Karl Eriksson

A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial.

A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients

The best treatment for the active and lucid elderly patient with a displaced intracapsular fracture of the femoral neck is still controversial. Randomised controlled trials have shown that a primary total hip replacement is superior to internal fixation as regards the need for secondary surgery, hip function and health-related quality of life. Despite good results achieved with total hip replacement in this group, most orthopaedic surgeons still advocate hemiarthroplasty for this injury. We studied 120 patients with a mean age of 81 years (70 to 90) with an acute displaced intracapsular fracture of the femoral neck. They were randomly allocated to be treated with either a bipolar hemiarthroplasty or total hip replacement. Outcome measurements included peri-operative data, general and hip-specific complications, hip function and health-related quality of life. The patients were reviewed at four and 12 months. The duration of surgery was longer in the total hip replacement group (102 minutes (70 to 151)) versus 78 minutes (43 to 131) (p<0.001), and the intra-operative blood loss was increased 460 ml (100 to 1100) versus 320 ml (50 to 850) (p<0.001), but there were no differences between the groups regarding any complications or mortality. There were no dislocations in either group. Hip function measured by the Harris hip score was significantly better in the total hip replacement group at both follow-up periods (p=0.011 and p<0.001, respectively). The health-related quality of life measure was in favour of the total hip replacement group but did not reach statistical significance (p=0.818 at four months and p=0.636 at 12 months). These results indicate that a total hip replacement provides better function than a bipolar hemiarthroplasty as soon as one year post-operatively, without increasing the complication rate. We recommend total hip replacement as the primary treatment for this group of patients.

Increased Risk of Osteoarthritis After Anterior Cruciate Ligament Reconstruction A 14-Year Follow-up Study of a Randomized Controlled Trial

Background: The reported prevalence of radiological osteoarthritis (OA) after anterior cruciate ligament (ACL) reconstruction varies from 10% to 90%. Purpose/Hypothesis: To report the prevalence of OA after ACL reconstruction and to compare the OA prevalence between quadrupled semitendinosus tendon (ST) and bone–patellar tendon–bone (BPTB) grafts. The hypothesis was that there would be no difference in OA prevalence between the graft types. The secondary aim was to study whether patient characteristics and additional injuries were associated with long-term outcomes. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Radiological examination results, Tegner activity levels, and Knee injury and Osteoarthritis Outcome Score (KOOS) values were determined in 135 (82%) of 164 patients at a mean of 14 years after ACL reconstruction randomized to an ST or a BPTB graft. Osteoarthritis was defined according to a consensus by at least 2 of 3 radiologists of Kellgren-Lawrence grade ≥2. Using regression analysis, graft type, sex, age, overweight, time between injury and reconstruction, additional meniscus injury, and a number of other variables were assessed as risk factors for OA 14 years after ACL reconstruction. Results: Osteoarthritis of the medial compartment was most frequent, with 57% of OA cases in the ACL-reconstructed knee and 18% of OA cases in the contralateral knee (P < .001). There was no difference between the graft types: 49% of OA of the medial compartment for BPTB grafts and 65% for ST grafts (P = .073). The KOOS results were lower for patients with OA in all subscales, indicating that OA was symptomatic. No difference in the KOOS between the graft types was found. Meniscus resection was a strong risk factor for OA of the medial compartment (odds ratio, 3.6; 95% CI, 1.4-9.3) in the multivariable logistic regression analysis. Conclusion: A 3-fold increased prevalence of OA was found after an ACL injury treated with reconstruction compared with the contralateral healthy knee. No differences in the prevalence of OA between the BPTB and quadrupled ST reconstructions were found. An initial meniscus resection was a strong risk factor for OA; the time between injury and reconstruction was not.

The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement

We carried out a retrospective cohort study of 3309 patients undergoing primary total hip replacement to examine the impact of tobacco use and body mass index on the length of stay in hospital and the risk of short term post-operative complications. Heavy tobacco use was associated with an increased risk of systemic post-operative complications (p = 0.004). Previous and current smokers had a 43% and 56% increased risk of systemic complications, respectively, when compared with non-smokers. In heavy smokers, the risk increased by 121%. A high body mass index was significantly associated with an increased mean length of stay in hospital of between 4.7% and 7%. The risk of systemic complications was increased by 58% in the obese. Smoking and body mass index were not significantly related to the development of local complications. Greater efforts should be taken to reduce the impact of preventable life style factors, such as smoking and high body mass index, on the post-operative course of total hip replacement.

High body mass index is associated with increased risk of implant dislocation following primary total hip replacement: 2,106 patients followed for up to 8 years

Background and purpose Implant dislocation is one of the commonest complications following primary total hip replacement (THR). We investigated the effect of body mass index (BMI) and tobacco use on the risk of this complication. Subjects and methods Through linkage between the Swedish Construction Workers’ cohort and the Swedish Inpatient Register, 2,106 male patients who had undergone primary THR between 1997 and 2004 were identified. We used Cox multivariable regression analysis to study the association between BMI and tobacco use and the risk of implant dislocation. Results 53 patients (2.5%) developed implant dislocation during a mean of 2 (0–3) years of follow-up. We found overweight and obesity to be associated with increased risk of implant dislocation (HR = 2.5,95% CI: 1.1–5.5 and HR = 3.7, 95% CI: 1.5–9.3, respectively as compared to those of normal weight). There was no statistically significant association between tobacco use and the risk of dislocation. Interpretation Greater attention should be given to high BMI as a risk factor for implant dislocation following THR.

Semitendinosus Muscle in Anterior Cruciate Ligament Surgery: Morphology and Function

PURPOSE To evaluate the fate of the hamstring muscles in general and the semitendinosus muscle in particular, after anterior cruciate ligament (ACL) reconstruction with an autologous semitendinosus tendon graft from the ipsilateral side. TYPE OF STUDY Prospective consecutive case series investigation. METHODS Included were 16 consecutive patients, 14 male and 2 female, with a mean age of 26 years. The inclusion criterion was chronic unilateral ACL insufficiency with no concomitant knee ligament injuries. ACL reconstruction was performed with a quadruple semitendinosus tendon graft using the EndoButton technique (Acufex, Mansfield, MA). Intraoperatively, muscle specimens were taken from the semitendinosus muscle on the harvested side. Follow-up at a minimum of 6 months included clinical examination, isokinetic strength performance, magnetic resonance imaging (MRI) of the thigh and knee, and ultrasound-guided muscle biopsy procurement from the semitendinosus muscle for histochemical and enzymatic analyses. RESULTS Of the patients, 75% showed regeneration of their semitendinosus tendons. The neotendons all inserted below the knee joint where they had fused with the gracilis tendon to a conjoined tendon inserting in the pes anserinus. The semitendinosus muscle had a smaller cross-sectional area on the operated side but none showed total atrophy. Less atrophy was present in the patients with a regenerated semitendinosus neotendon compared with those without regeneration (P =.029). In the latter group the semimembranosus muscle seemed to compensate for this with hypertrophy (P =.019). Cross-sectional muscle fiber areas, the relative number of each fiber type and oxidative potential as estimated by citrate synthase activity, showed no significant differences between the operated and nonoperated legs. The isokinetic strength of the hamstrings and quadriceps was significantly lower in the operated leg than in the nonoperated leg. CONCLUSIONS With this surgical technique, the semitendinosus muscle can recover and the tendon has, according to the MRI images, a great potential to regenerate after its removal.

Semitendinosus tendon regeneration after harvesting for ACL reconstruction. A prospective MRI study.

Abstract Utilisation of the semitendinosus and gracilis tendons in reconstruction of the anterior cruciate ligament (ACL) has become more common during the last few years. In recent studies a regeneration potential in the harvested tendons has been observed. In this study, 11 consecutive patients who underwent ACL reconstruction with a quadruple semitendinosus graft were examined 6–12 months postoperatively by MRI. Another two patients were examined within 2 weeks after surgery. The median age of the patients was 24 years and there were 8 males and 3 females. The right knee was involved in six patients and the left knee in five. A low-field 0.2 Tesla Siemens open MRI was used for examinations and T1 and T2 weighted transaxial sequences over the thigh and the knee joint were performed. In some instances, additional sagittal sequences were used. ROI analysis of the pixel value of the signal and area determinations on transaxial sequences was performed for both the involved and the healthy side. In 8 of the 11 patients examined 6–12 months postoperatively, a regeneration of the semitendinosus tendon with normal anatomical topographies to the level of the tibial plateau was found. Three of these eight patients were analysed more distally and fusion of the semitendinosus and gracilis tendons was found approximately 30 mm below the joint line before they inserted as a “conjoined tendon” into the pes anserinus. At the mid-thigh level, the semitendinosus muscle had a smaller area and a higher signal than that on the normal side. However, this difference was smaller in the patients showing normal distal tendon regeneration. This study indicates that the semitendinosus tendon has a strong potential for regeneration and that the muscle atrophy seems to be less in the patients with a more normalised distal insertion of the tendon in the pes anserinus.

The semitendinosus tendon regenerates after resection: A morphologic and MRI analysis in 6 patients after resection for anterior cruciate ligament reconstruction

Recently, the surprising observation has been made, supported by clinical and MRI findings, that the semitendinosus tendon can regenerate after being harvested in its whole length and thickness for anterior cruciate ligament reconstruction. We studied 6 patients with previous anterior cruciate ligament reconstruction, using a quadruple semitendinosus tendon autograft. In 5 of these, physical examination and MRI showed that the tendond had regenerated. In all 6 patients, the findings were documented macroscopically by open surgical exploration and in the 5 regenerated tendons, also morphologically by biopsies. Macroscopically, histologically and immunohistochemically the regenerated tendons closely resembled normal ones with focal scar-like areas. Our present findings and earlier studies show that full length and thickness harvesting of the semitendinosus tendon in most cases result in full-length tendon regeneration with tissue closely resembling the normal tendon.

Quality of Life and Clinical Outcome After Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Graft or Quadrupled Semitendinosus Graft: An 8-Year Follow-up of a Randomized Controlled Trial

Background: Randomized controlled trials after anterior cruciate ligament reconstructions with long-term follow-up including assessment of health-related quality of life are rare. Purpose: To compare clinical outcome and health-related quality of life 8 years after anterior cruciate ligament reconstruction using 2 types of graft. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Long-term follow-up of 164 patients with anterior cruciate ligament injury randomized to arthroscopic reconstruction with a quadrupled semitendinosus graft or a bone–patellar tendon–bone graft was undertaken. After a mean 8 years, 153 patients were available for follow-up, including instrumented laxity, 1-legged hop test, a knee-walking test, and assessment with International Knee Documentation Committee, Lysholm, Tegner, and patellofemoral pain score. Health-related quality of life was assessed with Knee Osteoarthritis Outcome Score and Short Form–36. Results: Patients in both graft groups retained the same stability, knee function, and health-related quality of life. The patellofemoral pain score was similar for both groups; the bone–patellar tendon–bone group had more donor site morbidity from kneeling and knee walking. In the bone–patellar tendon–bone group, 19 patients had no kneeling problems, 23 slight problems, 31 moderate problems, and 5 unable to kneel. Corresponding figures for the semitendinosus group were 25, 32, 16, and 2 (P < .001). Patients with early reconstructions (<5 months) had a lower risk for meniscal injuries (37%) than did later reconstructed (62%, P = .008). Health-related quality of life regarding physical functioning in Short Form–36 was better for the early-reconstructed patients than for the later reconstructed (92 vs 85; P = .014). Patients without medial meniscal surgery had higher Knee Osteoarthritis Outcome Scores for all subscales than did patients with medial meniscal surgery, with most significant difference for sport and recreation (63 vs 75, P = .008). Conclusion: In the long term, the semitendinosus graft provided similar stability, knee function, and health-related quality of life but with less kneeling morbidity than did the bone–patellar tendon–bone graft.

There are differences in early morbidity after ACL reconstruction when comparing patellar tendon and semitendinosus tendon graft

The main objective of this study was to study solely early postoperative morbidity following anterior cruciate ligament (ACL) reconstruction by comparing the gold standard procedure, the bone‐patellar tendon‐bone graft (BTB), and one of the most common alternatives, the semitendinosus tendon graft (ST). The prospective study included 107 randomized patients (50 BTB and 57 ST). The follow‐up period was set to 20–35 weeks postoperatively (mean 26.8±3.5 weeks). One patient suffered early graft rupture and 89 (84%) of the remaining 106 patients were able to attend the follow‐up within the given time limit. There were no differences in sick leave between the groups. The Lysholm score, Tegner activity level score and Visual Analog Scales (VAS) with the questions “How does your knee function?” and “How does your knee affect your activity level?” revealed no differences between the groups. Subjective patellofemoral pain, patellofemoral compartment findings and donor site morbidity were more common in the BTB group, P<0.05. Lachman test grade 1+ was more common in the ST group, P<0.05, but there was no significant difference in instrumented Lachman side‐to‐side comparison. The ST group scored better in the one‐leg hop test than the BTB group, P<0.05. No correlations between these clinical and functional findings and subjective knee function scores were found. In conclusion, ACL reconstruction with ST tendon graft presented fewer short‐term postoperative problems as compared to reconstruction with BTB.