Rectangular bone-patellar tendon bone grafts reduce early graft failure in chronic ACL-Deficient knees.

BACKGROUND: The aim of this study was to assess early graft failure after anterior cruciate ligament (ACL) reconstruction according to chronicity of ACL deficiency (ACLD) and clarify predisposing factors. METHODS: A total of 731 patients who underwent anatomic ACL reconstruction were divided into 3 groups based on chronicity of ACLD: <6 months (Group 1), 6 months to 2 years (Group 2), and >2 years (Group 3). Types of ACL grafts used included single-bundle hamstring tendon (HT), multiple-bundle HT, and rectangular bone-patellar tendon-bone (BTB) grafts. Preoperatively and immediately postoperatively, lateral radiographs in full extension were taken to examine anterior tibial subluxation (ATS). All ACL grafts were evaluated by MRI at 6 months to identify graft failure. The group with the highest failure rate was further examined to compare possible risk factors between the intact and failure subgroups, followed by multivariate logistic regression analysis to identify predisposing factors. RESULTS: Early graft failure on MRI without any episode of postoperative trauma was observed in 7 (1.4%), 2 (1.8%), and 11 (9.2%) patients in Groups 1, 2, and 3, respectively, with a significantly higher rate in Group 3 (P < 0.001). Of the 119 patients in Group 3, significant differences were observed between intact and failure subgroups with regard to surgical procedure (P = 0.03), chondral lesions (P < 0.01), and preoperative ATS (P < 0.01). Multivariate logistic regression analysis revealed that surgical procedures (odds ratio, 3.8; 95%CI, 1.16-12.59) and preoperative ATS (odd ratio, 2.4; 95%CI, 1.26-4.38) were predisposing factors of early graft failure. CONCLUSION: Patients with ACLD for >2 years experienced early graft failure with an incidence rate of 9.2%. Predisposing factors of early graft failure in these patients included the use of single-bundle HT grafts and preoperative ATS. The use of rectangular BTB grafts resulted in a lower graft failure rate. STUDY DESIGN: Case Series.

The lateral meniscal extrusion after repair with concomitant anterior cruciate ligament reconstruction at a mean follow-up of 3.5 years.

BACKGROUND: A meniscal repair is often performed on radial/flap or longitudinal tears of the lateral meniscus (LM) combined with anterior cruciate ligament reconstruction (ACLR). However, it is unknown if meniscal extrusion changes over time after repair. This study evaluated whether meniscal extrusion of the LM is maintained after repair or progresses with time using magnetic resonance imaging (MRI). METHODS: Among 574 patients who underwent primary anatomic ACLR, 123 patients followed up for more than 2 years were retrospectively analyzed. Forty patients with concomitant radial/flap tears of the LM (group R), 43 with longitudinal LM tears (group L), and 40 with intact LM (group C, matched-control group) were included. Clinical findings (pain, range of motion, swelling, and anterior laxity), lateral joint space on radiograph, and meniscal extrusion on MRI were assessed. Lateral/posterior meniscal extrusions were examined preoperatively, within 3 weeks after surgery, and at the final follow-up, and the absolute values and relative values (the preoperative values as baseline) were assessed respectively. RESULTS: There were no significant differences in the clinical and roentgenographic findings among the groups. No difference was observed in the relative values within 3 weeks after surgery among three groups, although the absolute values were larger in the repaired groups than in group C. At the final follow-up, however, the lateral extrusion in group L had progressed significantly, compared with that in group C (P = 0.033), while no significant difference was detected in the lateral extrusion between groups R and C (P = 0.177). The posterior extrusion in groups R and L had progressed significantly compared with that in group C (P < 0.001). CONCLUSIONS: LM extrusion could not be improved even immediately after meniscal repair, and it progressed laterally and posteriorly for more than 2 years after surgery.

Posterior Ankle Impingement Caused by Hyaline-Like Cartilage Generation in Ballet Dancers-A Report of 2 Cases.

Posterior ankle impingement syndrome is mainly seen in ballet dancers and frequently associated with specific movements in ballet such as pointe and demi pointe in which the whole-body weight is applied to the maximally plantar flexed ankle. We performed arthroscopic debridement for 2 dedicated ballet dancers on the intervening soft tissue causing posterior ankle impingement syndrome (PAIS). In both cases, T2-weighted magnetic resonance imaging (MRI) revealed low-signal intensity of meniscus-like soft tissue without abnormal osseous findings, connecting from the posterior side of the talus to Kager's fat pad. To examine the intervening soft tissue in detail, we performed histological evaluation by hematoxylin and eosin staining, Safranin O fast green staining, and immunohistochemistry for type I collagen and type II collagen. Hematoxylin and eosin staining showed that there was cartilage-like tissue including chondrocyte-like cells in contact with fibrous tissue. The extracellular matrix in the cartilage zone was consistently stained by Safranin O staining and type II collagen without any staining with type I collagen. These findings suggested that the meniscus-like soft tissue appearing as low-signal intensity on MRI at the posterior side of talus included hyaline-like cartilage. To the extent of our knowledge, these were rare cases of hyaline-like cartilage generation causing PAIS in ballet dancers, which might be associated with ballet specific movements resulting in chondrogenesis.

Chronological changes in cross-sectional area of the bone-patellar tendon-bone autograft after anatomic rectangular tunnel ACL reconstruction.

PURPOSE: The purpose of this study was to evaluate the change in cross-sectional area (CSA) of bone-patellar tendon-bone (BTB) autografts up to 5 years after the anatomic rectangular tunnel (ART) anterior cruciate ligament reconstruction (ACLR). The changing pattern in CSA might be a potential indicator of the graft remodeling process. METHODS: Ninety-six (62 males, 34 females, mean age 27.0 years) patients were enrolled in this study with a total of 220 MRI scans after ART BTB ACLR to evaluate the CSA of the ACL autografts. The patients with first time unilateral ACLR that consented to undergo MRI evaluations at postoperative periods were included in this study. Intraoperatively, the CSA of the graft was measured directly using a custom-made area micrometer at the midpoint of the graft. Postoperatively, using an oblique axial slice MRI that was perpendicular to the long axis of the graft, the CSA of the graft was measured with digital radiology viewing program "SYNAPSE" at the midpoint of the graft. The postoperative MRI scans were classified into seven groups according to the period from ACLR to MRI evaluation: Group 0-2 months (m.), Group 3-6 m., Group 7-12 m., Group 1-2 years (y.), Group 2-3 y., Group 3-4 y., and Group 4 y.-. The percent increase of the CSA was calculated by dividing the postoperative CSA by the intraoperative CSA. RESULTS: The postoperative CSA was significantly larger than the intraoperative CSA in each group, with the exception of Group 0-2 m. The mean percent increase of the CSA in Group 0-2 m., 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., 4 y.- was 101.8 ± 18.2, 188.9 ± 27.4, 190.9 ± 43.7, 183.3 ± 28.9, 175.2 ± 27.9, 163.9 ± 19.8, 164.5 ± 25.4% respectively. The percent increase in Group 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., and 4 y.- was significantly greater than that in Group 0-2 m. CONCLUSIONS: The CSA of the BTB autografts after the ART BTB ACLR increases rapidly by 3-6 months after ACLR, reached a maximum value of 190% at around 1 year, decreases gradually after that, and reaches a plateau at around 3 years. The current study might help clinicians to estimate an individual BTB autograft's remodeling stages when considering returning patients to sports. LEVEL OF EVIDENCE: IV.

Importance of functional performance and psychological readiness for return to preinjury level of sports 1 year after ACL reconstruction in competitive athletes.

PURPOSE: This study aimed to identify independent predictive factors for return to sports (RTS) after anterior cruciate ligament (ACL) reconstruction in competitive-level athletes and to determine optimal cut-off values for these factors at 6 months after surgery. METHODS: A total of 124 competitive athletes (50 males and 74 females; mean age, 17.0 years; preinjury Tegner activity scale > 7) who underwent primary ACL reconstruction were enrolled. Assessments at 6 months after surgery consisted of knee functional tests [quadriceps index, hamstrings index, and single-leg hop for distance (SLH)] and 2 self-report questionnaires [IKDC subjective score and ACL-Return to Sport after Injury scale (ACL-RSI)]. At 1 year after surgery, athletes were classified into the RTS group (n = 101) or non-RTS group (n = 23) based on self-reported sports activities. After screening possible predictive factors of RTS, multivariate logistic regression and receiver operating characteristic curve analyses were performed to identify independent factors. RESULTS: Multivariate logistic regression analysis identified SLH (odds ratio, 2.861 per 10 unit increase; P < 0.001) and ACL-RSI (odds ratio, 1.810 per 10 unit increase; P = 0.001) at 6 months as independent predictors of RTS at 1 year after surgery. Optimal cut-off values of SLH and ACL-RSI were 81.3% (sensitivity = 0.891; specificity = 0.609) and 55 points (sensitivity = 0.693; specificity = 0.826), respectively. CONCLUSION: In competitive athletes, SLH < 81% and ACL-RSI < 55 points at 6 months after surgery were associated with a greater risk of unsuccessful RTS at 1 year after surgery. SLH and ACL-RSI at 6 months could serve as screening tools to identify athletes who have difficulties with returning to sports after ACL reconstruction. LEVEL OF EVIDENCE: III.

Cross-sectional area of hamstring tendon autograft after anatomic triple-bundle ACL reconstruction.

PURPOSE: The purpose was to evaluate the cross-sectional area changes in hamstring tendon autografts up to 5 years after the anatomic triple-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: A total of 178 MRI scans from 139 patients (35 males, 104 females, mean age 30.4 years) with the anatomic triple-bundle ACL reconstructions were obtained to evaluate the cross-sectional area of the ACL grafts. They were classified into seven groups according to the period from reconstruction to MRI evaluation: Group -2 months (m.), Group 3-6 m., Group 7-12 m, Group 1-2 years (y.), Group 2-3 y., Group 3-4 y., and Group 4 y.-. Intra-operatively, the cross-sectional area of the graft was measured directly using a custom-made area micrometre. Post-operatively, the cross-sectional area of the grafts' mid-substance was measured with oblique axial MRI slices perpendicular to the long axis of the grafts using a digital radiology viewing program. The percent increase in the cross-sectional area was calculated by dividing the post-operative cross-sectional area by the intra-operative cross-sectional area. RESULTS: The mean percent increase in the cross-sectional area in Groups -2 m., 3-6 m., 7-12 m., 1-2 y., 2-3 y., 3-4 y., and 4 y.- was 105.7 ± 14.0, 134.9 ± 20.0, 137.3 ± 27.8, 129.4 ± 22.2, 124.1 ± 20.4, 117.8 ± 16.9, and 117.1 ± 17.2 %, respectively. The percent increase in Groups 3-6 m., 7-12 m., and 1-2 y. was significantly greater than in Group -2 m., while that in Group 4 y.- was significantly less than in Group 7-12 m. CONCLUSIONS: The cross-sectional area of the hamstring tendon autografts after the anatomic triple-bundle ACL reconstruction increases over time up to 1 year post-operatively, decreases gradually thereafter, and reaches plateau at around 3 years. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Post-operative deformation and extrusion of the discoid lateral meniscus following a partial meniscectomy with repair.

PURPOSE: The purpose of this study was to investigate the morphology of the discoid lateral meniscus sequentially following a partial meniscectomy with repair using magnetic resonance imaging (MRI). METHODS: Nine patients with a symptomatic discoid lateral meniscus with a peripheral tear were enrolled in this study, and a partial meniscectomy with repair was performed arthroscopically. An MRI examination was performed 2 weeks after surgery (before weight bearing was permitted) and again 6 months after surgery (when sporting activities could resume). The width, height and distance of the discoid lateral meniscus were measured. The distance was defined as the distance between the edges of the discoid lateral meniscus and the tibia. RESULTS: The width of the anterior, middle and posterior segments significantly decreased from 2 weeks to 6 months after surgery. The height of the middle and posterior segments significantly increased from 2 weeks to 6 months after surgery, whereas the height of the anterior segment did not significantly change. The distance of the anterior, middle and posterior segments significantly decreased from 2 weeks to 6 months after surgery. CONCLUSION: The discoid lateral meniscus exhibited deformation and extrusion from 2 weeks to 6 months after a partial meniscectomy with repair. Therefore, the function of load transmission might not be maintained appropriately after surgery. LEVEL OF EVIDENCE: IV.

Biomechanical characteristics of the anatomic rectangular tunnel anterior cruciate ligament reconstruction with a bone-patellar tendon-bone graft.

PURPOSE: To clarify 1) the force sharing between two portions of BTB graft in anatomic rectangular tunnel (ART) reconstruction and 2) the knee stability in ART technique under anterior tibial load. METHODS: Eleven fresh cadaveric knees were used. First, anterior-posterior (A-P) laxity was measured with Knee Laxity Tester® in response to 134 N of A-P tibial load at 20° on the normal knees. Then ART ACL reconstruction was performed with a BTB graft. For graft, the patellar bone plug and tendon portion was longitudinally cut into half as AM and PL portions. After the tibial bone plug was fixed at femoral aperture, AM/PL portions were connected to the tension-adjustable force gauges at tibial tubercle, and were fixed with 10 N to each portion at 20°. Then the tension was measured 1) under anterior tibial load of 134 N at 0, 30, 60, and 90°, and 2) during passive knee extension from 120 to 0°. Next the graft tension was set at 0, 10, 20, 30, or 40 N at 20°, and the A-P laxity was measured by applying A-P load of 134 N. By comparing the laxity for the normal knee, the tension to restore the normal A-P laxity (LMP) was estimated. RESULTS: The AM force was significantly smaller at 0° and larger at 90° than the PL force under anterior load, while the force sharing showed a reciprocal pattern. During knee extension motion, the tension of both portions gradually increased from around 5 N to 20-30 N with knee extended. And the LMP was 1.6 ± 1.0 N with a range from 0.3 to 3.5 N. CONCLUSION: The pattern of force sharing was similar to that in the normal ACL in response to anterior tibial load and during passive knee extension motion. LMP in this procedure was close to the tension in the normal ACL. LEVEL OF EVIDENCE: Level IV, a controlled-laboratory study.

Deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tear: a report of two cases and a review of the literature.

Drop foot is typically caused by neurologic disease such as lumbar disc herniation, but we report two rare cases of deep peroneal nerve palsy with isolated lateral compartment syndrome secondary to peroneus longus tears. Both patients developed mild pain in the lower legs while playing sport, and were aware of drop foot. As compartment pressures were elevated, fasciotomy was performed immediately, and the tendon of the peroneus longus was completely detached from its proximal origin. The patients were able to return their original sports after 3 months, and clinical examination revealed no hypesthesia or muscle weakness in the deep peroneal nerve area at the time of last follow-up. The common peroneal nerve pierced the deep fascia and lay over the fibular neck, which formed the floor of a short tunnel (the so-called fibular tunnel), then passed the lateral compartment just behind the peroneus longus. The characteristic anatomical situation between the fibular tunnel and peroneus longus might have caused deep peroneal nerve palsy in these two cases after hematoma adjacent to the fibular tunnel increased lateral compartment pressure.

Association of Stability and Size of Unhealed Area With Failure After Internal Fixation for Osteochondritis Dissecans Lesions of the Knee: Radiological Evaluation Using Computed Tomography.

BACKGROUND: Open reduction and internal fixation (ORIF) has been widely performed because the osteochondral component of the osteochondritis dissecans (OCD) lesion is the most suitable for reconstructing the joint structure. PURPOSE: To evaluate radiological healing in terms of reconstructed bony structure after ORIF with bone graft by computed tomography (CT), to identify preoperative prognostic factors for failure, and to determine the cutoff value of radiological healing for risk of failure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A retrospective cohort study of 42 patients (44 knees) who underwent internal fixation with bone graft for OCD lesions of the knee from 2004 to 2018 was conducted. All patients were evaluated 6 months postoperatively, and if not healed 6 months after surgery, they were evaluated by CT periodically thereafter. Radiological healing was judged according to the following 3 criteria: (1) reossification of the OCD lesion, (2) bony continuity between the OCD lesion and basal floor, and (3) reconstructed bony surface of the femoral condyle reconstructed to match the normal joint. Then, the percentage of the radiological healing area was calculated as the ratio of the healing length to the total lesion length. The nonhealing area was calculated by multiplying the sum of the total nonhealing length. Clinical failure was defined as any definitive reoperation for the same OCD lesion, such as fragment excision, or a cartilage restoration procedure. After 6 months, all eligible patients underwent arthroscopy to check for protrusion of the absorbable pin into the joint; the removal of an absorbable pin protruding into the joint was not considered a failure. RESULTS: Clinical failure was recorded for 4 cases (9.1%). The mean overall percentage of the radiological healing area of OCD 6 months after ORIF with bone graft was 79.5% ± 24.4%, and the mean overall nonhealing area at 6 months was 87.8 ± 107.9 mm2. The percentages of radiological healing area of stable (International Cartilage Regeneration & Joint Preservation Society OCD II) lesions and femoral condylar (lateral femoral condyle + medial femoral condyle) lesions were significantly lower than unstable lesions and femoral groove lesions, respectively (P = .01 and P = .03, respectively). On receiver operating characteristic curve analysis, the cutoff points for predicting a significantly increased risk of failure were 33.9% (sensitivity, 100%; specificity, 100%; area under the curve, 1) for the percentage of radiological healing area and 222.9 mm2 (sensitivity, 95%; specificity, 100%; area under the curve, 0.956) for the nonhealing area 6 months postoperatively. CONCLUSION: A stable lesion and a femoral condylar lesion were the predictors of poor radiological healing on CT images 6 months after ORIF with bone graft. The risk of failure was increased significantly in cases with only approximately one-third of the lesion healed or in cases with large nonhealing areas at 6 months postoperatively.

Change of signal intensity in the displaced medial meniscus after its reduction on MRI.

PURPOSE: To compare magnetic resonance (MR) signal intensity in the medial meniscus at the time of displacement and after its reduction in patients with a displaced bucket-handle tear of the meniscus associated with anterior cruciate ligament (ACL) injury. METHODS: Nine chronic ACL-deficient patients (3 male, 6 female, mean age 29 years) with locking due to a displaced fragment of the medial meniscus following a bucket-handle tear were involved in this study. In all patients, the following two-stage surgeries were planned as follows: first operation, arthroscopic reduction of the meniscus; second operation, meniscal repair and ACL reconstruction after immobilization for 1-2 weeks. Magnetic resonance imaging (MRI) evaluation using coronal T2*-weighted images was performed when the knee was locked and after the meniscus was reduced. Signal intensity before and after meniscal reduction was compared in the same patients. RESULTS: In 8 of the 9 patients, the displaced fragment exhibited high signal intensity in 1 patient and mildly high in 7 patients. After its reduction, the signal intensity changed to low in all 8 patients. CONCLUSIONS: A high-intensity signal in the displaced fragment of the medial meniscus may change to low after its reduction to its original position. Therefore, at the time of decision-making regarding meniscus repair for a displaced meniscus in a locked knee, surgeons should give priority to arthroscopic findings rather than to signal intensity on MRI. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Clinical outcomes after repair of an isolated radial tear in the middle segment of the lateral meniscus - All-inside suture repair vs trans-capsular suture repair.

Background/objective: For radial tears, all-inside suture (AIS) repair was clearly biomechanically superior, compared to conventional trans-capsular suture (TCS) repairs. However, clinical comparative studies of these two repairs techniques have not to be performed. Therefore, the aim of this study was to compare the clinical outcomes after AIS repair and TCS repairs for isolated radial tear at middle segment of lateral meniscus (RTMLM) in stable knees of young athletes. Methods: Twenty-six athletes (mean age, 19.1 years) underwent AIS repair with the double horizontal suture technique, using SutureLasso™ (Arthrex, Naples, FL) for isolated RTMLM (AIS group), and 20 athletes (mean age, 19.0 years) underwent inside-out repair, one of TCS repairs, with tie-grip suture technique (TCS group). All athletes were assessed for preoperative and two-year postoperative Knee injury and Osteoarthritis Outcome Score (KOOS). At six-month after repair, the lateral meniscal extrusion on mid-coronal plane on MRI and healing status on second-look arthroscopy were also evaluated in all patients. Results: In both groups, KOOS improved to either good or excellent postoperatively, while complete healing was found in only 23 and 25% at second-look arthroscopy. We identified no group-dependent differences in KOOS or healing status on arthroscopy. However, a close examination of failure rates revealed significant lower rates in AIS group relative to that of TCS group (p = 0.048). Moreover, the change from preoperative to postoperative lateral meniscal extrusion in AIS group was significantly smaller than that in TCS group (p = 0.038). Conclusions: AIS and TCS repairs for RTMLM were comparable in providing satisfactory clinical results with low rates of complete healing on arthroscopy. However, AIS repair could have lower failure rate of healing on arthroscopy and minimize postoperative lateral meniscal extrusion more effectively than TCS repair on MRI.

The prevalence of shoulders with a large glenoid defect and small bone fragment increases after several instability events during conservative treatment for traumatic anterior instability.

Background: Unstable shoulders with a large glenoid defect and small bone fragment are at higher risk for postoperative recurrence after arthroscopic Bankart repair. The purpose of the present study was to clarify the changes in the prevalence of such shoulders during conservative treatment for traumatic anterior instability. Methods: We retrospectively investigated 114 shoulders that underwent conservative treatment and computed tomography (CT) examination at least twice after an instability event in the period from July 2004 to December 2021. We investigated the changes in glenoid rim morphology, glenoid defect size, and bone fragment size from the first to the final CT. Results: At first CT, 51 shoulders showed no glenoid bone defect, 12 showed glenoid erosion, and 51 showed a glenoid bone fragment [33 small bone fragment (<7.5%) and 18 large bone fragment (≥7.5%); mean size: 4.9 ± 4.2% (0-17.9%)]. Among patients with glenoid defect (fragment and erosion), the mean glenoid defect was 5.4 ± 6.6% (0-26.6%); 49 were considered a small glenoid defect (<13.5%) and 14 were a large glenoid defect (≥13.5%). While all 14 shoulders with large glenoid defect had a bone fragment, small fragment was solely seen in 4 shoulders. At final CT, 23 of the 51 shoulders persisted without glenoid defect. The number of shoulders presenting glenoid erosion increased from 12 to 24, and the number of shoulders with bone fragment increased from 51 to 67 [36 small bone fragment and 31 large bone fragment; mean size: 5.1 ± 4.9% (0-21.1%)]. The prevalence of shoulders with no or a small bone fragment did not increase from first CT (71.4%) to final CT (65.9%; P = .488), and the bone fragment size did not decrease (P = .753). The number of shoulders with glenoid defect increased from 63 to 91 and the mean glenoid defect significantly increased to 9.9 ± 6.6% (0-28.4%) (P < .001). The number of shoulders with large glenoid defect increased from 14 to 42 (P < .001). Of these 42 shoulders, 19 had no or a small bone fragment. Accordingly, among a total of 114 shoulders, the increase from first to final CT in the prevalence of a large glenoid defect accompanied by no or a small bone fragment was significant [4 shoulders (3.5%) vs. 19 shoulders (16.7%); P = .002]. Conclusions: The prevalence of shoulders with a large glenoid defect and small bone fragment increases significantly after several instability events.

In vivo graft tension in anatomic double-bundle anterior cruciate ligament reconstruction during active leg-raising motion with the knee splinted.

PURPOSE: The purpose of this study was to measure the in vivo graft tension in anatomic 2-bundle anterior cruciate ligament (ACL) reconstruction during active leg-raising exercise with the knee immobilized. METHODS: Anatomic double-bundle ACL reconstruction was performed with autogenous semitendinosus tendons in 7 patients while under general anesthesia. Two grafts were fixed with 2 EndoButton-CL devices (Smith & Nephew Endoscopy, Andover, MA) on the femur and were temporarily fixed to 2 tension-adjustable force gauges on the anterior tibial cortex. Then, a knee brace in semi-flexion was put around the knee, and 10 N of initial tension was applied to each graft at 20° of flexion. The tension on the anteromedial (AM) and posterolateral (PL) grafts was continuously measured during active leg-raising motion with the knee immobilized after patients had awoken from anesthesia. Then, the tension measurement was repeated during active leg-raising motion with the knee immobilized while a 2-kg weight was fitted around the ankle. RESULTS: In situ graft tension during active leg-raising motion with a knee brace was 10.9 ± 4.0 N for the AM graft and 8.6 ± 5.1 N for the PL graft, whereas the tension with a 2-kg weight around the ankle was 10.9 ± 3.4 N for the AM graft and 9.9 ± 3.6 N for the PL graft. There was no significant difference between each graft in the 2 motions with a paired t test. CONCLUSIONS: Graft tension with the knee immobilized with a semi-flexed knee brace during active leg-raising motion was 19.5 N with no weight and 20.8 N with additional weight, both of which were almost equal to the initial graft tension at the time of fixation at 20°. Thus the leg-raising exercise can be recommended as safe when a semi-flexed knee brace is worn after ACL reconstruction. CLINICAL RELEVANCE: These findings will help to plan postoperative rehabilitation programs with security.

Effect of patient age on morphology of anterior cruciate ligament grafts at second-look arthroscopy.

PURPOSE: The purpose of this study was to evaluate the effect of patient age on the morphology of anterior cruciate ligament (ACL) graft after ACL reconstruction, as well as to investigate the relation between morphology and clinical outcomes. METHODS: Anatomic double-bundle ACL reconstruction by use of autogenous semitendinosus tendon graft was performed in 193 patients. Of these, 102 patients (51 male and 51 female patients) had consented to undergo second-look arthroscopy at the time of hardware removal within 2 years of ACL reconstruction. These patients were divided into the following 3 groups according to their age: group A, 29 years or younger (55 cases); group B, 30 to 49 years (36 cases); and group C, 50 years or older (11 cases). At second-look arthroscopy, the grafts were evaluated based on synovial coverage around the grafts, tension, and damage/tear of the grafts themselves. Clinical outcomes were evaluated with a physical examination including the Lachman test and side-to-side difference by KT-2000 knee arthrometer (MEDmetric, San Diego, CA), subjective assessment including International Knee Documentation Committee subjective assessment and Lysholm score, and sports activity level including Tegner activity scale. The Mann-Whitney U test, Kruskal-Wallis test, analysis of variance, and χ² test were used for statistical analysis. RESULTS: Good synovial coverage over the graft was found in 49 cases (89%) in group A, 30 (83%) in group B, and 5 (46%) in group C. Synovial coverage in group C was significantly poorer than that in the other 2 groups. No statistical difference was found in tension of graft among the 3 groups, whereas the incidence of a "partial tear" tended to increase with age. With respect to clinical outcome, there was no significant difference among the 3 groups except for sports activity. CONCLUSIONS: Although clinical outcomes were comparable among the 3 groups, synovial coverage of ACL grafts in elderly patients was significantly poorer than that in younger patients. LEVEL OF EVIDENCE: Level II, prognostic study.

Early integration of a bone plug in the femoral tunnel in rectangular tunnel ACL reconstruction with a bone-patellar tendon-bone graft: a prospective computed tomography analysis.

PURPOSE: The purpose of this prospective study was to evaluate how early the bone plug was integrated into the rectangular femoral tunnel after anatomical ACL reconstruction using a bone-patellar tendon-bone (BTB) graft via a rectangular tunnel (RT BTB ACL-R). METHODS: Twenty consecutive patients who had undergone the reconstruction procedure were evaluated by CT scans at 4 and 8 weeks postoperatively. In each scan, 30 slices for multiplanar reconstruction were collected parallel to the long axis of the parallelepiped femoral tunnel and perpendicular to the tendinous plane of the bone plug. Each slice was classified as "complete," indicating no visible gap between the plug and the tunnel wall or trabecular continuity or "incomplete," showing a visible gap. Bone plug-tunnel integration was evaluated as "excellent," "good," "fair," or "poor" for >20, 11-20, 5-10, and <4 "complete" slices, respectively. RESULTS: In this evaluation, 55% of the patients were rated as "excellent" on the first scan, and 80% were "excellent" on the second scan, showing healing over time. The CT values at the anterior interface between the bone plug and the tunnel wall were also measured on both scans. The mean changes in CT value at 8 weeks were significantly lower than those at 4 weeks. CONCLUSION: This study shows that bone plug-femoral tunnel integration was almost complete by 8 weeks after surgery using RT BTB ACL-R.

Bipolar Bone Defects in Shoulders With Primary Instability: Dislocation Versus Subluxation.

BACKGROUND: In shoulders with traumatic anterior instability, a bipolar bone defect has been recognized as an important indicator of the prognosis. PURPOSE: To investigate bipolar bone defects at primary instability and compare the difference between dislocation and subluxation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: There were 156 shoulders (156 patients) including 91 shoulders with dislocation and 65 shoulders with subluxation. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography (CT) scans and were allocated scores ranging from 0 (no defect) to 4 points (very large defect). To assess the combined size of the glenoid defect and Hill-Sachs lesion, the scores for both lesions were summed (range, 0-8 points). Patients in the dislocation and subluxation groups were compared regarding the prevalence of a glenoid defect, a bone fragment of bony Bankart lesion, a Hill-Sachs lesion, a bipolar bone defect, and an off-track Hill-Sachs lesion. Then, the combined size of the bipolar bone defects was compared between the dislocation and subluxation groups and among patients stratified by age at the time of CT scanning (<20, 20-29, and ≥30 years). RESULTS: Hill-Sachs lesions were observed more frequently in the dislocation group (75.8%) compared with the subluxation group (27.7%; P < .001), whereas the prevalence of glenoid defects was not significantly different between groups (36.3% vs 29.2%, respectively; P = .393). The combined defect size was significantly larger in the dislocation versus subluxation group (mean ± SD combined defect score, 2.1 ± 1.6 vs 0.8 ± 0.9 points, respectively; P < .001) due to a larger Hill-Sachs lesion at dislocation than subluxation (glenoid defect score, 0.5 ± 0.9 vs 0.3 ± 0.6 points [P = .112]; Hill-Sachs lesion score, 1.6 ± 1.2 vs 0.4 ± 0.7 points [P < .001]). Combined defect size was larger in older patients than younger patients in the setting of dislocation (combined defect score, <20 years, 1.6 ± 1.2 points; 20-29 years, 1.9 ± 1.5 points; ≥30 years, 3.4 ± 1.6 points; P < .001) but was not different in the setting of subluxation (0.8 ± 1.0, 0.7 ± 0.9, and 0.8 ± 0.8 points, respectively; P = .885). An off-track Hill-Sachs lesion was observed in 2 older patients with dislocation but was not observed in shoulders with subluxation. CONCLUSION: The bipolar bone defect was significantly more frequent, and the combined size was greater in shoulders with primary dislocation and in older patients (≥30 years).

Sequential Changes in Posterior Tibial Translation After Posterior Cruciate Ligament Reconstruction: Risk Factors for Residual Posterior Sagging.

BACKGROUND: Residual posterior sagging may occur after posterior cruciate ligament (PCL) reconstruction (PCLR), yet when it mainly occurs is not fully understood. PURPOSE: To elucidate sequential changes in radiographic posterior tibial translation (PTT) after PCLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The authors retrospectively investigated the radiographic findings from 22 patients who underwent bisocket double-bundle PCLR for isolated PCL injury with at least 2 years of follow-up (mean, 4.5 years; range, 2-10 years). Injury severity was assessed using PTT on lateral radiographs with gravity sag views and was stratified according to side-to-side difference in the tibial-femoral stepoff: grade 1 (<5 mm), grade 2 (5 to <10 mm), or grade 3 (≥10 mm). Measurements were taken preoperatively and then immediately, 3 months, 6 months, 1 year, and ≥2 years postoperatively. The authors also investigated the risk factors for residual posterior sagging, indicated when PTT was ≥5 mm (grade ≥2) at the minimum 2-year follow-up. RESULTS: Preoperatively, 13 patients had a grade 2 injury, and 9 had grade 3 injury. The PTT, restored immediately after PCLR, significantly increased at 3 months (P < .001) but remained unchanged thereafter ≥2 years. There were 7 cases of postoperative PTT ≥5 mm on radiographs. Patients with residual posterior sagging had significantly larger mean PTT than did those without residual posterior sagging at all time points except for immediately postoperatively (preoperatively, 9.1 ± 1.6 vs 12.2 ± 2.3 mm; 3-month follow-up, 2.7 ± 1.6 vs 7.0 ± 1.8 mm; ≥2-year follow-up, 3.4 ± 1.0 vs 6.5 ± 1.4 mm; P < .001 for all). Multivariate logistic regression analysis showed that preoperative grade 3 injury was independently associated with residual posterior sagging (OR, 26.809; 95% CI, 1.257-571.963; P < .001). CONCLUSION: The initially reduced postoperative PTT significantly increased within 3 months using conventional rehabilitation protocols, but no progression was observed up to 4.5 years after PCLR. Preoperative grade 3 injury was independently associated with residual posterior sagging.

Tunnel Enlargement Correlates With Postoperative Posterior Laxity After Double-Bundle Posterior Cruciate Ligament Reconstruction.

BACKGROUND: There exists little information in the relevant literature regarding tunnel enlargement after posterior cruciate ligament (PCL) reconstruction (PCLR). PURPOSE: To sequentially evaluate tunnel enlargement and radiographic posterior laxity through double-bundle PCLR using autologous hamstring tendon grafts. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We prospectively analyzed 13 patients who underwent double-bundle PCLR for an isolated PCL injury. Three-dimensional computed tomography images were obtained at 3 weeks, 6 months, and 1 year postoperatively, and the tunnel enlargement was calculated by sequentially comparing the cross-sectional areas of the bone tunnels. We also sequentially measured radiographic posterior laxity. The correlation between the tunnel enlargement ratio and the postoperative increase in posterior laxity was evaluated. RESULTS: The cross-sectional area at the aperture in each tunnel significantly increased from 3 weeks to 6 months (P < .003), but it did not continue doing so thereafter. The 6-month tunnel enlargement ratios of the femoral anterolateral tunnel, the femoral posteromedial tunnel, the tibial anterolateral tunnel, and the tibial posteromedial tunnel were 31.6% ± 23.5%, 90.3% ± 54.7%, 30.5% ± 26.8%, and 49.6% ± 37.0%, respectively, while the corresponding ratios at 1 year were 28.1% ± 19.8%, 83.1% ± 56.9%, 26.8% ± 32.8%, and 47.6% ± 39.0%, respectively. The posterior laxity was 9.0 ± 4.0 mm, -1.5 ± 2.3 mm, 3.4 ± 2.0 mm, and 3.9 ± 1.9 mm, preoperatively, immediately after surgery, 6 months and 1 year postoperatively, respectively. From the immediate postoperative period, the posterior laxity significantly increased at 6 months postoperatively (P < .001), but it did not thereafter. The postoperative increase in posterior laxity had a significant positive correlation with the anterolateral tunnel enlargement ratio in both femoral and tibial tunnels at 6 months (ρ = 0.571-0.699; P = .011-.041) and 1 year (ρ = 0.582-0.615; P = .033-.037). CONCLUSION: Tunnel enlargement after PCLR mainly occurred within 6 months, with no progression thereafter. The anterolateral tunnel enlargement positively correlated with postoperative increase in posterior laxity.