Quadrupled bone-semitendinosus anterior cruciate ligament reconstruction: a clinical investigation in a group of athletes

Purpose: The hypothesis of our study was that a quadrupled bone-semitendinosus (STB) graft could provide a clinically stable construct, allow recovery of normal limb strength, give high patient satisfaction with early return to active sports, and involve low donor-site morbidity. Type of Study: Outcomes study. Methods: Anterior cruciate ligament (ACL) reconstruction with an STB graft was performed on 80 athletes with isolated ACL injury from January 1996 to December 1999. Femoral fixation was obtained with EndoButton (Smith & Nephew, Andover, MA) and tibial fixation with Fastlok (Neoligaments, Leeds, England). At a mean follow-up time of 36 months (range, 24–52 months), patients were evaluated using standard knee scores (Noyes, Lysholm, Tegner, and International Knee Documentation Committee [IKDC] rating) and functional strength tests; postoperative pain rating; knee radiographs performed after surgery and at final follow-up; magnetic resonance imaging (MRI) at 3 to 6 months; isokinetic flexion-extension and internal-external rotation tests at 3, 6, and 12 months; and computed laxity analysis at final evaluation. Results: At final evaluation, subjective knee rating was 87%, kneeling test was positive in 7%, and Werner score was 44 of 50 (range, 30–48). Lachman test was negative in 90% at final evaluation. Sensory changes were present in 30% at 3 months, and 10% had definite hyposthesia. Computed laxity analysis revealed 90% with less than 3 mm side-to-side difference. Isokinetic testing showed normal hamstring and quadriceps peak torques at 12 months. The one-leg hop test and vertical jump were normal by 6 months. At final evaluation, average Noyes score was 88 (range, 65–100); Lysholm score, 91 (range, 70–100); postoperative Tegner rating, 6.5 (range, 5–9); and preinjury Tegner rating, 7.5 (range, 7–10). IKDC score showed 72 knees normal or nearly normal, 7 abnormal, and 1 severely abnormal. Sixty-five percent of patients returned to the same preinjury sports level. Conclusions: The quadrupled bone-semitendinosus graft is a viable graft for ACL reconstruction and should be considered, especially for patients with extensor mechanism problems.     

Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton femoral fixation: A prospective study

Purpose: This prospective study was conducted to compare the single-socket and the bi-socket anterior cruciate ligament (ACL) reconstruction techniques in terms of outcome. Type of Study: Nonrandomized control trial. Methods: There were 160 consecutive patients with unilateral chronic ACL insufficiency who underwent endoscopic single- or bi-socket ACL reconstruction alternately using multiple-stranded medial hamstring tendon and EndoButton (Smith & Nephew, Andover, MD) femoral fixation. All patients underwent the same postoperative rehabilitation protocol. Of them, 106 patients (57 single, 49 bi) were available for 2-year follow-up. Results: According to the IKDC Knee Ligament Evaluation Form, 23 patients (40%) of the single-socket group were subjectively graded as normal, 30 (53%) as nearly normal, and 4 (7%) as abnormal. Twenty-six patients (53%) of the bi-socket group were graded as normal, 21 (43%) as nearly normal, and 2 (4%) as abnormal (P =.19). The mean side-to-side anterior laxity difference (KT-1000 manual maximum force) was 0.9 ± 1.8 mm for the single-socket group and 0.7 ± 1.2 mm for the bi-socket group (P =.44). Fifty-three of 57 patients (93%) in the single-socket group and all patients in the bi-socket group showed anterior laxity differences of ±3 mm or less (P =.12). There were no differences in thigh muscle strength between the groups. Conclusions: Both single- and bi-socket ACL reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton fixation provided satisfactory anterior stability, and there were no statistically significant differences in subjective results or measured restored stability between the 2 groups.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: pp 801–807     

保留并牵张残留纤维的前十字韧带双束重建术

目的 评估在亚急性期进行保留并牵张残留纤维的前十字韧带双束重建的临床效果.方法 2006年1月至2006年6月,对56例前十字韧带损伤患者在亚急性期进行保留并牵张残留纤维的前十字韧带双束重建.前十字韧带双束重建采用四隧道八股肌腱移植的方法.使用PDS缝线穿缝胫骨侧残留纤维,经深束股骨隧道牵张固定.使用IKDC及Lysholm评分标准评估疗效.结果 53例随访2年以上.末次随访时所有患者Lachman试验均为阴性.屈膝25°KT-1000检测结果显示双侧膝关节松弛度差值为(-0.44±1.53)mm,与术前(8.01±1.83)mm比较差异有统计学意义(t=37.03,P=0.0001).29例(54.7%)双侧膝关节松弛度差值小于0mm,提示患膝相对于健侧更为稳定或紧张.24例(45.3%)双侧膝关节松弛度差值为0～2mm.所有患者轴移试验均阴性.48例膝关节活动度正常,2例有5°屈曲受限,1例有小于5°屈曲受限,2例有5°过伸受限.根据IKDC评估标准,51例(96.2%)正常,2例(3.8%)接近正常.IKDC主观评分为(95.6±3.1)分,Lysholm评分为(94.8±2.9)分.受伤前Tegner评分平均为7.3分,末次随访时为7.1分.结论 根据2年以上随访结果,以IKDC为评估标准,保留并牵张残留纤维的前十字韧带双束重建能够使96.2%的患者恢复正常,3.8%的患者接近正常.     

Quadrupled bone-semitendinosus ACL reconstruction: a prospective clinical investigation in 100 patients

Abstract The hypothesis of our study was that a quadrupled bonesemitendinosus tendon graft could combine the advantage of bone-tobone healing with the high cross-sectional area of a quadrupled hamstring graft in ACL reconstruction. ACL reconstruction with a semitendinosus tendon graft was performed on 100 patients with isolated ACL injury from January 1996 to December 1999: femoral fixation was obtained with Endobutton and tibial fixation with Fastlok. Patients were evaluated for standard knee scores and functional strength tests, postoperative pain rating, knee radiographs taken after surgery and at final follow-up, magnetic resonance images at 3 and 6 months, isokinetic flexion-extension and internal-external rotation tests at 3, 6, and 12 months. Computerized laxity analysis was performed at final evaluation. Average surgical time was 85 minutes, including 13 minutes for graft preparation; 90% of the patients were discharged within 24 h. Subjective knee rating was 80%; kneeling test was positive in 7% and Werner score was 44 (range, 30–48). Lachman test was negative in 90% at final evaluation (mean follow-up, 38 months). Sensory changes at the anterior part of the proximal tibia were present in 30% at 3 months and 10% had definite hyposthesia. MRI showed graft incorporation at 3 months. Computerized laxity analysis revealed 90% with less than 3-mm side-to-side differences. Isokinetic testing showed normal hamstring and quadriceps peak torques at 12 months. The functional strength tests were normal by 6 months. Average Noyes score was 87.9, Lysholm score 93, and Tegner activity rating 6.0 (pre-injury, 6.1). IKDC score showed 90 normal or nearly normal knees, 9 abnormal, and one severely abnormal knee. Quadrupled bone-semitendinosus is a viable graft for ACL reconstruction and should be considered, especially in patients with pre-existing extensor mechanism problems.     

One-stage arthroscopically assisted anterior and posterior cruciate ligament reconstruction

Purpose: To retrospectively evaluate 15 consecutive patients who underwent simultaneous isolated, arthroscopically assisted anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction. Type of Study: Case series. Methods: A bone–patellar tendon–bone autograft was used as the PCL substitute and doubled hamstring tendons were used as the ACL graft. The IKDC evaluation form and the HSS, Lysholm, and Tegner clinical rating scales were used to make clinical evaluations. Anteroposterior translation was measured with the KT-2000 arthrometer and stress view radiography. Results: At final IKDC evaluation, 3 patients (20%) were graded A, 7 (46.7%) were graded B, 3 (20%) were graded C, and 1 patient (6.7%) was graded D. One patient underwent revision surgery in another hospital for severe postoperative residual laxity. Two C-graded patients had an unsatisfactory outcome as a result of serious complications related to knee injuries. All patients with a grade A or B returned to sports activity. At stress view examination, mean posterior side-to-side translation measured at the lateral tibial plateau was 5.8 ± 1.1 mm and the mean translation at the medial tibial plateau was 7.3 ± 1.5 mm; the mean anterior dislocation was 3.3 ± 0.4 mm. The preoperative HSS score rated an average of 32 ± 9. Postoperatively, the average score reached was 89.6 ± 8.3. The preoperative Lysholm score was 65.5 ± 9.1 (range, 48 to 78) in patients with chronic lesions and at follow-up was 95.1 ± 4.5 (range, 88 to 100). The average Tegner activity score decreased in patients with chronic lesions from 6.9 ± 1.7 (range, 4 to 9) before injury to 5.5 ± 1.6 (range, 2 to 9) at follow-up (P = .053 ). At follow-up, 7 patients (50%) returned to their preinjury level after surgery. Conclusions: These results show the effectiveness and safety of simultaneous arthroscopic reconstruction of both cruciate ligaments using autografts that can adequately restore satisfactory stability, even in the presence of minimal peripheral laxity (1° or 2°). We conclude that the use of autografts can restore ligament function with good patient compliance and without significant surgical complications.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 7 (September), 2001: pp 700–707     

Arthroscopic posterior cruciate ligament reconstruction by using hamstring tendon autograft and transosseous screw fixation: minimal 3 years follow-up

Background

The aim of this trial is to prospectively evaluate the outcomes of PCL reconstruction by means of quadruple hamstring tendon autograft with a double-fixation method at minimal 3-year follow-up.

Materials and methods

Only patients who underwent PCL reconstruction without any other concomitant injury were included in this study. A hamstring tendon graft is composed of a quadruple-stranded gracilis tendon and semitendinosus tendon about 10 cm in length. An arthroscopic technique via a two incision and a double-fixation method was applied. Clinical evaluations were performed for 52 patients. Clinical assessment of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle evaluation, and radiographic investigation.

Results

On the Lysholm knee score, 90 % of the patients displayed good or excellent rating in the final assessment. In the IKDC rating analyses, 60 % of the patients demonstrated 3–5-mm ligament laxity. For the IKDC final rating, 81 % were normal or nearly normal. Seventy-nine percent of the cases revealed less than a 10-mm difference in thigh girth between their reconstructed and contra lateral limbs.

Conclusion

Arthroscopic PCL reconstruction using quadruple hamstring tendon autograft provides acceptable outcomes at a minimum 3-year follow-up. The four-stranded hamstring tendon graft is suitable in graft size and results in minimal harvesting morbidity. We recommend that quadruple hamstring tendon graft be chosen for PCL reconstruction to achieve good ligament reconstruction. A double-fixation method which has been applied in this trial can be used to provide rigid fixation.     

Reconstruction of the anterior cruciate ligament in females

Purpose: To compare the clinical results of anterior cruciate ligament reconstruction in female patients using quadruple-looped hamstring autograft versus patellar tendon autograft at minimum 2-year follow-up. Type of Study: Case series. Methods: A prospective clinical review was performed to compare the results of ACL reconstruction with hamstring versus patellar tendon autograft in a group of female patients. Exclusion criteria included chronic injuries (greater than 3 months), associated collateral ligament injuries, Workers’ Compensation or litigation cases, and bilateral anterior cruciate ligament injuries. There were 39 female patients in the hamstring group (average follow-up, 40.9 months) and 37 female patients in the patellar tendon group (average follow-up, 52 months). Both types of grafts were fixed with an EndoButton proximally and with sutures tied over a post or button distally. The postoperative rehabilitation regimen was identical for both groups. Objective parameters evaluated included preinjury and postoperative Tegner and Lysholm scores, side-to-side KT-1000 maximum-manual arthrometer differences, and clinical examination including Lachman and pivot-shift tests. Graft failure was defined by any one of the following: a KT-1000 difference of greater than 5 mm, a 2+ Lachman, a 1+ or greater pivot shift, or revision surgery. Results: The failure rate in the hamstring group was 23% versus 8% in the patellar tendon group, which was not statistically significant (P > .1). Comparison of preinjury Tegner activity scores to postoperative scores revealed that patients in the hamstring group did not return to their preinjury level of activity (preinjury 6.54 v postoperative 5.17) as well as patients in the patellar tendon group (preinjury 6.20 v postoperative 6.59). Patients in the hamstring group had a significant increase in pain compared with the patellar tendon group (P = .034). Conclusions: Although not statistically significant, the hamstring group had more failures, more laxity on clinical examination, and more patients with larger KT-1000 arthrometer differences. These results indicate a trend toward increased graft laxity in female patients undergoing reconstruction with hamstring autograft compared with patellar tendon when evaluated by a single surgeon using similar fixation techniques at short- to medium-range follow-up. More studies with larger patient numbers using current fixation techniques are necessary to confirm these findings.     

Application of a computerised navigation technique to assist arthroscopic anterior cruciate ligament reconstruction

Purpose

Based on biomechanical cadaver studies, anatomical double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of this study was to compare rotational and translational stability after computer-navigated standard single-bundle and anatomical double-bundle ACL reconstruction.

Methods

The authors investigated 42 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure using autogenous hamstring tendon grafts and ENDOBUTTON fixation in patients who had been followed up for a minimum of 24 months. Post-operative anteroposterior and rotational laxity was measured with the KT3000 and compared between groups.

Results

Both surgical procedures significantly improve rotational and translational stability compared to the preoperative ACL-deficient knee (P<0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. The International Knee Documentation Committee (IKDC) and Lysholm scores were significantly higher in the double-bundle group. However, the results were excellent in both groups.

Conclusions

The use of computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Long-term results of at least five years are needed to determine whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, exerts an influence in terms of avoiding osteoarthritis or meniscus degeneration.     

Arthroscopic reconstruction of the posterior cruciate ligament with quadruple hamstring tendon graft: a double fixation method

BACKGROUND: Surgical reconstruction is indicated for posterior cruciate ligament (PCL) reconstruction for a grade III or IV injury, combined ligament or meniscus injuries, and chronic symptomatic posterior instability. Considerable controversy continues over the choice of graft tissues. Hamstring tendon has been popular in recent years. The purpose of this study is to prospectively assess the outcomes of PCL reconstruction using quadruple hamstring tendon autograft with a double-fixation technique at minimal 2-year follow-up. METHODS: Only patients who received PCL reconstruction without combined associated posterolateral injury reconstruction were included in the series. A hamstring tendon graft is composed of a quadruple-stranded semitendinosus tendon and gracilis tendon 10 cm in length. An arthroscopic technique using a two-incision method and a double-fixation technique were used. Clinical assessments were performed for 30 patients, of which 27 were available for final outcome analysis. Clinical review of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle assessment, and radiographic evaluation. RESULTS: On the Lysholm knee rating, 89% of the patients demonstrated good or excellent results in the final assessment. In the IKDC rating analyses, 56% of the patients revealed 3- to 5-mm ligament laxity. Four patients (15%) had grade II laxity. For the IKDC final rating, 26% were normal and 55% were nearly normal. Seventy-eight percent of the patients had less than a 10-mm difference in thigh girth between their reconstructed and opposite limbs. CONCLUSION: Arthroscopic PCL reconstruction with quadruple hamstring tendon autograft appears to produce acceptable results at a minimal 2-year follow-up. The four-stranded hamstring tendon graft is adequate in graft size and associated with minimal harvesting morbidity. The double-fixation method for the graft could provide a rigid fixation. We believe that this technique could afford good ligament function after reconstruction and could be a reasonably acceptable choice for PCL injury.     

Improved outcomes after anterior cruciate ligament reconstruction with quadrupled hamstring autografts and additional bone plug augmentation at five year follow-up

Purpose

Hybrid fixation has been proposed to improve outcomes of anterior cruciate ligament (ACL) reconstructions. This study evaluated midterm outcomes after transfemoral graft fixation using either a conventional or a modified technique using additional bone plug augmentation (BPA) of the femoral tunnel aperture.

Methods

Seventy-one consecutive patients undergoing ACL reconstruction using a quadrupled hamstring autograft with transfemoral graft fixation and tibial interference screw fixation were included. Of these, 56 patients could be followed up 61 months (range 52–69 months) after ACL reconstruction both clinically and by magnetic resonance imaging (group A, conventional technique, n = 34; group B, modified technique, n = 22). Anteroposterior (AP) laxity measurements and International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scoring were performed, while imaging included assessment of bone tunnel diameters, graft condition and graft filling at the femoral bone tunnel aperture.

Results

Patients with additional BPA had a significantly higher degree of graft filling at the femoral bone tunnel aperture (p = .0135) and ‘healthier’ grafts (p = .0495). They also tended to display less AP laxity difference in terms of mean differences and total patient numbers. Lysholm, IKDC and Tegner activity index scores and bone tunnel diameters were not significantly different.

Conclusions

Additional BPA is an easy-to-perform, cheap and safe manoeuvre, which has the capacity to improve morphological and clinical outcomes at five year follow-up. However, femoral tunnel widening is unaffected by additional BPA.     

The incidence and significance of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation

Purpose: The purpose of this study was to evaluate the amount of femoral tunnel widening that occurred after anterior cruciate ligament reconstruction using quadrupled hamstring autografts and to determine the clinical significance of any such tunnel enlargement. Type of Study: Retrospective clinical analysis. Methods: Twenty-nine patients who had undergone reconstruction of a torn anterior cruciate ligament with quadrupled hamstring autograft and cross pin femoral fixation were evaluated to determine the incidence and significance of postoperative femoral tunnel widening. A single surgeon performed all procedures, and average follow-up was 18.4 months (range, 12 to 31.5 months). All patients underwent flexion posteroanterior and lateral radiographs, an examination for determination of an International Knee Documentation Committee (IKDC) rating, had KT-1000 data collected, and completed Lysholm and Knee Outcome Survey functional questionnaires. Femoral tunnels were clearly seen in 27 patients. The tunnel diameters were measured at the opening of the tunnel, at the widest part of the tunnel, and just proximal to the cross pin. The amount of tunnel widening for each patient was then compared with the individual’s KT-1000 data, IKDC rating, and Lysholm and knee outcome survey scores to assess correlation. Results: Four different tunnel morphologies were noted, with the linear type being the most common. The widening at the greatest tunnel diameter was 65.5% on average. Side-to-side KT-1000 differences averaged 1.04 mm at 30 lb, and 1.10 mm at manual maximum. Eleven patients had IKDC overall ratings of normal, 13 had ratings that were nearly normal, and 2 had abnormal. Average Lysholm and knee outcome survey scores were 92.6 and 93.9, respectively. A significant correlation was found only between F2 and F3 widening with Lysholm scores. However, the significance was eliminated with removal of 2 outliers. Conclusions: The exact etiology of postoperative anterior cruciate ligament tunnel widening remains unknown. The present study reveals that significant tunnel widening occurs with quadrupled hamstring autografts and femoral cross pin fixation. However, the widening does not appear to have a significant effect on postoperative ligament laxity or functional knee scores, at least in the short term.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: pp 470–476     

Functional outcome of double-bundle anterior cruciate ligament reconstruction

Background/PurposeThe anterior cruciate ligament (ACL) is one of the most frequently injured ligaments in the knee joint and is generally treated by surgical reconstruction. A possible reason for the unsatisfactory nature of this reconstruction is that the complex function of the ACL is not reproduced by the traditional ACL reconstruction procedure, which replicates only a single bundle rather than the two separate bundles that form the original ACL. It has been suggested that re-establishment of the double-bundle anatomy of the ACL is crucial for obtaining a better restoration of the normal biomechanics of the knee and improving the knee's rotatory stability. The purpose of this study was to evaluate the authors' current double-bundle ACL reconstruction technique and assess the various functions of the anteromedial and posterolateral bundles.MethodsPatients were assessed for instability and laxity after a mean follow-up of 16 months (range, 12–26 months). The range of motion was measured and compared with the opposite normal knee. Clinical evaluation was performed using the modified Lysholm scoring scale, the Tegner activity scale, and the International Knee Documentation Committee (IKDC) rating system.ResultsThe study included 20 patients, 15 males and five females, with a mean age of 22.7 years (range, 18–29 years) at the time of surgery. Following the procedure described by Yasuda et al, double-bundle ACL reconstruction, which anatomically reproduces the anteromedial and posterolateral bundles using hamstring tendon grafts, was performed on patients under general anesthesia. The clinical results for the Lysholm rating system were good to excellent, being 71 points preoperatively and 94 postoperatively. The IKDC rating was 65% preoperatively and 92% postoperatively. All patients showed a negative pivot shifting test.ConclusionThe ACL not only is the primary restraint on anterior tibial translation but also contributes considerably to normal knee kinematics. Our study showed that the four-tunnel double-bundle ACL reconstruction provides significant advantages in terms of anterior and rotational stability as well as objective IKDC. The subjective measurement of postoperative functional results using either the Lysholm or the IKDC rating system revealed a promising outcome after a short follow-up period.     

Arthroscopic anterior cruciate ligament reconstruction using a hamstring graft with interference screw fixation.

BACKGROUND AND AIMS: This study assessed the clinical and radiographic results 3 to 8 years after an arthroscopic ACL reconstruction using a hamstring graft with interference screw fixation on femoral and tibial sites. MATERIAL AND METHODS: Seventy-six of 100 patients, who underwent an arthroscopic ACL reconstruction, could be re-examined with a mean follow-up of 5 years. RESULTS: The mean Tegner activity score was 4 (scale: 0 to 10) before surgery, and 5 at the follow-up. Fifty-four patients (78%) achieved a satisfactory result in the IKDC rating. The mean Lysholm score was 85 (scale: 0 to 100), the score being better in patients without meniscal resection than those with (P = 0.04). The mean side-to-side difference in anterior-posterior knee laxity was 1.8 mm, and 62 patients (90%) had good stability. Sixty-four patients (93%) had normal range of motion of the knee. Twelve patients (46%) with meniscal resection had osteoarthritic changes, compared with only 8 of those (20%) without meniscal resection (P = 0.03). CONCLUSIONS: This medium-term follow-up study showed that good stability and function and normal range of motion of the knee can be achieved in majority of the patients who have undergone an ACL reconstruction with a hamstring graft and interference screw fixation.     

Patellar tendon or hamstring graft anterior cruciate ligament reconstructions in patients aged above 50 years

Background:

The treatment of anterior cruciate ligament (ACL) injury consists of arthroscopic ACL reconstruction with patellar tendon or hamstring graft. Satisfactory results have been reported so far in the younger age group. Dilemma arises regarding the suitability of ACL reconstruction in patients aged 50 years and above. This retrospective analyses the outcome of ACL reconstruction in patients aged 50 years and above.

Materials and Methods:

55 patients aged 50 years and above presented to our institution with symptomatic ACL tear and were managed with arthroscopic reconstruction with patellar tendon/hamstring graft. 22 patients underwent ACL reconstruction with bone- patellar tendon-bone graft and the remaining 33 with a hamstring graft. Evaluation of functional outcome was performed using International Knee Documentation Committee (IKDC) and Lysholm scoring in the preoperative period, at the end of 1 year and at the final followup. Radiographic evaluation was performed using the Kellgren–Lawrence grading system.

Results:

The mean preoperative IKDC score was 39.7 ± 3.3. At the end of 1-year following the operation, the mean IKDC score was 73.6 ± 4.9 and at the final followup was 67.8 ± 7.7. The mean preoperative Lysholm score was 40.4 ± 10.3. At the end of 1-year following the intervention, the mean Lysholm score was 89.7 ± 2.1 and at final followup was 85.3 ± 2.5. Overall, 14 out of 42 patients who underwent radiographic assessment showed progression of osteoarthritis changes at the final followup after the intervention.

Conclusion:

In our study, there was a statistically significant improvement in the IKDC and Lysholm scores following the intervention. There was a slight deterioration in the scores at the final followup but the overall rate of satisfaction was still high and most of the patients were able to do their routine chores and light exercises suitable for their age group. Around one-third of patients show progression of radiographic changes in the postoperative period and this requires long term evaluation.     

正向、反向束间构型在前十字韧带双束重建中的临床效果比较

 目的比较关节镜下前十字韧带(anterior cruciate ligament. ACL)双束重建中正向、反向束间构型的初期临床效果。方法 2008年 4月至 2009年 8月.采用 8股自体腘绳肌肌腱双束重建 ACL治疗单纯 ACL损伤患者 97例.根据患者入: 时住: 号的奇偶数随机分成正向组(采用正向束间构型. 47例)和反向组(采用反向束间构型.50例).移植物均采用微型钢板纽扣进行悬吊式固定。术后患者随访期均超过 1年.根据 IKDC、Lysholm和 Tegner评分标准进行膝关节功能评估。结果术后随访 12~17个月.平均(13.71±1.32)个月。末次随访时.正向组 2例(4.2%)患者伸膝活动受限 10°.5例(10.6%)膝关节轻度屈曲受限(均<15°);反向组所有患者伸膝活动正常.4例(8.0%)屈曲受限约 5°。根据 Lachman试验.正向组 1例(2.1%)I度阳性和 1例(2.1%) II 度阳性.反向组 1例(2.0%) II 度阳性。 KT-1000(屈膝 30°.30N)双膝松弛度差异值正向组为(1.04±1.11) mm.反向组为(0.86±1.12) mm。按照 IKDC客观评级标准.正向组 46例(97.9%)正常或接近正常.反向组 48例(96.0%)正常或接近正常。根据 IKDC、 Lysholm和 Tegner评分标准.两组的差异均无统计学意义。结论采用 8股自体腘绳肌肌腱正向、反向束间构型双束重建 ACL均能有效地恢复膝关节稳定性.两组短期临床效果的差异无统计学意义。但反向束间构型能有效地防止移植物和髁间凹的撞击。     

Multiple arthroscopic debridement and graft retention in septic knee arthritis after ACL reconstruction: a prospective case–control study

Purpose

This study was undertaken to prospectively analyse, at a mean five-year follow-up, the clinical, functional, and radiographic outcomes in patients who developed postoperative acute septic knee arthritis following anterior cruciate ligament (ACL) reconstruction using hamstring autograft. We also assessed the effect of multiple arthroscopic debridement and graft retention on the functional outcomes in comparison with the matched control group.

Methods

From a consecutive case series of 2,560 ACL-injured patients who were treated with arthroscopic ACL reconstruction, we report on 24 cases with postoperative septic knee arthritis. These patients were individually matched for age, sex, comorbidity, body mass index (BMI) and preinjury Tegner activity scale in a ratio of 1/1. Clinical, laboratory, synovial fluid analysis and culture were performed. Arthroscopic debridement and graft retention was done for all cases, in addition to antibiotic therapy IV. A detailed physical examination, KT1000 laxity testing, Lysholm knee score, Tegner activity level scale, International Knee Documentation Committee (IKDC), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed.

Results

In all cases, treatment of infection was successful after a median of three (range one to six) repeated arthroscopic graft debridement and retention, in addition to antibiotic therapy IV. At an average of five years follow-up, two patients had over five millimetres manual maximum side-to-side difference in laxity. There were no significant differences between groups regarding Lysholm score, IKDC and KOOS. Median final Tegner activity score was 5.5 versus 7 in the control group (p = 0.004). Complications included graft rupture in three patients, loss of range of motion in five, Sudeck’s atrophy in one and moderate joint narrowing in two. There were no recurrences of septic arthritis or bone infection.

Conclusion

Graft retention seems not only possible but appropriate in view of the experience presented in this article for postoperative septic knee arthritis using hamstring autograft. A potential residual complication is arthrofibrosis, which deserves maximum attention.     

Effects of initial graft tension on knee stability after anterior cruciate ligament reconstruction using hamstring tendons: a cadaver study

Purpose: Tension degradation within hamstring grafts and anterior knee laxity were analyzed in a cadaveric anterior cruciate ligament (ACL) reconstruction model undergoing cyclic motion. It was hypothesized that suture fixation of a hamstring graft would lose tension during cycling initially and then stabilize, and that anterior knee laxity would increase as tension was lost. Hamstring grafts fixed under 3 different loads were evaluated to determine how initial graft tension affected knee laxity after cyclic motion. Type of Study: Cadaveric biomechanical analysis. Methods: Eighteen pairs of fresh-frozen hamstring tendons were tested on 2 cadaveric knees undergoing ACL reconstruction. The hamstring pairs were separated equally and randomly into one of 3 tension groups: 68 N (15 lb), 45 N (10 lb), and 23 N (5 lb). The loads were applied to the graft at 30° of flexion, and the grafts were secured to the tibia with a suture and post technique. The knee was then cycled 1,000 times using an Instron machine (Instron, Canton, MA) through a range of motion between 0° to 90°. Constant monitoring and recording of graft tension was performed. A KT-1000 (Medmetrics, San Diego, CA) was performed (1) on the intact knee, (2) after ACL excision, (3) after ACL reconstruction and initial graft fixation, and (4) at the completion of the 1,000 cycles. An analysis of variance test was used to evaluate data. Results: The tension within the grafts after 1,000 cycles decreased to 34.5 N (7.6 lb), 16.8 N (3.7 lb), and 15.4 N (3.4 lb) from the preloads of 68, 45, and 23 N, respectively (P < .05 in all cases). This represented an average decrease of 50.2% of the initial tension after 1,000 cycles. Manual-maximum KT testing of the intact knees was 5.8 ± 0.3 mm, and after ACL excision was 13.2 ± 0.9 mm. KT testing revealed 6.0 ± 0.9 mm, 8.1 ± 1.9 mm, and 8.9 ± 1.1 mm of anterior translation after fixation in the tension groups of 68, 45, and 23 N, respectively. After 1,000 cycles, the translation increased to 7.8 ± 1.0 mm, 10.5 ± 1.9 mm, and 10.3 ± 1.5 mm, respectively. Conclusions: This study showed that initial graft tension decreases with cyclic loading, resulting in increased knee laxity. To restore anterior translation to within 3 mm of the native ACL condition after cyclic loading, approximately 68 N of initial tension is required using this fixation technique.     

Description of a new endoscopic posterior cruciate ligament reconstruction and comparison with a 2-incision technique

Purpose: We introduce our technique (a new route for the graft) of endoscopic posterior cruciate ligament (PCL) reconstruction and describe the advantages in comparison with the conventional surgical technique. Type of study: Nonrandomized control study. Methods: The idea of this surgical technique is to minimize graft angulation at the inner edge of the bone tunnel. The tibial entry point of the guide pin is under the tibial lateral subcondylar flare, approximately 1 to 2 cm anterior to the posterior cortex. This creates less graft angulation on the posterior aspect of the tibia. A new drill system has been devised to allow antegrade femoral drilling starting from inside the notch. This method also allows better femoral tunnel orientation. As a substitute graft material, we use autogenous hamstring tendons, and we secure them with an EndoButton (Smith & Nephew, Andover, MA) and post screw. From 1992 to 1995, 43 2-incision PCL reconstructions using autogenous hamstring tendons were performed. From 1995 to 2001, 90 endoscopic PCL reconstructions using looped autogenous hamstring tendons and an EndoButton were performed. Cases were specified according to the inclusion criteria of this study. As a result, 51 patients were included in this study. The 2-incision group comprised 22 patients, and the endoscopic group comprised 29 patients. The clinical evaluation was performed using the International Knee Documentation Committee (IKDC) form. The quadriceps strength was measured using Biodex System II (Biodex, New York, NY). The period of time to achieve 90° flexion after surgery was also compared. Results: No significant differences were seen between the 2 groups tested with respect to the overall IKDC rating score. Side-to-side differences of anteroposterior total laxity (KT-1000, manual maximum) was 3.95 ± 1.96 mm in the 2-incision group and 2.38 ± 1.42 mm in the endoscopic group (P < .05). The average time to achieving 90° of flexion after surgery was 16.6 ± 8.6 days in the 2-incision group and 12.1 ± 3.5 days in the endoscopic group. Achievement of range of motion in the endoscopic group was significantly shorter. The peak torque of isokinetic contraction in the endoscopic group was significantly greater than in the 2-incision group 1 year after surgery. Conclusions: Better posterior stability and quicker postoperative recovery of range of motion and muscle strength were advantages of the endoscopic technique over the 2-incision technique in PCL reconstruction.     

Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17–20 years

Purpose

The aim of our study was to review the clinical and radiological outcome of patients who had undergone anterior cruciate ligament (ACL) reconstruction in comparison to a group of non-operatively treated patients.

Methods

In a retrospective study we compared ACL reconstruction using a bone-patellar tendon-bone graft with a non-operatively treated group of patients 17–20 years later. Fifty-four patients that met the inclusion criteria, with arthroscopically proven ACL rupture, were treated between 1989 and 1991. Thirty-three patients underwent ACL reconstruction, forming group one. Eighteen non-reconstructed patients continued with rehabilitation and modification of activities (group two). The International Knee Documentation Committee (IKDC) subjective and objective evaluation forms and the Lysholm and Tegner scale were used to assess the knees at follow-up. Radiographic assessment was performed using the IKDC grading scale.

Results

Follow-up results showed that 83% of reconstructed patients had stable knees and normal or nearly normal IKDC grade. Patients in the non-reconstructed group had unstable knees with 84% having abnormal or severe laxity. The subjective IKDC score was significantly in favour of group one: 83.15 compared to 64.6 in group two. The Lysholm and Tegner score was also significantly better in group one. Conservatively treated patients all had unstable knees and worse scores. The rate of osteoarthritis showed more severe changes in non-reconstructed patients with additional meniscus injury.

Conclusions

We can conclude that 94% of patients who underwent ACL reconstruction had stable knees after 15–20 years and there was a significantly lower percentage of osteoarthritis in comparison to conservatively treated patients.     

Anterior cruciate ligament reconstruction in men and women: An outcome analysis comparing gender

Purpose: Recent studies have shown that female athletes suffer a higher incidence of anterior cruciate ligament (ACL) tears than comparable male athletes. The purpose of this study was to evaluate the effect gender has on outcome in ACL reconstruction using bone–patellar tendon–bone autograft. Type of Study: Retrospective case review and outcome study. Methods: A retrospective review of a single surgeon’s practice revealed 279 ACL reconstructions that met our criteria for inclusion. Two-hundred forty-nine of these patients (91%) were contacted. Two-hundred (72%) were evaluated with physical examination, KT-1000 testing, functional testing, and radiographic evaluation. Outcome was assessed with Tegner, Lysholm, modified HSS, and Cincinnati Knee rating scales, as well as the SF-36 health survey and a self-administered questionnaire. There were 137 men and 63 women. Data were evaluated with Wilcoxon rank sum testing, analysis of variance testing, χ-square analysis, and the Student t test. The level of significance was set at P <.05. Results: Postoperatively, no differences were noted on Lachman, anterior drawer, pivot shift, or functional testing in either groups. Male patients had a significantly greater mean prone heel height difference (1.80 v 1.10 cm, P =.0018) and mean KT-1000 maximum manual side-to-side difference (0.76 v 1.73 mm, P =.014). However, no differences were noted in the percentage of patients with greater than 5-mm side-to-side difference, with 5 men (4%) and 2 women (3%) classified as arthrometric failures. No differences were noted in mean Tegner, Lysholm, Noyes Cincinnati, and modified HSS scores. Men had significantly lower HSS radiographic scores (24.98 v 26.22, P =.0016). Men and women were compared with gender-matched controls for SF-36 testing, and women scored higher compared with controls than did men in the Role Physical, Body Pain, and General Health categories. No differences were noted in either group regarding donor-site pain, patellofemoral crepitance, or problems with stair climbing. Ninety-six percent of men and 98% of women would have had the surgery over again given similar circumstances. Conclusions: Objective criteria failed to detect clinically significant differences in physical examination and arthrometric results between men and women. Knee rating scale scores were similar. Comparable outcome with high satisfaction and equal success can be expected in both men and women undergoing ACL reconstruction using bone–patellar tendon–bone autograft. No basis exists for the inclusion of gender as a determining factor regarding the decision to perform ACL reconstructive surgery with bone–patellar tendon–bone autograft.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 588–596