Bernard R. Bach

Arthroscopic Anterior Cruciate Ligament Reconstruction A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts

Background The best choice of graft tissue for use in anterior cruciate ligament reconstruction has been the subject of debate. Hypothesis: Anterior cruciate ligament reconstruction with patellar tendon autograft leads to greater knee stability than reconstruction with hamstring tendon autograft. Study Design Metaanalysis. Methods A Medline search identified articles published from January 1966 to May 2000 describing arthroscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring tendon autograft and with a minimum patient follow-up of 24 months. Results There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%). Conclusions Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain.

Gait adaptations by patients who have a deficient anterior cruciate ligament.

Sixteen patients who had unilateral deficiency of the anterior cruciate ligament and ten healthy control subjects were analyzed during level walking, jogging, and ascending and descending stairs. Kinematic and kinetic findings for the right and left hips, knees, and ankles of all of the patients and control subjects were recorded during each activity. Substantial differences from normal function were observed for both limbs of the patients during level walking and during jogging. The magnitude of the maximum moment that tended to flex the knee was reduced the most (140 per cent) during level walking. It was reduced less (30 per cent) during jogging, it was not changed while the patient descended stairs, and it was slightly increased while he or she ascended stairs. The reduction in the magnitude of the flexion moment about the knee was interpreted as the patients effort to reduce or avoid contraction of the quadriceps. Reduction of the flexion moment reduces any contraction of the quadriceps because there must be a mechanical balance between the external moment (due to body weight and the weight and inertia of the segment of the limb) that tends to flex the knee and an internal moment (generated by contraction of the quadriceps) that tends to extend the knee. This so-called quadriceps-avoidance gait was related to the angle of flexion of the knee when the maximum flexion moment occurred during each activity. This angle of flexion was 20 degrees during walking, 40 degrees during jogging, and approximately 60 degrees during stair-climbing.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Autograft Five- to Nine-Year Follow-up Evaluation

We retrospectively reviewed the results of 97 patients with anterior cruciate ligament reconstructions using an arthroscopically assisted two-incision technique without extraarticular augmentation at an intermediate followup of 5 to 9 years postoperatively. Evaluation included detailed history, physical examination, functional testing, KT-1000 arthrometer measurements, multiple scoring systems, and radiographs. The results were compared with those from a previous study that evaluated a smaller patient cohort using the identical surgical technique at a 2- to 4-year followup. The post-operative physical examination and KT-1000 arthrometer results were statistically improved when compared with preoperative findings. A negative pivot shift result was noted in 83% of patients, and a 1 result in 17% of patients. Seventy percent of patients had 3 mm difference on manual maximum side-to-side testing. Functional testing averaged less than 2% asymmetry for vertical jump, single-legged hop, or timed 6-meter hop. The Tegner activity level was significantly improved from prereconstruction ratings and similar to preinjury ratings. The mean Lysholm score was 87. The modified Hospital for Special Surgery scores resulted in good or excellent results in 82% of the patients (mean, 87 points). The mean Noyes sports function score was 89, and the reoperation rate for a symptomatic knee flexion contracture was 12%. Ninety-seven percent of patients indicated that they would undergo the procedure again. When compared with this same population at 2 to 4 years, we saw no deterioration in scoring scale results.

Incidence and trends of anterior cruciate ligament reconstruction in the United States

Background: Anterior cruciate ligament (ACL) injury is among the most commonly studied injuries in orthopaedics. The previously reported incidence of ACL injury in the United States has varied considerably and is often based on expert opinion or single insurance databases. Purpose: To determine the incidence of ACL reconstruction (ACLR) in the United States; to identify changes in this incidence between 1994 and 2006; to identify changes in the demographics of ACLR over the same time period with respect to location (inpatient vs outpatient), sex, and age; and to determine the most frequent concomitant procedures performed at the time of ACLR. Study Design: Descriptive epidemiological study. Methods: International Classification of Diseases, 9th Revision (ICD-9) codes 844.2 and 717.83 were used to search the National Hospital Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS) for the diagnosis of ACL tear, and the procedure code 81.45 was used to search for ACLR. The incidence of ACLR in 1994 and 2006 was determined by use of US Census Data, and the results were then stratified based on patient age, sex, facility, concomitant diagnoses, and concomitant procedures. Results: The incidence of ACLR in the United States rose from 86,687 (95% CI, 51,844-121,530; 32.9 per 100,000 person-years) in 1994 to 129,836 (95% CI, 94,993-164,679; 43.5 per 100,000 person-years) in 2006 (P = .015). The number of ACLRs increased in patients younger than 20 years and those who were 40 years or older over this 12-year period. The incidence of ACLR in females significantly increased from 10.36 to 18.06 per 100,000 person-years between 1994 and 2006 (P = .0003), while that in males rose at a slower rate, with an incidence of 22.58 per 100,000 person-years in 1994 and 25.42 per 100,000 person-years in 2006. In 2006, 95% of ACLRs were performed in an outpatient setting, while in 1994 only 43% of ACLRs were performed in an outpatient setting. The most common concomitant procedures were partial meniscectomy and chondroplasty. Conclusion: The incidence of ACLR increased between 1994 and 2006, particularly in females as well as those younger than 20 years and those 40 years or older. Research efforts as well as cost-saving measures may be best served by targeting prevention and outcomes measures in these groups. Surgeons should be aware that concomitant injury is common.

Repair of Full Thickness Rotator Cuff Tears: Gender, Age, and Other Factors Affecting Outcome

Seventy-two full thickness rotator cuff tears (72 patients) were treated with an open rotator cuff repair between 1986 and 1993. The average postoperative followup was 54 months (range, 24-102 months; standard deviation, 22 months). Fifty-three (74%) patients had no pain, 16 (22%) patients had slight pain without restriction of activities, and three (4%) patients had moderate pain with activity compromise. Women with an associated biceps tendon rupture tended to have worse results. Women had a negative, statistically significant relationship between age and shoulder scoring scales, but age at the time of surgery was not related to any outcome variables for men. A rotator cuff tear greater than or equal to 5 cm2 as determined at the time of surgery was associated with a poorer outcome. The average University of California at Los Angeles score was 32 points (range, 7-35 points; standard deviation, 5 points). The average Constant-Murley score was 78 of 100 points (range, 12-95 points; standard deviation, 15 points). A yes response was given for an average of 10 of 12 questions on the Simple Shoulder Test (range, 0-12 questions; standard deviation, 3 questions). More than 4 years after open rotator cuff repair, patients had a 94% patient satisfaction rate with lasting relief of pain and improved function.

Arthroscopy-assisted Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Substitution Two- to Four-year Follow-up Results

The purpose of this retrospective study was to evaluate clinically, functionally, and objectively our initial expe rience using free, autogenous middle third patellar ten don for anterior cruciate ligament reconstruction without extraarticular augmentation in 62 of 75 patients (80% followup) who were available for clinical review at a minimum 2-year followup. Subjective, clinical, func tional, Cybex dynamometer, and KT-1000 arthrometer tests were performed along with modified tests of the Hospital for Special Surgery, Noyes Cincinnati, Tegner, and Lysholm knee rating scales. Ninety-two percent had a negative pivot shift at followup. The mean Cybex dynamometer extension deficits postoperatively were 9% and 7% at 180 and 240 deg/sec. Mild patellar pain symptoms were noted in 18%. The reoperation rate was 10% with a mild flexion contracture as the most common reason. The Hospital for Special Surgery scoring scale postoperatively was 88; Noyes, 86; Lysholm, 88; and Tegner, 6. Mean postoperative single-legged and ver tical jump indices were 88% and 87%, respectively. The KT-1000 arthrometric evaluation postoperatively revealed a mean maximum manual difference of 0.3 mm; 92% of the patients had a maximum manual dif ference of ≤3 mm. Subjectively, 95% indicated that they would undergo the procedure again. Early results demonstrate excellent stability, preservation of motion, and encouraging evaluations by scoring scales and arthrometric evaluation.

Arthrometric evaluation of knees that have a torn anterior cruciate ligament.

We used the KT-1000 arthrometer to test the knees of 107 patients who had an acute tear of the anterior cruciate ligament, 153 patients who had a chronic tear, and 141 control subjects, for a total of 401 individuals. The three testing parameters were the extent of anterior translation at eighty-nine newtons of force and at maximum manual force, and the compliance index. The differences between the involved and the uninvolved knees were calculated. At eighty-nine newtons, all but one of the control subjects had anterior translation of ten millimeters or less, compared with 58 per cent of the patients who had a chronic tear. At maximum manual force, all but two of the control subjects had translation of ten millimeters or less, compared with 20 per cent of the patients who had an acute or a chronic tear. Analysis of variance showed that the clinical diagnosis correlated well with the results for all tests (p less than 0.001). However, when the uninjured knees of patients who had an acute or a chronic tear were compared with the knees of the control subjects, significant differences were noted (p less than 0.001 to 0.006). In the patients who had a chronic tear, there was no relationship between the time from injury to operation and the extent of anterior translation. The arthrometric test at maximum manual force was the strongest discriminant; it differentiated normal from abnormal knees (p less than 0.001) with high sensitivity (92 per cent), high specificity (95 per cent), and high positive predictive accuracy; the cut-off point was eleven millimeters or less.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications and Reoperations During and After Hip Arthroscopy: A Systematic Review of 92 Studies and More Than 6,000 Patients

PURPOSE To determine the prevalence of complications and reoperations during and after hip arthroscopy. METHODS A systematic review of multiple medical databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. All clinical outcome studies that reported the presence or absence of complications and/or reoperations were eligible for inclusion. Length of follow-up was not an exclusion criterion. Complication and reoperation rates were extracted from each study. Duplicate patient populations within separate distinct publications were analyzed and reported only once. RESULTS Ninety-two studies (6,134 participants) were included. Most were Level IV evidence studies (88%) with short-term follow-up (mean 2.0 years). Labral tears and femoroacetabular impingement (FAI) were the 2 most common diagnoses treated, and labral treatment and acetabuloplasty/femoral osteochondroplasty were the 2 most common surgical techniques reported. Overall, major and minor complication rates were 0.58% and 7.5%, respectively. Iatrogenic chondrolabral injury and temporary neuropraxia were the 2 most common minor complications. The overall reoperation rate was 6.3%, occurring at a mean of 16 months. Total hip arthroplasty (THA) was the most common reoperation. The conversion rate to THA was 2.9%. CONCLUSIONS The rate of major complications was 0.58% after hip arthroscopy. The reoperation rate was 6.3%, and the most common reason for reoperation was conversion to THA. Minor complications and the reoperation rate are directly related to the learning curve of hip arthroscopy. As surgical indications evolve, patient selection should limit the number of cases that would have been converted to THA. Similarly, the number of minor complications is directly related to technical aspects of the procedure and therefore will decrease with surgeon experience and improvement in instrumentation. LEVEL OF EVIDENCE Level IV, a systematic review of Level I to IV studies.

Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss.

Recurrent instability of the glenohumeral joint is usually associated with a Bankart tear—a soft-tissue injury of the glenoid labrum attachment. However, patients with recurrent shoulder instability often present with osseous injury to the glenoid and humeral head as well. Understanding and appropriately addressing irregularities in the osseous architecture of the glenohumeral joint are critical to the overall success of surgical repair for the treatment of glenohumeral instability1. The integrity of the osseous architecture of the glenoid has recently been highlighted as one of the most important factors related to the success of surgical repair2,3. After the initial traumatic shoulder dislocation, an associated glenoid rim fracture or attritional bone injury may compromise the static restraints of the glenohumeral joint, making further instability more likely. With recurrent instability, there can be further attritional glenoid bone loss. Glenoid bone deficiency with recurrent shoulder instability is an increasingly recognized cause of failed shoulder stabilization surgery. It is critical to evaluate all patients with recurrent shoulder instability for the presence of osseous injuries to the glenoid. Specific findings in the history and the physical examination provide important clues to the presence of glenoid bone loss, and a careful preoperative evaluation to diagnose and quantify anterior glenoid deficiency is crucial for the success of surgical treatment. Appropriate preoperative imaging is essential for detection and quantification of osseous abnormalities in patients with recurrent shoulder instability. The apical oblique view described by Garth et al.4, the West Point view5, and the Didiee view6 are recognized as being the most sensitive radiographs for detecting osseous abnormalities of the glenoid. Magnetic resonance imaging and magnetic resonance arthrography may be used, but they are primarily employed to assess the surrounding soft tissues. If any osseous lesion is discovered on radiographs, …

Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder : a meta-analysis

Background In published comparative studies, it remains unknown if arthroscopic techniques for performing Bankart repair for anterior shoulder instability equal the success of open repair. Hypothesis The current literature supports a lower rate of recurrent instability after open Bankart repair compared to arthro-scopic repair with bioabsorbable tacks or transglenoid sutures. Study Design Meta-analysis. Methods A Medline search identified all randomized controlled trials or cohort studies that directly compared open repair to arthroscopic techniques of Bankart repair for traumatic, unilateral, recurrent anterior instability. Data collected from each study included patient demographics, surgical technique, rehabilitation, outcome, and complications. Results Six studies met all inclusion criteria. There were 172 patients in the arthroscopic group (90 patients with transglenoid sutures, 77 patients with arthroscopic tacks, and 5 patients with suture anchors) and 156 patients in the open group. The groups were similar in demographic characteristics. When comparing the arthroscopic to the open group, there was a significantly higher rate of recurrent dislocation (12.6% vs 3.4%; P = .01) and total recurrence (recurrent dislocation or subluxation) (20.3% vs 10.3%; P = .01). In addition, there was a higher proportion of patients with an excellent or good postoperative Rowe score in the open group (88%) than in the arthroscopic group (71%) (P = .01). Conclusions Arthroscopic Bankart repair using transglenoid sutures or bioabsorbable tacks results in a higher rate of recurrence of instability compared to open techniques. Studies comparing open repair to newer arthroscopic techniques using suture anchor fixation and capsular plication are necessary.