James H. Lubowitz

Outcome of Single-Bundle Versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament A Meta-Analysis

Background The anterior cruciate ligament (ACL) has 2 anatomic bundles. Standard ACL reconstruction is with a single-bundle graft, but double-bundle reconstruction may better control knee rotational torque, a potential cause of failure after single-bundle reconstruction. The authors investigated outcomes of single-bundle versus double-bundle ACL reconstruction. Hypothesis There is no difference in outcomes of single-bundle versus double-bundle reconstruction. Study Design Meta-analysis. Methods The authors systematically identified randomized controlled trials (RCTs) comparing single-bundle versus double-bundle ACL reconstruction (secondary analysis includes nonrandomized trials). Outcomes reported in a majority of included trials were meta-analyzed. Results Four RCTs were included (secondary analysis including 5 additional trials yielded reassuringly similar results). Two outcome measures were reported (in a manner permitting meta-analysis) in at least 3 of 4 trials: KT-1000 arthrometer and pivot-shift testing. On average, KT-1000 arthrometer side-to-side difference was 0.52 mm closer to normal in patients treated with double-bundle reconstruction. This difference is demonstrated to be clinically insignificant. In addition, there was no statistical difference in the odds of having a normal or nearly normal pivot-shift result in patients treated with double-bundle versus single-bundle reconstruction. Conclusion Double-bundle reconstruction does not result in clinically significant differences in KT-1000 arthrometer or pivot-shift testing. The pivot-shift results have particular clinical relevance because the test is designed to evaluate knee rotational instability; the results do not support the theory that double-bundle reconstruction better controls knee rotation. Improved quality of future RCTs would allow meta-analysis of a greater number of outcome measures including measures of symptoms and disabilities most important to patients.

Anteromedial Portal Technique for the Anterior Cruciate Ligament Femoral Socket: Pitfalls and Solutions

Creating the anterior cruciate ligament (ACL) femoral socket using the anteromedial (AM) portal technique has advantages. Furthermore, the technique is ideal for anatomic double-bundle (particularly posterolateral bundle) and all-inside ACL techniques. However, although the AM portal technique has advantages, the learning curve is steep when making the transition from familiar, transtibial reaming to the AM portal technique for ACL femoral tunnel creation. Complications and challenges are many when learning the AM portal technique. The purpose of this technical note is to describe tips and pearls for surgeons contemplating the transition to the AM portal technique for the ACL femoral socket.

All-Inside Anterior Cruciate Ligament Graft-Link Technique: Second-Generation, No-Incision Anterior Cruciate Ligament Reconstruction

We describe an anatomic, single-bundle, all-inside anterior cruciate ligament (ACL) graft-link technique using second-generation Flipcutter guide pins (Arthrex, Naples, FL), which become retrograde drills, and second-generation cortical suspensory fixation devices with adjustable graft loop length: femoral TightRope (Arthrex) and tibial ACL TightRope-Reverse Tension (Arthrex). The technique is minimally invasive using only four 4-mm stab incisions. Graft choice is no-incision allograft or gracilis-sparing, posteriorly harvested semitendinosus material. The graft is sutured 4 times through each strand in a loop and linked, like a chain, to femoral and tibial adjustable TightRope graft loops. With this method, graft tension can be increased even after graft fixation. The technique may be modified for double-bundle ACL reconstruction.

Current Concepts Review Comprehensive Physical Examination for Instability of the Knee

A careful history and physical examination are the cornerstones of orthopaedic sports medicine. When evaluating a patient for ligamentous instability of the knee joint, an understanding of the contribution of anatomic structures to stability enhances a practitioners ability to achieve an accurate clinical diagnosis. This article reviews the various types of knee instability and the associated anatomic structures. Ultimately, information must be obtained from multiple tests to reach the final diagnosis. We describe in detail the pathologic and biomechanical basis of the tests for both tibiofemoral and patellofemoral instability of the knee joint and provide recommendations for performance and interpretation of these physical examinations.

Anterior Cruciate Ligament Femoral Tunnel Length: Cadaveric Analysis Comparing Anteromedial Portal Versus Outside-In Technique

PURPOSE The purpose was to measure anterior cruciate ligament (ACL) femoral tunnel lengths comparing anteromedial (AM) portal and outside-in techniques. METHODS ACL femoral guide pins were drilled into 12 cadaveric knees through the AM portal technique and then the outside-in technique in each specimen. Pin intraosseous distance was measured in millimeters by a MicroScribe 3-dimensional digitizer (Immersion, San Jose, CA). RESULTS With the AM portal technique, the mean ACL femoral tunnel distance was 30.5 mm. With the outside-in technique, the mean ACL femoral tunnel distance was 34.1 mm. The difference was statistically significant (P = .04). CONCLUSIONS Our results show that the outside-in technique for creating the ACL femoral tunnel results in a longer mean tunnel length than the AM portal technique for creating the ACL femoral tunnel. The outside-in technique best prevents excessively short tunnels. CLINICAL RELEVANCE Our results have clinical relevance for surgeons who desire to perform independent, rather than transtibial, drilling of the ACL femoral tunnel and desire adequate length of tendon graft within the femoral bone tunnel.

Cost-effectiveness analysis of the most common orthopaedic surgery procedures: knee arthroscopy and knee anterior cruciate ligament reconstruction.

PURPOSE The purpose of this study was to determine the cost-effectiveness of knee arthroscopy and anterior cruciate ligament (ACL) reconstruction. METHODS Retrospective analysis of prospectively collected data from a single-surgeon, institutional review board-approved outcomes registry included 2 cohorts: surgically treated knee arthroscopy and ACL reconstruction patients. Our outcome measure is cost-effectiveness (cost of a quality-adjusted life-year [QALY]). The QALY is calculated by multiplying difference in health-related quality of life, before and after treatment, by life expectancy. Health-related quality of life is measured by use of the Quality of Well-Being scale, which has been validated for cost-effectiveness analysis. Costs are facility charges per the facility cost-to-charges ratio plus surgeon fee. Sensitivity analyses are performed to determine the effect of variations in costs or outcomes. RESULTS There were 93 knee arthroscopy and 35 ACL reconstruction patients included at a mean follow-up of 2.1 years. Cost per QALY was

Randomized Controlled Trial Comparing All-Inside Anterior Cruciate Ligament Reconstruction Technique With Anterior Cruciate Ligament Reconstruction With a Full Tibial Tunnel

5,783 for arthroscopy and

Two Steps Forward, One Step Back

10,326 for ACL reconstruction (2009 US dollars). Sensitivity analysis shows that our results are robust (relatively insensitive) to variations in costs or outcomes. CONCLUSIONS Knee arthroscopy and knee ACL reconstruction are very cost-effective.

Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis.

PURPOSE The purpose of this investigation was to compare the clinical effectiveness of full-tunnel anterior cruciate ligament (ACL) reconstructive surgery with all-inside ACL reconstruction. METHODS After statistical power analysis was performed and institutional review board approval and patient informed consent were obtained, 150 patients having ACL reconstruction were prospectively randomized to an all-inside or full-tibial tunnel technique. Outcome (International Knee Documentation Committee [IKDC] Knee Examination Form, IKDC Subjective Knee Evaluation Form, Knee Society Score [KSS], Short Form 12 [SF-12] score, femoral or tibial tunnel or socket widening, narcotic consumption, and visual analog scale [VAS] pain score compared with baseline) was measured and recorded preoperatively and at various postoperative time points with a minimum follow-up of 2 years. RESULTS There were no differences between groups with regard to IKDC Knee Examination Form, IKDC Subjective Knee Evaluation Form, KSS score, SF-12 score, or femoral socket or tibial tunnel or socket widening, or narcotic consumption. The VAS pain score compared with baseline was significantly lower for the all-inside technique on day 1, on day 7, at 1.5 weeks, and at 24 months. CONCLUSIONS The null hypothesis (no difference between all-inside ACL reconstruction and ACL reconstruction with a full tibial tunnel) is supported for IKDC scores, KSS score, SF-12 score, narcotic consumption, and tibial and femoral widening, whereas all-inside ACL reconstruction results in a lower VAS pain score compared with baseline. LEVEL OF EVIDENCE Level I, randomized controlled clinical trial with greater than 80% patient follow-up 2 years postoperatively.

Outcome of Single-Bundle versus Double-Bundle Reconstruction of the Anterior Cruciate Ligament

In Mixed Signals, Kathryn Sikkink has crafted a wellwritten, succinct, and engaging overview not only of the general evolution of the human rights tradition in U.S. foreign policy, but also of its specific application and manifestation in U.S. relations with Latin America. While this book will appeal principally to students of U.S. international relations, and specifically to students of U.S.-Latin American relations, its attention to the evolution of the human rights agenda in Congress and in various U.S. executive agencies also offers an excellent case study of how foreign policy is rooted in the domestic political culture and political system of the United States.