The Risk of Growth Disturbance Is Low After Pediatric Anterior Cruciate Ligament Reconstruction With a Femoral Growth Plate Sparing Technique.

Purpose: To evaluate radiological tibial and femoral length and axis growth disturbances, as well as clinical outcome in skeletal immature anterior cruciate ligament reconstruction (ACLR) patients treated with a femoral growth plate-sparing ACLR technique. Methods: Skeletally immature patients who underwent operation between 2013 to 2019 with ALCR using the femoral growth plate-sparing technique were investigated with follow-up after growth plate closure. The inclusion criteria were isolated ACL rupture in patients with open physis in the distal femur and proximal tibia seen at plain radiography. The minimum follow-up time was 29 months. Patients were evaluated with full extremity radiographs measuring limb length discrepancy and coronal knee alignment compared to contralateral leg, as well as clinical evaluation with Rolimeter measurements and the Knee Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective knee form (IKDC), and Tegner Activity Scale scores. Results: Sixty-five patients were examined with radiography, and 52 patients were assessed with clinical examination. The mean follow-up time was 68 (range, 29-148) months. No limb-length discrepancy (-0.65 mm [confidence interval {CI}, -2.21 to 0.92]) or angular deformity at tibia (-0.25° [CI, -0.78° to 0.28°]) was found. There was a small but statistically significant different angular deformity at the distal femur compared to the contralateral leg (-1.51° [CI, -2.31 to -0.72]) at follow-up. The side-to-side difference in knee laxity at follow-up was 2.4 mm. At follow-up the KOOS Sport, KOOS Quality of Life (QoL), IKDC, and Tegner scores were 80, 75, 86, and 5, respectively. Sixty-seven percent of the patients met the Patient Acceptable Symptom State, and 52% reported results exceeding the KOOS Sport MCID Level and 69% the KOOS QoL level. Conclusions: Femoral physis-sparing ALCR is associated with a low risk of alignment and length disturbances. The technique provides otherwise good subjective clinical outcome and knee stability. Level of Evidence: Level IV, therapeutic case series.

Combined anterior cruciate ligament revision with reconstruction of the antero-lateral ligament does not improve outcome at 2-year follow-up compared to isolated acl revision; a randomized controlled trial.

PURPOSE: It is essential to obtain rotational stability of the knee after anterior cruciate ligament reconstruction (ACL-R) and it is suggested that a supplementary reconstruction of the antero-lateral ligament (ALL-R) may supports this. Theoretically, ALL-R may be particularly advantageous to support revision of failed ACL-Rs. It was hypothesized that ACL revision combined with ALL-R will result in superior outcome compared to isolated ACL revision. METHODS: The study was designed as a randomized controlled trial. Patients eligible for first time ACL revision were randomized to either isolated ACL revision (- ALL group) or ACL revision combined with a single-stranded allograft ALL-reconstruction (+ ALL group). Patient reported outcomes and function were evaluated at two-year follow-up by KNEES-ACL, KOOS, and Tegner activity scale. Objective knee laxity was evaluated at one-year follow-up using an instrumented Rolimeter test, the pivot shift test, and a manual Lachman test. RESULTS: A total of 103 patients were enrolled with 49 patients randomized to the + ALL group and 54 patients in the - ALL group. There were no differences at baseline between groups regarding age, gender, body mass index, preoperative patient reported outcome scores and concomitant meniscus or cartilage injury. The ACL revision was performed with an allograft in 10 patients (20%) in the + ALL group and 8 patients (15%) in the -ALL group. At follow-up there was no significant difference between the groups in patient reported outcome scores and clinical knee laxity. CONCLUSION: Supplementary ALL-R does not improve subjective outcome of first time ACL revision at two-years and clinical knee stability at one-year follow-up compared to isolated ACL revision. LEVEL OF EVIDENCE: Level I.

Similar outcomes after anterior cruciate ligament reconstruction in paediatric and adult populations: a 1-year follow-up of 506 paediatric operations in Denmark.

PURPOSE: To present 1-year results after all paediatric anterior cruciate ligament (ACL) reconstructions in Denmark (5.9 M inhabitants) for the 10½ year period, 1 July 2011 to 31 December 2021. METHODS: All children who had an ACL reconstruction were enrolled. They were asked to complete Pedi-IKDC preoperatively and at 1-year follow-up. Independent observers performed pivot shift test and instrumented laxity assessment preoperatively and at 1-year follow-up. RESULTS: The median age of the 506 children (47.2% girls) was 14.3 years (9.3-15.9). The Pedi-IKDC score increased from preoperatively 61.6 ± 15.8 (mean ± SD) to 85.9 ± 13.0 at 1-year follow-up (p < 0.0001). There were concomitant injuries (to meniscus and/or cartilage) in 49.9%, but these children had preoperative and follow-up Pedi-IKDC scores similar to the scores for children with isolated injury to ACL (n. s.). Instrumented anterior laxity was 4.3 ± 1.4 (mean ± SD) mm preoperatively and 1.4 ± 1.4 mm at follow-up (p < 0.0001). Preoperatively, 3% had no pivot shift whilst this was the case for 68% postoperatively (p < 0.0001). Twenty-five children (5.6%) had 4 mm instrumented laxity or more relative to the unoperated knee at follow-up. Two patients (0.4%) had an operatively treated deep infection, three (0.5%) were operated on for reduced range of motion and two (0.4%) had a revision ACL reconstruction. CONCLUSION: ACL reconstruction resulted in a clinically meaningful increase in Pedi-IKDC, an improved instrumented stability, a reduction in the grade of pivot shift and the complication rate was low at 1-year follow-up. The risk of graft insufficiency at 1-year follow-up was the same as in an adult population. LEVEL OF EVIDENCE: II.

The impact of a patient decision aid on treatment choices after anterior cruciate ligament injuries.

PURPOSE: The present study aimed to investigate whether exposure to a patient decision aid (PDA) had an impact on the proportion of patients selecting non-surgical or surgical treatments after anterior cruciate ligament (ACL) injuries and whether exposure to a PDA affected the proportion of patients switching from non-surgical to surgical treatment within the first year. METHODS: In a consecutive case series, proportions of surgery and non-surgery were compared before and after patients' exposure to a PDA. Data were collected from the health records of patients with ACL injuries who presented to the Clinic of Sports Traumatology. To identify proportional differences between the two groups, t-tests and proportion tests were used. RESULTS: In total, 1,053 patients with ACL injuries were included: 563 patients with no exposure to the PDA (January 2015 to January 2017) and 490 patients with exposure to the PDA (January 2017 to January 2019). Before implementing the PDA, 27% of the patients selected non-surgical treatment. After implementing the PDA, 30% choose non-surgical treatment (p > 0.05). Before implementing the PDA, 21% of patients who initially chose non-surgical treatment had surgery within the first year. After implementation of the PDA, this number fell to 16%, but the difference was not statistically significant (p > 0,05). CONCLUSION: Exposure to the PDA did not significantly alter the proportion of ACL injury patients selecting non-surgical or surgical treatments or the proportion of patients switching to surgery within the first year.

Pedi-IKDC exhibits questionable measurement properties in a cohort of pediatric patients with ACL rupture.

BACKGROUND: Pedi-IKDC is commonly used to evaluate anterior cruciate ligament (ACL) deficiency in children. However, its construct validity has not been thoroughly assessed. The aim was to examine the measurement properties of the Pediatric International Knee Documentation Committee (Pedi-IKDC) by modern test theory (MTT) models, confirmatory factor analysis (CFA), and item response theory (IRT). METHODS: The cohort consisted of all children and adolescents in Denmark (n = 535, age 9-16) treated with physeal-sparing ACL reconstruction 2011-2020. Patient-reported outcome measure (PROM) data were collected before surgery and at 1 year follow-up. Structural validity of Pedi-IKDC was assessed with MTT models. Reliability was reported as McDonalds coefficient omega. Responsiveness was evaluated with standardized response means. RESULTS: Sufficient PROM data were available for 372 patients. The original unidimensional construct did not fit CFA model expectations neither before surgery (χ2 = 462.0, df = 163, p < 0.0001; RMSEA: 0.109, CFI: 0.910, TFI: 0.895) nor at follow-up. Neither did a two-factor CFA model with "Symptoms" and "Sports activities" as individual subscales (χ2 = 455.6, df = 162, p < 0.0001) nor a bifactor model (χ2 = 338.9, df = 143, p < 0.0001), although fit indices improved with the latter (RMSEA: 0.094, CFI: 0.941, TFI: 0.922). The IRT models confirmed this pattern. The scale was responsive (SRM 1.66 (95% CI: 1.46-1.88)). Coefficient omega values were 0.866 before surgery and 0.919 at follow-up. CONCLUSIONS: The Pedi-IKDC exhibited inadequate structural validity. Neither the original construct, a two-factor model, nor bifactor models fitted data well. We advise that data obtained by Pedi-IKDC are interpreted with caution.

Development and Test of a Decision Aid for Shared Decision Making in Patients with Anterior Cruciate Ligament Injury.

Background. Patients with anterior crucial ligament injury are faced with a choice between surgery or nonsurgical treatment with intensive rehabilitation. Patients must be involved in the decision making to choose a treatment that meets their individual values, lifestyle, and conditions. The aim of the study was to describe, develop, and evaluate a patient decision aid to support shared decision making. Methods. The development of a patient decision aid was based on international criteria, current literature, and former patients' experiences and suggestions on how to optimize the decision-making process. The patient decision aid was evaluated by the SDM-Q9 questionnaire and semistructured interviews with patients and doctors. Results. On a scale from 0 to 5, patients experienced a high degree of shared decision making in their treatment decision both before (score 4.3) and after (score 4.3) implementation of the patient decision aid (P = .72). From interviews, patients expressed that they found the patient decision aid very useful. Reflection time was especially important for some patients. Doctors reported that the patient decision aid improved shared decision making by supporting the dialogue clarifying patients' values concerning issues important for treatment choices. Conclusion. A systematic process involving patients with an anterior crucial ligament injury was successfully used to develop a patient decision aid for treatment options. No statistically significant difference in the SDM-Q9 score was found presumably caused by the ceiling effect. However, patients experienced the decision aid as very useful when making treatment decisions, and doctors reported that it improved the dialogue clarifying patients' values important for the treatment options. The developing process and patient decision aid can be used as inspiration in similar situations to increase shared decision making in treatment choices. Highlights: A patient decision aid for anterior cruciate ligament injured patients was developed based on international criteria, the current literature, and patients' experiences and suggestions on how to optimize the decision-making process about surgical and nonsurgical treatment.The decision aid improved shared decision making by supporting the dialog between the patient and the doctor to clarify the patients' values concerning issues important for the treatment options.

Xenograft for anterior cruciate ligament reconstruction was associated with high graft processing infection.

PURPOSE: To evaluate clinical ad radiological outcomes of anterior cruciate ligament (ACL) reconstruction with an immunochemically modified porcine patellar tendon xenograft controlled against human Achilles tendon allograft at 24-month minimum follow-up. METHODS: 66 patients undergoing arthroscopic ACL reconstruction were randomized into 2 groups: 34 allografts and 32 xenografts treated to attenuate the host immune response. Follow-up was 24-month minimum. Anterior knee stability was measured as KT - 1000 side-to-side laxity difference (respect to the contralateral healthy knee). Functional performance was assessed by one-legged hop test. Objective manual pivot-shift test and subjective (IKDC, Tegner and SF-36) outcomes were collected. MRI and standard X-Ray were performed. RESULTS: 61 subjects (32 allograft, 29 xenograft) were evaluated at 12 and 24 months. Six of the subjects in xenograft group (20.6%) got an infection attributed to a water-based pathogen graft contamination in processing. Intention-to-treat analysis (using the last observation carried forward imputation method) revealed higher KT - 1000 laxity in xenograft group at 24-month follow-up (P = .042). Also pivot-shift was higher in xenograft group at 12-month (P = .015) and 24-month follow-up (P = .038). Per-protocol analysis (missing/contaminated subjects excluded) did not revealed clinical differences between groups. Tibial tunnel widening in the allograft group was low, whereas xenograft tunnel widening was within the expected range of 20-35% as reported in the literature. No immunological reactivity was associated to xenograft group. CONCLUSIONS: High infection rate (20.6%) was reported in xenograft group. Both groups of patients achieved comparable clinical outcomes if missing/contaminated subjects are excluded. Improved harvesting/processing treatments in future studies using xenografts for ACL reconstruction are needed to reduce infection rate, otherwise xenograft should not be used in ACL reconstruction. LEVEL OF EVIDENCE: Multicenter and double-blinded Randomized Controlled Clinical Trial, Level I.

Bone ingrowth into open architecture PEEK interference screw after ACL reconstruction.

PURPOSE: Open or fenestrated interference screw design that allow bone ingrowth is a concept for improved bone healing to softtissue graft and bone filling in bone tunnels after anterior cruciate ligament reconstruction (ACLR) The aim of the current study was to assess CT scanning evaluated bone ingrowth into an open architecture interference screws in the tibial tunnel of patients undergoing ACL with soft tissue grafts. It was hypothesized that open architecture interference screws would stimulate bone ingrowth into the screw cavities. METHODS: Twelve patients requiring ACLR were included. They underwent arthroscopic ACLR with semitendinosus-/gracilis tendon graft and an open architecture polyetheretherketone (PEEK) interference screw. The patients were scanned with a multi-slice CT scanner two weeks, six and twelve months postoperatively. On CT reconstruction slices bone ingrowth into the screw was measured. Subjective and objective clinical outcome international knee documentation committee score and instrumented knee laxity determination were collected. RESULTS: At six months no implants demonstrated more than 10% bone ingrowth. At twelve months 42% (5/12) implants had more than 10% bone ingrowth (p = 0.009). The average bone filling into the screws was 7.7%. There was no tunnel widening or cyst formation seen in relation to any of the implants. Subjective IKDC score improved significantly from 50.6 baseline to 80.1 at 24 month follow-up. Preoperative side-to-side knee laxity improved from 3.7 (2.1) to 1.4 (1.2) mm at twelve months. There were no serious adverse events in relation to the new open architecture thread PEEK interference screw during or after hamstring ACL reconstruction. CONCLUSION: The present study demonstrated that open architecture thread PEEK interference screw can stimulate bone ingrowth into the screws after soft tissue ACL reconstruction with at 12 months with an average bone filling into screws was 7.7%. Knee stability, functional, subjective and objective outcomes were similar to large volume ACL outcome studies. TRIAL REGISTRATION: The study was registered at ClinicalTrials # NCT02382341 . 12-09-2014. LEVEL OF EVIDENCE: IV.

Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomised controlled trial.

OBJECTIVE: We performed a randomised controlled trial (RCT) in patients undergoing ACL reconstruction (ACLR) using either quadriceps tendon graft (QT) or semitendinosus/gracilis hamstring (STG) graft. We compared subjective outcome (primary outcome) and knee stability, donor site morbidity and function (secondary outcomes). METHODS: From 2013 to 2015, we included 99 adults with isolated ACL injuries in the RCT. Fifty patients were randomised to QT grafts and 49 to STG grafts and followed for 2 years. Patient evaluated outcomes were performed by subjective International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Kujala and Tegner activity scores. Knee laxity was measured with a KT-1000 arthrometer. Donor site morbidity was evaluated by the 'donor site-related functional problems following ACLR score'. One-leg hop test tested limp strength symmetry. RESULTS: At 2-year follow-up, there was no difference between the two graft groups regarding subjective patient outcome, knee stability and reoperations. Also, at 2 years, donor site symptoms were present in 27% of patients in the QT group and 50% of patients in the STG group. The donor site morbidity score was 14 and 22 for the QT and STG, respectively. Hop test demonstrated lower limp symmetry for QT graft than STG graft of 91% and 97% respectively. CONCLUSION: QT graft for ACLR did not result in inferior subjective outcome compared with STG graft. However, QT graft was associated with lower donor site morbidity than STG grafts but resulted in more quadriceps muscle strength deficiency than hamstring grafts. Both graft types had similar knee stability outcome. TRIAL REGISTRATION NUMBER: NCT02173483.

No Difference in Outcome Between Femoral Soft-Tissue and Screw Graft Fixation for Reconstruction of the Medial Patellofemoral Ligament: A Randomized Controlled Trial.

PURPOSE: The aim of the present randomized controlled trial was to compare 2 different medial patellofemoral ligament reconstruction (MPFL-R) techniques that utilize different femoral fixation principles, which could affect subjective clinical outcomes and surgical morbidity. METHODS: Sixty patients were randomly assigned to 2 MPFL-R techniques: bone or soft-tissue fixation of the graft at the femoral condyle. Patients had operations performed between 2010 and 2015 at a single center. Indication for surgery was 2 or more patellar dislocations. When the bone fixation technique was used, the gracilis tendon was fixed with the use of an interference screw. When the soft-tissue fixation technique was used, the gracilis tendon was looped around the adductor magnus tendon. Both techniques used patella-graft fixation with drill holes in the medial patellar edge. Clinical outcomes were evaluated by means of Kujala, knee injury and osteoarthritis outcome, and pain scores before the operation and at 1- and 2-year follow-up examinations. Surgical morbidity was evaluated by pain on palpation along the reconstruction site. RESULTS: Kujala scores were 88 and 89 for bone and soft-tissue fixation groups, respectively, with no difference between groups (P = .73). No significant differences in knee injury osteoarthritis outcome or pain scores were found. Analysis of surgical morbidity, defined as femoral-based tenderness overlying the fixation site, demonstrated that 13% and 12% of patients had significant tenderness at the reconstruction site after bone and soft-tissue MPFL-R, respectively. No patellar re-dislocations were observed in either group. CONCLUSIONS: MPFL-R with soft-tissue graft fixation at the femoral condyles resulted in findings for subjective clinical outcome, patellar stability, and pain level similar to those associated with MPFL-R with bone fixation. Surgical morbidity was also similar between patients who had soft-tissue and those who had bone fixation MPFL-R. Soft-tissue femoral graft fixation does not result in inferior clinical outcomes compared with screw fixation, and it can be used safely for MPFL-R.

[Treatment of patellar instability].

First-time patellar luxation appears typically in teenagers and young adults below the age of 16 years, with a prevalence of 45/100,000/year. This luxation is treated with brief limited mobility in a bandage, and with a complementary physiotherapy if the mobility is influenced afterwards. Risk factors for patellar instability are patellofemoral dysplasia, hyperlaxity, patella alta and valgus malalignment in the knee joint. In case of repeated luxation the treatment is surgical, i.e. reconstruction of the medial patellofemoral ligament recreating the medial patella-stabilizing structures. If the dysplasia is severe, tuberositas tibiae-osteotomy and trochlea plastic can correct a lateral tracking of the knee joint. Generally, patella-stabilizing surgery is successful with a reluxation rate of only a few per cent.

Posterior cruciate ligament reconstruction in skeletal immature children.

PURPOSE: Rupture of the posterior cruciate ligament (PCL) is a rare knee injury in children with open growth plates. The follow-up results of six patients with open physes treated with PCL reconstruction are presented. The objective is to evaluate the clinical outcomes of PCL reconstruction for six skeletally immature patients. METHODS: Between 2006 and 2010, six skeletally immature patients were treated with PCL reconstruction. At the time of surgery, the median age was 9 years (range 6-14). The median follow-up time after surgery was 50 months (range 41-90). Outcomes were evaluated by KOOS and Tegner scores, instrumented knee laxity, and radiologic long-axis leg length measurements. RESULTS: The median KOOS score at follow-up was 88 (range 26-98). The median Tegner score was 6 (range 4-7). The median side-to-side difference in laxity according to KT-1000 was 2 mm (range 1-5) at 25° of flexion and 3 mm (range 3-6) at 70° of flexion. A median side-to-side difference in flexion of 8° was found. All but one patient had returned to playing sports at follow-up. One patient's index leg had a length discrepancy of 16 mm. CONCLUSIONS: PCL reconstruction resulted in fair to good clinical outcomes for skeletally immature children. Clinically relevant leg length discrepancy was found in one of the six patients examined in this study. LEVEL OF EVIDENCE: Level IV.

The Risk of Transphyseal Drilling in Skeletally Immature Patients With Anterior Cruciate Ligament Injury.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) in skeletally immature patients can result in growth plate injury, which can cause growth disturbances. PURPOSE: To evaluate radiological tibial and femoral length and axis growth disturbances as well as clinical outcomes in skeletally immature ACLR patients treated with a transphyseal drilling technique. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 39 pediatric patients with ACL injury and open physes at time of surgery, as diagnosed clinically and with magnetic resonance imaging (MRI), were treated using transphyseal ACLR using hamstring graft. Mean patient age was 11.7 years (range, 9.0-14.0 years). Patients were evaluated with full extremity radiographs measuring leg length discrepancy and malalignment, as well as clinical evaluation with KT-1000 arthrometer measurements and Tegner activity scale and Knee injury and Osteoarthritis Outcome Score (KOOS) outcomes after follow-up of 68 months (range, 29-148 months). RESULTS: Of the 39 initial patients, 33 were evaluated both clinically and radiographically. We found a mean femoral length shortening of 3.5 mm (P = .01) on the operated leg. Eight patients (24%) had a more than 10-mm shortening of the operated leg, whereas only 1 patient (3%) had a 10-mm shortening of the nonoperated leg. In 27 of 33 patients (82%; P < .001), the anatomic femoral axes of the operated leg were found to be more than 2° of valgus compared with the nonoperated leg. The tibial anatomic axes changed into a less pronounced varus angulation (P = .02). The femoral-tibial anatomic axes were not significantly different when comparing the 2 legs. We did not find any statistical difference in growth arrest comparing patients treated surgically at the ages of 13 to 14 years to patients younger than 13 years. Tegner and KOOS scores were significantly lower among girls compared with boys. Side-to-side KT-1000 arthrometer difference improved from 5.2 mm preoperatively to 1.6 mm at follow-up. CONCLUSION: This study shows that transphyseal ACLR in children results in minor length growth disturbances in 24% of patients. The surgically induced distal femoral valgus angulation is counterbalanced by a proximal tibial varus angulation. Growth disturbance after surgery is not associated with a certain pediatric age group. Otherwise, transphyseal ACLR has satisfactory clinical outcomes, with good subjective outcomes, function level, and knee stability.

Clinical outcome after reconstruction of the medial patellofemoral ligament in paediatric patients with recurrent patella instability.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction has recently been broadly accepted as primary surgical treatment in adults. Reconstruction techniques with osseous fixation in femur cannot be used for patients with open growth plates. Operative treatment of patella instability in children therefore is a challenge and requires alternative MPFL reconstruction techniques. Limited knowledge exists concerning outcome after MPFL reconstruction in children and adolescents. This study present clinical outcome in a consecutive single clinic series of children treated with paediatric MPFL reconstruction using a soft tissue femoral fixation technique. METHODS: Twenty-four MPFL reconstructions in 20 operated children aged 8-16 were included in the study. Indication for surgery was two or more patella dislocations. MPFL reconstruction was performed by looping the released gracilis tendon around the adductor magnus tendon insertion and through drill holes in the proximal medial patella edge. Clinical outcome was evaluated by Kujala score and NRS pain score preoperatively, at 1-year follow-up and final follow-up at 39 months. Outcome was compared with a cohort of 179 adult patients with recurrent patella instability operated with an adult MPFL reconstruction technique. RESULTS: Kujala score improved from 61 (13) to 81 (16). NRS pain score improved from 3.0 (3.1) to 1.5 (1.3) in activity. Four patients (20%) experienced redislocation within the first postoperative year compared with 5% in an adult patient population. Five patients (25%) experienced subluxations. One patient with a redislocation was re-operated with adult MPFL reconstruction technique. Cartilage injury was seen in six patients. CONCLUSIONS: There are clinical relevant improvements in knee function and pain after MPFL reconstruction in paediatric patients. Patella stability after MPFL reconstruction using femoral soft tissue graft fixation in paediatric patients was inferior to MPFL reconstruction using bony femoral fixation in adult patients. LEVEL OF EVIDENCE: Case-Control study, Level III.

Analgesic effect of hamstring block after anterior cruciate ligament reconstruction compared with placebo: a prospective randomized trial.

PURPOSE: To evaluate the effect of a hamstring block for postoperative pain management using 20 mL of 0.25% bupivacaine compared with placebo after anterior cruciate ligament (ACL) reconstruction with a hamstring autograft. METHODS: In a 3-month period, 45 patients undergoing ACL reconstruction with a hamstring autograft who all received a femoral nerve block were randomized to receive either 20 mL of 0.25% bupivacaine or 20 mL of saline water administered through a catheter into the donor-site space. The patients and recovery staff were blinded to the treatment. Postoperative donor-site pain was evaluated subjectively by the patients using a pain score (Likert scale from 0 to 10). The pain was registered for each hour in the first 6 hours and thereafter once daily for 8 days. Furthermore, the requirement for postoperative analgesic medicine was registered. RESULTS: The hamstring block group (n = 23) had significantly less pain for each of the first 6 postoperative hours. The pain score was reduced from 4.2 to 2.3 (95% confidence interval, 1.3 to 3.3) (P = .01) in the first hour and from 2.8 to 1.3 (95% confidence interval, 0.6 to 1.9) in the sixth hour, and there was a significantly lower overall requirement for early postoperative fentanyl, reduced from a mean of 58 to 35 µg (P = .02), and morphine, reduced from a mean of 10 to 6 mg (P = .04). After 6 hours, there was no difference in the pain level and use of analgesics between the 2 groups. CONCLUSIONS: With the use of a donor-site block in hamstring ACL reconstruction, the donor-site pain level, as well as the overall requirement for fentanyl and morphine, was significantly reduced in the first 6 postoperative hours. No effect of the donor-site block was seen after 6 hours. LEVEL OF EVIDENCE: Level I, therapeutic, randomized controlled study.

Clinical outcome after reconstruction of the medial patellofemoral ligament in patients with recurrent patella instability.

PURPOSE: We present the clinical results of a large consecutive, prospective, single-clinic series of patients treated with medial patellofemoral ligament (MPFL) reconstruction for recurrent patellar instability. METHODS: The study included 224 patients undergoing MPFL reconstruction in a total of 240 knees between 2008 and 2011. Indication for surgery was two or more patellar dislocations and ADL limitations due to patella instability. SURGICAL PROCEDURE: A gracilis tendon autograft was fixed in drill holes in the medial edge of the patella and with screws at the femoral MPFL insertion point. Outcomes were evaluated with the Kujala Anterior Knee Pain Score and pain scores preoperatively and at follow-up (12-60 months). Furthermore, incidences of re-dislocations, subluxations and revision surgery were evaluated. RESULTS: The Kujala score improved from 62.5 (17) to 80.4 (18) (p<0.001) at the 1-year follow-up. Pain during activity improved from 3.2 (2.6) to 1.3 (2.7) at 1 year (p<0.001). The revision rate was 2.8%. Some degree of pain at the medial femoral condyle was seen in 30% of the patients. The reconstruction was supplemented with a tibial tuberosity osteotomy in 23% of cases. The outcome for these patients did not differ from that of patients with isolated MPFL reconstruction. Female gender BMI>30, age>30 years and grade 3-4 cartilage injury predisposed a poor subjective outcome. CONCLUSIONS: The present study is the largest MPFL reconstruction patient material reported to date. MPFL reconstruction with a gracilis tendon autograft consistently normalised the patella stability and improved knee function. Moderate medial pain was seen. Age above 30, obesity, cartilage injury and female gender are predictors of a poor subjective outcome. LEVEL OF EVIDENCE: Level IV.

Is quadriceps tendon a better graft choice than patellar tendon? a prospective randomized study.

PURPOSE: The purpose of this randomized controlled study was to compare knee stability, kneeling pain, harvest site pain, sensitivity loss, and subjective clinical outcome after primary anterior cruciate ligament (ACL) reconstruction with either bone-patellar tendon-bone (BPTB) or quadriceps tendon-bone (QTB) autografts in a noninferiority study design. METHODS: From 2005 to 2009, a total of 51 patients were included in the present study. Inclusion criteria were isolated ACL injuries in adults. Twenty-five patients were randomized to BPTB grafts and 26 to QTB grafts. An independent examiner performed follow-up evaluations 1 and 2 years postoperatively. Anteroposterior knee laxity was measured with a KT-1000 arthrometer (MEDmetric, San Diego, CA). Anterior knee pain was assessed clinically and by knee-walking ability. Knee Injury and Osteoarthritis Outcome Score (KOOS) and subjective International Knee Documentation Committee (IKDC) score were used for patient-evaluated outcome. RESULTS: Anterior knee laxity was equal between the 2 groups with KT-1000 values of 1.1 ± 1.4 mm and 0.8 ± 1.7 mm standard deviation (SD) at follow-up in QTB and BPTB groups, respectively (P = .65), whereas positive pivot shift test results were seen less frequently (14% compared with 38%, respectively; P = .03). Anterior kneeling pain, evaluated by the knee walking ability test, was significantly less in the QTB group, with only 7% of patients grading knee walking as difficult or impossible compared with 34% in the BPTB group. At 1 and 2 years' follow-up, there was no difference between the 2 groups in subjective patient-evaluated outcome. The IKDC score was 75 ± 13 patients and 76 ± 16 SD at 1-year follow-up in QTB and BPTB groups, respectively (P = .78). At 2 years, 12 patients were lost to follow-up, resulting in 18 in the BPTB group and 21 in the QTB group. CONCLUSIONS: The use of the QTB graft results in less kneeling pain, graft site pain, and sensitivity loss than seen with BPTB grafts; however, similar anterior knee stability and subjective outcomes are seen. The results of this study show that QTB is a viable option for ACL reconstruction. LEVEL OF EVIDENCE: Level II, randomized controlled clinical trial.

Risk for Revision After Anterior Cruciate Ligament Reconstruction Is Higher Among Adolescents: Results From the Danish Registry of Knee Ligament Reconstruction.

BACKGROUND: The number of children and adolescents with anterior cruciate ligament (ACL) reconstructions is increasing, and disturbing reports on high rerupture rates in this group have been noted. PURPOSE: To describe the outcome of ACL reconstruction in children and adolescents based on data from the Danish Knee Ligament Reconstruction Registry (DKRR). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data were retrieved from the DKRR, a national population-based registry. The analysis was based on a population of 14,806 ACL-reconstructed patients. The outcome was evaluated using risk of ACL revision, subjective outcome score (Knee injury and Osteoarthritis Outcome Score [KOOS]), Tegner function score, and objective knee laxity. Three age groups were defined (A, <13 years; B, 13-15 years; and C, 15-20 years) and compared with D, patients ≥20 years (adults). There were 95 patients in group A, 327 in B, 2888 in C, and 11,496 in D. RESULTS: There was a significantly increased risk of revision surgery in the age groups B (6.7%) and C (4.9%) compared with the adults in group D (2.0%). Objective knee laxity did not differ between the 4 groups. Groups A, B, and C had a higher score on the combined KOOS symptoms, pain, sport, and quality of life subscales (KOOS4; 79.6, 76.6, and 73.1, respectively) compared with the adults (69.7). Group B had higher KOOS quality of life (76.6) and sports (71.1) scores than did group C (73.1 and 66.4, respectively). The Tegner activity score did not differ between the 4 groups. No impact of the use of extracortical graft fixation was detected in the youngest age group. CONCLUSION: Study results indicated an increased risk of graft failure in patients between 13 and 20 years of age. This is in contrast to the better subjective and equal objective knee score found in the same age groups. CLINICAL RELEVANCE: The new knowledge about the high revision rate among ACL-reconstructed teenagers is important for evidence-based preoperative information of ACL patients and their parents.

Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens.

BACKGROUND: The optimal rehabilitation program after meniscus repair has not been established. Numerous regimens have been suggested as beneficial for meniscus healing, but no controlled trials exist in the literature. HYPOTHESIS: The purpose of this prospective randomized trial was to investigate outcome with a free or a restricted rehabilitation regimen after isolated meniscus repair. The hypothesis was that free rehabilitation would result in increased failure of meniscus healing. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: A total of 60 patients were included in this study within 2 to 3 days after meniscus repair. No patients with concomitant ligament reconstruction or cartilage repair surgery were included. Meniscus repair was performed with the all-inside technique; only vertical meniscus lesions close to the capsule were repaired. Patients were randomized to free (n = 32) or restricted (n = 28) rehabilitation. Free rehabilitation consisted of 2 weeks (range of motion [ROM], 0°-90°, no brace) and touch weightbearing, with unrestricted activity and free ROM allowed thereafter. Restricted rehabilitation consisted of 6 weeks of hinged brace use with a gradual increase ROM to 90° and only touch weightbearing during the 6 weeks. Patients were seen for follow-up at 3 months, 1 year, and 2 years. Those patients with joint line pain at the 3-month follow-up underwent MRI scanning to evaluate meniscus healing; a subsequent arthroscopy was performed for final evaluation meniscus healing if the MRI indicated lack of meniscus healing. At follow-up, the Knee Osteoarthritis Outcome Score (KOOS), Tegner function score, pain assessment, and patient satisfaction were used to evaluate outcomes. RESULTS: Eleven patients were lost to follow-up. Repeat arthroscopy in patients with persistent symptoms demonstrated partial healing or lack of healing in 28% and 36% of patients in the free and the restricted rehabilitation groups, respectively (P = .53, nonsignificant). The KOOS and Tegner function scores were similar between groups at all follow-up times, as was patient satisfaction. Patients who underwent subsequent partial meniscectomy because of meniscus repair failure had lower KOOS score and Tegner function score than did patients without repair failure. CONCLUSION: Free rehabilitation after meniscus repair is safe and does not entail increased failure rates compared with restricted rehabilitation. Subjective and functional outcomes at 1- and 2-year follow-up were not affected by rehabilitation regimen. Clinical outcomes in patients with repair failure who underwent subsequent partial meniscectomy were poorer than in those with healed meniscus repairs. A concern is the 30% overall lack of healing for patients with isolated meniscus lesions repaired with the all-inside technique.