Scott E. Urch

Primary Anterior Cruciate Ligament Reconstruction Using the Contralateral Autogenous Patellar Tendon

We studied patients who underwent primary anterior cruciate ligament reconstruction using either the contralateral (N 434) or ipsilateral (N 228) autogenous patellar tendon graft to determine the difference between groups for the return of range of motion, quadriceps muscle strength, and return to sports. The contralateral group had statistically significantly more flexion than the ipsilateral group at 1 week and 2 weeks postoperatively. The contralateral group had statistically significantly greater quadriceps muscle strength in the reconstructed knee at 1, 2, and 4 months postoperatively and in the donor knee at 1 and 2 months postoperatively. Mean KT-1000 arthrometer results were 1.9 1.3 mm for the contralateral group and 2.2 1.1 mm for the ipsilateral group. The mean time to return to sports at full capability in a competitive subgroup was 4.1 months for contralateral patients and 5.5 months for ipsilateral patients. Overall, 49% of patients in the contralateral group and 12% of patients in the ipsilateral group returned to their preinjury levels of activity by 4 months postoperatively. Our results indicate that the contralateral patellar tendon can be used to restore range of motion and strength sooner than an ipsilateral patellar tendon graft. Patients can also have a faster return to full capability in sports without compromising ultimate stability.

Loss of Normal Knee Motion After Anterior Cruciate Ligament Reconstruction Is Associated With Radiographic Arthritic Changes After Surgery

Background: Meniscectomy and articular cartilage damage have been found to increase the prevalence of osteoarthritis after anterior cruciate ligament reconstruction, but the effect of knee range of motion has not been extensively studied. Hypothesis: The prevalence of osteoarthritis as observed on radiographs would be higher in patients who had abnormal knee range of motion compared with patients with normal knee motion, even when grouped for like meniscal or articular cartilage lesions. Study Design: Cohort study; Level of evidence, 3. Methods: We prospectively followed patients at a minimum of 5 years after surgery. The constant goal of rehabilitation was to obtain full knee range of motion as quickly as possible after surgery and maintain it in the long term. Range of motion and radiographs were evaluated at the time of initial return to full activities (early follow-up) and final follow-up according to International Knee Documentation Committee (IKDC) objective criteria. A patient was considered to have normal range of motion if extension was within 2° of the opposite knee including hyperextension and knee flexion was within 5°. Radiograph findings were rated as abnormal if any signs of joint space narrowing, sclerosis, or osteophytes were present. Results: Follow-up was obtained for 780 patients at a mean of 10.5 ± 4.2 years after surgery. Of these, 539 had either normal or abnormal motion at both early and final follow-up. In 479 patients who had normal extension and flexion at both early and final follow-up, 188 (39%) had radiographic evidence of osteoarthritis versus 32 of 60 (53%) patients who had less than normal extension or flexion at early and final follow-up (P = .036). In subgroups of patients with like meniscal status, the prevalence of normal radiograph findings was significantly higher in patients with normal motion at final follow-up versus patients with motion deficits. Multivariate logistic regression analysis of categorical variables showed that abnormal knee flexion at early follow-up, abnormal knee extension at final follow-up, abnormal knee flexion at final follow-up, partial medial meniscectomy, and articular cartilage damage were significant factors related to the presence of osteoarthritis on radiographs. Abnormal knee extension at early follow-up showed a trend toward statistical significance (P = .0544). Logistic regression showed the odds of having osteoarthritis were 2 times more for patients with abnormal range of motion at final follow-up; these odds were similar for those with partial medial meniscectomy and articular cartilage damage. Conclusion: The prevalence of osteoarthritis on radiographs in the long term after anterior cruciate ligament reconstruction is lower in patients who achieve and maintain normal knee motion, regardless of the status of the meniscus.

Return to Basketball and Soccer After Anterior Cruciate Ligament Reconstruction in Competitive School-Aged Athletes

Background: Little is known about the return to sports after anterior cruciate ligament reconstruction and whether sex differences exist regarding the level and timing at which athletes return. Hypotheses: Compared to school-aged girls, boys return to full sports earlier and at a higher frequency after surgery (1). Athletes who return to sports earlier will not have a higher incidence of subsequent injury to either knee after surgery (2). Study Design: Cohort. Methods: The patient population comprised 413 consecutive school-aged athletes who were injured while competing in basketball or soccer. Patients were enrolled prospectively, and activity levels were obtained through follow-up visits, surveys, phone calls, and e-mail. Results: Follow-up was obtained for 402 patients (basketball: 58 boys, 242 girls; soccer: 25 boys, 77 girls). Eighty-seven percent of girls and boys returned to high school basketball after surgery: the mean time to return to full participation in basketball was 5.2 ± 2.1 months for girls and 5.3 ± 2.2 months for boys (P = .92). Similarly, 93% of girls and 80% of boys returned to compete in high school soccer after surgery (P = .13); the mean time to return to full participation in soccer was 5.1 ± 1.9 months for girls and 5.1 ± 2.0 for boys (P = 1.00). About 20% of athletes went on to compete in their sport in college. The time of return to sports was not a statistically significant factor for the incidence of subsequent anterior cruciate ligament injury. Conclusion: Of 402 athletes competing in basketball and soccer, women and men returned at the same rate and same level of sport after surgery. Athletes who returned to sports at earlier times after surgery did not have a higher incidence of subsequent anterior cruciate ligament injury than patients who returned at later times.

Outcomes After Arthroscopic Excision of the Bony Prominence in the Treatment of Tibial Spine Avulsion Fractures

PURPOSE The purpose of this study was to determine the outcomes after arthroscopic excision of the bony prominence after a tibial spine avulsion fracture. METHODS This study included 7 subjects (5 female and 2 male subjects; mean age, 21.4 years). All subjects underwent preoperative rehabilitation focused on range of motion (ROM) and swelling control. Postoperative rehabilitation focused on regaining symmetric knee hyperextension and flexion. Objective examinations and subjective surveys were obtained at least 1 year after surgery. RESULTS All subjects achieved normal knee extension; 6 patients achieved normal knee flexion, whereas 1 patient had nearly normal flexion. Physical examination showed a negative Lachman test with a firm end point in all patients, and the mean side-to-side difference for the KT-1000 manual maximum test (MEDmetric, San Diego, CA) was 1.3 mm. No subjects required subsequent anterior cruciate ligament reconstruction. All subjects returned to their previous level of activity without instability symptoms. At a mean of 5.7 years after surgery, the mean International Knee Documentation Committee subjective survey score was 90.6 points overall, with 4.7 out of 5 possible points for the instability question. At latest follow-up, the mean ROM was from 6° of hyperextension to 147° of flexion in the involved knee, compared with 6° of hyperextension to 148° of flexion for the noninvolved knee. CONCLUSIONS The results of arthroscopic excision of the bony fragment after type II, III, or III+ tibial spine avulsion fracture are positive, with good stability, symmetric ROM, and high subjective scores. Most importantly, this procedure allows patients to regain full, symmetric hyperextension of the knee, avoiding the complications associated with extension loss. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Axial Linear Patellar Displacement A New Measurement of Patellofemoral Congruence

Background The tools for measuring the congruence angle with digital radiography software can be difficult to use; therefore, the authors sought to develop a new, easy, and reliable method for measuring patellofemoral congruence. Hypothesis The linear displacement measurement will correlate well with the congruence angle measurement. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods On Merchant view radiographs obtained digitally, the authors measured the congruence angle and a new linear displacement measurement on preoperative and postoperative radiographs of 31 patients who suffered unilateral patellar dislocations and 100 uninjured subjects. The linear displacement measurement was obtained by drawing a reference line across the medial and lateral trochlear facets. Perpendicular lines were drawn from the depth of the sulcus through the reference line and from the apex of the posterior tip of the patella through the reference line. The distance between the perpendicular lines was the linear displacement measurement. The measurements were obtained twice at different sittings. The observer was blinded as to the previous measurements to establish reliability. Measurements were compared to determine whether the linear displacement measurement correlated with congruence angle. Results Intraobserver reliability was above r2 = .90 for all measurements. In patients with patellar dislocations, the mean congruence angle preoperatively was 33.5°, compared with 12.1 mm for linear displacement (r2 = .92). The mean congruence angle postoperatively was 11.2°, compared with 4.0 mm for linear displacement (r2 = .89). For normal subjects, the mean congruence angle was —3° and the mean linear displacement was 0.2 mm. Conclusion The linear displacement measurement was found to correlate with congruence angle measurements and may be an easy and useful tool for clinicians to evaluate patellofemoral congruence objectively.

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 medial retinacular imbrication in patients with unilateral patellar dislocation.

Many surgical methods are used for treating malaligned patella after patellar dislocation, but one surgical method may not be appropriate for all patients. The purpose of this study was to determine the radiographic and subjective outcomes of patients who underwent imbrication of redundant medial structures. A total of 42 patients met the inclusion criteria of suffering a traumatic, unilateral patellar dislocation and had no J-sign, no patella alta, asymmetry on Merchant view radiograph with normal patella alignment on the noninvolved side, and MRI showing injury to the medial retinaculum. Patients were prospectively evaluated. A total of 38 patients (mean age 19.2 years) completed follow-up evaluations at a mean of 31.7 months postoperatively. Mean congruence angle improved from 19.7° preoperatively to 5.4° postoperatively (p < 0.001) and was not statistically significantly different than the noninvolved knee of 4.1 (p = 0.5194). The mean linear displacement measurement improved from 6.0 mm preoperatively to 1.6 mm postoperatively (p < 0.001) and was not statistically significantly different than the noninvolved knee of 1.4 mm (p = 0.6294). Total 33 of 38 patients (87%) returned to their preinjury activity level including sports. Three patients had recurrence of patellar dislocation after surgery while playing sports. For patients who have the specific indications for imbrication of the medial retinaculum, surgery can be successful for re-establishing normal patellofemoral alignment and restoring function.

Perioperative Rehabilitation Using a Knee Extension Device and Arthroscopic Debridement in the Treatment of Arthrofibrosis

Background: Arthrofibrosis is a postoperative complication of intra-articular knee surgery that can be difficult to treat. Evidence suggests that maximizing knee range of motion may improve outcomes in patients with arthrofibrosis who undergo arthroscopic debridement. Hypothesis: Patients who achieve greater knee range of motion will have better subjective scores. Study Design: Retrospective case series analysis. Methods: A review of records was performed for 33 patients with arthrofibrosis who underwent knee arthroscopy and scar resection coupled with perioperative rehabilitation to maximize knee range of motion. Patient demographics and preoperative and postoperative range of motion measurements were extracted from the records. The International Knee Documentation Committee (IKDC) Subjective Knee Form was administered to assess pain, activity, and knee function. Patients performed a preoperative and postoperative rehabilitation program utilizing a knee extension device to maximize knee extension. Results: According to the IKDC range of motion criteria, 27 of 33 patients achieved normal knee extension, and 14 of 33 achieved normal knee flexion at a mean of 8.6 months after surgery. Patients with normal knee motion had a mean IKDC Subjective Knee Form score of 72.6 ± 13.6, which was significantly higher than patients who did not achieve normal motion (P = .04). Overall, mean IKDC Subjective Knee Form scores improved from 45.3 ± 16.7 preoperatively to 67.1 ± 18.0 postoperatively (P < .01) at a mean of 14.7 months after surgery. Conclusions: Perioperative rehabilitation that emphasizes restoration of normal knee range of motion appears to improve outcomes in patients with arthrofibrosis who undergo arthroscopic scar resection. In support of our hypothesis, patients who achieved greater knee range of motion had better subjective knee scores.

Indications for Meniscus Repair

The menisci provide important protective functions within the knee joint by improving joint congruity, decreasing joint contact pressure, and serving as secondary stabilizers of the knee. When the meniscus is injured, its ability to perform these protective functions is hindered. Certain types of meniscus tears are amenable to repair, while other types of tears are unlikely to heal and may necessitate removal. Clinical decision making to determine the best form of treatment is dependent upon a solid understanding of the factors affecting meniscal healing, the implications of different tear types and locations, and the underlying cause of the meniscus tear. This chapter will discuss the general indications for repair based on tear location, type of tear, and the status of the anterior cruciate ligament.