Objective International Knee Documentation Committee Research Articles

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.

Tibial plateau lesions. Surface reconstruction with a biomimetic osteochondral scaffold: Results at 2 years of follow-up

IntroductionTibial plateau articular pathology caused by post-traumatic or degenerative lesions is a challenge for the orthopaedic surgeon and can lead to early osteoarthritis. The aim of the present study was to evaluate the results of treatment of these complex defects with implantation of an osteochondral scaffold, which is designed to target the cartilage surface and to reconstruct joint anatomy by addressing the entire osteochondral unit. Materials and methodsEleven patients (5 female and 6 male) with a mean age of 37.3±11.0 years and osteochondral lesions of the tibial plateau (mean 5.1±2.7cm2; range 3.0–12.5cm2) were treated with the implantation of an osteochondral biomimetic collagen-hydroxyapatite scaffold (Maioregen®, Fin-Ceramica, Faenza, Italy). Comorbidities were addressed taking care to restore the correct limb alignment. Patients were evaluated pre-operatively and prospectively followed-up for 2 years using the International Knee Documentation Committee (IKDC) subjective and objective scores; activity level was documented using the Tegner score. ResultsThree patients experienced minor adverse events. No patients required further surgery for treatment failure during the study follow-up period, and 8 patients (72.7%) reported a marked improvement. The IKDC subjective score improved from 42.5±10.2 before treatment to 69.8±19.0 at 12 months (p<0.05), with stable results at 24 months. The IKDC objective score increased from 27.3% normal and nearly normal knees before treatment to 85.7% normal and nearly normal knees at 24 months of follow-up. The Tegner score increased from 2.3±2.1 before treatment to 4.8±2.4 at 12 months (p<0.05), and was stable at the final follow-up. ConclusionThe present study on the implantation of an osteochondral scaffold for the treatment of tibial plateau lesions showed a promising clinical outcome at short-term follow-up, which indicates that this procedure can be considered as a possible treatment option, even in these complex defects, when comorbidities are concomitantly addressed.

Neglected ununited tibial eminence fractures in the skeletally immature: arthroscopic management.

The purpose of this study was to prospectively evaluate outcomes of arthroscopic management of neglected ununited tibial eminence fractures in skeletally immature patients. The study was conducted and cases performed by two surgeons from two centres as a prospective case series of 13 patients with neglected ununited tibial eminence fractures: nine were girls and four were boys; ten were right knees and three were left. The average age at surgery was ten [standard deviation (SD) 2.6] years. Average follow-up was 10.8 (SD 6.8) months. Primary outcome measures used for evaluation were the Objective International Knee Documentation Committee Score (IKDC), subjective IKDC and modified Lysholm knee score. Secondary outcome measures were visual analogue scales (VAS) for pain and patient satisfaction. Twelve patients had grade A objective IKDC score and one patient had grade B. Average subjective IKDC score was 80.5 (SD 16.7). Average modified Lysholm score was 91.2 (SD 8.9). Average VAS for operation satisfaction was 9.6 (SD 0.5) and for pain was 0.4 (SD 0.5). All patients showed radiological union and anatomical reduction at an average of 12.4 weeks postoperatively. At follow-up, all 13 patients showed complete range of motion (ROM). Eleven patients had negative Lachman, anterior drawer and pivot-shift tests, while two patients had grade 1 positive Lachman and negative anterior drawer and pivot-shift tests. No patient had complained of instability. Neglected ununited tibial eminence fractures in skeletally immature patients achieve good functional outcome results when treated with arthroscopic reduction and internal fixation using sutures.

Clinical outcomes and complications of a collagen meniscus implant: a systematic review.

The purpose of this systematic review was to summarise and evaluate the clinical outcomes of the collagen meniscus implant (CMI) and its complication and failure rates. These data were then used to evaluate the results of the CMI at different follow-up time periods and investigate possible differences in the behaviour of lateral and medial CMI. A comprehensive search was performed in PubMed, MEDLINE, CINAHL, Cochrane, EMBASE and Google Scholar databases using various combinations of the following keywords: "collagen meniscus implant" or "collagen meniscal implant". All studies evaluating medial or lateral CMI using the Lysholm score, visual analogue scale (VAS) for pain, Tegner activity scale and subjective or objective International Knee Documentation Committee (IKDC) scores were included in the systematic review. Eleven studies were included in the systematic review. The pooled number of patients involved in CMI surgery were 396 (90.2 % medial, 9.8 % lateral), with a mean age at surgery of 37.8 years. Concomitant procedures were present in 48.8 % of patients; most of them were anterior cruciate ligament (ACL) reconstruction, high tibial osteotomy (HTO) and microfractures. The Lysholm score and VAS for pain showed an improvement at six months up to ten years. No noticeable differences were present comparing short-term values of Lysholm score between medial and lateral CMI. The Tegner activity level reached its peak at 12 months after surgery and showed a progressive decrease through five and ten years post CMI implantation, however always remaining above the pre-operative level. Only a few knees were rated as "nearly abnormal" or "abnormal" at IKDC grading at all follow-up evaluations. The CMI could produce good and stable clinical results, particularly regarding knee function and pain, with low rates of complications and reoperations.

Effect of Cigarette Smoking on the Clinical Outcomes of ACL Reconstruction.

We compared the clinical outcomes of nonsmokers, current smokers, and former smokers following reconstruction of the anterior cruciate ligament (ACL) and investigated the association between the amount of smoking and outcomes following ACL reconstruction. We retrospectively reviewed the records of 251 patients who underwent unilateral ACL reconstruction with use of bone-patellar tendon-bone autograft between January 2002 and August 2009. Patients were divided into three groups according to smoking history: Group 1, nonsmokers; Group 2, current smokers; and Group 3, former smokers. Preoperative values and twenty-four-month postoperative findings were compared among the groups. The stability of the ACL was evaluated with use of the Lachman test and the pivot-shift test, and anterior translation was tested with a KT2000 arthrometer. Functional outcomes were assessed on the basis of the Lysholm score and the International Knee Documentation Committee (IKDC) subjective score and objective grade. The three groups differed significantly in terms of postoperative knee translation, Lysholm score, and IKDC subjective score. The mean side-to-side difference in anterior translation (and standard deviation) was 2.08 ± 1.08 mm in Group 1 (nonsmokers), 2.65 ± 1.31 mm in Group 2 (smokers), and 2.15 ± 1.05 mm in Group 3 (former smokers) (p = 0.003). The mean Lysholm score was 90.5 ± 6.5 in Group 1, 86.0 ± 7.1 in Group 2, and 89.8 ± 6.3 in Group 3 (p < 0.001). The mean IKDC subjective score was 89.3 ± 5.1 in Group 1, 84.9 ± 7.5 in Group 2, and 88.5 ± 4.2 in Group 3 (p < 0.001). However, the difference in the IKDC subjective score among the three groups did not demonstrate a minimal clinically important difference. A dose-dependent association was noted between pack-years of exposure and postoperative anterior translation (estimate, 0.039; p = 0.015) and IKDC objective grade (odds ratio, 1.083; p = 0.002). A comparison of the three subgroups of smokers showed a significant difference in anterior translation (a mean side-to-side difference in anterior translation of 2.31 ± 1.17 mm for the light smokers, 2.60 ± 1.14 mm for the moderate smokers, and 3.29 ± 1.55 mm for the heavy smokers; p = 0.038). The three subgroups also differed significantly in terms of the proportion of cases by IKDC objective grade; among the light smokers, thirteen (42%) were grade A, fifteen (48%) were grade B, two (7%) were grade C, and one (3%) was grade D; among the moderate smokers, seven (35%) were grade A, eight (40%) were grade B, four (20%) were grade C, and one (5%) was grade D; and among the heavy smokers, one (6%) was grade A, eight (44%) were grade B, eight (44%) were grade C, and one (6%) was grade D (p = 0.013). Cigarette smoking appeared to have a negative effect on subjective and objective outcomes of ACL reconstruction, and heavy smokers showed greater knee instability. Patients who had stopped smoking at least one month prior to ACL reconstruction had no significant difference in outcomes compared with patients who had never smoked. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Large Knee Osteochondral Lesions With a Biomimetic Scaffold

Background: Osteochondral knee lesions represent a challenging condition encountered by orthopaedic surgeons. A variety of methods have been developed to repair articular cartilage defects. However, these techniques are limited by donor site morbidity or by the requirement for a staged procedure. Purpose: To assess the effectiveness of a biomimetic osteochondral scaffold for the treatment of large osteochondral knee lesions. Study Design: Case series; Level of evidence, 4. Methods: From 2009 to 2011, a total of 49 patients affected by isolated large osteochondral knee lesions (mean [± SD] size, 4.35 ± 1.26 cm2) were treated with the biomimetic scaffold. Patients were evaluated using the International Knee Documentation Committee (IKDC), Tegner, and visual analog scale (VAS) pain scores, as well as magnetic resonance imaging (MRI) up to 3-year follow-up. The MOCART (magnetic resonance observation of cartilage repair tissue) score was performed to analyze different variables. Biopsies were carried out in 5 patients. Four of the 5 second-look arthroscopies and biopsies were performed on patients with failed results because of ethical issues. Results: The mean IKDC subjective score increased significantly from 45.45 ± 19.29 preoperatively to 70.86 ± 18.08 at 1-year follow-up and to 75.42 ± 19.31 at 2-year follow-up (P < .001). The IKDC objective score changed from 50% normal and nearly normal knees before treatment to 89.79% at the 2-year follow-up. There was a statistically significant improvement (P < .005) in VAS score from the preoperative level (6.69 ± 1.88) to the 2-year follow-up (1.96 ± 2.47). Tegner scores increased (P < .001) from the preoperative value (2.20 ± 0.67) to the 2-year follow-up (4.9 ± 1.73) without achieving preinjury level. A correlation was found between the IKDC subjective score and age (P < .001, r = −0.497, ρ = −0.502). Patients affected by osteochondritis dissecans (OCD) achieved a statistically significantly better outcome (P < .05). A subgroup of 19 competitive athletes showed a statistically significantly improvement (P < .001) in the subjective IKDC (86.5 ± 13.2) compared with the nonathletic subpopulation (69.03 ± 19.41) at the 2-year follow-up. The MRI findings of 30 patients were available at 2-year follow-up: 70% showed complete filling of the lesion, 63.3% had an intact articular surface, and 86% had mild or no effusion. In all cases, in dual T2-weighted fast spin echo sequence, the repair tissue showed a hyperintensive signal with respect to the surrounding subchondral bone; however, no edema was observed. Conclusion: The study findings indicate that the biomimetic scaffold that was investigated is an off-the-shelf, cell-free, and cost-effective implant that can regenerate either cartilage or subchondral bone. The scaffold allows a 1-step surgical procedure that can be used for osteochondral lesions, OCD, and in some cases osteonecrosis.

Treatment of Full-Thickness Chondral Defects With Hyalograft C in the Knee

Background: Matrix-associated autologous chondrocyte transplantation (MACT) has become an established articular cartilage repair technique. It provides good short-term and midterm results; however, long-term results are lacking. Purpose: To prospectively assess the clinical outcome after MACT in the knee to report long-term results. Study Design: Case series; Level of evidence, 4. Methods: Fifty-three subjects (females/males, 22/31; mean age, 32 ± 12 years) were treated between 2000 and 2006 with a hyaluronan-based MACT product and were followed prospectively. The mean body mass index (BMI) was 24.5 ± 3.8 kg/m2 and the mean defect size was 4.4 ± 1.9 cm2. Fifty patients had single defects and 3 had multiple defects (41 medial femoral condyle, 6 lateral femoral condyle, 2 patella, 1 tibia). Two patients had 2 defects (medial femoral condyle [MFC]/lateral femoral condyle and tibial/MFC), and in 1 case, multiple defects on the MFC were treated. The patients were stratified into 23 “simple,” 22 “complex,” and 8 “salvage” cases. Instability or malalignment was treated before or at the time of graft implantation. For 6 patients with small defects (<2 cm2), microfracturing was used as first-line treatment before MACT. Clinical assessment was performed once a year with the subjective and objective International Knee Documentation Committee (IKDC) scores, Lysholm score, and a modified Cincinnati Knee Rating System. Results: The mean follow-up time was 9.07 ± 2.9 years (range, 5-12 years). Treatment failure occurred in 12 of 53 cases (22.6%) an average of 2.99 ± 1.40 years after surgery. There was 1 failure (4.3%) among the simple cases, 4 failures (18.2%) in complex cases, and 7 failures (87.5%) in salvage cases. Statistically significant increases were observed in all scores at all time points compared with presurgery levels (P < .05). The subjective IKDC score improved from median 40.4 preoperatively to 74.7 at 10-year follow-up (n = 13 patients; P < .05). Conclusion: MACT is an excellent surgical therapy for full-thickness cartilage defects of the knee, with good long-term results for simple defects. However, it should not be used in salvage cases.

Computer-assisted navigation in ACL reconstruction is attractive but not yet cost efficient

Conventional reconstruction of the anterior cruciate ligament (ACL) has a high success rate. Computer-assisted navigation systems (CANSs) have been developed to further improve the accuracy of tunnel positioning. What is the economic impact from the hospital perspective? Patients having a first ACL reconstruction procedure were included in a prospective multicentre open controlled study comparing two groups: CANS versus conventional surgery. The primary clinical efficacy criterion was the objective International Knee Documentation Committee score at 1-2-year follow-up. Costs were collected retrospectively nationwide. No significant differences were found for the clinical effectiveness between conventional surgery (100 patients) and CANS (114 patients) at follow-up: ORadjusted 1.01 [0.36-2.84] (n.s). Junior surgeons achieved a significant mean decrease in operating time during the study period: 30% in the CANS group compared with 10% in the control group (p<0.01). The average cost of surgery was 704<euro> for the control group and 1,158<euro> for the CANS group (p<0.01). The cost of the operating room accounts for >70% of the total cost. The surgeon's status and the technical CANS learning effect influenced this cost. The cost differential between the two groups decreased with 'CANS' expertise: 238<euro> and 271<euro> in 'expert' centres versus 427<euro> to 731<euro> in other centres. While our study demonstrates the feasibility and the potential interest of CANS for training in ACL reconstruction, from a hospital perspective it is not cost efficient at present. Economic and decision analysis-developing an economic or decision model, Level II.

Anatomic anterior cruciate ligament double-bundle reconstruction

Background Many techniques for reconstruction of the anterior cruciate ligament (ACL) have been described. There is a trend towards the use of double-bundle techniques for the reconstruction of the ACL. Such techniques aim to reconstruct both bundles, and, theoretically, should provide a superior construct that would reduce rates of failure and improve the functional anatomy. In this study, the clinical results of double-bundle ACL reconstruction have been reported. Patients and methods Between 2008 and 2010, 19 patients suffering from ACL tear were treated using double-bundle ACL reconstruction. Results The objective International Knee Documentation Committee score and the modified Cincinnati subjective score were significantly higher in the double-bundle technique. The pivot-shift test was negative in 97% of the patients. Conclusion The main advantage of double-bundle rather than single-bundle reconstruction is its better rotational stability.

Short-term functional outcomes of a delayed single-stage reconstruction of chronic posterior cruciate ligament and posterolateral corner deficiency.

To evaluate the functional outcomes of a delayed (>6 months post-injury) and combined reconstruction of grade III posterior cruciate ligament (PCL) and grade III posterolateral corner (PLC) deficiencies. Between March 2006 and October 2009, a delayed surgery consisting of arthroscopically-assisted PCL reconstruction and open reconstruction of the PLC was performed on 19 men and 2 women (average age, 29 years). The mean time-to-surgery was 18 months (range, 7-51 months) and duration of follow-up was 22 months (range, 12-48 months). Postoperatively, patients were evaluated using Lysholm score, Tegner activity score, and International Knee Documentation Committee (IKDC) subjective and objective scores. At the final follow-up, majority of the knees (61.9%) achieved either normal or nearly normal rating objective IKDC score. The means of IKDC subjective score, Lysholm score and Tegner activity level were 62.09, 74.35 and 5.14 respectively. One patient was able to participate in competitive sport, 5 patients were able to be involved in recreational sports for at least 5 times per week, 10 patients were able to perform heavy labour and recreational sports for at least twice weekly, 4 patients were able to engage in moderately heavy labour work and one patient was only able to perform light labour work. There was no significant statistical association found between the time-to-surgery and the final patients' outcomes. A delayed simultaneous reconstruction of chronic grade III PCL and PLC deficiencies can restore sufficient function for standard daily and recreational sports activities to the patients.

Symptomatic Early Osteoarthritis of the Knee Treated With Pulsed Electromagnetic Fields: Two-Year Follow-up.

Objective:In vitro and in vivo studies have proven a pro-anabolic and anti-catabolic activity within cartilage with the use of pulsed electromagnetic fields (PEMFs). This has piqued interest of sports physicians for its use in the treatment of early osteoarthritis (OA). The aim was to determine if the use of PEMFs in patients with early OA of the knee would lead to an improved clinical outcome.Study design:Prospective case series.Methods:Twenty-two patients aged between 30 and 60 years who underwent treatment with PEMFs (4-hour treatment per day, duration 45 days) were included. All patients presented with symptomatic early OA with grade 0-2 changes (Kellgren-Lawrence classification) at the pretreatment evaluation. Patients were evaluated before treatment, at 1- and 2-year follow-up using visual analogue scale for pain, International Knee Documentation Committee objective, Tegner, and Knee Injury and Osteoarthritis Outcome Scores.Results:A significant improvement in all scores was observed at 1-year follow-up (P = 0.008). At 2-year follow-up, results deteriorated but were still superior to pretreatment levels (P = 0.02). No adverse reactions or side effects were seen.Conclusions:This study showed that the use of PEMFs in patients with symptomatic early OA of the knee led to significant improvement in symptoms, knee function, and activity at 1-year follow-up. There was a significant decline in all the scores at 2-year follow-up.

Management of Combined Anterior Cruciate Ligament–Posterolateral Corner Tears

Background: A consensus on the treatment of combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries is still lacking. Purpose: To review the available literature on the management of these combined lesions to investigate the influence that injuries of knee posterolateral structures play in the outcome of an ACL lesion. Study Design: Systematic review; Level of evidence, 4. Methods: A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: “posterolateral corner,” “plc,” “posterolateral instability,” “posterolateral injury,” “anterior cruciate ligament,” and “acl.” Results: A total of 6 studies involving 95 patients were included. For those with PLC lesions, 14 patients were treated nonoperatively, 9 underwent an early anatomic repair, while the remaining 72 underwent a reconstruction. In all 95 patients, an ACL reconstruction was performed. Sixty-seven of the 72 patients who underwent a PLC reconstruction were assessed for anteroposterior laxity, with a mean side-to-side difference of 1.5 ± 1.1 mm. Evaluated by the objective International Knee Documentation Committee (IKDC) Knee Form, 88% of the patients who underwent a PLC reconstruction were graded as good/excellent (A/B). The 9 patients who underwent an early surgical repair of the PLC lesion were evaluated by means of the objective IKDC score, with 3 patients (33%) graded as good/excellent (A/B), and by means of a clinical evaluation, with 5 of 9 patients (56%) graded as 1+ for varus laxity. For the 14 patients who were managed nonoperatively for PLC injuries, the only clinical score available was the subjective IKDC score, with a mean value of 80.5 (87.8 for the 6 patients with type A PLC injuries and 75.0 for type B PLC injuries). Conclusion: There is a paucity of literature focused on the management of combined ACL and PLC injuries. Combined ACL and PLC reconstruction seems to be the most effective approach to these combined lesions. However, future work is needed to explore the long-term outcome of the different treatment options.

Arthroscopic Meniscus Allograft Transplantation in Male Professional Soccer Players

Background: Meniscus allograft transplantation (MAT) is an option for symptomatic patients who have undergone subtotal meniscectomy and can potentially result in pain relief and increased function. Hypothesis: Professional soccer players would benefit from arthroscopic MAT in terms of pain, knee function, and return to play at 36-month follow-up. Study Design: Case series; Level of evidence, 4. Methods: Twelve male patients who had undergone MAT (6 medial, 6 lateral) were prospectively evaluated at 12- and 36-month follow-up. The mean age at the time of surgery was 24.5 ± 3.6 years (range, 19-29 years), and the mean time from meniscectomy to surgery was 37 ± 31 months (range, 2-82 months). The transplantation was performed in patients who had undergone subtotal meniscectomy using an arthroscopic bone plug–free technique with a single tibial tunnel plus “all-inside” meniscus sutures. The anterior horn of the transplanted meniscus was sutured to the capsule and to the remnant of the anterior horn of the native meniscus. Seven patients (58%) underwent concurrent procedures. All patients were evaluated at follow-up by the Tegner, Lysholm, International Knee Documentation Committee (IKDC) subjective, IKDC objective, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and visual analog scale (VAS) for pain scores. Information regarding rehabilitation, return to play, and return to official competition was recorded. Results: Eleven of the 12 patients (92%) returned to play soccer. At 36-month follow-up, 9 patients (75%) were still playing as professionals (Tegner score of 10), whereas 2 patients (17%) were playing as semiprofessionals (Tegner score of 9). The mean time from surgery to the end of rehabilitation was 7.5 ± 2 months, whereas the mean time to official competition was 10.5 ± 2.6 months. Patients demonstrated significant improvements on the median Tegner score from 8 (interquartile range, 3-10) to 10 (interquartile range, 9-10) (P = .0391); the mean Lysholm score from 67 ± 14 to 92 ± 10 (P = .0021); the mean IKDC subjective score from 61.8 ± 16.3 to 85.3 ± 9.8 (P = .0026); the mean IKDC objective score from 1 A, 8 B, 1 C, and 2 D to 7 A and 5 B (P = .0077); the mean WOMAC score from 77.1 ± 15.9 to 92.2 ± 9.1 (P = .0242); and the mean VAS score from 61 ± 16 to 29 ± 32 (P = .0029) at 12-month follow-up. There were no significant improvements in these outcomes at 36-month follow-up. One patient developed a knee infection after MAT plus anterior cruciate ligament allograft reconstruction. This complication was successfully treated, but the patient stopped playing soccer (Tegner score of 3 at 36-month follow-up), and this was considered a failure (8%). Conclusion: Arthroscopic MAT in professional soccer players allowed a return to play at the same level (Tegner score of 10) in 75% of the cases at 36-month follow-up.

Transtibial Versus Independent Drilling Techniques for Anterior Cruciate Ligament Reconstruction

Background: While numerous cadaveric, in vivo, and clinical studies have compared transtibial and independent drilling of femoral tunnels during anterior cruciate ligament reconstruction, there is no evidence-based consensus on which technique affords the best outcome. Hypothesis: There is no difference in clinical outcome between transtibial and independent drilling of femoral tunnels. Study Design: Systematic review with meta-analysis and meta-regression. Methods: Cadaveric, in vivo, and clinical studies comparing transtibial and independent drilling techniques were systematically identified. A qualitative synthesis of nonrandomized studies and meta-analysis of randomized controlled trials (RCTs) were performed. In addition, a meta-regression analysis of RCTs that did not directly compare drilling techniques was performed. Results: A total of 49 studies were included in the qualitative review, and 15 were included in the meta-analysis; 22 studies were included in the meta-regression. In biomechanical studies, independent drilling placed the center of the femoral tunnel closer to the center of the femoral footprint (mean difference, 2.69 mm; 95% CI, 0.46-4.92; P < .00001). Independent drilling reduced anterior tibial translation with the Lachman examination (mean difference, 2.2 mm; 95% CI, 0.34-4.07; P = .02), 134 N of anterior load (mean difference, 1 mm; 95% CI, 0.29-1.71; P = .006), and simulated pivot shift (mean difference, 3.36 mm; 95% CI, 1.88-4.85; P < .00001). The meta-analysis showed improved Lysholm scores with independent drilling (mean difference, −0.62 points; 95% CI, −1.09 to −0.55; P = .009), although the clinical relevance of this small difference is questionable. There were no significant differences in International Knee Documentation Committee (IKDC) objective scores or Tegner scores between groups. With the meta-regression, there were no significant differences in failure rates or IKDC objective scores. Conclusion: While there are biomechanical data suggesting improved knee stability and more anatomic graft placement with independent drilling, no significant clinical differences were found between the 2 techniques. Clinical Relevance: The current evidence shows that transtibial and independent drilling techniques have equivalent clinical outcomes at short-term to midterm follow-up. The long-term effects of subtle differences in tunnel position and postoperative knee kinematics should be further studied in dedicated, prospective cohort and randomized studies.

Graft Selection in Anterior Cruciate Ligament Reconstruction for Smoking Patients

Background: There has been no previous study regarding graft selection in anterior cruciate ligament (ACL) reconstruction for smoking patients. Purpose: To compare the clinical outcomes of ACL reconstruction between smokers and nonsmokers and to find an optimal graft in ACL reconstruction with regard to clinical outcomes for smoking patients. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 487 patients who underwent unilateral ACL reconstruction were retrospectively reviewed. Included patients were divided into 2 groups according to their history of smoking. Group 1 was composed of patients who had never smoked (n = 322), and group 2 consisted of patients who had reported smoking before ACL reconstruction and during rehabilitation (n = 165). Additionally, each group was divided into 4 subgroups according to the selected graft type (bone–patellar tendon–bone autograft, hamstring [semitendinosus-gracilis] tendon autograft, quadriceps tendon–bone autograft, or Achilles tendon–bone allograft). Patients were assessed for knee instability with the Lachman and pivot-shift tests as well as anterior translation measured by the KT-2000 arthrometer. Functional outcomes were evaluated with the Lysholm knee score, International Knee Documentation Committee (IKDC) subjective score, and IKDC objective grade. Results: The minimum follow-up period was 24 months. At the final follow-up evaluation, there were significant mean between-group differences regarding the side-to-side difference in anterior translation (group 1, 2.15 ± 1.11 mm; group 2, 2.88 ± 1.38 mm; P < .001), Lysholm knee score (group 1, 90.25 ± 6.18; group 2, 84.79 ± 6.67; P < .001), IKDC subjective score (group 1, 89.16 ± 5.01; group 2, 83.60 ± 7.48; P < .001), and IKDC objective grade (group 1, grade A = 151, B = 130, C = 36, D = 5 patients; group 2, grade A = 48, B = 71, C = 37, D = 9 patients; P < .001). With regard to differences in outcomes between the selected grafts within each group, the Achilles tendon–bone allograft showed the worst outcomes, with statistically significant mean differences for smoking patients in the side-to-side difference in anterior translation (3.59 ± 1.26 mm), Lysholm knee score (81.05 ± 2.82), and IKDC subjective score (79.73 ± 4.29). Conclusion: Unsatisfactory outcomes with regard to stability and functional scores were shown in the smoking group compared with the nonsmoking group. In smokers, the patients receiving an Achilles tendon–bone allograft had poorer outcomes than those with autografts. The bone–patellar tendon–bone autograft is recommendable for ACL reconstruction in a smoking patient.

Anatomic, Physeal Sparing Anterior Cruciate Ligament Reconstruction in the Skeletally Immature

This case series evaluates an anatomic, physeal sparing ACL reconstruction technique in four patients that has preliminarily proven to be effective, both objectively and subjectively, in the skeletally immature. With the growing incidence of anterior cruciate ligament (ACL) injuries in the pediatric population, there has been interest in developing a technique to reconstruct the ligament without disturbing the physes. Previously described all epiphyseal reconstructions spare the growth plates but do not restore the native orientation of the ACL. This case series evaluates an all-epiphyseal technique where the graft is more anatomically placed, particularly on the tibial side. Four skeletally immature patients, one female and three males with an average age of 10.3 ± 2 yrs. (8.4-12.2 yrs.), underwent soft tissue allograft anterior cruciate ligament reconstruction using an all-epiphyseal approach. Two patients had acute ACL tears (< 4 weeks old) and two patients had chronic tears. One of the chronic tear patients had an acute lateral meniscal tear. All reconstructions were performed with an arthroscopically assisted approach by the senior author (CHB). The femoral tunnel was drilled parallel to the physis in the epiphysis of the lateral femoral condyle. The tibial tunnel was drilled from inside to outside using a retrograde drill to the level of the physis. A 2mm guide pin traversing the tibial physis was used to guide the tibial retrograde drill. Intraoperative C-arm imaging confirmed that drilling did not violate the physes. The tibial sided graft was fixed to the anterior tibial cortex over a button. The femoral side was secured with an absorbable interference screw placed from outside to inside. All patients underwent radiographic and MRI evaluation at final follow-up. Subjective and objective measures included KT-1000 testing as well as International Knee Documentation Committee (IKDC) subjective and objective and Lysholm scoring. Mean follow-up was 2.3 ± 0.55 yrs. (1.6-2.9 yrs.). All patients had stable knees and no evidence of limb length discrepancy or angular deformity. Pre-operative KT-1000 testing demonstrated a mean side to side difference of 6mm. Post-operative KT-1000 testing revealed a mean side to side difference of 1.4 ± 0.75mm (0.5-2.0mm). The mean IKDC subjective knee score was 95.7 ± 1.5 (93.8-96.9). The mean Lysholm knee score was 95.5 ± 5.7 (88-100). IKDC objective knee form ratings were A (normal) for the two acute patients, B (nearly normal) for one chronic patient, and C (abnormal) for the one chronic ACL/lateral meniscus repair patient. MRI at two years post operation demonstrated no meniscal or chondral injuries, intact ACL grafts, and no evidence of asymmetric physeal arrest. All patients returned to pre-injury activity levels. This anatomic, all-epiphyseal anterior cruciate ligament reconstruction has preliminarily proven to be effective, both objectively and subjectively, in the skeletally immature. In this series the acutely reconstructed patients had better knee scores. Further follow-up and larger series are needed to confirm long-term efficacy.

Reply to comment on Gong et al.: Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis

1. The readers argue that we did not focus specifically or in any detail on the issue of the completeness of the search strategy report for databases. We agree with them that the search strategy report is important in a meta-analysis. We did not list detailed index terms in the article, however, this did not mean that we neglected the role of the search strategy. Two authors (XL and CPX) independently retrieved relevant studies by means of electronic search. In addition, the reference lists of identified studies were manually checked to identify other potentially eligible trials. This process was performed iteratively until no additional articles could be identified. But we thank the readers for the suggestion all the same. 2. The readers point out that the method of Mantel-Haenszel (M-H) or inverse-variance (IV) with the assumptions of a random-effects model detail should be changed to the DerSimonian and Laird random-effects model which is more suitable. We greatly appreciate the advice by the readers, whereas we are sorry to state that the statistical software used in our article is Revman 5.0, so that we could not consider the latter statistical choice due to the functional limitations of the software. But, again, we pooled the data of the groups and performed further meta-analysis using the DerSimonian and Liard random effects model with the help of STATA version 11.0 (Stata Corporation, College Station, Texas, USA), and found that it did not materially alter the previous pooled results which show our main finding was robust. 3. The results of the objective International Knee Documentation Committee (IKDC) are really incorrect. Amazingly, the standpoint of the readers is also wrong. By our scrutiny, there is an obvious clerical error in the context: “The forest plot showed doublebundle reconstruction had better objective IKDC final score, and the difference was statistically significant.” It is not difficult to see that “the difference was statistically significant” should be replaced by “the difference was not statistically significant” according to the consecutive content. 4. We also agree that statistical quantitative tests should be adopted to evaluate funnel plot symmetry. Nevertheless, the mission is also impossible to complete by Revman software. Additionally, the readers recommend that publication bias should be assessed for all the outcomes. Actually, we really considered the issue beforehand. Because of space limitation, we decided to adopt a typical funnel plot. Besides, we agree that limited publication language may cause a bias. So the language limitation has been already emphasised in our discussion, furthermore, it is a common limitation in a meta-analysis [3, 4], so we do not think it is a controversial. X. Li : J.<q. Song :N. Jiang : B. Yu (*) Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, No.1838, Guangzhou Avenue North, Guangzhou 510515, People’s Republic of China e-mail: nanfanghot@126.com

Partial ACL Tears: Anatomic Reconstruction Versus Nonanatomic Augmentation Surgery

Treatment of partial anterior cruciate ligament (ACL) tears requires ACL remnant preservation. The goal of this study was to compare the outcome of anatomic reconstruction of the torn bundle with nonanatomic augmentation using the over-the-top femoral route. Fifty-two athletes (mean age, 23.3 years) with partial ACL lesions underwent anatomic reconstruction (n=26) or nonanatomic augmentation (n=26). Intraoperative damage of the healthy bundle that required a standard ACL reconstruction occurred in 2 patients in the anatomic reconstruction group. International Knee Documentation Committee (IKDC) score, Tegner score, and arthrometer evaluation were used pre-operatively and at follow-up for up to 5 years postoperatively. One failure occurred in the anatomic reconstruction group. Mean IKDC subjective score at follow-up was 88.2 ± 5.7 in the anatomic reconstruction group and 90.2 ± 4.7 in the nonanatomic augmentation group. According to the IKDC objective score at final follow-up, 96% of knees in the nonanatomic augmentation group were normal vs 87.5% in the anatomic reconstruction group. No significative differences were observed between the 2 groups at final follow-up. Anteromedial bundle reconstruction showed significantly lower IKDC subjective and objective scores and higher residual instability values as evaluated with the arthrometer compared with posterolateral bundle reconstruction (P=.017). The surgical treatment of ACL partial tears is demanding. Adapted portals, perfect control of the tunnel drilling process, and intercondylar space management are required in anatomic reconstruction. The nonanatomic augmentation technique is simpler, providing excellent durable results over time with a lower complication rate. Anteromedial bundle reconstruction is associated with a poorer outcome, especially when performed with anatomic reconstruction.

Comment on Li et al.: Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis

Dear Editor, In International Orthopaedics, Xue Li and his colleagues published a meta-analysis conducted to compare the efficacy of arthroscopic single-bundle and double-bundle anterior cruciate ligament reconstruction, and they did very well [1]. However, the meta-analysis has brought a few questions to our minds that we would like to convey to the authors: Publication language was limited to English in the meta-analysis. Therefore, the authors should mention the potential importance of language bias in the limitations of their meta-analysis. In the article, the authors used the odds ratio (OR) for dichotomous outcomes to report the risk value rather than relative risk (RR). As there are 17 randomised controlled trials (RCTs) included, RR can report the real risk value better than OR. Therefore, we suggest that RR should be used to report the risk value in this article. It is not sufficient that publication bias was only assessed by visual examination of a funnel plot. Funnel plot symmetry should be further assessed by statistical tests (e.g. Egger’s linear regression test or Begg’s rank correlation test). Moreover, in the meta-analysis, publication bias was only assessed for KT1000 arthrometer measurements. Actually, publication bias should be assessed for other comparisons (such as Lysholm score, objective International Knee Documentation Committee score, negative pivot-shift test). Therefore, publication bias may be present, distorting the meta-analysis. It is not appropriate that summary OR and standard mean difference (SMD) estimates with corresponding 95 % confidence intervals were derived by using the method of Mantel-Haenszel (M-H) or inverse variance (IV) with the assumptions of a random effects model. However, studies should be combined by using the DerSimonian and Laird random effects model, which considers both within- and between-study variations [2]. The difference in the follow-up periods between studies was large, which may cause heterogeneity. Subgroup analysis was performed by stratifying the available data according to follow-up periods. To make the article more credible, the authors should analyse the effect of single-bundle versus double-bundle anterior cruciate ligament reconstruction according to different ages and sexes on account of the limitation of the studies included. Moreover, further high-quality RCTs based on larger sample sizes are still needed. Evidence indicated that only the larger study should be included for analysis when some publications contained the same or overlapping data. There are two studies performed by Jarvela et al. [3, 4] containing overlapping data. In the two studies, all patients were recruited from Hatanpaa Hospital, Tampere, Finland. Concerning patients with anterior cruciate ligament reconstruction, the study by Jarvela et al. [3] carried out in 2005 included 52 single-bundle and 25 double-bundle reconstructions, and the second study by Jarvela et al. [4] included 25 single-bundle and 35 double-bundle reconstructions. Therefore, the larger group of single-bundle reconstructions and the larger group of double-bundle reconstructions by Jarvela et al. [3, 4] should be included in this meta-analysis. Moreover, further high-quality RCTs based on larger sample sizes are still needed to compare arthroscopic single-bundle and double-bundle anterior cruciate ligament reconstructions. We believe that our remarks will contribute to more accurate elaboration of the results presented by Li et al.

Letter regarding article by Li et al.: Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis

Dear Editor, Recently, we read with great interest the article by Li et al. [1] entitled “Single-bundle versus double-bundle anterior cruciate ligament reconstruction: an up-to-date meta-analysis” published in February 2013 in “International Orthopaedics”. Li et al. performed a meta-analysis to compare the results of arthroscopic single-bundle and double-bundle anterior cruciate ligament (ACL) reconstruction. It is an interesting study. Nevertheless, we have several queries which we would like to communicate with the authors. Five electronic databases (PubMed, Cochrane Library, EMBASE, BIOSIS and Ovid) for randomised controlled trials were systematically searched by the authors. However, the authors did not focus specifically or in any detail on the issue of the completeness of the search strategy report for databases. The search strategy report plays an important role in meta analysis. It is not appropriate that summary odds ratio (OR) and standard mean difference (SMD) estimates with corresponding 95 % CIs were derived by using the method of Mantel-Haenszel (M-H) or inverse variance (IV) with the assumptions of a random-effects model in the forest plots (Figures 3, 5 and 9). Rather, studies should be combined by using the DerSimonian and Laird random-effects model, which consider both within- and between-study variations. The authors clearly stated that “the pooling of data showed that there was no significant difference between the single bundle and double-bundle techniques (OR 1.56; 95 % CI 0.82–2.95; P = 0.18)” in the objective International Knee Documentation Committee (IKDC) results section, which was controversial. We suggest that “no significant difference” should be replaced by “significant difference” in the results section. Meanwhile, the result of the forest plots for objective IKDC showed that the difference was statistically significant between single-bundle and double-bundle techniques. The publication language was limited to English in the meta-analysis. Therefore, the authors should mention the potential importance of language bias in the limitations of their meta-analysis. It is sufficient that publication bias was assessed by visual examination of the funnel plot. Funnel plot symmetry should be further assessed by statistical tests (e.g., Egger’s linear regression test or Begg’s rank correlation test). However, it is not clear that publication bias was assessed for which outcome. Actually, publication bias should be assessed for all the outcomes. Moreover, further high quality RCTs based on larger sample sizes are still needed to compare the arthroscopic single-bundle and double-bundle ACL reconstruction. We believe that our remarks will contribute to more accurate elaboration of the results presented by Li et al.