Postoperative IKDC Scores Research Articles

Prognostic factors for all-inside meniscal repair. A 87-case series

IntroductionRepair is indicated for tears in non-degenerative menisci. The literature reports a 15% failure rate for all-inside repair. The aim of the present study was to determine prognostic factors for failure of all-inside meniscal repair. The study hypothesis was that epidemiological, clinical and surgical factors affect success. Material and methodsA retrospective study included 87 meniscal repair procedures, with or without anterior cruciate ligament (ACL) tear. Lesions were located in red-red or red-white zones. After freshening, repair comprised an all-inside arthroscopic technique using the FasT-Fix® system (Smith & Nephew), with (70.1%) or without ligament reconstruction; all ACL tears were reconstructed. Preoperative data comprised: age, gender, smoking status, sports activity, trauma-to-surgery time, body mass index (BMI), frontal morphotype, and IKDC score. Intra- and postoperative data comprised: meniscal lesion characteristics, location, number of sutures, type of ACL reconstruction, presence of chondropathy, authorized postoperative ranges of motion, and IKDC score. Failure was defined by secondary meniscectomy. ResultsAt 31 months’ follow-up, there were 13 failures (15%). Mean postoperative IKDC score was 88.19 (range: 64.37–98.95). Bucket-handle lesion (P=0.006) and BMI>25 (P=0.014) emerged as significant factors of poor prognosis. DiscussionThe present failure rate matched those reported in the literature. The more extensive the lesion, the higher the risk of failure. High BMI incurs mechanical stresses that increase the risk of failure. Level of evidenceIV, retrospective cohort study.

Satisfactory knee function after single-stage posterolateral corner reconstruction in the multi-ligament injured/dislocated knee using the anatomic single-graft technique.

Increasing importance has been placed on the posterolateral corner (PLC) in maintaining varus and rotational stability of the knee. The goal of this study was to evaluate knee function and clinical stability following a single-graft PLC reconstruction technique and identify factors associated with poor knee function. This study identified patients with a multi-ligament knee injury between 2006 and 2013. Patients who received a single-graft fibular collateral ligament and PLC reconstruction with a single-stage surgery during the study period and had a minimum follow-up of 2years after surgery were included. Functional outcomes were assessed using Lysholm and IKDC scores. Varus and rotational knee laxity and range of motion were assessed using physical examination. The final study cohort included 61 patients who underwent PLC reconstruction using a single-graft technique. The mean IKDC score was 74.1 (±22.3) and the mean Lysholm score was 80.3 (±21.8) at mean follow-up of 3.8years (range 2-9years). Mean range of motion at final follow-up measured from 0° to 126° [range flexion: 95-145, range extension: 0-5]. Fifty-eight patients (95%) had grade 0 varus laxity in full knee extension, and 54 patients (88.5%) had grade 0 varus laxity at 30° of knee flexion. Female gender was associated with a lower postoperative IKDC score (p=0.04). Surgical treatment of the PLC using a single-graft technique can result in satisfactory knee function and stable physical examination findings at minimum 2years after surgery. Female gender was predictive of poor knee function after PLC reconstruction. Surgical treatment of PLC injuries should be individualized based on the timing of surgery, specific injured knee structures, and physical examination findings. This study helps validate the use of a single-graft technique for PLC reconstruction and can be used to help counsel patients about expected knee function after surgical treatment of PLC injuries. Level of evidence IV.

Clinical Outcomes of All Soft Tissue Quadriceps Tendon Autograft in ACL Reconstruction

Objectives:The quadriceps tendon (QT) autograft has been successfully utilized for anterior cruciate ligament (ACL) reconstruction for decades. While many studies have shown QT autografts are an effective graft choice, few have prospectively examined short and intermediate-term clinical outcomes following revision procedures. This study examines prospectively collected intermediate-term clinical outcomes, including complication rates, following primary ACL reconstruction with all soft tissue QT autograft.Methods:353 patients undergoing primary ACL reconstruction with an all soft tissue QT autograft were prospectively followed. All procedures were performed by a single surgeon, utilizing a minimally invasive graft harvest technique and suspensory fixation. All patients received aggressive rehabilitation without functional bracing post-operatively. Subjective assessment of knee function was obtained using pre-operative and post-operative IKDC scores, with a minimum of 1-year follow-up. Postoperative KT-1000 arthrometer and isokinetic strength testing measurements were collected at regular intervals. The incidence of graft harvest site hematoma, arthrofibrosis, and graft failure were recorded.Results:The mean age of the study population was 20.4 ± 6.4 (mean ± SD) years, with an average follow up of 2.53 ± 1.04 years. Primary ACL reconstruction was performed in 353 patients. The patient population was approximately evenly split by gender with 27 male (56%) and 21 female (44%). and the preoperative mean IKDC score was 44.9 ± 15.5, and postoperative mean IKDC score was 85.2 ± 14.3, (p<0.0001). The percentage of patients with ≤3 mm side-to-side difference on KT-1000 arthrometer testing at 6-weeks, 3-months, and 6-months was found to be 97%, 96%, and 93%, respectively. No significant increase (p>0.05) in side-to-side measurements was found between the 6-week to 3-month or the 3-month to 6-month intervals. Isokinetic strength testing at 6 months post-operatively showed the mean extension torque at 60°/s and 180°/s was 75.2% and 80.3% respectively. These values increased significantly at 1 year to 86.1% (p<.0006) and 87.5% (p = .018). Graft harvest site hematoma developed in 11 patients (2.7%) and arthrofibrosis occurred in 30 (7.5%). Graft failure requiring revision occurred in 17 (4.2%) patients, with a mean time to revision procedure of 542 ± 210 days post-operatively.Conclusion:ACL reconstruction with an all soft tissue QT autograft using a minimally invasive harvest technique and suspensory fixation has acceptable short and intermediate-term clinical outcomes. No evidence of early graft failure or lengthening was discovered, confirming suspensory fixation is sufficient for aggressive rehabilitation in a young, athletic patient population. The low complication and failure rates in patients that received QT autograft for ACL reconstruction compare favorably to published data on alternate autograft options. The results of this study support the use of all soft tissue QT autograft in ACL reconstruction.

Equivalent Outcomes for Patients Following Trochleoplasty as a Primary or Revision Patellar Stabilizing Procedure

Objectives:Patients with trochlear dysplasia often undergo primary procedures other than a trochleoplasty for recurrent patellar instability. When these other procedures fail and a trochleoplasty is performed, it is unknown if these patients do as well as those that had a trochleoplasty as their primary operation. The purpose of this study was to compare the clinical outcomes after trochleoplasty for severe trochlear dysplasia between a group of patients who previously underwent surgery for patellar instability to a group who underwent trochleoplasty as their initial procedure.Methods:In this prospective cohort study with IRB approval, 40 patients who underwent a sulcus-deepening trochleoplasty as well as additional related procedures with at least one year follow-up were divided into two cohorts: 1) patients with prior surgery for patellar instability (n=19) [Table 1] and 2) patients with no prior surgery for patellar instability (n=21). Preoperative and postoperative IKDC and Kujala scores, in addition to patient satisfaction scores, recurrent dislocation events, and reoperations were compared between the two cohorts.Results:33 females and 7 males with an overall average age of 20.4 years with an average follow-up of 2 years were included in the study. Compared to preoperative scores, significant increases were seen in the postoperative IKDC and Kujala scores in both the primary (26.9 +/- 24.3, 21.5 +/- 22.3, respectively) and revision cohorts (22.7 +/- 23.0, 12.7 +/- 15.7, respectively) [Table 2]. There were no significant differences between outcome scores between cohorts with regard to final scores (p=0.661, 0.810, respectively) or absolute improvement (p=0.624, 0.284, respectively). There were no episodes of recurrent instability in either cohort. 23.8% of the primary cohort and 26.3% of the revision cohort underwent a secondary procedure for arthrofibrosis (p=0.420). There was no significant difference in satisfaction scores between the two cohorts, with an average score of 9.2 +/- 1.8 amongst all patients (p=.404).Conclusion:Patients with severe trochlear dysplasia will experience significant improvement postoperatively and will have equivalent outcomes if a trochleoplasty is performed as an index procedure or as a revision procedure following a prior failed patellar stabilizing procedure.Table 1.List of procedures that the revision cohort Underwent prior to the trochleoplasty. Note: Twelve patients underwent more than 1 prior patellar stabilizing procedure so the number of patients add up to more than the cohart size of 19.Prior ProcedureNumber of PatientsAnteromedialization Tibial Tubercle Osteotomy7Medial Patellofemoral Ligament Reconstruction7Medial Patellofemoral Ligament Imbrication7Lateral Release9Patellofemoral Shaving Chondroplasty6Removal of Knee Loose Bodies6Table 2.Comparison of preoperative patient characteristics between the two cohorts.Preoperative CharacteristicPrimary CohortRevision Cohort p valueTotal Number of Patients2119-Female Gender17160.787Age (years)17.4±3.723.6±7.60.002Duration of Instability (months)56.8±54.3102.8±91.70.058Type B Trochlea18160.894Tobacco Use001.000Diabetes Mellitus100.335Body Mass Index (kg/m2)29±7.026.0±5.40.115

Trochleoplasty is a Viable Option for Patellar Instability in Patients with Severe Trochlear Dysplasia: Early Outcomes Analysis of the U.S. Experience

Objectives:Patellar instability caused by severe trochlear dysplasia is best treated by sulcus-deepening trochleoplasty. There have been no studies examining outcomes after this procedure in the United States. The purpose of this study was to evaluate the early outcome data of patients undergoing sulcus-deepening trochleoplasty for high-grade trochlear dysplasia at our institution.Methods:A total of 43 patients (49 knees) with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty. 23 out of 49 (46.9%) knees had prior surgery related to patellar instability, and six knees had more than one such surgery. Concomitant procedures during the trochleoplasty included medial patellofemoral ligament reconstruction (100%), lateral release (49.0%), tibial tubercle osteotomy (36.7%), and some type of cartilage procedure (49.0%). Physical examination, radiographic analysis, and clinical follow up were obtained for all patients. Patients also completed pre and postoperative Kujala and IKDC scores, in addition to reporting on return to sport and any instances of recurrent instability.Results:79.6% of patients were female with an average age of 20.1 +/- 6.3 years. Follow up ranged from 6 weeks to 49 moths (mean 10.6 +/- 10.5 months). There were no episodes of recurrent instability. All patients reported clinically significant improvements compared with baseline preoperative outcome scores. Patellar tracking was normal in all cases with no patellar apprehension at final follow up. The mean preoperative IKDC score was 49.6, which improved to 78.3 (p < 0.001), and the mean preoperative Kujala score was 54.5 which improved to 82.8 (p < 0.001). Patients reported high satisfaction rates (mean 9.3 +/- 1.8 out of 10), and 81.5% patients were able to return to sport. 9 knees (18.4%) developed arthrofibrosis and required manipulation under anesthesia, 7 of which underwent simultaneous arthroscopic lysis of adhesions. At the latest follow-up, average knee range of motion was 126.6 +/- 13.7 degrees. Radiographic analysis of the sulcus angle demonstrated a significant decrease from 144.2 degrees preoperatively to 133.0 postoperatively (p < 0.001).Conclusion:When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty can provide a reliable and successful surgical solution to recurrent patellar instability. Early follow up demonstrates improved radiographic parameters coupled with excellent clinical outcomes and no recurrent instability.

An anatomical-like triangular-vector ligament reconstruction for the medial collateral ligament and the posterior oblique ligament injury with single femoral tunnel: a retrospective study

BackgroundThe purpose of this study was to evaluate the clinical outcomes of anatomical-like triangular-vector ligament reconstruction (TLR) in treating the combined injury of medial collateral ligament (MCL) and posterior oblique ligament (POL).MethodsDuring July 2013 to May 2014, 26 patients who received anatomical-like TLR were included into this study. All patients received clinical physical examination, imaging examination, and knee joint function score both preoperative and follow-up. The stability of the medial structure of the knee joint was examined by physical examination and imaging evaluation, including excessive knee medial opening (EKMO) and tibial external rotation angle (TERA). The function of the knee was evaluated by the subjective questionnaire, including Lysholm, Tegner, and IKDC score. SPSS software was used for statistics analysis.ResultsThe mean follow-up time exceeds 24 months. Two patients occurred with serious heterotopic ossification, and one patient received revision because of screw breakage. EKMO over the contralateral state at 0° decreased from 9.76 ± 2.76 mm to 2.79 ± 1.02 mm with statistical significance (P < .001) and 10.32 ± 2.75 mm decreased to 3.13 ± 0.85 mm at 30° (P < .001). Meanwhile, TERA significantly decreased from 53.38 ± 6.71° to 27.15 ± 4.92° (P < .001). The postoperative Lysholm, Tegner, and IKDC score were superior to preoperative with statistical significance (P < .001).ConclusionsAnatomical-like TLR can reconstruct the graft to cover the insertions which can regain anatomic form and function with a cramped space. Not only the valgus stability and rotational stability can be restored obviously at follow-up but also the usage of implantation can be reduced, decreasing the incidence rate of allergy and saving costs.

The Effects of Tunnel Position in Patients Who Underwent the Anterior Cruciate Ligament Reconstruction with Transfix Method on the Clinical and Functional Results

Objective:The aim of this study is to analyse the effects of femoral and tibial tunnel localization in the sagittal plane in the patients who underwent the anterior cruciate ligament reconstruction with transfix method in our clinic on the clinical and functional results.Methods:36 patients underwent the anterior cruciate ligament reconstruction performed by different surgeons with the same method between January 2010 and December 2014 in Istanbul Medeniyet University Goztepe Training and Research Hospital Orthopaedics and Traumatology Clinic. Femoral and tibial tunnel localization was conducted on the lateral radiography of the knee of the patients. The clinical evaluations of the patients were carried out with lysholm score, IKDC score, tegner activity score, extensor and flexor measured by CYBEX CSMI dynamometer for muscular strength loss.Results:It was observed that femoral tunnel positions of 47.2% (n=17) of the patients were at the intended location while the ones of 52.8% (n=19) were in anterior. Tibial tunnel positions of 52.8% (n=19) of the patients were at the intended location while the ones of 33.3% (n=12) were in anterior, and the ones of 13.9% (n=5) were in posterior. The postoperative lysholm scores of F (+) T (+) group were significantly higher than F (+) T (-) (p=0.004), F (-) T (+) (p=0.004) and F (-) T (-) (p=0.004) groups. The postoperative IKDC score normality of F (+) T (+) group were significantly higher than F (-) T (+). The postoperative tegner measurements of F (+) T (+) group were significantly higher than F (-) T (+). The measurements of extensor deficit of F (+) T (+) (p=0.022) group and F (+) T (-) (p=0.049) group were significantly lower than F (-) T (-) group. The measurements of flexor deficit of F (+) T (+) group were significantly lower than F (-) T (+) (p=0.011) group and F (-) T (-) (p=0.040) group and F (+) T (-) group of flexor deficit measurements significantly lower than F (-) T (+) group (p=0.028) (p<0.05).Conclusion:Misplacement of femoral and tibial tunnels has negative effects on clinic functional results. While misplacement of tibial tunnel can be tolerated better, the placement of femoral tunnel in anterior cannot be tolerated and has further effects on the results.

How expensive is the decision to suture a meniscal tear? Surgical and monetary concerns in a workers’ compensation population

The cost of meniscal sutures and the rate of failure are important concerns in a worker's compensation population. Hypothesis We prospectively analysed our cohort of workers’ compensation patients operated to a meniscal tear in a two years’ period (2013 and 2014) to test two hypothesis: patients submitted to a meniscus suture stay out of work for a longer period of time–monetary compensation is smaller in patients with the sutured meniscus. Material and methods We prospectively analysed a sample of 51 consecutive patients, under 45 years, submitted to either a meniscal suture or a partial meniscectomy (minimum follow-up of 12 months). The exclusion criteria where unstable knees, relevant cartilage lesion (outerbridge grade > = III) and any concomitant surgical procedures (like ligament reconstruction). The patients were analysed using this criteria: cost of surgery (in euros) –sick leave period, permanent disability (measured in percentage) which will lead to monetary compensation, pre and postoperative Lysholm and IKDC scores. Results There were 51 patients consecutively operated due to a meniscal tear who met the inclusion criteria. The patients were divided in–Group A–31 patients submitted to partial meniscectomy, Group B–20 patients submitted to meniscal suture The follow-up was similar between groups–group A (average 21, 8 months; min 15, max 28) group B (average 20,3 months; min 12, max 47). In Group A (meniscectomy) the direct cost of the surgery was 1373,8€ (min 1241,52; max 1584,2). Clinical preoperative scores–Lysholm–average 14,9; min 1; max 57.–IKDC–average 20,8; min 5,7; max 47,1. Final postoperative scores - Lysholm- average 63,2; min 16; max 92.–IKDC–average 61,7; min 12,6; max 97,7. Overall 90,3% were satisfied with the treatment result. Permanent disability–8,94% (SD37) The sick leave period was 152,13 (average, with 72,7SD) In Group B, (meniscal suture) the direct cost of the surgery was 1979,8,8€ (min 2462,4; max 4080). Clinical preoperative scores–Lysholm–average 15,7; min 0; max 30.–IKDC–average 21,1; min 8; max 65,5. Final postoperative scores–Lysholm average 88,7; min 70; max 100.–IKDC (at discharge) –average 86; min 34,5; max 100. All patients were satisfied with the treatment result. Permanent disability–1,65% (SD 1,98) The sick leave period was 228,75 (average, with 327 SD). Conclusion The cost of surgery is significantly higher in the suture group ( P P

Arthroscopic reduction and utilization of Suture Bridge tech reconstructing footprint area structure for the treatment of anterior cruciate ligament avulsion fracture

To evaluate the preliminary curative effect of arthroscopic reduction and utilization of Suture Bridge tech reconstructing footprint area structure for anterior cruciate ligament avulsion fracture. From March 2010 to September 2012, 6 patients suffered anterior cruciate ligament avulsion fracture were treated with arthroscopic Suture bridge fixation for anterior cruciate ligament tibial side footprint reconstruction. There were 2 males and 4 females, ranging in age from 14 to 52 years old. There were 2 cases of type III and 4 cases of type IV displaced fractures classified by Meyers-McKeever-Zaricznyj. Preoperative ADT and Lachman tests were positive. All the patients was follow up more than 2 years. Postoperative ADT and Lachman tests were negative without limitation of knee extension. Postoperative X ray and MRI showed that displaced fracture with a good reduction and union, recovered normal shapeness of ACL. The postoperative Lysholm and IKDC scores at different time points(3 months, 1 year, 2 years after operation) improved significantly comparing with preoperative, and the differences were statistically significant (P<0.01). Suture Bridge tech reconstructing footprint area structure for ACL avulsion fracture is an effective and safe method, especially for adolescent patients with unclosed epiphysis and comminuted avulsion fracture.

A new point of view for mosaicplasty in the treatment of focal cartilage defects of knee joint: honeycomb pattern.

Background A focal full thickness cartilage lesion of knee joint is one of the commonly seen intraarticular pathologies among the joint cartilage problems. Osteochondral autograft transfer mosaicplasty is a method which has satisfactory outcomes among the treatment preferences of cartilage defects. In spite of the favorable clinical results there are some pitfalls of mosaicplasty treatment especially in cases of large defects. One of the major problems of the classical OAT mosaicplasty is the gap spaces between the plugs. The objective of the present study is to report the early clinical and radiological outcomes and to evaluate the clinical application of a new hexagonal osteochondral graft system (HOGS) with the hypothesis of improvement of the OAT mosaicplasty method with the use of hexagonally shaped plugs. The study has intended to answer two questions. (1) Does mosaicplasty with the new HOGS has favorable early clinical outcomes? (2) Is it possible to arrange the osteochondral autografts without leaving gap spaces by using hexagonal pattern in OAT mosaicplasty?Patients and methodsWe designed a retrospective study to report analysis of early outcomes of the initial case series of OAT mosaicplasty by using a new HOGS. Six male individuals with the diagnosis of osteochondral defect and treated with HOGS and reached sixth month follow-up formed the basis of the study. The clinical status of the patients were evaluated with IKDC score. The radiological evaluations were carried out with direct X-rays and magnetic resonance imaging (MRI) studies. The mosaicplasty procedures were carried out via standard surgical method of classical OAT mosaicplasty by using the HOGS following a diagnostic arthroscopy in the same session. The inclusion criteria was a full thickness osteochondral lesion of femoral condyle between 1.5 and 6 cm2 and completion of 6 month follow-ups. The patients having deformities around the knee or major ligament lesions were excluded. MOCART scoring system was used for the evaluation of follow-up MRI findings. The clinical status of the patients were evaluated with IKDC scores.ResultsThe mean age of the patients was 40.8 (±5.2) years and the mean duration of the symptoms on presentation was 16 (±4.3) months. On the initial MRI studies mean defect area was measured 3.7 cm2 (±0.9) which was compatible with arthroscopic findings. During the surgical procedures it was possible to fill the defect area completely. The mean number of plugs in this series was 4.8 (±1.1). We did not faced with insufficient donor reserve problem in any of the cases. On the sixth month follow-up physical examination there was no limitation of the knee joint range of motion in the cases. All patients were able to bear weight on to their operated extremities without pain. The mean postoperative IKDC score improvement was 70.2 (±3.5) which shows significant improvement compared to preoperative scores. On the control MRI studies the bone integration of the hexagonal plugs were complete the cartilage continuity of the articular surfaces were intact and the grafts were well incorporated in all cases. The mean MOCART score on the 6th month MRI studies was 65.8 (±4.1).ConclusionThe early outcomes of OAT mosaicplasty with HOGS are comparable to studies on the classical mosaicplasty. According to our observations in this study we can say that the gap space left between the cylindrical plugs can be solved by using hexagonal prism shaped plugs.

Recurrent posterior knee laxity: diagnosis, technical aspects and treatment algorithm

Aim of this study was to determine the characteristics, clinical and radiological diagnostic methods of PCL isolated and combined knee injuries. One hundred and twelve patients with a recurrent posterior knee laxity were surgically treated. Clinical examination, MRI, Telos™ stress dynamic X-rays, KT-1000 measurements and the IKDC questionnaire were used to diagnose and evaluate these injuries. Median follow-up was 4.5years (2-11years). Thirty-two patients (28.6%) had an isolated posterior laxity, 53 (47.3%) a posterior posterolateral laxity, 21 (18.7%) a posterior posteromedial laxity and six (5.4%) patients had a complex posterior and mediolateral laxity. Road traffic accidents and sports injuries were the main causes of trauma. The mean preoperative value of posterior tibial translation was 13.5mm (SD 1.4) and the mean postoperative value was 4.4mm (SD 1.7) as measured with the Telos device. In the cases with a concomitant ACL rupture, the mean preoperative value of anterior tibial translation was 6.5mm (SD 1.3) and the mean postoperative value was 1.7mm (SD 0.8). The mean pre- and postoperative IKDC scores were 74.5 (SD 4.2) and 87.9 (SD 3.1), respectively. Meniscal and/or cartilage injuries were found in 80 patients (71.4%). Recurrent posterior knee laxity can be restored with the one-stage PCL reconstruction using a quadriceps graft and reconstruction of the posteromedial-posterolateral lesions using the LaPrade techniques. The benefits of this study include enabling surgeons to accurately manage these injuries from a clinical perspective, and treating them with a specific surgical algorithm. III.

Discoid Lateral Meniscus Incidence During Knee Arthroscopy

Abstract Discoid meniscus is a morphological anomaly of the lateral meniscus that appears in 1–5% of meniscectomies. A precise diagnosis remains difficult to make, and many dilemmas hinder effective treatment. To evaluate the incidence of discoid meniscus in patients who underwent knee arthroscopy, as well as the discoid meniscus type, follow-up problems, combined knee lesions, and postoperative results. This retrospective study included 1357 patients who received knee arthroscopy during the period between January 2007 and December 2013. We analysed the discoid meniscus incidence, sex distribution, type distribution (Monllau classification), noted preoperative symptomatology, rupture incidence and type (O’Connor classification), anomaly presence and other intra-articular lesion correlations. The IKDC score was used to evaluate the operative treatment results. The DLM incidence was 1.03%. The most common type of discoid meniscus was complete 5 (35.71 %). The dominant symptom was pain, which was reported by 12 (85.71%) patients. Eleven (78.57 %) patients exhibited ruptures, and the most common type was horizontal, which was reported in 4 (36.36%) cases. The number of ruptures was significantly higher in patients older than 18 (9 patients; 90%), compared to those younger than 18 (2 patients; 40%). Operative treatment resulted in an improvement for all patients in terms of subjective symptom reduction. The incidence of DLM in our study was 1.03%, and the dominant symptom was pain in the knee (85.71%). The most common lesion of the meniscus was a horizontal split, primarily in patients older than 18 years. Patients also presented with joint intra-articular lesions; the most common type was ACL rupture. In all patients, an improved postoperative IKDC score was reported.

Arthroscopic double strand wire fixation anteriorly and posteriorly to anterior cruciate ligament for tibial intercondylar eminence fracture

To explore the clinical outcomes of arthroscopic double strand wire fixation anteriorly and posteriorly to anterior cruciate ligament (ACL) for tibial intercondylar eminence fracture. From January 2009 to February 2012, 12 patients with tibial intercondylar eminence fracture were selected. There were 4 males and 8 females with an average age of 19.5 ± 10 (10-50) years. Time from injury to operation was 4 days to 2 years. All cases belonged to Meyers-Mekeever type II and type III. Arthroscopic double strand wire compressive fixation was performed anteriorly and posteriorly to ACL. Other measures included postoperative rehabilitation and supports with brace in knee extension when weight-bearing for 4-6 weeks. The average follow-up period was 15.6 (6-30) months. Final clinical results showed good range of motion and good knee stability. On postoperative radiology, there were good reduction of intercondylar eminence fracture and excellent healing. There was no occurrence of wire rupture. Postoperative IKDC and Lysholm scores were excellent (n = 10) and good (n = 2). There was no such complication as fragmentation of intercondylar eminence fracture bone, neurovascular injury or infection. Arthroscopic double strand compressive fixation for tibial intercondylar eminence fracture may be easily performed without injury to ACL substance. The reduction is both stable and reliable. And the clinical outcome is excellent.

Smaller Graft Size is Associated with Poorer Outcomes and Increased Risk of Revision 2 Years After Primary ACL Reconstruction with Hamstring Autograft: A MOON Cohort Study

Smaller hamstring autograft size is correlated with lower KOOS and subjective IKDC scores two years following ACL reconstruction and graft size less than 8.5 mm is associated increased risk of revision ACL reconstruction, especially in younger patients. Hamstring autografts are frequently utilized for anterior cruciate ligament (ACL) reconstruction. Commonly used 4-strand grafts average about 8 mm in diameter but significant variation among patients has been noted. Previous retrospective studies have demonstrated increased failure rates with smaller grafts, particularly in younger patients. No studies have evaluated the effect of graft size on patient-reported outcomes following ACL reconstruction. We hypothesize that decreased hamstring autograft size is associated with poorer patient reported outcome scores and increased risk of revision ACL reconstruction. Through use of prospectively collected cohort data augmented with retrospective chart review, 263 of 320 consecutive patients (82.2%) undergoing primary ACL reconstruction with hamstring autograft at two academic centers were evaluated. Graft size, patient sex, femoral tunnel drilling technique, patient age and BMI at the time of ACL reconstruction, pre-operative and 2-year post-operative KOOS and IKDC scores, and whether each patient underwent revision ACL reconstruction during the 2 year follow-up period were recorded. The 263 patients included 144 males (54.8%) and ranged in age from 13 to 58 years (mean, 25.6 years). After controlling for age, sex, operative side, surgeon, BMI, and femoral tunnel drilling technique, a 1mm decrease in ACL graft size predicted a decrease the in KOOS-pain subscale by 3.0 points (p = 0.009), a decrease in the KOOS-sport/recreation function subscale by 4.6 points (p = 0.015), and a decrease in the subjective IKDC score by 2.9 points (p = 0.05). Fifteen of the 263 patients (5.7%) underwent revision ACL reconstruction. Two revisions were performed in the 178 patients over age 18 (1.1%), but 13 revisions were required in the 85 patients age 18 and under (15.3%) (p < 0.0001). Revision was required in 0 of 61 patients (0.0%) with grafts greater than 8mm in diameter and 14 of 202 patients (6.5%) with 8 mm or smaller grafts (p = 0.037). Among patients age 18 and under, revision was required in 0 of 14 patients (0.0%) with grafts greater than 8mm in diameter and 13 of 71 patients (18.3 %) with 8 mm or smaller grafts. Most failures (13 of 15) were noted to occur in patients age 18 and under with grafts 8mm in diameter or less. The revision rate in this population was 18.3% (13 of 71 patients). Smaller hamstring autograft size is a predictor of poorer patient-reported outcome scores 2 years following primary ACL reconstruction. Larger sample size is required to confirm the relationship between smaller graft size and increased risk of revision ACL reconstruction.

Rotational profile alterations after anatomic posterolateral corner reconstructions in multiligament injured knees

Injuries of the posterolateral corner (PLC) are rare and severe knee injuries, resulting in posterolateral rotatory instability and an increase in external rotation. Surgical reconstruction techniques reproducing the normal anatomy showed promising results. In vivo evaluations of static rotational knee laxity at 30° of knee flexion have not been reported so far. The purpose of this study was to evaluate static rotational knee laxity after anatomic PLC reconstructions. This is a retrospective clinical cohort study. Twenty patients with PLC reconstructions with an average follow-up time of 39 ± 22 months and no history of knee trauma or surgery of the contralateral knee were included in the study. They underwent a routine clinical examination and static rotational laxity measurements at 30° of knee flexion in the prone position. Side-to-side differences were recorded and compared to a group of matched controls. The postoperative IKDC score was graded A for 8 patients, B for 16, C for 6 and D for one patient. The primary goal of the surgical procedure which consists in reducing excessive external tibiofemoral rotation could be reached in 18 of the 20 patients (90%). Anatomic PLC reconstructions yielded a comparable rotational profile in operated and healthy knees in 7 patients (35%). Thirteen patients (65%) presented a significantly altered rotational profile in comparison with a healthy control group. Unexpected increases in internal rotation were found in 8 patients (40%). Anatomic PLC reconstructions reduced excessive external tibiofemoral rotation in a vast majority of patients. Static rotational laxity measurements allowed for a determination of the patients' individual rotational profile after PLC reconstructions. This profile was normalised in only one-third of the patients. The understanding of this finding needs further investigation as well as the clinical impact of rotational profile alterations on knee function. Diagnostic studies, Level III.

Influence of Cell Quality on Clinical Outcome After Autologous Chondrocyte Implantation

Background: Several factors influence clinical outcome after autologous chondrocyte implantation (ACI) for the treatment of cartilage defects of the knee joint. Hypothesis/Purpose: The aim of the present study was to investigate the influence of cell quality on clinical outcome after ACI. The hypothesis of the authors was that cell quality at the time of transplantation influences clinical outcome after ACI for cartilage defects. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 80 patients were included in the present study. Knee function was assessed before surgery as well as 6, 12, and 24 months after ACI using standard instruments (International Knee Documentation Committee [IKDC], Lysholm, and Tegner scores). Cell quality was evaluated by determination of antigen expression of CD44 expression, aggrecan, collagen type II, and cell viability. A linear regression analysis including preoperative knee function, defect size, defect location, defect origin, body mass index, patient age, and other parameters was performed to evaluate the influence of these parameters on postoperative knee function. Results: Preoperative IKDC score increased from 49.6 ± 13.8 points to 75.5 ± 14.6 points at 24 months (P < .05). Postoperative IKDC score at 6, 12, and 24 months was significantly influenced by collagen type II expression, CD44 expression, and cell viability (all P < .05). No correlation between aggrecan and outcome was found. Quantitative influence of individual factors differed between different time points. Conclusion: Cell quality seems to be one of many factors that influences clinical outcome after ACI in patients with cartilage defects of the knee joint. It constitutes one aspect among various others affecting clinical outcome.

Combined PCL and PLC reconstruction in chronic posterolateral instability

The posterolateral corner (PLC) is more likely to be injured in combination with the posterior cruciate ligament (PCL) or the anterior cruciate ligament than in isolation. This leads to instability of the knee and loss of function. We hypothesised that combined PCL and PLC reconstruction would restore sufficient stability to allow improvement in patient symptoms and function. 19 patients who underwent arthroscopic-assisted single-bundle PCL and PLC reconstruction by a single surgeon were analysed retrospectively. The PLC reconstruction was a modified Larson reconstruction of the lateral collateral ligament and the popliteofibular ligament. The IKDC and Tegner scores were used to assess outcome. Dial test and varus laxity were used to assess improvements in clinical laxity. Posterior laxity was tested using the KT-1000. The mean follow-up was 38months (±(2× standard deviations), ±12.3). There were no postoperative complications. All patients had less than 5mm posterior step-off. 17 of 19 patients had negative dial and varus stress tests. Measured range of motion was reduced by a mean of 10°, but patients did not report any daily activities restrictions. Tegner scores improved from a median pre-operative value of 2 (range 1-4) to 6 (4-9) at final follow-up. The mean postoperative IKDC score was 86 (±11). Subjectively, the knee stability achieved allowed daily activities. However, there were remaining abnormalities in range of motion, posterior drawer and rotational laxity, suggesting that normal knee laxity was not restored. IV.

Graft retaining debridement in patients with septic arthritis after anterior cruciate ligament reconstruction.

Although septic arthritis following anterior cruciate ligament (ACL) reconstruction is a rare complication, it has a high morbidity deteriorating the clinical outcome. Current treatment options include long-term antibiotic therapy, open or arthroscopic surgical lavage, aspiration, continuous irrigation, graft preservation, and removal of graft and fixation materials with or without reimplantation. The aim of our study was to evaluate the results of long-term antibiotic treatment with arthroscopic debridement without graft and fixation materials removal in the treatment of septic arthritis following ACL reconstructions. Seven patients (6 male, 1 female; mean age: 29 years; range: 21 to 40 years) who had septic arthritis following ACL reconstruction at Uludag; University, Department of Orthopaedics and Traumatology were included in this study. Three of the patients were athletes, 1 was a heavyduty worker, 3 were light-medium-duty workers and 1 was an amateur sportsman. Long-term antibiotic therapy was used for 6 weeks. Rehabilitation was arranged according to the patients effusion, pain and general condition. Evaluations were made using clinical results, manual Lachman and pivot shift tests, and Tegner activity, Lysholm, and IKDC scores. Patients had a mean of 6 (range: 0 to 15) degrees of flexion loss and 3 (range: 0 to 5) degrees of extension loss. Manual Lachman test was near normal for all patients. Pivot shift was positive for 3 and negative for 4 patients. Preoperative and postoperative mean Tegner activity scores were 6 (range: 4 to 7) and 5 (range: 4 to 7), respectively. Preoperative and postoperative mean Lysholm scores were 73.2 (range: 67 to 79) and 74.1 (range: 79 to 89), respectively. Preoperative and postoperative mean IKDC scores were 78.0 (range: 70 to 100) and 80.0 (range: 70 to 100), respectively. Mean leg circumference across the quadriceps muscle was 91% (range: 88 to 93) of the contralateral leg. Single-leg longitudinal jumping length was 78% (range: 63 to 100) of the uninvolved leg. Single-leg horizontal jumping was 72% (range: 88 to 93) of the contralateral leg. Long-term antibiotic therapy and arthroscopic drainage without graft or fixation material removal is effective in patients of regular activity level. Although this procedure is equally successful for treating the infection in competitive athletes and heavy workers, it also results in slight performance loss. Further review is necessary to determine which treatment is suitable for which activity level.

Does bone impaction technique reduce tunnel enlargement in ACL reconstruction?

The aim of this study was to investigate effects of bone impaction technique on tunnel enlargement after ACL reconstruction at a minimum 2 years follow-up. Two groups of patients who had been operated upon with the same arthroscopic technique with the exception of tibial tunnel constitution were compared. Twenty-one patients of group A (drilling to 6 mm followed enlargement to 8-9 mm by using dilators) and 23 patients of group B (directly drilling to the size of the graft) were evaluated clinically and radiographically based on multislice computerised tomography (MSCT) retrospectively. At follow-up, there was no statistical difference between tunnel diameters between two groups at the femoral site, but significant difference at the tibial site (p = 0.00192 for coronal; p = 0.0171 for sagittal diameter). Both groups were comparable according pre- and postoperative Lysholm and IKDC scores (p < 0.5 Mann-Whitney U test). Compacted tunnel walls may resist enlargement, suggesting this technique resulted in better tunnel diameter values especially with intratunnel fixation.

Revision anterior cruciate ligament reconstruction due to knee instability

The primary goal of anterior cruciate ligament reconstruction is to provide stability to the knee and regain full range of motion. Although great improvement has been achieved in surgical techniques and rehabilitation, some patients are not completely satisfied with the results of surgery and a revision anterior cruciate ligament reconstruction is necessary. Revision arthroscopic anterior cruciate ligament reconstruction was carried out in eleven patients with bone-tendon-bone autografts. The surgery was performed in a standard manner and the graft was taken from the opposite knee. Eight men and three women were evaluated. The mean age of patients was 26 (17-34) years. Repeated instability of the knee was caused by injury in five patients, while six patients were unsatisfied with the position of the graft. The follow up was 4,2 years (2-8) respectively. The mean Lysholm and Gillquist score after operation was 88 (65-90). Preoperative and postoperative tibial shift was 9mm (6-15) and 2mm (0-4), respectively. The preoperative pivot shift test was grade 2 and 3 in all patients. Postoperative pivot shift test was negative in seven patients, in three it was grade 1 and grade 2 in one patient. According to the IKDC scale, preoperative results were abnormal in three patients and in eight they were severly abnormal. Postoperative IKDC score was normal in five patients, in four nearly normal, and in one patient the score was still abnormal. Five patients continued to be active in sports activities, four patients decreased the level of sports activity and two stopped all sports activities. Success of revision anterior cruciate ligament reconstruction requires detailed preoperative evaluation of the repeated instability of the knee. The treatment plan is then decided upon. The patients must be preoperativevely informed about the real possibilities of revision surgery. Only a mutual collaboration between the patient, physiatrist and a surgeon is a key for successful treatment and return to previous level of sports activities.