Intra-articular Anterior Cruciate Ligament Reconstruction Research Articles

Notch Regrowth After Anterior Cruciate Reconstruction (SS-42)

outcomes, there was no statistically or clinically significant difference between the groups (pain P=.54, ext loss P=.75, flex loss P=.45) Pain (VAS). Despite an average drainage volume of 154 mls there was no difference in the grade of haemarthrosis or thigh circumference between the groups. There were no infections or wound dehiscence in either group. Two patients in each treatment arm had an aspiration for a persistent effusion during the eight week follow-up. Conclusions: There are no demonstrable benefits in the routine use of an intra-articular suction drain post ACL reconstruction. Given the cost and need for an additional patient visit for removal, it’s use is difficult to justify.

Extra-articular lateral reconstruction technique

Summary: This article describes an anterolateral reconstruction procedure that, when used in combination with an intra-articular anterior cruciate ligament (ACL) reconstruction, restores rotary and anterior knee stability. We believe that failing to recognize lateral instabilities and to perform an extra-articular reconstruction is an under-recognized cause of failure of ACL reconstruction. We also describe the indications, medical histories, and physical examination tests used to determine when an anterolateral reconstruction is needed. One should suspect a compromise of the lateral structures when presented with a failed ACL reconstruction in which the tunnels, the graft, and the rehabilitation all seem to have been done properly, or when a prior lateral procedure has been attempted and failed. In our experience, if a second ACL reconstruction is undertaken without the benefit of a lateral reconstruction, it may fail as well.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 5 (July), 2000: pp 553–557

Anterior Cruciate Ligament Reconstruction Alters the Patellar Alignment

Summary: Although there are many articles dealing with anterior cruciate ligament (ACL) reconstruction, there are none dealing with the possibility of changes of the patellofemoral alignment after these procedures. Forty-six patients were evaluated preoperatively and 1 year postoperatively, after undergoing intra-articular ACL reconstruction, for changes of the patellofemoral alignment. Patella-tilt and congruence angles were measured on tangential view radiographs that were taken in the supine position. Analysis of covariance was performed and revealed a significant change of the congruence angle 1 year postoperatively. The patella-tilt did not change. One year postoperatively, the patella shifted on average 5° medially after ACL grafting. It can be deduced that anterior knee pain after ACL reconstruction could be caused by distinct changes in the patellofemoral alignment.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 2 (March), 1999: pp 165–168

Intra-articular ACL reconstruction in the over-40-year-old patient.

We compared two groups of patients who had undergone anterior cruciate ligament (ACL) reconstruction. The groups were similar in regard to sex distribution, index injury, absence of meniscal or chondral lesions, surgical technique, and postoperative rehabilitation programs, but different in age. In the study group the mean age was 42.6 years, while in the control group the mean age was 20 years. The clinical results were assessed at a mean of 29 months after surgery using the Lysholm score, International Knee Documentation Committee form, Tegner activity level, and the KT-1000 arthrometer test. No significant differences were reported. Standard X-ray studies showed no variation between the two groups in the postoperative period. Intra-articular ACL reconstruction using a bone-patellar tendon-bone graft can be recommended in selected patients over 40 years of age as an alternative to conservative treatment.

ACL reconstruction in children with open physes.

Nine male patients with wide open physes who underwent intra-articular anterior cruciate ligament (ACL) reconstruction using semitendinosus and gracilis tendon grafts passed through the tibial physis and over the top of the femoral condyles were retrospectively reviewed at an average follow-up of 39 months (range: 24 to 72 months). Five patients underwent reconstruction < 6 weeks following injury (range: 11 days to 41 days); the other four underwent reconstruction 2, 3, 5, and 24 months following injury. Seven patients had excellent results and fully returned to their sport. Mean Lysholm score in these patients was 99 (range: 95 to 100), and the mean maximum KT-1000 difference (available for six patients) was 2.8 mm (range: 0 to 5.5 mm). Four of six intact grafts had a mean maximum KT-1000 difference < or = 3.5 mm. Two grafts ruptured and were considered failures (one complete rupture at 10 months and one partial rupture at 3 years). Postoperative height increase averaged 10.7 cm (range: 4 to 22.9 cm). No patient had a clinically significant leg-length discrepancy, angular deformity, or radiographic evidence of physeal injury.

Anterior Cruciate Ligament Tears in Children: An Analysis of Operative Versus Nonoperative Treatment

A 12-year retrospective analysis of 42 children with arthroscopically confirmed anterior cruciate ligament disruption was undertaken to determine (a) the subjective efficacy of treatment, (b) the clinical and biomechanical results of operative and nonoperative management, and (c) the most appropriate long-term outcome measurements. Patients were followed up for a mean of 5.3 years from the time of initial treatment and were between the ages of 5 and 17 years (mean, 14.4) at the time of treatment. The children were treated nonoperatively by primary ligament repair or by intraarticular anterior cruciate ligament reconstruction. In the child, a complete tear of the anterior cruciate ligament was best managed by intraarticular surgical reconstruction. This was confirmed by clinical examination (p < 0.01), by a composite knee score involving a clinical examination and patient questionnaire (p < 0.0005), and by testing with the KT-1000 arthrometer. No significant differences in outcome could be attributed to the patient age or the maturity of the growth plates. In the active child, anterior cruciate reconstruction for complete tears resulted in a more stable and functional knee.

ACL Surgery and Accelerated Rehabilitation: Revisited

Rehabilitation following intraarticular anterior cruciate ligament (ACL) reconstruction has undergone a dramatic evolution during the last decade. This paper describes our accelerated rehabilitation program, which is divided into four phases. The preoperative phase begins immediately after injury and emphasizes control of swelling and restoration of full range of motion (ROM) and strength before surgery. Phase II, which includes the first 2 weeks after surgery, emphasizes helping the patient obtain full terminal knee extension and weight bearing. The final two phases focus on improving lower extremity strength and full return to daily and athletic activities. This accelerated program has resulted in an earlier return of ROM and strength as well as a decrease in postoperative procedures, without compromising ligamentous stability.

Revision anterior cruciate ligamentreconstruction

Anterior cruciate ligament (ACL) reconstruction has gained, wide acceptance as the treatment of choice for thefunctionally unstable ACL-deficient knee and is now performed on about a half million individuals, per year. The documented long-term good or excellent result rates for functional stability, relief of symptoms, and return to activity for intra-articular ACL reconstructions is approximately 75% to 95%. This leaves a substantial group of patients with an unsatisfactory result secondary to a variety of reasons. Review of the literature reveals that recurrent instability and graft failure are responsible for unsatisfactory results in as high as 8% of these patients. In this article, the factors responsible for graft failure and recurrent instability are discussed. In addition, the planning and difficulties that the orthopedic surgeon must address before, during, and after the procedure, are also reviewed.

Management of anterior cruciate ligament injuries in skeletally immature adolescents.

Anterior cruciate ligament (ACL) injuries in skeletally immature adolescents are being diagnosed and reported with increasing frequency. Nonoperative management of mid-substance ACL injuries in adolescent athletes frequently results in a high incidence of giving-way episodes, recurrent meniscal tears, and early onset of osteoarthritis. An intraarticular ACL reconstruction (using the central 10-mm patellar tendon graft) in young athletes approaching skeletal maturity provides predictable excellent knee stability, and the athletes are able to return to competitive sports with a decreased risk of recurrent meniscal and/or chondral injury. Guidelines for the management of ACL injuries in skeletally immature adolescents are presented.

Revision anterior cruciate ligament surgery: experience from Miami.

Failed anterior cruciate ligament reconstruction as defined by recurrent patholaxity is increasingly commonplace. This report presents the findings of 54 patients who had unsuccessful intraarticular anterior cruciate ligament reconstruction to correct persistent instability and who subsequently underwent revision anterior cruciate ligament surgery. Before revision, patients were evaluated by clinical examination, KT-1000 arthrometer, radiographs, Lysholm knee score, Tegner activity scale, and subjective questionnaire. The results were compared at a mean of 32 months following revision surgery. There was an average of 16 months from index procedure to the time of revision. Autogenous patellar tendon grafts were used in 61% of the cases with 30% of these harvested from the contralateral knee. Fresh frozen patellar tendon was used in 35% and autogenous hamstring tendons in 4%. Revision was successful in objectively improving stability in all patients with an average KT-000 of 2.8 mm. Autogenous tissue grafts provided greater objective stability when compared with allograft tissue with average KT-1000 of 2.2 and 3.3, respectively. Functionally, however, there was no significant difference in outcome between the 2 groups. Harvesting of the contralateral patellar tendon was found to have no adverse long term effect. Subjectively, the results were significantly worse depending on the degree of articular cartilage degeneration. Only 54% of patients returned to their preanterior cruciate ligament injury activity level. Competence in various anterior cruciate ligament reconstruction techniques will facilitate revision surgery especially in avoiding preexisting tunnels and hardware. Correct graft placement and addressing the secondary restraints are critical to successful revision surgery.

Long-term followup of anterior cruciate ligament reconstruction using freeze-dried fascia lata allografts.

We identified 79 patients who underwent arthroscopically assisted intraarticular anterior cruciate ligament reconstruction with freeze-dried fascia lata allografts and an additional lateral extraarticular reconstruction. We were able to contact 62 patients (79%) for follow-up evaluation at an average of 134.5 months. Forty patients (51%) returned for objective evaluation. Lysholm scores at followup averaged 92.3 and Tegner activity scores averaged 5.1. Only four (6%) of the 62 patients contacted reported episodes of full giving way. Thirty (75%) of the 40 patients examined demonstrated 3 mm or less side-to-side difference on KT-1000 arthrometer manual maximum evaluation. Forty-eight (77%) of the 62 patients were participating in sporting activities at final followup. No patient had evidence of graft rejection.

Anterior cruciate ligament reconstruction combined with valgus tibial osteotomy (combined procedure).

We assessed the patients who were operated on in a combined procedure from 1980 to 1992 with anterior cruciate ligament (ACL) insufficiency, cartilaginous lesions of the medial compartment, lesion of medial meniscus and varus malalignment. The combined operative procedure was autologous intra-articular ACL reconstruction with the middle third of the patellar ligament--partially augmented with Kennedy-ligament augmentation device (LAD) in hot dog technique--and high tibial osteotomy. The patients were examined according to the criteria of IKDC including testing of anterior stability with the KT-1000 arthrometer. Radiographically we checked axis and arthritis according to a modified score of Kannus. Twenty-seven of 34 patients who fulfilled the inclusion criteria could be followed up in three categories (2-5 years post-operatively, 5-10 years postoperatively, over 10 years post-operatively). Total qualification was good in 37%; there were no perioperative complications. Rehabilitation was not prolonged. Eighty-nine percent practised their preoperative job, over 50% had a higher level of sports activities than preoperatively, and more than 25% regained their pretraumatic sports capacity. Two-thirds had no giving way and less than 3 mm translation difference in comparison to the contralateral knee. Seventy-five percent of patients would accept the operation again. Radiological findings had no correlation to overall qualification. The encouraging results with respect to many of the criteria suggest using the combined procedure in a young patient with ACL insufficiency, varus malalignment and medial compartment damage including medial meniscus lesion.

Anterior cruciate ligament injuries in young athletes. Recommendations for treatment and rehabilitation.

Complete midsubstance tears of the anterior cruciate ligament (ACL) in skeletally-immature adolescents are being diagnosed and reported with increasing frequency. Conservative treatment of such ACL tears in junior high schools, subsequent meniscal tears, and very early osteoarthritis. Results of primary repair of the torn ACL and extra-articular reconstructive procedures have been disappointing. Intra-articular ACL reconstruction in young athletes approaching skeletal maturity using the autogenous patellar tendon graft gives excellent knee stability, and decreases the risk of meniscal tears. Athletes are able to return to competitive sports at their preinjury level. Here, the existing literature on the subject of midsubstance ACL tears in young athletes is reviewed, and guidelines for the management of ACL-deficient knee in this population are provided.

Results of surgical treatment of arthrofibrosis after ACL reconstruction.

We prospectively studied 31 knee arthrolyses performed for loss of motion after intra-articular anterior cruciate ligament (ACL) reconstruction. The arthrolysis was performed on average 10.6 months after the reconstruction (range 4-25). Seven knees were localized forms. They were treated with arthroscopic removal of a fibrous nodule and scar tissue anterior to the ACL, which was preserved. Twenty-four knees were global forms and treated arthroscopically (14) or in open procedure (10). Suprapatellar, medial, and lateral gutter adhesions were sectioned, and fibrous tissue was removed from the anterior compartment. A posteromedial and/or posterolateral capsulotomy was necessary in 7 knees. The ACL graft was nonfunctional and/or malpositioned in 19 knees. The results were evaluated with the IKDC form with an average follow-up of 3.5 years (range 1.5-7). Preoperatively the localized forms had an average extension loss of 11 degrees and an average flexion loss of 14 degrees compared to the opposite knee. At follow-up all the knees were satisfactory for symptoms. All except one achieved a satisfactory motion (within 5 degrees of extension loss and 15 degrees of flexion loss) and a satisfactory final result. Global forms had a greater preoperative flexion loss (average 34 degrees) and extension loss (average 17 degrees). At follow-up 58% were satisfactory for symptoms and 71% for arc of motion. However, the final result was satisfactory in only 37%. In conclusion, local forms have a good prognosis. In global forms motion may be improved by surgery, but the final result is downgraded by symptoms. Arthrolyses performed within 8 months from index operation had a better outcome.

Graft failure in intra-articular anterior cruciate ligament reconstructions: A review of the literature

There exists a substantial group of patients with unsatisfactory results following anterior cruciate ligament (ACL) reconstructions. This may be attributable to graft failure. Revision surgery, for the correction of abnormal anterior translation or laxity, requires a careful analysis of the causes of failure to ensure the success of the salvage procedure. This review attempts to present an overview of some of the important studies in the literature pertaining to the intraoperative and postoperative factors that probably cause graft failure. It was done by initial identification of the articles from a Medline database followed by the use of cross references. It shows that failures can be minimised by adhering to the correct operative and post-operative techniques wherein proper attention to the factors, such as: adequate notchplasty, proper tunnel placements, proper tensioning, adequate fixation, optimal selection and harvest of the graft, and rehabilitation, are ensured.

Can a regular leg extension bench be used in testing deficits of the quadriceps muscle during rehabilitation?

Fifty-nine people, 31 healthy subjects with no previous knee injuries and 28 who had undergone an intra-articular anterior cruciate ligament reconstruction 6-12 months prior to testing took part in the study. The subjects were randomly tested bilaterally on a Cybex 6000 isokinetic testing device (ITD) and on an ordinary leg extension bench (LEB). Strength and endurance were tested with both methods. The linear relationships for paired strength and endurance differences between ITD and LEB were found to be acceptable for the operated group. The LEB alone explained 57% and 38% of the ITD outcome for strength and endurance, respectively. The agreement between observed and predicted ITD values based on the LEB measurements was found satisfactory with a positive standardized agreement index. This indicates that the LEB can be used as a helpful tool in evaluation of quadriceps muscle strength deficits.

Current Concepts on Accelerated ACL Rehabilitation

It is well established that intra-articular anterior cruciate ligament reconstruction with autogenous bone-patellar tendon-bone graft provides satisfactory long-term stability. However, the rehabilitation programs employed following this surgical procedure have been a topic of considerable debate. This paper describes an accelerated rehabilitation protocol that is divided into four phases. The first phase encompasses the preoperative period, during which the patient will work to decrease swelling and restore range of motion and strength. The second phase involves Weeks 1 and 2 following surgery, with the patient emphasizing immediate terminal knee extension and weight bearing. The final two phases involve improving lower extremity strength and full return to daily and athletic activities. This accelerated rehabilitation protocol has resulted in an earlier return of range of motion and strength without compromising ligamentous stability.

The effect of intra-articular ACL reconstruction on the growth plates of rabbits

We performed intra-articular reconstruction of the anterior cruciate ligament (ACL) with the semitendinosus tendon placed in 2 mm diameter tunnels in 21 skeletally immature rabbits. The operation caused 11% damage to the physis of the femur on the frontal plane and 3% of its cross-sectional area but no alteration of growth or axial deviation of the bone resulted. In the tibia, the operation caused 12% damage to the physis in the frontal plane and 4% of the cross-sectional area. Two tibiae developed valgus deformities and one was shortened. Histological examination showed no areas of epiphysiodesis. There was no abnormality of growth-plate thickness in the two cases of tibia valga. Osseous metaplasia in the grafted tendons did not occur. The results suggest the need for careful evaluation of the percentage of damage to the growth plate before using intra-articular methods for reconstruction of the anterior cruciate ligament in adolescents.

Tibial attachment area of the anterior cruciate ligament in the extended knee position. Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo.

Knowledge of the anatomy of the anterior cruciate ligament (ACL), including its course and orientation in relation to the roof of the intercondylar fossa, is a prerequisite for successful intra-articular ACL reconstruction. To attain precision placement of the tibial attachment site and to avoid graft/roof conflict in the extended knee position, we assessed the anteroposterior tibial insertion of the ACL in the midsagittal plane of the extended knee. We measured the anterior-posterior (AP) limits and the center of the tibial attachment area of the ACL from the anterior tibial margin. The inclination angle of the intercondylar fossa roof was measured with respect to the shaft axis of the femur. The tibial attachment area of the ACL was determined in ten cadaveric knees. Using the cryoplaning technique, we determined the tibial attachment of the ACL in five knees. Using contrast magnetic resonance arthrography (MRA), we measured the tibial insertion of the ACL in 35 patients (23 male and 12 female) with intact ACLs. The total AP midsagittal diameter of the tibia averaged 51.0 +/- 5.8 mm in the cadaveric knees, 49 mm on cryosections, and 53.7 mm in men and 49.0 mm in women with MRA. The average anterior limit of the ACL, measured from the anterior tibial margin, was 14 +/- 4.2 mm in the cadaveric knees, 12.1 mm at cryosectional anatomy, and 15.2 mm in men and 13.4 mm in women with MRA.(ABSTRACT TRUNCATED AT 250 WORDS)

Outpatient surgical management of arthrofibrosis after anterior cruciate ligament surgery.

We present a consecutive series of nine patients who were referred to us because of arthrofibrosis (loss of > 15 degrees of extension) after intraarticular anterior cruciate ligament reconstruction using autogenous patellar tendon (eight patients) or semitendinosus (one patient) graft. Eight patients had surgery within 2 weeks of injury. All patients had been immobilized in flexion after the anterior cruciate ligament reconstruction and they had failed to improve despite vigorous physical therapy and other closed methods of treatment. The mean time from anterior cruciate ligament reconstruction to the subsequent surgery was 10.2 months (range, 3 to 14). The patients underwent an outpatient arthroscopic anterior scar resection, notchplasty, a closed knee manipulation for flexion, and extension casting. Serial daily extension cast changes allowed the patients to obtain full extension, which was maintained by a bivalved extension splint for bedtime use. Flexion was actively sought by aggressive outpatient physical therapy. All patients except one noted near-normal ultimate range of motion. One patient could only attain 10 degrees short of flat extension at the end of his rehabilitation and was considered a failed result. At final followup (mean, 31 months), no patient complained of symptoms of instability, all had a normal gait, and all but one were able to return to athletic activities.