Sue D. Barber-Westin

High Tibial Osteotomy and Ligament Reconstruction for Varus Angulated Anterior Cruciate Ligament-Deficient Knees*

In a consecutive series, we treated 41 young patients who had anterior cruciate ligament deficiency, lower limb varus angulation, and varying amounts of posterolateral ligament deficiency. Seventy-three percent of the patients (N 30) had lost the medial meniscus and 63% (N 26) had marked articular cartilage damage in the medial compartment. All patients were treated with high tibial osteotomy and, in the majority (N 34), anterior cruciate ligament reconstruction a mean of 8 months later. Posterolateral reconstructions were also required in 18 knees. A 100% follow-up was obtained at a mean of 4.5 years after osteotomy. Gait analysis testing was done in 17 knees before and after osteotomy. At follow-up, a reduction in pain was found in 71% (29 knees); elimination of giving way, in 85% (35 knees); and resumption of light recreational activities without symptoms, in 66% (27 knees). The patient rating of the knee condition was normal or very good in 37% (15 knees) and good in 34% (14 knees). The mean Cincinnati Knee Rating Score significantly improved from 63 to 82 points. The mean adduction moment, 35% higher than controls preoperatively, significantly decreased to below normal values postoperatively. Correction of varus alignment was maintained in 33 knees (80%). We recommend osteotomy in addition to ligament reconstructive procedures in these knees with complex injury patterns.

Rigorous Statistical Reliability, Validity, and Responsiveness Testing of the Cincinnati Knee Rating System in 350 Subjects with Uninjured, Injured, or Anterior Cruciate Ligament-Reconstructed Knees

Although many instruments are used to assess outcome after knee ligament reconstruction, their reliability, validity, and responsiveness have not been adequately proven. Our purpose was to assess these statistical measures in a commonly used instrument, the Cincinnati Knee Rating System. Reliability was determined from the responses of 100 subjects who completed the instrument twice, a mean of 7 days apart. Validity and responsiveness were assessed from 250 patients observed for at least 2 years after autogenous ACL reconstruction. Questionnaire items included symptoms, functional limitations with sports and daily activities, patient perception of the knee condition, and sports- and occupational-activity levels. The items demonstrated high test-retest reliability, supporting their use in evaluating groups of patients between two different treatment periods (all intraclass correlation coefficients 0.70). In addition, the questionnaire demonstrated good content validity, construct validity, and item-discriminant validity. For the overall rating score, no “floor effects” (worst score possible) were found before or after surgery. No “ceiling effects” (best score possible) were found before surgery, and, at follow-up, these effects were calculated in only 22 patients (9%). The questions were found to be highly responsive to detecting changes between evaluations. The data demonstrated that this rating system has acceptable reliability, validity, and responsiveness for use in outcome studies after knee ligament reconstruction.

The drop-jump screening test: Difference in lower limb control by gender and effect of neuromuscular training in Female athletes

Background A valgus lower limb alignment has been noted during noncontact anterior cruciate ligament injuries. A video dropjump test can indicate an athletes ability to control lower limb axial alignment in the coronal plane. Hypotheses Female athletes have decreased knee separation distances on landing and acceleration; male athletes have a neutrally aligned lower limb position. A neuromuscular training program will significantly increase knee separation distance in female athletes. Study Design Cohort study; Level of evidence, 2. Methods The authors tested 325 female and 130 male athletes aged 11 to 19 years. The distance between the hips, knees, and ankles was measured during a drop-jump test. The separation distance between the knees and ankles was normalized by the hip separation distance. A neuromuscular training program (Sportsmetrics) was completed by 62 female athletes, and their jump-landing characteristics were reexamined. Results A marked decrease in knee separation distance was found on takeoff in 80% of female athletes and in 72% of male athletes. There was no difference between male and female athletes in the normalized knee and ankle separation distance during the landing and takeoff phases. The knee separation distance on landing was 23 ± 9 cm in the female athletes and 22 ± 8 cm in the male athletes. The normalized knee separation distance was 51% ± 19% in the female athletes and 51% ± 15% in the male athletes. After training, statistically significant increases were found in the female athletes in the knee separation distance on landing (29 ± 8 cm, P<. 0001) and in the normalized knee separation distance (68% ± 18%, P<. 0001). The trained female athletes had significantly greater knee separation distance and normalized knee separation distance than did the males (P<. 0001). Conclusions The majority of untrained female and male athletes demonstrated a valgus alignment appearance on the video test. After neuromuscular training, female athletes had improved knee separation distances and a more neutral lower limb alignment on landing and takeoff.

Anterior Cruciate Ligament Allograft Reconstruction in the Skeletally Immature Athlete

The purpose of this study was to evaluate anterior cru ciate ligament allograft reconstruction in skeletally im mature athletes. Eight patients (mean age, 13 years, 6 months; range, 10 to 15 years) with radiographic docu mentation of open growth plates had anterior cruciate ligament repair and reconstruction with fascia lata or Achilles tendon allograft tissue. A 7-mm graft was cen trally placed across the tibial physes and in an over- the-top position on the femur. All patients returned for followup a mean of 58 months (range, 22 to 94) post operatively. All had an immediate knee motion and re habilitation exercise program. The results were rated on a comprehensive rating system that assessed 20 vari ables. At followup, all patients showed closure of the growth plates. The difference in lower limb length, measured on scanograms, was not clinically significant. On KT-1000 arthrometer testing, 5 patients had less than 3 mm of increased anterior-posterior displacement (normal knee minus reconstructed knee) and 3 patients had between 3 and 5 mm. The final overall ratings were 6 excellent, 1 good, and 1 fair. The procedure is infre quently used, but appears to have merit in select, skel etally immature athletes who desire not to modify ath letic activity or when associated meniscal repairs warrant consideration for reconstruction.

Arthroscopic Repair of Meniscal Tears that Extend into the Avascular Zone A Review of 198 Single and Complex Tears

We assessed the results of 198 meniscal tears that had a major segment in the central avascular region repaired with an arthroscopically assisted inside-out technique. There were 177 patients whose mean age was 28 years. Eighty-two percent were injured during sports, and 71% also required anterior cruciate ligament reconstruction. The menisci were evaluated by clinical examination (180 repairs) a mean of 42 months postoperatively, by follow-up arthroscopic evaluation (91 repairs) a mean of 18 months postoperatively, or both. At followup, 159 (80%) of the 198 tears were asymptomatic for tibiofemoral joint symptoms, and 39 (20%) required repeat arthroscopic surgery for these symptoms. Of the 91 repairs evaluated arthroscopically, 23 (25%) were classified as healed, 35 (38%) as partially healed, and 33 (36%) as failed. We recommend repair of meniscal tears that extend into the avascular region for select patients, including those in their 20s and 30s and highly competitive athletes. This studys reoperation rate of 20% should not be interpreted as the rate of meniscal healing, but as the incidence of tibiofemoral joint symptoms. Even though this is a higher rate than that reported for the repair of peripheral meniscal tears, we believe the benefits of a potentially functional meniscus outweigh the risks of reoperation.

Revision Anterior Cruciate Surgery with Use of Bone-Patellar Tendon-Bone Autogenous Grafts

Background: A prospective study was done to determine the functional results, patient satisfaction, and graft failure rate after fifty‐seven consecutive revision replacements of the anterior cruciate ligament with use of a bone‐patellar tendon‐bone autogenous graft. Methods: Fifty‐four patients (fifty‐five operations) were followed in this study. Concurrent operative procedures were performed during the revision procedure in thirty-seven knees (67%). These procedures included repair of a meniscal tear in twenty knees (36%) and reconstruction of deficient posterolateral or medial ligament structures in seventeen knees (31%). Nine knees (16%) had a high tibial osteotomy to correct varus malalignment before the revision operation. The results were evaluated with the Cincinnati Knee Rating System. Results: There were significant improvements in the scores for pain (p < 0.0001), activities of daily living (p < 0.01), sports participation (p < 0.001), patient satisfaction (p < 0.0001), and overall rating of the knee (p < 0.0001). Thirty‐three (60%) of the replaced ligaments were functional, nine (16%) were partially functional, and thirteen (24%) had failed. Conclusions: Many knees (93%) had compounding problems, including articular cartilage damage, prior meniscectomy, loss of secondary ligament restraints, varus malalignment, and concomitant ligament replacement or meniscal repair. Therefore, the results were generally less favorable than those following primary operations. The rate of graft failure was three times higher than our previously reported failure rate after primary replacements of the anterior cruciate ligament with a bone‐patellar tendon‐bone autogenous graft. Even so, symptoms and functional limitations with regard to daily and sports activities were found to have decreased and patient satisfaction improved. We advocate correction of varus malalignment prior to anterior cruciate procedures. Associated posterolateral ligament deficiencies should be surgically corrected during anterior cruciate procedures to prevent excessive loading on the graft from abnormal lateral tibiofemoral joint opening. Meniscal tears, including complex tears that extend into the avascular zone, can be concurrently repaired successfully during the revision.

Reconstruction of the Anterior and Posterior Cruciate Ligaments After Knee Dislocation Use of Early Protected Postoperative Motion to Decrease Arthrofibrosis

We report a critical rating of results for 11 patients with bicruciate ligament reconstructions and immediate pro tected knee motion after knee dislocations (seven acute and four chronic). Six patients had concurrent repair or reconstruction of medial ligamentous struc tures, and six had reconstruction of the lateral and posterolateral ligaments. All patients returned for fol lowup at a mean of 4.8 years postoperatively. Fol low-up arthrometric testing at 20° of flexion showed 10 knees had less than 3 mm of increased total anterior- posterior displacement and 1 knee had 7 mm of in crease. At 70° of flexion, 9 knees had less than 3 mm of increased displacement and 2 knees had more than 6 mm of increase. The failure rates were as follows: 18% of posterior cruciate ligament reconstructions (2 of 11), 9% of anterior cruciate ligament reconstructions (1 of 11), 17% of lateral and posterolateral procedures, and 0% of medial collateral ligament procedures. At followup, five of the seven patients with acute injuries had no limitations with daily or sports activities. Three of the four patients with chronic ruptures were asymp tomatic with daily activities, but only one was asymp tomatic with light sports. Five patients (all acute inju ries) required treatment for knee motion limitations. Nine patients had full range of motion at followup. We concluded that simultaneous bicruciate ligament re constructions, performed with associated medial or lat eral procedures, are warranted to restore function to all ligament structures. Even though immediate motion was used, several patients required early manipulation or arthroscopic debridement, which restored full motion and prevented permanent arthrofibrosis.

Surgical Restoration to Treat Chronic Deficiency of the Posterolateral Complex and Cruciate Ligaments of the Knee Joint

We report the results of treatment of combined defi ciency of the posterolateral complex and one or both cruciate ligaments. The posterolateral complex defi ciencies were corrected by a proximal advancement procedure of the lateral collateral ligament and pos terolateral complex tissues. The cruciate ligaments were reconstructed with either autogenous or allogenic tissue. Twenty-three consecutive patients were in cluded in the study, 21 returned for followup at a mean of 42 months (range, 23 to 94) postoperatively, and one reconstruction failed before the 2-year evaluation. The results were evaluated using the Cincinnati Knee Rating System. Using another classification system that assesses lateral joint opening, external tibial rota tion, and varus recurvatum tests, we found the pos terolateral advancement was fully functional in 14 knees (64%) at followup; in 6 knees (27%) there was partial function; and in 2 knees (9%) the advancement had failed. The proximal advancement represents a simplified method to restore tension in the posterolat eral complex. It allows early knee motion and is war ranted in knees in which structurally intact but lax ligamentous structures are present. The procedure is not performed when inadequate, thinned, or scarred posterolateral structures exist (these require graft re construction) or in varus-aligned knees. Associated cruciate ligament deficiencies should be surgically cor rected at the time of the posterolateral advancement procedure.

Meniscal Transplantation in Symptomatic Patients Less Than Fifty Years Old

BACKGROUND The purpose of this study was to prospectively evaluate the results of meniscal transplantation in a consecutive series of younger patients treated for pain in the tibiofemoral compartment following a previous meniscectomy. METHODS Forty cryopreserved menisci were implanted into thirty-eight patients. Sixteen knees also had an osteochondral autograft transfer, and nine had a knee ligament reconstruction. The clinical outcome and failure rate of all transplants were evaluated at a mean of forty months postoperatively. Meniscal allograft characteristics were determined with use of a rating system that combined subjective, clinical, and magnetic resonance imaging factors. RESULTS Thirty-four (89%) of the thirty-eight patients rated the knee condition as improved. Before surgery, thirty patients (79%) had pain with daily activities, but only four (11%) had such pain at the time of the latest follow-up. While noteworthy pain was present in the tibiofemoral compartment in all forty knees before surgery, twenty-seven knees (68%) had no pain and thirteen (33%) had only mild compartment pain at the time of the latest follow-up. Twenty-nine patients (76%) returned to light low-impact sports without problems. Concomitant osteochondral autograft transfer and knee ligament reconstruction procedures improved knee function and did not increase the rate of complications. Meniscal allograft characteristics were normal in seventeen knees (43%), altered in twelve (30%), and failed in eleven (28%). CONCLUSIONS The short-term results of meniscal transplantation are encouraging in terms of reducing knee pain and increasing function; however, long-term transplant function and any chondroprotective effects remain unknown and require further investigation.

Reconstruction of the anterior cruciate ligament with human allograft : Comparison of early and later results

Sixty-eight patients who had had reconstruction of an acute rupture of the anterior cruciate ligament with either a fascia lata or a bone-patellar ligament-bone allograft returned for two follow-up evaluations, at two to four years and at five to nine years (mean, seven years) postoperatively. The early (two to four-year) results in these patients have been reported previously. The mean time between the early and the later evaluation was fifty-six months (range, twenty to ninety-six months). At the early evaluation, fifty-two (78 per cent) of the sixty-seven patients who were tested with an arthrometer at eighty-nine newtons had less than three millimeters of increased anterior-posterior displacement compared with that of the contralateral limb; at the later evaluation, fifty-four (79 per cent) of the sixty-eight patients had this finding (p = 0.97). With use of arthrometric and pivot-shift-test data, forty-eight (75 per cent) of sixty-four grafts were classified as functional at the early evaluation and fourteen (22 per cent), as partially functional; two (3 per cent) had failed. (Four grafts could not be classified because of incomplete data.) At the later examination, fifty (74 per cent) of the sixty-eight grafts were functional, thirteen (19 per cent) were partially functional, and five (7 per cent) had failed. At the early evaluation, sixty-two (93 per cent) of sixty-seven patients had no palpable patellofemoral crepitus and five (7 per cent) had moderate crepitus. At the later evaluation, fifty-one (75 per cent) of the sixty-eight patients continued to have no crepitus, sixteen (24 per cent) had moderate crepitus, and one (1 per cent) had severe crepitus. An increase in crepitus between the early and the later evaluation was found in twelve (19 per cent) of the sixty-two patients who had normal crepitus at the early evaluation. With the numbers available, no factor, such as the type of graft, associated ligamentous injury, or meniscal repair, correlated significantly with the amount of patellofemoral crepitus at either follow-up evaluation. At the early evaluation, the result was rated excellent or good for thirty-eight (60 per cent) of sixty-three patients, fair for twenty-one (33 per cent), and poor for four (6 per cent). (The result could not be rated for four patients because of incomplete data.) At the later evaluation, the result was rated excellent or good for forty-five (66 per cent) of the sixty-eight patients, fair for eighteen (26 per cent), and poor for five (7 per cent). For nine patients (13 per cent), the over-all rating deteriorated from excellent or good at the early evaluation to fair or poor at the later examination. For six patients (9 per cent), the rating improved from fair at the early evaluation to excellent or good at the later evaluation. With the numbers available, we could detect no significant decrease in anterior-posterior displacement of the knee, patellofemoral crepitus, the pain or the jumping score, or the over-all knee rating over the time-period studied. While we currently recommend arthroscopically assisted reconstruction with a bone-patellar ligament-bone autogenous graft as the first choice for an acute rupture of the anterior cruciate ligament, our study shows that favorable results can be obtained with allografts and justifies their use when the surgeon and patient choose this approach.