Timo Järvelä

Double-bundle anterior cruciate ligament reconstruction using hamstring autografts and bioabsorbable interference screw fixation: prospective, randomized, clinical study with 2-year results.

Background Conventional anterior cruciate ligament reconstruction techniques have focused on restoration of the anterome-dial bundle only, which, however, may be insufficient in restoring the rotational stability of the knee. Hypothesis Rotational stability of the knee is better when using a double-bundle technique instead of a single-bundle technique for anterior cruciate ligament reconstruction. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Seventy-seven patients were randomized into 3 different groups for anterior cruciate ligament reconstruction with hamstring tendons: double-bundle with bioabsorbable screw fixation (n = 25), single-bundle with bioabsorbable screw fixation (n = 27), and single-bundle with metallic screw fixation (n = 25). The evaluation methods were clinical examination, KT-1000 arthrometric measurement, and the International Knee Documentation Committee and Lysholm knee scores. Results There were no differences between the study groups preoperatively. Seventy-three patients (95%) were available at a minimum 2-year follow-up (range, 24–35 mo). The rotational stability of the knee, as evaluated by the pivot-shift test, was the best in the patients in the double-bundle group. In addition, the patients in the single-bundle groups had more graft failures than those in the double-bundle group. Concerning the anterior stability of the knee as measured with the KT-1000 arthrometer, the group differences were not statistically significant. No significant differences were found between the groups in knee scores. Conclusion Rotational stability of the knee is better when using the double-bundle technique instead of the single-bundle technique in anterior cruciate ligament reconstruction.

The Incidence of Patellofemoral Osteoarthritis and Associated Findings 7 Years After Anterior Cruciate Ligament Reconstruction with a Bone-Patellar Tendon-Bone Autograft

To evaluate the development of postoperative patellofemoral osteoarthritis, we performed a retrospective clinical and radiographic study of 100 patients who had undergone anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft an average of 7 years before the follow-up. Radiographic evaluation showed no patellofemoral osteoarthritis in 53 patients (group I), mild osteoarthritis in 34 patients (group II), moderate osteoarthritis in 12 patients, and severe osteoarthritis in 1 patient (group III, moderate and severe changes). The average shortening of the patellar tendon was 2.4 mm in group I, 3.9 mm in group II, and 6.8 mm in group III. The placement of the femoral or tibial tunnel of the graft, as measured from lateral radiographs, did not correlate significantly with the degree of patellofemoral osteoarthritis. Patients who developed patellofemoral osteoarthritis experienced worse final outcomes, were more often dissatisfied with the condition of the operated knee, experienced more frequent pain and swelling in the knee joint, and had poorer range of motion and poorerquadriceps muscle strength than did patients without patellofemoral osteoarthritis. Only three patients had an unstable knee, and degenerative changes in the tibiofemoral joint were uncommon.

Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction A Prospective Randomized Study With 5-Year Results

Background: Surgical technique is essential in anterior cruciate ligament (ACL) reconstruction. Purpose: This randomized 5-year study tested the hypothesis that double-bundle ACL reconstruction with hamstring autografts and aperture screw fixation has fewer graft ruptures and rates of osteoarthritis (OA) and better stability than single-bundle reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Ninety patients were randomized: double-bundle ACL reconstruction with bioabsorbable screw fixation (DB group; n = 30), single-bundle ACL reconstruction with bioabsorbable screw fixation (SBB group; n = 30), and single-bundle ACL reconstruction with metallic screw fixation (SBM group; n = 30). The following evaluation methods were used: clinical examination, KT-1000 arthrometer measurement, and International Knee Documentation Committee (IKDC) and Lysholm knee scores. Additionally, radiographic evaluation was made by a musculoskeletal radiologist who was unaware of the patients’ clinical and surgical data. A single orthopaedic surgeon performed all the operations, and clinical follow-up assessments were made in a blinded manner by an independent examiner. Results: Preoperatively, there were no differences between the groups. Eleven patients (7 in the SBB group, 3 in the SBM group, and 1 in the DB group) had a graft failure during the follow-up and went on to ACL revision surgery (P < .043). Of the remaining 79 patients, a 5-year follow-up was performed for 65 patients (20 in the DB group, 21 in the SBB group, and 24 in the SBM group) who had their grafts intact. At 5 years, there was no statistically significant difference in the pivot-shift or KT-1000 arthrometer tests. In the DB group, 20% of the patients had OA in the medial femorotibial compartment and 10% in the lateral compartment, while the corresponding figures were 33% and 18% in the single-bundle groups, again an insignificant finding. Further, no significant group differences were found in the knee scores. Conclusion: The double-bundle surgery resulted in significantly fewer graft failures and subsequent revision ACL surgery than the single-bundle surgeries during the 5-year follow-up. Knee stability and OA rates were similar at 5 years. In view of the size of the groups, some caution should be exercised when interpreting the lack of difference in the secondary outcomes.

Double-Bundle Versus Single-Bundle Anterior Cruciate Ligament Reconstruction: Randomized Clinical and Magnetic Resonance Imaging Study With 2-year Follow-up

Background One aspect of the debate over the reconstruction of the anterior cruciate ligament is whether it should be carried out with the single-bundle or double-bundle technique. Hypothesis The double-bundle technique results in fewer graft failures than the single-bundle technique in anterior cruciate ligament reconstruction. Study Design Randomized controlled trial; Level of evidence, 1. Methods A total of 153 patients were prospectively randomized into 2 groups of anterior cruciate ligament reconstruction with hamstring autografts using aperture interference screw fixation: single-bundle technique (SB group, n = 78) and double-bundle technique (DB group, n = 75). The evaluation methods were clinical examination, KT-1000 arthrometric measurement, the International Knee Documentation Committee (IKDC) and the Lysholm knee scores, and magnetic resonance imaging (MRI) evaluation. All of the operations were performed by 1 experienced orthopaedic surgeon, and all clinical assessments were made by 2 blinded and independent examiners. A musculoskeletal radiologist blinded to the clinical data made the MRI interpretation. Results There were no differences between the study groups preoperatively. Ninety percent of patients (n = 138) were available at a minimum 2-year follow-up (range, 24-37 months). Eight patients (7 in the SB group and 1 in the DB group) had graft failure during the follow-up and had anterior cruciate ligament revision surgery (P = .04). In addition, 7 patients (5 in the SB group and 2 in the DB group) had an invisible graft on the MRI assessment at the 2-year follow-up. Also, the anteromedial bundle was partially invisible in 2 patients and the posterolateral bundle in 9 patients. Together, the total number of failures and invisible grafts were significantly higher in the SB group (12 patients, 15%) than the DB group (3 patients, 4%) (P = .024). No significant group differences were found in the knee scores or stability evaluations at the follow-up. Conclusion This 2-year randomized trial showed that the revision rate of the anterior cruciate ligament reconstruction was significantly lower with the double-bundle technique than that with the single-bundle technique. However, additional years of follow-up are needed to reveal the long-term results.

Anterior cruciate ligament reconstruction in patients with or without accompanying injuries: A re-examination of subjects 5 to 9 years after reconstruction.

PURPOSE The purpose of this study was to compare the clinical and radiologic results of an anterior cruciate ligament (ACL) reconstruction in patients with an isolated ACL tear and patients with an ACL tear and accompanying injuries. TYPE OF STUDY A retrospective investigation. METHODS Seventy-two patients who did not have previous knee surgery or surgery of the contralateral knee were re-examined 5 to 9 years after the primary ACL reconstruction. The clinical assessment was made using the International Knee Documentation Committee (IKDC) evaluation system, and the Lysholm and the Marshall knee scores. Also, radiographic evaluation and isokinetic strength testing were performed. There were 34 patients (25 men and 9 women) with an isolated ACL tear (group A), and 38 patients (23 men and 15 women) with an ACL tear and accompanying injuries (group B). The mean age was 29 years (SD 9; range, 15 to 49 years) in group A, and 34 years (SD 12; range, 15 to 61 years) in group B. Bone-patellar tendon-bone autograft with mini-arthrotomy technique and screw fixation was used in all patients. Postoperative rehabilitation was also similar in both groups. In group B, 10 medial and 12 lateral (partial or subtotal) arthroscopic meniscectomies were performed at the same time as the ACL reconstruction. Also, 18 of the 19 medial collateral ligament ruptures, the 2 lateral collateral ligament ruptures, and the 1 posterior cruciate ligament rupture were treated surgically at this operation. RESULTS Subjectively (overall assessment, pain, swelling, and giving way of the knee) and objectively (range of motion, stability, crepitation, isokinetic strength testing, and radiological changes of the knee), the groups did not have any significant differences in the 5- to 9-year results. Also, the final evaluation results using the IKDC and the Lysholm and the Marshall knee scores were similar in both groups. However, there were significantly more subsequent knee surgeries in the injured knee in group B than in group A. CONCLUSIONS Our results show no large differences between patients with an isolated ACL tear and those with an ACL tear with accompanying injuries 5 to 9 years after an ACL reconstruction with a bone-patellar tendon-bone autograft. Tibiofemoral osteoarthritis was quite rare, and this may be partly attributable to the fact that the ACL reconstructions were successful, so that all the knees were stable at the re-examination. However, the future will show the final outcome for the patients.

Bone-patellar tendon-bone reconstruction of the anterior cruciate ligament: A long-term comparison of early and late repair

Abstract Ninety-one patients were assessed 5–9 years after an anterior cruciate ligament reconstruction (bone patella-tendon bone autograft). Forty-eight patients had been treated within 6 weeks of the injury (Group I) and 43 patients more than 3 months after the injury (Group II). 73 patients had either a normal or nearly normal final outcome. The mean Lysholm score was 82 and the mean Marshall score was 42. Eighty nine patients had normal or nearly normal stability in the operated knee when compared to the contralateral joint. In none of these results was there any significant difference between the groups. Results of functional and of isokinetic strength tests, as well as the presence of anterior knee pain, were also similar in both groups. However, patients with early reconstruction had fewer degenerative changes in the tibio-femoral joint and were more satisfied with the result. They also returned to their pre-injury level of sports activity more often than those patients in the late reconstruction group.Résumé Nous avons revu quatre-vingt douze patients ayant eu une reconstruction du ligament croisé antérieur du genou par autogreffe os-tendon rotulien-os, avec un recul de 5 á 9 ans. Quarante-huit patients ont été opérés dans les 6 semaines suivants le traumatisme (groupe I) et quarante-trois patients plus de trois mois aprés le traumatisme (groupe II). Soixante-trois patients ont un résultat normal ou presque normal. Le score Lysholm a été 82 et le score Marshall a été 42. La stabilité du genou opéré a été normale ou presque normale dans quatre-vingt neuf cas. Il n’y a pas eu de différence significative dans les deux groupes. Le résultat des tests fonctionnels, la force musculaire isokinétique et la douleur résiduelle dans le genou ont été similaires dans les deux groupes. Cependant, dans la reconstruction précoce il y a eu moins de lésions dégénératives de l’articulation tibio-fémorale, moins de gêne ou de douleurs et le retour á l’activité sportive a été plus fréquent. Nos résultats montrent que la réparation précoce est préférable.

Interference Screw Fixation of Soft Tissue Grafts in Anterior Cruciate Ligament Reconstruction: Part 2 Effect of Preconditioning on Graft Tension During and After Screw Insertion

Background Preconditioning of tendon grafts is believed to eliminate natural viscoelasticity of the tendons and prevent knee laxity after anterior cruciate ligament (ACL) reconstruction. Hypothesis Preconditioned ACL grafts maintain their initially set tension. Study Design Randomized experimental study. Methods Forty-two human anterior tibialis (AT) tendon grafts were subjected to either no preconditioning (group 1), cyclic preconditioning (group 2), or isometric preconditioning (group 3). The residual graft tension was then recorded immediately after the application of an initial graft tension of 80 N and fixation into tibia with an interference screw, as well as 10 minutes later. In another experiment, the residual graft tension was recorded 1, 10, and 60 minutes after 10 AT nd quadrupled hamstring tendon (HT) grafts alone (no fixation) had been subjected to isometric preconditioning (80 N). Results Immediately after screw insertion, the residual (AT) graft tensions were 79 ± 19 N, 100 ± 17 N, and 102 ± 15 N in groups 1 through 3, respectively. Ten minutes later, the corresponding values were 49 ± 16 N, 60 ± 11 N, and 64 ± 12 N. For the AT and HT grafts alone, the residual graft tensions were 67 ± 2 N and 67 ± 2 N, 45 ± 2 N and 46 ± 4 N, and 29 ± 3 N and 34 ± 5 N at 1, 10, and 60 minutes, respectively. Conclusions A steady decrease (–60% within 60 minutes after initial tensioning) occurs in the initially set tension of the soft tissue ACL grafts. Clinical Relevance Clinically applicable preconditioning protocols cannot eliminate the intrinsic viscoelasticity from ACL soft tissue grafts, and thus, the reasonableness of preconditioning per se is questioned in ACL reconstruction.

Anterior knee pain 7 years after an anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft.

In order to evaluate the occurrence and predicting factors of anterior knee pain in patients after an anterior cruciate ligament reconstruction with a bone‐patellar tendon‐bone autograft, a functional, clinical and radiographic evaluation was performed on 91 patients on average 7 years after the surgery. Also, the isokinetic muscle torque was measured. At 7 years, anterior knee pain, as classified by the International Knee Documentation Committee (IKDC), was absent in 40 patients, mild in 47 patients, and moderate in 4 patients. None was classified as suffering from severe anterior knee pain. In the logistic regression analysis of predicting factors (forward‐stepping), knee extension torque deficit of the operated limb was the only factor that showed significant association with anterior knee pain. The other objective measurements of the knee (flexion torque deficit, range of motion, stability evaluation, and radiographic evaluation of the knee) were not associated with anterior knee pain. Subjectively and not surprisingly, the patients without anterior knee pain were more often satisfied with the overall outcome than the patients with anterior knee pain. Also, the Lysholm and Marshall knee scores and the final outcome in the IKDC rating scale were significantly better in patients without than with anterior knee pain.

Interference screw fixation of soft tissue grafts in anterior cruciate ligament reconstruction: part 1: effect of tunnel compaction by serial dilators versus extraction drilling on the initial fixation strength.

Background Compaction of the bone-tunnel walls by serial dilation is believed to enhance the interference screw fixation strength of the soft tissue grafts in anterior cruciate ligament (ACL) reconstruction. Hypothesis Serial dilation enhances the fixation strength of soft tissue grafts in ACL reconstruction over extraction drilling. Study Design Randomized experimental study. Methods Initial fixation strength of the doubled anterior tibialis tendon grafts (fixed with a bioabsorbable interference screw) was assessed in 21 pairs of human cadaver tibiae with either serially dilated or extraction-drilled bone tunnels. The specimens were subjected to a cyclic-loading test, and those surviving were then tested using the single-cycle load-to-failure test. Results During the cyclic-loading test, there were 3 fixation failures in the serially dilated and 6 failures in the extraction-drilled specimens but no significant stiffness or displacement differences between the groups. In the subsequent load-to-failure test, the average yield loads were 473 ± 110 N and 480 ± 115 N for the 2 groups respectively (P= .97) and no difference with regard to stiffness or mode of failure. Conclusions Serial dilation does not increase the strength of interference fixation of soft tissue grafts in ACL reconstruction over extraction drilling. Clinical Relevance The results of this experiment do not support the use of serial dilators in ACL reconstruction.

All-Inside Meniscal Repair With Bioabsorbable Meniscal Screws or With Bioabsorbable Meniscus Arrows A Prospective, Randomized Clinical Study With 2-Year Results

Background All-inside meniscal repairs have gained popularity in the past few years. However, only a few prospective, randomized clinical studies have been done to compare different all-inside meniscal repair techniques. Hypothesis Meniscal repair with bioabsorbable meniscal screws and arrows results in similar clinical outcome on short-term follow-up. Study Design Randomized controlled trial; Level of evidence, 2. Methods Forty-two patients were prospectively randomized to have all-inside meniscal repair either by using bioabsorbable meniscal screws or bioabsorbable meniscus arrows (21 patients, 23 meniscal repairs in each group) for the fixation. The evaluation methods were clinical examination, Lysholm score, the International Knee Documentation Committee (IKDC) knee score, and magnetic resonance arthrography (MRA) evaluation. The average follow-up time was 27 months (standard deviation, 8). Results There were no differences between the study groups preoperatively. All 42 patients (100%) were available for the follow-up. However, during the follow-up, 11 patients had clinical failure, confirmed at second-look arthroscopy, of the repair leading to partial meniscal resection. Four failures (all on the medial meniscus) were observed with the use of meniscal screw fixation (17%), and 7 (4 on the medial meniscus, and 3 on the lateral meniscus) with the use of meniscus arrow fixation (30%) (P = .242). Six patients with meniscus arrows (29%) had chondral damage on the femoral condyles evaluated by MRA or at second-look arthroscopy, while none of the patients with the meniscal screws had the same (P = .018). However, the Lysholm and the IKDC scores were similar in both groups at follow-up. Conclusion All-inside meniscal repair with bioabsorbable meniscal screws and arrows resulted in similar clinical outcome, although significantly more chondral damage was observed when using bioabsorbable meniscus arrows for fixation.