IKDC Subjective Knee Evaluation Research Articles

Comparison between Outcomes of Open and Arthroscopic Fixation of Tibial Spine Avulsion Fractures

OBJECTIVES This study aimed to compare the functional outcomes of fragment reduction and to measure the rate of postoperative complications between arthrotomy (ORIF) and arthroscopy(ARIF) pediatric tibial spine avulsion fractures using the Lysholm knee scoring system (limp, pain swelling, climbing stairs) and IKDC subjective knee evaluation form. METHODS: This Comparative Study was conducted at the Department of Orthopedic Surgery, Jinnah Hospital Lahore, between 2021-2022. A total of 42 patients who had tibial spine avulsion fracture with follow-up of 6 months were included. Twenty-one patients were treated with ORIF, and 21 were treated with ARIF. Functional outcomes were assessed using the IKDC score and LYSHOLM score (Follow-up rate was 95 %). Radiographic findings of patients were recorded, and a statistical study was done. The level of significance was set at <0.05. RESULTS: The study revealed that out of 42 Participants, 36(85.71%) males and 6 (14.29 %) females participated in the survey with the age range of 8-16 years with a mean age of 12.02± (2.53) years. Out of 42 Participants, 22 (52.4%) had motor vehicle accidents with type 3(38.1%) and 4(54.8%) modified Meyers and Mckeever fracture classification. At the end of the follow-up period, the mean IKDC score was 90.52 + 1.50 (p = 0.00, CI = 95%). The Lysholm score was 90.676.11 compared to the last follow-up (p=0.20, CI = 95%). Compared to ORIF, only 5(11.9%) patients complained of post-op infection or vascular injury. CONCLUSION: This study observed better functional outcomes in arthroscopic reduction and immobilization than in open reduction internal fixation. Arthroscopy for TSAF decreases the risk of arthrofibrosis and minimizes morbidities and better management of symptoms. Compared to OIRF, ARIF showed good content validity for the IKDC and Lysholm scales.

Poster 294: Patellar Tendon Insertion is Not Distalized following Tibial Tubercle Osteotomy with Distalization

Objectives: Patella alta is a common anatomic risk factor in patients with patellofemoral instability and/or patellofemoral cartilage lesions, occurring in nearly 25% of these patients. Distalization tibial tubercle osteotomy (TTO) is effective in patients with patella alta in association with patellofemoral instability and cartilage lesions. Prior studies have suggested that increased patellar tendon length itself is a risk factor for recurrent patellofemoral instability, and have proposed the addition of a patellar tendon tenodesis via placement of a suture anchor proximal to the distalization TTO. However, concerns regarding increased patellofemoral cartilage stresses with addition of patellar tendon tenodesis have limited its adoption. The purpose of this study was to evaluate patellar tendon length and alignment parameters on preoperative and postoperative MRI and to evaluate patient reported outcomes (PROs) following distalization tibial tubercle osteotomy (TTO) without patellar tendon tenodesis in patients with patella alta. Methods: We conducted a retrospective review of 20 adult patients who underwent distalization TTO for patellar alta at our institution (December 2014-August 2021). All patients underwent preoperative and postoperative magnetic resonance (MR) imaging of the affected knee. Distalization TTO utilized a wedge-shaped osteotomy measuring ˜5cm in length and was fixed with two 4.5mm bicortical fully threaded screws following TT transfer. Caton-Deschamps (CDI), axial and sagittal TT-TG indices1, patellar tendon length and distances from tibial plateau to patellar tendon insertion and tibial tubercle were assessed (Figure 1). PROs included IKDC Subjective Knee Evaluation, KOOS Quality of Life Form, Kujala Anterior Knee Pain From, and Veterans RAND 12 Item Mental (VR12-MH) and Physical Health (VR12-PH) Surveys. Clinical data, including demographics, complication and perioperative data, was obtained from preoperative and postoperative charts in our electronic medical record. Results: Average age at time of surgery was 27.4 years (range: 14 – 42 years) and all patients were female. Average BMI was 24.9 +/- 4.4 kg/m2. Eleven patients (55%) were diagnosed with isolated patellofemoral cartilage lesions, four patients (20%) were diagnosed with patellofemoral instability without associated cartilage lesions and five patients (25%) were diagnosed with both instability and cartilage lesions. At the time of TTO distalization, eleven patients (55%) underwent matrix-induced autologous chondrocyte implantation (MACI), nine patients (45%) underwent MPFL reconstruction, four patients (20%) underwent lateral release/lengthening, and three patients (15%) underwent osteochondral allograft (OCA) implantation. Fourteen patients (70%) underwent anteromedialization of the tibial tubercle in addition to distalization. Radiographic parameters demonstrated improved patellar height (CDI decreased from 1.36 to 1.11 (p < 0.001), improved rotational alignment (axial TT-TG decreased from 14.3mm to 11.1mm (p = 0.018)) and anteriorization of the TT (sagittal TT-TG increased from -4.3mm to -1.4mm (p = 0.037)) following distalization TTO. Distance from the tibial plateau to the PT insertion decreased from 20.1mm preoperatively to 17.9mm postoperatively (p< 0.020) and patellar tendon length decreased from 53.4mm preoperatively to 50.0mm postoperative (p < 0.001). Average distalization was 6.4mm. IKDC scores increased from 37.1 to 60.5 (p = 0.011), KOOS QOL scores increased from 19.5 to 42.1 (p < 0.001), Kujala scores increased from 50.9 to 70.6 (p = 0.018), VR12-MH scores increased from 52.7 to 59.2 (p = 0.024) and VR12-PH scores increased from 35.1 to 41.7 (p = 0.009). Of the patients with preoperative patellofemoral instability, there were no cases of recurrent instability postoperatively. Ten patients (50%) underwent elective removal of hardware of TTO screws at an average of 10.7 months. There were four (20%) complications in this cohort, with two cases (10%) of postoperative arthrofibrosis requiring manipulation under anesthesia, one case (5%) of postoperative MRSA infection of the MPFL graft and one case (5%) of tibial tubercle delayed union requiring bone grafting and revision fixation. Conclusions: Distalization TTO without patellar tendon tenodesis is an effective surgical technique for improving patellar height in patients with patella alta and patellofemoral instability and/or patellofemoral cartilage lesions, with improvements in radiographic parameters and PROs postoperatively. There were no cases of recurrent instability in this cohort. The patellar tendon insertion does not appear to be significantly distalized following distalization TTO, likely related to scarring of the patellar tendon just proximal to the osteotomy site postoperatively. Given the complexity of risk factors associated with patellofemoral instability and patellofemoral cartilage lesions, distalization TTO provides an additional tool for patient-specific surgical management, without the need for patellar tendon tenodesis.

Poster 210: Effects of a Comprehensive Behavioral Health Program on Functional Outcomes after Osteochondral Allograft Transplantation in the Knee

Objectives:To use prospectively collected registry data to evaluate an evidence-based shift in practice for implementation of a comprehensive behavioral health program, including preoperative screening and education in conjunction with postoperative counseling for their effects on patient-reported mental health scores and functional outcomes after osteochondral allograft (OCA) transplantation in the knee. We hypothesized that patient-reported preoperative mental health issues would be associated with inferior outcomes and that the comprehensive behavioral health program led by a health behavior psychologist would be associated with superior outcomes for these patients.Methods:With IRB approval and informed consent, patients undergoing transplantation in the knee were enrolled in a lifelong registry designed to collect comprehensive outcomes data. Patients that had large (>4cm2) shell-graft OCA transplants and complete one-year data for patient-reported IKDC subjective knee evaluation, VAS Pain, SANE, PROMIS Physical Function, and PROMIS Mental Health measures for pre-operative and 1-year time points were included in analyses. One-year improvement (D) scores for each variable were calculated as the difference between each score compared to the respective pre-operative score. Patients who required OCA revision surgery or total knee arthroplasty within the study period were defined as graft failures. Patients treated after the shift in practice were assigned to the Psych cohort. Patients who self-reported a history of mental health issues (Anxiety, Depression, Bipolar, ADHD, Schizophrenia) were assigned to the Mental Health Issue (MHI) cohort. Patients whose mental health history could not be obtained were not included in the respective analyses. Two-tailed t-Tests were used to analyze the survey scores between cohorts. Chi-square tests were used to compare proportions of successful versus failed outcomes between cohorts. A p value < 0.05 was used to indicate statistical significance for all tests.Results:A total of 269 patients met criteria for inclusion in the Psych analysis and 189 patients met criteria for inclusion in the MHI analysis. One-year SANE raw scores (p=0.03), one-year Physical Function D scores (p<0.0001), one-year IKDC D scores (p<0.0001), and one-year Pain D scores (p=0.01) were significantly better for patients in the comprehensive behavioral health program cohort. One-year PROMIS Mental Health D scores (p<0.0001), one-year Physical Function raw scores (p=0.03), and one-year Physical Function D scores (p<0.0001) were significantly better for patients who did not have a history of mental health issues, while one-year SANE D scores (p<0.0001) were significantly better in the MHI cohort. A significantly higher proportion of patients in the comprehensive behavioral health program cohort had successful 1-year outcomes (87.5 versus 64%, p=0.037). No statistically significant difference in proportions of successful versus failed grafts was noted between patient cohorts with self-reported preoperative mental health issues compared to those without self-reported preoperative mental health issues (p=0.23).Conclusions:The results of this study highlight the potential impacts of mental and behavioral health on outcomes after osteochondral allograft transplantation surgeries in the knee. Improvements in pain, knee function, and overall physical function were significantly better in patients enrolled in a comprehensive behavioral health program prior to surgery, while patients with self-reported preoperative mental health issues including anxiety, depression, bipolar disorder, ADHD, or schizophrenia had significantly worse outcomes with respect to mental health, physical function, and knee function. In addition, graft failure rate as defined by the need for OCA revision or TKA was significantly lower (12.5%) for patients undergoing comprehensive preoperative behavioral health screening and education. Taken together, these data suggest that mental and behavioral health can have significant influences on clinical outcomes after OCA transplantation in the knee and that preoperative assessment and education in conjunction with postoperative counseling and support may result in more successful outcomes for patients. However, based on the multifactorial nature of outcomes in these complex cases, longer term outcome studies in a larger population of patients are required before conclusions regarding the direct impact of this shift in practice can be made.

Poster 227: Correlations among Patient Reported Mental Health Scores and Functional Outcomes after Osteochondral Allograft Transplantation in the Knee

Objectives:To use prospectively collected registry data to examine the relationships among self-reported mental health scores and functional outcomes after osteochondral allograft (OCA) transplantation in the knee. The study hypothesis was that Patient-reported Outcomes Measurement Information System (PROMIS) Mental Health scores would strongly correlate with patient-reported pain and function scores, as well as with failure of functional graft survival after OCA transplantation in the knee.Methods:With IRB approval and informed consent, patients undergoing OCA transplantation in the knee were enrolled in a lifelong comprehensive outcomes registry. Patients with large (>4cm2) shell-graft OCA transplants and complete 2-year outcomes data for patient-reported IKDC subjective knee evaluation, VAS Pain, SANE, PROMIS Physical Function, and PROMIS Mental Health measures for pre-operative, 1-year, and 2-year postoperative time points were analyzed. Patients who required OCA revision surgery or total knee arthroplasty within the study period were defined as graft failures. Pearson’s correlations analyses were used to examine strength of relationships among patient reported outcomes scores at each time point and for change in scores between time points. General logistic regression models were used to analyze associations between PROMIS Mental Health scores and graft failure. Statistical significance was defined a priori as p<0.05.Results:A total of 299 patients met criteria for inclusion. Across time points, PROMIS Mental Health scores were found to be moderately correlated with IKDC (r2 = 0.42) and PROMIS Physical Function scores (r2 = 0.43), and weakly correlated with Pain (r2 = 0.27) and SANE scores (r2 = 0.34). One-year PROMIS Mental Health improvement scores were found to be weakly correlated with one-year IKDC (r2 = 0.2), SANE (r2 = 0.27), and PROMIS Physical Function improvement scores (r2 = 0.3). Two-year PROMIS Mental Health scores were found to be moderately correlated with two-year SANE improvement scores (r2 = 0.42). Preoperative PROMIS Mental Health was significantly (p=0.006) associated with graft failure, while PROMIS Mental Health improvement scores were not (p>0.48).Conclusions:Self-reported mental health was more strongly correlated with measures of function than measures of pain for patients undergoing OCA transplantation in the knee. Importantly, the data also indicated a significant association for self-reported mental health at baseline with graft failure during the first two years after OCA transplantation, while changes in mental health score were not significantly associated with graft failure. Taken together, the results of this study suggest that assessment of patients’ mental health prior to osteochondral allograft transplantation knee surgery can provide valuable information to patients and healthcare providers with respect to their clinical outcomes.

Long-Term Minimum 15-Year Follow Up After Lateral Discoid Meniscal Preservation Surgery in Children and Adolescents

Background:Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated.Purpose:The aim of this study was to examine long-term patient-reported outcomes of lateral discoid menisci (LDM) treated with meniscal-preserving techniques.Methods:Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated IKDC Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and WOMAC Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and standard deviation (SD), median and interquartile range (IQR), or frequency and percent, as appropriate.Results:Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (± SD) age at initial surgery was 10.8 (± 3.4) years and 30.3 (± 3.7) years at final follow-up. The mean (± SD) follow-up time from initial surgery was 19.5 (± 2.8) years (range, 16–27). Patient-reported outcomes included: IKDC 77.4 ± 17.2, Lysholm 78.6 ± 21, WOMAC 7.6 ± 11.3, Tegner Activity 7 (out of 10), and Marx Activity Rating Scale 8 (out of 10) (Table 1). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement (Table 2).Conclusions:Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of lateral discoid meniscus. While two-thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with radiographs will be important to determine how meniscus-preserving procedures may curb the development of arthritis.Table 1.Overall Postoperative Outcomes (N=25 patients)a Table 2.Postoperative Outcomes by Discoid Type and Surgery (N=26)a

Augmentation of Primary ACL Reconstruction With a Modified Ellison Lateral Extra-articular Tenodesis in High-Risk Patients: A Pilot Study.

Background:Lateral extra-articular tenodesis (LET) has been used to augment primary anterior cruciate ligament (ACL) reconstruction to reduce the risk of reinjury. Most LET procedures result in a construct that is fixed to both the femur and the tibia. In a modified Ellison procedure, the construct is only fixed distally, reducing the risk of inadvertently overconstraining the lateral compartment.Purpose:To evaluate the use of the modified Ellison procedure in a cohort of patients deemed to be at a high risk of further ACL injury after primary ACL reconstruction.Study Design:Case series; Level of evidence, 4.Methods:Included were 25 consecutive patients with at least 2 of the following risk factors: age <20 years at the time of surgery, previous contralateral ACL reconstruction, positive family history of ACL rupture (parent or sibling), generalized ligamentous laxity (Beighton ≥4), grade 3 pivot shift in the consulting room, a desire to return to a pivoting sport, and an elite or professional status. All patients underwent primary ACL reconstruction with an additional modified Ellison procedure. Postoperatively, patients completed the IKDC subjective knee evaluation form (International Knee Documentation Committee), KOOS Quality of Life subscale (Knee injury and Osteoarthritis Outcome Score), ACL–Return to Sport After Injury Scale, Marx Activity Rating Scale, and SANE score (Single Assessment Numeric Evaluation).Results:At 12-month follow-up, the mean outcome scores were as follows: SANE, 94/100; IKDC, 92/100; Marx, 13/16; ACL–Return to Sport, 85/100; and KOOS, 77/100. At 24 months, return-to-sport data were available for 23 of 25 patients; 17 (74%) were playing at the same level or higher than preinjury and 2 at a lower level. One patient (4%) sustained a contact mechanism graft rupture at 12 months. There were 2 (9%) contralateral ACL injuries, including 1 ACL graft rupture, at 11 and 22 months postoperatively. There was a further contralateral ACL graft rupture at 26 months.Conclusion:The use of the modified Ellison procedure as a LET augmentation of a primary ACL reconstruction to produce a low graft rupture rate appeared to be safe in a cohort considered to be at a high risk of reinjury. The procedure showed promise in terms of reducing further graft injuries.

Клиническая эффективность анатомической пластики передней крестообразной связки коленного сустава

Purpose Evaluate clinical effectiveness of anatomical reconstruction of the anterior cruciate ligament (ACL) and determine the perspectives for practical health care. Material and methods The review included 706 patients who underwent arthroscopic reconstruction of the ACL and graft interference screw fixation between 2010 and 2018. ACL reconstruction was performed using either anteromedial portal (n = 396, Group I) or an isometric transtibial tunnel technique (n = 310, Group II). Outcomes were evaluated clinically and radiographically using the 2000 International Knee Documentation Committee (2000 IKDC) Subjective Knee Evaluation Form, the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Lysholm scoring scale. Clinical and economic outcome measures included surgical time, rehabilitation and disability periods and period of recovery for sports performance. Results The knee anterior drawer test was equally negative and showed no significant differences in the groups. The Lachman test and the pivot shift test showed better results in Group I (p &lt; 0.001). Contractures, atrophic femoral muscles (p &lt; 0.05), synovitis (p &lt; 0.01), vertical position of the femoral graft channels and pathologically extended bone channels with wind-wiper effect (p &lt; 0.001) were more common among patients of Group II. Although knee function returned to normal, as rated with the 2000 IKDC Subjective Knee Evaluation Form, in 91.3 % of cases pathological changes in the knee (C) and severely impaired function (D) were 2.5 and 5 times less common in group I than in Group II (p &lt; 0.05). Pain, symptoms and sport scores were significantly higher on the KOSS scale for Group I (p &lt; 0.05). Surgical time was longer in patients of Group I (p &lt; 0.05) who had shorter rehabilitation period (p &lt; 0.05). Conclusion Anatomical reconstruction of ACL using anteromedial portal was shown to be a more reliable technique as compared to transtibial approach to ensure overall knee stability arranging adequate bone channels. The technique is capable to protect the graft from injury, reduce the likelihood of pain, synovitis, contractures, muscle atrophy, providing shorter rehabilitation, disability period and recovery for sport performance.

Clinical and radiological outcome after anterior cruciate ligament reconstruction using the T-lock Osteotrans resorbable tendon anchor: early experience and midterm follow-up

PurposeReconstruction of the Anterior cruciate ligament (ACL) using tendon grafting is an established method for restoring knee function and stability. Multiple methods are established for graft fixation. Several involve anchoring the autograft distant to the joint with hardware that remains implanted. This study reports the first early to midterm results in patients who received ACL reconstruction (ACLR) using the T-Lock Osteotrans femoral near joint fixation method with a tibial fixation using the BioactIF Osteotrans interference screw.MethodsThis consecutive prospective series included 20 Patients (14 Male, 6 Female) with a primary ACL rupture. All patients were treated with an ACLR using a semitendinosus autograft fixated with the T-Lock Osteotrans and were followed-up postoperatively. The following parameters were assessed: Side-to-side difference of the posterior-anterior translation measured using the KT-1000 arthrometer, Tegner activity score, Lysholm score, IKDC subjective knee evaluation form. Magnetic resonance imaging (MRI) was done to assess tunnel enlargement and integrity of the anchoring device.ResultsThe average follow-up duration was 2 years (range 1–4.2 years). One patient was lost to follow-up. Two Patients suffered a traumatic ACL re-rupture 2 years postoperatively and received a 2-stage revision ACLR. Difference in the posterior-anterior translation was 1.8 mm (range 0–5). The median Tegner score was 6 (range 4–10) and 9 patients (45%) returned to their preinjury level of activity. The mean IKDC subjective knee evaluation form scored 91 points (range 77–100). The mean Lysholm score was 86 points (74–96). All mentioned scores were significantly better compared to preoperative values. No relevant tunnel enlargement was seen on MRI. The anchoring device was evaluated to be intact in all patients.ConclusionACLR with the aforementioned procedure leads to good clinical and radiological outcome.

Early clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after anterior cruciate ligament reconstruction.

To determine clinical and neuromuscular properties in patients with normal or sub-normal subjective knee function after finalisation of 6months' post-operative rehabilitation following anterior cruciate ligament reconstruction (ACLR). Sixty patients after primary anatomical single-bundle hamstring ACLR were prospectively enrolled. Demographics, subjective, clinical and functional status of the injured knee were recorded at baseline, 6 and 12months post-operatively. Return to pre-injury activities time (months) was monitored. Tensiomyography and isokinetic dynamometry of thigh muscles were performed at 6months, when standard ACLR rehabilitation is finalized. Based on their IKDC Subjective Knee Evaluation scores at 6months, they were assigned into "Normal" or "Sub-normal" group. All the above measured parameters were then compared between the two groups. At 6months' timeline, 21 patients (35%) perceived their knee function as "Normal", while 39 (65%) were "Sub-normal". There were no differences in clinical status between both groups, but patients in Normal group achieved higher IKDC, Lysholm, Tegner scores as well as higher single-leg hop test. They were taller, had lower body mass index and more of them achieved their preinjury level of activity at 12months (67% vs. 33%). Tensiomyography revealed higher biceps femoris as well as semitendinosus and semimembranosus radial displacement values on the operated leg in Normal group. Isokinetic dynamometry showed significantly higher normalised peak torque and average power of knee extensor muscles. Patients who perceive their knee function as normal at 6months following ACLR presented with better neuromuscular properties of the thigh muscles. Decreased hamstring stiffness seems to be the key to higher return-to-preinjury activity. Postoperative rehabilitation should be more focused on reducing hamstring stiffness in addition to improving knee extensor muscle strength. Level of evidence II (prospective cohort study).

Is Cyclic Exercise Performed before Tibial Fixation Effective on Grafts during Anterior Cruciate Ligament Reconstruction?

Objectives:The necessity of cyclic exercise to pre-stretch the autograft before tibial fixation during ACL reconstruction is unknown. In this study, we evaluated whether there was a statistically significant difference between the results of patients who underwent cyclic exercise by way of physical examinations, knee joint stability tests, and functional evaluation tests, compared with the patients who underwent ACL reconstructions with or without cyclic exercise.Methods:Between March 2016 and May 2018, 59 patients with at least eight months’ follow-up of an ACL reconstruction were identified. Thirty patients (Group 1) who underwent cyclic exercise before tibial fixation and 29 patients (Group 2) who did not undergo cyclic exercise were evaluated and compared.Results:The mean age of the patients in Group 1 and Group 2 was 25.9 (range, 18-36) years and 25.2 (range, 18-35) years, respectively. The mean follow-up period in Group 1 was 14.6 (range, 8-22) months and 13.5 months in Group 2 (range, 8-21 months).The mean Lysholm scores of Group 1 and 2 were 95.1 (range, 83-100) and 87.1 (range, 78-100), respectively. The modified Cincinnati scores of Groups 1 and 2 were 28.7 (range, 24-30) and 26.2 (range, 21-30). The mean IKDC subjective knee evaluation scores in Groups 1 and 2 were 91.9 (range, 83-100) and 86.7 (range, 75-100). The mean thigh atrophy was 1.5 cm in Group 1 and 2.5 cm in Group 2. In Group 1, 23 patients jumped 85% of the distance compared with the intact side in the single-legged hop test, and 12 patients in Group 2 were able to hop this distance successfully.Group 1 had statistically significantly better results in Lysholm activity scores, modified Cincinnati scores, IKDC subjective knee assessment scores, two-time IKDC activity scale results, comparison of thigh diameters, and single-legged hop tests (p<0.05). No significant difference was found in other examinations and tests.Conclusion:Cyclic exercise during the operation had a positive effect on functional scores. We believe that cyclic exercise should be added to the operative procedure.

Outcome analysis following arthroscopic augmentation with autologous hamstring graft in partial tear of the anterior cruciate ligament with preservation of an intact bundle: A case series

Background: The anatomic approach to anterior cruciate ligament (ACL) reconstruction has shifted management focus of the commonly encountered partial tear from resection and complete reconstruction to augmentation (i.e. selective bundle reconstruction with preservation of intact remnant bundle). The purpose of this study was to prospectively evaluate functional outcome after augmentation of partial ACL tears. Methods: Thirty-four patients with a partial ACL tear in whom a conservative trial failed were treated with either anteromedial or posteromedial single-bundle reconstruction, using an isolated semitendinosus graft and conserving the remnant bundle. Outcomes were evaluated clinically using the 2000 International Knee Documentation Committee [IKDC] knee examination forms, and manual laxity tests. Subjective evaluation was done using the 2000 IKDC subjective knee evaluation, Lysholm knee score, and 2000 IKDC functional score. Patient activity level was determined using the Tegner activity score. IKDC knee grades were assigned based on final evaluation on the 2000 IKDC knee examination forms. Results: At final follow-up 2000 IKDC knee examination grades significantly improved, with 21 in group B (61.8%) and 12 in group A (35.3%), while preoperatively most were classified as group C (76.5%). Similarly, IKDC subjective and Lysholm scores were significantly better after follow-up. The difference between mean Tegner activity level preinjury (6.029±0.9040) and at follow-up (5.67±1.006) was not significant. Conclusions: Selective bundle reconstruction with preservation of remnants restores knee stability and function. The results are encouraging, with excellent improvement in functional scores. Level of Evidence: Level IV.

Does anterolateral ligament rupture affect functional outcomes in patients who underwent an anterior cruciate ligament reconstruction?

BackgroundStudies have shown that the anterolateral ligament contributes to knee stability. This study aims to compare the results of postoperative physical examinations, knee joint stability tests, and functional assessment tests of patients with intact anterolateral (AL) ligaments and patients with ruptured anterolateral (AL) ligaments. Material and methodThis study consisted of 101 patients, with at least a 12-month follow-up period, who underwent an anterior cruciate ligament reconstruction between 2010 and 2016, and whose AL ligaments were evaluated by the radiologist with the preoperative and postoperative magnetic resonance images (MRI). Of these patients, 41 had intact AL ligament (Group 1) in MRI and other 60 had ruptured AL ligament (Group 2). Groups were compared according to postoperative physical examinations, knee joint stability tests, and functional assessment tests. ResultsThe average Lysholm score of Group 1 was 94.9 (range: 81–100), and the score of Group 2 was 87.2 (range: 74–100). The modified Cincinnati score of Group 1 was 28.7 (24–30), while the score of Group 2 was 25.6 (21–30). The average IKDC subjective knee evaluation score of Group 1 was 91.9 (range: 83–100), and the score of Group 2 was 86.6 (range: 75–100). The average thigh atrophy value was 1.5 centimeters (cm) in Group 1 and 2.4 cm in Group 2. Thirty-three patients in Group 1 were able to jump over 85% of the distance in single-legged hop test compared to the intact side, while 16 patients in Group 2 were able to jump over this distance successfully.As a result of the analysis, it was determined that the Lysholm activity scoring results, the Modified Cincinnati scoring results, IKDC subjective knee evaluation results, two-cycle IKDC activity scale results, comparison of thigh diameters and the single-legged hop tests of two groups showed a statistically significant difference, and the results of the patients with intact AL ligaments who underwent an ACL reconstruction were found to be better (p < 0.05). No significant difference was found in other examinations and tests. ConclusionSince the rupture of the AL ligament has negative effects on functional outcomes, we think that the reconstruction of the AL ligament in the same session with the ACL reconstruction or later will have a positive effect on functional outcomes.

Long term results after transepiphysal ACL reconstruction in children and adolescent

Aims and Objectives: The aim of our study was to review the long term clinical and radiological (MRI) outcomes of adult patients who underwent ACL reconstruction as children or adolescent with emphasize to the features of growth disturbance, angular deformity, meniscal and cartilage damage and revision rate Materials and Methods: We retrospectively evaluated patient who underwent ACL reconstruction in our clinic with arthroscopic transepiphyseal technique using hamstrings graft in childhood or adolescence between the years 1997 and 2009. A total of 43 Patients were assessed. 25 male and 18 female. The average age at time of surgery was 13,5 years (8 - 16 y.), at time of assessement 22,4 years (18 - 30 y.) . The mean follow up was 10 years (4 - 16 years).The physical development of the patients was assessed with the Lysholm score and the Cincinnati Knee score scale, their satisfaction was recorded on the basis of the IKDC subjective knee evaluation form and the Tegner activity score . Leg deformity or leg length discrepancy was evaluated clinically by the observers. The instrumented Lachman test using KT1000 and manual Pivot shift test was performed to assess knee stability. MRI was used to detect graft integrity, cartilage and meniscal damages. Results: No significant leg deformities or leg length discrepancy had been detected. The average Lysholm score was 91 points (83 - 100), the Cincinnati Knee Score was 90,4 (79 - 100) points on average . The mean IKDC score was 92 points (82 -100). The Tegner-Activity-Score changed from preop 6,8 (2-10) to post op 5,8 (2-9).2 Patient underwent revision ACL reconstruction due to rerupture (3 and 9 years post op). 2 Patients underwent meniscal surgery during follow up (1 resection and one refixation). KT1000 evaluation showed 67% excellent, 21% good and in 12% bad results. The MRI scan showed 42 intact grafts and one unverifiable graft. One patient with cartilage damage up to 3° (ICRS), 3 patients with meniscal degeneration up to grade 2. Each patient showed a free range of motion Conclusion: Our data underlines that transepiphyseal ACL reconstruction in children and adolescent with hamstrings is a save procedure leading to good long term results without causing angular deformity or growth disturbance

Arthroscopic Repair of the Medial Meniscus Radial/Oblique Tear Prevents the Progression of Meniscal Extrusion in Mildly Osteoarthritic Knees.

Extrusion of the medial meniscus (MM) is associated with knee joint pain in osteoarthritic knees. The relationships among MM radial/oblique tears, MM extrusion (MME), and the effect of arthroscopic meniscal repair are not established. Here we evaluated the effects of arthroscopic all-inside MM repair on MME and the clinical outcomes in patients with radially oriented MM tears and mildly osteoarthritic knees. Twenty patients with a symptomatic radial or oblique tear of the MM posterior segment, MME ≥2.5 mm, and mildly osteoarthritic knees were treated using FasT-Fix 360 All-inside Meniscal Suture devices. We used magnetic resonance imaging (MRI) to measure the patients' MM body width (MMBW), absolute MME, and relative MME. The Japanese Knee Injury and Osteoarthritis Outcome Score, Lysholm, Tegner, IKDC Subjective Knee Evaluation, and Visual Analogue Scale scores were obtained. Arthroscopic all-inside MM repair prevented increases of absolute and relative MME. The preoperative and 3- and 12-month MRI-based MMBW values were similar. Over a 24-month follow-up after the MM repairs, the clinical scores showed significant improvements. Our results suggest that all-inside meniscal repairs would be useful in preventing the progression of MME in patients suffering from symptomatic MM radial/oblique tears associated with mildly osteoarthritic knees.

Good clinical results with autologous matrix-induced chondrogenesis (Amic) technique in large knee chondral defects.

Autologous matrix-induced chondrogenesis (AMIC) is a treatment for focal full-thickness cartilage defects combining microfracturing with an exogenous I/III collagen matrix (Chondro-Gide). The aim of the present study was to determine the 7years outcomes of patients treated with the AMIC technique for knee chondral defects larger than 2cm2. The hypothesis was that the positive short-term outcomes achieved in the previous series would not deteriorate at a 7-year follow-up. Twenty-one patients treated with the AMIC technique were retrospectively analysed. Patients were assessed through the IKDC subjective knee evaluation questionnaire and the Lysholm scoring system. All patients underwent a complete imaging study including radiographs and magnetic resonance. The median defect size was found to be 4.3 (range 2.9-8) cm2. At a median follow-up of 7 (±1.4) years, the mean IKDC score improved from 31.7 (±8.9) points preoperatively, to 80.6 (±5.3) at the latest follow-up (p<0.05). The mean Lysholm score improved from 38.8 (±12.4) points preoperatively to 72.6 (±19.5) points at the last follow-up (p<0.05). At the last follow-up, 76.2% of patients were satisfied or extremely satisfied with their outcomes, while 66.6% of patients showed good quality repair tissue on magnetic resonance imaging. AMIC was found to be an effective method to treat full-thickness knee chondral defects larger than 2cm2, with significant clinical and functional improvement maintained over a 7-year follow-up. IV.

Return to sport activity after anterior cruciate ligament reconstruction in skeletally immature athletes with manual drilling original all inside reconstruction at 8 years follow-up

ObjectiveAnterior cruciate ligament (ACL) tears are common injuries in adolescent athletes, especially in those who bear high stress on their knees due to shearing forces. The goal of the surgical procedures in skeletally immature patients is to restore joint stability avoiding the adverse effects on the growth process.The aim of this study was to verify the return of the skeletally immature professional athletes to sports in the long-term, following ACL reconstruction with the original all-inside technique and with manual drilling. MethodsThis study included 24 athletes (14 boys, 10 girls; mean age: 13.15 years, range: 9–14 years) who had radiographic evidence of open physes, were less than 14 years of age at the time of surgery and those with a minimum follow-up of eight years. All patients completed a questionnaire, the IKDC subjective knee evaluation form, and Tegner Activity Scale. Biomechanical outcomes of the KT-1000 arthrometer, gait analysis, and stabilometric and isokinetic results were also evaluated. A plain radiograph of both lower limbs was taken to obtain a precise measurement of the limb length and mechanical axis angles. ResultsThe patients returned to sport activities in a mean time of 6.43 months. No rerupture or resurgery due to growth abnormalities was observed. The mean difference in length between the operated and contralateral legs was 0.4 (range: −0.2 to 0.7) cm. The mean side-to-side difference measured with the KT-1000 arthrometer was 5.2 (range: 3.5 to 7) mm in the preoperative and 0.8 (range: 0 to 2.5) mm in the postoperative measurements. ConclusionIn conclusion, the original all-inside technique with manual drilling with a half tunnel and short graft seems to be a very effective technique for the surgical management of ACL injuries in pediatric/adolescent athletes. A good rate of return to sports at pre-injury levels or higher, high patient satisfaction and a decent motor and proprioceptive function is possible as shown by our analysis. Level of evidenceLevel IV, Therapeutic study.

Autologous osteochondral mosaicplasty in osteochondritis dissecans of the patella in adolescents.

Osteochondritis dissecans of the patella (OCDP) is rare in adolescents. The objective of this study was to evaluate functional results of OCDP management in adolescents with mosaicplasty and to analyze proper integration of osteochondral grafts via MRI. This is a retrospective series of eight cases of OCDP treated by mosaicplasty. Mean age at the surgery was 15years (range 12-17). Clinical features were represented by retropatellar pain, hydarthrosis, locking and crepitus. All patients benefited from knee radiographs as well as pre-operative MRI. Six OCDP were evaluated International Cartilage Repair Society (ICRS) grade III and two were ICRS grade IV. Mean surface of the lesion was 97.5mm2. The pre- and post-operative assessments were conducted with scores obtained on the IKDC subjective knee evaluation form, Lysholm knee score, and Tegner activity scale. These assessments were completed by post-operative MRI. The magnetic resonance observation of cartilage repair tissue (MOCART) score was calculated from the latest MRI examination conducted after surgery. Mean follow-up was 28.6months. At the latest follow-up, the mean IKDC score was 86.5, Lysholm score was 89, and Tegner activity scale score was 6.2 (pre-operative scores were respectively 49.9, 53.8, and 4.5). Radiographs and MRI showed a complete integration of grafts at the latest follow-up with a satisfactory reconstruction of the joint surface. Mean MOCART score was 75/100. Autologous osteochondral mosaicplasty to manage OCDP in adolescents appears to be a reliable technique on the short term to restore patellar joint surface and obtain satisfactory functional results.

Long-Term Follow-Up of Arthroscopic Treatment of Discoid Lateral Meniscus in Children

Objectives:The discoid meniscus, occurring almost exclusively on the lateral side, can lead to pain, popping, snapping, and decreased knee extension. The purpose of this study was to examine the long-term clinical outcomes of arthroscopic partial meniscectomy for the treatment of discoid lateral meniscus in children.Methods:A previous study at our institution identified 27 consecutive patients who underwent arthroscopic meniscal saucerization by one of two surgeons between 1997 and 2002. These patients were included in this study if they were willing and able to complete the five outcomes questionnaires (IKDC Subjective Knee Evaluation, Kujala Scoring Questionnaire, Lysholm Knee Scoring Scale, Marx Activity Rating Scale and Tegner Activity Scale). Seven additional patients that were treated consecutively at least 10 years ago were also included in the study. Patients were also given the opportunity to receive a knee exam performed by one of the two treating surgeons. The exam was documented as per the IKDC knee examination protocol. Associations between outcome scores and discoid type, meniscal stability, location of instability, and age at time of surgery were identified.Results:Of the 34 eligible patients (23 female, 11 male), 22 patients were contacted, and 21 agreed to participate. The average length of follow-up was 13.7 years, ranging from 10.3 years to 16.6 years. Average age at the time of surgery was 9.3 years. Long-term follow-up revealed average IKDC, Kujala, and Lysholm scores of 82.87, 86.63 and 83.73, respectively. Additionally, average Marx and Tegner scores were 5.36 and 5.63, respectively. Stratifying the Lysholm scores revealed outcomes that were 45.4% excellent, 18.2% good, 27.3% fair, and 9.1% poor. The average IKDC Knee Examination score was A (normal). In total, 20.6% (7 of 34) of eligible patients underwent a subsequent surgical procedure on the affected knee.Conclusion:Numerous studies have demonstrated good to excellent short-term outcomes after arthroscopic treatment of discoid meniscus. At an average follow-up of nearly 14 years, our data suggests that clinical outcome scores decline over time. Compared to our previous study with 2-year follow-up, there is an increased rate of knee pain, mechanical symptoms, and functional limitations. Despite excellent post-operative IKDC examination scores, approximately 40% of our patient cohort demonstrated relatively low Lysholm scores (fair and poor).

Randomized Controlled Trial Comparing All-Inside Anterior Cruciate Ligament Reconstruction Technique With Anterior Cruciate Ligament Reconstruction With a Full Tibial Tunnel

The purpose of this investigation was to compare the clinical effectiveness of full-tunnel anterior cruciate ligament (ACL) reconstructive surgery with all-inside ACL reconstruction. After statistical power analysis was performed and institutional review board approval and patient informed consent were obtained, 150 patients having ACL reconstruction were prospectively randomized to an all-inside or full-tibial tunnel technique. Outcome (International Knee Documentation Committee [IKDC] Knee Examination Form, IKDC Subjective Knee Evaluation Form, Knee Society Score [KSS], Short Form 12 [SF-12] score, femoral or tibial tunnel or socket widening, narcotic consumption, and visual analog scale [VAS] pain score compared with baseline) was measured and recorded preoperatively and at various postoperative time points with a minimum follow-up of 2 years. There were no differences between groups with regard to IKDC Knee Examination Form, IKDC Subjective Knee Evaluation Form, KSS score, SF-12 score, or femoral socket or tibial tunnel or socket widening, or narcotic consumption. The VAS pain score compared with baseline was significantly lower for the all-inside technique on day 1, on day 7, at 1.5 weeks, and at 24 months. The null hypothesis (no difference between all-inside ACL reconstruction and ACL reconstruction with a full tibial tunnel) is supported for IKDC scores, KSS score, SF-12 score, narcotic consumption, and tibial and femoral widening, whereas all-inside ACL reconstruction results in a lower VAS pain score compared with baseline. Level I, randomized controlled clinical trial with greater than 80% patient follow-up 2 years postoperatively.

Osteochondral autologous graft transfer system in the knee; mid-term results

IntroductionThe purpose of this study was to determine the effectiveness of the osteochondral autologous graft transfer system in the treatment of chondral and osteochondral lesions of the knee. MethodsSixty five knees of sixty four patients who underwent autologous osteochondral graft transfer were evaluated with clinical scores and imaging techniques. ResultsThe average follow up was 82.2 (51–145) months. The patients were evaluated according to Tegner activity scale, Lysholm scale and IKDC subjective knee evaluation form. According to all these scales, all patients showed increasing results in various rates in the last follow up. Accordingly, mean increases of 59.2±15.9 points, 3.6±1.4 points, and 42.6±11.5 points were achieved in Lysholm knee scores, Tegner activity scale scores, and IKDC subjective knee evaluation form, respectively (p≤.0001). Moreover, we found no significant correlation between functional results and age, functional results and localization of osteochondral defect, functional results and additional knee pathologies. ConclusionIn our study we achieved significant increases in all the scales in the last follow up. Furthermore, we found no significant correlation between functional results and age, defect localization and additional knee pathologies.