Peter A. Indelicato

Bone Tunnel Enlargement After Anterior Cruciate Ligament Replacement

Radiographic increase in the size of tibial and femoral tunnels has been observed. This retrospective study compared tibial tunnel diameter in 56 autograft and 87 allograft patellar tendon bone-tendon-bone anterior cru ciate ligament replacements whose observed tunnel changes were correlated with clinical results at 1 year postoperatively. Tibial tunnel sclerotic margins were measured approximately 1 cm below the joint line. Ex act tunnel dimension was calculated by using a mag nification factor determined by the interference screw of known diameter within the same tunnel. Average al lograft tunnel enlargement was 1.2 mm (-2.5 to 6.0) compared with the autograft tunnel enlargement of 0.26 mm (-2.5 to 2.7); the difference was significant (P> 0.0002). No significant difference was seen in KT-1000 arthrometer measurements between autograft or allograft groups, and no correlation was seen be tween increased tunnel size and clinical outcome as determined by the modified Hughston knee evaluation system. Tunnel measurement reproducibility was con firmed by independent repeated measurements. The significance of this tunnel enlargement is unknown and does not appear to adversely affect clinical outcome of allograft utilization. Possible explanations include an immune response with resorption, stress shielding proximal to the interference screw resulting in resorp tion, or an inflammatory response by synovium in the tunnel.

A perspective of lesions associated with ACL insufficiency of the knee. A review of 100 cases.

A retrospective study was conducted to survey the extent of intracapsular damage associated with ACL insufficient knees in both the acute and chronic situation. Previously unoperated knees were studied to assess the effect that reinjury had on the knee joint. One hundred patients with confirmed anterior cruciate ligament damage, both clinically and under general anesthesia, were examined arthroscopically and the findings recorded on video tape. Both anterolateral and posteromedial approaches were used to well visualize the entire intra-articular structures of the knee joint. The incidence of meniscal tears increased from 77% in the acute injury to 91% in the chronically reinjured knee (p less than .06). Furthermore, articular surface disease increased from 23% in the acute injury to 54% in the chronically ACL lax knee (p less than .002). The majority of meniscal tears were medial and amenable to peripheral suture repair (63%). Irrespective of how one approaches ACL insufficiency of the knee acutely, one cannot ignore the likelihood of finding these significant associated lesions. Reinjury to the knee will likely enhance the incidence of meniscal tears and articular changes.

Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players

During five consecutive football seasons at a major university, 28 varsity football players sustained complete isolated tears of the medial collateral ligament of the knee. All were managed nonoperatively with early protected motion and physical therapy. Twenty-one patients returned for follow-up examination. The mean follow-up time was 46 months. Eighteen patients were followed for over two years after the original injury. Twenty patients had results ranging from good to excellent. The average time from injury to return to full-contact drills was 9.2 weeks. The key to success in the nonoperative management of complete tears of the knee is to exclude cases with damage to the anterior cruciate ligament.

The results of fresh-frozen patellar tendon allografts for chronic anterior cruciate ligament deficiency of the knee

This prospective study was done to evaluate the clinical outcome of fresh-frozen patellar bone-tendon-bone al lograft tissue used as a substitute for chronic insuffi ciency of the anterior cruciate ligament. Forty-one pa tients were followed at a mean of 27 months after surgery. The mean time from injury to reconstruction was 34 months. The same operative procedure and postoperative rehabilitation was performed on each patient. The evaluation method consisted of subjective, objective, and instrumented laxity testing. Thirty-seven patients (90%) thought their knee was normal or im proved after surgery and had no further episodes of giving way. The combined modified Hughston Knee Score re vealed 30 patients (73%) with an excellent or good result and 9 patients (22%) with a fair or poor result. The mean postoperative Lysholm Knee Score was 91 (range, 56 to 100). Thirty-two had a negative pivot shift (78%). The postoperative KT-1000 arthrometer re vealed 37 patients had an injured-to-uninjured differ ence of 5 mm or less (mean, 1.32 mm; range, 0 to 5). There were three traumatic failures at 24 months post operatively in this group. There was no rejection phe nomenon noted postoperatively. In addition, clinical observation showed less postoperative morbidity when compared to a matched autogenous patellar tendon control group.

Concussion (mild traumatic brain injury) and the team physician: a consensus statement--2011 update.

No same-day return-to-play (RTP). Neurological examination emphasizing cognitive function and balance. Role and limitations of neuropsychological (NP) testing. Utility of standardized baseline and postinjury assessments. Importance of preseason planning. Acknowledged importance of cognitive rest. Acknowledged emerging technologies and their role in concussion research. Recognition of long-term complications of concussion. Legislation and governing body regulations for concussion.

Early experience with the GORE-TEX polytetrafluoroethylene anterior cruciate ligament prosthesis:

A prospective study of 41 patients with acute and chronic ACL deficiency underwent reconstruction with the GORE-TEX polytetrafluoroethylene (PTFE) ACL prosthesis beginning in November 1983. Thirty-nine patients who were at least 2 years from their surgical procedure were available for follow-up evaluation, which included subjective questionnaire, clinical exam ination, and instrumented ligamentous laxity tests. Eight patients had an acute injury to the ACL and 31 patients had chronic ACL insufficiency for which recon struction was performed. Thirty-four patients had satisfactory results, allowing full return to activity with no appreciable symptomatol ogy. Of the remaining five patients, four had a complete rupture of the prosthesis. The average knee arthrome tric measurement improved from a 5.4 mm left/right difference preoperatively to a 2.0 mm left/right differ ence at 2 year followup. Nine patients had postopera tive complications of one or more atraumatic episodes of a sterile effusion. Six patients had recurrent effu sions ; in five, arthroscopy revealed partial tears of less than one-third of the prosthesis. Three patients who had recurrent effusions had PTFE particles in their synovial biopsies. One patient had an immediate post operative infection and to date has had salvage of the prosthesis and currently has a stable knee with full return to activities. Based on the early results of this study, the GORE- TEX PTFE ACL prosthesis provided a satisfactory method of reconstruction for ACL deficient knees. Based on the evaluation used, 87% of the patients had satisfactory results. Problems associated with use of this prosthesis include partial or complete tears of the prosthesis and sterile effusions, possibly due to syno vial irritation from the PTFE particles. Appropriate placement of the graft, anterior and posterior notch plasty, and removal of sharp edges from the bony tunnels may help eliminate these problems.

Nonirradiated Versus Irradiated Achilles Allograft In Vivo Failure Comparison

Background Many studies suggest that gamma irradiation decreases allograft strength in a dose-dependent manner. No study has demonstrated that this decrease in strength translates into higher clinical failures. Hypothesis Irradiation of allograft tissue will lead to higher early clinical failure in anterior cruciate ligament (ACL) reconstruction. Study Design Cohort study; Level of evidence, 3. Methods Medical records were reviewed for 90 consecutive patients who had received Achilles allograft reconstruction for unilateral primary ACL injuries at one institution between July 2001 and June 2002. One half of patients received nonirradiated Achilles allograft and the other half received irradiated Achilles allograft at a dose range of 2.0 to 2.5 Mrad. The ACL allograft reconstructions were performed using the same surgical technique. The rehabilitation program was identical for both groups. All clinical failures were recorded. Results At least 6 months’ follow-up was available on 42 subjects in the nonirradiated group and 33 subjects in the irradiated group. A significant difference was noted in early failure rates between the groups (P < .01). The nonirradiated group had 1 in 42 (2.4%) catastrophic failure. In the irradiated group, 11 of 33 (33%) Achilles tendon grafts failed. Conclusions Less than satisfactory results led the senior authors to discontinue the use of irradiated allografts in ACL surgery. Continued research into alternatives to gamma irradiation is needed.

Correctable elbow lesions in professional baseball players: a review of 25 cases.

In a retrospective study, 20 of 25 professional baseball pitchers (mean age, 24 years; range, 19 to 28 years) who had had a reconstructive surgical procedure on the dominant elbow had satisfactory results (able to return to competitive throwing for one full season or more after surgery). Gentle motion was initiated 1 week after the operation on each patient. Exercises for mobilization and muscle strengthening of grip, arm, and shoulder were increased until throwing was initiated 10 to 12 weeks postoperatively. Throwing was gradually increased over several weeks from 30 feet at no more than half speed for 15 min to 60 feet at three-quarter speed. Pitchers were instructed to warm up before throwing and warm down and to continue this practice after they began competitive throwing. The longest period of follow-up has been 4 years (mean, 2.8 years). Four of the 25 pitchers had unsatisfactory results (released from their team in less than one full season because of ineffective pitching and were not picked up by another team). The cause of the release of the other patient-player is controversial. This 25- patient group is too small and the follow-up period is too short for definite conclusions. Our evidence does suggest that surgi cal procedures directed at medial soft tissue and posterior intra-articular changes carry better prognosis for competitive throwers than other procedures. The radiohumeral articular condition should be evaluated at surgery.

Longitudinal Changes in Psychosocial Factors and Their Association With Knee Pain and Function After Anterior Cruciate Ligament Reconstruction

Background Evidence in the musculoskeletal rehabilitation literature suggests that psychosocial factors can influence pain levels and functional outcome. Objective The purpose of this study was to examine changes in select psychosocial factors and their association with knee pain and function over 12 weeks after anterior cruciate ligament (ACL) reconstruction. Design This was a prospective, longitudinal, observational study. Methods Patients with ACL reconstruction completed self-report questionnaires for average knee pain intensity (numeric rating scale [NRS]), knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), and psychosocial factors (pain catastrophizing [Pain Catastrophizing Scale], fear of movement or reinjury [shortened version of the Tampa Scale for Kinesiophobia (TSK-11)], and self-efficacy for rehabilitation tasks [modified Self-Efficacy for Rehabilitation Outcome Scale (SER)]). Data were collected at 4 time points after surgery (baseline and 4, 8, and 12 weeks). Repeated-measures analyses of variance determined changes in questionnaire scores across time. Hierarchical linear regression models were used to examine the association of psychosocial factors with knee pain and function. Results Seventy-seven participants completed the study. All questionnaire scores changed across 12 weeks. Baseline psychosocial factors did not predict the 12-week NRS or IKDC-SKF score. The 12-week change in modified SER score predicted the 12-week change in NRS score (r2=.061), and the 12-week change in modified SER and TSK-11 scores predicted the 12-week change in IKDC-SKF score (r2=.120). Limitations The psychometric properties of the psychosocial factor questionnaires are unknown in people with ACL reconstruction. The study focused on short-term outcomes using only self-report measures. Conclusions Psychosocial factors are potentially modifiable early after ACL reconstruction. Baseline psychosocial factor levels did not predict knee pain or function 12 weeks postoperatively. Interventions that increase self-efficacy for rehabilitation tasks or decrease fear of movement or reinjury may have potential to improve short-term outcomes for knee pain and function.

Histology of the Torn Meniscus A Comparison of Histologic Differences in Meniscal Tissue Between Tears in Anterior Cruciate Ligament–Intact and Anterior Cruciate Ligament–Deficient Knees

Purpose The purpose of this case control study was to evaluate possible preexisting structural differences between torn menisci in anterior cruciate ligament–intact and anterior cruciate ligament–deficient knees. Materials and Methods Subjects were prospectively enrolled into the study from new patient referrals to the orthopaedic clinic. Forty-four meniscal specimens were retrieved during routine arthroscopy. The anterior cruciate ligament–deficient group included 24 patients (15 men and 9 women, average age of 26.5 years, SD = 9.5) with 24 acute, displaced, longitudinal, bucket-handle tears of the medial meniscus in unstable, anterior cruciate ligament–deficient knees. The anterior cruciate ligament–intact group included 20 patients (14 men and 6 women, average age of 30.4 years, SD = 13.4) with similar tears in anterior cruciate ligament–intact knees. Longitudinal and transverse section specimens were stained with hematoxylin and eosin and safranin O, divided into zones based on proximity to the tear, and graded on safranin O uptake or tissue composition. Results Descriptive statistics and χ2 analyses were used to assess differences between groups within each zone. Significant differences (P < .05) were observed between anterior cruciate ligament–deficient and anterior cruciate ligament–intact specimens stained with hematoxylin and eosin in zone 3 for both transverse and longitudinal cuts. Significant differences were not found between anterior cruciate ligament–deficient and anterior cruciate ligament–intact specimens stained with safranin O. Conclusion Longitudinal meniscal tears occurring in anterior cruciate ligament–intact knees may result from early degenerative disease processes. Attempted repair of this diseased tissue may fail to have a positive effect on long-term preservation of the meniscus.