Patient-Centered Outcomes and Revision Rate in Patients Undergoing ACL Reconstruction Using Bone-Patellar Tendon-Bone Autograft Compared With Bone-Patellar Tendon-Bone Allograft: A Matched Case-Control Study.

PURPOSE: To determine whether outcomes after ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft are similar to those of BPTB allograft, while controlling for graft, surgical technique, and surgeon. METHODS: This study was approved by the institutional review board at The Vail Valley Medical Center in Vail, Colorado. Patients 18 to 70 years old who underwent primary ACL reconstruction were included. Patients in each group were matched by age and gender. Patient demographic data, surgical data, and subjective data were collected prospectively. Subjective questionnaires were administered at a minimum of 2 years after ACL reconstruction. RESULTS: This study included 192 knees (191 patients; 143 male, 48 female; mean age, 33 years; range, 18 to 57 years), with 96 knees in each group. No autografts required ACL revision. The revision rate for allograft group was 14% (n = 11; mean age, 23 years; range, 18 to 40 years). Of 11 revisions, 9 (82%) were ≤25 years old. In allograft group, patients ≤25 years old were 23 times (95% confidence interval, 4.4 to 123.0) more likely to require revision ACL reconstruction than patients >25 years (P < .001). Follow-up was available for 87% of patients (n = 156/180). Mean follow-up time in the allograft group was 4.7 years (range, 2.0 to 9.8 years), and in the autograft group, 8.6 years (range, 2.0 to 16.2 years; P < .001). There was no significant difference between allografts and autografts for mean Lysholm (85.6 v 83.4; P = .43), mean Tegner (6.0 v 5.4; P = .09), or mean patient satisfaction (9.0 v 8.8; P = .57). Lysholm score correlated to Tegner (rho = 0.404; P < .001) and patient satisfaction with outcome (rho = 0.443; P ≤ .001). Tegner was correlated with age at surgery (rho = -0.274; P < .001). CONCLUSIONS: There was no significant difference in patient-centered outcomes based on graft type; however, the allograft group required more revisions. Patient satisfaction was high for both groups. ACL reconstruction using BPTB autograft or allograft produces similar outcomes; however, revision rates were higher for allografts. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Surgical treatment for early osteoarthritis. Part I: cartilage repair procedures.

Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. This review of cartilage repair techniques will discuss currently available procedures, specifically pertaining to experiences in the setting of early OA. Level of evidence IV.

Relationship of anterior knee laxity to knee translations during drop landings: a bi-plane fluoroscopy study.

PURPOSE: Passive anterior knee laxity has been linked to non-contact ACL injury risk. High deceleration movements have been implicated in the non-contact ACL injury mechanism, and evidence suggests that greater anterior tibial translations (ATT) may occur in healthy knees that are lax compared to a tight knee. The purpose of this study was to determine the relationship between anterior knee laxity scores and ATT during drop landings using biplane fluoroscopy. METHODS: Sixteen healthy adults (10 women; 6 men) performed stiff drop landings (40 cm) while being filmed using a high-speed, biplane fluoroscopy system. Initial, peak and excursions for rotations and translations were calculated and regression analysis used to determine the 6DoF kinematic relationships with KT1000 scores with peak ATT occurring during the landing. RESULTS: KT1000 values were (+) correlated with peak ATT values for group (r = 0.89; P < 0.0001) and both genders (males, r = 0.97; P = 0.0003; females, r = 0.93; P = < 0.0001). Regression analysis yielded a significant linear fit for the group (r (2) = 0.80; Y (ATT-group) = - 0.516 + 1.2 × X (KT1000-group)) and for each gender (females: r(2) = 0.86; Y (ATT-females) = 0.074 + 1.2 × X (KT1000-females) and males: r (2) = 0.94; Y (ATT-males) = - 0.79 + 1.2 × X (KT1000-males)). CONCLUSION: A strong relationship was observed between passive anterior knee laxity measured via KT1000 and peak ATT experienced during dynamic activity in otherwise healthy persons performing a stiff drop-landing motion.

[Microfracture and specific rehabilitation for treating osteoarthritis of the knee. Indications, surgical technique, and rehabilitation protocol]. / Die spezifische Rehabilitation nach Mikrofrakturierung bei Arthrose des Kniegelenkes. Mikrofrakturierung und spezifische Rehabilitation zur Behandlung von Arthrose des Kniegelenks. Indikationsstellung, operative Technik und Rehabilitationsprotokoll.

Treatment of osteoarthritis in young and middle-aged patients, in whom joint replacement is usually not appropriate, is a challenge to orthopaedic surgeons. Arthroscopic techniques can help control patients' symptoms. In particular, the microfracture procedure combined with management of the joint volume and a specific rehabilitation protocol shows good results in patients with osteoarthritis and cartilage defects by resurfacing the defect with a combination of types I and II cartilaginous tissue. Microfracture is a single-staged arthroscopic procedure that can be combined with any other arthroscopic treatment for osteoarthritis of the knee. With an appropriate rehabilitation protocol and techniques for controlling the joint volume, these treatments are very effective for pain relief and functional improvement. The described technique is our choice for initial surgical treatment of osteoarthritis of the knee.

Differential Pathogenicity of Xanthomonas campestris pv. phaseoli and X. fuscans subsp. fuscans Strains on Bean Genotypes with Common Blight Resistance.

Both the common bacterial blight (CBB) pathogen (Xanthomonas campestris pv. phaseoli) and X. fuscans subsp. fuscans, agent of fuscous blight, cause indistinguishable symptoms in common bean, Phaseolus vulgaris. Yield losses can exceed 40%. Lack of information about the specificity between X. campestris pv. phaseoli strains and major quantitative trait loci (QTL) or alleles conferring resistance makes the task of identifying genetic changes in host-pathogen interactions and the grouping of bacterial strains difficult. This, in turn, affects the choice of pathogen isolates used for germplasm screening and complicates breeding for CBB resistance. Common bean host genotypes carrying various sources and levels of resistance to CBB were screened with 69 X. campestris pv. phaseoli and 15 X. fuscans subsp. fuscans strains from around the world. Differential pathogenicity of the CBB pathogen was identified on the 12 selected bean genotypes. The X. fuscans subsp. fuscans strains showed greater pathogenicity than X. campestris pv. phaseoli strains having the same origin. African strains were most pathogenic. The largest variation in pathogenicity came from X. campestris pv. phaseoli strains that originated in Caribbean and South American countries. Pathogenic variation was greater within X. campestris pv. phaseoli than within X. fuscans subsp. fuscans strains. Implications for breeding for CBB resistance are discussed.

Virulence Diversity of the Common Bean Rust Pathogen Within and Among Individual Bean Fields and Development of Sampling Strategies.

There is a dearth of information on pathogen variation within an individual field. In this study, virulence diversity of Uromyces appendiculatus, cause of bean rust, within individual fields was investigated. From six bean fields in the United States, Honduras, Dominican Republic, and South Africa, 380 U. appendiculatus isolates were differentiated into 65 virulence phenotypes on bean lines containing Andean- and Middle American-derived rust resistance genes. Race variation among bean rust isolates from different geographic regions was found, and virulence phenotypes found in fields from tropical and subtropical regions were more virulent and diverse than those found in fields from temperate regions. The variance components between fields was greater than the variance within a field based on mean disease score on 12 differentials but the variance components within a field were greater than the variances between fields based on number of virulence phenotypes. This is the first report that multiple site samples are needed to represent the fungal virulence diversity in a diseased field. In developing sampling plans, the entire cost of sampling one field is higher than the cost of taking more samples; therefore, to estimate virulence diversity variation, we recommend selecting fewer fields and collecting more samples per field.

Rehabilitation of the anterior cruciate ligament in the athlete.

Recent medical advances in diagnosis, surgical technique, bracing and postoperative rehabilitation have greatly improved subjective and objective results following anterior cruciate ligament surgery. A team approach involving patient, therapist, athletic trainer, and surgeon is vital to a successful outcome. Surgical rationale and postoperative rehabilitation should be based on sound scientific data, recognising the need for static and dynamic knee stability. The rehabilitation programme should incorporate principles which enhances the well-being of the musculoskeletal system, avoiding potential problems such as periarticular contractures, disuse atrophy, negative cartilage changes, and cardiopulmonary deconditioning. This article is an attempt to summarise the scientific data and principles, and describe a rehabilitation programme which adheres to the data and principles outlined.

The surgical treatment of knee injuries in skiers.

Although the overall skin injury incidence continues to decline, knee injuries requiring surgery remain extremely common. Emphasis is placed on the history of the skier's fall in making an accurate diagnosis. This injury pattern is then assessed with the skier's age and activity level in determining the most appropriate surgical procedure. The actual surgical intervention is just a portion of the rehabilitation process in returning a skier back to sport as quickly as possible. The most common injuries requiring surgical intervention include meniscal tears, osteochondral fractures, and ligament tears. Our indications and techniques are described. Early focus on postoperative range of motion is emphasized. Strengthening begins only when full, pain-free range of motion is obtained. Utilizing these principles, our goals have been to complete the rehabilitation process coexistent with healing of the injury.

Muscle activity in wedge, parallel, and giant slalom skiing.

Muscle activity patterns of six alpine skiers were compared during nine runs each of wedge (W), short radius parallel (P), and giant slalom (GS) turns. Bipolar surface electrodes were placed over 12 muscles on the right side of the body: anterior tibialis, medial gastrocnemius, vastus medialis, vastus lateralis, rectus femoris, medial hamstrings, biceps femoris, gluteus maximus, adductors, rectus abdominis, external obliques, and erector spinae. Repeated measures ANOVA was used to test for differences in average and peak EMG amplitudes between W, P, and GS (P < 0.1). Average amplitude was significantly different between all turning styles (W < P < GS) for four muscles (vastus lateralis, medial hamstrings, biceps femoris, and external obliques) and significantly less for W versus P or GS for four muscles (anterior tibialis, vastus medialis, rectus femoris, and rectus abdominis). The gluteus maximus was the only muscle that had significantly greater activity in W than P. Average amplitude was greater than 50% MVC for the vastus medialis, vastus lateralis, biceps femoris, gluteus maximus, and adductors in all conditions; and for the anterior tibialis, medial hamstrings, and rectus femoris in GS and P; and for the medial gastrocnemius and erector spinae in GS. Peak amplitude was greater than 150% maximal voluntary contraction (MVC) for the vastus medialis, vastus lateralis, biceps femoris, gluteus maximus, and adductors in all conditions, and for the medial gastrocnemius, rectus femoris, and erector spinae in GS. This research indicates that with the exception of the gluteus maximus, greater muscle activity is required in GS followed by P and W turns.

Effects of walking poles on lower extremity gait mechanics.

PURPOSE: The purpose of this study was to determine whether walking with poles reduces loading to the lower extremity during level over ground walking. METHODS: Three-dimensional gait analysis was conducted on 13 healthy adults who completed 10 walking trials using three different poling conditions (selected poles, poles back, and poles front) and without the use of poles (no poles). The inverse dynamics approach was used to calculate kinetic data via anthropometric, kinematic, and kinetic data. RESULTS: All walking with poles conditions increased walking speed (P = 0.0001-0.0004), stride length (P < 0.0001), and stance time (P < 0.0001) compared with the no poles condition. There also was a decrease in anterior-posterior GRF braking impulse (P = 0.0001), a decrease in average vertical GRF walking with poles (P < 0.0001-0.0023), and a decrease in vertical (compressive) knee joint reaction force (P < 0.0001-0.0041) compared with the no poles condition. At the knee, extensor impulse decreased a 7.3% between the no poles and selected poles conditions (P = 0.0083-0.0287) and 10.4% between the no poles and poles back conditions (P < 0.0001). The support moment was reduced between the no poles and poles back (P = 0.0197) and poles front (P = 0.0002) conditions. Ankle plantarflexor work (A2) was reduced in the poles-front condition (P = 0.0334), but no differences were detected in all other ankle, knee or hip power and work variables (P > 0.05). CONCLUSION: There were differences in kinetic variables between walking with and without poles. The use of walking poles enabled subjects to walk at a faster speed with reduced vertical ground reaction forces, vertical knee joint reaction forces, and reduction in the knee extensor angular impulse and support moment, depending on the poling condition used.

Muscle activity in slalom and giant slalom skiing.

The purpose of this study was to document and compare the muscular activity patterns observed in seven competitive racers during slalom (SL) and giant slalom (GS) skiing using quantitative parameters of EMG and qualitative video recordings. Twelve muscles of the leg and trunk were monitored using surface electrodes and telemetry. EMG activity was related to phases of movement determined from the video. SL was partitioned into two phases (initiation and turning) and a third phase (completion) was distinguished for GS. The majority of muscles were active at a moderate to high level for the whole turn, with average amplitudes (AA) between 58% and 112% maximum voluntary contraction. Large peak amplitudes (PA) were attributed to the substantial components of centrifugal and gravitational force that the skier must resist in the latter part of the turn. The similarity in muscle activity between SL and GS was surprising. The only significant differences were increases of 11.8% in AA for the AT in SL and 8.8% in PA for the EO in GS. There was ample evidence of co-contraction, suggesting a quasistatic component to skiing.

Regeneration of meniscal cartilage with use of a collagen scaffold. Analysis of preliminary data.

A collagen scaffold was designed for use as a template for the regeneration of meniscal cartilage and was tested in ten patients in an initial, Food and Drug Administration-approved, clinical feasibility trial. The goal of the study was to evaluate the implantability and safety of the scaffold as well as its ability to support tissue ingrowth. The study was based on the findings of in vitro and in vivo investigations in dogs that had demonstrated cellular ingrowth and tissue regeneration through the scaffold. Nine patients remained in the study for at least thirty-six months, and one patient voluntarily withdrew after three months for personal reasons. The collagen scaffold was found to be implantable and to be safe over the three-year period. Histologically, it supported regeneration of tissue in meniscal defects of various sizes. No adverse immunological reactions were noted on sequential serological testing. On second-look arthroscopy, performed either three or six months after implantation, gross and histological evaluation revealed newly formed tissue replacing the implant as it was resorbed. At thirty-six months, the nine patients reported a decrease in the symptoms. According to a scale that assigned 1 point for strenuous activity and 5 points for an inability to perform sports activity, the average score was 1.5 points before the injury, 3.0 points after the injury and before the operation, and 2.4 points at six months postoperatively, 2.2 points at twelve months, 2.0 points at twenty-four months, and 1.9 points at thirty-six months. According to a scale that assigned 0 points for no pain and 3 points for severe pain, the average pain score was 2.2 points preoperatively and 0.6 point thirty-six months postoperatively. One patient, who had had a repair of a bucket-handle tear of the medial meniscus and augmentation with the collagen scaffold, had retearing of the cartilage nineteen months after implantation. Another patient had debridement because of an irregular area of regeneration at the scaffold-meniscus interface twenty-one months after implantation. Magnetic resonance imaging scans demonstrated progressive maturation of the signal within the regenerated meniscus at three, six, twelve, and thirty-six months. These findings suggest that regeneration of meniscal cartilage through a collagen scaffold is possible. Additional studies are needed to determine long-term efficacy.

Reconstruction of the anterior cruciate ligament in patients who are at least forty years old. A long-term follow-up and outcome study.

The long-term results were reviewed for seventy-two patients (seventy-five knees) who had had a bone-patellar ligament-bone intra-articular reconstruction of the anterior cruciate ligament between August 1984 and May 1992. The mean age of the patients at the time of the operation was forty-five years (range, forty to sixty years). Three patients had a bilateral procedure. The primary mechanisms of injury were accidents that occurred during skiing (thirty-two knees), tennis (fourteen knees), and soccer (five knees). We analyzed the responses to subjective questionnaires, the functional results, and the objective clinical data. The clinical examination included assessment of the range of motion, performance of Lachman and pivot-shift tests, and measurements with use of a KT-1000 arthrometer. All knees were evaluated with use of three common rating scales: that of Lysholm and Gillquist; that of The Hospital for Special Surgery, as modified by Insall et al.; and the International Knee Ligament Standard Evaluation Form. At the latest follow-up evaluation, at a mean of fifty-five months (range, twenty-six to 117 months), three patients reported pain or swelling. No patient reported giving-way or symptoms related to the patellofemoral joint. The mean range of extension was -12 to 6 degrees, compared with -8 to 42 degrees preoperatively, and the mean range of flexion was 112 to 150 degrees, compared with 52 to 154 degrees preoperatively. Flexion was limited to 112 degrees in one patient, but this was 5 degrees greater than that of the uninvolved knee. Sixty knees (80 per cent) had a negative pivot-shift test, and ten knees (13 per cent) had a grade of 1+. On testing with the KT-1000 device at maximum manual pressure, the mean difference between the injured and uninjured knees was found to have improved by 5.1 millimeters, from 6.4 millimeters preoperatively to 1.4 millimeters postoperatively (p < 0.01). The grade on the International Knee Ligament Standard Evaluation Form improved markedly; seventy-two knees (96 per cent) had a grade of C or D preoperatively, whereas seventy knees (93 per cent) had a grade of A or B postoperatively. The Hospital for Special Surgery score improved from a mean of 69 points preoperatively to a mean of 92 points postoperatively (p < 0.01). The mean score according to the scale of Lysholm and Gillquist increased from a mean of 63 points preoperatively to a mean of 94 points postoperatively (p < 0.01). All patients indicated that they were pleased with the result of the procedure. Bicycling was resumed at a mean of four months; jogging, at a mean of nine months; skiing, at a mean of ten months; and tennis, at a mean of twelve months.

Anterior cruciate ligament repairs in world class skiers.

From 1979 to 1984, 27 skiers who were either present or past members of the United States Ski Team or professional skiers had 30 ACL tears that were repaired primarily. Only two of the repairs were augmented with autogenous patellar tendon grafts. Five patients had complete knee dislocations, including tears of both cruciate ligaments. Nineteen patients had a concomitant extraarticular iliotibial band tenodesis. Twenty-seven knees (24 patients) were followed an average of 57.6 months postoperatively. Recreational skiing was resumed at 5.4 months on average, and in ski racing and pivot-requiring sports all but three patients resumed participation at an average of 9.1 months. In 78% of the knees there was pain-free function. Mild pain was reported in 19%, the majority of which (4/5) was related to vigorous activity. Of the total, only two knees were reported to have a sensation of giving way. On clinical examination 85% (23/27) had normal pivot shift examination with no evidence of abnormal motion. Four percent (1/27) had a 1+ test and 11% (3/27) had "glides." Arthrometer measurements revealed an average of 7.76 mm anterior displacement with 20 pounds of force on the knee with an ACL repair as compared to 5.56 mm on the uninjured knee. The laxity measurements of knees with repaired ACLs fell within the range reported for uninjured knees in the normal population. Five patients had reinjuries to the ACL at an average time of 28 months postoperatively, with two of five undergoing rerepair. Only one patient had an iliotibial band tenodesis to supplement the original ACL repair.(ABSTRACT TRUNCATED AT 250 WORDS)

A nonparallel, nonisometric synthetic graft augmentation of a patellar tendon anterior cruciate ligament reconstruction. A model for assessment of stress shielding.

The potential for a rigidly fixed synthetic graft placed in the over-the-top position to be stress shielding/stress sharing with the patellar tendon autograft was assessed in a primate model. A patellar tendon autograft was placed anatomically and tensioned at 2 pounds for all of the groups. In the augmented animals, a 30 strand braided graft 10 cm in length of expanded polytetrafluoroethylene was tightened with the knee in full extension. After 6 months of unrestricted cage activity the animals were sacrificed and biomechanical testing performed. The augmented patellar tendon autografts demonstrated less laxity in extension as compared to the autografts alone. A minimal decrease in the load and stiffness to failure for the augmented groups as compared to the nonaugmented knees was noted. However, both the reconstruction groups had a significant decrease in the load to failure at 6 months (50% of the normal ACL). In summary, this study demonstrated that a synthetic graft augmentation can be performed in the over-the-top position and minimize knee laxity, especially during terminal extension. With this technique, the laxity was minimized while the incorporation and strengthening of the biologic autograft occurred at a rate similar to the unaugmented reconstruction.

Measurements of the intercondylar notch by plain film radiography and magnetic resonance imaging.

The purpose of this investigation was twofold. In Part I, we determined the accuracy of morphometric analysis of the knee using magnetic resonance imaging and plain film radiography. The results of Part I validated the accuracy of magnetic resonance measurements and its superiority over plain film measurements. In Part II, we evaluated knee morphometry in 20 asymptomatic athletes with chronic anterior cruciate ligament insufficiency to determine if any predisposing factors to anterior cruciate ligament disruption could be detected. With our analysis, we could detect no predisposing factors to explain the anterior cruciate ligament disruption in the cohort group.

Meniscal regeneration with copolymeric collagen scaffolds. In vitro and in vivo studies evaluated clinically, histologically, and biochemically.

We sought to create a regeneration template for the meniscal cartilage of the knee to induce complete meniscal regeneration, and to develop the technique for implanting the prosthetic appliance in vivo. We designed a resorbable collagen-based scaffold and conducted in vitro and in vivo studies. In vivo, the scaffold was implanted in the knees of immature swine and mature canines and evaluated clinically, histologically, and biochemically. Because the canine stifle joint meniscus is more clinically relevant to the human meniscus, this paper emphasizes those results. We studied 24 mixed breed dogs (14 males and 10 females) with an average weight of 25.5 kg (range, 20 to 35) that were obtained from a USDA-licensed supplier. The dogs were deemed clinically and radiographically skeletally mature. None of the dogs had a preexisting knee joint abnormality. All dogs underwent an 80% subtotal resection of the medial meniscus bilaterally. A collagen template was implanted in one stifle (N = 24). The contralateral side served as a control: 12 dogs had a total resection alone and the other 12 dogs had an immediate replantation of the autologous meniscus. Results were tabulated at 3, 6, 9, and 12 months. At final evaluation, before the animals were euthanized, the results were submitted for statistical analysis as well as histologic and biochemical analyses. The results demonstrated that a copolymeric collagen-based scaffold can be constructed that is compatible with meniscal fibrochondrocyte growth in vitro and in vivo, that does not inhibit meniscal regeneration in an immature pig, and that may induce regeneration of the meniscus in the mature dog.(ABSTRACT TRUNCATED AT 250 WORDS)

Internal and external tibial rotation strength after anterior cruciate ligament reconstruction using ipsilateral semitendinosus and gracilis tendon autografts.

The internal and external tibial rotation torques of subjects who had undergone anterior cruciate ligament reconstruction using semitendinosus and gracilis tendon grafts were measured to determine whether harvest of the tendons results in weakness of tibial internal and external rotation. Cybex NORM dynamometer examinations were performed to measure internal and external tibial torque at angular velocities of 60, 120, and 180 deg/sec in 23 subjects. The sex-specific average torque data of the reconstructed limbs were compared with those of the contralateral limbs. Relative internal and external torque scores were calculated for each subject by subtracting the peak torque of the reconstructed knee from that of the contralateral knee. These relative scores were averaged and compared with the null hypothesis that each score should be statistically similar to zero. Subjects were evaluated at an average of 51 +/- 40 months postoperatively. The mean relative internal torque scores of the reconstructed limbs showed a statistically significant decrease from those of the contralateral limbs at all angular velocities. The mean relative external torque scores of the reconstructed limbs were statistically similar to those of the contralateral limbs at all angular velocities. Subjects who had undergone ligament reconstruction using semitendinosus and gracilis tendons demonstrated internal tibial rotation weakness in their reconstructed knees compared with their contralateral knees at all angular velocities tested. These results suggest that semitendinosus and gracilis tendon harvest causes weakness of internal tibial rotation.

Pull-out strength and stiffness of meniscal repair using absorbable arrows or Ti-Cron vertical and horizontal loop sutures.

We tested pull-out strength and linear stiffness of meniscal repair using bioabsorbable arrows and vertical and horizontal loop sutures in fresh-frozen bovine lateral menisci. In phase I, menisci repaired either with 2-0 Ti-Cron vertical or horizontal loop suture, or 10-, 13-, or 16-mm Meniscus Arrows were loaded to failure at 12.5 mm/sec. In phase II, we examined the number of barbs engaged and angle of insertion using 10- and 13-mm arrows. Pull-out strengths of both suture repair groups were significantly higher than those of the arrow groups. Vertical loop sutures were significantly stiffer than horizontal sutures and 10-mm arrows. In phase II, the mean ultimate load to failure for the 10-mm arrows was 35.1 N, significantly stronger than in phase I (18.5 N); however, stiffness remained low (7.9 N/mm). Five arrows in the 13-mm group were inserted parallel to the tibial surface and showed no significant difference from phase I. Five arrows were inserted at more than a 30 degrees angle. This group was significantly weaker than in phase I. Single vertical loop suture showed the highest overall pull-out strength. Although weaker than sutures, arrows should provide sufficient stability for meniscal healing. The number of barbs engaged and angle of insertion are critical.

Anterior cruciate ligament injury incidence among male and female professional alpine skiers.

A retrospective review of anterior cruciate ligament injuries among professional alpine skiers was performed to compare sex-related differences in injury incidence. We screened 7155 ski patrollers or instructors (4537 men and 2618 women) for knee injuries before each ski season between 1991 and 1997. Screening involved a ski history questionnaire, a knee injury history questionnaire, and a knee physical examination. Any patient with an equivocal Lachman or pivot shift test was evaluated by KT-1000 arthrometry and excluded from the study if the manual maximum side-to-side difference was 3 mm or more. Thus, the study population was limited to subjects with intact anterior cruciate ligaments. Skiers injured during the study were identified through mandatory workers' compensation claims. Each injured skier was reevaluated using an injury questionnaire and physical examination. The men skied an average of 110 days per year (499,070 skier-days) and the women skied an average of 87 days per year (227,766 skier-days). Thirty-one skiing-related anterior cruciate ligament injuries were diagnosed, 21 in men and 10 in women. The incidence of ACL disruption was 4.2 injuries per 100,000 skier-days in men and 4.4 injuries per 100,000 skier-days in women. These data suggest that the incidences of anterior cruciate ligament injuries among male and female professional alpine skiers are similar.