Treatment of tear of the anterior cruciate ligament combined with localised deep cartilage defects in the knee with ligament reconstruction and autologous periosteum transplantation

An acute tear of the anterior cruciate ligament (ACL) is frequently associated with injuries to the joint cartilage and subchondral bone. These injuries may progress to deep cartilage defects, causing disabling pain, and represent a therapeutic challenge in patients with the combination instability and pain. At our clinic we treat patients with the combined injury with simultaneous ACL reconstruction and autologous periosteum transplantation of the cartilage defect. This report describes the technique for periosteum transplantation of full-thickness cartilage defects in the medial femoral condyle. Our clinical report includes the first 7 patients (6 men and 1 woman, mean age 29.1 years at operation) who have been followed for 2 years or longer of 14 consecutive patients (12 men and 2 women). All patients had suffered a total tear of the ACL and a full-thickness defect of the cartilage at the medial femoral condyle. The cartilage defects had a mean area of 7.3 cm² (range 1.0–13.5 cm²). All patients had disabling instability and medial knee pain when walking. The anterior cruciate ligament was reconstructed with a bone-tendon-bone graft of the central third of the patellar ligament. After preparation of the cartilage lesion, the periosteum transplant was anchored to the underlying bone with suture anchors and fibrin glue. Postoperatively, these patients (n = 7) were initially treated with continuous passive motion, followed by active flexibility training and slowly progressing strength training and weight-bearing activities. At follow-up a mean of 31.3 months (range 24–38 months) later, 6 patients evidenced subjectively stable knees, no pain during rest or when walking, and had returned to not too heavy knee-loading work. One patient had a subjectively stable knee, but felt medial knee pain. Meticulous surgical technique and rigorous postoperative rehabilitation are probably of the greatest importance in this procedure. With the use of suture anchors and fibrin glue, the periosteum transplant can be well adapted to the condylar subchondral bone bed. Received: 14 April 1998 Accepted: 4 September 1998     

Treatment of isolated chondral and osteochondral defects in the knee by autologous matrix-induced chondrogenesis (AMIC)

Purpose

The purpose of this study is to evaluate clinical and radiological outcomes of patients treated with autologous matrix-induced chondrogenesis (AMIC) for full-thickness chondral and osteochondral defects of the femoral condyles and patella.

Method

A retrospective evaluation of clinical and radiographic outcomes of patients treated with AMIC for chondral and osteochondral full-thickness cartilage defects of the knee was performed with a mean follow-up of 28.8 ± 1.5 months (range, 13–51 months).

Results

Significant improvements in clinical outcome scores (IKDC, Lysholm, Tegner, and VAS pain score) were noted. The largest improvements were seen in the osteochondral subgroup (mean age 25.9 years), whereas patients treated for chondral defects in the patellofemoral joint and on the femoral condyles improved less. Patients in all groups were generally satisfied with their results. MRI evaluation showed that tissue filling was present but generally not complete or homogenous.

Conclusions

AMIC is a safe procedure and leads to clinical improvement of symptomatic full-thickness chondral and osteochondral defects and to regenerative defect filling. The value of AMIC relative to other cartilage repair procedures and to the natural course remains undefined.

Level of evidence

Case series, Level IV.     

Prospective evaluation of prolonged fresh osteochondral allograft transplantation of the femoral condyle: minimum 2-year follow-up

BACKGROUND: Focal articular cartilage lesions of the knee in young patients present a therapeutic challenge. Little information is available pertaining to the results after implantation of prolonged fresh grafts. HYPOTHESIS: Prolonged fresh osteochondral allografts present a viable option for treating large full-thickness articular cartilage lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study presents the results of 25 consecutive patients who underwent prolonged fresh osteochondral allograft transplantation for defects in the femoral condyle. The average patient age was 35 years (range, 17-49 years). The average length of follow-up was 35 months (range, 24-67 months). Prospective data were collected using several subjective scoring systems, as well as objective and radiographic assessments. RESULTS: Statistically significant improvements (P < .05) were seen for the Lysholm (39 to 67), International Knee Documentation Committee scores (29 to 58), all 5 components of the Knee injury and Osteoarthritis Outcome Score (Pain, 43 to 73; Other Disease-Specific Symptoms, 46 to 64; Activities of Daily Living Function, 56 to 83; Sport and Recreation Function, 18 to 46; Knee-Related Quality of Life, 22 to 50), and the Short Form-12 physical component score (36 to 40). Overall, patients reported 84% (range, 25% to 100%) satisfaction with their results and believed that the knee functioned at 79% (range, 35% to 100%) of their unaffected knee. Radiographically, 22 of the grafts (88%) were incorporated into host bone. CONCLUSION: Fresh osteochondral allograft transplantation is an acceptable intermediate procedure for treatment of localized osteochondral defects of the femur. At 2-year follow-up, it is well incorporated and offered consistent improvements in pain and function. CLINICAL RELEVANCE: Prolonged fresh allograft transplantation is a safe and effective technique for addressing symptomatic osteoarticular lesions in the knees of young patients.     

Anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon graft in rugby players

The purpose of this study was to evaluate prospectively the results of anterior cruciate ligament (ACL) reconstruction with doubled hamstring tendon graft in a selected group of 18 rugby players. The graft was fixed with a transcondylar screw (Transfix) on the femur, and with an absorbable interference screw and a metallic staple on the tibia. All the patients followed the same rehabilitation program. Return to sports activities was allowed after 6 months. Follow-up was 2 years in all cases. The athletic level of the patients was rated according to the Tegner scoring system. Clinical results were evaluated using the International Knee Documentation Committee (IKDC) scoring system. Furthermore, an instrumented evaluation of the anterior laxity with a KT–1000 arthrometer, and an isokinetic evaluation were performed 6 and 24 months after surgery. The Tegner mean score at follow-up (8.2) was similar to that prior to injury (8.3). IKDC overall results were normal in ten cases (55.6%), nearly normal in six cases (33.3%), and abnormal in two cases (11.1%). Side-to-side difference of anterior laxity measured with KT–1000 at 6 and 24 months did not show an impairment of knee stability with time. Isokinetic evaluation showed a significant improvement on peak torque both in extension and flexion on comparison between 6- and 24-month measurements. The results reported in this study showed that the use of doubled hamstring tendon graft for ACL reconstruction in athletes that were at risk for high-energy traumas to the knees, such as rugby players, gave normal or nearly normal results in about 90% of the cases. Recovery of muscle strength was almost complete 2 years after surgery, and there was no impairment of knee stability with time.     

Full-thickness cartilage lesion do not affect knee function in patients with ACL injury

There is debate in the literature regarding the impact of full-thickness cartilage lesion on knee function in patients with ACL injury. The hypothesis of the current study is that a full-thickness cartilage lesion at the time of ACL reconstruction does not influence knee function as measured by the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients with ACL injury. Of the 4,849 primary ACL surgery cases in the Norwegian National Knee Ligament Registry as of 12 December 2007, 30 patients met the following inclusion criteria: a full-thickness cartilage lesion (International Cartilage Repair Society [ICRS] grades 3 and 4), age less than 40 years, no associated pathology or meniscus injury, and less than 1 year between knee injury and ACL reconstruction. Each of the 30 patients in this study group was matched with two control participants without cartilage lesions. Preoperatively, the patients completed the KOOS, and the surgeon recorded the location and size of the cartilage lesion and graded the cartilage injury according to ICRS standards. There were no significant differences between the case and control groups for any of the five subscales of the KOOS. A cartilage lesion was located in the medial compartment in 67% of the cases, in the lateral compartment in 20% of the cases, and in the patellofemoral joint in 13% of the cases. In conclusion, the combination of a full-thickness cartilage lesion and an ACL rupture did not result in inferior knee function at the time of the ACL reconstruction as measured by the KOOS.     

Autologous chondrocyte implantation in the knee using fibrin

Autologous chondrocyte implantation (ACI) is widely used to treat symptomatic articular cartilage injury of the knee. Fibrin ACI is a new tissue-engineering technique for the treatment of full-thickness articular cartilage defects, in which autologous chondrocytes are inserted into a three-dimensional scaffold provided by fibrin gel. The objective of this study is to document and compare mean changes in overall clinical scores at both baseline and follow-up. Fibrin ACI was used to treat deep cartilage defects of the femoral condyle in 30 patients. There were 24 men and 6 women with a median age of 35 years (range 15–55) and with a mean defect size of 5.8 cm² (range 2.3–12). Clinical and functional knee evaluations were performed using different scoring systems, MRI was performed 24 months postoperatively, and arthroscopy was performed 12 months postoperatively. All patients achieved clinical and functional status improvements following surgery (P < 0.01). The mean scores of the Henderson classification (MRI evaluation) significantly improved from 14.4 to 7 (P = 0.001), and no graft-associated complications were noted. Arthroscopic assessments performed 12 months postoperatively produced nearly normal (grade II) International Cartilage Repair Society scores in 8 of the 10 study patients. Fibrin ACI offers the advantages of technical simplicity, minimal invasiveness, a short surgery time, and easier access to difficult sites than classical ACI. Based on the findings of this clinical pilot study, we conclude that fibrin ACI offers a reliable means of treating articular cartilage defects of the knee.     

Press-fit fixation in reconstruction of anterior cruciate ligament,using bone–patellar tendon–bone graft

We studied arthroscopic reconstruction of the anterior cruciate ligament (ACL) using patellar ligament-bone graft fixed to the femur by press-fit technique. The main feature of this technique was a stable bony fixation on the femoral site without using interference screws or other fixation devices. We treated 42 patients with ACL rupture by this technique; clinical examination was carried out preoperatively and at 3 months, 6 months, and then every 6 months using the standard criteria for evaluation of the IKDC (mean follow-up 29 months, 22–41). CT and MRI were performed 6 months postoperatively. According to IKDC score 37 knee (88%) were graded as normal or nearly normal, 4 (10%) as abnormal, and one (2%) as severely abnormal, none of the poor results was due to instability. Reconstruction of the ACL by press-fit technique is a more anatomically oriented method of fixation without the complications of interference screws at the femoral attachment of the graft.     

Combined reconstruction for posterolateral rotatory instability with anterior cruciate ligament injuries of the knee

If posterolateral rotatory instability (PLRI) injury in patients with a torn anterior cruciate ligament (ACL) is not diagnosed and treated, ACL reconstruction can fail. We retrospectively evaluated the clinical outcome after reconstructions between 2002 and 2007 of both the ACL and the posterolateral corner (PLC) in 44 knees with combined ACL and PLC injuries. The median follow-up duration was 49 months (range, 24–68 months). ACL reconstruction employed autogenous hamstring grafts from the ipsilateral knee. For grade II PLRI, a posterolateral corner sling through the fibular head was placed obliquely from the anteroinferior aspect to the posterosuperior aspect using autogenous hamstring grafts of the contralateral knee. Clinical outcomes were evaluated using the OAK (Orthopadishe Arbeitsgruppe Knie) and IKDC (International Knee Documentation Committee) knee scoring systems. Anterior stability was measured on pull stress radiographs using a Telos stress device and the manual maximum displacement test using a KT-1000™ arthrometer with the knee flexed 30 degrees. PLRI was classified according to varus and rotational instability preoperatively and at final follow-up. Median OAK scores improved from 71 points (range, 48–86) to 93 points (range, 75–100). Satisfactory IKDC results were achieved in 39 knees (89%). As for anterior stability, as measured by anterior stress radiography, mean side-to-side displacement difference dropped significantly from 6.9 ± 1.9 preoperatively to 1.4 ± 1.1 mm at final follow-up. Forty patients (91%) had the same or better rotational stability compared to the normal side. Varus stress radiographs showed mean side-to-side displacement differences dropped from 1.8 ± 1.7 preoperatively to 0.4 ± 0.8 mm at final follow-up. Thus, chronic ACL deficiency is often accompanied by grade II PLRI and can be treated successfully by arthroscopic ACL reconstruction paired with posterolateral reconstruction employing a single sling through the fibular tunnel and a hamstring tendon autograft.     

Patellar tendon anterior cruciate ligament reconstruction with conical press-fit femoral fixation: 5-year results in athletes population

Bone-patellar tendon autograft is probably the most widely used graft for ACL reconstruction. Several methods for graft fixation have been described. To avoid intra-articular hardware we adopt biological fixation with a femoral conical press-fit fixation. A prospective study was performed on 40 consecutive active athletes who underwent ACL reconstruction with this technique by the same surgeon between November 1994 and September 1995 (mean follow-up 46 months, range 36-62). Results were evaluated by an independent examiner using radiography, computed tomography, subjective and objective evaluation, and isokinetic and functional strength tests. Assessment using the IKDC knee scoring revealed 85% of the patients with a normal or nearly normal knee joint; Tegner's score was 7.5 preoperatively and 6.0 postoperatively, with 60% of the athletes returning to the preinjury sport and level. No patients had instability, with 90% having less than 3 mm side-to-side difference on computerized analysis. The isokinetic test showed mild quadriceps deficit at 3 and 6 months, with no deficit at final follow-up; four patients complained of anterior knee pain and had a positive kneeling test. We found no graft dislocation. All cases showed radiological evidence of graft integration at 3 months time. Long-term results support this technique asx a simple, cost-effective, and reliable alternative for patellar tendon fixation in ACL reconstruction.     

Arthroscopic osteochondral autograft transplantation in anterior cruciate ligament reconstruction: A preliminary clinical study

The high incidence of chondral defects of the femoral condyles associated with chronic ACL tears is widely recognised. However, treatment is difficult and controversial. This preliminary report presents our experience with arthroscopic osteochondral autograft transplantation in ACL-deficient knees. The series consists of 12 cases of arthroscopic osteochondral autograft transplantation in conjunction with ACL reconstruction using bone-patellar tendon-bone autograft; eight procedures were primary, and four were revisions of failed synthetic grafts. The patients' ages ranged from 22 to 42 years. There were ten male and two female patients. Chondral lesions in this series ranged from 10 to 22 mm in diameter. Donor site was selected prior to notchplasty, and three to five osteochondral cylinders, 5–10 mm in diameter, 10–15 mm long, were harvested. Improved surgical technique, tubular cutting instruments enabling minimal damage to harvested articular cartilage, and press-fit insertion yielded promising uniform results in ten of 12 cases with 2 years' follow-up. This study addresses the important issue of articular cartilage defects in ACL-deficient knees and possible prevention of premature joint degeneration. The aim of arthroscopic osteochondral autograft transplantation is to slow down the development of osteoarthrosis.     

No negative effect on patient-reported outcome of concomitant cartilage lesions 5–9 years after ACL reconstruction

Purpose

To compare patient-reported outcome 5–9 years after anterior cruciate ligament (ACL) reconstruction in patients with and without a concomitant full-thickness [International Cartilage Repair Society (ICRS) grade 3–4] cartilage lesion.

Methods

This is a prospective follow-up of a cohort of 89 patients that were identified in the Norwegian National Knee Ligament Registry and included in the current study in 2007, consisting of 30 primary ACL-reconstructed patients with a concomitant, isolated full-thickness cartilage lesion (ICRS grade 3 and 4) and 59 matched controls without cartilage lesions (ICRS grade 1–4). At a median follow-up of 6.3 years (range 4.9–9.1) after ACL reconstruction, 74 (84 %) patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), which was used as the main outcome measure. Secondary outcomes included radiographic evaluation according to the Kellgren–Lawrence criteria of knee osteoarthritis (OA).

Results

At follow-up, 5–9 years after ACL reconstruction, no statistically significant differences in KOOS were detected between patients with a concomitant full-thickness cartilage lesion and patients without concomitant cartilage lesions. Radiographic knee OA of the affected knee, defined as Kellgren and Lawrence ≥2, was significantly more frequent in subjects without a concomitant cartilage lesion (p = 0.016).

Conclusion

ACL reconstruction performed in patients with an isolated concomitant full-thickness cartilage lesion restored patient-reported knee function to the same level as ACL reconstruction performed in patients without concomitant cartilage lesions, 5–9 years after surgery. This should be considered in the preoperative information given to patients with such combined injuries, in terms of the expected outcome after ACL reconstruction and in the counselling and decision-making on the subject of surgical treatment of the concomitant cartilage lesion.

Level of evidence

Prognostic; prospective cohort study, Level I.

     

Treatment of deep cartilage defects of the patella with periosteal transplantation

Twenty-six consecutive patients (19 men and 7 women) with a mean age of 31.5 years (range 19–52 years) who suffered from an isolated full-thickness cartilage defect of the patella (area ranged from 0.75 to 20.0 cm²) and disabling knee pain were treated with autologous periosteal transplantation (without any chondrocytes). The duration of symptoms was 59 months (range 11–144 months). During the first 5 postoperative days all patients were treated with continuous passive motion (CPM). This was followed by active motion, slowly progressive strength training, and slowly progressive weight-bearing. After a mean follow-up of 42 months (range 24–76 months), 17 patients (65%) were graded as excellent (were painfree), 8 patients (31%) as good (had pain with strenous knee-loading activities), and 1 patient as poor (had pain at rest). Twenty-two patients (85%) had returned to their previous occupation. Twelve patients (46%) had resumed sports or recreational activities at their former level. Repeated magnetic resonance imaging (MRI) investigations showed progressive, and finally complete, filling of the articular defects. Biopsies taken in five randomly selected cases showed hyaline-like cartilage. Patients with full-thickness cartilage defects of the patella and disabling knee pain can be treated with autologous periosteal transplantation (without any chondrocytes), followed by CPM, and slowly progressive strength training and weight-bearing. We believe this is a good method to accomplish regeneration of articular cartilage and satisfactory clinical results. Received: 25 March 1998 Accepted: 14 April 1998     

Symptomatic ring-shaped lateral meniscus: magnetic resonance imaging and arthroscopy

In addition to minimizing graft site morbidity, providing stable fixation, and enabling early progressive rehabilitation, the ideal PCL reconstruction would closely simulate natural ligament function. This study retrospectively examined the 2-year postoperative outcomes of 19 athletically active patients referred with clinically symptomatic PCL-deficient knees. Preoperatively 18 patients had severely abnormal knee ligament examination scores, and one had an abnormal score (IKDC). All but one patient was confirmed negative for observable posterolateral corner injury via MRI. Eighteen patients had clinical evidence of posterolateral instability. All patients underwent double-bundle PCL reconstruction (using allograft tissue) without concomitant posterolateral corner reconstruction. Two years after surgery 100% of patients had normal ( n=18) or near normal ( n=1) passive knee joint motion. The results were: one-leg hop test, 58% normal, 37% nearly normal, 5% abnormal; knee ligament examination, 47% normal, 42% nearly normal, 5% abnormal, 5% severely abnormal; knee arthrometry, 2.4+/-2 mm posterior tibial displacement; IKDC subjective assessment section, 47% normal, 42% nearly normal, 5% abnormal, 5% severely abnormal; IKDC symptom-activity level section, 47% normal, 42% nearly normal, 5% abnormal, 5% severely abnormal; final knee ligament evaluation, 47% normal, 42% nearly normal, 5% abnormal, 5% severely abnormal; Lysholm knee scoring scale, 63% excellent, 27% good, 5% fair and 5% poor. Improved stability with clinical ligamentous laxity tests and good IKDC subjective and symptom-activity results 2 years after surgery suggest that for patients with PCL rupture and grade I or II posterolateral instability the double-bundle procedure alone sufficiently restores PCL function through a greater range of knee motion than traditional single-bundle techniques.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon autograft: clinical outcome in 4–7 years

Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. In the present study, we describe the clinical results of quadriceps tendon-patellar bone autograft for ACL reconstruction. From 1996 to 1998, the graft has been used in 38 patients. Thirty-four patients with complete final follow-up for 4–7 years were analyzed. The average follow-up time was 62 (48–84) months. Thirty-two patients (94%) achieved good or excellent results by Lysholm knee rating. Twenty-six patients (76%) could return to moderate or strenuous activity after reconstruction. Twenty-eight patients (82%) had ligament laxity of less than 2 mm. Finally; 31 patients (91%) were assessed as normal or nearly normal rating by IKDC guideline. Twenty-five patients (73%) had less than 10 mm difference in thigh girth between their reconstructed and normal limbs. Thirty-two (94%) and 31 (91%) patients could achieve recovery of the extensor and flexor muscle strength in the reconstructed knee to 80% or more of normal knee strength, respectively. A statistically significant difference exists in thigh girth difference, extensor strength ratio, and flexor strength ratio before and after reconstruction. Tunnel expansion with more than 1 mm was identified in 2 (6%) tibial tunnels. Our study revealed satisfactory clinical subjective and objective results at 4–7 years follow-up. Quadriceps tendon autograft has the advantage of being self-available, relatively easier arthroscopic technique, and having a suitable size, making it an acceptable graft choice for ACL reconstruction. There is little quadriceps muscle strength loss after quadriceps harvest. A quadriceps tendon-patellar autograft is an adequate graft choice to ACL reconstruction.     

Autologous osteochondral grafts in the treatment of cartilage defects of the knee joint

Autologous osteochondral grafting (mosaicplasty) was performed on 18 patients with grade IV cartilage defects of the knee joint. The average age of these 12 men and 6 women was 36 years, follow-up time was 27.2 months and defect size was 252 mm² (18×14 mm). After plain anteroposterior and lateral radiographs and MRI (STIR sequence) examination, diagnostic arthroscopy was performed, followed by autologous osteochondral grafting, avoidance of weight bearing for 6–8 weeks, physiotherapy and continuous passive motion. All patients showed, radiologically (MRI), a full coverage of the defect with articular surface congruity postoperatively. The postoperative ICRS score was normal for 12 and nearly normal for 6 patients. Seven patients showed early persistent joint effusion for an average of 5.3 months. Hyaline-like cartilage coverage was found in four patients on second-look arthroscopy. The transplantation of autologous osteochondral grafts is being applied in an effort to reconstruct the affected articular surface with properties similar to those of hyaline cartilage. This method retains the integrity and function of a damaged joint, providing promising results in terms of preventing the development of early arthritis in young patients.     

Good clinical results with autologous matrix-induced chondrogenesis (Amic) technique in large knee chondral defects

Purpose

Autologous matrix-induced chondrogenesis (AMIC) is a treatment for focal full-thickness cartilage defects combining microfracturing with an exogenous I/III collagen matrix (Chondro-Gide). The aim of the present study was to determine the 7 years outcomes of patients treated with the AMIC technique for knee chondral defects larger than 2 cm². The hypothesis was that the positive short-term outcomes achieved in the previous series would not deteriorate at a 7-year follow-up.

Methods

Twenty-one patients treated with the AMIC technique were retrospectively analysed. Patients were assessed through the IKDC subjective knee evaluation questionnaire and the Lysholm scoring system. All patients underwent a complete imaging study including radiographs and magnetic resonance. The median defect size was found to be 4.3 (range 2.9–8) cm².

Results

At a median follow-up of 7 (±1.4) years, the mean IKDC score improved from 31.7 (±8.9) points preoperatively, to 80.6 (±5.3) at the latest follow-up (p < 0.05). The mean Lysholm score improved from 38.8 (±12.4) points preoperatively to 72.6 (±19.5) points at the last follow-up (p < 0.05). At the last follow-up, 76.2% of patients were satisfied or extremely satisfied with their outcomes, while 66.6% of patients showed good quality repair tissue on magnetic resonance imaging.

Conclusion

AMIC was found to be an effective method to treat full-thickness knee chondral defects larger than 2 cm², with significant clinical and functional improvement maintained over a 7-year follow-up.

Level of evidence

IV.

     

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26–35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.     

Mid-term results of Autologous Matrix-Induced Chondrogenesis for treatment of focal cartilage defects in the knee

Articular cartilage defects heal poorly. Autologous Matrix-Induced Chondrogenesis (AMIC) is an innovative treatment for localized full-thickness cartilage defects combining the well-known microfracturing with collagen scaffold and fibrin glue. The purpose of this prospective study was to evaluate the medium-term results of this enhanced microfracture technique for the treatment of chondral lesions of the knee. Thirty-two chondral lesions in 27 patients were treated with AMIC. Within the context of clinical follow-up, these patients were evaluated for up to 5 years after the intervention. Five different scores (Meyer score, Tegner score, Lysholm score, ICRS score, Cincinatti score) as well as radiographs were used for outcome analysis. Articular resurfacing was assessed by magnetic resonance imaging (MRI). The average age of patients (11 females, 16 males; mean body mass index 26, range 20–32) was 37 years (range 16–50 years). The mean defect size of the chondral lesions was 4.2 cm² (range 1.3–8.8 cm²). All defects were classified as grade IV according to the Outerbridge classification. The follow-up period was between 24 and 62 months with a mean of 37 months. Twenty out of 23 individuals (87%) questioned were subjectively highly satisfied with the results after surgery. Significant improvement (P < 0.05) of all scores was observed as early as 12 months after AMIC, and further increased values were notable up to 24 months postoperatively. MRI analysis showed moderate to complete filling with a normal to incidentally hyperintense signal in most cases. Results did not show a clinical impact of patient’s age at the time of operation, body mass index and number of previous operations (n.s.). In contrast, males showed significant higher values in the ICRS score compared to their female counterparts. AMIC is an effective and safe method of treating symptomatic full-thickness chondral defects of the knee in appropriately selected cases. However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time.     

Use of the International Knee Documentation Committee guidelines to assess outcome following anterior cruciate ligament reconstruction

The purpose of this project was to determine if guidelines established by the International Knee Documentation Committee (IKDC) could distinguish differences in outcome, as indicated by the patients’ subjective rating of knee function following ACL reconstruction, and to determine if all subgroups included in the IKDC rating system contribute to the prediction of the overall final IKDC rating. A total of 133 patients undergoing ACL reconstruction were evaluated according to IKDC guidelines 1–5 years postoperatively. Each subject was rated in each of four subgroups on the IKDC scale: patient subjective assessment, symptoms, range of motion (ROM), and laxity. The worst rating for the subgroups defined the overall final rating. The outcome from the patient’s perspective was determined by asking them to rate the function of their knee on a scale from 0 to 100 with 100 being the level of function before injury. Average length of follow-up was 3.2 years (range 1.1– 6.3 years). ANOVA indicated that the patients’ subjective rating of knee function on a scale from 0 to 100 differed according to the overall final IKDC rating (F = 16.1, P < 0.001). The average subjective rating of knee function for those with a normal IKDC rating was 95.2, nearly normal was 91.2, abnormal was 84.9, and severely abnormal was 75.4. The average subjective rating of knee function for those who were severely abnormal was significantly different from those rated normal, nearly normal, and abnormal, and the average subjective rating for those who were abnormal was significantly different from those who were normal or nearly normal. There was no significant difference in average subjective rating between those who were rated as normal or nearly normal. Regression analysis indicated that all four subgroups contributed significantly to the prediction of the final IKDC rating (r ² = 0.70), but the majority of the variance (62%) was accounted for by symptoms and laxity. These results appear to indicate that the IKDC guidelines are useful for describing the outcome following ACL reconstruction. Further testing of the IKDC guidelines is necessary to determine if they are capable of detecting a change in the patients over time following treatment and/or surgery of the knee.     

Anterior cruciate ligament reconstruction in patients over the age of 50 years: 2- to 8-year follow-up

We present medium-term results in 30 prospectively followed patients aged over 50 years at the time of ACL reconstruction (31 procedures); mean follow-up time was 46 months (range 24-95). Mean Lysholm score improved significantly from 63 pre-operatively to 93 at final review Cincinnati score from 49 to 89. In IKDC score 25 knees (81%) were considered normal or nearly normal and 6 abnormal; there were no severely abnormal results. Mean Tegner activity scores improved from pre-operatively from 3.7 to 5.2 at review. Mean side-to-side difference measured by the KT-1000 at maximal manual pressure was 2.7 mm; two knees had. a measured difference greater than 5 mm. The mean torque ratio for isokinetic flexion strength was 102% and for extension strength 94%. Poor results as determined by the three scoring systems were associated mainly with advanced articular degenerative changes (Outerbridge grade 3 or 4) seen at the time of reconstruction. Despite this all patients reported improvement in stability and overall function of the knee. Degenerative change itself was associated with increased time to surgery from injury. This study demonstrates that the ACL can be reliably reconstructed in patients over the age of 50 years with good symptomatic relief, restoration of function and return to sporting activity.