G. Zaccherotti

Patellar Tendon Versus Doubled Semitendinosus and Gracilis Tendons for Anterior Cruciate Ligament Reconstruction

The results of intraarticular anterior cruciate ligament reconstruction with either the patellar tendon or the semitendinosus and gracilis tendons (four strands) were prospectively compared in a consecutive series of 60 patients with chronic injuries. A single surgeon per formed arthroscopically assisted reconstructions in an alternating sequence. Preoperative and operative data revealed no significant differences between the two groups. After 28 months of followup there were no sig nificant differences in the incidence of symptoms, and recurrent giving way was present in only one knee with semitendinosus and gracilis tendon graft. Return to sport participation was more frequent in the patellar ten don group (80% versus 43%, P < 0.01 ). A minor ex tension loss (≤3°) was more frequent in the patellar tendon group (47% versus 3%, P < 0.001 ). Other dif ferences between the two groups were not significant. KT-2000 arthrometer side-to-side difference of anterior displacement >5 mm at 30 pounds was present in 13% of the knees with patellar tendon grafts and in 20% of those with semitendinosus and gracilis; a patellofemo ral crepitation developed in 17% and 3% of the two groups, respectively. Based on these data we routinely use patellar tendon grafts. Semitendinosus and gracilis tendons are preferred in selected cases: older patients, patients with preexisting patellofemoral problems, and those with failed patellar tendon grafts.

Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon A 5–8-year follow-up

Abstract We reviewed 89 arthroscopically assisted patellar tendon anterior cruciate ligament (ACL) reconstructions for chronic isolated injuries with an average follow-up of 7 years (range 5.4 to 8.6 years). Pain was present in 7 knees (8%). Giving-way symptoms were reported by 7 patients (8%). A KT-2000 side-to-side difference over 5 mm at 30 lbs was recorded in 12 cases (16%). The pivot shift was glide in 17 cases (19%) and clunk in 10 (11%). A 3°– 5° extension loss compared with the normal side was present in 20 knees (22%) and 6°–10° in 4 knees (4%). The intra-articular exit of the femoral tunnel was misplaced in the anterior 50% of the condyles along the roof of the notch in 10% of the knees. This positioning significantly (P = 0.003) increased the frequency of graft failure (62.5%) compared with the cases with a more posterior placement (graft failure 12%). An anterior position of the intra-articular exit of the tibial tunnel (in the anterior 15% of the sagittal width of the tibia) significantly (P = 0.01) increased the frequency of extension loss > 5°. Medial meniscectomy was associated with a 35% incidence of narrowing of the medial joint space, which was significantly higher compared with knees with normal menisci (9%; P = 0.04) or with medial meniscal repair (7%; P = 0.05). In conclusion this study showed satisfactory anterior stability (KT-2000 side-to-side difference up to 5 mm and pivot absent or glide) in 83% of the knees. This percentage increases to 88% in the knees with a correct posterior and proximal femoral tunnel placement. Accuracy in tunnel positioning is essential for the success of ACL surgery. Meniscal repair was effective in decreasing joint space narrowing and should be attempted when possible.

Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis

Forty-four patients with symptomatic chronic anterior cruciate ligament instabilities that had been recon structed with the central one-third patellar tendon and a lateral extraarticular iliotibial band tenodesis were studied at an average followup of 7 years (range, 4 to 10). The cases with associated medial, lateral, or pos terior laxity were not included, nor were the cases with more than minimal preoperative degenerative changes. The average age at surgery was 21 years (range, 16 to 33). A postoperative cast was used for 4 weeks. Satisfactory objective stability, which was defined as a KT-1000 side-to-side difference of up to 5 mm at the manual maximum test, was obtained in 37 (84%) of the patients. In 25 patients (57%), stability was restored within normal limits (≤3 mm). No deterioration of the KT-1000 stability was noted at two follow-up visits performed by the same examiner (at an average of 4 and 7 years). A return to high-risk sports was possible in 27 (62%) of the patients. Difficulties in regaining a complete range of motion were recorded in 5 (11 %) of the patients. A flexion contracture of 5° to 7° was also found in 5 patients. Significant patellofemoral symptoms were present in 4 patients (9%). A 5% to 11% shortening of the patella tendon was observed in 14 (32%) of the knees, but did not correlate with patellar problems. Moderate radio graphic changes were noted in eight patients (18%) at followup and correlated with meniscectomy and pain. Overall satisfactory results were obtained in this initial experience in 29 (66%) of the patients. We believe that the operation gives reliable stability in the majority of the cases, but the results may be improved with more attention to isometry, earlier postoperative mobilization with complete extension, and a faster rehabilitation course.

Arthroscopic anterior cruciate ligament reconstruction with patellar tendon

Anterior cruciate ligament reconstruction using a bone-patella tendon-bone free autologous graft was performed with an arthroscopic technique in 73 patients with chronic insufficiency. Sixty-nine (94.5%) were available for personal follow-up 3-5 years after the operation. Six patients (8%) had had postoperative difficulties in regaining a complete range of motion. Symptoms of giving-way were cured in 97% of the cases, and 89% had returned to vigorous activities. Residual anterior laxity (defined as pivot shift 2+, and/or Lachman 2+, and/or KT-1000 > 5 mm at the manual maximum) was found in 13% and was more frequent in patients with an uncorrected varus laxity. Patellofemoral crepitus was present in 17% of the knees and was associated with pain and/or swelling in a further 4%; it correlated with radiographic evidence of patellofemoral incongruence (p = 0.009). Comparison of the results with those of a previous series performed by arthrotomy revealed a decreased incidence of limited range of motion, severe patellar symptoms, and changes in patellar height. Stability was the same.

A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction

We performed a comparative study of two series of 25 patellar tendon arthroscopic reconstructions of isolated chronic anterior cruciate ligament injuries, alternating between a double-incision (using a rear-entry guide) or single-incision technique (using a transtibial approach). The patients were reviewed to assess the clinical, KT-2000 and radiological differences at an average follow-up of 14 months (range 8–18 months). For the clinical evaluation the International Knee Documentation Committee Form was used. The following radiographic parameters were measured: (1) the direction of the femoral and tibial tunnels in the antero-posterior (AP) and lateral (LL) views; (2) the location of the anterior border of the intra-articular exit hole of the femoral tunnel in the LL radiologic view; (3) femoral interference screw divergence with the bone block. An extension loss ≤5° was detected in 40% of the double-incision and 36% of the single-incision patients (NS). A flexion loss≤10° was present in 8% of the double-incision and 16% of single-incision group (NS). There were no differences in terms of pivot shift test between the two groups (pivot glide in 12% of both groups). The average side-to-side KT-2000 differences at the manual maximum test were 1.98 mm in the double-incision and 2.64 mm in the single-incision group. With the double-incision technique the fermoral and tibial tunnels were divergent in the AP plane and crossed the joint at an angle of 37° and 72°, respectively. With the single-incision technique the bone tunnels were almost parallel and crossed the joint at an average angle of 68°. The location of the intra-articular exit of the femoral tunnel was posterior in both techniques (63% and 66%, respectively). Screw divergence (≥20°) on the femoral side was absent in the double-incision and present in 12% in the single-incision group (NS). In conclusion, even without straight line tunnels, satisfactory results in terms of stability may be obtained. Despite our similar results, we feel that the single-incision technique is perhaps preferable because there is less postoperative pain and swelling, and it is preferred by the patients. The single-incision technique has a long learning curve.

Anatomic versus non-anatomic tibial fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft

Abstract We prospectively compared two series of 30 anterior cruciate ligament (ACL) reconstructions each where the bone-patellar tendon-bone graft was alternately fixed at the level of the tibial plateau (group A; anatomic fixation) or distal to the plateau level (group B; non-anatomic fixation). In group A, a 35-mm-long tibial tuberosity bone block was harvested. The distal 10–15 mm were resected and fixed proximally to the undersurface of the tendon to shorten it. After an average 18 months’ follow-up, there were no significant differences between the two groups concerning subjective evaluation, symptoms, range of motion and objective stability. Tibial tuberosity pain was more frequent in group A (53% vs 17%, P = 0.01). Radiographic evaluation showed that tibial tunnel enlargement was less frequent in group A (23% vs 43%, P = 0.02). There was no correlation between tunnel enlargement and objective stability. In conclusion, fixation of the graft at the tibial plateau level did not improve objective stability in this study. Because of the greater technical difficulty and occurrence of tibial tuberosity pain, this technique is not recommended.

Neural system of the human posterior cruciate ligament in osteoarthritis

The purpose of this study was to quantify the neural elements in a group of posterior cruciate ligaments from osteoarthritic patients in comparison with normal subjects. Nine ligaments obtained from total knee arthroplasty procedures and five control ligaments from amputated limbs or fresh cadavers were stained with gold chloride. The percentage area occupied by the receptors and the neural network was determined by means of a computer-assisted image analyzer. A significant reduction of the neural elements was observed in the group of ligaments from osteoarthritic patients (0.44 +/- 0.132 SEM vs 0.958 +/- 0.13 SEM, P = .001). The loss of mechanoceptors and the consequent reduction of neural afferences may reduce the functional stability of the joint, participating in the osteoarthritic degenerative process.

Results of surgical treatment of arthrofibrosis after ACL reconstruction.

We prospectively studied 31 knee arthrolyses performed for loss of motion after intra-articular anterior cruciate ligament (ACL) reconstruction. The arthrolysis was performed on average 10.6 months after the reconstruction (range 4–25). Seven knees were localized forms. They were treated with arthroscopic removal of a fibrous nodule and scar tissue anterior to the ACL, which was preserved. Twenty-four knees were global forms and treated arthroscopically (14) or in open procedure (10). Suprapatellar, medial, and lateral gutter adhesions were sectioned, and fibrous tissue was removed from the anterior compartment. A posteromedial and/or posterolateral capsulotomy was necessary in 7 knees. The ACL graft was nonfunctional and/or malpositioned in 19 knees. The results were evaluated with the IKDC form with an average follow-up of 3.5 years (range 1.5–7). Preoperatively the localized forms had an average extension loss of 11° and an average flexion loss of 14° compared to the opposite knee. At follow-up all the knees were satisfactory for symptoms. All except one achieved a satisfactory motion (within 5° of extension loss and 15° of flexion loss) and a satisfactory final result. Global forms had a greater preoperative flexion loss (average 34°) and extension loss (average 17°). At follow-up 58% were satisfactory for symptoms and 71% for arc of motion. However, the final result was satisfactory in only 37%. In conclusion, local forms have a good prognosis. In global forms motion may be improved by surgery, but the final result is downgraded by symptoms. Arthrolyses performed within 8 months from index operation had a better outcome.

Insall-Burstein posterior-stabilized knee prosthesis in rheumatoid arthritis

The authors reviewed 65 Insall-Burstein (Zimmer, Warsaw, IN) total condylar posterior-stabilized knee prostheses in 50 patients with rheumatoid arthritis with a follow-up period of at least 5 years (range, 5-13 years). Forty-two knees in 31 patients were evaluated using the Knee Society knee and functional rating scores. Radiographic assessment was performed using standing long radiographs (hip to ankle). Radiolucent lines were studied using fluoroscopic-centered views. Excellent or good clinical results were obtained in 95% of the cases, and the average knee score improved from 22.5 to 90 points. No cases of radiologic loosening were observed. Incomplete radiolucent lines around the tibial component were detected in only 17% and were nonprogressive. Two patients developed hematogenous late deep infection, which required removal of the prosthesis in both, followed, at a second stage, by arthrodesis in one and prosthesis reimplantation in the other. Three knees (7%) had a painful impingement of the patella. Two of these were successfully reoperated with arthroscopic debridement of the peripatellar synovial tissues. Survivorship analysis, based on endpoints such as prosthesis removal for any cause or radiologic loosening (complete radiolucent line thicker than 1 mm, tilt, or subsidence of the component), showed a cumulative success rate of 96.2% at 13 years.