Anterior Cruciate Ligament Reconstruction Using Bone-Patella Tendon-Bone Autograft With Press-Fit Femoral Fixation: The Original Chambat Technique.

Patellar tendon grafts have long been considered the gold standard for anterior cruciate ligament reconstruction (ACLR). This Technical Note describes ACLR using bone-patella tendon-bone (BPTB) autograft with press-fit femoral fixation using an outside-in drilling technique.

Long-term Natural History of Unrepaired Stable Ramp Lesions: A Retrospective Analysis of 28 Patients With a Minimum Follow-up of 20 Years.

BACKGROUND: There is a lack of consensus about whether stable ramp lesions associated with anterior cruciate ligament (ACL) injuries need to be repaired. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate how many stable ramp lesions left in situ during ACL reconstruction (ACLR) have subsequently failed after >20 years of follow-up. We hypothesized that ACL-reconstructed knees with ramp lesions left in situ without repair have a high risk of meniscal failure over the long term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients who underwent arthroscopic ACLR by a single experienced surgeon between January 1998 and December 2000 were evaluated retrospectively. Included were all cases of longitudinal tears in the meniscocapsular junction or the red zone of the posterior horn of the medial meniscus that were left in situ and identified through the anterior portals. Successful anterior probing confirmed a meniscal tear of the posterior segment. A lesion was considered stable if it was ≤2 cm and did not extend beyond the lower pole of the femoral condyle. The following data were collected preoperatively and at the last follow-up: demographics, time to surgery, side-to-side laxity, pivot shift, Lysholm score, subjective International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, Tegner activity scale, and meniscal failure rate. We defined 2 groups based on our findings: medial meniscal failure versus no medial meniscal failure. RESULTS: A total of 716 knees underwent primary ACLR during this period. The 39 (5.4%) stable unrepaired ramp lesions identified were included in the case series. Mean ± standard deviation follow-up was 262.1 ± 10.5 months. Eleven patients (28%) were lost to follow-up. Of the remaining patients, 8 (28.6%) had a medial meniscal failure, of which 6 (21.4%) were bucket-handle tears. The average time elapsed before complications was 87.8 ± 52 months (range, 6-156 months). The medial meniscal survival rate was 93% at 5 years, 75% at 10 years, and 71% at 15 and 20 years. The failure event mainly happened between 96 and 120 months (8 and 10 years) after ACLR. No risk factors for failure were found, but some trends appeared, such as older age, higher body mass index, and preoperative rotational instability. All postoperative scores were significantly improved at the last follow-up (P < .0001); 16 patients (57%) returned to their sport of choice. CONCLUSION: With nearly one-third of patients developing meniscal complications, including a large share of bucket-handle tears and mostly occurring 8 years after the ACLR, it may not be wise to leave stable ramp lesions unrepaired.

Implant survival of 3rd-condyle and post-cam posterior-stabilised total knee arthroplasty are comparable at follow-up > 10 years: a systematic review.

PURPOSE: To summarise the literature on 3rd-condyle total knee arthroplasty (TKA) designs and compare their survival rates to those of post-cam TKA designs. The null hypothesis was that 3rd-condyle TKAs would have equivalent survival rates compared to contemporary post-cam TKAs. METHODS: An electronic literature search for Level I-V studies was independently conducted by two researchers using Medline® and Web of Science for studies published between January 1984 and October 2020 that specifically reported on rates of implant survival and complications, joint kinematics, clinical outcomes, and radiographic outcomes of 3rd-condyle TKA. The methodological quality of clinical studies was assessed according to the Downs and Black Quality Checklist for Health Care Intervention Studies, and for in vitro and in silico studies according to the Joanna Briggs Institute (JBI) tool for assessing analytical cross-sectional studies. Findings extracted for each TKA design were presented as reported and synthesised narratively. Survival rates at 5, 10 and > 10 years of 3rd-condyle TKA designs were graphically compared to rates of post-cam TKA designs published in joint registries. RESULTS: A total of 38 studies were identified that reported on kinematics, clinical outcomes, radiographic alignment, and rates of complications and survival. Mean survival rates ranged from 96 to 98% at 5 years, 78-100% at 5-10 years, and 86-99% at > 10 years for 3rd-condyle PS TKAs. Mean survival rates ranged from 93 to 98% at 5 years, 89-99% at 5-10 years, and 88-95% at > 10 years for post-cam PS TKAs. CONCLUSION: Implant survival rates of 3rd-condyle TKAs are comparable to those of post-cam TKAs at follow-up > 10 years. When compared to post-cam PS TKA, 3rd-condyle designs offer an alternative for younger and more active patients when considering the added benefits of a lowered point-of-contact and larger congruent contact area at the intercondylar tibial sulcus, that reduce risks of loosening and component wear. LEVEL OF EVIDENCE: V.

Validation of a Composite Test for Assessment of Readiness for Return to Sports After Anterior Cruciate Ligament Reconstruction: The K-STARTS Test.

BACKGROUND:: There is limited information on the appropriate timing of return to sports after anterior cruciate ligament (ACL) reconstruction. A composite test was developed to assess the athlete's ability to return to sports after ACL reconstruction: the Knee Santy Athletic Return To Sport (K-STARTS) test. HYPOTHESIS:: The K-STARTS test meets validation criteria for an outcome score assessing readiness for return to sports after ACL reconstruction. STUDY DESIGN:: Diagnostic study. LEVEL OF EVIDENCE:: Level 3. METHODS:: A prospective comparative study identified 410 participants: 371 participants who had undergone ACL reconstruction and a control group of 39 healthy participants. The K-STARTS score is calculated as the sum of 7 tests (8 components), for a maximal value of 21 points. Construct validity, internal consistency, discriminant validity, and sensitivity to change were used to validate this new test. RESULTS:: The K-STARTS assessment showed a high completion rate (100%), high reproducibility (intraclass correlation coefficient, 0.87; coefficient of variation, 7.8%), and high sensitivity to change. There was moderate correlation with the ACL Return to Sports after Injury scale (ACL-RSI) and hop tests. There were no ceiling or floor effects. There was a significant difference between K-STARTS scores assessed at 6 and 8 months postoperatively (11.2 ± 2.7 vs 17.1 ± 3.2; P < 0.001). The K-STARTS score in the control group was significantly higher than that in the ACL reconstruction group (17.3 ± 2.1 and 13.7 ± 3.8, respectively; P < 0.001). CONCLUSION:: The K-STARTS test is an objective outcome measure for functional improvement after ACL reconstruction. CLINICAL RELEVANCE:: It is important for the clinician to determine when return to sports is optimal after ACL reconstruction to reduce the current high risk of reinjury.

Extension deficit after ACL reconstruction: Is open posterior release a safe and efficient procedure?

BACKGROUND: Extension loss is a potentially devastating consequence of anterior cruciate ligament reconstruction (ACLR). It can often be treated by anterior arthroscopic release. In rare cases, a chronic flexion contracture requires an additional posterior open release. To our knowledge, no study analysing the results of both posteromedial and posterolateral approaches has been performed so far. The purposes of this study were (1) to analyse the midterm outcome and complications of a combined procedure, anterior arthroscopic debridement and posterior open capsulotomy - for the treatment of chronic extension deficits after ACLR and (2) to describe the surgical technique of posterior open release with both posteromedial and posterolateral approaches. MATERIAL AND METHODS: This is a retrospective clinical cohort study. Twelve patients presenting a chronic flexion contracture of 10° or more after ACLR treated by open posterior arthrolysis with an average follow-up time of 38months (range six to 90) were included. At last follow-up, they underwent both a clinical examination with range of motion analysis, International Knee Documentation Committee (IKDC) and KOOS scores. RESULTS: At follow-up, all patients except one (93%) achieved complete extension. Only one patient (7%) had a residual post-operative flexion deformity of five degrees. The range of motion (ROM) improved significantly after arthrolysis from 96°±14.3° (SD) to 14.3°±7°(SD)(p<0.001). No post-operative complications were recorded. No patients required further open debridement. The post-operative objective IKDC score was grade A for five patients, B for seven versus C for five patients and D for seven preoperatively. The mean post-operative subjective IKDC score was 86.4±9.7. The post-operative Knee injury and Osteoarthritis Outcome Score (KOOS) distribution was as follows: pain 93.8±5 (SD); symptoms 88±8.6 (SD); ADL 96.8±3.7 (SD); sports activities 83.6±12.3 (SD); and quality of life 82.9±8.8 (SD). Mean patients' satisfaction was 9.25±0.6 (SD) out of 10 after arthrolysis. CONCLUSIONS: Open posterior release with both posteromedial and posterolateral approaches is a safe and efficient additional procedure in case of persistent flexion contracture after ACLR with good ROM gain, functional scores and patients' satisfaction. LEVEL OF EVIDENCE: Therapeutic study - Level IV.

Return to Sport Among French Alpine Skiers After an Anterior Cruciate Ligament Rupture: Results From 1980 to 2013.

BACKGROUND: There is little known about return to sport and performance after anterior cruciate ligament (ACL) tear in high-level alpine skiers. PURPOSE: To analyze the parameters that influence the return to sport and performance after an ACL tear in French alpine skiers from 1980 to 2013. STUDY DESIGN: Descriptive epidemiology study. METHODS: The study population included 239 male and 238 female skiers who competed on the national French alpine ski team for at least 1 season between 1980 and 2013 in the speed (downhill and super-G) and technical disciplines (giant slalom and slalom). Two groups were formed: group 1 (G1) included athletes who had sustained an ACL rupture, and group 2 (G2) included athletes who had never sustained an ACL rupture. Three performance indicators were selected: International Ski Federation (FIS) points calculation, FIS ranking, and podium finishes in the World Cup, World Championships, and Olympic Games. RESULTS: The first-decile FIS points and international FIS ranking showed that G1 skiers obtained better performance than did G2 skiers. The mean ± SD career length of G1 skiers (men, 7.9 ± 4.7 years; women, 7.1 ± 4.1 years) was longer than that of G2 skiers (men, 4.5 ± 3.3 years; women, 4.2 ± 3.5 years). In addition, 12.8% (61 of 477) of the skiers achieved at least a podium finish during their careers: 23.0% (34 of 148) in G1 and 8.3% (27 of 329) in G2. The mean age at ACL rupture was 22.6 ± 4.1 years for men and 19.9 ± 3.5 years for women. In G1, 55 podiums were achieved before ACL rupture and 176 after in all competitions. Skiers who improved their performances after ACL rupture were significantly younger (men, 22.2 ± 3.0 years; women, 18.7 ± 2.2 years; P < .0001) at the time of injury than those showing a performance deterioration after ACL rupture (men, 25.3 ± 4.2 years; women, 22.4 ± 4.0 years). All skiers who had ACL tears continued their competitive careers after the injury. CONCLUSION: The overall results showed that it is possible to return to preinjury or even higher levels of performance after an ACL rupture and that age is the main element that guides postsurgical recovery.

Partial tearing of the anterior cruciate ligament: diagnosis and treatment.

Partial tears of the anterior cruciate ligament (ACL) are common and represent 10-27% of the total. The main reasons for attending to cases of non-torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction.

Lesões parciais do ligamento cruzado anterior (LCA) são comuns e representam 10­27% das totais. As principais razões para atenção ao feixe não rompido são biomecânicas, vasculares e proprioceptivas. A permanência do feixe serve ainda de proteção durante o processo cicatricial. A definição dessa lesão é controversa, baseada na anatomia, no exame clínico, na medida da translação, nos exames de imagem e na artroscopia. Seu tratamento vai depender da frouxidão e da instabilidade existentes. O tratamento conservador é opcional para casos sem instabilidade, com enfoque na reabilitação motora. O tratamento cirúrgico é desafiador, pois exige correto posicionamento dos túneis ósseos e conservação dos remanescentes do feixe rompido. O teste do pivot-shift sob anestesia, os achados à ressonância magnética, o nível e o tipo de atividade esportiva prévia e o aspecto artroscópico dos remanescentes e suas propriedades mecânicas auxiliarão o ortopedista no processo decisório entre o tratamento conservador, o tratamento cirúrgico com reforço do LCA nativo (reconstrução seletiva) ou a reconstrução clássica (anatômica).

Partial tearing of the anterior cruciate ligament: diagnosis and treatment / Lesão parcial do ligamento cruzado anterior: diagnóstico e tratamento

Partial tears of the anterior cruciate ligament (ACL) are common and represent 10-27% of the total. The main reasons for attending to cases of non-torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction...

Lesões parciais do ligamento cruzado anterior (LCA) são comuns e representam 10%-27% das totais. As principais razões para atenção ao feixe não rompido são biomecânicas, vasculares e proprioceptivas. A permanência do feixe serve ainda de proteção durante o processo cicatricial. A definição dessa lesão é controversa, baseada na anatomia, no exame clínico, na medida da translação, nos exames de imagem e na artroscopia. Seu tratamento vai depender da frouxidão e da instabilidade existentes. O tratamento conservador é opcional para casos sem instabilidade, com enfoque na reabilitação motora. O tratamento cirúrgico é desafiador, pois exige correto posicionamento dos túneis ósseos e conservação dos remanescentes do feixe rompido. O teste do pivot-shift sob anestesia, os achados à ressonância magnética, o nível e o tipo de atividade esportiva prévia e o aspecto artroscópico dos remanescentes e suas propriedades mecânicas auxiliarão o ortopedista no processo decisório entre o tratamento conservador, o tratamento cirúrgico com reforço do LCA nativo (reconstrução seletiva) ou a reconstrução clássica (anatômica)...

Clinical and radiographic results of arthroscopic partial lateral meniscectomies in stable knees with a minimum follow up of 20 years.

PURPOSE: The purpose of this retrospective multicentric study was to evaluate the long-term effects of lateral meniscectomy and to identify those patients who are at the most risk of developing osteoarthritis (OA). METHODS: Eighty-nine arthroscopic partial lateral meniscectomies in stable knees with a mean follow-up of 22 ± 3 years were included. The following influencing factors were analyzed: age, sex, body mass index (BMI), physical activity, alignment, the types of meniscal lesions, the extent of meniscal resections and the initially associated cartilage lesions. An independent examiner reviewed all patients, using subjective (KOOS and IKDC scores) and objective clinical and radiological evaluations (IKDC score). The contralateral knee was used as a reference to calculate the prevalence and the incidence of OA. RESULTS: The mean age at the time of surgery was 35 ± 13 years. The main location of the lesions was the mid-section of the lateral meniscus (79% of the cases). At the latest follow-up, 48% of the patients had an active lifestyle with as many as 48% of the patients enjoying moderate to intense physical activity 22 years after the procedure (vs. 71% before surgery). The KOOS score evolved from 82 to 69% during the same period. The prevalence of OA was 56% in the affected knee and the difference of prevalence between the operated and healthy knees was 44%. In those patients presenting with an OA of the operated knee and a normal contralateral knee, the incidence of OA was 53%. Predictors of OA were an age superior to 38 years at the time of surgery, obesity (BMI >30), and valgus malalignment as well as the presence of cartilage and degenerative meniscal lesions at the time of surgery. CONCLUSION: In the long term, arthroscopic partial lateral meniscectomy in stable knees without initial cartilage lesions might yield good to excellent results in young patients. Patients are at higher risk to develop symptomatic OA if they are over 40, having a high BMI, valgus malalignment and cartilage lesions at the time of surgery. This study provides precise guidelines for the surgical treatment of lateral meniscus tears. LEVEL OF EVIDENCE: IV.

Bilateral custom-fit total knee arthroplasty in a patient with poliomyelitis.

In limbs affected by poliomyelitis, total knee arthroplasty results in satisfactory pain relief. However, the risk of failure is high, especially if the preoperative quadriceps power is low. Therefore, treating osteoarthritis in the current patient represented a challenging procedure. A 66-year-old man presented with tricompartmental osteoarthritis of both knees, with valgus deformity of 14° on the left knee and 11° on the right knee. He walked with a bilateral knee recurvatum of 30° and a grade 1 quadriceps power. The authors treated both knees with cemented custom-fit hinged total knee arthroplasty with 30° of recurvatum in the tibial keel. Clinical scores showed good results 1 year postoperatively, especially on the subjective data of quality of life and function. At follow-up, radiographs showed good total knee arthroplasty positioning on the right side and a small mechanical loosening at the end of the tibial keel on the left side. Only 5 studies (Patterson and Insall; Moran; Giori and Lewallen; Jordan et al; and Tigani et al) have reported total knee arthroplasty results in patients with poliomyelitis. This study reports an original case of bilateral custom-fit hinged total knee arthroplasty in a patient with poliomyelitis. To the authors' knowledge, this is the first report of this type of procedure in the literature. The key point is the degree of recurvatum that is needed to allow walking, avoiding excessive constraints on the implants that can lead to early mechanical failure.

Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Physicians should consider an increased posterior tibial slope (PTS) as a risk factor for graft failure when proposing anterior cruciate ligament (ACL) re-revision. PURPOSE: To describe the surgical technique of combined ACL revision and proximal tibial anterior closing wedge osteotomy and to evaluate its clinical outcome in cases of recurrent graft failure with associated increased tibial slope. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2008 and 2010, 5 combined ACL re-revisions with proximal tibial anterior closing wedge osteotomy were retrospectively evaluated after a mean 31.6 months' follow-up (range, 23-45 months). All patients reported subjective knee instability preoperatively and demonstrated increased laxity on physical examination. Intrinsic risk factors for graft failure (excessive tibial slope) were identified in all cases. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale. RESULTS: The mean Lysholm score was 46.2 preoperatively (range, 26-69) and 87.8 (range, 60-100) postoperatively. The mean IKDC subjective score was 39.5 (range, 21.8-64.4) before surgery and 79.1 (range, 48.3-98.9) at the last follow-up. The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last follow-up. The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The mean differential anterior laxity was 10.4 mm (range, 8-14 mm), and this significantly decreased to 2.8 mm (range, 2-4 mm) at the last follow-up. Using the Kellgren-Lawrence classification to evaluate the presence of arthritis, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3. CONCLUSION: Combined ACL re-revision with proximal tibial anterior closing wedge osteotomy restores knee stability and function with satisfactory clinical outcomes in patients who experience recurrent ACL ruptures with an associated increased PTS.

Rapid chondrolysis of the knee after partial lateral meniscectomy in professional athletes.

BACKGROUND: Postoperative knee joint chondrolysis is a rare but serious complication. The aim of our study is to report the clinical presentation, the early, mid and long-term outcomes of rapid chondrolysis after a partial lateral meniscectomy in elite athletes. METHODS: Clinical records of 10 consecutive cases of rapid chondrolysis after partial lateral meniscectomy in eight professional athletes were retrospectively reviewed. There were seven males and one female with a mean age of 25.2 years (range 20-32 years) at index procedure. An initial conservative approach to its treatment was attempted in all cases. Arthroscopic lavage was advocated in two cases. Patients were clinically reviewed at last follow-up with comparative X-rays, a subjective IKDC, a Lysholm and Tegner scale. RESULTS: All patients resumed their pre-injury level of activity at a mean 8 (±2.45) months after the index procedure. At a mean of 82 (±36) months of follow-up, the mean subjective IKDC, Lyshom and Tegner scale were respectively 82.64 (±8.61), 86.6 (±6.44), 9 (±1.41). All knees demonstrated joint space narrowing scored Kellgren and Lawrence II (n=1) III (n=4) or IV (n=5) on conventional radiographs. CONCLUSION: By reviewing the common factors in each of these cases we believe that rapid chondrolysis occurs primarily due to the excessive loading of the articular cartilage in the lateral compartment of the knee. In this series, although the results in the medium term were good, the long-term outcome must be guarded due to the high rate of radiographic osteoarthritis of the lateral compartment seen in this population. STUDY DESIGN: Retrospective case series, Level IV.

The evolution of ACL reconstruction over the last fifty years.

Anterior cruciate ligament (ACL) reconstruction has evolved considerably over the past 30 years. This has largely been due to a better understanding of ACL anatomy and in particular a precise description of the femoral and tibial insertions of its two bundles. In the 1980s, the gold standard was anteromedial bundle reconstruction using the middle third of the patellar ligament. Insufficient control of rotational laxity led to the development of double bundle ACL reconstruction. This concept, combined with a growing interest in preservation of the ACL remnant, led in turn to selective reconstruction in partial tears, and more recently to biological reconstruction with ACL remnant conservation. Current ACL reconstruction techniques are not uniform, depending on precise analysis of the type of lesion and the aspect of the ACL remnant in the intercondylar notch.

Prevalence of septic arthritis after anterior cruciate ligament reconstruction among professional athletes.

BACKGROUND: Septic arthritis of the knee after anterior cruciate ligament (ACL) reconstruction is a rare complication. Its prevalence and characteristics have never been reported among professional athletes. PURPOSE: To report the prevalence and the characteristics of septic arthritis after ACL reconstruction in professional athletes and a general population of patients. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: A retrospective analysis of a consecutive series of 1957 patients who underwent an ACL reconstruction between 2003 and 2008 was performed; 88 patients were professional athletes. The patient demographics, the prevalence of infection, the involved organism, and the method of treatment were reviewed. Three potential risk factors for infection-level of sporting participation, indoor/outdoor sports, and the presence or not of a combined lateral tenodesis-were assessed using univariate and multivariate logistic regression analysis. RESULTS: The prevalence of septic arthritis was 0.37% in the nonprofessional group and 5.7% in the professional athlete population. Being a professional athlete (odds ratio [OR], 16.0; 95% confidence interval [CI], 3.9-59.8; P = .0001) or having a combined lateral tenodesis (OR, 4.8; 95% CI, 1.04-18.04; P = .02) was found to be significantly correlated with septic arthritis after ACL reconstruction. A significant correlation exists between being a professional athlete and having a combined lateral tenodesis (χ(2) = 16.7; P = 4 × 10(-5)), suggesting a potential confounding role is played by one of these variables. All the cases of infection in the professional athletes occurred in those who participated in outdoor sports, although this was not found to be statistically significant (P = .17). CONCLUSION: Participation in professional sports and having a combined lateral tenodesis are risk factors for the development of infection after ACL reconstruction. We hypothesize that professional athletes may be part of a specific group of patients at higher risk of infection after ACL reconstruction.

Activity level recovery after arthroscopic PCL reconstruction: a series of 21 patients with a mean follow-up of 29 months.

Surgical treatment of PCL tears is often indicated after conservative management failure and it is known to be challenging with unpredictable outcomes. This study aims to describe and to evaluate the outcome of an arthroscopic PCL anterolateral bundle reconstruction using a quadriceps tendon autograft. Our hypothesis is that knee stability and function can be restored using this technique allowing patients to resume their pre-injury level of activity. Between 2005 and 2008, 21 consecutive patients underwent an isolated PCL reconstruction and were evaluated after a mean follow-up of 29 months (range 12-48). The mean time from injury to surgery was 28 months. All patients were assessed pre- and post-operatively using IKDC evaluation, Tegner and Lysholm scores. The differential laxity was measured radiologically using the Telos® stress device. Pre-operatively, no patients were classified A or B on the IKDC objective score. At last follow-up, 81% of patients were classified A or B. The average differential anteroposterior laxity was 11.2 mm (range 8-15) in the preoperative evaluation and 3.6 mm (range 0-7) at the final follow-up (p=0.01). The mean subjective IKDC score was 39.5 before surgery and 74.5 at the last follow-up (p<0.01). The Tegner and Lysholm scores were significantly improved (p<0.001). 81% of patients were able to resume the same pre-injury level of activity. Patients with high level activity before injury were found to have the best subjective outcomes. Satisfactory laxity control and clinical outcomes were obtained in this series allowing patients to resume their pre-injury activities and sports.

Clinical and operative characteristics of cyclops syndrome after double-bundle anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to investigate the clinical and operative characteristics of cyclops lesion in a consecutive series of patients with anterior cruciate ligament (ACL) double-bundle reconstruction. METHODS: Included were 387 patients who underwent an ACL double-bundle reconstruction with quadriceps or hamstring tendons and were followed up at 6 weeks and 3, 6, and 12 months for clinical examination. When a persistent extension deficit was observed 3 months postoperatively, magnetic resonance imaging was performed to eventually diagnose a cyclops syndrome, and arthroscopic removal of the nodule was performed in these cases. The aspect of the nodule was explored before debridement. These patients were reviewed at a mean follow-up of 12 months (minimum, 6 months; maximum, 20 months) after nodule debridement for evaluation. RESULTS: There were 14 patients who had cyclops syndrome (3.61%); 10 cases (5.37%) occurred in the quadriceps tendon group and 4 cases (1.99%) in the hamstring tendon group. In the postoperative period these patients had a mean loss of extension of 6° (range, 5° to 15°), and 78.6% had pain and/or swelling. At the 6-week follow-up, 78.6% of the 14 patients had a significant quadriceps dysfunction associated with an active extension deficit. During arthroscopic debridement, the cyclops lesion was always located on the roof of the intercondylar notch. At the last follow-up, 12 patients had full range of motion, but an extension loss was still present in 2 patients. On the International Knee Documentation Committee objective evaluation, 78.5% of patients were graded A, 14.3% were graded B, and 7.2% were graded C. CONCLUSIONS: Cyclops syndrome after double-bundle ACL reconstruction was more frequently observed with quadriceps tendon graft than with hamstring graft. Its unique characteristic is that the nodule localization is from the roof of the intercondylar notch. The majority of the patients with cyclops syndrome presented with a significant quadriceps dysfunction and an active extension deficit in the immediate postoperative period. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Preoperative factors correlating with prolonged range of motion deficit after anterior cruciate ligament reconstruction.

BACKGROUND: Impaired postoperative range of motion remains one of the most frequent complications after anterior cruciate ligament reconstruction. PURPOSE: This study was undertaken to determine the preoperative factors associated with prolonged range of motion deficit after anterior cruciate ligament reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between January 2007 and March 2008, a consecutive series of 217 patients underwent anterior cruciate ligament reconstruction and were reviewed at 6 weeks and 3 months after surgery. In this series, all data of patients who required a further surgery for arthrolysis until December 2009 were studied. Goniometric range of motion measurement was performed the day before surgery and at 6 weeks and 3 months postoperatively. Bone contusions were analyzed on preoperative magnetic resonance imaging (MRI). All MRI scans were performed in the 6 months before surgery. Seven potential risk factors-age, sex, limited preoperative range of motion, meniscal lesions, bone contusion(s), operative delay less than 45 days, and rehabilitation-were assessed using univariate analysis. The correlations between the significant factors previously identified were analyzed further using multivariate logistic regression analysis. RESULTS: Limited preoperative range of motion (P < .001), typical bone contusions of the lateral compartment (P < .001), operative delay less than 45 days (P = .003), and female sex (P = .049) were found to be significantly correlated with delayed recovery. The limited preoperative mobility and the presence of typical contusions were strongly correlated (P < .001). In the group of patients who underwent surgery within 45 days, delayed recovery was strongly correlated with limited preoperative mobility (P = .0008) and to the presence of typical contusions (P < .001). Arthrolysis was correlated with delayed range of motion (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.9-50; P =.001) and bone bruise (OR, 7.6; 95% CI, 1.7-46.1; P = .002). CONCLUSION: Preoperative limited range of motion and typical bone bruises of the lateral femoral condyle and tibial plateau are major risk factors for a difficult rehabilitation after anterior cruciate ligament reconstruction.

Arthroscopic identification of isolated tear of the posterolateral bundle of the anterior cruciate ligament.

PURPOSE: The goal of this study was to arthroscopically identify and assess the progressive changes in isolated ruptures of the posterolateral bundle of the anterior cruciate ligament (ACL) over time. METHODS: This prospective study investigated 174 patients for isolated posterolateral bundle tears during arthroscopic ACL reconstruction. The preoperative side-to-side anterior laxity was measured in all patients. The torn ACLs were inspected and analyzed arthroscopically to determine the tear pattern. RESULTS: Complete ACL tears were identified in 78.7% of patients and partial ACL tears in 21.3%. Isolated anteromedial bundle tears were identified in 22 patients and posterolateral bundle tears in 15 patients. Statistical analysis showed a significant difference in preoperative differential knee laxity between the group with complete ACL rupture and the group with partial ACL rupture. On arthroscopic evaluation, the posterolateral bundle had retracted distally toward the tibial surface over time. The amount of retraction was correlated to the time period from injury to reconstruction. CONCLUSIONS: In this study the exact diagnosis of an ACL partial tear was made at arthroscopy in all cases. Our observations confirm the evolution of the ruptured posterolateral bundle, which shows a retraction toward the tibia over time. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria based on consecutive patients with a universally applied gold standard.

Arthroscopic identification of the anterior cruciate ligament posterolateral bundle: the figure-of-four position.

Anatomic double-bundle reconstruction in anterior cruciate ligament (ACL) tears has been developed during the last few years. Although anteromedial (AM) bundle reconstruction is routinely performed, finding the femoral attachment of the posterolateral (PL) bundle remains a problem. We describe how a classic arthroscopic position, the figure-of-4 position, allows the PL bundle to be easily recognized. During flexion, the femoral attachment of the PL bundle describes an arc around the AM femoral attachment. The femoral attachment of the AM bundle is the center of rotation of the ACL, which explains the isometric behavior of this bundle. After 45 degrees of flexion, the PL femoral attachment becomes anterior to the AM femoral attachment. The AM bundle is tight during flexion, whereas the PL bundle is under tension when the knee is extended and becomes lax with knee flexion. At 90 degrees of flexion, the PL bundle is difficult to identify because it is lax; only its femoral insertion lies anterior to the AM bundle close to the articular cartilage of the lateral condyle. The use of an additional tibial varus torque and internal rotation (i.e., the figure-of-4 position) tightens the PL bundle and enhances the visualization of its insertion, allowing for easy identification of this bundle.