attributed to osteoarthritic changes inherent to the revision ACLR group. Level III, therapeutic case-control study.

Remnant Posterior Cruciate Ligament–Augmenting Stent Procedure for Injuries in the Acute or Subacute Stage

To evaluate the results of a remnant posterior cruciate ligament (PCL)-augmenting stent procedure for acute- or subacute-stage PCL injuries in terms of stability and clinical results. Between September 2003 and March 2006, 32 patients with a PCL tear underwent a reconstructive stent procedure with an autogenous hamstring tendon graft to augment the remains of the injured PCL. Of these patients, 20 who satisfied our inclusion criteria and could be followed up for a minimum duration of 24 months were enrolled in our study. The remnant PCL and synovium were preserved, and augmentation was performed by use of the transtibial technique. A femoral tunnel was created near the footprint of the anterolateral bundle. Stability was measured on posterior stress radiographs and by use of a maximum manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee (IKDC) and Orthopädische Arbeitsgruppe Knie scoring systems were used for clinical evaluation. Stress radiographs showed that the mean side-to-side differences in displacement were reduced from 9.9 +/- 4.0 mm preoperatively to 3.0 +/- 2.6 mm at the last follow-up, whereas KT-1000 tests showed that these differences were reduced from 6.9 +/- 2.1 mm preoperatively to 2.7 +/- 1.5 mm. The final IKDC score was A in 7 patients (35%), B in 10 (50%), C in 2 (10%), and D in 1 (5%). The mean Orthopädische Arbeitsgruppe Knie score improved from 61.6 +/- 13.1 to 88.2 +/- 9.5. Of the patients, 90% showed satisfactory posterior stability and 85% had a normal or nearly normal rating based on the IKDC score at a mean of 3 years after the remnant PCL-augmenting stent procedure in the acute or subacute stage of PCL injuries.

Comparison between Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction

Background Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published. Purpose The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation. Results All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more “normal knees” in the DB group than in the SB group (P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08). Conclusion In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed.

Long-term Results of Isolated Anterolateral Bundle Reconstructions of the Posterior Cruciate Ligament

Background Little is known about the parameters that influence the long-term results of isolated arthroscopically assisted reconstructions of the anterolateral bundle of the posterior cruciate ligament (PCL). Hypothesis Chondrosis, time interval from injury to surgery, and graft choice significantly influence the long-term results of single-bundle PCL reconstructions. Study Design Case series; Level of evidence, 4. Methods Between 1995 and 2001, 22 male and 3 female patients with a mean age of 30.8 years (range, 17-52) underwent an anterolateral bundle reconstruction of the PCL for functional instability and pain. Nine were treated with a bone–patellar tendon– bone autograft (BPTB), 15 with a semitendinosus gracilis (STG) autograft, and 1 with an Achilles tendon allograft. Twenty-two patients were clinically and radiographically reviewed at a mean follow-up of 9.1 years (range, 6.5-12.6). Three patients were interviewed by telephone. Thirteen patients had chondrosis at time of surgery. The mean time from injury to surgery was 1.5 years. Results The mean final International Knee Documentation Committee (IKDC), Lysholm, and functional visual analog scale (VAS) scores (65, 75, and 8, respectively) were fair to good and were significantly better than preoperatively (38, 50, and 4, respectively) (P <. 001). The final Tegner (5.7) score was significantly lower than the preinjury score (7.2) (P <. 001). The mean anteroposterior laxity measured by KT-1000 arthrometer and Telos stress radiographs was significantly increased on the operated side (mean side-to-side difference of 2.1 mm and 4.7 mm, respectively). The functional scores were not significantly different between the BPTB and STG reconstructions. Patients without chondrosis at time of surgery and patients operated within the first year from injury had significantly better functional results at final follow-up (P <. 05). Conclusion Arthroscopically assisted reconstructions of the anterolateral bundle of the PCL in patients with symptomatic isolated grade II to IV PCL-deficient knees lead to significantly improved functional results at long term if there is no cartilage damage at time of surgery. Nonoperative treatment should not be extended more than 1 year from injury. Graft choice did not significantly influence the functional outcome at long term.

Popliteofibular ligament reconstruction for posterolateral external rotation instability of the knee

The aim of this study was to assess the clinical outcome of popliteofibular ligament (PFL) reconstruction for posterolateral external rotation instability of the knee. PFL reconstruction was performed consecutively in 22 patients with chronic external rotation instability of the knee. The inclusion criterion for surgery was tibial external rotation of 10 degrees more than the contralateral uninjured knee without varus laxity. A double bone tunnel was created at the PFL insertion of the fibular head through the lateral incision of the knee joint and a single bone tunnel at the popliteus tendon insertion on the femoral side. A semitendinosus autograft tendon or tibialis anterior allograft tendon was introduced through the fibular tunnel as a loop, then both free ends of the graft were introduced through the femoral tunnel and a bioabsorbable interference screw was used to fix the graft. The minimum follow-up was 2 years. Clinical review included the International Knee Documentation Committee (IKDC) scale and tibial external rotation assessment. All patients' preoperational tibial external rotation averaged 15 degrees more than the contralateral uninjured knee. operatively the tibial external rotation was decreased, average -3 degrees compared with the contralateral side. This difference was statistically significant. The final IKDC grades were: 22 cases with grade D preoperatively, and 6 were grade A, 8 were grade B, 7 were grade C and 1 was grade D postoperatively. In this small clinical series, PFL reconstruction technique was shown to correct pathological excessive tibial external rotation.

Repeat Revision of Anterior Cruciate Ligament Reconstruction

Background To the authors’ knowledge, no previous published study has focused on management and outcome of repeat revision of anterior cruciate ligament reconstruction in terms of functional result and meniscus and articular cartilage status. Hypothesis Repeat revision of anterior cruciate ligament reconstruction improves knee stability, but with inferior results for functional outcome compared with primary anterior cruciate ligament reconstruction. Meniscal tears and subsequent articular cartilage degeneration are more prevalent with successive revisions due to recurrent laxity. Study Design Case series; Level of evidence, 4. Materials and Methods: Between February 2003 and November 2006, a consecutive series of 10 patients with an average age at 30 years (range, 17-48) were operated on for a repeat revision of anterior cruciate ligament reconstruction (2 revisions after a primary reconstruction) with arthroscopic procedures. A clinical and a radiographic evaluation were performed to assess anterior cruciate ligament reconstruction failures, outcome of revisions, and causes of failures. Meniscal tears and articular cartilage lesions were analyzed. Results The average follow-up of the second revision was 38 months (range, 12-61). At latest follow-up, final International Knee Documentation Committee assessment was excellent or good in 7 cases. Postoperatively, only 2 patients recovered to the same sports activity level they had before their first anterior cruciate ligament reconstruction. Four had a lower level, and 4 discontinued sports activity. The postoperative average side-to-side KT-1000 arthrometer maximum manual difference was 1.3 ± 1.9 mm. Nine patients had meniscal tears and 7 had articular cartilage lesions. Meniscal tears, meniscectomies, and articular cartilage degeneration increased after the second revision (P = .016, P = .0098, and P = .0197, respectively). Severe articular cartilage degeneration (International Cartilage Repair Society grade III and IV lesions) was found in patients with bad functional outcome (final International Knee Documentation Committee assessment C or D) (P = .0472). Incidence of articular cartilage degeneration was found to be more prevalent in cases of meniscal tears and partial meniscectomy at the same tibiofemoral compartment (P = .0157). Index anterior cruciate ligament reconstruction and first revision failures were caused by recurrent trauma (60% and 70%, respectively) or a surgical technical error with tunnel malpositioning (40% and 10%, respectively). Conclusion Outcome of repeat revision of anterior cruciate ligament reconstruction was excellent or good in 70% of the cases, although decreased after the second revision, in relation to the occurrence of meniscal tears and articular cartilage lesions. Meniscal and articular cartilage lesions were more frequent and more severe with recurrent laxity. The cause of failures was mainly recurrent trauma, followed by surgical technical errors.

Clinical Comparison of Anteromedial versus Anterolateral Tibial Tunnel Direction for Transtibial Posterior Cruciate Ligament Reconstruction

Background It has been suggested that transtibial posterior cruciate ligament reconstruction may be compromised by graft abrasion at the “killer turn,” where the graft emerges from the tibia. In 1998, one of the authors suggested that beginning the tibial tunnel anterolaterally rather than anteromedially would reduce the killer turn and possibly improve the results of posterior cruciate ligament reconstruction. Purpose This article is intended to present the clinical results of single-bundle transtibial posterior cruciate ligament reconstruction, comparing cases in which the tibial tunnel was begun anteromedially with cases in which the tunnel was begun anterolaterally. Study Design Cohort study; Level of evidence, 3. Methods The authors retrospectively studied 23 patients (group I) using the anteromedial tibial tunnel technique from April 1998 to August 2003 and 37 patients (group II) using the anterolateral tibial tunnel technique from February 1998 to August 2003. The average follow-up period was 58.6 months in group I and 56.9 months in group II. The minimum follow-up period was 24 months in each group. All revision cases and patients with general laxity were excluded. Results The mean side-to-side difference of posterior tibial translation by Telos stress radiography was 3.98 ± 1.27 mm (range, 1.80-7.80 mm) in group I and 2.87 ± 1.25 mm (range, 1.43-6.82 mm) in group II, which was a statistically significant difference (P < .01). The final mean Lysholm knee score was 88.6 ± 7.10 points (range, 77-98 points) in group I and 88.4 ± 6.44 points (range, 78-98 points) in group II, which was not a statistically significant difference (P = .4358). According to the final International Knee Documentation Committee (IKDC) evaluation in group I, 30.4% (7 of 23) were normal (A), 60.9% (14 of 23) were nearly normal (B), and 8.7% (2 of 23) were abnormal (C). In group II, 24.3% (9 of 37) were normal (A), 73.0% (27 of 37) were nearly normal (B), and 2.7% (1 of 37) were abnormal (C) (P = .467). With respect to the mean side-to-side difference of range of motion, there was no statistically significant difference (P = .1697). The mean was 4.7° ± 2.38° (range, 2°-10°) in group I and 4.0° ± 1.73° (range, 0°-8°) in group II. Conclusion The anterolateral tibial tunnel technique is preferred to the anteromedial technique in terms of the objective results; however, clinical results as judged by Lysholm and IKDC scores are not significantly correlated to these results.

Simultaneous Arthroscopic Reconstruction of the Anterior and Posterior Cruciate Ligament Using Hamstring and Quadriceps Tendon Autografts

Most dislocated knees involved tears in the two cruciate ligaments were often accompanied by other collateral ligament complexes. Surgical repair or reconstruction seems to achieve results superior to conservative treatment. Various methods of reconstructing anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) after knee dislocation have been described, but few reports discuss simultaneous ACL and PCL reconstructions in a single operation. Eleven consecutive patients (6 males and 5 females) with both ACL and PCL disruptions were enrolled in the prospective study and treated with arthroscopic combined reconstruction of ACL and PCL using hamstring and quadriceps tendon autografts in a single operation. The average period from injury to operation was 76 days (range, 30-150 days), and the mean age was 33 years (range, 19-48 years) for those who underwent the operation. Mean follow-up time was 55 months (range, 36-78 months). Follow-up examinations included Lysholm knee score, Tegner activity score, International Knee Documentation Committee (IKDC) score, thigh muscle assessment, and radiographic evaluation. Ten of 11 (91%) patients showed good or excellent results. Statistically significant improvements were observed in Lysholm score (p = 0.008), Tegner score (p = 0.038), postoperative KT-1000 scores (p = 0.001), final IKDC rating (p = 0.032), and thigh atrophy and muscle strength (p < 0.05). Regarding IKDC final rating, 82% (9 of 11) of the patients were assessed as normal or nearly normal (grade A or B). Simultaneous arthroscopically assisted reconstruction of both ACL and PCL using hamstring and quadriceps autografts can effectively and safely restore knee stability.

A pilot clinical evaluation comparing the Mitek bone–tendon–bone cross pin and bioabsorbable screw in anterior cruciate ligament reconstruction fixation, a randomized double blind controlled trial

Purpose To compare the clinical efficacy of ACL reconstruction using the Mitek bone–tendon–bone cross pin (RIGIDfix) to the Linvatec Bioscrew (control device). Methods Forty subjects were randomized into one of two groups: the RIGIDfix or control group. Eligible subjects were male and female, 18years of age and older, with an ACL injury of at least 3weeks duration and no evidence of ACL insufficiency on the contralateral side. Subjects were followed for 24-month post-operatively. Evaluations included the International Knee Documentation Committee (IKDC) Knee Ligament Standard Evaluation, Mohtadi's ACL Deficiency Quality of Life (ACL-QOL) questionnaire and the attainment of six rehabilitation milestones. Subjects and assessors were blinded to the surgical device used. Results Four subjects in the RIGIDfix group and four controls were lost to follow-up. The change in final IKDC scores did not differ significantly between groups with the majority demonstrating an improvement of one to two grades. The change in ACL-QOL scores did not differ significantly between the RIGIDfix subjects (40.0 + 4.4) and controls (46.0 + 3.6). Furthermore, the number of weeks that the RIGIDfix subjects versus controls attained full active extension, functional range of motion, normal gait, stair climbing, running gait and sprinting did not differ significantly. Conclusions The RIGIDfix results in a similar post-operative course to the control device and is efficacious for the reconstruction of the ACL. No adverse events were associated with the use of the RIGIDfix. The results of this study should be considered preliminary due to the small sample size.

Surgical Management of Traumatic Knee Dislocation

The purpose of this study was to evaluate our method of surgical treatment of traumatic knee dislocation, by use of a standardized protocol, and to report our clinical results. Thirty-six consecutive patients presented with a grossly dislocated or reduced knee. Ten of these patients were not included in this series. Five had vascular or neurovascular injury. Three had open fracture dislocation, and two had associated severe injury. The remaining 26 patients were treated by primary arthroscopic reconstruction with autologous grafting of the anterior cruciate ligament, posterior cruciate ligament, and collateral ligaments. The anterior cruciate ligament and posterior cruciate ligament were reconstructed via the gracilis and semitendinosus tendons of the uninjured and injured limbs. The collateral ligaments were reconstructed via artificial ligaments (LARS Ligament; J. K. Orthomedic, Dollard-des-Ormeaux, Quebec, Canada). Of the 26 patients, 20 returned for subjective and objective evaluation at a minimum of 24 months after the operation. Early mobilization via a continuous passive motion machine and active exercise were started on the fourth day postoperatively. At a mean follow-up of 43 months, the mean Lysholm score was 91 points, the mean score on the survey of daily activities was 90 points, and the sports activities score on the Knee Outcome Survey averaged 86 points. On the basis of the rating of Meyers et al., the results were excellent in 5 patients, good in 12, fair in 2, and poor in 1. The final International Knee Documentation Committee rating was not normal in any knee, nearly normal in 9, abnormal in 9, and severely abnormal in 2. The mean loss of extension was 0 degrees to 2 degrees , and the mean loss of flexion was 10 degrees to 15 degrees . By use of the described method of arthroscopic-assisted reconstruction of the cruciate ligaments and repair or reconstruction of the collateral ligament and other injured structures, 45% of the patients had good subjective results and functional stability and 45% had satisfactory subjective and functional stability within 2 to 3 weeks after surgery. According to the International Knee Documentation Committee 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.

Femoral Bioabsorbable Cross-Pin Fixation in Anterior Cruciate Ligament Reconstruction

The purpose of this study was to retrospectively evaluate clinical results after arthroscopic anterior cruciate ligament (ACL) reconstruction by use of hamstring autograft with femoral fixation via 2 bioabsorbable cross pins (Rigidfix system; DePuy Mitek, Raynham, MA). We evaluated the results of 117 knees (117 patients) that had been treated with arthroscopic ACL reconstruction by use of hamstring autograft with femoral fixation via 2 bioabsorbable cross pins from September 2001 to November 2002. The mean follow-up period was 26.9 months (range, 25 to 32 months). Patients were evaluated by the Lachman test, pivot-shift test, KT-2000 arthrometer (MEDmetric, San Diego, CA) test, Lysholm score, and International Knee Documentation Committee grade at the preoperative and follow-up examinations. Of the knees, 74 were assessed by second-look arthroscopy. The mean Lysholm score was 72.6 (range, 51 to 86) preoperatively and 93.7 (range, 71 to 99) postoperatively. On the basis of the final International Knee Documentation Committee grade, 75 knees were normal (A), 36 were nearly normal (B), 6 were abnormal (C), and none were severely abnormal (D). KT-2000 arthrometer analysis revealed that 112 knees (95.7%) were grade A or B, with a median laxity of 1.3 mm (range, 1 to 6 mm) at final follow-up. Of the 74 knees that were assessed by second-look arthroscopy, 52 had preserved good tension, 22 had some laxity, and none had graft failure or rupture. ACL reconstruction via 4-strand hamstring autograft with femoral fixation by use of 2 bioabsorbable cross pins eliminated anterior tibial translation in 93.1% of patients at a mean follow-up of 26.9 months. The bioabsorbable cross-pin femoral fixation method via hamstring tendon autograft can be effective, useful, and reproducible. Level IV, therapeutic case series.

The Lateral Intercondylar Ridge—A Key to Anatomic Anterior Cruciate Ligament Reconstruction

As our techniques for anterior cruciate ligament reconstruction have evolved, our focus has drifted from anatomy. We believe that it is important to hearken back to anatomy and to fully understand normal anatomy so that we can try to restore it with anterior cruciate ligament reconstruction surgery. The results associated with current anterior cruciate ligament reconstruction techniques are adequate but not exceptional. A recent meta-analysis of the outcomes of anterior cruciate ligament reconstruction indicated that only 33% of patients who had reconstruction with hamstring tendon graft and 41% of those who had reconstruction with bone-patellar tendon-bone graft had normal outcomes according to the final International Knee Documentation Committee score1. There is clearly room for improvement, and we think that the keys to improvement will be based on anatomical anterior cruciate ligament reconstruction. In their paper entitled “Morphology of the Femoral Intercondylar Notch,” Farrow et al. evaluate the anatomy of the lateral intercondylar notch in 200 cadaveric specimens. The authors' goal—namely, to perform a detailed study of the area where the anterior cruciate ligament attaches in order to provide more reliable guidance for femoral tunnel placement—is admirable. The authors note that the osseous ridge that Dr. Clancy termed the “resident's ridge” was present in 194 of …

The Lateral Intercondylar Ridge-A Key to Anatomic Anterior Cruciate Ligament Reconstruction

The Lateral Intercondylar Ridge-A Key to Anatomic Anterior Cruciate Ligament Reconstruction

Arthroscopic Reconstruction of the Posterior Cruciate Ligament by Using a Quadriceps Tendon Autograft: A Minimum 5-Year Follow-up

We prospectively assessed 22 consecutively treated patients to determine the effectiveness and safety of arthroscopically assisted posterior cruciate ligament (PCL) reconstruction by using a quadriceps tendon autograft. Twenty-two patients with isolated PCL injury who underwent PCL reconstruction with a quadriceps tendon autograft were enrolled in the prospective study. The average follow-up period was 66 months (range, 60-76). Follow-up included Lysholm knee scores, Tegner activity scores, International Knee Documentation Committee (IKDC) score, thigh muscle assessment, and radiographic assessment. The mean preoperative Lysholm score for 22 knees was 67 (range, 50 to 75), and the mean postoperative Lysholm score was 89 (range, 75 to 98). Nineteen of 22 patients (86%) displayed good or excellent results in the final assessment. The mean preoperative Tegner score for 22 knees was 3 (range, 2 to 5), whereas the mean postoperative Tegner score was 6 (range, 3 to 9). There were statistically significant improvements in Lysholm score (P = .009), Tegner score (P = .039), postoperative KT-1000 arthrometer (MEDmetric, San Diego, CA) scores (P = .006), final IKDC rating (P = .035), and thigh atrophy and muscle strength (P < .05) when compared with preoperative data. Regarding IKDC final rating, 82% of the patients (18 of 22) were assessed as normal or nearly normal (grade A or B). After follow-up for more than 60 months, the analytical results showed patients achieved satisfactory function after PCL reconstruction by using a quadriceps tendon-patellar bone autograft. This study suggests that a quadriceps tendon autograft is sufficiently large and strong and can achieve good ligament function after reconstruction. Level IV, therapeutic study.

Biodegradable and Metallic Interference Screws in Anterior Cruciate Ligament Reconstruction Surgery Using Hamstring Tendon Grafts

Background The use of biodegradable screws in anterior cruciate ligament reconstruction has grown in popularity. Purpose To compare the clinical and radiographic results in arthroscopically assisted anterior cruciate ligament reconstruction using 4-strand hamstring tendon grafts and either metallic (metal group) or biodegradable (PLLA group) interference screw fixation. Study Design Randomized controlled trial; Level of evidence, 1. Methods A randomized series of 77 patients, all with a unilateral anterior cruciate ligament rupture, was included in the study. The preoperative assessments in both groups were similar in gender, Tegner activity level, Lysholm score, KT-1000 arthrometer measurements, and single-legged hop test results. In both groups, interference screw fixation of the graft was used at both ends, and 68 of 77 (88%) patients returned for a radiographic examination at 6 and 24 months, respectively. Results At follow-up, no significant differences were found between the 2 groups in KT-1000 arthrometer laxity measurements, Tegner activity level, or Lysholm score. The PLLA group had a significantly better outcome in the single-legged hop test and the final International Knee Documentation Committee classification (P=. 007 and P=. 03,respectively). At 6 and 24 months after the index operation, the PLLA group displayed significantly larger drill holes on the radiographs than did the metal group on both the tibial (8.1 vs 6.6 mm at 6 months [P=.0007]; 6.0 vs 3.2 mm at 24 months [.0001]) and femoral sides (7.8 vs 5.6 mm at 6 months [P <.0001]; 6.3 vs 1.9 mm at 24 months [P <.0001]). Conclusion There were significantly larger radiographically visible drill holes on both the tibial and femoral sides in the PLLA group compared with the metal group at 6 and 24 months. Clinical examination at 2 years revealed no major differences between the groups. The larger drill holes in the PLLA group did not correlate with inferior clinical results.

Clinical Outcomes Following Isolated Lateral Meniscal Allograft Transplantation

The purpose of our study was to determine the clinical outcomes following isolated lateral meniscal allograft transplantation. Thirty-two patients were retrospectively reviewed following isolated lateral meniscal allograft transplantation. Twenty-five were available for subjective follow-up, and 17 were available for a complete physical examination and postoperative radiographs. The average duration of follow-up was 3.3 years (range, 2 to 6 years), and the average age of the subjects was 30 years (range, 19 to 45 years). In all, 17 patients had bony fixation and 8 had suture fixation of the anterior and posterior horns of the meniscal allograft. Ninety-six percent of patients believed that their overall function and activity level were improved following surgery. Short Form-36 (SF-36) physical and mental component summary scores for these subjects were higher than age- and sex-matched scores from the US population. Joint space narrowing of the transplanted lateral compartments was not significantly different when compared with the joint space narrowing of the lateral compartment of the contralateral knee. In addition, preoperative and postoperative radiographic joint space measurements of the involved lateral compartment were significantly associated with subjective assessment, symptoms, sports activity score, Lysholm score, and final International Knee Documentation Committee (IKDC) rating at latest follow-up. Finally, patients fixed with the bony technique had significantly better range of motion, according to IKDC criteria at latest follow-up, compared with the suture fixation group. Our results suggest that isolated meniscal allograft transplantation can be a beneficial procedure in properly selected symptomatic patients with a lateral meniscus-deficient knee. The data also suggest that earlier meniscal transplantation, before the onset of significant joint space narrowing, may result in improved outcomes. Finally, bony fixation may have a significant advantage over suture fixation, particularly with regard to knee range of motion. Level IV, therapeutic case series.

Arthroscopic Reconstruction of the Posterior Cruciate Ligament With Use of a Quadruple Hamstring Tendon Graft With 3- to 5-Year Follow-up

This study prospectively evaluated 20 patients treated consecutively to determine patient outcomes, efficacy, and complication potential of arthroscopically assisted posterior cruciate ligament (PCL) reconstruction performed with hamstring tendon grafts. Twenty patients (15 men and 5 women), each with an isolated PCL injury, underwent PCL reconstruction with hamstring tendon autograft and were enrolled in this prospective study. Average age at time of surgery was 29 years (range, 20 to 57 years). Average time from injury to surgery was 4 months (range, 3 to 12 months). Average follow-up period was 40 months (range, 36 to 50 months). Patients underwent regular follow-up after clinical and radiographic preoperative and postoperative evaluation. Follow-up examinations comprised the Lysholm Knee Score, the Tegner Activity Score, the International Knee Documentation Committee (IKDC) score, thigh muscle assessment, and radiographic evaluation. Mean preoperative Lysholm score for 20 knees was 63 +/- 10 (range, 48-73); mean postoperative Lysholm score was 93 +/- 9 (range, 77-100). Eighteen of 20 patients (90%) showed good or excellent results at final assessment. Mean preinjury and preoperative Tegner scores were 7 +/- 1.5 (range, 5-9) and 3 +/- 1.9 (range, 2-5), respectively; mean postoperative Tegner score for 20 knees was 6.3 +/- 2.4 (range, 4-9). In final IKDC ratings, 85% of patients (17 of 20) were assessed as normal or near normal (grade A or B). A statistically significant improvement was seen in thigh girth difference, extensor strength ratio, and flexor strength ratio before and after reconstruction at a minimum of 3 years of follow-up. After follow-up for longer than 36 months, 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. IV, therapeutic case series.