Rodney W. Benner

Return to Sports and Subsequent Injury Rates After Revision Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft

Background: The return-to-sport and reinjury rates are not well defined after revision anterior cruciate ligament (ACL) reconstruction. Hypothesis: School-age athletes would have a higher rate of return to sports and reinjury to either knee after revision ACL surgery compared with college or recreational athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Patients were prospectively studied after revision ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft. Participants were grouped by competitive sport levels of school age (mean age, 16.6 ± 0.9 years; n = 84), college (19.6 ± 1.2 years; n = 58), or recreational adult (27.6 ± 4.1 years; n = 117). An activity survey was used to determine the specific sport and sport level patients participated in before and after surgery. The International Knee Documentation Committee (IKDC) knee survey and Cincinnati Knee Rating System (CKRS) survey responses were also obtained. Results: The rate of return to the same sport at the same level was 62 of 84 school-age athletes (74%), 43 of 58 college athletes (74%), and 73 of 117 recreational athletes (62%) (P = .1065). The number of patients who had a subsequent ACL graft tear rate after revision surgery was 2 of 84 (2.3%) in the high school group, 3 of 58 (5.1%) in the college group, and 4 of 117 (3.4%) in the recreational group (P = .6706). The number of patients who had a subsequent ACL tear in the contralateral knee was 1 of 84 (1.1%) in the school-age group, 1 of 58 (1.7%) in the college group, and 2 of 117 (1.7%) in the recreational group (P = .9501). At 2 years postoperatively, the mean IKDC subjective total score was 86.1 ± 11.7 points and the mean CKRS total score was 89.7 ± 11.1 points. Conclusion: Revision ACL reconstruction with BPTB autograft and perioperative rehabilitation allowed high school and college athletes to return to sports at the preinjury level at a rate of 74%; the return rate for recreational-level adults was 62%. Reinjury rates in the first 5 years after revision surgery ranged from 2% to 5%, which is lower than what has been reported for young competitive athletes after primary surgery.

Intercondylar Notch Width Measurement Differences Between African American and White Men and Women With Intact Anterior Cruciate Ligament Knees

Background A recent report of professional womens basketball found that white European American female players were 6.5 times more likely to tear their anterior cruciate ligament than their nonwhite European American counterparts. African Americans accounted for 95% of the nonwhite European American group. Hypothesis African American men and women have wider intercondylar notches than white men and women. Study Design Cohort study (prevalence); Level of evidence, 2. Methods We obtained 45° flexed weightbearing posteroanterior radiographs on 517 patients who had knee problems other than an anterior cruciate ligament injury or arthrosis. One experienced observer measured the intercondylar notch width with no knowledge of race or gender, and the measurements were analyzed based on race and gender. Results The mean intercondylar notch width was 15.5 mm (SD = 2.8; range, 9-22) for African American women and 14.1 mm (SD = 2.5; range, 8-21) for white women; this difference was statistically significant (P = .009). Similarly, the mean intercondylar notch width was 18.0 mm (SD = 3.6; range, 10-27) for African American men and 16.9 mm (SD = 3.1; range, 9-27) for white men; these values were statistically significantly different (P = .003). Conclusion We conclude that African Americans have statistically significantly wider intercondylar notch widths on 45° flexed weightbearing posteroanterior radiographs than whites of the same gender. This relationship may offer an explanation for the difference between races with regard to risk of anterior cruciate ligament tears.

Tear Patterns, Surgical Repair, and Clinical Outcomes of Patellar Tendon Ruptures After Anterior Cruciate Ligament Reconstruction With a Bone–Patellar Tendon–Bone Autograft

Background: Patellar tendon ruptures are rare after graft harvest for anterior cruciate ligament (ACL) reconstruction. Few reports are available in the literature. Purpose: To report the common tear patterns and results of treatment with tendon repair and cable augmentation. Study Design: Case series; Level of evidence, 4. Methods: All tendon ruptures were repaired to bone with suture anchors and augmented with a Dall-Miles cable, followed by an aggressive rehabilitation protocol. The tear location was recorded. Range of motion, strength, and subjective survey testing were conducted preoperatively and postoperatively. Results: Thirteen patellar tendon ruptures were found from our database of 5364 ACL reconstructions, for an incidence of 0.24%. Seven ruptures occurred from the patellar origin medially and the tibial attachment laterally in a Z-shaped pattern. Four were completely distal, and 2 were completely proximal ruptures. All patients exhibited early flexion loss, but 11 of 13 patients maintained full, terminal hyperextension throughout treatment. The mean postoperative side-to-side flexion deficit was 33° at 1 month, 6° at 3 months, and 3° at latest follow-up at a mean of 4.8 years after tendon repair (range, 1-16 years). By International Knee Documentation Committee (IKDC) criteria, 10 patients had normal flexion, and 3 were nearly normal at latest follow-up. Twelve patients had normal extension, and 1 had nearly normal extension at latest follow-up. Mean isokinetic quadriceps muscle strength was 68.7% of the other side at 3 months after repair and 100.0% at latest follow-up, occurring at a mean of 47.5 months (range, 12-120 months). At a mean of 2 years (range, 1-4 years) after repair, the mean modified Noyes subjective score was 89.8 ± 9.2. Conclusion: Patellar tendon ruptures are rare after ACL graft harvest. These ruptures usually occur in either a proximal-medial and distal-lateral pattern or an entirely distal pattern, in contrast to the proximal-only tear pattern commonly observed in unharvested patellar tendons. Good objective and subjective results were achieved with repair of postoperative patellar tendon ruptures using suture anchors and Dall-Miles cable augmentation, followed by aggressive, immediate range of motion exercises.

Results of Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autografts: Objective Factors Associated With the Development of Osteoarthritis at 20 to 33 Years After Surgery:

Background: Few studies exist that report objective radiographic and physical examination results at >20 years after anterior cruciate ligament (ACL) reconstruction. Hypothesis: The risk of osteoarthritis (OA) at >20 years after surgery would be statistically significantly higher if an increased severity of factors was present. Study Design: Cohort study; Level of evidence, 2. Methods: Between 1982 and 1994, 1428 knees met the inclusion criteria of being primary ACL surgery, having no existing OA or other ligamentous laxity, and having no known graft tear. Prospective data analyzed included demographics; meniscus and articular cartilage status; ratings of bilateral standing posteroanterior weightbearing, lateral, and Merchant view radiographs; KT-1000 arthrometer measurements; and range of motion measurements. Radiographs were graded for joint space narrowing, sclerosis, and osteophytes according to International Knee Documentation Committee (IKDC) criteria. Multivariate and univariate logistic models were used to determine the effect of potential predictors on the odds of having radiographic evidence of OA. IKDC and Cincinnati Knee Rating System (CKRS) subjective surveys were conducted. Results: A minimum 20-year objective follow-up was obtained for 423 knees at a mean of 22.5 ± 2.1 years postoperatively. If a patient lacked normal extension or flexion at discharge, the odds of lacking normal extension or flexion at follow-up were 19.7 and 7.97, respectively (P < .001). Radiographic ratings were normal for 35.2%, nearly normal for 36.2%, abnormal for 20.1%, and severely abnormal for 8.5%. Multivariate analysis showed that the predictive factors for the presence of OA in the long-term were medial meniscectomy, older age at surgery, and less than normal knee extension at discharge. The odds ratios for statistically significant factors for the presence of any OA at follow-up were 2.02 for knee extension loss at discharge, 2.98 for medial meniscectomy, 1.65 for lateral meniscectomy, 1.06 for age at follow-up, 1.62 for chronic injury type, and 2.17 for articular cartilage damage. The IKDC and CKRS subjective scores were progressively and statistically significantly lower as the level of OA was greater. Conclusion: The prevalence rate of developing moderate to severe OA at >20 years after ACL reconstruction was 28.6%. Significant factors predictive of OA in the long-term were older age at surgery, medial meniscectomy, and knee extension loss.

Return to Sports and Subsequent ACL Injury Rates after Revision ACL reconstruction with Patellar Tendon Autograft.

Objectives: We sought to determine the rate at which competitive and recreational athletes of different age groups returned to the same sport at the same level after revision ACL reconstruction with a patella tendon autograft, as well as define the subsequent ACL injury rate to either knee. Methods: We prospectively studied patients after revision ACL reconstruction with patellar tendon autograft. Patients who were involved in jumping/pivoting sports when they injured the ACL reconstructed knee and had the desire to return to the same sport at the same competitive level were included in the study. All patients underwent a perioperative rehabilitation program that emphasized limiting postoperative hemarthrosis, obtaining full range of motion, and achieving quadriceps muscle control before participating in an aggressive strengthening and functional progression program. Patients were grouped by age and competitive sport levels of high school (age <17.5 years, mean 16.6 ± 0.9 years; N=84), college (ages 18 to 21.9 years, mean 19.6 ± 1.2 years; N=58) or recreational (22 to 35 years, mean age 27.6 ± 4.1 years; N=117). A subjective activity survey was used to determine what specific sport and sport level patients participated in before and after surgery. The International Knee Documentation Committee (IKDC) and modified Noyes knee surveys were also obtained. Results: Of 84 high school athletes, 62 (74%) returned to play the same sport in high school. Of 58 college athletes, 43 (74%) returned to play the same sport at the college level. Of 117 recreational athletes, 73 (62%) returned to the same sport at a recreational level. The number of patients who had a subsequent ACL graft tear rate after revision surgery was 2 of 84 (2.3%) in the high school group, 3 of 58 (5.1%) in the college group, and 4 of 117 (3.4%) in the recreational group. The number of patients who had a subsequent ACL tear in the contralateral knee was 1 of 84 (1.1%) in the high school group, 1 of 58 (1.7%) in the college group, and 2 of 117 (1.7%) in the recreational group. Long-term subjective follow-up was obtained for 210 patients at 7.2 ± 5.3 years after surgery. The mean IKDC subjective total score was 86.1 ± 11.7 points at 2 years after surgery and 76.7 ± 18.3 at long-term follow-up. The mean modified Noyes total score was 89.7 ± 11.1 points at 2 years after surgery and 83.7 ± 16.2 points at long-term follow-up. Conclusion: Revision ACL reconstruction with a patellar tendon autograft combined with perioperative rehabilitation allows patients to return to the same sport at the same level at a high rate, which is higher than what is reported for revision surgery with hamstring grafts or allografts. Subsequent ACL injury rates to either knee is low and appears lower than after primary surgery, which may indicate that although patients report they return to the same level of sport, they may be doing so at a lower intensity.