Anders Mølster

A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate ligament

Treatment of ACL tears is controversial. Recent reports on nonoperative treatment have shown poor results. Results after primary repair have deteriorated with time, leading to augmentation procedures that seem to have improved the results. However, there have been few prospective, randomized studies in this field. Our goal was to compare primary repair with a bone-patellar tendon-bone augmentation method and with a new method using the Kennedy Ligament Augmentation Device. One hundred fifty patients aged 16 to 50, all of whom had acute ACL tears, were randomized with the closed envelope method to one of three groups treated with open surgical methods. Fifty patients were treated with primary repair, 50 patients with patellar tendon aug mentation, and 50 patients were augmented with the Kennedy Ligament Augmentation Device. All patients were operated on within 10 days of injury. The rehabil itation protocol was identical, consisting of a long leg cast for 2 weeks, followed by a brace with no weight bearing and limited motion for 6 weeks. The patients were followed prospectively by one surgeon (LE) using the Lysholm functional score, Tegner activity level score, clinical evaluation and KT-1000 arthrometer at 6 months, 1, and 2 years. Three patients were lost to followup. There was no age or activity level difference between the groups. Sport activities led to 85% of the injuries, with skiing, soccer, and European handball representing 80% of injuries. All three groups reduced their activity level the 1 st year. The repair group remained at the same level after 2 years. The Ligament Augmentation Device group had a small increase, while the patellar tendon group had a significant increase to almost the preinjury level. The patellar tendon group was judged to have results superior to the other groups, according to Lach man, pivot shift, and KT-1000 test results. The Liga ment Augmentation Device group fared better than the primary repair group, according to the Lysholm score, Lachman test, and pivot shift. In general, the results were as follows: the repair group deteriorated from 1 to the 2 years control, the Ligament Augmentation Device group did not change, and the patellar tendon group improved.

A sixteen-year follow-up of three operative techniques for the treatment of acute ruptures of the anterior cruciate ligament.

BACKGROUND This study compares three surgical procedures that we used in the past to treat ruptures of the anterior cruciate ligament: acute primary repair, acute repair augmented with a synthetic ligament-augmentation device, and acute repair augmented with autologous bone-patellar tendon-bone graft. METHODS This is the third report on a group of patients who were randomized to the three different procedures between 1986 and 1988. There were fifty patients in each group. The patients were evaluated prospectively at one, two, five, and sixteen years with use of the Tegner activity score and the Lysholm functional score. Stability of the knee was assessed with clinical examination and with use of the KT-1000 arthrometer. RESULTS One hundred and twenty-nine (88%) of the 147 patients who were available for follow-up completed the study. Eleven patients (24%) who had a primary repair, four patients (10%) who had repair with a ligament augmentation device, and one patient (2%) who had augmentation with autologous bone-patellar tendon-bone graft underwent anterior cruciate ligament revisions between the primary operation and the sixteen-year follow-up examination. The rate of revision was ten times higher in the group that had primary repair than in the group that had repair with bone-patellar tendon-bone graft (p = 0.003). In the remaining patients, those who had repair with a bone-patellar tendon-bone graft had significantly more stable knees than those who had repair with a ligament augmentation device, as measured by the Lachman test (p = 0.026). Nine (11%) of the eighty-five patients for whom data were available had osteoarthritis in the primarily reconstructed knee, and three patients (3.5%) had osteoarthritis in the contralateral knee at sixteen years (p = 0.001); no difference was noted among the three groups. The mean Lysholm score at sixteen years was 88 points for the knees that had primary repair, 85 points for those that had repair with the ligament augmentation device, and 90 points for those managed with a bone-patellar tendon-bone graft (p = 0.286). CONCLUSIONS At long-term (sixteen-year) follow-up, the rate of revision anterior cruciate ligament surgery is much higher following primary repair than after primary repair augmented by a bone-patellar tendon-bone graft. It can be expected that approximately 10% of patients undergoing anterior cruciate ligament reconstruction acutely will have osteoarthritis develop in the reconstructed knee. We no longer perform any of these surgical techniques as open procedures.

A Prospective, Randomized Study of Three Operations for Acute Rupture of the Anterior Cruciate Ligament. Five-Year Follow-up of One Hundred and Thirty-one Patients*

A five-year, prospective, randomized follow-up study was done to compare three methods for repair of a rupture of the anterior cruciate ligament of the knee: acute primary repair (Group 1), acute repair with a synthetic ligament-augmentation device (Group 2), and acute repair augmented with an autologous bone-patellar ligament-bone graft (Group 3). One hundred and fifty patients who had an acute rupture of the anterior cruciate ligament were randomized to one of the three repair groups, with fifty patients in each group. The patients were between sixteen and fifty years old (mean, twenty-nine years old). All patients had the operation within ten days after the injury. The rehabilitation protocol was identical for each group. The patients were evaluated prospectively at one, two, and five years with use of the Tegner scoring system for level of activity and the scoring system of Lysholm and Gillquist for function, and the stability of the knee was assessed with clinical examination and with use of the KT-1000 arthrometer. One hundred and thirty-one patients completed the study and ten other patients were known to have had a failure of the procedure, a 94 per cent rate of follow-up. All three groups had a lower level of activity at the five-year follow-up evaluation than they had had before the injury. The patients who had had augmentation with a patellar-ligament graft had a significantly higher mean level of activity at two years than those who had had non-augmented repair (p = 0.002) and those who had had repair with a synthetic ligament-augmentation device (p = 0.01). They also had a significantly higher mean level of function at two years than those who had had non-augmented repair (p = 0.0001) and those who had had repair with a synthetic ligament-augmentation device (p = 0.03) and a significantly higher mean level of function at five years than those who had had non-augmented repair (p = 0.004). The ability to attain full extension improved significantly in all three groups during the five-year follow-up period; the highest gains occurred in the group that had had augmentation with a patellar-ligament graft. Rotatory and anterior instability progressively increased during the follow-up period for all three groups. At one, two, and five years, the knees that had had repair with a patellar-ligament graft were significantly more stable than those that had had non-augmented repair and those that had had repair with a ligament-augmentation device (p < 0.0001 to p = 0.03). The findings of this study reinforce the conclusions of our two-year follow-up report that a non-augmented primary repair should not be performed, a repair with a ligament-augmentation device has an unacceptably high rate of failure (more than one-third of the patients), and a repair that is augmented with the patellar ligament has the best outcome.

Open reduction and internal fixation of displaced intraarticular fractures of the distal radius: 31 patients followed for 3-7 years

We have used open reduction and internal fixation with a T-plate in 31 displaced, intraarticular fractures of the distal radius which were judged irreducible or in which closed reduction failed. The mean follow-up time was 4 (3-7) years. The dorsal angulation, the radial length, the articular step-off and the intraarticular gap between fragments were substantially improved after surgery. 30 patients had excellent or good extraarticular alignment, and only 1 patient had a postoperative intraarticular step-off of 2 mm. The function was excellent or good in 26 patients at follow-up. Complications occurred in 6 patients: 1 compartment syndrome, 1 postoperative wound infection, 2 ruptures of the extensor pollicis longus tendon, and 2 patients had median nerve paresthesias.

Lateral ligament injuries of the knee

Abstract Between 1982 and 1994 28 patients were treated for acute lateral knee ligament injuries; 25 patients, with a median age of 25.5 (range 16–75) years at injury, appeared for follow-up. Seven patients had isolated injury of the lateral collateral ligament/capsular structures, the remaining 19 patients had concomitant ligament injuries in the knee. Eight patients were treated conservatively, 1 with plaster immobilization and 7 with early mobilization. Eighteen patients underwent surgery, 17 of these within 3 weeks of injury. Repair/reconstruction of the cruciate ligaments was done at the same time as the lateral collateral ligament repair in 10 patients. At follow-up after a median of 7.5 years (range 6 months to 13 years), 11 had no varus instability, 7 had 1+, 5 had 2+, and 2 patients had 3+ varus instability. All patients with a final result of 2+ or 3+ had combined ligament injuries. The surgically treated lateral collateral ligament injuries all had a primary instability of 2+ or more. These patients showed an improvement in varus instability from a mean of 2.83+ preoperatively to a mean of 1.17+ postoperatively. Two-thirds of the surgically treated patients were stable or had a 1+ instability at follow-up. One conservatively treated patient with a 2+varus instability and 1 with 1+ showed no improvement. Five conservatively treated patients with initial varus instability of 1+ were stable at follow-up. One patient with a 1+ varus instability had anterior cruciate ligament (ACL) rupture. He had a primary ACL reconstruction without lateral repair. He had no varus instability at follow-up. Our study supports the notion that operation performed at an early stage in fresh injuries with a varus instability of 2+ or more gives improved stability as a final result. Conservative treatment may not be expected to give an improved stability, but is sufficient in mild varus instability (1+) without additional cruciate ligament injuries.

Effect of Instability on Experimental Fracture Healing

Bilateral tibial osteotomy with fracturing of the fibula was performed on ten Wistar rats weighing 300--350 g. Intramedullary nailing was performed with 1.4 mm nails after reaming. On the left side solid stainless rods were used, while on the right side the nails had a middle part made of titanium-nickel wire covered with polyvinylchloride (PVC), giving the nail a high degree of flexibility. After 8 weeks, nine of the ten flexible nails showed fracture of the central wire. The continuity was, however, maintained by the PVC tube. The bones with flexible nailing always showed hypertrophic callus while there was only scanty callus on the side with rigid nailing. Strength, deformation at fracture and stiffness were measured in a three-point bending test after removal of the solid nails and the fibulae. The strength of the tibiae was greatest on the side with flexible nailing, as was the deformation at fracture. The mean stiffness was higher in the bones with rigid nails, but the difference here was not statistically discernible.

Primary repair in posterior cruciate ligament injuries

A retrospective study of 32 consecutive patients with acute injury of the posterior cruciate ligament (PCL) treated by primary repair is presented. Only six patients had isolated injuries of the PCL, five of these as avulsion of a bone fragment from the tibia. The remaining 26 patients sustained combined ligament injuries, including 18 total ACL tears. All ruptured ligaments were repaired. At follow-up after 4 (1-7) years, function in 26 patients was excellent-good and in six fair-poor. Moderate or severe posterior instability was found in seven patients by clinical examination but their function was as good as in those with stable knees. Inferior functional results, however, were more often related to rotatory instability. Primary repair of PCL-injuries, including all associated ligament injuries, is recommended.

Effects of rotational instability on healing of femoral osteotomies in the rat

Three different degrees of rotational instability were induced in transversally osteotomized rat femora by means of intramedullary steel nails with various degrees of interlocking. Union was delayed in osteotomies with the greatest rotational instability. The strength, stiffness and energy absorption of the osteotomies at 4, 8 and 16 weeks were also lower in this group. At 25 weeks, the end-point of the experiment, there were no differences in incidence of union or in the mechanical properties between the experimental groups. We conclude that a high degree of rotational instability caused delayed fracture healing.

Effects of instability on fracture healing in the rat

The effect of bending and rotational instability on the healing of a femoral osteotomy was studied in rats using intramedullary fixation with nails made of either steel or flexible polyacetal. All osteotomies were made rotationally unstable by reaming the medullary cavity to a diameter wider than the nails. At 16 weeks, four osteotomies had healed, and 17 had not healed. However, bending tests gave higher values for strength and energy absorption in non-unions with flexible as compared to Stiff nails. Rotational instability thus caused a high rate of non-union in the present model, which has given safe healing when the osteotomy has been stabilized for rotation. Flexible nailing increased strength and energy absorption in bones with non-union, but did not affect the incidence of healing.

Surgery for posttraumatic wrist deformity: Radial osteotomy and/or ulnar shortening in 16 Colles' fractures

16 patients with pain and impaired function after malunited fracture of the distal radius were treated with opening wedge lengthening osteotomy of the radius with bone grafting (12 cases), shortening osteotomy of the ulna (3 cases), or a combination of these methods (1 case), with or without reattachment of the triangular fibrocartilage complex. 4 patients had to be reoperated because of redislocation, resorption of the graft, fracture of the plate, or persistent non-union. At re-examination after a median of 4 years, all patients but 2 were improved by the procedure.