J. Kartus

Complications following arthroscopic anterior cruciate ligament reconstruction. A 2-5-year follow-up of 604 patients with special emphasis on anterior knee pain.

Abstract The aim of the study was to assess knee function after arthroscopic anterior cruciate ligament reconstruction and to analyse complications impeding rehabilitation, additional surgery until the final follow-up, as well as residual patellofemoral pain and donor-site problems. Between 1991 and 1994, 635 patients were operated on using patellar tendon autografts and interference screw fixation. Of these, 604 (95.1%) patients (403 male and 201 female) were re-examined by independent observers at the final follow-up 38 (range 21–68) months post-operatively. The Lysholm score was 85 (range 14–100) points and the Tegner activity level was 6 (range 1–10). Using the IKDC score, 206 patients (34.1%) were classified as normal, 244 (40.4%) as nearly normal, 122 (20.2%) as abnormal and 32 (5.3%) as severely abnormal. In patients with an uninjured contralateral knee (n = 527), the KT-1000 revealed a total side-to-side difference of 1.5 (range –7–11) mm, and 384/527 (72.9%) had a side-to-side difference of ≤ 3 mm. The one-leg-hop test was 95% (range 0%–167%). One or more complications impeding rehabilitation were recorded in 184/604 patients (30.5%). The most common was an extension deficit (> 5°), in 81 patients (13.4%). During the period until the final follow-up, 196 re-operations were performed in 161/604 (26.7%) patients. More than one re-operation was required in 27 patients. Shaving and anterior scar resection due to extension deficit were the most common procedures performed (on 65 occasions). Moderate to severe subjective anterior knee pain related to activity, walking up and down stairs, and sitting with the knee flexed was found in 203/604 patients (33.6%). The median loss of anterior knee sensitivity was 16 (range 0–288) cm2. Patients with a full range of motion had less anterior knee pain than patients with isolated flexion or extension deficits, or combined flexion and extension deficits (P < 0.05, P = 0.08 and P < 0.001, respectively). Patients with a full range of motion had less anterior knee pain than patients with extension deficits (with and without flexion deficits) (P < 0.001). Patients with a full range of motion and a minimal loss (≤ 4 cm2) of anterior knee sensitivity had significantly (P < 0.01) less subjective anterior knee pain than patients who did not fulfil these criteria. A considerable number of complications hindering the rehabilitation and conditions requiring additional surgery until the final follow-up were recorded. Anterior knee pain and problems with knee-walking were correlated with the loss of range of motion and anterior knee sensitivity.

Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts

Abstract The objective of this study was to assess knee function after anterior cruciate ligament reconstruction focusing on residual donor-site problems. Ninety consecutive patients with chronic unilateral anterior cruciate ligament rupture were operated on by the same surgeon using patellar tendon autografts, the all-inside arthroscopic technique, and interference screw fixation. At the follow-up examination 24 (range 22– 32) months after the index operation, the median total anterior-posterior KT-1000 side-to-side difference was 2.5 (–7 to 11) mm. The median Lysholm score was 86 (range 37–100) points and the median Tegner activity level was 6 (range 1–9). Using the IKDC evaluation system, 62 of 90 (69%) were classified as normal or nearly normal. The median one-leg-hop quotient was 93 (range 0– 167)% of the uninjured leg. Of 90 patients, 44 (49%) had minor or no discomfort when asked to walk on their knees (kneewalkers) and 46 of 90 (51%) patients had severe problems or found it impossible to perform the test (non-kneewalkers). The ‘kneewalkers’ had a median loss of anterior knee sensitivity of 10 (range 0–120) cm2. The corresponding value for the ‘non-kneewalkers’ was 25 (range 0–200) cm2 (P = 0.0001). Palpatory donor-site tenderness was registered in 19 of 44 (43%) of the ‘kneewalkers’ and 37 of 46 (80%) of the ‘non-kneewalkers’ (P < 0.001). Full hyperextension was not regained by 9 of 44 (20%) of the ‘kneewalkers’ and 19 of 46 (41%) of the ‘non-kneewalkers’ (P < 0.05). Additional surgery during the follow-up period was required by 6 of 44 (14%) of the ‘kneewalkers’ and 19 of 46 (41%) of the ‘non-kneewalkers’ (P < 0.01). Magnetic resonance imaging focusing on the donor site was performed on 31 randomly selected patients and revealed no difference between the ‘kneewalkers’ and the ‘non-kneewalkers’ in terms of patellar tendon width, thickness, length, and residual donor-site gap size. The kneewalking test was found to be a functional and reliable test for detecting donor-site morbidity. It appears that donor-site morbidity was related to problems requiring additional surgery during the follow-up period, such as extension deficit and pain near the metal implant on the tibial side, as well as the loss of anterior knee sensitivity. It appears to be important to attempt to preserve the sensitivity in the operated area during surgery and to regain full hyperextension in the post-operative period to minimize donor-site morbidity.

Arthroscopic and open shoulder stabilization using absorbable implants. A clinical and radiographic comparison of two methods.

Abstract The aim of this study was to compare the clinical and radiographic results in patients with recurrent unidirectional, post-traumatic shoulder instability (dislocations/subluxations). All the patients had a Bankart lesion and underwent reconstruction using either an open or an arthroscopic technique and absorbable implants. Thirty-three consecutive patients (36 shoulders) were operated on by one surgeon. Group A comprised 18 shoulders which underwent an open Bankart reconstruction using absorbable 3.7-mm TAG suture anchors. Group B comprised 18 shoulders which underwent a combination of an intra- and extra-articular arthroscopic stabilization using 8-mm Suretac fixators. The median number of dislocations before the reconstruction was 5 (0–45) in group A and 4 (0–30) in group B (NS). The follow-up examination was performed by an independent observer after a median of 31 (range 25–38) months in group A and 28 (range 18–46) months in group B (NS). An independent radiologist without any knowledge of the surgical procedure evaluated all the radiographs. There were no re-dislocations in either group. In group A, the Rowe and Constant scores were 86 (range 61–98) and 89 (range 73–99), respectively. The corresponding values in group B were 92 (range 83– 98; P = 0.05) and 96 (range 75– 100; NS). The external rotation in abduction was 65° (range 20°–90°) in group A and 83° (range 65°–105°) in group B (P = 0.0017). The radiographs revealed that 10/18 (56%) in group A and 4/18 (23%) in group B had visible drill-holes or cystic formations in conjunction with the drill-holes (P = 0.002). In this study the open procedure resulted in a restriction in external rotation more frequently than the arthroscopic procedure. The radiographs revealed visible drill-holes or cystic formations in conjunction with the drill-holes more frequently when TAG suture anchors were used than when Suretac fixators were used. The radiographic changes did, not appear to affect the clinical outcome, however.

Evaluation of the reproducibility of the KT‐1000 arthrometer

The aim of the study was to examine whether the KT‐1000 arthrometer was reliable when it came to distinguishing between a group of patients with a chronic anterior cruciate ligament (ACL) rupture and a group of patients without an ACL rupture, and to examine the reproducibility of the examination between two experienced examiners. The aim was also to examine whether the KT‐1000 measurements were dependent on whether the patients were awake or under anaesthesia. The study comprised 40 patients: Group A consisted of 20 patients who had a chronic unilateral ACL rupture and Group B consisted of 20 patients who were scheduled for arthroscopy due to knee problems other than an ACL rupture. The KT‐1000 examination was performed before surgery by two experienced physiotherapists (PT I and PT II). PT II subsequently performed a retest of the patients under anaesthesia. The mean anterior side‐to‐side laxity difference between PT I and PT II was 0.2 mm in Group A and 1.8 mm in Group B (n.s., P=0.03). The anterior side‐to‐side measurements of knee laxity revealed significant differences between Group A and Group B, independent of who the measurements were made by when the patients were awake (PT I P=0.011, PT II P=0.001). However, no significant difference (P=0.063) was found when the patients were under anaesthesia. The interclass correlation coefficient (ICC) between PT I and PT II in Group A was 0.55 (P=0.005) for the anterior side‐to‐side laxity, while it was 0.60 (P=0.002) in Group B. There were no significant differences within Group A or Group B between the measurements made when people were awake compared with those under anaesthesia. The conclusions of the study were that the KT‐1000 arthrometer was able to distinguish a group of patients with an ACL rupture from a group without one. The reproducibility of the KT‐1000 measurements of anterior knee laxity between two experienced examiners was considered as fair. Furthermore, the measurements were not dependent on whether the patients were awake or under anaesthesia.

A comparison of results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes A two‐ to five‐year follow‐up of 429 patients

The aim of this study was to compare the results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes who had a pre‐injury Tegner activity level of ≥7 and a non‐injured contralateral anterior cruciate ligament. One hundred and thirty‐three female and 296 male patients were followed at 38 (21–68) months after the index operation. All the patients were operated on by experienced knee surgeons using patellar tendon autografts and interference screw fixation. At the index operation the median age of the female patients was 23 (16–45) years and the median age of the male patients was 26 (16–47) years. The reconstruction was performed a median of 10 (0–141) and 10 (0–203) months after the injury in women and men respectively. The patients were re‐examined by independent observers. At the follow‐up, the median Lysholm score was 89 (38–100) points in the female group and 90 (22–100) points in the male group (P=0.015). The IKDC evaluation system, subjective anterior knee pain, subjective evaluation of the results, the knee‐walking test and the KT‐1000 tests revealed no differences between the groups. The mean (±2 SD) pre‐injury Tegner activity level was 8.1 (±1.9) (median 8 (7–10)) in the female group and 8.4 (±1.8) (median 9 (7–10)) in the male group (P=0.003). At the follow‐up, the Tegner activity level was 6.2 (±3.8) in the female group and 6.8 (±3.6) in the male group (P=0.012). At the follow‐up, the Tegner activity level had decreased by 1.9 (±3.8) for the women and 1.6 (±3.3) for the men, as compared with the pre‐injury level (n.s.). The difference between the performed and the desired activity level at the follow‐up was 1.1 (±3.2) in the female group and 0.9 (±3.0) in the male group (n.s.). In the female group 53/133 (40%) and in the male group 115/296 (39%) returned to the pre‐injury activity level (n.s.). The median one‐leg‐hop quotient was 93 (0–116)% in the female group and 96 (0–130)% in the male group (P=0.006). Concomitant meniscal injuries prior to the index operation, at the index operation or during the follow‐up period were found in 64/133 (48%) women and in 185/296 (62%) men (P<0.01). The main conclusion was that the overall results in female and male athletes were comparable two to five years after the anterior cruciate ligament reconstruction. However, concomitant meniscal injuries were more common in male than females athletes after anterior cruciate ligament injuries.

Serial magnetic resonance imaging of the donor site after harvesting the central third of the patellar tendon. A prospective study of 37 patients after arthroscopic anterior cruciate ligament reconstruction.

Abstract The aim of this prospective study was to follow the development of repair tissue in the donor-site area using serial magnetic resonance imaging (MRI) evaluation and to assess whether the MRI findings were correlated with donor-site morbidity. Thirty-seven consecutive patients with unilateral anterior cruciate ligament injuries undergoing elective reconstruction of the ligament were included in the study. They were aged 27 (range 14–50) years. The graft was harvested through two 25-mm vertical incisions with the aim of protecting the infrapatellar nerve and sparing the paratenon. The tendon defect was left open. The patients underwent MRI evaluation at 6 weeks, 6 months and 27 months postoperatively. A final clinical follow-up was made 25 (range 23–29) months postoperatively. MRI demonstrated that the donor-site gap, i.e. the area corresponding to a pathological non-tendinous-like tissue signal, was 9 (range 4–18) mm at 6 weeks, 5 (range 2–14) mm at 6 months and 2 (range 0–5) mm at 27 months. The size of the donor-site gap had significantly decreased at 6 months compared with 6 weeks (P = 0.0001), as well as at 27 months compared with 6 months (P = 0.0001). We conclude that the patellar tendon at the donor site healed gradually, as expressed by a decrease in the area of non-tendinous-like tissue signal on the serial MRI evaluations.

Comparison of arthroscopic one-incision and two-incision techniques for reconstruction of the anterior cruciate ligament.

The purpose of this study was to assess the outcome of arthroscopic anterior cruciate ligament reconstruction performed using either the ‘one‐incision’ technique or the rear‐entry ‘two‐incision’ technique. A series of 221 consecutive patients who underwent anterior cruciate ligament reconstruction was reviewed retrospectively. In the study population, two subgroups were defined. Group A consisted of 118 patients who underwent reconstruction using the one‐incision transtibial endoscopic technique and Group B consisted of 103 patients who underwent reconstruction using the two‐incision technique. The groups were comparable in terms of age, sex and activity level. The follow‐up was performed after 47 (40–68) months in Group A and 55 (40–68) months in Group B. The Lysholm score at the final follow‐up was significantly lower in Group A (90, 38–100) than in Group B (94, 34–100) (P=0.002). The median KT‐1000 total side‐to‐side difference was 1.5 (‐6 to 7.5) mm in Group A, and 2.0 (‐3.5 to 9) mm in Group B (n.s.). No significant difference between the groups was found when the IKDC evaluation system was used. Four intra‐operative complications were registered in Group A and none in Group B (P=0.06). No significant difference was found in terms of anterior knee pain, the one‐leg‐hop quotient or the activity level at the final follow‐up. In this study the two methods gave similar and satisfactory results. Serious intra‐operative complications were, however, recorded in four cases when the one‐incision technique was used.

Outcome of anterior cruciate ligament reconstruction with emphasis on sex-related differences

The aim of this retrospective study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using the four‐strand semitendinosus‐gracilis (ST/G) autograft in male (n=141) vs female (n=103) patients. The patients were operated on between 1996 and 2005, using interference screw fixation and drilling the femoral tunnel through the anteromedial portal. The pre‐operative assessments and demographics, apart from age (males 29 years, females 26 years; P=0.02), were comparable at the time of surgery. At 25 (23–36) months post‐operatively, no significant differences were found between the study groups in terms of anterior side‐to‐side knee laxity, manual Lachman test, Tegner activity level, Lysholm knee score, range of motion or donor‐site morbidity. Both study groups improved significantly in most clinical assessments and functional scores compared with their pre‐operative values. Two years after ACL reconstruction using ST/G autografts, there were no significant differences between male and female patients in terms of clinical outcome or functional scores.

Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction

The life situation of many patients changes after an anterior cruciate ligament (ACL) rupture and subsequent reconstruction, and this may affect their health‐related quality of life in many ways. It is well known that the overall clinical results after ACL reconstruction are considered good, but pre‐operative predictive factors for a good post‐operative clinical outcome after ACL reconstruction have not been studied in as much detail. The purpose of this study was to identify pre‐operative factors that predict a good post‐operative outcome as measured by the Short Form 36 (SF‐36) and Knee Osteoarthritis Outcome Score (KOOS) 3–6 years after ACL reconstruction. Seventy‐three patients scheduled for ACL reconstruction were clinically examined pre‐operatively. The SF‐36 and KOOS questionnaires were sent by mail to these patients 3–6 years after reconstruction. Predictive factors for health‐related quality of life were investigated using a stepwise regression analysis. In conclusion, pre‐operative factors, such as pivot shift, knee function, and range of motion, may predict a good post‐operative outcome and explain up to 25% in terms of health‐related quality of life after ACL reconstruction. Furthermore, it appears that the patients’ pre‐injury and pre‐operative Tegner activity levels are important predictors of post‐operative health‐related quality of life.

Comparison of functional outcome after anterior cruciate ligament reconstruction resulting in low, normal and increased laxity

The aim of the study was to analyse and compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using patellar tendon autografts in three groups of patients. The groups were determined by knee laxity as measured with the KT‐1000 arthrometer at the follow‐up two to five years after the reconstruction. Group A (n=15) had an anterior side‐to‐side laxity difference of <−3 mm (i.e. the reconstructed knee was less lax than the contralateral non‐injured knee), Group B (n=376) had a difference of ≥−1, but ≤+2 mm and Group C (n=38) had a difference of ≥6 mm. All the patients had a normal contralateral knee. In Group A, 7/15 (47%) patients and, in Group B, 82/375 (22%) patients had an extension deficit of ≥5° (P=0.052). The corresponding values in terms of flexion deficit were 8/15 (53%) and 99/375 (26%) respectively (P=0.04) (one missing value in Group B). In Group C, 14/38 (37%) had an extension deficit (P=0.04; Group B vs Group C). Group C displayed worse results than Group B in terms of the Lysholm score and the one‐leg‐hop test (P=0.001 and P=0.011 respectively). The corresponding comparison between Group A and Group B revealed no significant differences. We conclude that a considerable number of patients showed persisting deficits in range of motion (ROM) after an ACL reconstruction. No major differences were found if they were analysed in subgroups with decreased, near normal or with increased knee laxity. The worst residual functional impairment, as measured with the Lysholm score and one‐leg‐hop test, was found in the group with increased knee laxity and most ROM deficits in the knees with decreased laxity.