Editorial Commentary: Meniscus Tears Seen at the Time of Anterior Cruciate Ligament Reconstruction Are Overtreated.

Meniscus tears seen at the time of anterior cruciate ligament reconstruction are usually asymptomatic, and treatment varies greatly between surgeons, with meniscus repair being used for tears that could be left in situ. Recent outcome studies of most types of lateral meniscus tears show that leaving the tears in situ can give equal or superior results. Meniscus repair being performed for degenerative medial meniscus tears does not give better results than removing the tears. As an alternative to repair, trephination through the meniscus into the peripheral capsule can create many bloody channels to promote healing. Long-term follow-up of meniscus treatment with anterior cruciate ligament reconstruction can help us understand outcomes and prevent us from overtreating tears.

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.

Nonoperative management of a partial patellar tendon rupture after bone-patellar tendon-bone graft harvest for ACL reconstruction.

This is a case report of a young athlete who sustained a partial tear of the patellar tendon after anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone (BPTB) autograft. The injury, diagnostic workup, and decision-making process that lead to the choice of nonsurgical treatment are described. Furthermore, the rehabilitation process is described in detail. The patient returned to his previous level of sports activity and had a good clinical outcome as measured by range of motion, isokinetic quadriceps muscle strength testing, single leg hop testing, and the modified Noyes survey. In the absence of extensor mechanism incompetence or radiographic evidence of significant patella alta, partial ruptures of the patella tendon after ACL reconstruction using a BPTB autograft may be treated nonoperatively.

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.

Outcomes after arthroscopic excision of the bony prominence in the treatment of tibial spine avulsion fractures.

PURPOSE: The purpose of this study was to determine the outcomes after arthroscopic excision of the bony prominence after a tibial spine avulsion fracture. METHODS: This study included 7 subjects (5 female and 2 male subjects; mean age, 21.4 years). All subjects underwent preoperative rehabilitation focused on range of motion (ROM) and swelling control. Postoperative rehabilitation focused on regaining symmetric knee hyperextension and flexion. Objective examinations and subjective surveys were obtained at least 1 year after surgery. RESULTS: All subjects achieved normal knee extension; 6 patients achieved normal knee flexion, whereas 1 patient had nearly normal flexion. Physical examination showed a negative Lachman test with a firm end point in all patients, and the mean side-to-side difference for the KT-1000 manual maximum test (MEDmetric, San Diego, CA) was 1.3 mm. No subjects required subsequent anterior cruciate ligament reconstruction. All subjects returned to their previous level of activity without instability symptoms. At a mean of 5.7 years after surgery, the mean International Knee Documentation Committee subjective survey score was 90.6 points overall, with 4.7 out of 5 possible points for the instability question. At latest follow-up, the mean ROM was from 6° of hyperextension to 147° of flexion in the involved knee, compared with 6° of hyperextension to 148° of flexion for the noninvolved knee. CONCLUSIONS: The results of arthroscopic excision of the bony fragment after type II, III, or III+ tibial spine avulsion fracture are positive, with good stability, symmetric ROM, and high subjective scores. Most importantly, this procedure allows patients to regain full, symmetric hyperextension of the knee, avoiding the complications associated with extension loss. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

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.

Correlation of joint line tenderness and meniscus pathology in patients with subacute and chronic anterior cruciate ligament injuries.

We evaluated joint line tenderness (JLT) as a test for meniscus pathology in 3531 patients who underwent anterior cruciate ligament (ACL) reconstruction >30 days postinjury. If the patient had no additional giving-way episode after the index ACL injury, the injury was considered subacute; otherwise, it was considered chronic. Immediately before surgery, the presence or absence of medial or lateral JLT was evaluated. During ACL reconstruction, the presence or absence of meniscal tears was documented. In the subacute population, JLT was 41% sensitive, 56% specific, and 50% accurate for detecting medial meniscal tears and 57% sensitive, 44% specific, and 49% accurate for detecting lateral meniscal tears. In the chronic population, JLT was 55% sensitive, 50% specific, and 52% accurate for detecting medial meniscal tears and 46% sensitive, 52% specific, and 50% accurate for detecting lateral meniscal tears. The presence of JLT alone should not be used in the clinical decision making process to guide treatment.

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.

Joint space narrowing after partial medial meniscectomy in the anterior cruciate ligament-intact knee.

Osteoarthritis of the knee is common after total medial meniscectomy. In anterior cruciate ligament-intact knees, the reported outcomes of partial medial meniscectomy are variable. Radiographic assessment using a posteroanterior weight-bearing view is a reliable tool for detecting minor medial joint space narrowing, which may be an early sign of osteoarthritis. Studies that assessed the effect of partial medial meniscectomy found a low percentage of patients with >50% joint narrowing at 10 to 15 years after surgery. Digital radiography, using a posteroanterior weight-bearing view, is a highly sensitive method for observing minor joint space narrowing in the involved knee. A recent study showed that 88% of patients who underwent partial medial meniscectomy had joint space narrowing of <2 mm, and none had narrowing >or=2 mm, at a mean follow-up of 12 years. Subjective results after partial medial meniscectomy are favorable, with 88% to 95% of patients reporting good to excellent results.

Isolated anterior cruciate ligament reconstruction in the chronic ACL-deficient knee with degenerative medial arthrosis.

Isolated anterior cruciate ligament (ACL) reconstruction may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention. Fifty-three patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction alone. Subjective evaluation at mean 10 years postoperatively indicated statistically significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation, performed for 33 patients at a mean of 5.5 years postoperatively, indicated 25 normal or nearly normal International Knee Documentation Committee ratings; 2 patients have undergone subsequent osteotomy or total knee arthroplasty. Isolated ACL reconstruction provides long-term symptomatic pain relief, increased activity, and improved function. Anterior cruciate ligament reconstruction can effectively provide stability to the ACL-deficient knee with degenerative medial arthrosis without compromising range of motion or strength. Obtaining and maintaining full range of motion equal to the normal knee is important for the optimal result.

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.

Digital radiographic evaluation of medial joint space narrowing after partial meniscectomy of bucket-handle medial meniscus tears in anterior cruciate ligament-intact knees.

BACKGROUND: Few studies exist that evaluate the effect of partial medial meniscectomy in knees with intact anterior cruciate ligaments. HYPOTHESIS: Partial meniscectomy of bucket-handle medial meniscus tears will cause joint space narrowing. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 1982 and 2001, 135 patients met the study criteria of a partial medial meniscectomy, intact ligaments, no surgery to the contralateral knee, and no chondromalacia greater than grade II. Seventy-nine patients living within 150 miles of the clinic were asked to return for physical examination. Joint space narrowing was measured from the middle of the femoral condyle to the middle of the tibial plateau using digitally magnified weightbearing 45 degrees flexed posteroanterior and full-extension anteroposterior radiographs. Measurements were performed twice with the observer blinded to the previous measurements. Subjective follow-up was obtained prospectively on an annual basis with International Knee Documentation Committee and modified Noyes knee questionnaires. RESULTS: Forty-nine patients were examined at a mean of 11.8 years postoperatively. Mean medial joint space narrowing was 1.2 +/- 0.5 mm on 45 degrees flexed posteroanterior radiograph and 0.2 +/- 0.9 mm on full-extension anteroposterior radiographs (P < .001). Four patients had 2 mm or more of joint space narrowing. Subjective surveys obtained from 95 patients showed a mean subjective score of 89.9 points. Subjective scores did not decrease through time, and there was no correlation of joint space narrowing to lower subjective scores. CONCLUSION: Partial medial meniscectomy in stable knees causes only mild joint space narrowing (mean, 1.2 mm) at a mean 12-year follow-up. Digitally magnified 45 degrees flexed posteroanterior radiographs are more likely to demonstrate joint space narrowing than are full-extension anteroposterior radiographs.

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.

Responsiveness of the International Knee Documentation Committee Subjective Knee Form.

BACKGROUND AND PURPOSE: The International Knee Documentation Committee Subjective Knee Form was developed to measure change in symptoms, function, and sports activity in patients treated for a variety of knee conditions. Although previous research has demonstrated reliability and validity of the form, its responsiveness has not been evaluated. The purpose of this study was to determine responsiveness of the International Knee Documentation Committee Subjective Knee Form. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 1. METHODS: Patients who participated in the original validation study for the International Knee Documentation Committee Subjective Knee Form completed the form and a 7-level global rating of change scale that ranged from greatly worse to greatly better after a mean of 1.6 years (range, 0.5-2.3 years). Analyses included calculation of the standardized response mean and mean change in International Knee Documentation Committee Subjective Knee Form score compared to the patient's perception of change on the global rating of change scale. In addition, a receiver operating characteristic curve was plotted to determine the change in score that best distinguished patients who improved from those who did not. RESULTS: The overall standardized response mean was 0.94, which is considered large. With the exception of those who were slightly worse or unchanged, the mean change in the International Knee Documentation Committee Subjective Knee Form score compared to the patients' perceived global ratings of change was as expected (greatly worse, -15.1; somewhat worse, -8.4; slightly worse, 20.6; no change, 10.7; slightly better, 5.9; somewhat better, 18.1; greatly better, 38.7). The receiver operating characteristic curve analysis revealed that a change score of 11.5 points had the highest sensitivity, and a change score of 20.5 points had the highest specificity to distinguish between those who were or were not improved. CONCLUSION: The International Knee Documentation Committee Subjective Knee Form is a responsive measure of symptoms, function, and sports activity for patients with a variety of knee conditions.

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.