Evaluation of Peripheral Vertical Nondegenerative Medial Meniscus Tears Treated With Trephination Alone at the Time of Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine (1) subjective results and incidence of symptomatic medial meniscus tears (MMTs) in patients treated with trephination alone compared with a control group without meniscus tears and (2) if trephination treatment resulted in a higher incidence of knee arthritis compared with controls with intact menisci. METHODS: Between 1997 and 2010, 419 patients met the inclusion criteria of having an isolated anterior cruciate ligament (ACL) tear, peripheral vertical nondegenerative MMT treated with trephination alone, no lateral meniscus tears, normal radiographs before surgery, and no bilateral knee involvement. A control group of 462 patients included patients who met the same criteria but without MMT. Objective data included International Knee Documentation Committee (IKDC) objective evaluation. Subjective data included IKDC and Cincinnati Knee Rating System (CKRS) scores. RESULTS: Objective follow-up was obtained for 191 patients in the study group and 200 patients in the control group (mean, 5.6 and 5.9 years, respectively; range, 2 to 16 years). Subjective survey follow-up was obtained for 312 patients in the study group and 343 patients in the control group (mean, 7.0 and 7.1 years, respectively). The mean CKRS score was 91.8 ± 13.3 for the study group and 92.3 ± 10.9 for the control group (P = .27). The mean IKDC score was 86.5 ± 15.8 for the study group and 86.7 ± 16.3 for the control group (P = .81). Subsequent MMTs occurred in 51 patients (16.3%) in the study group and 20 patients (5.8%) in the control group (P < .0001). IKDC radiographic ratings were normal for 95% of the study group and 92% of the control group (P = .18). CONCLUSIONS: Patients with peripheral nondegenerative MMTs treated with trephination alone had a 16.3% rate of subsequent symptomatic MMTs compared with 6% in patients with intact menisci. However, no statistically significant differences were found between groups for radiographic and subjective results. LEVEL OF EVIDENCE: Level III, therapeutic case control study.

Results of medial retinacular imbrication in patients with unilateral patellar dislocation.

Many surgical methods are used for treating malaligned patella after patellar dislocation, but one surgical method may not be appropriate for all patients. The purpose of this study was to determine the radiographic and subjective outcomes of patients who underwent imbrication of redundant medial structures. A total of 42 patients met the inclusion criteria of suffering a traumatic, unilateral patellar dislocation and had no J-sign, no patella alta, asymmetry on Merchant view radiograph with normal patella alignment on the noninvolved side, and MRI showing injury to the medial retinaculum. Patients were prospectively evaluated. A total of 38 patients (mean age 19.2 years) completed follow-up evaluations at a mean of 31.7 months postoperatively. Mean congruence angle improved from 19.7° preoperatively to 5.4° postoperatively (p < 0.001) and was not statistically significantly different than the noninvolved knee of 4.1 (p = 0.5194). The mean linear displacement measurement improved from 6.0 mm preoperatively to 1.6 mm postoperatively (p < 0.001) and was not statistically significantly different than the noninvolved knee of 1.4 mm (p = 0.6294). Total 33 of 38 patients (87%) returned to their preinjury activity level including sports. Three patients had recurrence of patellar dislocation after surgery while playing sports. For patients who have the specific indications for imbrication of the medial retinaculum, surgery can be successful for re-establishing normal patellofemoral alignment and restoring function.

Range of Motion, Strength, and Function After ACL Reconstruction Using a Contralateral Patellar Tendon Graft.

Background: Regaining preinjury levels of activity and progressing rehabilitation factors after anterior cruciate ligament (ACL) reconstruction have shown mixed results. Purpose: To evaluate the timing and rate of return for knee range of motion (ROM), stability, strength, and subjective scores after ACL reconstruction with contralateral patellar tendon graft (PTG). Study Design: Case series; Level of evidence, 4. Methods: Included were 2148 patients (1238 male patients, 910 female patients) who underwent primary ACL reconstruction with a contralateral PTG between 1995 and 2017 and had complete objective data through 3 months of follow-up. All patients participated in a rehabilitation program specific to goals for each knee. Patients were evaluated objectively with goniometric measurement of ROM, isokinetic quadriceps strength testing, and laxity with a KT-2000 arthrometer. Subjective data were collected at 2 and 5 years. Results: Normal extension on the reconstructed knee was attained for 95% of patients at 1 week postoperatively; normal flexion on the reconstructed knee was reached by 77% of patients by 3 months. At 3 months postoperatively, mean limb symmetry index strength was 104%, and the strength on the ACL-reconstructed and graft-donor knees was 87% and 86% of their respective preoperative strength. Mean manual maximum side-to-side difference in laxity was 2.0 mm at 1 month. Most patients (90%) returned to level 8 sports or higher and did so at an average of 5.7 months. Mean International Knee Documentation Committee scores for the ACL-reconstructed and graft-donor knees were 89 and 91 at 2 years (n = 1015 patients) and 84 and 90 at 5 years (n = 1275 patients), respectively. Mean Cincinnati Knee Rating Scale scores for the ACL-reconstructed and graft-donor knees were 92 and 96 at 2 years (n = 1184) and 88 and 94 at 5 years (n = 1236), respectively. Conclusion: For patients who underwent ACL reconstruction with a contralateral PTG, postoperative ROM and strength were restored quickly by splitting the rehabilitation into different goals between the two knees. Using a contralateral PTG, this structured rehabilitation plan can lead to a relatively quick return to sport and good subjective long-term outcomes.

Posterior Tibial Slope in Patients Undergoing Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft: Analysis of Subsequent ACL Graft Tear or Contralateral ACL Tear.

BACKGROUND: Reports on greater posterior tibial slope (PTS) and its relationship to subsequent anterior cruciate ligament (ACL) injury show conflicting results; it has not been studied much in patients after ACL reconstruction with patellar tendon autograft (PTG). HYPOTHESIS: Patients who suffered a subsequent ACL injury would have a larger PTS than patients who did not suffer a subsequent injury after primary or revision ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients received primary (n = 2439) or revision (n = 324) ACL reconstruction with PTG and were followed prospectively to determine the rate of graft tear and contralateral ACL tear. The PTS was measured preoperatively on digital lateral view radiographs. Intersecting lines were drawn along the medial tibial plateau and posterior tibia; the value of the acute angle at the lines' intersection was then subtracted from 90° to obtain the PTS. This procedure was completed by a clinical assistant with an intrarater reliability of 0.89. Chi-square analysis and t tests were used to determine the differences between rate of tears and measurements between groups. A threshold of PTS ≥10° was used for analysis. RESULTS: The mean follow-up time was 11.6 ± 4.0 years. After primary surgery, the mean PTS in patients with graft tears was 5.4°± 3.1° versus 4.8°± 2.9° for patients without a tear (P = .041). The mean PTS was 4.9°± 3.4° for patients with contralateral tears (not statistically significantly different than the no-tear group; P = .80). Furthermore, patients with primary reconstruction with PTS ≥10° had a statistically significantly higher rate of graft tear (9.7%) than patients with PTS ≤9° (4.8%) (P = .003), but not a higher rate of contralateral tear. Among patients undergoing revision surgery, there were no statistically significant differences between the graft tear, contralateral tear, and no-tear groups with relation to PTS ≥10°. CONCLUSION: After primary ACL reconstruction, patients with PTS >10° had a higher rate of subsequent graft tear but not a higher rate of contralateral tear. With revision surgery, there was no significant association between PTS and the rate of subsequent tear. Therefore, caution should be exercised when considering more radical interventions, such as osteotomy, to prevent retear in patients with high PTS.

Knee Osteoarthritis: Alternative Range of Motion Treatment.

The number of total knee arthroplasty (TKA) surgeries is expected to soar, and an effective nonoperative rehabilitation program is needed. We began treating patients with knee osteoarthritis with a range-of-motion (ROM) -based rehabilitation program that was delivered systematically, starting with ROM exercises for knee extension, followed by exercises for flexion and swelling reduction, before starting a strengthening program. In a group of 396 patients, significant improvements were made in knee extension, flexion, and KOOS subjective scores for pain, symptoms, activities of daily living, sport, and quality of life. Furthermore, the program prevented 76% of patients from undergoing TKA surgery.

Intercondylar notch width measurement differences between African American and white men and women with intact anterior cruciate ligament knees.

BACKGROUND: A recent report of professional women's basketball found that white European American female players were 6.5 times more likely to tear their anterior cruciate ligament than their nonwhite European American counterparts. African Americans accounted for 95% of the nonwhite European American group. HYPOTHESIS: African American men and women have wider intercondylar notches than white men and women. STUDY DESIGN: Cohort study (prevalence); Level of evidence, 2. METHODS: We obtained 45 degrees flexed weightbearing posteroanterior radiographs on 517 patients who had knee problems other than an anterior cruciate ligament injury or arthrosis. One experienced observer measured the intercondylar notch width with no knowledge of race or gender, and the measurements were analyzed based on race and gender. RESULTS: The mean intercondylar notch width was 15.5 mm (SD = 2.8; range, 9-22) for African American women and 14.1 mm (SD = 2.5; range, 8-21) for white women; this difference was statistically significant (P = .009). Similarly, the mean intercondylar notch width was 18.0 mm (SD = 3.6; range, 10-27) for African American men and 16.9 mm (SD = 3.1; range, 9-27) for white men; these values were statistically significantly different (P = .003). CONCLUSION: We conclude that African Americans have statistically significantly wider intercondylar notch widths on 45 degrees flexed weightbearing posteroanterior radiographs than whites of the same gender. This relationship may offer an explanation for the difference between races with regard to risk of anterior cruciate ligament tears.

Knee dislocation with lateral side injury: results of an en masse surgical repair technique of the lateral side.

BACKGROUND: Knee dislocations with lateral side injury are rare and disabling if not treated. HYPOTHESIS: An en masse surgical technique to repair the lateral side will provide good stability, and the posterior cruciate ligament will heal when left in situ. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty-three patients underwent an en masse lateral side repair after knee dislocation injury; all but 1 patient had anterior cruciate ligament reconstruction. Physical examination included the International Knee Documentation Committee score, isokinetic strength testing, KT-2000 arthrometer testing, radiography (including varus stress), and magnetic resonance imaging scan. Patients were evaluated subjectively with several surveys. RESULTS: Mean objective evaluation occurred for 17 patients at 4.6 years postoperatively, and 21 subjective evaluations occurred for 21 patients at 5.6 years postoperatively. The objective overall grade was normal for 10 patients and nearly normal for 7 patients. Lateral laxity was graded as normal in 15 patients and 1+ in 2 patients. The posterior drawer was normal in all but 3 patients, who had 1+ posterior laxity. The postoperative varus stress radiography demonstrated a mean increase of 1.1 +/- 1.7 mm (range, -1.2-4.7) between knees. Magnetic resonance scans showed that the lateral side was thickened but intact in all patients. The posterior cruciate ligament was viewed as healed or intact in all patients but was sometimes seen as elongated or buckled. The mean subjective total scores were 91.3 points for the IKDC survey, 93.0 for the modified Noyes survey, and 8.0 for an activity score, but scores were higher for patients who underwent surgery within 4 weeks from the injury. CONCLUSIONS: The en masse surgical technique to repair the lateral side combined with an anterior cruciate ligament reconstruction after knee dislocation provides excellent long-term stability. The repaired lateral side and untreated posterior cruciate ligament heal with continuity. Patients can return to high levels of activity.

Results of Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts: Objective Factors Associated With the Development of Osteoarthritis at 20 to 33 Years After Surgery.

BACKGROUND: Few studies exist that report objective radiographic and physical examination results at >20 years after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: The risk of osteoarthritis (OA) at >20 years after surgery would be statistically significantly higher if an increased severity of factors was present. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 1982 and 1994, 1428 knees met the inclusion criteria of being primary ACL surgery, having no existing OA or other ligamentous laxity, and having no known graft tear. Prospective data analyzed included demographics; meniscus and articular cartilage status; ratings of bilateral standing posteroanterior weightbearing, lateral, and Merchant view radiographs; KT-1000 arthrometer measurements; and range of motion measurements. Radiographs were graded for joint space narrowing, sclerosis, and osteophytes according to International Knee Documentation Committee (IKDC) criteria. Multivariate and univariate logistic models were used to determine the effect of potential predictors on the odds of having radiographic evidence of OA. IKDC and Cincinnati Knee Rating System (CKRS) subjective surveys were conducted. RESULTS: A minimum 20-year objective follow-up was obtained for 423 knees at a mean of 22.5 ± 2.1 years postoperatively. If a patient lacked normal extension or flexion at discharge, the odds of lacking normal extension or flexion at follow-up were 19.7 and 7.97, respectively ( P < .001). Radiographic ratings were normal for 35.2%, nearly normal for 36.2%, abnormal for 20.1%, and severely abnormal for 8.5%. Multivariate analysis showed that the predictive factors for the presence of OA in the long-term were medial meniscectomy, older age at surgery, and less than normal knee extension at discharge. The odds ratios for statistically significant factors for the presence of any OA at follow-up were 2.02 for knee extension loss at discharge, 2.98 for medial meniscectomy, 1.65 for lateral meniscectomy, 1.06 for age at follow-up, 1.62 for chronic injury type, and 2.17 for articular cartilage damage. The IKDC and CKRS subjective scores were progressively and statistically significantly lower as the level of OA was greater. CONCLUSION: The prevalence rate of developing moderate to severe OA at >20 years after ACL reconstruction was 28.6%. Significant factors predictive of OA in the long-term were older age at surgery, medial meniscectomy, and knee extension loss.

Optimal management of posterior cruciate ligament injuries: current perspectives.

BACKGROUND: The optimal management of posterior cruciate ligament (PCL) injuries is debated by orthopedic surgeons. A natural history study (NHS) of acute, isolated PCL tears in patients with a mean follow-up of 14.3 years was previously published. The purpose of this study was to compare and contrast the results of the NHS study with those of other studies with similar follow-up time after operative and nonoperative management of isolated PCL tears. MATERIAL AND METHODS: With reviewing the literature, six operative management and six nonoperative management studies were found for treating isolated PCL injuries. We analyzed the subjective and objective outcomes of these 12 studies and compared them to the results of the NHS to determine optimal management of PCL injuries. RESULTS: Final follow-up times ranged from a mean of 6.2 to 15 years in the nonoperative studies and 6.3 to 12 years in the operative studies. Side-to-side differences in laxity following surgical management ranged from 1.1 to 7 mm on KT-1000 arthrometer testing and 2.8 to 4.7 mm on Telos stress testing. Tegner scores at final follow-up ranged from 6.6 to 7.7 in nonoperative studies and 5.7 to 7.4 in operative studies. International Knee Documentation Committee scores were 73.4, 82.7, and 84 in nonoperative studies and 65 and 87 in the operative studies. Lysholm scores were 85.2 in the nonoperative study and ranged from 81 to 92.1 in operative studies. Osteoarthritis was reported with ranges from 17% to 88% in nonoperative studies and 13.3% to 63.6% in operative studies. CONCLUSION: We found that the subjective and objective results in the NHS compare favorably to those of outcomes for PCL reconstruction. Unless a technique is found that can completely restore knee stability, it is unlikely that simply reducing posterior laxity will improve outcomes or prevent the development of osteoarthritis.

Recalcitrant patellar tendinosis in elite athletes: surgical treatment in conjunction with aggressive postoperative rehabilitation.

BACKGROUND: Recalcitrant patellar tendinosis is difficult to treat, and results are varied. HYPOTHESIS: Surgical removal of necrotic tissue, surgical stimulation of remaining tendon, and aggressive and specific rehabilitation after patellar tendonectomy will allow athletes to return to sports. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From December 1996 to July 2002, 16 high-level athletes (4 professional, 2 Olympic, 9 collegiate, 1 preparatory), aged 16 to 25 years (mean, 19.7 years), with 22 symptomatic patellar tendons had failed nonoperative care of their patellar tendinosis symptoms and were unable to compete effectively in their sports. Magnetic resonance imaging showed confirmation of disease, with typical findings being necrosis in the posterior half of an abnormally thick patellar tendon, often in conjunction with partial tearing of the posterior half with a compensatory enlargement of the anterior half. Each patient then underwent tendonectomy of the necrotic portion in conjunction with stimulation of the remaining tendon by making multiple longitudinal cuts in the tendon. Patients participated in a postoperative rehabilitation protocol that included immediate range of motion, full flexion, and immediate high-repetition, low-resistance quadriceps muscle exercise. RESULTS: Subjective improvement was noted in all athletes. Return to the same sport at prior level of intensity was accomplished by 14 of 16 patients (87.5%) at a mean of 8.1 months (range, 3-12 months). CONCLUSION: Overall, tendonectomy, surgical tendon stimulation, and aggressive postoperative rehabilitation were found to be a safe, effective way to return high-level athletes to their sports.

The Degree of Knee Extension Does Not Affect Postoperative Stability or Subsequent Graft Tear Rate After Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft.

BACKGROUND: There is concern that high degrees of hyperextension may lead to an increase in graft laxity or graft failure after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: Patients with a high degree of hyperextension will have a higher rate of graft tear/failure and lower subjective scores after surgery compared with patients with less knee extension. STUDY DESIGN: Cohort study, Level of evidence, 2. METHODS: Of 2329 patients who underwent ACL reconstruction with patellar tendon autograft between 1998 and 2008, there were 625 patients who met the inclusion criteria of having primary ACL surgery, no bilateral ACL injuries, no existing osteoarthritis, and having either ≥6° of knee hyperextension before and after surgery (group A: n = 318; mean hyperextension, 8° ± 2° [range, 6°-15°]) or ≤3° of knee hyperextension before and after surgery (group B: n = 307; mean hyperextension, 0° ± 3° [range, 3° hyperextension to -4° short of 0° neutral]). KT-1000 arthrometer manual maximum difference between knees, range of motion measurements, and subjective follow-up with International Knee Documentation Committee (IKDC) and Cincinnati Knee Ratings Scale (CKRS) surveys were used to evaluate results. Subsequent graft tear related to specific injury within 5 years of surgery was recorded. Graft failure was defined as a KT-1000 manual maximum difference of >5 mm. RESULTS: Follow-up was obtained from 278 (87%) in group A and 275 (90%) in group B at a mean of 4.1 ± 1.1 years after surgery. The KT-1000 arthrometer manual maximum difference between knees was 2.0 ± 1.4 in group A and 2.1 ± 1.6 in group B (P = .701). Subsequent ACL graft tear/failure occurred in 22 patients (6.9%) in group A and 30 patients (9.8%) in group B (P = .246). Further subanalysis showed that the graft tear/failure rate was 6 of 81 (7.4%) for patients with ≥10° of hyperextension versus 16 of 237 (6.8%) for patients with 6° to 9° of hyperextension. There was no difference in IKDC or CKRS scores between groups after surgery (P = .933 and .155, respectively). CONCLUSION: Obtaining full hyperextension that is anatomically normal for most patients does not affect objective stability, ACL graft tear/failure rates, or subjective scores after ACL reconstruction with patellar tendon autograft.

Anterior cruciate ligament reconstruction with contralateral autogenous patellar tendon graft: evaluation of donor site strength and subjective results.

BACKGROUND: Few surgeons use a contralateral patellar tendon autograft for primary anterior cruciate ligament (ACL) reconstruction because of concern for donor site morbidity. HYPOTHESIS: There will be no difference in quadriceps muscle strength or International Knee Documentation Committee (IKDC) subjective scores in patients with contralateral grafts compared with patients with ipsilateral grafts. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between 2007 and 2009, a total of 279 patients who underwent primary ACL reconstruction with autogenous patellar tendon graft from the contralateral knee met the inclusion criteria of unilateral knee involvement, no arthritic changes preoperatively, and minimum 2-year follow-up objective and subjective evaluations. A control group was obtained of 58 patients who had the same inclusion criteria and were of the same age but who underwent surgery with ipsilateral graft. Patients underwent a goal-directed and sequential postoperative rehabilitation program that first emphasized controlling a hemarthrosis and obtaining full knee range of motion immediately after surgery, followed by increasing leg strength and performing functional activities. The rehabilitation for the contralateral donor site emphasized high-repetition/low-resistance exercises beginning the day after surgery. The IKDC subjective data were compared between surgery groups. Quadriceps muscle strength was evaluated in both knees compared with the preoperative values obtained in the noninvolved knee and between knees at 2 years postoperatively. RESULTS: Quadriceps muscle strength compared with the preoperative normal value (mean ± SD) was 105% ± 29% in the ipsilateral ACL-reconstructed knee versus 114% ± 28.4% in the contralateral donor knee (P < .01) and 116% ± 25% in the contralateral ACL-reconstructed knee (P = .0339). Mean side-to-side strength (ACL-reconstructed knee/opposite knee) was 98.4% ± 13.6% in the contralateral group versus 92.9% ± 13.0% in the ipsilateral group (P < .01). The mean total IKDC score was 92.4 ± 9.6 for the contralateral donor knee. The mean IKDC total score for the ACL-reconstructed knee was 88.8 ± 12.3 in the contralateral group and 88.9 ± 11.2 in the ipsilateral group (P = .626). CONCLUSION: After ACL reconstruction with contralateral patellar tendon graft, patients can achieve strength symmetry between legs after surgery without experiencing adverse subjective symptoms after graft harvest. Furthermore, strength return can be superior with a contralateral graft than with an ipsilateral graft.

Outcome of untreated traumatic articular cartilage defects of the knee: a natural history study.

BACKGROUND: Articular cartilage damage has been reported in 23% of knees with an acute anterior cruciate ligament (ACL) injury and 54% of those with chronic ACL laxity. Because the purpose of surgery is to reconstruct the ACL, the chondral lesion is usually an incidental finding. It is not known if any of the numerous treatments that have been recommended for chondral defects alters the natural history of the untreated lesion. We sought to determine what effect, if any, an isolated articular cartilage defect observed at the time of ACL reconstruction would have on the radiographic, subjective, and objective results after surgery if no intervention was performed on the cartilage lesion itself. METHODS: From 1987 to 1999, 2770 ACL reconstructions were performed, and 125 of them were done in patients who had an articular cartilage defect of Outerbridge grade 3 or 4 but had both menisci intact. The mean defect size was 1.7 cm (2) (range, 0.5 to 6.5 cm (2) ). Postoperative rehabilitation was not altered because of the chondral defect, and patients were allowed full weight-bearing and the full range of motion of which they were capable. A control group of patients matched on the basis of sex and age at surgery was identified from the database. No patient in the control group had a chondral defect or meniscal tear. Patients were evaluated at one, two, and five years after surgery and every five years thereafter with use of the IKDC (International Knee Documentation Committee) criteria, modified Noyes subjective questionnaire, and radiographs. RESULTS: Subjective follow-up was carried out more than two years after surgery (mean time, 8.7 years after surgery) for 101 patients. The results of objective evaluation were available for fifty-two patients, at a mean of 6.3 years. The patients in the control group had significantly higher subjective scores than did the patients with a defect in the medial compartment (mean, 95.2 points versus 94.0 points; p = 0.0451) and those with a defect in the lateral compartment (mean, 95.9 points versus 92.8 points; p = 0.0047). There was no significant correlation between larger defect size and lower subjective scores (p = 0.2543). The distribution of IKDC radiographic ratings was not significantly different between the groups. At least 79% of the patients in both groups returned to jumping, twisting, and pivoting sports at least at the recreational level. CONCLUSIONS: While statistical analysis revealed a difference in subjective scores between the defect and control groups, an average of 93 points for the patients with a lateral defect and 94 points for those with a medial defect indicates that most patients have very few symptoms. This study provides a baseline of information that can be used to compare the results of procedures designed to treat articular cartilage defects.

Results of transphyseal anterior cruciate ligament reconstruction using patellar tendon autograft in tanner stage 3 or 4 adolescents with clearly open growth plates.

BACKGROUND: Drilling across the physes for intra-articular anterior cruciate ligament reconstruction is considered risky for skeletally immature patients. HYPOTHESIS: Skeletally immature patients with clearly open growth plates can safely undergo intra-articular anterior cruciate ligament reconstruction with patellar tendon autograft without suffering growth plate disturbance. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Surgery involved drilling tunnels through the tibial and femoral physes, the bone plugs were placed proximal to the physes, and button fixation was placed on the cortex. Of 272 skeletally immature patients, 16 had clearly open growth plates. Tanner stage of physical development was evaluated. Follow-up evaluation included objective and subjective data. RESULTS: At the time of surgery, 7 patients were Tanner stage 3 and 9 were Tanner stage 4. Clinical follow-up (mean, 3.4 years after surgery) showed that the mean growth after surgery was 11.7 +/- 4.2 cm for boys and 6.6 +/- 2.3 cm for girls. No patients had growth plate disturbances, gross leg deformities, or gross leg-length discrepancies. Subjective results (mean, 5.6 years after surgery) showed a mean total score of 97.6 +/- 2.9 for the modified Noyes survey and 95.4 +/- 6.9 for the International Knee Documentation Committee survey. All patients returned to competitive sports after surgery. CONCLUSION: In 16 skeletally immature patients with clearly open growth plates who were Tanner stage 3 or 4, an intra-articular anterior cruciate ligament reconstruction was performed using a patellar tendon autograft with no gross growth disturbance; however, the surgical technique was meticulous for placing the bone plugs proximal to the physes, and the graft was not overtensioned.

Return to Sports and Subsequent Injury Rates After Revision Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft.

BACKGROUND: The return-to-sport and reinjury rates are not well defined after revision anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: School-age athletes would have a higher rate of return to sports and reinjury to either knee after revision ACL surgery compared with college or recreational athletes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients were prospectively studied after revision ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft. Participants were grouped by competitive sport levels of school age (mean age, 16.6 ± 0.9 years; n = 84), college (19.6 ± 1.2 years; n = 58), or recreational adult (27.6 ± 4.1 years; n = 117). An activity survey was used to determine the specific sport and sport level patients participated in before and after surgery. The International Knee Documentation Committee (IKDC) knee survey and Cincinnati Knee Rating System (CKRS) survey responses were also obtained. RESULTS: The rate of return to the same sport at the same level was 62 of 84 school-age athletes (74%), 43 of 58 college athletes (74%), and 73 of 117 recreational athletes (62%) (P = .1065). The number of patients who had a subsequent ACL graft tear rate after revision surgery was 2 of 84 (2.3%) in the high school group, 3 of 58 (5.1%) in the college group, and 4 of 117 (3.4%) in the recreational group (P = .6706). The number of patients who had a subsequent ACL tear in the contralateral knee was 1 of 84 (1.1%) in the school-age group, 1 of 58 (1.7%) in the college group, and 2 of 117 (1.7%) in the recreational group (P = .9501). At 2 years postoperatively, the mean IKDC subjective total score was 86.1 ± 11.7 points and the mean CKRS total score was 89.7 ± 11.1 points. CONCLUSION: Revision ACL reconstruction with BPTB autograft and perioperative rehabilitation allowed high school and college athletes to return to sports at the preinjury level at a rate of 74%; the return rate for recreational-level adults was 62%. Reinjury rates in the first 5 years after revision surgery ranged from 2% to 5%, which is lower than what has been reported for young competitive athletes after primary surgery.

Minimum 10-year follow-up of patients after an acute, isolated posterior cruciate ligament injury treated nonoperatively.

BACKGROUND: Few studies report long-term subjective or objective results for acute, isolated posterior cruciate ligament (PCL) injuries in patients followed prospectively. HYPOTHESIS: Subjective or objective results will not differ based on PCL laxity. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Sixty-eight patients with an acute, isolated PCL injury were treated nonoperatively and followed prospectively with yearly subjective surveys and periodic objective evaluations. Physical examination included evaluation of range of motion, effusion, and quadriceps strength; radiographic grading of osteoarthritis; and measurements of joint space width. Subjective follow-up included the International Knee Documentation Committee (IKDC) and modified Cincinnati Knee Rating System (CKRS) surveys. RESULTS: A total of 44 patients were available for both objective and subjective evaluations at a mean of 14.3 years (range, 10-21 years) after injury. All 68 patients underwent subjective follow-up at a mean of 17.6 years after injury. The mean quadriceps muscle strength was 97% of the noninvolved leg; all patients maintained normal knee range of motion. The overall grade of radiographs was rated as normal in 26 patients (59%), nearly normal in 13 patients (30%), abnormal in 4 patients (9%), and severely abnormal in 1 patient (2%). The grade of osteoarthritis on radiographs was not different in any knee compartment based on PCL laxity grade. Five patients (11%) had medial joint space narrowing greater than 2 mm. Mean IKDC and modified CKRS subjective scores at a mean of 17 years after injury were 73.4 ± 21.7 and 81.3 ± 17.4, respectively; there was no difference in subjective scores between PCL laxity grades. There was no difference in subjective scores between patients who completed a minimum 10-year objective follow-up and patients who completed surveys only. CONCLUSION: Long-term results after an isolated PCL injury show that patients remain active, have good strength and full knee range of motion, and report good subjective scores. The prevalence of moderate to severe osteoarthritis was 11%. Results were not different based on PCL laxity grade. This natural history study of nonoperatively treated PCL injuries can serve as a baseline for comparison with patients treated with PCL reconstruction.

Evaluation of Joint Space Width and Narrowing After Isolated Partial Medial Meniscectomy for Degenerative Medial Meniscus Tears.

BACKGROUND: Few studies have evaluated the effect of existing articular cartilage damage and sex on joint space measurements after isolated degenerative medial meniscus tears. PURPOSE: To determine what factors affected joint space width and narrowing in patients after removal of isolated degenerative medial meniscus tears. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 62 patients (15 women and 47 men) with all ligaments intact, no previous surgery to either knee, and an isolated degenerative medial meniscus tear removed in 1 knee were examined. The mean age at examination was 58.2 years at a mean follow-up of 9.4 years (range, 4-20 years). Subjective results were obtained with the International Knee Documentation Committee (IKDC) knee survey. Radiographs were taken using 45° weightbearing posteroanterior views. Midpoint and perceived minimum joint space width of the medial and lateral compartments of both knees were measured to the nearest 0.1 mm by 2 observers at different times, and they were blinded as to the previous measurements (Pearson intra- and interclass correlations, >0.93). Joint space narrowing was found by calculating the difference in joint space width between knees. Percentage of normal joint space loss was calculated by dividing joint space narrowing by the joint space width in the contralateral knee. Other factors considered were patient sex and Outerbridge grading of articular cartilage. RESULTS: Women had a mean 1.5 mm less normal joint space width than men in the involved and noninvolved knees (P < .01). Mean joint space narrowing was 0.7 mm for both measurements. The mean ± standard deviation narrowing was 0.4 ± 1.2 mm for patients with grade 0-2 damage and 1.1 ± 1.3 for patients with grade 3-4 damage (P = .04). Five women (33%) and 3 men (6%) had narrowing of >50% of the normal joint space as measured in the noninjured knee (P = .016). The mean IKDC total score was 66.1 points for women, which was statistically significantly lower than the mean of 82.7 points for men (P < .01). CONCLUSION: Patients undergoing partial medial meniscectomy have greater joint space narrowing and lower subjective scores after surgery if they also have existing Outerbridge grade 3-4 damage. Women have less normal joint space than men, and more women than men experience >50% joint space narrowing after surgery.

Meniscus tears that can be left in situ, with or without trephination or synovial abrasion to stimulate healing.

To determine which meniscus tears to leave in situ, the clinician must know whether the meniscus tear is degenerative or nondegenerative, stable or unstable, in an anterior cruciate ligament (ACL)-stable or ACL-unstable knee, and whether it is in the medial or lateral compartment. Symptomatic medial meniscus tears in ACL-intact knees are almost always degenerative in nature and should be removed. Generally, the only type of medial meniscus that can be left in situ is a peripheral, vertical, nondegenerative tear, but these tears are not displaceable, are asymptomatic, and are usually seen in a patient with an ACL tear. In the lateral compartment, most tears can be left in situ and the only tears that need to be repaired are displaceable tears that extend anterior to the popliteus tendon. Although many meniscus repair techniques and fixation devices are available, all factors related to healing and stability should be considered to determine treatment.

Osteoarthritis after anterior cruciate ligament reconstruction: the importance of regaining and maintaining full range of motion.

CONTEXT: Several factors have been associated with the development of osteoarthritis after anterior cruciate ligament (ACL) reconstruction, yet little attention has been given to the association between range of motion (ROM) and osteoarthritis after ACL reconstruction. Several studies have shown a link between ROM loss and a higher incidence of osteoarthritis. EVIDENCE ACQUISITION: A search was performed with PubMed (MEDLINE) for English-language level I-IV studies involving the long-term evaluation of ROM and osteoarthritis after ACL reconstruction. Keywords were osteoarthritis, anterior cruciate ligament, and range of motion. RESULTS: SIX STUDIES CONSIDERED WHETHER ROM WAS A FACTOR IN ASSOCIATION WITH OSTEOARTHRITIS AFTER ACL RECONSTRUCTION: In 3 of these studies, an association was found between loss of knee motion and the development of osteoarthritis, while the other 3 studies failed to identify a significant association. Two studies identified an association between ROM loss and decreased subjective outcomes after ACL reconstruction. CONCLUSIONS: Previous studies have shown an association between loss of knee ROM and osteoarthritic changes on radiographs in the long term after ACL reconstruction. Loss of ROM and osteoarthritis are also associated with lower subjective scores. Other factors related to osteoarthritis, such as meniscal and articular cartilage status, cannot be modified, but through implementation of a directed rehabilitation program before and after ACL surgery, the achievement of full symmetric ROM can be promoted. More emphasis needs to be placed on careful and precise examination of knee ROM, as well as rehabilitation to achieve and maintain full symmetric ROM in the long term after ACL reconstruction.