International Knee Documentation Committee Evaluation Research Articles

Factors Affecting Subjective and Objective Outcomes and Return to Play in Anterior Cruciate Ligament Reconstruction: A Retrospective Cohort Study.

Purpose To analyze the prognostic factors influencing subjective and objective outcomes and return to play (RTP) after anterior cruciate ligament reconstruction (ACL-R). Methods Primary ACL-Rs using a transtibial technique performed between 2008 and 2012 were included. Data regarding patients, surgery, sports, and rehabilitation, including an on-field rehabilitation (OFR) and duration of the rehabilitation program, were collected. The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms, and the Knee Injury and Osteoarthritis Outcome Score and Lysholm questionnaires were used for the assessment of subjective and objective outcomes. The Subjective Patient Outcome for Return to Sports and ACL–return to sport after injury (RSI) scores were used for RTP evaluation. Several potential predictors of outcome were tested with a univariate analysis. All the variables with p < 0.1 were retested in a logistic regression model to evaluate their association with the outcomes. Results In total, 176 cases were included with an average follow-up of 44.1 months. Of the patients, 92.2% were rated as normal or nearly normal at the IKDC evaluation. In addition, 90.1% of the patients returned to sport, with 57.6% returning to the same preinjury level. Objective outcomes were negatively influenced by late rehabilitation (odds ratio [OR] = 2.75). Performing an OFR phase during the rehabilitation was associated with better subjective outcomes (OR = 2.71). Length of rehabilitation strongly influenced the RTP rate (OR = 13.16). Conversely, higher ACL-RSI score was inversely related to RTP. Objective IKDC score was inversely related to the ACL-RSI (OR = 0.31), whereas subjective score was correlated with both the total ACL-RSI score (OR = 0.15) and the level of activity (OR = 0.20). Conclusion This study confirmed the role of rehabilitation on subjective and objective outcomes and on RTP. Particularly, the complete adherence to a rehabilitation program, including an OFR phase, resulted in better subjective outcomes and higher RTP rate. The relationship between psychological factors, measured through the ACL-RSI score, and RTP was confirmed. Level of Evidence Level III, observational study without a control group.

Comparison of Return to Pre-Injury Sport After 10 mm Size Bone-Patellar Tendon-Bone (BPTB) versus 8 mm Hamstring Anterior Cruciate Ligament Reconstruction: A Retrospective Study with a Two-Year Follow-Up

BackgroundThe aim of this study was to evaluate the reconstruction of a torn anterior cruciate ligament (ACL) with 10 mm diameter BPTB (bone-patellar tendon-bone) autograft versus 8 mm HT (hamstring tendon) autografts, to compare the ability to restore pre-injury sports activities and reduce revision risk after these procedures.Material/MethodsA prospective clinical review was performed to compare results of patients who underwent primary anatomical ACLR with 10 mm BPTB autografts with patients who underwent 8 mm diameter HT autografts, between January 2011 and January 2014.ResultsThere were 183 patients evaluated: the 8 mm HT group showed statistically significant higher knee laxity values compared to the 10 mm BPTB group (p=0.042), and significant difference were detected in subjective International Knee Documentation Committee (IKDC) evaluation scores; the average subjective IKDC evaluations after two-year follow-up in the HT group was 88.45±2.8 versus 89.24±2.5 in BPTB group (p=0.047). In the evaluation of the IKDC objective protocol, results were excellent and good in 83 patients (94.3%) after BPTB and in 78 patients (82%) after HT ACLR (p<0.05). The average score on the Tegner activity scale in the HT group decreased from 6.5 at pre-injury to 5.8 at two-year follow-up (p<0.001) and from 6.7 at pre-injury to 6.5 at two-year follow-up in the BPTB group (p=0.4). The ability to restore pre-injury sports activities was higher in the BPTB group (6.5) versus the HT group (5.8) (p<0.001). Revision was required for two patients (2.2%) in the BPTB group compared with 14 patients (14.7%) in the HT group (p<0.05).ConclusionsSmaller HT graft size was a predictor of higher knee laxity and greater revision risk at two-year post primary ACL reconstruction. Larger diameter BPTB ACL grafts had a better ability to restore knee stability and greater ability to restore pre-injury sports activities.

Results of Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts: Objective Factors Associated With the Development of Osteoarthritis at 20 to 33 Years After Surgery

Background: Few studies exist that report objective radiographic and physical examination results at >20 years after anterior cruciate ligament (ACL) reconstruction. Hypothesis: The risk of osteoarthritis (OA) at >20 years after surgery would be statistically significantly higher if an increased severity of factors was present. Study Design: Cohort study; Level of evidence, 2. Methods: Between 1982 and 1994, 1428 knees met the inclusion criteria of being primary ACL surgery, having no existing OA or other ligamentous laxity, and having no known graft tear. Prospective data analyzed included demographics; meniscus and articular cartilage status; ratings of bilateral standing posteroanterior weightbearing, lateral, and Merchant view radiographs; KT-1000 arthrometer measurements; and range of motion measurements. Radiographs were graded for joint space narrowing, sclerosis, and osteophytes according to International Knee Documentation Committee (IKDC) criteria. Multivariate and univariate logistic models were used to determine the effect of potential predictors on the odds of having radiographic evidence of OA. IKDC and Cincinnati Knee Rating System (CKRS) subjective surveys were conducted. Results: A minimum 20-year objective follow-up was obtained for 423 knees at a mean of 22.5 ± 2.1 years postoperatively. If a patient lacked normal extension or flexion at discharge, the odds of lacking normal extension or flexion at follow-up were 19.7 and 7.97, respectively (P < .001). Radiographic ratings were normal for 35.2%, nearly normal for 36.2%, abnormal for 20.1%, and severely abnormal for 8.5%. Multivariate analysis showed that the predictive factors for the presence of OA in the long-term were medial meniscectomy, older age at surgery, and less than normal knee extension at discharge. The odds ratios for statistically significant factors for the presence of any OA at follow-up were 2.02 for knee extension loss at discharge, 2.98 for medial meniscectomy, 1.65 for lateral meniscectomy, 1.06 for age at follow-up, 1.62 for chronic injury type, and 2.17 for articular cartilage damage. The IKDC and CKRS subjective scores were progressively and statistically significantly lower as the level of OA was greater. Conclusion: The prevalence rate of developing moderate to severe OA at >20 years after ACL reconstruction was 28.6%. Significant factors predictive of OA in the long-term were older age at surgery, medial meniscectomy, and knee extension loss.

Combined Intra- and Extra-Articular Technique in Revision Anterior Cruciate Ligament Reconstruction.

Purpose The aim of the study was to evaluate the “over the top” (OTT) nonanatomical technique for revision of anterior cruciate ligament (ACL) reconstruction. Methods Twenty-four patients with a mean age of 31.9 ± 11.2 years underwent revision of ACL reconstruction using OTT technique. International Knee Documentation Committee (IKDC) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, Tegner score, Subjective Patient Outcome for Return to Sport (SPORTS) score, Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale, and KT-1000 evaluation were recorded at a mean follow-up of 30.7 ± 18.9 months. Results Postoperatively, the IKDC objective total score significantly improved ( p = 0.0046). The KOOS, Lysholm, and Tegner scores also improved, but the results were not statistically significant (62.4 vs. 72.6, 6.5 vs. 75.8, and 4.1 vs. 6.0, respectively). The subjective IKDC evaluation score improved from an average of 51.1 points to 63.7 points at the last follow-up ( p = 0.0027). The RTP prevalence was 81.8%, with 44.4% of the patients returning to the same preinjury level. According to the SPORTS score, 16.6% of patients played sport without limitations in activity and performance. The average ACL-RSI score was 52.1 ± 27.0. No major complications were reported. A total of 21.5% of patients underwent surgical removal of staples. The failure prevalence was 14.3% and the cumulative survivorship, calculated using the Kaplan–Meier method, was equal to 70% at 60 months of follow-up. Conclusion The OTT technique in the revision ACL reconstruction provided improvement in objective and subjective scores, good RTP prevalence, and acceptable rate of complication and failure. One of the advantages was the possibility to avoid the femoral tunnel. Level of Evidence Level IV, therapeutic case series.

Comparison of patellar versus hamstring tendon autografts in arthroscopic anterior cruciate ligament reconstruction: A 6-month follow-up of a randomized clinical trial.

Background:The purpose of this study was to compare the outcomes of anterior cruciate ligament (ACL) reconstruction using the patellar versus hamstring tendon (HT) autograft.Materials and Methods:In this randomized clinical trial, fifty patients undergoing arthroscopic ACL reconstruction were randomized into two equal groups: Those treated with either autogenous patellar tendon grafts (PT group) or HT group grafts. All patients were reviewed immediately after surgery, at 6 and 12 weeks after surgery, and then at 6 months using the International Knee Documentation Committee evaluation form. Infection, severity of pain (visual analog scale), duration of rehabilitation, and clinical and magnetic resonance imaging (MRI) findings were assessed at the 6-month follow-up. Positive pivot shift and Lachman test were considered clinical signs and symptoms of treatment failure. In addition, the absence of the ACL or transverse ACL rather than the posterior oblique ligament is an MRI finding that indicates treatment failure.Results:Comparing changes in pain and range of motion (ROM) in patients first and 6 months after therapy show that pain had been relief significantly (P < 0.001) and ROM dramatically changes (P < 0.001). The average rehabilitation period in the PT group was 13.2 ± 2.08 weeks whereas in the HT group, it was 9.28 ± 2.26 weeks. A significant difference was seen between the two groups in terms of the rehabilitation period (P < 0.001). No significant difference was found in the normal ROM between the groups (P = 0.32). When the pain severity was considered, a significant difference was found between the PT group and the HT group (P < 0.001). The HT group patients had less knee pain than did the PT group patients. No significant difference in infection rates was seen between two groups (P = 0.66).Conclusion:Considering the better outcomes of HT reconstructions for the two parameters of pain severity and rehabilitation period, we consider HTs to be the ideal graft choice for ACL reconstructions.

A new technique for hamstring tendon graft harvesting

Introduction Harvesting of hamstring tendon is a very important step in anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction. Although there are many advantages for using the hamstring tendon for cruciate ligaments reconstruction, there are many disadvantages of the traditional technique for hamstring tendon harvesting. Therefore, we have used a new technique to avoid all the disadvantages and allow for fast, easy, and perfect hamstring tendon graft harvesting. The aim of our new technique for hamstring tendon harvesting is to avoid all complications and difficulties related to graft harvesting and keeping sartorial fascia in a good and repairable condition. Patients and methods We carried out arthroscopic ACL reconstruction using hamstring tendons autograft. We used a new technique for hamstring tendons harvesting. This work was done on 12 patients with an average age of 24 years (20–38) between March 2010 and December 2010. Results Subjective assessment was done according to International knee Documentation Committee rating system. This was defined as four grades as follows: normal (a), nearly normal (b), abnormal (c), and severely abnormal (d). Before ACL injury, 12 (100%) patients considered their knees to have been grade A. Twenty-four months after reconstruction, 11 patients rated their knees as normal or nearly normal. One patient rated his knee as abnormal at 2 years of follow-up. This patient had severe osteoarthritic changes. Conclusion It would be advisable to follow this technique of graft harvesting for all individuals undergoing arthroscopic ACL reconstruction using hamstring tendons to avoid the problems encountered with the standard technique and also to achieve an excellent outcome.

Clinical outcome of arthroscopic management of isolated posterior cruciate ligament injuries

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

Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players.

The growing popularity of elite soccer among female participants has led to increased incidents of anterior cruciate ligament (ACL) ruptures. Many authors underline a positive glide after ACL reconstruction (ACLR), especially in women. In fact, an isolated intra-articular ACLR may be inadequate to control rotational instability after a combined injury of the ACL and the peripheral structures of the knee. Extra-articular procedures are sometimes used in primary cases displaying excessive antero-lateral rotatory instability. The purpose of this case series was to report subjective and objective outcomes after combined ACL and lateral extra-articular tenodesis (LET) with a minimum 4-year follow-up in a selected high-risk population of elite female football players. Between January 2007 and December 2010, 16 elite Italian female football players were included in the study. All patients underwent the same surgical technique: anatomical ACLR with autogenous semitendinosus and gracilis tendons. After the intra-articular reconstruction was performed, an additional extra-articular MacIntosh modified Coker-Arnold procedure was carried out. Patients were assessed pre- and post-operatively with the subjective and objective International Knee Documentation Committee (IKDC) evaluation form, Tegner activity scale (TAS) and Lysholm score. Joint laxity was assessed with KT-1000 by measuring the side-to-side (S/S) differences in displacement at manual maximum (mm) testing. At a mean follow-up of 72.6 ± 8.1months, two independent examiners reviewed all players. All of the patients had a fully recovered range of motion. Lachman test was negative in all patients (100%). The evaluation of joint laxity and clinical evaluation showed a statistically significant improvement. No patients experienced complication or a re-rupture. The rationale of combining extra-articular procedures with ACLR is to restrict the internal rotation of the reconstructed knee, taking advantage of its long lever arm and thus providing more stability in the rotational axis and preventing the ACL graft from undergoing further excessive strain. The combination of an LET with ACLR in elite female football players demonstrated excellent results in terms of subjective scales, post-operative residual laxity and re-rupture rate with no complication, and a complete return to sport activity.

Long-term Survivorship and Function of Meniscus Transplantation

Background: Clinical outcomes and survivorship of meniscus transplants remain unclear, especially when magnetic resonance imaging (MRI) and weightbearing radiographic findings are included as endpoints. Many studies calculate survivorship based only on subsequent operative procedures. Purpose: We prospectively determined long-term survivorship and functional outcomes of 72 consecutive meniscus transplants. The effects of articular cartilage damage, concurrent osteochondral autograft transfer (20 knees), patient age, and tibiofemoral compartment were evaluated. Study Design: Case series; Level of evidence, 4. Methods: The long-term function and survival rates of 69 of 72 consecutive medial and lateral bone-meniscus-bone transplants (96% follow-up) were determined. Survival endpoints of reoperations, MRI failure (grade 3 signal intensity, extrusion >50% of meniscal width), meniscal tear on examination, and radiographic loss of joint space provided a worst-case outcome. Long-term functional analysis was performed in 58 transplants a mean of 11.9 ± 3.2 years postoperatively. The Cincinnati and International Knee Documentation Committee rating systems were used to evaluate outcomes. Results: For all transplants, the estimated probability of survival was 85% at 2 years, 77% at 5 years, 69% at 7 years, 45% at 10 years, and 19% at 15 years. There were significant improvements for pain, swelling, walking, stair climbing, and patient knee rating (P < .05). Further surgery was performed in 37 cases. Knees that had concurrent osteochondral autograft transfer had significantly lower survival rates beginning at the seventh postoperative year; however, there was no significant difference in the long-term symptom, function, and patient perception scores between these knees and the rest of the cohort. The factors of articular cartilage damage (grade 2B/3 vs none), patient age (<30 years vs 30-49 years), and tibiofemoral compartment (medial vs lateral) had no significant effect on the survival, symptom, or functional analyses. Conclusion: A survival analysis that includes reoperations, MRI, radiographs, and a comprehensive examination provides a worst-case but realistic analysis of transplant function. Many patients experienced a short- and long-term benefit of reduced symptoms and improved function. However, meniscus transplants undergo a deleterious remodeling process and eventually fail. Patients should be advised that the procedure is not curative in the long term, and additional surgery will likely be required.

Intra-articular Hyaluronic Acid (HA) and Platelet Rich Plasma (PRP) injection versus Hyaluronic acid (HA) injection alone in Patients with Grade III and IV Knee Osteoarthritis (OA): A Retrospective Study on Functional Outcome.

Introduction: Intra-articular hyaluronic acid (HA) is widely utilized in the treatment of knee osteoarthritis whereas platelet rich plasma (PRP) enhances the regeneration of articular cartilage. This study analyses the efficacy of HA and PRP in grade III and IV knee osteoarthritis.Methodology: This is a cross sectional study with retrospective review of 64 patients (101 knees) which includes 56 knees injected with HA+ PRP, and 45 knees with HA only.Results: During the post six months International Knee Documentation Committee (IKDC) evaluation, HA+PRP group showed marked improvement of 24.33 compared to 12.15 in HA group. Decrement in visual analogue score (VAS) in HA+PRP was 1.9 compared to 0.8 in HA group.Conclusion: We propose intra-articular HA and PRP injections as an optional treatment modality in Grade III and IV knee osteoarthritis in terms of functional outcome and pain control for up to six months when arthroplasty is not an option.

A quadrupled semitendinosus only anterior cruciate ligament reconstruction with tibial suspensory fixation

Purpose: Study is designed to analyze the postoperative outcome of arthroscopic ACL reconstruction with quadrupled semitendinosus tendon autograft fixed in femoral tunnel using tight rope and in the tibial tunnel using suture disc. Methods: A prospective study on a continuous series of 102 patients, operated for ACL rupture, using the same technique, from September 2010 to March 2013. Results:The longest follow-up was at 24 months. At 2 year follow-up the mean International Knee Documentation Committee (IKDC 1999)evaluation score revealed that 63.7% had a normal overall grade A. The mean Lysholm score improved from 59.4 to 92.4 at follow-up. The improvement in the limb symmetry index by single hop test was statistically significant. Laxity assessment at 12 months showed 87.2% had a grade 0 or 1 Lachman laxity with a hard end point. Patients had no motion deficit and the knee was stable in deep flexion and retained their strength during internal rotation of the knee. Conclusion: a quadrupled semitendinosus graft was adequate in order to be used alone as a four-strand graft and to get a minimum length and thickness for our graft construct. This enhanced our post-operative rehabilitation by contribution to stability in deep flexion and retaining the strength during internal rotation of the knee. It is cost effective to use atightropeat the femoral end and suture disc at the tibial end as compared to an aperture fixation by a bioscrew.

Isolated posterior cruciate ligament injuries: Results of arthroscopic management

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

Bilateral ACL Reconstructions with Hamstring Autografts.

Bilateral anterior cruciate ligament (ACL) injuries are rare with incidence between 2 and 4%, and presently no definitive guidelines for proper management exist. Ideal treatment protocol remains controversial between a single-stage and two-stage bilateral ACL reconstruction. The purpose of this study is to evaluate the outcome of single-stage bilateral ACL reconstruction with hamstring tendon autografts in bilateral ACL injuries. A prospective study was undertaken including a total of 14 consecutive patients with bilateral ACL deficient knee who underwent single-stage bilateral ACL reconstruction with hamstring tendon autograft with a mean follow-up duration of 28 months (24-38 months). Functional outcomes were evaluated by range of movements, International Knee Documentation Committee (IKDC), Lysholm and Tegner activity score, and stability tests. The mean age was 30 years (range 18-42 years). Average duration of rehabilitation was 8 weeks. Time to return to full-time work and full sports was 5.6 weeks and 6.2 months, respectively. Clinical examination demonstrated full range of motion; a total of 12 patients (86%) had a negative Lachman test and 13 patients (93%) had a negative pivot shift at the final follow-ups. The mean IKDC evaluation score was 89 points, the mean Tegner activity score was 7 points, and the mean Lysholm knee score was 91 points. A total of 12 patients (86%) returned to their preinjury level of activity and an overall greater than 90% satisfaction rate was achieved. Single-stage bilateral ACL reconstruction using hamstring autografts is clinically safe, effective, and cost-effective with better patient compliance and with comparable functional outcome as opposed to two-stage ACL reconstructions.

Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation

To retrospectively compare the clinical outcomes of displaced tibial-side posterior cruciate ligament (PCL) avulsion fractures treated with open reduction and screw fixation versus arthroscopic suture fixation. From 2005 to 2013, all displaced PCL tibial-side avulsion fractures treated surgically-initially by an open posterior approach andlater by arthroscopic-assisted suture fixation-were retrospectively reviewed. The cases with radiographic evidence ofgreater than 3 mm of displacement and/or grade II or III laxity on the posterior drawer test were included in the studygroup. The associated injuries were duly treated. A conservative rehabilitation protocol was followed until radiologic fracture union occurred. The patients' clinicoradiologic assessment data at 1 year of follow-up were used for comparison between the open and arthroscopic groups. Forty-seven patients were available with 1 year of follow-up: 27 in the open group and 20 in the arthroscopic group. More than 90% of patients in both groups rated their knee function as normal or nearly normal. At 1 year of follow-up, knee function in terms of the Lysholm score (mean of 95.3 with 95% confidence interval [CI] 92.85 to 97.75 in open group and mean of 94.8 with 95% CI 91.38 to 98.22 in arthroscopic group; P= .812), Tegner activity level (mean of 6.8 with 95% CI 6.16 to 7.44 in open group and mean of 7.0 with 95% CI 6.44 to 7.66 in arthroscopic group, P= .677), International Knee Documentation Committee evaluation, and 1-leg hop test was comparable in both groups. The postoperative arthrometric laxity measurements with a KT-2000 arthrometer (MEDmetric, San Diego, CA) were better in thearthroscopic group, with 0 to 3 mm of laxity in 85% of cases in the arthroscopic group versus 74% in the open group.Avulsed fracture fragments were usually united by 3 months after surgery. No significant complication was noted. Both arthroscopic and open methods of treatment for PCL tibial-side avulsion injuries resulted in comparably good clinical outcomes, radiologic healing, and stable knees at short-term follow-up. Level III, retrospective comparative study.

A Prospective Randomized Study of Anterior Cruciate Ligament Reconstruction With Autograft, γ-Irradiated Allograft, and Hybrid Graft

To compare the results of patients who underwent anterior cruciate ligament (ACL) reconstruction with autograft, γ-irradiated allograft, or hybrid graft in a prospective randomized study with a minimum clinical follow-up period of 5 years. In this prospective, randomized, comparative study, 102 patients with ACL tears underwent ACL reconstruction with autograft (gracilis and semitendinosus tendons), γ-irradiated allograft (tibialis anterior tendons), or hybrid graft (γ-irradiated tibialis anterior tendon allograft and semitendinosus tendon autograft). Laboratory testing of the erythrocyte sedimentation rate and C-reaction protein level were performed; clinical results were evaluated with the KT-1000 arthrometer (MEDmetric, San Diego, CA), Lachman test, Lysholm score, Tegner activity score, and International Knee Documentation Committee evaluation (both objective and subjective). There were 32 patients in the autograft group, 31 in the hybrid graft group, and 32 in the γ-irradiated allograft group at last follow-up. No differences were found among the 3 groups regarding patient demographic data and the duration from injury to operation (P > .05). The C-reaction protein and erythrocyte sedimentation rate values were statistically higher in the γ-irradiated allograft group than in the other 2 groups on the third, seventh, and fourteenth days (P < .05). No significant differences were found between the autograft and hybrid graft groups (P > .05). The KT-1000 examination showed more anterior laxity in the γ-irradiated allograft group than in the other 2 groups (P < .05). No significant differences in the Lachman test and pivot-shift test findings were found among the 3 groups (P > .05). The Lysholm score, Tegner activity score, and International Knee Documentation Committee evaluation (subjective and objective) showed no differences among the 3 groups (P > .05). Patients undergoing primary ACL reconstruction with hybrid graft or autograft had satisfactory and similar objective and subjective clinical results. On KT-1000 measurement of anteroposterior knee laxity, both the autograft and hybrid graft groups showed statistically significant differences compared with the γ-irradiated allograft group. Level II, prospective comparative study.

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using an Outside-in Technique: Two- to Six-Year Clinical and Radiological Follow-up.

PurposeWe evaluated the clinical and radiological outcomes of double-bundle anterior cruciate ligament (ACL) reconstruction using an outside-in technique with a follow-up of two- to six-years, especially in terms of the sports activity level and radiological degeneration.Materials and MethodsSixty-seven patients who were available for a minimum two-year follow-up after double-bundle ACL reconstruction using an outside-in technique were retrospectively evaluated. The mean follow-up period was 43.7 months. The knee function and stability were evaluated before the operation, one year after the operation (short-term follow-up), and more than two years after the operation (last follow-up).ResultsRegarding the knee function, the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, and hop test showed significant improvement. Regarding the stability, the Lachman test, pivot shift test, KT-2000 arthrometer data, and anterior drawer radiographs using Telos showed significant improvement. Regarding the sports activity level, the patients who returned to pre-injury level activity was 68.7% according to the Tegner activity score and 76.1% according to the Cincinnati sports activity scale score. The incidence of aggravated degeneration or development of greater than IKDC grade A degeneration after surgery was 10.4%.ConclusionsDouble-bundle ACL reconstruction using an outside-in technique showed favorable clinical and radiological outcomes with respect to the knee function and stability, joint degeneraion, and, especially, return to pre-injury sports activity.

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

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

Arthroscopic posterior cruciate ligament reconstruction by using hamstring tendon autograft and transosseous screw fixation: minimal 3 years follow-up.

The aim of this trial is to prospectively evaluate the outcomes of PCL reconstruction by means of quadruple hamstring tendon autograft with a double-fixation method at minimal 3-year follow-up. Only patients who underwent PCL reconstruction without any other concomitant injury were included in this study. A hamstring tendon graft is composed of a quadruple-stranded gracilis tendon and semitendinosus tendon about 10 cm in length. An arthroscopic technique via a two incision and a double-fixation method was applied. Clinical evaluations were performed for 52 patients. Clinical assessment of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle evaluation, and radiographic investigation. On the Lysholm knee score, 90 % of the patients displayed good or excellent rating in the final assessment. In the IKDC rating analyses, 60 % of the patients demonstrated 3-5-mm ligament laxity. For the IKDC final rating, 81 % were normal or nearly normal. Seventy-nine percent of the cases revealed less than a 10-mm difference in thigh girth between their reconstructed and contra lateral limbs. Arthroscopic PCL reconstruction using quadruple hamstring tendon autograft provides acceptable outcomes at a minimum 3-year follow-up. The four-stranded hamstring tendon graft is suitable in graft size and results in minimal harvesting morbidity. We recommend that quadruple hamstring tendon graft be chosen for PCL reconstruction to achieve good ligament reconstruction. A double-fixation method which has been applied in this trial can be used to provide rigid fixation.

Outcomes After Repair of Chronic Bucket-Handle Tears of Medial Meniscus

The purpose of this study was to determine the outcomes after repair of chronic bucket-handle medial meniscal tears by use of magnetic resonance imaging, clinical examination, and patient-reported outcomes. A retrospective review of patients with chronic bucket-handle medial meniscal tears that had been repaired with meniscal sutures was undertaken. The following criteria for inclusion were adopted: minimum tear length of 2cm and chronic medial meniscal tear identified at the time of arthroscopy. The tears were susceptible to dislocation with probing. Data collected included demographic, clinical, radiologic, and surgical data. Postoperative healing was assessed with the clinical criteria of Barrett etal. The International Knee Documentation Committee rating, Lysholm score, and Tegner activity level were determined, and postoperative magnetic resonance imaging was used to evaluate healing in accordance with the criteria of Henning etal. Twenty-four patients fulfilled the inclusion criteria. The mean time from injury to surgery was 10months (range, 2 to 60months). Sixteen patients underwent anterior cruciate ligament reconstruction, 1 patient underwent posterior cruciate ligament reconstruction, and 6 patients underwent meniscus repair only. A median of 5 sutures (range, 3 to 6 sutures) were used for repair. Four cases (all of which had undergone meniscus repair only) required revision. Complete healing was achieved in 83% of cases according to the criteria of Barrett etal. The mean follow-up time was 48months (range, 24 to 112months). An International Knee Documentation Committee rating of A or B was achieved in the 20 patients who did not require revision. The median Lysholm score was 95 (range, 92 to 100). The median Tegner activity level before injury was 7, and it remained unchanged after surgery in all cases. This study showed that repair of chronic bucket-handle meniscal tears can lead to good clinical outcomes and a relatively low (17%) failure rate. In addition, repairs of isolated meniscal tears had a significantly higher risk of failure than repairs performed in conjunction with anterior cruciate ligament reconstruction. Level IV, therapeutic case series.

Tunnel Volume Enlargement After Posterior Cruciate Ligament Reconstruction: Comparison of Achilles Allograft With Mixed Autograft/Allograft—A Prospective Computed Tomography Study

The purpose of this study was to evaluate and compare femoral and tibial tunnel volume enlargement (TVE) after arthroscopic posterior cruciate ligament (PCL) reconstruction by remnant bundle preservation using Achilles allograft or mixed graft. Seventy-eight patients undergoing primary arthroscopic single-bundle PCL reconstruction were initially included. Fifty-six of these patients underwent follow-up for a minimum of 1 year postoperatively and were divided into 2 groups: group A received Achilles allograft (n= 27), and group B received mixed graft (n= 29). The clinical evaluation included the International Knee Documentation Committee rating, Lysholm score, Tegner activity score, and Telos stress test (Telos, Weiterstadt, Germany). All of the patients were evaluated for TVE by computed tomography scanning at the 1-year follow-up; the results were compared with the data from 1 week postoperatively. A volume increment of more than 44%, which indicates 2 mm of widening of the tunnel diameter, was defined as TVE. The overall incidence of TVE after single-bundle PCL reconstruction was 3.6% (2 of 56 patients) for the femoral tunnel and 5.4% (3 of 56 patients) for the tibial tunnel. The overall mean tunnel difference between 1 week postoperatively and the final follow-up was 12.0% for the femoral tunnel and 10.6% for the tibial tunnel. The mean femoral TVE was 10.1% in group A and 13.8% in group B; the mean tibial TVE was 9.9% in group A and 11.2% in group B. These differences were not statistically significant. The functional outcome was improved in both groups, showing no statistical difference at the 1-year follow-up. The femoral and tibial TVE caused by single-bundle PCL reconstruction using the remnant bundle-preservation technique showed no significant differences between the Achilles allograft and the mixed graft over a short-term follow-up. Furthermore, the overall incidence of TVE in PCL reconstruction in this study was low. Level II, prospective comparative study.