Roger V. Larson

Semitendinosus Augmentation of Acute Patellar Tendon Repair with immediate Mobilization

We report four cases of acute midsubstance rupture of the patellar tendon that were treated with primary sur gical repair along with semitendinosus autograft aug mentation. The goal of this treatment was to allow im mediate mobilization of the knee with a single operative procedure. We also demonstrate a technique for de termining patellar position intraoperatively. Patients were tested for functional performance at an average final followup of 40 months (range, 20 to 66) including hamstring and quadriceps muscle strength evaluation, completion of a functional questionnaire, functional test performance, range of motion assessment, and patellar tendon length measurement. In evaluating the results, all cases were essentially identical to the nonoperated side, except one knee that had multiple associated liga ment injuries. The multitude of injuries to this knee are likely the cause of the discrepancy. Immediate midsub stance patellar tendon repair with semitendinosus aug mentation allowed immediate mobilization, which de creased the recovery period and improved the outcome of rehabilitation. Furthermore, a second surgery for hardware removal was not needed. These two factors— early and improved rehabilitation and the decreased chance of a second surgery—affect the cost of treat ment of this injury. All isolated patellar tendon injuries in the study had excellent function at followup. For these reasons, we recommend this procedure for acute pa tellar tendon ruptures.

High resolution sonography of the menisci of the knee.

High-resolution real-time ultrasonography (5, 7.5, and 10 MHz) was used to examine the menisci of the knee in ten normal volunteers and in ten patients with knee injuries. The posterior horns of the medial and lateral menisci were easily demonstrated. Normal anatomy and pathologic changes could be imaged in the menisci, capsular ligaments, and articular cartilage. While the menisci were seen in all subjects, the weight-bearing portion of the femoral articular cartilage could not be seen in several of the symptomatic patients who could not flex their knees. Ultrasound promises to be a useful, noninvasive adjunct to conventional techniques in evaluating the injured knee--especially in assessing the posterior horns of the menisci, an area difficult to assess with arthroscopy.

Reliability of the Genucom Knee Analysis System. A pilot study.

Instrumented knee laxity testing is now common practice in many orthopedic and rehabilitative practices around the country. The Genucom Knee Analysis System is marketed as a comprehensive quantitative knee joint laxity testing device. To examine the intrarater reliability of the Genucom, the authors evaluated five normal subjects, each on three independent occasions. All testing was done by a single examiner. Anteroposterior (AP) drawer, valgus/varus, and tibial rotation tests were performed. The average variability for repeated testing was determined and this variability was then used to estimate the smallest statistically significant difference for a single repeat examination that would represent true change, i.e., change over and above the inherent variability of the measurement. The results indicate that: (1) anterior drawer variability and tibial rotational variability are dependent on the knee flexion angle; (2) reporting anterior drawer may be more reproducible than reporting total AP motion; and (3) on average, changes exceeding 3 mm for anterior drawer tests, 5 mm for total valgus-varus motion, and 7 degrees-17 degrees of tibial rotation are needed to be 95% confident that the change in a measure from one time to the next is real and not due to measurement variability.

High Satisfaction Yet Decreased Activity 4 Years After Transphyseal ACL Reconstruction

BackgroundACL injuries in preteens and teens are common occurrences. Reconstruction is believed to be optimum treatment for those wishing to return to running, cutting, and jumping sports. Rates of reoperation, satisfaction, and long-term return to and maintenance of preinjury activity after ACL reconstruction in young athletes are important information for physicians, patients, and parents.Questions/purposesThe purposes of this study were to address the following questions in this skeletally immature patient population undergoing ACL reconstruction: (1) What is the reinjury rate and the need for subsequent surgeries? (2) How do patient satisfaction and function as assessed by patient and physician correlate with return to sport? (3) What factors contribute to failure to return to preinjury activity levels?MethodsThis is a retrospective review of 29 patients who underwent transphyseal ACL reconstruction using soft tissue grafts passed through open physes and followed to skeletal maturity, and at least 2 years from their index surgery, who were invited and returned for a study interview and examination. Pre- and postinjury activity levels were assessed via the Tegner activity score, satisfaction was determined using a 10-point Likert scale, function was assessed via the Lysholm score and IKDC grade, and an open-ended questionnaire was used for explanations of changes in activity levels. Reoperations were classified as major or minor, determined from a review of the medical records conducted after interview and examination.ResultsAt a minimum followup of 2 years (mean, 4 years; range, 2–8 years), four revision reconstructions and seven minor operations were performed for a reoperation rate of 11 of 29 (38%). Eight of 29 patients (28%) sustained contralateral ACL ruptures. The mean satisfaction score was 9 (range, 4–10) and mean Lysholm score was 91 (range, 61–100). Only 12 of 29 (41%) patients returned to and maintained their preinjury level of sport. High satisfaction correlated with return to prior level of sports, although there was no relationship between function and activity level. Reoperation on the index knee or contralateral ACL tear did not correlate with a change in activity level; rather, most patients who were less active indicated a change in interest with advancing age.ConclusionsDespite high satisfaction and function, less than 50% of patients maintained their preinjury level of play 4 years after ACL reconstruction. Satisfaction correlated significantly with knee function; highly satisfied patients were more likely to return to and maintain their prior level of participation in sports. Contributing factors to decreased activity include changes in lifestyle with increasing age. Reoperation did not correlate with lower activity scores or failure to return to sports.Level of EvidenceLevel IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Anterior cruciate ligament reconstruction with hamstring tendons

Abstract Reconstruction of the anterior cruciate ligament using hamstring tendons can be successfully accomplished.Semitendinosus and gracilis tendon autografts offer advantages over other commonly used autografts in that they are strong, have stiffness characteristics similar to a normal anterior cruciate ligament, have a large surface area for revascularization, and are adaptable to precise intraarticular positioning. The use of hamstring tendon autografts for anterior cruciate ligament reconstruction avoids the potential surgical morbidity associated with the harvest of autogenous patellar tendon grafts. As with all anterior cruciate ligament reconstructive procedures, attention to detail is essential for a predictable successful outcome, Attention must be paid to graft preparation, tunnel placement, graft fixation and tensioning, and postoperative rehabilitation. When proper attention to detail is performed, restoration of normal anterior laxity with a full range of knee motion can be expected. This technique is particularly applicable in those cases where avoidance of the extensor mechanism is desirable.

Complications in the use of hamstring tendons for anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament with hamstring tendon autografts is a well accepted procedure which involves a relatively low morbidity rate. Complications can occur; they are divided into those occurring with graft harvest, with graft placement and fixation, at the donor site, and with the implanted graft. This article discusses these potential complications and provides tips for avoiding them.

Can Magnetic Resonance Imaging Predict Posterior Drawer Laxity at the Time of Surgery in Patients With Knee Dislocation or Multiple-Ligament Knee Injury?

Background: Previous studies indicate that isolated posterior cruciate ligament injuries demonstrate magnetic resonance imaging (MRI) and clinical evidence of healing when treated nonoperatively; however, the authors are unaware of any other study that has looked at whether initial MRI can predict posterior cruciate ligament stability at the time of surgery in patients with knee dislocation. Hypothesis: An MRI grading system will predict laxity on posterior drawer testing at the time of surgery in patients with knee dislocations. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Forty-two consecutive patients with knee dislocation or multiple-ligament knee injury evaluated by MRI were included in the study. An assignment of grade 0 (intact), grade I (injured/fibers intact), grade II (partial tearing of ligament), or grade III (complete tear) was made after each reading on 2 separate occasions by 3 surgeons. Posterior laxity of the knee was graded by the magnitude of excursion on the posterior drawer test by the senior author at the time of surgery. Interobserver and intraobserver reliability of the MRI grading scheme expressed by the kappa statistic κ, as well as the predictive value of MRI grade in determining stability of the posterior cruciate ligament at the time of surgery, was assessed. Results: The posterior cruciate ligament injury grading scheme tested demonstrated moderate to substantial intraobserver agreement (κ = 0.66, κ = 0.53, and κ = 0.52, respectively, for all raters). Interobserver reliability demonstrated only moderate agreement (κ = 0.49). If the grading scheme was changed to group both grades 0 and I (intact) and grades II and III (disrupted), intraobserver reliability demonstrated substantial to almost perfect agreement (κ = 0.83, κ = 0.80, and κ = 0.75), and interobserver reliability demonstrated substantial agreement (κ = 0.70). If the posterior cruciate ligament was classified as intact (grade 0 [intact] or grade I [injured]) on initial MRI, the injured knee was judged clinically stable (tibia anterior to or flush with the femoral condyles on posterior drawer testing) at the time of surgery 98.5% (95% confidence interval, 93%-100%) of the time. When the posterior cruciate ligament was classified as disrupted (grade II [partial tear] or grade III [complete tear]), the injured knee was judged unstable (tibia posterior to the femoral condyles on posterior drawer testing) 57.5% (95% confidence interval, 40%-73%) of the time. Conclusion: The presented system of grading posterior cruciate ligament injury in patients with knee dislocation on initial MRI demonstrates moderate to substantial interobserver and intraobserver reliability that increases if the grading scheme is modified. An initial MRI scan read as grade I may predict stability to posterior drawer at the time of surgery. Even with MRI evidence of disruption in the posterior cruciate ligament (grade II and grade III injuries), posterior cruciate ligament reconstruction may not be clinically indicated at the time of reconstruction and/or repair of other associated injuries.

Anterior Cruciate Ligament Reconstruction with Hamstring Tendon Autografts and Endobutton Femoral Fixation

The efficacy of ACL reconstruction procedures to improve function in symptomatic ACL-insufficient knees has been well established. Initial satisfactory results utilizing patellar tendon autografts were compromised to varying extent by harvest site morbidity. In an attempt to reduce harvest site morbidity, other autogenous graft sources have been used as ACL substitutes. Several studies now exist comparing results of ACL reconstruction with quadrupled hamstring grafts and patellar tendon grafts and show no significant subjective differences. Successful reconstruction utilizing any appropriate graft is dependent on the adherence to principles and details of graft harvest and preparation, tunnel placement, fixation, and rehabilitation. In this article, the technique specific to ACL reconstruction with double semitendinosus and gracilis tendons utilizing Endobutton femoral fixation is discussed as well as potential complications of the procedure.

Lateral Collateral Ligament Reconstruction Utilizing Semitendinosus Tendon

Traumatic injury to the knee joint is one of the more common complaints seen by the sports medicine physician. Injuries to the lateral collateral ligament and posterolateral complex of the knee are part of this broad spectrum. Without proper attention, these often unappreciated injuries can result in significant functional limitations. The treatment options for an isolated lateral collateral ligament disruption are numerous. They include conservative care, primary repair, augmentation with repair, ligament reconstruction, and tightening of existing structures. When reconstruction is the treatment of choice, structural restraints from the lateral femoral epicondyle to the fibular head offer many advantages. A free semitendinosus tendon graft technique, presented here, can be used to reconstruct the lateral collateral ligament with excellent isometry and minimal morbidity. This procedure may be used in isolation or in combination with other knee reconstructive measures.

Surgical Treatment of Posterolateral Instability

Injury to the posterior cruciate ligament (PCL) is thought to account for 3% to 20% of all knee ligament injuries.1 The true incidence of PCL injuries remains unknown because many isolated PCL injuries may go undetected.2,3 It is generally accepted that isolated ruptures of the PCL do not generally cause functional instability and are best managed by nonoperative treatment.4–7 When functional instability is present, the situation is usually not an isolated PCL injury, but a combined ligamentous injury frequently involving the posterolateral corner.8–11 Posterolateral instability of the knee in combination with PCL insufficiency is frequently the cause of functional instability, and management of this instability requires addressing not only the PCL injury, but the associated posterolateral corner injury.