High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction.

BACKGROUND: ACL injuries in preteens and teens are common occurrences. Reconstruction is believed to be optimum treatment for those wishing to return to running, cutting, and jumping sports. Rates of reoperation, satisfaction, and long-term return to and maintenance of preinjury activity after ACL reconstruction in young athletes are important information for physicians, patients, and parents. QUESTIONS/PURPOSES: The purposes of this study were to address the following questions in this skeletally immature patient population undergoing ACL reconstruction: (1) What is the reinjury rate and the need for subsequent surgeries? (2) How do patient satisfaction and function as assessed by patient and physician correlate with return to sport? (3) What factors contribute to failure to return to preinjury activity levels? METHODS: This is a retrospective review of 29 patients who underwent transphyseal ACL reconstruction using soft tissue grafts passed through open physes and followed to skeletal maturity, and at least 2 years from their index surgery, who were invited and returned for a study interview and examination. Pre- and postinjury activity levels were assessed via the Tegner activity score, satisfaction was determined using a 10-point Likert scale, function was assessed via the Lysholm score and IKDC grade, and an open-ended questionnaire was used for explanations of changes in activity levels. Reoperations were classified as major or minor, determined from a review of the medical records conducted after interview and examination. RESULTS: At a minimum followup of 2 years (mean, 4 years; range, 2-8 years), four revision reconstructions and seven minor operations were performed for a reoperation rate of 11 of 29 (38%). Eight of 29 patients (28%) sustained contralateral ACL ruptures. The mean satisfaction score was 9 (range, 4-10) and mean Lysholm score was 91 (range, 61-100). Only 12 of 29 (41%) patients returned to and maintained their preinjury level of sport. High satisfaction correlated with return to prior level of sports, although there was no relationship between function and activity level. Reoperation on the index knee or contralateral ACL tear did not correlate with a change in activity level; rather, most patients who were less active indicated a change in interest with advancing age. CONCLUSIONS: Despite high satisfaction and function, less than 50% of patients maintained their preinjury level of play 4 years after ACL reconstruction. Satisfaction correlated significantly with knee function; highly satisfied patients were more likely to return to and maintain their prior level of participation in sports. Contributing factors to decreased activity include changes in lifestyle with increasing age. Reoperation did not correlate with lower activity scores or failure to return to sports. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Can magnetic resonance imaging predict posterior drawer laxity at the time of surgery in patients with knee dislocation or multiple-ligament knee injury?

BACKGROUND: Previous studies indicate that isolated posterior cruciate ligament injuries demonstrate magnetic resonance imaging (MRI) and clinical evidence of healing when treated nonoperatively; however, the authors are unaware of any other study that has looked at whether initial MRI can predict posterior cruciate ligament stability at the time of surgery in patients with knee dislocation. HYPOTHESIS: An MRI grading system will predict laxity on posterior drawer testing at the time of surgery in patients with knee dislocations. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Forty-two consecutive patients with knee dislocation or multiple-ligament knee injury evaluated by MRI were included in the study. An assignment of grade 0 (intact), grade I (injured/fibers intact), grade II (partial tearing of ligament), or grade III (complete tear) was made after each reading on 2 separate occasions by 3 surgeons. Posterior laxity of the knee was graded by the magnitude of excursion on the posterior drawer test by the senior author at the time of surgery. Interobserver and intraobserver reliability of the MRI grading scheme expressed by the kappa statistic κ, as well as the predictive value of MRI grade in determining stability of the posterior cruciate ligament at the time of surgery, was assessed. RESULTS: The posterior cruciate ligament injury grading scheme tested demonstrated moderate to substantial intraobserver agreement (κ = 0.66, κ = 0.53, and κ = 0.52, respectively, for all raters). Interobserver reliability demonstrated only moderate agreement (κ = 0.49). If the grading scheme was changed to group both grades 0 and I (intact) and grades II and III (disrupted), intraobserver reliability demonstrated substantial to almost perfect agreement (κ = 0.83, κ = 0.80, and κ = 0.75), and interobserver reliability demonstrated substantial agreement (κ = 0.70). If the posterior cruciate ligament was classified as intact (grade 0 [intact] or grade I [injured]) on initial MRI, the injured knee was judged clinically stable (tibia anterior to or flush with the femoral condyles on posterior drawer testing) at the time of surgery 98.5% (95% confidence interval, 93%-100%) of the time. When the posterior cruciate ligament was classified as disrupted (grade II [partial tear] or grade III [complete tear]), the injured knee was judged unstable (tibia posterior to the femoral condyles on posterior drawer testing) 57.5% (95% confidence interval, 40%-73%) of the time. CONCLUSION: The presented system of grading posterior cruciate ligament injury in patients with knee dislocation on initial MRI demonstrates moderate to substantial interobserver and intraobserver reliability that increases if the grading scheme is modified. An initial MRI scan read as grade I may predict stability to posterior drawer at the time of surgery. Even with MRI evidence of disruption in the posterior cruciate ligament (grade II and grade III injuries), posterior cruciate ligament reconstruction may not be clinically indicated at the time of reconstruction and/or repair of other associated injuries.

Timeline of tibial tunnel expansion after single-incision hamstring anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to determine the time frame for tibial tunnel expansion in patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring autografts using an endoscopic technique. Does this expansion occur immediately after surgery or over the first 12 weeks of rehabilitation? TYPE OF STUDY: Observational study involving 10 patients. METHODS: The single incision technique used a transtibial approach for drilling the femoral tunnel. Femoral fixation was accomplished with a closed-loop EndoButton (Acufex, Smith & Nephew; Mansfield, MA) and tibial fixation with a soft tissue screw and washer augmented by a polylactic acid interference screw. Computed tomography (CT) scans were taken in a consistent manner at weeks 1 and 12 after surgery to measure tibial and femoral tunnel expansion. RESULTS: The CT scans showed significant widening of the tibial tunnel between 1 and 12 weeks (mean area of tibial tunnel increased from 82.5 to 112.7 mm2; P =.001). Expansion of the femoral tunnel was also seen; however, this change was not statistically significant (P =.18). CONCLUSIONS: The expansion after surgery occurred over time, not immediately after surgery, and was probably caused by factors other than surgical technique. The significance of tibial tunnel expansion needs to be clinically correlated with a long-term study on the effect of tunnel expansion on graft survival.

Ligament injuries in children.

Complete disruption of the anterior cruciate ligament in children is becoming increasingly prevalent as children are participating in high-risk athletic activities at younger ages. The activities of children with functional knee-ligament instability are difficult to control, and repeated injuries and secondary meniscal pathology are prevalent in the population. Although it would be preferable to delay surgical intervention until skeletal maturity has been achieved, it is often not feasible to do so because the risk for reinjury frequently outweighs the risks associated with surgical intervention. The major concern with surgical intervention in this age group is how it will affect subsequent growth.