Included International Knee Documentation Committee Research Articles

Double-bundle reconstruction results in superior clinical outcome than single-bundle reconstruction

To compare the short- and long-term clinical outcomes of the double-bundle (DB) anterior cruciate ligament (ACL) reconstruction with those of single-bundle (SB) ACL reconstruction. An electronic search of the database PubMed (1966-September 2011), EMBASE (1984-September 2011), and Cochrane Controlled Trials Register (CENTRAL; 3rd Quarter, 2011) was undertaken to identify relevant studies. Main clinical outcomes were knee stability measurements including KT-1000 arthrometer measurement, Pivot shift test, and Lachman test, and clinical outcome measurements including International Knee Documentation Committee (IKDC), Lysholm knee score, Tegner activity score, and complications. Eighteen studies were finally included in this meta-analysis, which were all classified as high risk of bias according to the Collaboration's recommended tool. It is seen that compared to SB ACL reconstruction, DB ACL reconstruction results in a KT-1000 arthrometer outcome 0.63 and 1.00mm closer to the normal knee in a short- and long-term follow-up, respectively. Our results also reveal that DB-treated patients have a significantly higher negative rate of the pivot shift test (p<0.00001 and=0.006 in a short- and long-term follow-up, respectively) and Lachman test (n.s. and p<0.0001 in a short- and long-term follow-up, respectively) compared to SB-treated patients. As for the clinical outcome measurements, a significant difference is found between SB versus DB ACL reconstruction regarding the IKDC (p=0.006 and<0.0001 in a short- and long-term follow-up, respectively) and complications (p=0.03), while there is no significant difference between the two groups regarding Lysholm knee score (n.s.) and Tegner activity score (n.s.). Overall, double-bundle ACL reconstruction yields better clinical outcomes when compared to single-bundle ACL reconstruction. II.

Double-Bundle Anterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Allograft

Background: Nonanatomic transtibial single-bundle anterior cruciate ligament reconstruction (SB-ACLR) with a bone–patellar tendon–bone (BPTB) allograft has been used for a long time and has shown the same satisfactory clinical results as an autograft; however, it has not been reported if a double-bundle ACLR (DB-ACLR) could be performed with a BPTB allograft and achieve even better results. Hypothesis: The DB-ACLR with a BPTB allograft is technically feasible and will be superior to the SB technique in restoring better anterior and rotating stability. Study Design: Cohort study; Level of evidence, 2. Methods: The study was performed with 56 patients, and 52 (25 in the DB group and 27 in the SB group) of them were followed up at 2 to 5 years. With an irradiated deep-frozen BPTB allograft, a standard single-incision arthroscopic technique was used, and the graft was fixed with bioabsorbable interference screws on both the femoral and tibial sides. Outcome assessment at final follow-up included International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores; side-to-side difference by conventional KT-2000 arthrometer; total anteroposterior (AP) laxity by the back-pushing KT-2000 arthrometer; pivot shift (0, +, ++); range of motion (ROM); and isokinetic muscle strength evaluation. Results: Mean follow-up was 47.3 ± 11.5 and 58.2 ± 6.6 months for the DB group and SB group, respectively. A statistically significant difference in favor of the DB group was found with the total AP laxity at 30° (P < .05). The overall incidence of pivot shift in the DB group (4% ++) was significantly lower than that in the SB group (26%: 19% + and 7% ++; P = .029). No significant differences were found between the 2 groups in terms of IKDC score, Lysholm score, Tegner score, conventional KT-2000 arthrometer anterior laxity, ROM, and muscle strength. Conclusion: A DB-ACLR with a BPTB allograft is feasible and achieved more satisfactory results than the transtibial SB technique in terms of total AP stability and rotational stability in spite of no significant differences among other clinical parameters.

Arthroscopic Suture Anchor Repair Versus Pullout Suture Repair in Posterior Root Tear of the Medial Meniscus: A Prospective Comparison Study

To evaluate functional and radiographic results of arthroscopic suture anchor repair for posterior root tear of the medial meniscus (PRTMM) and compare with pullout suture repair. From December 2006 to August 2008, 51 consecutive patients underwent arthroscopic repair of PRTMM at our hospital. The repair technique was switched over time from pullout suture repair (group 1) to suture anchor repair (group 2). Of the patients, 6 were lost to follow-up, leaving a study population of 45 patients, with 22 menisci (48.9%) in group 1 and 23 (51.1%) menisci in group 2. The mean follow-up duration was 25.9 months (range, 24 to 27 months) in group 1 and 26.8 months (range, 24 to 28 months) in group 2. Compared variables included International Knee Documentation Committee criteria, Kellgren-Lawrence grade, gap distance at PRTMM, structural healing, meniscal extrusion, and cartilage degeneration of the medial femoral condyle. At 2 years postoperatively, both groups showed significant improvements in function (P < .05) and did not show significant differences in Kellgren-Lawrence grade (P > .05) compared with preoperatively. On magnetic resonance imaging, the gap distance at PRTMM was 3.2 ± 1.1 mm in group 1 and 2.9 ± 0.9 mm in group 2 preoperatively (P > .05). Complete structural healing was seen in 11 cases in group 1 and 12 cases in group 2 (P > .05). Mean meniscal extrusion of 4.3 ± 0.9 mm (group 1) and 4.1 ± 1.0 mm (group 2) preoperatively was significantly decreased to 2.1 ± 1.0 mm (group 1) and 2.2 ± 0.8 mm (group 2) postoperatively (P < .05). Regardless of repair technique, incompletely healed cases showed progression of cartilage degeneration (4 cases in group 1 and 2 cases in group 2). For PRTMM, our results show significant functional improvement in both the suture anchor repair and pullout suture repair groups. Reduction of meniscal extrusion seems to be appropriate to preserve its protective role against progression of cartilage degeneration after complete healing at PRTMM. Level III, prospective therapeutic comparative study.

Effect of Patient Age on Morphology of Anterior Cruciate Ligament Grafts at Second-Look Arthroscopy

The purpose of this study was to evaluate the effect of patient age on the morphology of anterior cruciate ligament (ACL) graft after ACL reconstruction, as well as to investigate the relation between morphology and clinical outcomes. Anatomic double-bundle ACL reconstruction by use of autogenous semitendinosus tendon graft was performed in 193 patients. Of these, 102 patients (51 male and 51 female patients) had consented to undergo second-look arthroscopy at the time of hardware removal within 2 years of ACL reconstruction. These patients were divided into the following 3 groups according to their age: group A, 29 years or younger (55 cases); group B, 30 to 49 years (36 cases); and group C, 50 years or older (11 cases). At second-look arthroscopy, the grafts were evaluated based on synovial coverage around the grafts, tension, and damage/tear of the grafts themselves. Clinical outcomes were evaluated with a physical examination including the Lachman test and side-to-side difference by KT-2000 knee arthrometer (MEDmetric, San Diego, CA), subjective assessment including International Knee Documentation Committee subjective assessment and Lysholm score, and sports activity level including Tegner activity scale. The Mann-Whitney U test, Kruskal-Wallis test, analysis of variance, and χ² test were used for statistical analysis. Good synovial coverage over the graft was found in 49 cases (89%) in group A, 30 (83%) in group B, and 5 (46%) in group C. Synovial coverage in group C was significantly poorer than that in the other 2 groups. No statistical difference was found in tension of graft among the 3 groups, whereas the incidence of a "partial tear" tended to increase with age. With respect to clinical outcome, there was no significant difference among the 3 groups except for sports activity. Although clinical outcomes were comparable among the 3 groups, synovial coverage of ACL grafts in elderly patients was significantly poorer than that in younger patients. Level II, prognostic study.

Return to Sports Activity After Postoperative Septic Arthritis in ACL Reconstruction

Background: Septic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction is a rare but potentially serious complication. Several different options have been proposed to treat this condition. Our study aims to report the clinical, radiological, and sports activity results using our original protocol based on outpatient irrigation of the knee as well as parenteral and oral antibiotics. Methods: From January 2001 to January 2009, 14 patients (all active in sports) were treated for postoperative septic arthritis of the knee after ACL reconstruction in our institute. The treatment protocol included outpatient irrigation of the knee and parenteral antibiotics, followed by oral antibiotics. Repetitive irrigation was performed if necessary. The average follow-up period for our series was 38 months (range, 8–54 months). Follow-up included International Knee Documentation Committee (IKDC) forms, radiographs, Tegner and Lysholm scores, and KT-1000™ arthrometric evaluation. Results: Treatment of infection was successful in all cases. At final examination, pivot shift score was negative in 12 of 14 patients, and was > 1 in 2 of 14 patients, whereas the Lachman item score was negative in all cases. The mean postoperative Tegner score was 7, and 12 of 14 patients returned to the same sport at the same level after surgery. The mean Lysholm score was 96. Using the IKDC score, 12 of 14 patients were graded as group A, and 2 of 14 patients were graded as group B. The mean postoperative manual maximum KT-1000™ side-to-side difference was 2.5 mm. No significant bone tunnel enlargement was found when evaluating the patients' radiographs. Conclusion: The treatment regimen previously described provides reliable results for this complication. There were no recurrences of septic arthritis or bone infection, and no further surgeries were required. The graft could be retained during treatment of septic arthritis. Almost all patients returned to the preoperative and preinfection sport at the same level.

Clinical and radiological outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction

BackgroundSeptic arthritis after arthroscopic anterior cruciate ligament (ACL) reconstruction is a rare complication. In the literature, several treatments have been proposed. The aim of the study was to report our results using ambulatory irrigation of the knee and parenteral and oral antibiotics. MethodsFrom January 2001 to December 2008, a total of 12 patients were treated for postoperative septic arthritis of the knee after ACL reconstruction in our hospital. The average age at trauma was 24 years (range 16–43 years). The treatment protocol included irrigation of the knee (for 2 days) and parenteral antibiotics and oral antibiotics subsequently. Repetitive irrigation was performed if necessary. The average duration of follow-up for our series was 38 months (range 6–54 months). Follow-up included International Knee Documentation Committee (IKDC) forms, radiography, Tegner and Lysholm scores, and KT-1000 arthrometric evaluation. ResultsIn all cases treatment of infection was successful. Neither graft nor hardware removal was needed in any of the cases. At final examination, the pivot shift was negative in 10 of 12 patients, and it was 1+ in the other 2 patients; the Lachman was negative in all cases. The mean postoperative Tegner score was 7.2, and the mean Lysholm score was 98.3. In all, 10 of the 12 patients were graded as group A and the other 2 as group B using the IKDC form. The mean postoperative manual maximum KT-1000 side-to-side difference was 2.3. No significant bone tunnel enlargement was found at radiographic evaluation. ConclusionsThe described treatment regimen gives reliable results for this complication. There were no recurrences of septic arthritis or bone infection. No further surgeries were required, and the graft was retained during the treatment of septic arthritis.

Anterior cruciate ligament reconstruction using autografts and double biodegradable femoral cross-pin fixation: functional, radiographic and MRI outcome after 2-year minimum follow-up

Double biodegradable cross-pins are increasingly used for femoral fixation in arthroscopically assisted reconstruction of the anterior cruciate ligament (ACL). There are no studies combining functional outcome analysis, radiographs and magnetic resonance images (MRI) to evaluate this technique. The authors examined 45 patients after ACL reconstruction using double biodegradable femoral cross-pin fixation and biodegradable tibial interference screw fixation with a minimum follow-up of 24 months. Clinical evaluation included International Knee Documentation Committee (IKDC) and modified Lysholm score. Radiographic analysis included standard X-rays in anterior-posterior and lateral views and Telos stress device measurements. MRI was analyzed to obtain information about hardware, intra-articular graft, osseous graft-integration and cartilage. IKDC score revealed 28 (62.2%) patients with normal knee function (group A), 15 (33.3%) patients with nearly normal (group B) knee function and 2 (4.4%) patients with abnormal knee function (group C). The Lysholm score was 94.6 (+/-7.2) in the operated knee and 98.8 (+/-7.4) in the non-operated knee. Mean Telos stress device values were +4.6 (+/-2.6) in the operated and +3.9 (+/-2.4) in the non-operated knee. MRI showed an intact intra-articular graft in all but one patient. Complete femoral graft integration was seen in 88.9% and complete tibial graft integration in 86.7%. Biodegradable cross-pins were partially or fully visible in all patients. The biodegradable tibial interference screw was fully visible in 16 (35.6%) and partially visible in 20 (44.4%) patients. Thirty-one (68.9%) patients showed signs of cartilage degeneration on MRI at follow-up. The graft fixation with double biodegradable pin fixation appears to be a reliable technique for ACL reconstruction providing a stable close-to-joint graft fixation.

Meniscal Healing after Meniscal Repair

Background Studies evaluating healing of repaired meniscus are rare and primarily retrospective. The aim of this study was to assess whether there were different healing rates for arthroscopic meniscal repair with respect to the different zones of the meniscus. Purpose This study was conducted to assess outcomes and to document anatomic characteristics of the repaired meniscus with postoperative arthrography combined with computed tomography (arthro-CT), particularly the dimensions and healing of the repaired meniscus. Study Design Case series; Level of evidence, 4. Methods Fifty-three arthroscopic meniscal repairs were prospectively evaluated between 2002 and 2004 in 2 orthopaedic departments. There were 36 medial and 17 lateral torn menisci. All ACL tears (n = 31, 58.5%) underwent reconstruction. Patients were preoperatively evaluated by magnetic resonance imaging. Clinical evaluation included International Knee Documentation Committee (IKDC) scores before the operation and 6 and 12 months afterward. Healing criteria were evaluated at 6 months by arthro-CT scan. Three parameters were evaluated—healing in thickness (Henning criteria), overall healing rate, and reduction in the width of the remaining meniscus. Results According to the objective IKDC score, 26 patients were graded A, 20 B, and 4 C (92% good results). The mean subjective IKDC score was 78.9 (standard deviation [SD], 16.2). According to Henning's criteria, 58% of the menisci healed completely, 24% partially, and 18% failed. The overall healing rate was 73.1% (SD, 38.5). Twenty tears located in the posterior part had a healing rate of 59.8% (SD, 46.0). Nineteen tears extending from the posterior to the middle part had a healing rate of 79.2% (SD, 28.2). Isolated tears located in the posterior part had a lower healing rate (P < .05). There was a 9% ± 1.2% reduction in the width of the remaining medial meniscus in the middle and posterior repaired portions (P < .02). There was a 15% ± 14% reduction in the width of the remaining lateral meniscus in the middle repaired portion (P < .01). Complete healing of the posterior segment was associated with reduction in the width of the meniscus (P < .04). Conclusion A modern technique using all-inside fixation or outside-in sutures provided good clinical and anatomic outcomes. No statistically significant effect on ACL reconstruction or laterality (medial vs lateral) on overall healing after meniscal repair was identified. Partial healing occurred often, with a stable tear on a narrowed and painless meniscus. The posterior segment healing rate remained low, suggesting a need for further technical improvements.

Septic Arthritis of the Knee after Anterior Cruciate Ligament Surgery

Background Septic arthritis is a rare complication after anterior cruciate ligament surgery. All case series reported so far have been retrospective, and case numbers of septic arthritis have ranged from 4 to 11. Hypothesis A stage-adapted treatment regimen for septic arthritis after anterior cruciate ligament surgery can provide reliable results. Study Design Case series; Level of evidence, 4. Methods From June 1993 to May 2003, 24 patients met the inclusion criteria for this study. The average age at trauma was 32.5 years. Treatment protocol was based on the grade of infection. Options included transarthroscopic treatment for Gaechter grades 1 and 2 infections or medial and lateral arthrotomy for grades 3 and 4 infections. Graft retention was decided based on clinical findings. The setting was a specialized trauma hospital. Follow-up included International Knee Documentation Committee forms, radiographs, and the Tegner and Lysholm scores at a mean of 66 months (range, 11-142) after treatment. Results In all cases, treatment of infection was successful; overall, a mean of 2.2 operations were required. In 7 cases, it was possible to salvage the graft. The Tegner activity level before the knee injury was 6.1 points. At follow-up, the average score was 3.8 points. The postoperative subjective International Knee Documentation Committee score averaged 64. The mean Lysholm score was 65.6. On clinical examination, a mean extension deficit of 3° and a mean maximum flexion of 120° were found. In the single-legged hop test, a mean capacity of 63% compared with the uninjured side was measured. Conclusion The described treatment regimen gives reliable results for this complication. There were no recurrences of septic arthritis or bone infection. Early infection can be managed arthroscopically with satisfactory results regarding the treatment of infection. In advanced or chronic infection, a more radical approach seems favorable. Results in these cases are overall only fair compared with patients with an uncomplicated anterior cruciate ligament reconstruction.

Reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone graft with double biodegradable femoral pin fixation

The purpose of this study was to evaluate the early clinical outcomes of the bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction using biodegradable cross pin fixation. The nature of this study is a prospective nonrandomized clinical outcome study. Thirty-five patients who underwent BPTB ACL reconstruction with a minimum of 2 years follow-up evaluation were included in the study. Thirty BPTB autografts and five BPTB allografts were fixed with two biodegradable 2.7 mm cross pins (Rigid Fix) on the femoral side. Clinical evaluation included International Knee Documentation Committee (IKDC), Lysholm and Tegner activity score, and Telos stress device measurements. The average Lysholm knee score was 94.7 (of 100). Twenty-four patients reported an excellent result. The other eight patients were in a good group. According to the IKDC scores, 23 (66%) patients reported normal function, 12 (34%) patients reported nearly normal function, and no (0%) patient reported abnormal or severely abnormal function. Telos stress device values were less than 3 mm of sagittal displacement in 28 patients and 5 mm in 7 patients. No patients complained that their knees gave way fully, even with moderate or strenuous activities. All of the patients have returned to their preinjury level of activity and athletic participation. Clinical results support this technique as a reliable alternative for patellar tendon fixation in ACL reconstruction.

Hamstring anterior cruciate ligament reconstruction: a comparison of bioabsorbable interference screw and endobutton-post fixation

Purpose The purpose of this study was to evaluate hamstring anterior cruciate ligament (ACL) reconstruction using aperture fixation with bioabsorbable interference screw (BIS) and distant fixation using EndoButton (Smith & Nephew, Andover, MA) and screw-post (ENDO). Type of study Prospective nonrandomized clinical outcome study. Methods Two groups of 15 patients who underwent autogenous hamstring ACL reconstruction with a minimum of 2 years’ follow-up evaluation (mean 35 months) were included in the study. The BIS group underwent poly-L-lactic acid interference screw fixation at both femoral and tibial tunnels and the ENDO group underwent EndoButton fixation on the femoral side and screw-post fixation on the tibial side. Clinical evaluation included International Knee Documentation Committee (IKDC) and arthrometer measurements. Tunnel enlargement, screw integrity, graft integrity, and graft-tunnel interface were evaluated using radiographs and magnetic resonance imaging. Statistical analyses were performed using the Student t test, with significance set at 0.05. Results All patients in both groups had functionally normal or near-normal IKDC scores. The average IKDC subjective knee form scores were 85 ± 11 versus 81 ± 17 (BIS v ENDO) and side-to-side KT differences were 3.2 ± 2.6 mm versus 2.4 ± 1.8 mm ( P > .05). For both groups, tunnel enlargement was present on radiographs at both femoral and tibial sides (36% to 77%). Tunnel enlargement was more significant at the femoral tunnels (53% to 77%) than the tibial tunnels (36% to 42%). In the BIS group, magnetic resonance imaging revealed 9 partially degraded screws and 2 intact screws on the femoral side. On the tibial side, 4 partially degraded and 10 intact screws were seen. For both groups, the grafts have partial or complete incorporation at all tunnels. Tunnel enlargement measured on radiographs correlate well with measurements on magnetic resonance images. Conclusions Our results showed that rigid aperture fixation using BIS did not lead to significant differences in clinical outcome when compared with distant fixation using ENDO at 24 to 40 months follow-up evaluation. Significant tunnel enlargement was present in both groups, more pronounced on the femoral side. Magnetic resonance imaging findings showed that BIS were not degraded even at 2 to 4 years after surgery. Level of evidence Level II.