Magnus Odensten

Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture : A randomized study with a 15-year follow-up

We investigated the long‐term outcome of 100 patients 15 years after having been randomly allocated to primary repair (augmented or non‐augmented) or non‐surgical treatment of an anterior cruciate ligament (ACL) rupture. The subjective outcome was similar between the groups, with no difference regarding activity level and knee‐injury and osteoarthritis outcome score but with a slightly lower Lysholm score for the non‐surgically treated group. This difference was attributed to more instability symptoms. The radiological osteoarthritis (OA) frequency did not differ between surgically or non‐surgically treated patients, but if a meniscectomy was performed, two‐thirds of the patients showed OA changes regardless of initial treatment of the ACL. There were significantly more meniscus injuries in patients initially treated non‐surgically. One‐third of the patients in the non‐surgically treated group underwent secondary ACL reconstruction due to instability problems. In this study, ACL repair itself could not reduce the risk of OA nor increase the subjective outcome scores. However, one‐third of the non‐surgical treated patients were later ACL reconstructed due to instability. The status of the menisci was found to be the most important predictor of developing OA. Early ACL repair and also ACL reconstruction can reduce the risk of secondary meniscus tears. Indirectly this supports the hypothesis that early stabilization of the knee after ACL injury is advantageous for the long‐term outcome.

Knee function after surgical or nonsurgical treatment of acute rupture of the anterior cruciate ligament: a randomized study with a long-term follow-up period.

One hundred fifty-six patients with a total rupture of the anterior cruciate ligament (ACL) were reexamined 41 to 80 months after injury. They were randomized to three treatment groups: (1) repair and augmentation of the ACL with an iliotibial strip, (2) repair without augmentation, and (3) nonsurgical ACL treatment. Associated injuries of menisci and other ligaments were treated in the same way for the three groups. Two-thirds of the patients in the nonsurgically treated group complained of instability and 17% had had a subsequent reconstruction of the ACL at the follow-up examination. The group treated with an augmented repair had a less abnormal laxity measured by a laxity-testing device. Sixty-three percent returned to competitive sports, as compared with 27% in the nonsurgical group and 32% in the only repair group. Relative strength of the quadriceps and hamstrings muscles were similar for all groups. The augmented-repair group had better hop tests, reflecting a superior stability, whereas running was not affected by treatment but was correlated with the activity level.

INTERCONDYLAR NOTCH MEASUREMENTS WITH SPECIAL REFERENCE TO ANTERIOR CRUCIATE LIGAMENT SURGERY

The femoral intercondylar notch width was measured in 93 patients with chronic anterior cruciate ligament (ACL) insufficiency (Group 1), in 62 patients with an acute tear of the ACL (Group 2), and in 38 fresh anatomic specimen knees (Group 3). In six of the specimen knees, further anatomic studies of the intercondylar notch were performed after tissue removal. The average intercondylar distance was 16.1 mm in Group 1, 18.1 mm in Group 2, and 20.4 mm in Group 3. All differences were highly significant. The intercondylar notch was wider in the posterior part and had no crossing bony ridges but had generally concave walls, which provided a functional shelf for the ACL to insert on the lateral side. Significant osteophyte formation and stenosis of the anterior outlet of the intercondylar notch occur early in the ACL-deficient knee. A narrow anterior outlet of the intercondylar notch without osteophytes was also found in knees with an acute ACL rupture. At reconstruction of the ACL, notchplasty should be performed concomitantly.

Suture of fresh ruptures of the anterior cruciate ligament: A 5-year follow-up

Thirty-five of 41 consecutive patients were followed for 5 years after early primary suture of the acutely torn anterior cruciate ligament and repair of all other injured structures; three early failures were excluded from the series, and three patients were lost to follow-up. Twenty-three of the patients also had an early follow-up 2 years postoperatively. From the early to the late follow-up, the function of the operated knees decreased significantly.

Evaluation of cruciate ligament injuries : A review.

A good system for evaluating the degree of impairment, disability, and handicap of the patient with a cruciate ligament injury includes functional score, activity grading, stability testing, and measurements of performance and strength, all of which are relevant to different aspects of knee function. The symptom-related knee score gives a more differentiated picture of the disability than does a binomial rating of symptoms. A way of grading the disability in an objective way is to use a performance test. This test could also be used for monitoring rehabilitation before full activity has been resumed. The activity grading scale is very useful for grading the handicap.

Sagittal Knee Stability After Anterior Cruciate Ligament Reconstruction with a Patellar Tendon Strip A Two-year Follow-up Study

Tibial anteroposterior displacement after anterior cru ciate ligament reconstruction with a patellartendon graft was followed prospectively for 2 years in 24 patients with an arthrometer. The femoral ligament insertion lo cation, in a lateral projection, and the change in intra articular fixation distance, measured with an isometer, were documented intraoperatively. Two years after sur gery, the overall mean injured-noninjured difference in anteroposterior displacement was 2.0 ± 2.3 mm. All grafts were fixed during surgery at 20° of knee flexion. Patients for whom this angle coincided with the angle of minimum intraarticular fixation distance (Group I), and patients who had a femoral ligament insertion location >2 mm anterior to the center of the normal anterior cru ciate ligament attachment (Group A) showed larger tibial displacement than the other patients. An injured- noninjured difference in tibial anteroposterior displace ment ≥3 mm was classified as failure. Groups I and A failure rates were higher than for the other patients. No correlation was found between anteroposterior dis placement and magnitude of the change in intraarticular fixation distance. We conclude that anterior femoral lo cations lead to larger sagittal play after 2 years than central or posterior locations and that the magnitude of the fixation distance is less important than the pattern.

Reconstruction of old anterior cruciate ligament tears with a Dacron prosthesis A prospective study

Seventy patients with chronic anterior instability under went anterior cruciate ligament reconstruction with a Dacron prosthesis pretensioned to 60 N. Of these patients, 49% (34) had combined medial instability, 32% (22) had failed previous anterior cruciate ligament sur gery, and 37% (26) had previous meniscectomy. At reconstruction, 12 patients had their medial instability treated; 22 did not. Follow-up intervals were 3, 6, and 12 months and then each year to 5 years. The 5-year followup included 69 patients; the other 1 had the ligament removed because of a synovial fistula at 8 months. Results were 23% prosthesis ruptures, 3% poor, 17% fair, 16% good, and 39% excellent. The 2-year results showed the same distribution, but a lower rupture rate, which was affected by placement of the tibial tunnel within the anterior one-third of the tibia (9 times increase) and coexisting nonrepaired me dial instability (5 times increase). Those patients with perfect placement of the ligament who also had good medial stability and no previous ligament surgery had no rupture at 5 years. The stability that was gained at surgery was gradually lost (-11.2% per year). At 5 years, the uninjured knee also had lost 41% of the preoperative stability; the mean laxity difference was within ±2 mm. The mean improvement in subjective knee function (Lysholm score 74.5 to 91.9) was main tained during the followup. The mean preoperative ac tivity level improved significantly, but did not reach the preinjury level. These results show that the Dacron prosthesis will not give acceptable results in salvage cases where other instabilities are left untreated.

The course of partial anterior cruciate ligament ruptures

In a prospective study 21 consecutive patients were followed up for an average of 6 years after partial tear of the anterior cruciate ligament (ACL) diagnosed by clinical examination and arthroscopy. The ACL tear was treated conservatively and associated lesions were su tured. At followup a knee function score was recorded. The maximum possible score was 100 points. The mean score at followup was 93 ± 6 points. All patients were classified as good or excellent. Three knees were unstable at followup, but the score was not impaired. With a partial tear of the ACL the course is benign and the long-term result good, in contrast to total ruptures of ACLs. It is, therefore, important to make an accurate diagnosis in order to choose the proper treat ment.

Precision in reconstruction of the anterior cruciate ligament: A new positioning device compared with hand drilling

To evaluate the precision of a drill guide for use in anterior cruciate ligament reconstruction and the reproducibility of the results, the device was tested in 30 operations (Group 1); 17 operations were done freehand (Group 2); 10 cadaver knees served as anatomic controls. The internal orifices of the bony channels in Groups 1 and 2 and the central point of the anterior cruciate ligament attachments in the cadaver group were identified on lateral radiographic views. The position of the tibial ligament attachments in the cadaver group did not differ from the orifices of the drilled channels in Groups 1 and 2. The position of the femoral attachments in the cadaver group did not differ from the orifices of the drilled channels in Group 1, but between the cadaver group and Group 2, and Groups 1 and 2, the positions of the femoral attachments differed. The hand-drilled channels were generally located too far anteriorly, and the scatter of the attachments was 1.8 times greater. The drill guide enables reproducible anatomic positioning of an anterior cruciate ligament graft.

Arthroscopic Reconstruction of the Anterior Cruciate Ligament

Arthroscopic reconstruction of the anterior cruciate ligament was compared with reconstruction through a miniarthrotomy. The operation time was significantly longer with arthroscopy, but the Lysholm scores and activity levels were the same in both groups before and 1 year after the operation. There was no difference in quadriceps torque between the groups before surgery and at 3, 6, and 12 months postoperatively. The measured stability in 20 degrees of knee flexion was similar in both groups before, immediately after, and 3, 6, and 12 months after surgery. A slow increase in the laxity was noted. One of 20 ligaments ruptured in the arthrotomy group due to a new trauma. In the arthroscopy group, there was one rupture due to abrasion. During the follow-up, two cases in the arthroscopy group had synovitis, in one case leading to removal of the prosthesis. There seems to be no major benefit from arthroscopic reconstruction in terms of rehabilitation. The miniarthrotomy is preferred since the notch plasty is easier to perform adequately during it than during arthroscopy.