Value of intercondylar notch plasty. CT studies and peroperative measurements of 127 knees

The intercondylar notch diameter was measured in six knees on CT scans before and after anterior cruciate ligament reconstruction. During the operation, direct measurements of the anterior notch diameter was also performed before and after notch plasty. There was good agreement between CT and peroperative measurements, showing that the enlargement of the intercondylar notch can be measured on the CT scan. Twenty-one patients previously reconstructed because of old anterior cruciate ligament injuries were reexamined after a median of 4 years, and their notch diameters were measured by CT or at reoperation. The notch remained open in stable knees, but was narrowed in unstable knees. The notch diameter before notch plasty was assessed with a calliper at operation on 45 patients with acute and 60 patients with old injuries. Both groups had a mean intercondylar diameter of 16 mm. The conclusion that the notch plasty stays open in stable knees emphasizes the importance of this step in the reconstruction procedure.     

Extraarticular repair of the unstable knee. Disappointing 6-year results of the Slocum and Ellison operations

Thirty-nine clinically unstable knees caused by anterior cruciate ligament rupture were evaluated 5-8 years after medial and lateral extraarticular stabilization according to Slocum and Ellison. At the follow-up, 10 knees had been subjected to an intraarticular anterior cruciate ligament reconstruction, and one knee was not available for follow-up. The mean Lysholm score for the 28 reexamined knees was 84 out of a maximum of 100 points. Activity scores were generally low, and all the knees had increased anterior drawer instability. The combination of the pes anserinus and lateral extraarticular repair did not give acceptable long-term results.     

Surgical or non-surgical treatment of acute rupture of the anterior cruciate ligament. A randomized study with long-term follow-up

One hundred and eleven consecutive patients who had acute injuries to the knee that included rupture of the anterior cruciate ligament, as shown by physical examination with the patient under anesthesia and by diagnostic arthroscopy, were randomized to three treatment groups: simple repair of all injured structures, repair of all injured structures and augmentation of the anterior cruciate ligament with a strip of the iliotibial band, and repair of all injured structures except the anterior cruciate ligament. In all other respects, the knees were treated in an identical fashion. Of the 111 patients, 107 were re-examined forty-five months or more after operation. At the most recent follow-up, the knees that had been treated by repair and augmentation of the anterior cruciate ligament were significantly more stable and had had significantly fewer subsequent meniscal tears. Sufficient instability to necessitate late reconstruction was also less frequent in the patients who had had an augmented repair. These patients had better function of the knee and a higher level of activity than the patients in the other two groups. Sixty-four per cent of these patients who had a rupture of the anterior cruciate also had a meniscal tear, and primary care was indicated for more than 50 per cent of the tears. Therefore, we believe that early arthroscopic examination is essential for patients who have an acute rupture of the anterior cruciate ligament.     

Knee stability following anterior cruciate ligament rupture and surgery. The contribution of irreducible tibial subluxation

BACKGROUND: Knee stability after anterior cruciate ligament reconstruction is generally determined by measuring total anteroposterior tibial motion. In spite of a decrease in excessive anteroposterior tibial motion after anterior cruciate ligament reconstruction, problems can still develop. In the present study, we sought to define the tibiofemoral relationship more accurately with use of stress radiographs of human knees after anterior cruciate ligament rupture and after anterior cruciate ligament reconstruction. METHODS: A previously described radiographic technique was used to evaluate the position of the tibia relative to the femur with the application of an anteriorly directed tibial force and subsequently with the application of a posteriorly directed tibial force. Tibial position and total tibial translation were calculated from these radiographs. In addition, KT-1000 measurements were obtained. Three groups of patients were studied: Group 1 included twenty-eight patients with an untreated anterior cruciate ligament rupture, Group 2 included nineteen patients who had undergone a clinically successful anterior cruciate ligament reconstruction, and Group 3 included twenty-five control subjects with normal knees. RESULTS: KT-1000 testing showed that the average side-to-side differences in Group 1 (5.8 mm) and Group 2 (2.7 mm) were significantly different from that in Group 3 (0.8 mm) (p < 0.01 and p < 0.05, respectively). Stress radiographs showed that the average total tibial translation in Group 1 (9.8 mm) was significantly different from those in Group 2 (5.6 mm) and Group 3 (4.3 mm) (p < 0.05 and p < 0.001, respectively). Within Group 1, knees with radiographic signs of osteoarthritis were more stable, with an average total tibial excursion of 6.8 mm. The improved stability of the reconstructed knees in Group 2 and the osteoarthritic knees in Group 1 was not entirely the result of decreased anterior tibial translation; it was, in part, due to an irreducible anterior subluxation of the tibia. A posteriorly directed stress in these knees did not reduce the tibia to the anatomic position relative to the femur; the osteoarthritic knees in Group 1 were 9.9 mm short of full reduction and the knees in Group 2 were 3.1 mm short of full reduction (p < 0.01) CONCLUSIONS: Irreducible tibial subluxation can be present in the knee following surgical reconstruction of the anterior cruciate ligament. Osteoarthritic changes following an untreated anterior cruciate ligament rupture are also associated with uncorrectable tibial subluxation along with a decrease in instability. The irreducible tibial subluxation could explain why osteoarthritic changes still may develop in stable, reconstructed knees in spite of the improved stability. Currently used arthrometric measurements, such as KT-1000 scores, do not measure this phenomenon.     

关节镜下掌骨钢板结合不可吸收缝线固定治疗前交叉韧带止点撕脱骨折

目的探讨关节镜下掌骨钢板结合不可吸收缝线固定治疗前交叉韧带（ACL）止点撕脱骨折的临床效果。方法对16例有明显移位的ACL止点撕脱骨折在关节镜下进行复位,使用掌骨钢板结合不可吸收Ethieon缝线进行固定。术后进行积极康复训练。结果16例获随访0．5～2．5年,术后所有骨折均获得愈合,无骨折移位出现。术后3个月,无膝关节松弛或者不稳定发生,所有患者膝关节活动度均恢复至伤前水平。末次随访时IKDC主观膝关节功能评分平均（95．1±2．8）分。结论关节镜下利用掌骨钢板和不可吸收缝线固定治疗ACL止点撕脱骨折复位和固定效果好、创伤小,可早期进行膝关节康复训练,能够尽快恢复膝关节功能。     

Value of intercondylar notch plasty: CT studies and peroperative measurements of 127 knees

The intercondylar notch diameter was measured in six knees on CT scans before and after anterior cruciate ligament reconstruction. During the operation, direct measurements of the anterior notch diameter was also performed before and after notch plasty. There was good agreement between CT and peroperative measurements, showing that the enlargement of the intercondylar notch can be measured on the CT scan. Twenty-one patients previously reconstructed because of old anterior cruciate ligament injuries were reexamined after a median of 4 years, and their notch diameters were measured by CT or at reoperation. The notch remained open in stable knees, but was narrowed in unstable knees. The notch diameter before notch plasty was assessed with a calliper at operation on 45 patients with acute and 60 patients with old injuries. Both groups had a mean intercondylar diameter of 16 mm.

The conclusion that the notch plasty stays open in stable knees emphasizes the importance of this step in the reconstruction procedure.     

Treatment of fresh tears of the anterior cruciate ligament. A comparison of primary suture and augmentation with carbon fibre

Early results after a follow-up of 1 year of primary suture and carbon fibre augmentation in the treatment of fresh anterior cruciate ligament tears in 57 consecutive and randomized patients are presented. There was no statistical difference between the two groups in the postoperative course. At an average of 13 months follow-up, complete stability was achieved regarding the pivot shift sign in 16 (55 per cent) and 18 (75 per cent) of the sutured and augmented groups respectively. There were 3/29 obvious pivot shifts in the sutured and 1/24 in the augmented knees. Seventeen carbon fibre reinforced knees were postoperatively arthroscoped at the 1-year follow-up. A structure resembling a ‘neoligament’ was observed in 8/16 knees. In 11 knees there were no signs of carbon material, in 4 knees subsynovial microparticles were scattered around the anterior compartment and in 3 knees the carbon fibre tow was bare in the joint despite careful covering within the ligament remnants at the time of the operation. Although no statistical difference was obtained between the two groups the augmentation procedure seemed to improve stability at the 1-year follow-up.     

Primary suture of the anterior cruciate ligament. A 6-year follow-up of 74 cases

Seventy-four consecutive patients were reviewed 6 (3-9) years after primary suture according to Palmer of a fresh rupture of the anterior cruciate ligament. Three fourths had excellent or good function as evaluated by the Lysholm score. The pivot shift test was trace-positive in one fifth and 2+ or 3+ in one quarter, and the Lachman test was 2+ or higher in one third. Tibial anterior instability was present in 23 knees. Radiographically, 15 knees had signs of arthrosis, 4 of which severe. Our 0.25 failure rate suggests that other procedures should be considered in the treatment of acute rupture of the anterior cruciate ligament.     

Repair of peripheral meniscal tears: open versus arthroscopic technique

Tears in the peripheral vascular zone of 71 menisci in 68 knees were repaired by us from 1978 to 1986. The meniscus repair was done by open arthrotomy in 26 cases and by arthroscopic techniques in 45 cases. We have assessed the relative efficacies of open and arthroscopic repair techniques. The results were compared in knees with and without anterior cruciate laxity. The indications for meniscal repair included unstable peripheral detachments and longitudinal tears of the outer third of the meniscus. Open repair was performed by a posteromedial arthrotomy incision. Arthroscopic repair was done using the double-lumen guide system with a limited posterior incision for retrieval of needles. We have found that the arthroscopic technique is easier to perform than the open repair because some tears are too far inside the rim to lend themselves to open suture. The average follow-up is 4 years, 2 months, with a range of 2-10 years. There have been no neurologic or vascular injuries from either technique. Twenty-five patients have had a repeat arthroscopy. The overall failure rate was 9.8%. The difference between the failure rate of 11% in the open-repair group and 8.8% in the arthroscopic repair group was not statistically significant. The failure rate in anterior cruciate-stable knees was 8% versus a 13% failure in cruciate-deficient knees. We conclude that both open and arthroscopic meniscus repair techniques are safe and effective with few complications in both stable and unstable knees. Anterior cruciate ligament stability is ideal, but it is not mandatory for a successful result.     

Extraarticular repair of the unstable knee: Disappointing 6-year results of the Slocum and Ellison operations

Thirty-nine clinically unstable knees caused by anterior cruciate ligament rupture were evaluated 5-8 years after medial and lateral extraarticular stabilization according to Slocum and Ellison. At the follow-up, 10 knees had been subjected to an intra-articularanteriorcruciate ligament reconstruction, and one knee was not available for follow-up. The mean Lysholm score for the 28 reexamined knees was 84 out of a maximum of 100 points. Activity scores were generally low, and all the knees had increased anterior drawer instability. The combination of the pes anserinus and lateral extraarticular repair did not give acceptable long-term results.     

Primary suture of the anterior cruciate ligament A 6-year follow-up of 74 cases

Seventy-four consecutive patients were reviewed 6 (3-9) years after primary suture according to Palmer of a fresh rupture of the anterior cruciate ligament. Three fourths had excellent or good function as evaluated by the Lysholm score. The pivot shift test was trace-positive in one fifth and 2+ or 3+ in one quarter, and the Lachman test was 2+ or higher in one third. Tibial anterior instability was present in 23 knees. Radiographically, 15 knees had signs of the arthrosis, 4 of which severe. Our 0.25 failure rate suggests that other procedures should be considered in the treatment of acute rupture of the anterior cruciate ligament.     

Total knee arthroplasty with retention of both cruciate ligaments. A nine to eleven-year follow-up study.

BACKGROUND: Although many early designs of total knee arthroplasty allowed the retention of both cruciate ligaments, in most current designs of knee replacement systems, either both cruciate ligaments are removed or the posterior cruciate ligament alone is retained. This report is a review of a series of total knee arthroplasties in which both cruciate ligaments were retained. METHODS: The results of 163 total knee arthroplasties (130 patients) in which both cruciate ligaments were retained were assessed prospectively. One hundred and seven knees (eighty-nine patients) were followed for an average of ten years. There were thirty-four men and ninety-six women, and the average age at the time of the index arthroplasty was sixty-seven years (range, forty-two to eighty-four years). The diagnosis was osteoarthritis in 122 (75 percent) of the knees and rheumatoid arthritis in forty-one (25 percent). Twenty-six knees had a valgus deformity, 109 had a varus deformity, and twenty-eight had a normal alignment of 5 to 10 degrees of valgus. The anterior cruciate ligament was relatively normal in ninety-six knees and was partly degenerated in sixty-seven knees. With use of the rating system of the Knee Society, all 163 knees were prospectively evaluated at yearly intervals; fifty-six of these knees (in forty-one patients) were followed in this manner until the patient died or was lost to follow-up. RESULTS: One hundred and four (97 percent) of the 107 knees available for study at an average of ten years had an excellent or good result. At the time of the latest follow-up, pain was adequately relieved in ninety-seven knees (91 percent) and the average range of flexion was 107+/-12.6 degrees (range, 65 to 135 degrees). Ninety-five knees (89 percent) had normal anteroposterior stability (less than five millimeters of movement in this plane), and twelve knees (11 percent) had five to ten millimeters of movement as demonstrated by the drawer sign. Ninety-six knees (90 percent) had normal mediolateral stability, and eleven (10 percent) had 5 to 10 degrees of laxity. Ninety-four knees (88 percent) had valgus alignment of 5 to 10 degrees. The average knee score was 91+/-8.4 points (range, 54 to 100 points), and the average functional score was 82+/-21 (range, 10 to 100 points). The survival rate at ten years, with revision as the end point, was 95+/-2.0 percent. Seven (4 percent) of the 163 knees in this series were revised. There were no revisions for patellar problems or aseptic loosening of the tibial component. CONCLUSIONS: The good anteroposterior stability in this series after an average follow-up period of ten years indicates that both the anterior and the posterior cruciate ligaments, even when partly degenerated, remain functional when they are preserved in a total knee arthroplasty.     

Instrumented testing for evaluation of sagittal knee laxity

Seventy-one patients with untreated ruptures of the anterior cruciate ligament of at least four years' duration had their knee laxity examined with a laxity testing device. Twenty of the 71 patients were tested by two examiners independently. Another 30 patients without previous knee injury were chosen as a reference group and tested. Patients with anterior cruciate-deficient knees had significantly increased anterior and total laxity. If the testing procedure was altered, the laxity changed. Thus, an increase of knee flexion from 15 degrees to 25 degrees resulted in an increased anterior laxity. Changes in the amount and placement of the tibial load also affected laxity. Inter-examiner reproducibility was high if a standardized testing procedure was followed. Sensitivity was 92% if the difference in total laxity between involved and uninvolved knees was determined with a high tibial load (180 N), whereas specificity was 70%. Therefore, the laxity tester has disadvantages as a diagnostic tool, but it is still valuable for evaluation of anterior cruciate ligament ruptures and their treatment.     

Effects of knee flexion angle at graft fixation on the outcome of anterior cruciate ligament reconstruction

Clinical outcome in 44 patients who underwent anterior cruciate ligament (ACL) reconstruction with hamstring tendons augmented by the ligament augmentation device for chronic ACL deficiency was studied; average follow-up was 38 months (range, 24 to 52 months). In 19 patients, grafts were fixed with the knees at full extension (group 1), whereas in 25 patients, the grafts were fixed with the knees at 30° of flexion (group 2). The results of subjective testing (Lysholm score), the Lachman test, the pivot-shift test, muscle strength testing, angle of extension loss, and follow-up arthroscopy were compared to assess the effects of flexion angle at fixation on stability and function. The range of motion in group 1 was significantly better than that in group 2. The stability of the knees and the arthroscopic appearance of the grafts in group 1 were, however, significantly worse than those in Group 2.     

Suture of fresh ruptures of the anterior cruciate ligament: A 5-year follow-up

Thirty-five of 41 consecutive patients were followed for 5 years after early primary suture of the acutely torn anterior cruciate ligament and repair of all other injured structures; three early failures were excluded from the series, and three patients were lost to follow-up.

Twenty-three of the patients also had an early follow-up 2 years postoperatively. From the early to the late follow-up, the function of the operated knees decreased significantly.     

Acute hemarthrosis of the knee: indications for diagnostic arthroscopy

The objective of this study was to define the role of early diagnostic knee arthroscopy for patients with an acute knee injury and hemarthrosis. Forty-five patients with an acute knee injury followed by a posttraumatic hemarthrosis during a 1-year period were prospectively reviewed. All patients were evaluated preoperatively followed by examination under anesthesia and arthroscopy of the knee. The majority of patients, 32 (71%), had an anterior cruciate ligament tear. Meniscal tears occurred in 21 patients (47%). Meniscal tears requiring surgery occurred in only 10 of 25 meniscal tears (40%). Seven patients (16%) had medial collateral ligament and/or posteromedial capsular sprain. Eight patients (18%) had an osteochondral fracture or patellar dislocation associated with an osteochondral fracture. The majority of knees with a torn meniscus or osteochondral fracture had an anterior cruciate ligament tear. Clinically, 18 of 21 knees (86%) with an acute complete anterior cruciate ligament tear were diagnosed preoperatively with the Lachman test. The Lachman test conducted with patients under anesthesia was positive for 19 of 21 knees (90%) with an acute complete anterior cruciate ligament tear. The preoperative examination correctly identified six of seven knees (86%) with a medial collateral ligament sprain. The preoperative Lachman test was positive in only two of five knees (40%) with a partial anterior cruciate ligament tear. The Lachman test with patients under anesthesia was positive for four of five knees (80%) with an acute partial anterior cruciate ligament tear. Preoperative examination yielded the correct diagnosis in only 9 of 21 knees (43%) with a meniscal tear and 1 of 6 knees (17%) with an osteochondral fracture.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term follow-up after primary repair of the anterior cruciate ligament: clinical and radiological evaluation 15–23 years postoperatively

Introduction We have previously reported results after 2–5 and 5–10 years follow-up of repair of acute anterior cruciate ligament (ACL) ruptures by suturing. Reports of results after more than 10 years are rare.Materials and methods A total of 140 patients were operated on in the period 1975–1983 (age range 13–71 years, median 28 years) by the modified Palmer technique. Only 2 meniscus resections and 4 meniscectomies were performed at the primary operation; while 28 menisci were sutured. At follow-up,12 patients were dead. Eighteen patients (13%) underwent repeat operations for secondary instability. Of the remaining 110 patients, 81 appeared for follow-up.Results Only 6 secondary meniscus resections were performed, all in the group of 18 patients operated on again for instability. No secondary meniscus surgery was performed on the 81 patients who appeared for follow-up. The median Lysholm score was 88, and 58 of the 81 patients (71%) classified their total knee function as good or excellent. By KT-1000 testing, 33 (41%) patients had less than 3 mm anterior instability, 29 (36%) had 3–5 mm instability, and 17 (21%) had more than 5 mm. With 18 patients from the total of 128 living patients re-operated for instability, we estimate the rate of total failure of stability as 27%. Radiological osteoarthritis grade C was present in 8 operated and 2 control knees, while only 1 operated knee revealed osteoarthritis grade D. Thirty-four operated and 20 control knees had grade B. Osteoarthritis was correlated to more advanced age at injury, while correlation to function could not be proven. Radiographs were obtained of 61 patients at follow-up.Conclusions Some 50% of patients had stable or slightly unstable knees, and 40% good or excellent function according to the Lysholm score. Re-operation for instability was more frequent in younger patients, while ostearthritis was more frequent in older patients. The rate of meniscus resection or extirpation was low. Open repair by suture is no longer recommended. Further research is indicated on the possible use of refixation of the ruptured ACL by arthroscopy.     

Pes anserinus transfer for the unstable knee. A 7-year follow-up of 43 cases of ruptured anterior cruciate ligament

On average 7 years postoperatively, we evaluated 43 consecutive patients who had had pesoplasty for chronic injury of the anterior cruciate ligament. Fourteen patients had undergone further surgery during the follow-up period; ten of these had extra- or intra-articular stabilizing procedures, and eight meniscectomies were performed after the index operation. At follow-up of the 33 knees that had not had additional stabilizing surgery, only one-third of the knees had normal radiograms, and the majority had anterolateral rotational instability (pivot shift) which, however, did not exclude satisfactory knee function. We conclude that improvement after transfer of the pes anserinus tendons was due to the simultaneous meniscectomy; we do not believe that the pesoplasty changed the natural course of the chronic rupture of the anterior cruciate ligament.     

Magnetic resonance imaging of reconstructed anterior cruciate ligament.

After anterior cruciate ligament reconstruction with autologous patellar tendon, 23 patients who had clinically stable knees were studied prospectively with sequential magnetic resonance imaging 1, 2, 3, 6, and 12 months after surgery. The images of the anterior cruciate ligament were obtained with a 1.5 tesla magnetic resonance scanner in the oblique sagittal, coronal, and oblique axial planes. The cross-sectional area and signal intensity on the reconstructed anterior cruciate ligament were measured in an oblique axial image. The usefulness of the oblique axial image in evaluating the integrity of the reconstructed anterior cruciate ligament was seen. The result showed that the diameter of the graft increased by 70% of its initial size and the signal intensity of the reconstructed graft also showed a tendency to increase. In three patients, there was discontinuity in the graft direction on the oblique sagittal image, but on the oblique axial image there was no evidence of reconstructed anterior cruciate ligament rupture in the sequential images. This shows the value of the oblique axial image in evaluating the integrity of the reconstructed anterior cruciate ligament. Also, sufficient notchplasty in anterior cruciate ligament reconstruction may be needed to prevent graft impingement.