Positive Lachman Test Research Articles

Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients' history elements and physical examination tests

ObjectiveTo assess the diagnostic validity of clusters combining history elements and physical examination tests to diagnose partial or complete anterior cruciate ligament (ACL) tears.DesignProspective diagnostic study.SettingsOrthopaedic clinics (n = 2), family medicine clinics (n = 2) and community-dwelling.ParticipantsConsecutive patients with a knee complaint (n = 279) and consulting one of the participating orthopaedic surgeons (n = 3) or sport medicine physicians (n = 2).InterventionsNot applicable.Main outcome measuresHistory elements and physical examination tests performed independently were compared to the reference standard: an expert physicians’ composite diagnosis including history elements, physical tests and confirmatory magnetic resonance imaging. Penalized logistic regression (LASSO) was used to identify history elements and physical examination tests associated with the diagnosis of ACL tear and recursive partitioning was used to develop diagnostic clusters. Diagnostic accuracy measures including sensitivity (Se), specificity (Sp), predictive values and positive and negative likelihood ratios (LR+/-) with associated 95% confidence intervals (CI) were calculated.ResultsForty-three individuals received a diagnosis of partial or complete ACL tear (15.4% of total cohort). The Lachman test alone was able to diagnose partial or complete ACL tears (LR+: 38.4; 95%CI: 16.0–92.5). Combining a history of trauma during a pivot with a “popping” sensation also reached a high diagnostic validity for partial or complete tears (LR+: 9.8; 95%CI: 5.6–17.3). Combining a history of trauma during a pivot, immediate effusion after trauma and a positive Lachman test was able to identify individuals with a complete ACL tear (LR+: 17.5; 95%CI: 9.8–31.5). Finally, combining a negative history of pivot or a negative popping sensation during trauma with a negative Lachman or pivot shift test was able to exclude both partial or complete ACL tears (LR-: 0.08; 95%CI: 0.03–0.24).ConclusionDiagnostic clusters combining history elements and physical examination tests can support the differential diagnosis of ACL tears compared to various knee disorders.

Ultrasonography and clinical examination of knee injuries in pre- and post- menarche dancers

ABSTRACTThis study aimed at evaluating whether the prevalence of knee injuries and morphological features are different among pre-and-post menarche dancers; Sixty-seven pre-and-post menarche dancers were screened for anthropometric parameters; knee laxity; patella femoral pain syndrome (PFPS), pathologies and anatomical structure of the knees. Both groups showed a high and similar prevalence of PFPS. The post-menarche dancers produced a significantly higher rate of Tanner stages 3–4 (p = .010), greater weight (p < .001) higher BMI (p = .003); and, higher prevalence of MCL pathology, pes planus, and scoliosis compared with pre-menarche dancers (p < .05). The pre-menarche dancers started dance practice earlier (p = .008); and, showed significantly higher prevalence of lateral laxity, patellar laxity, positive Lachman test and positive Drawer test compared with post-menarche dancers (p < .05). Interactions (menarche yes/no by PFPS no/one leg/both legs) were found for BMI (p = .044; η2 = .187), trochlear cartilage thickness (p = .020; η2 = 0.121) and tip of patella – trochlear groove distance (p = .024; η2 = .150). Pre-and-post-menarche female dancers demonstrated similar prevalence of knee injuries, with different body morphology.

Outcome of Arthroscopic Treatment of Mucoid Degeneration of the Anterior Cruciate Ligament.

BackgroundMucoid degeneration of the anterior cruciate ligament is a rare pathological entity. Several authors have identified this condition, described their experiences, and suggested their own guidelines for management. The aim of this study was to detail the clinical, radiological, arthroscopic, and pathological findings of mucoid degeneration of the anterior cruciate ligament and report the clinical outcomes following arthroscopic treatment.MethodsA historical cohort of patients who underwent arthroscopic total or partial excision of the anterior cruciate ligament due to mucoid degeneration between 2011 and 2014 were reviewed. The minimum follow-up was 3 years. Demographic, radiological, and histological findings, type of surgery, and clinical pre- and postoperative data were analyzed. The visual analogue scale score, the International Knee Documentation Committee score, and the Tegner Lysholm Knee Score were collected preoperatively, postoperatively, and during the follow-up period.ResultsSeventeen females (67%) and eight males (33%) were included in the final analysis. The mean age at the time of surgery was 57 years (range, 31 to 78 years). Partial resection of the anterior cruciate ligament was done in seven cases and a complete resection in 18 cases. No reconstruction was performed at the same time. A positive Lachman test and a negative pivot shift were noted after surgery in all cases. Anterior cruciate ligament reconstruction was required in only one young patient due to disabling instability. At last follow-up, the mean visual analogue scale score, International Knee Documentation Committee score, and Tegner Lysholm Knee score improved (p < 0.01).ConclusionsOur study provides further evidence that arthroscopic total or partial excision of anterior cruciate ligament is a safe and effective treatment for mucoid degeneration of the anterior cruciate ligament, improving patient satisfaction and function without causing clinical instability in daily activities. However, young patients should be forewarned about the risk of instability, and an anterior cruciate ligament reconstruction could be necessary.

The influence of femoral tunnel length on graft rupture after anterior cruciate ligament reconstruction

BackgroundFor ACL reconstruction, the minimum length of the femoral tunnel and the flexor tendon graft length needed within the tunnel for proper integration have not been defined. The aim of this study was to assess whether a short tunnel is a risk factor for poor prognosis and re-rupture by comparing the outcomes of patients with short femoral tunnels to those of patients with longer tunnels.Materials and methodsA retrospective observational study of 80 patients who underwent ACL reconstruction using flexor tendons via the medial transportal or transtibial technique was performed. Patients were categorized according to the amount of graft within the tunnel: ≤1.5 versus >1.5 cm; ≤2 versus >2 cm; ≤2.5 versus >2.5 cm; and ≤1.5 versus >2.5 cm. Patients were evaluated 2 years after surgery by performing a physical examination (Lachman, pivot shift and anterior drawer tests), using a KT1000 arthrometer, calculating objective and subjective International Knee Documentation Committee scores, conducting the Lysholm score, and recording re-ruptures.ResultsOf the 80 operated patients, nine were lost to follow-up. Comparative assessment of the patients with different amounts of graft within the tunnel indicated no significant differences in the evaluated outcomes, except for positive Lachman test results, which were more frequent in patients with tunnels with ≤2 cm of graft than in those with tunnels with >2 cm of graft.ConclusionThe amount of graft within the femoral tunnel does not appear to be a risk factor for clinical instability of the knee or re-rupture of the graft. Level of evidence: case series, level IV. Level of evidenceCase series, level IV.

Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients.

Bone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) reconstruction. Existing clinical trials, registry studies, and meta-analyses offer conflicting opinions regarding the most favorable graft choice. Which graft type for ACL reconstruction (bone-tendon-bone or hamstring) has a higher risk of (1) graft rupture and/or (2) graft laxity? We performed a meta-analysis of randomized controlled trials (RCTs), prospective cohort studies, and high-quality national registry studies to compare the outcomes of primary ACL reconstruction with bone-tendon-bone autograft or hamstring autograft. Studies that compared these graft types were identified through a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, and the Cochrane Library). Two independent reviewers utilized the Jadad scale for RCT study quality and the Modified Coleman Methodology Score for prospective comparative and registry study quality. The included studies were analyzed for the primary outcome measure of graft rupture with or without revision ACL surgery. In surviving grafts, secondary outcomes of graft laxity were quantified by KT1000/2000™ testing, a positive pivot shift test, and a positive Lachman test. Meta-analysis was performed with Review Manager. A total of 47,613 ACL reconstructions (39,768 bone-tendon-bone and 7845 hamstring) from 14 RCTs, 10 prospective comparative studies, and one high-quality national registry study were included in this meta-analysis. Mean age was 28 years in both groups. Sixty-three percent of patients in the bone-tendon-bone cohort were men versus 57% of patients in the hamstring cohort. Mean followup was 68 ± 55 months. Two hundred twelve of 7560 (2.80%) bone-tendon-bone grafts ruptured compared with 1123 of 39,510 (2.84%) in the hamstring group (odds ratio = 0.83, 95% confidence interval, 0.72-0.96; p = 0.01). The number needed to treat analysis found that 235 patients would need to be treated with a bone-tendon-bone graft over a hamstring tendon graft to prevent one graft rupture. Instrumented laxity analysis showed that 22% (318 of 1433) of patients in the bone-tendon-bone group had laxity compared with 18% (869 of 4783) in the hamstring tendon group (odds ratio = 0.86; p = 0.16). Pivot shift analysis showed a positive pivot shift in 19% (291 of 1508) of the bone-tendon-bone group compared with 17% (844 of 5062) in the hamstring group (odds ratio = 0.89; p = 0.51). Lachman testing showed a positive Lachman in 25% (71 of 280) of patients receiving bone-tendon-bone grafts compared with 25% (73 of 288) in the hamstring group (odds ratio = 0.96; p = 0.84). In this meta-analysis of short- to mid-term followup after primary ACL reconstruction, hamstring autografts failed at a higher rate than bone-tendon-bone autografts. However, failure rates were low in each group, the difference observed was small, and we observed few differences between graft types in terms of laxity. Both graft types remain viable options for primary ACL reconstruction, and the difference in failure rate should be one part of a larger conversation with each individual patient about graft selection that should also include potential differences in donor site morbidity, complication rates, and patient-reported outcome measures. Continued prospective collection of patient data will be important going forward as we attempt to further characterize the potential differences in outcomes attributable to graft selection. Level III, therapeutic study.

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.

Comparison Between Single- and Double-Bundle Anterior Cruciate Ligament Reconstruction With 6- to 8-Stranded Hamstring Autograft

Background: Whether double-bundle (DB) anterior cruciate ligament (ACL) reconstruction with 6- to 8-stranded hamstring autograft (HG) is better than single-bundle (SB) ACL reconstruction remains debatable, as long-term follow-up data are lacking. Purpose: To prospectively investigate and compare the long-term results of DB and SB ACL reconstruction with a 6- to 8-stranded HG. Study Design: Randomized controlled clinical trial; Level of evidence: 1. Methods: A total of 80 patients with chronic ACL rupture were randomized to SB or DB ACL reconstruction with a 6- to 8-stranded HG. In the SB group, both the semitendinosus tendon (ST) and the gracilis tendon (GT) were prepared in 3 or 4 strands, with a total of 6 to 8 strands. In the DB group, the ST was prepared in 3 or 4 strands used for the anteromedial bundle, and the GT was prepared in the same manner for the posterolateral bundle. Each graft was fixed with an EndoButton, a bioabsorbable interference screw, and a staple. Outcome assessment was performed by a blinded independent observer using International Knee Documentation Committee (IKDC), Tegner, and Lysholm scores, as well as range of motion (ROM), Lachman test, pivot-shift test, KT-2000 arthrometer side-to-side difference, and return-to-sport data. Results: A total of 68 patients (DB group, 34; SB group, 34) were observed for a mean of 80 months (range, 74-86 months). There were 2 traumatic instability failures and two 5° extension restrictions in the DB group, while no failures or 5° extension restrictions were observed in the SB group. The mean Lysholm, Tegner, and IKDC scores improved significantly in both groups compared with preoperation scores (P < .05). No patient had a positive Lachman test result. No significant differences were found between groups in functional scores, incidence of pivot shift, ROM, Lachman test, KT-2000 arthrometer anterior laxity, or time and level of return to sport. Conclusion: Both SB and DB ACL reconstruction with 6- to 8-stranded HG showed satisfactory results in subjective scores and anteroposterior and rotational stability over a nearly 7-year follow-up; neither technique was superior.

Efficacy of knee joint aspiration in patients with acute ACL injury in the emergency department

PurposeTo evaluate the influence of joint aspiration on the sensitivity of physical examination for diagnosing acute anterior cruciate ligament (ACL) lesion in the second outpatient-department (OPD) follow-up referred from emergency department (ED). MethodsThis retrospective study included sixty patients underwent ACL reconstruction with initial visit at ED. They were divided into two groups based on the presence or absence of joint aspiration at ED. All participants were referred to second OPD follow-up within 7–14days after the injury. Clinical manifestation (including visual analogue scale (VAS) for pain, range of motion (ROM), and severity of knee effusion) and physical examination (Lachman test and pivot shift test) were checked in ED and the second OPD follow-up. ResultsThe group of patients with joint aspiration (G1) showed substantial decreases in mean values of VAS for pain (p=0.005), ROM (p=0.001), and effusion level (p<0.001), even higher VAS and effusion level and lower ROM at the initial visit of ED than the other group (G2). The sensitivity of positive Lachman and pivot shift test was significantly (p<0.05) increased following knee joint aspiration. Positive Lachman test was recorded at 76.5% in the second follow-up in G1, which was significantly (p=0.047) higher than that (47.6%) in G2. The percentage of positive pivot shift test was recorded at 76.5% in the second follow-up in G1, which as significantly (p<0.001) higher than that (31.0%) in G2. ConclusionsKnee joint aspiration in acute ACL injury with suspected hemarthrosis could be considered as a diagnostic procedure. Joint aspiration in early medical attendance might be able to lower pain scores or raise the sensitivity of physical examination for diagnosing acute ACL injury at follow up visit in orthopedic outpatient department. Level of evidenceRetrospective cohort study III.

Multi-Ligamentous Knee Injury in Sports Involving Concomitant Anterior Cruciate Ligament and Patellar Tendon Disruption: A Review of Case Reports

Background:Injury to the anterior cruciate ligament (ACL) is one of the most common orthopedic injuries in the United States, while injury to the patellar tendon (PT) is less common. A combined rupture to the ACL and PT is consequentially uncommon and increases the difficulty of a correct initial diagnosis. The purpose of this paper is to critically appraise the current peer-reviewed literature regarding multi-ligamentous knee injuries (MLKI) in sport.Methods:A systematic review was undertaken to identify all relevant peer-reviewed articles regarding MLKI from March 1980 to January 2015. All articles pertaining to simultaneous rupture of the ACL and PT were included for review.Results:A total of 27 cases presented in 15 articles were used. Findings suggest that the combination of a palpable gap over the PT, a positive Lachman test, inability to complete terminal knee extension, and a superior position of the patella are clinical examination markers for a possible MLKI involving the ACL and PT.Conclusion:Simultaneous rupture to the ACL and PT is incredibly rare within the sport population, making diagnosis and treatment of such injury challenging. A thorough examination of the extensor mechanism of the knee is important in making the proper diagnosis.

EVALUATION OF RESULT OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH USE OF SEMITENDINOUS AND GRACILIS TENDON AT HUE UNIVERSITY HOSPITAL

Background: Anterior cruciate ligament (ACL) rupturecauses knee instability and secondary injuries at meniscus, cartilage and the other ligaments. Therefore, ACL reconstruction is necessary. The aim of the study is to evaluate the results of ACL reconstruction with autogenous semitendinous and gracilis tendons at the Hue University Hospital. Methods: A prospective study of 40 patients with ACL ruptures treated with arthroscopically assisted reconstruction with autogenous semitendinous and gracilis tendons. Knee stability and functional Lysholm scores were recorded at each visit, including preoperatively and at the third and sixth month of follow-up. Results: Forty patients (male : female = 1,6) with a mean age of thirty years) were involved in the study. The main cause of ACL rupture is trafic accident (62,5%). All of patients had positive Lachman test and thirdty two (80%) of the patients had positive drawtest. Mean knee functional Lysholm score was 56 points. Follow-up to six months, resulting in a final study of thirty one patients, Lachman test was negative in 93,6%. The mean Lysholm scores improved to 83 points at third month and 89 points at sixth month. Conclusions: We believe that, semitendinous and gracilis tendon graft was effective and safety technique for recovery of knee stability and function.

English

BACKGROUND: Pivot shift test has been in use as one of the diagnostic test for anterior cruciate ligament injuries over the years. Change in position of the leg was found to produce variation in appreciation of the test. In our observation we found doing the test with leg in external rotation produces better appreciation of the test. AIM: Comparison of external and internal rotation of leg in pivot shift test and quantitating it using image analysis in chronic anterior cruciate ligament injuries. METHODS: Thirty patients with complaints of pain and instability in the knee joint for 2 or more months following injury and having positive Lachman test were chosen randomly. The pivot shift test was performed in all 30 patients first with leg in external rotation and then in internal rotation under anesthesia. Movement of three bony points in relation to each other were captured using 12 mega pixel digital camera and evaluated using image analysis software. RESULTS AND DISCUSSION: The femoral Antero posterior (AP) translation from the Gerdy's point suddenly decreased by 6.5+ 1.8 mm (maximum 13mm, minimum 3mm) in all 30 patients on whom pivot shift was performed in external rotation, whereas the femoral AP translation decreased by 2.9+ 1.17 mm (maximum 5mm, minimum 1mm) in 29 patients when the pivot shift test was done in internal rotation. Arthroscopic findings correlated well with pivot shift test being done in external rotation than in internal rotation. CONCLUSION: The results of this study shows higher diagnostic value of pivot shift test for chronic anterior cruciate ligament (ACL) insufficiency when it is done with leg in external rotation.

Bilateral Congenital Posterior Cruciate Ligament Hypoplasia: A Case Report.

Congenital aplasia or hypoplasia of the cruciate ligaments is an infrequent condition. The absence of the posterior cruciate ligament (PCL) is extremely rare and is usually associated with other congenital abnormalities of the lower limb such as anterior cruciate ligament (ACL) agenesis, absence of one or both menisci, and absence or dysplasia of the patella1-7. To the best of our knowledge, only one case of a unilateral PCL absence8 and one case of bilateral PCL hypoplasia9 have been reported in the literature. We present the case of a professional athlete with bilateral congenital PCL hypoplasia without other associated congenital anomalies. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A twenty-nine-year-old female professional athlete, who had played handball from the age of twelve years and had competed in the premier league from the age of sixteen years, sustained a twisting injury to the right knee while landing. Seven days later, examination revealed a minimal right knee effusion and a positive Lachman test with a soft end point. The posterior drawer sign had a hard stop, and the posterior sag sign was negative. No lateral or medial instability was observed. Active and passive knee motion was intact. The patient denied any family history of skeletal congenital abnormalities; no abnormalities had been noted during pregnancy, childbirth, or childhood. Five years prior to this event, she had given birth to a healthy girl who had normal physical and mental development. Magnetic resonance imaging (MRI) of the right knee (Figs. 1-A, 1-B, and 1-C) demonstrated a recent ACL tear with a fully disorganized and partially retracted ligament as well as associated intra/periligamentous edema. The PCL did not have a normal appearance; there was only a thin, hypointense bandlike structure, …

A Comparison of Patellar Tendon Allograft to Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction in Athletes Under 25 Years of Age (SS-72)

Purpose: To compare the clinical outcomes of primary anterior cruciate ligament (ACL) reconstruction using either bone-patellar tendon-bone (BPTB) allograft or autograft performed in patients aged 25 years or younger. Methods: Prospectively collected data was reviewed retrospectively of a consecutive series of primary ACL reconstructions using BPTB allografts or autografts, fixed with bioabsorbable interference screws, and performed by a single surgeon using the same surgical technique. An inclusion criterion was patients no older than 25 years at the time of surgery. Graft choice was patient-selected. Patients were evaluated preoperatively and at a minimum of 24 months following their surgery using Cincinnati, Lysholm, Tegner, and International Knee Documentation Committee (IKDC) scores in addition to a physical examination which included range of motion, Lachman, and pivot-shift tests. Patients were also evaluated by KT arthrometer postoperatively and a side to side comparison was performed. Results: Two groups were identified. A total of 20 patients (12 males and 8 females) underwent allograft reconstruction (average follow-up 37 months). The mean postoperative scores were: Cincinnati 86 (60 preoperatively), Tegner 6.5, Lysholm 90 (67 preoperatively), and IKDC activity score was 3.1 out of 4 (2.0 preoperatively). A total of 26 patients (12 males and 14females) underwent autograft reconstruction (average follow-up 37 months). The mean postoperative scores were: Cincinnati 87 (40 preoperatively), Tegner 7, Lysholm 90 (46 preoperatively), and IKDC activity score was 3.0 (2.0 preoperatively). Only one allograft and two autograft patients had a positive Lachman test postoperatively. No patients had a positive postoperative pivot-shift test. One autograft patient had a KT side to side difference of 5 mm while all others had differences less than 3 mm. Mean KT difference for autografts was 1.0mm and 0.9 mm for allografts Both allograft and autograft ACL reconstructions provided excellent functional and clinical results in patients aged 25 years or younger less. No differences between these groups were identified.

Revision ACL reconstruction using contralateral hamstrings

Due to the increasing number of primary anterior cruciate ligament (ACL) reconstructions, the need for revision surgery has risen. The aim of this study was to evaluate the use of contralateral doubled semitendinosus and gracilis tendon (DGST) for revision anterior cruciate ligament reconstruction. Twelve patients undergoing revision ACL reconstruction with hamstring tendon were examined at an average follow-up of 3years. All patients underwent a thorough subjective and objective evaluation, which included a KT-1000 arthrometric evaluation, and a radiographic examination. Subjective evaluation yielded a median score of 5.5 (range 2-9) on the Tegner activity scale. The mean Lysholm score was 95 (SD 9.5), and the mean subjective IKDC 2000 score was 95.4 (SD 7.8). At physical examination, a negative Lachman test was found in ten patients; one patient had a positive Lachman test with a firm end-point, and one other patient had a clearly positive Lachman test. Two patients had a grade 1+ on pivot shift testing. Only 1 patient showed a side-to-side difference more than 5mm at the maximum manual KT-1000 arthrometer. Three patients (25%) showed initial signs of osteoarthritis. The results of the study show that the use of hamstring tendons harvested from the unaffected knee represents a valid option for revision surgery following a failed primary ACL reconstruction using DGST grafts. IV.

Displaced Tibial Intercondylar Eminence Fractures

To review outcomes of 19 patients with tibial eminence fractures. Records of 10 female and 9 male patients with type II (n=3) and type III (n=16) displaced tibial intercondylar eminence fractures were reviewed. Nine of whom were skeletally immature aged 6 to 15 (mean, 12) years; the remaining 10 patients were aged 19 to 55 (mean, 32) years. 14 involved the left knee. All patients presented with a painful haemarthrosis and reduced range of movement. The most common activity causing this injury was skiing (n=7, primarily in adult females [n=5]), followed by cycling or motocrossing (n=6) and falling or other sporting activities (n=6). The injury mechanisms entailed forced flexion with rotation (n=7), hyperextension with rotation (n=7, primarily in skeletally immature males [n=4]), and direct trauma (n=5, primarily in adult males [n=4]). Eight patients (60% of adults and 22% of children) had associated injuries of the knee, which commonly occurred after direct trauma. Two patients were treated in a cast or brace after closed or open reduction without fixation. Two patients underwent arthroscopic reduction and internal fixation, and 15 underwent open reduction and internal fixation (2 after failed arthroscopic reduction and 11 proceeded directly). Postoperatively, 7 patients had a positive Lachman test, but none complained of subjective instability. Ten patients had knee stiffness; all except one had been immobilised for 4 to 6 weeks. Seven patients had extension impingement; 6 of them had been treated with open reduction and internal fixation. Two patients underwent further surgery for debridement and screw removal at years 1 and 3. One patient developed arthrofibrosis and underwent arthrolysis at month 6, but knee stiffness remained. No patient underwent subsequent anterior cruciate ligament reconstruction. Tibial eminence fractures are as common in adults as in children. Female skiers are at higher risk. Stiffness is a more common complication than laxity. Early range-of-motion exercise may reduce stiffness and extension impingement.

Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Allograft: An Age-Dependent Outcome Evaluation

To compare the outcomes of a consecutive series of nonrevision bone-patellar tendon-bone (BPTB) allograft anterior cruciate ligament (ACL) reconstructions in patients aged 40 years or older and patients aged younger than 40 years. Prospectively collected data from consecutive BPTB allograft ACL reconstructions fixed with biodegradable interference screws and performed by a single surgeon were analyzed by use of established outcome measures. Preoperative and postoperative outcome assessments included Cincinnati, Lysholm, and Tegner scores and International Knee Documentation Committee (IKDC) activity scores. Lachman test, pivot-shift test, and KT arthrometer (MEDmetric, San Diego, CA) measurements were obtained at a minimum of 24 months after surgery. In total, 32 patients met the inclusion criteria (21 men and 11 women). The mean follow-up was 35 months (range, 24 to 58 months). Of the patients, 21 were aged younger than 40 years (66%) and 11 were aged 40 years or older (34%). The mean age was 35 years (range, 18 to 55 years). In patients aged younger than 40 years, the mean postoperative Cincinnati score was 82.4 (39.1 preoperatively); Tegner score, 6.2 (3.9 preoperatively); Lysholm score, 89.5 (46.8 preoperatively); and IKDC activity score, 2.7 out of 4 (1.7 preoperatively). Five patients had a positive postoperative Lachman test, but none had a positive pivot-shift test. KT examinations showed a manual maximum difference of less than 3 mm in all but 1 patient (mean, 0.7 mm). In patients aged 40 years or older, the mean postoperative Cincinnati score was 83.8 (44.4 preoperatively); Tegner score, 6.6 (3.9 preoperatively); Lysholm score, 88.8 (50.1 preoperatively); and IKDC activity score, 2.7 out of 4 (2.1 preoperatively). One patient had a positive postoperative Lachman test, but none had a positive pivot-shift test. KT examinations showed a manual maximum difference of less than 3 mm in all but 1 patient (mean, 1.3 mm). The outcomes of BPTB allograft ACL reconstructions were not different both subjectively and objectively for patients aged 40 years or older and patients aged younger than 40 years. BPTB allograft ACL reconstruction provides consistent results for patients of all age groups. Level III, retrospective comparative study.

Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament

Background The best means of ensuring knee stability after anterior cruciate ligament (ACL) reconstruction remains a core debate in sports medicine. Hypothesis There is no difference between ACL reconstruction with patellar tendon or hamstring tendon autografts with regard to postoperative knee laxity and instability. Study Design Meta-analysis of individual patient data. Methods Pooled analysis of individual patient data from 6 published randomized clinical trials included 423 patients with symptomatic unilateral anterior cruciate ligament injury randomly assigned to reconstruction with patellar tendon or hamstring tendon autograft. Knee instability, defined as a positive pivot-shift test result, was the primary outcome, and knee laxity, defined as a positive Lachman test result, was the secondary outcome. Odds ratios were computed before and after adjustment for potential confounders and trial effect. Regression analyses were performed to look for effects of covariates on outcomes, and mixed-effects models were used to account for a trial effect. Sensitivity analyses were conducted to explore the effects of missing data and excluding each trial. Results Anterior cruciate ligament reconstruction with patellar tendon autograft was significantly associated with a decreased risk of a positive pivot-shift test result (adjusted odds ratio, 0.46; 95% confidence interval, 0.24–0.86; P = .016). The risk of having a positive Lachman test result was not significantly different between the 2 groups. The estimated treatment effect was not substantially changed by differences in handling missing data or exclusion of any of the trials. A positive pivot-shift test result was more common in female (P = .003) and younger patients (P = .017). Conclusion Postoperative knee instability was less common after ACL reconstruction with patellar tendon autograft than with hamstring tendon autograft.

Functional outcomes and health-related quality of life after robot-assisted anterior cruciate ligament reconstruction with patellar tendon grafts

During a short period of time, surgical robots had been propagated for automated tunnel placement in anterior cruciate ligament (ACL) reconstruction. Clinical outcome data are currently unavailable. Between 2000 and 2003, 152 patients underwent ACL replacement with the assistance of the Computer Assisted Surgical Planning and Robotics system (CASPAR, OrtoMaquet, Germany) at our hospital. After minimal invasive pin placement in both the tibia and femur, computed tomography was used to register anatomical landmarks and to plan graft tunnel alignment. The robot was used to drill tibial and femoral tunnels in an outside-in fashion according to pre-operative planning. There was one procedure-specific Serious Adverse Event (i.e., an intraoperative transection of the posterior cruciate ligament). After IRB approval, all patients were invited for a follow-up examination. Data from 100 patients (35 women, 65 men, mean age 35 [SD 11] years, median follow-up 61 [range 42-77] months) form the basis of this report. Side-to-side differences in anterior laxity were measured with the KT-1000 arthrometer. Patient-centered outcomes included the Lysholm-Score, the lower extremity functional scale (LEFS), and the Short Form 36 (SF36). The mean KT-1000 side-to-side difference was 0.89 [95% confidence interval (CI) 0.52-1.26] mm. Eight and five patients had a positive Lachman and pivot shift test, respectively. The Lysholm-Score averaged 86 (95% CI 83-89) points. Excellent, good, fair, and poor outcomes were reported by 38, 32, 20, and 10 patients. The LEFS averaged 85 (95% CI 82-88) points. The mean SF36 Physical Component Score was 48.4 (95% CI 46.5-50.3), indicating residual deficits compared to the population norm. All tibial graft tunnels did not cross the Blumensaat line, but were placed slightly anterior to the optimal center of 42% reported in previous studies. Compared to literature data, robot-assisted ACL reconstruction with BTB grafts may lead to higher knee stability, but poorer functional outcomes. The immense additional efforts with the procedure did not pay off in a benefit to patients.

In vivo kinematics of anterior cruciate ligament deficient knees during pivot and squat activities

Background Knee kinematics during pivoting activities are not well studied, but might provide insight critical to understanding the pathology of the anterior cruciate ligament deficient knee. The purpose of this study was to compare in vivo kinematics during weight bearing pivot and squat activities in patients with unilateral anterior cruciate ligament deficient knees, and to contrast those kinematics with the uninjured contralateral knees. Methods Eight unilateral anterior cruciate ligament deficient patients with a mean age of 41 (SD 7) years were enrolled. Anterior cruciate injury was confirmed by positive Lachman test and MRI. Lateral fluoroscopic images of pivot and squat activities were recorded for both anterior cruciate ligament deficient and contralateral knees. Three-dimensional tibiofemoral kinematics and centers of rotation for each knee were determined using 3D–2D model registration techniques. Findings During pivoting, the tibia of the anterior cruciate ligament deficient knee was significantly more anterior than the contralateral knee during tibial neutral to internal rotation. The pivot activity showed lateral centers of rotation in both anterior cruciate ligament deficient and contralateral knees while squatting showed medial centers of rotation. Interpretation This dynamic method might be useful to objectively characterize restoration of dynamic function in knees with various types of anterior cruciate ligament reconstructions. These results also indicate kinematics during squatting type activities cannot be extrapolated to predict knee kinematics during pivoting types of activities.

Serial Evaluation of Human Anterior Cruciate Ligament Grafts by Contrast-Enhanced Magnetic Resonance Imaging: Comparison of Allografts and Autografts

The purpose of this study was to clarify the difference in remodeling between allografts and autografts in anterior cruciate ligament reconstruction. We examined 24 knees with bone-patellar tendon-bone allografts and 20 knees with central-third bone-patellar tendon-bone autografts. Surgical patients from January 1997 to December 2002 were included in the study, and more than 1 year had passed since surgery. The mean postoperative follow-up was 24.0 months in the allograft group and 21.3 months in the autograft group. Patients with a positive Lachman test were excluded. The operative method and postoperative rehabilitation programs were the same. All allografts were provided by Tokai Regional Bone Bank, the only regional bone bank in Japan. Contrast-enhanced magnetic resonance imaging (1.0 T, T1-weighted, sagittal section, infusion of 0.2-mL/kg gadolinium-diethylenetriamine pentaacetic acid [Gd-DTPA]) was performed for all knees at 1, 4, 6, and 12 months after surgery and performed for some knees irregularly thereafter. The signal/noise quotient (SNQ) of grafts was calculated by use of magnetic resonance imaging based on the method of Weiler et al. (2001) as follows: SNQ = (Signal of ACL graft - Signal of quadriceps tendon)/Signal of background. The SNQ of allografts was significantly lower than for autografts 12 months after surgery. As for the SNQ 1 month after surgery, there was no difference before or after Gd-DTPA infusion in the allografts; however, the SNQ was significantly higher after Gd-DTPA infusion in autografts. The SNQ after Gd-DTPA infusion continued to increase until 12 to 24 months in the allograft group but peaked at 4 or 6 months in the autograft group. Compared with autologous tendons, allogeneic tendons have a slower onset and rate of revascularization. Level III, retrospective comparative study.