Knee Surgery Sports Traumatology Arthroscopy

Published by Springer Verlag
Online ISSN: 1433-7347
Print ISSN: 0942-2056
Purpose Optimal postoperative analgesia after anterior cruciate ligament repair remains challenging. The objective of this prospective experimental clinical study was to compare the postoperative analgesic efficacy of two infusion regimens of 0.1 % bupivacaine administered via perineural femoral catheter. Methods Forty adult ASA I and II patients undergoing anterior cruciate ligament reconstruction were enrolled. Surgery was performed under spinal anesthesia combined with femoral nerve block. A perineural femoral catheter was connected to the patient controlled analgesia infusion pump filled with 0.1 % bupivacaine for postoperative pain control. Subjects were assigned to one of two groups according to the bupivacaine infusion regimen: (1) 5 mL/h basal infusion with on-demand 5 mL boluses and 30-min refractive periods, and (2) only on-demand 5 mL boluses and 15-min refractive periods. Quality of postoperative analgesia, adjunctive analgesic consumption, and overall patient satisfaction were recorded for 48 h. Results Pain control was better in Group I on the day of surgery (P = 0.001) and on the first postoperative day at rest and during mobilization (P = 0.02 and P = 0.009). On the second postoperative day, only pain control during mobilization was better in Group I (P = 0.047). Adjunctive analgesic consumption and patient satisfaction were similar. Conclusion Perineural femoral infusion of on-demand 5 mL boluses of 0.1 % bupivacaine combined with 5 mL/h basal infusion was more efficient than on-demand regimen alone for postoperative pain management after reconstruction of anterior cruciate ligament of the knee. Level of evidence II.
The results of magnetic resonance imaging (MRI) were compared with those of arthroscopy in a prospective series of 244 patients. A dedicated system for MRI of limbs and peripheral joints--the 0.2-T Artoscan (Esaote, Italy)--was used for imaging knee joint lesions. T1-weighted spin-echo sagittal images, T2-weighted gradient-echo coronal images, and axial views for lesions of the femoropatellar joint were acquired. Paraxial sagittal and oblique coronal views were obtained for imaging of the cruciate ligaments. This protocol allowed excellent visualization of the cruciate ligaments and medial and lateral meniscus in almost all patients. Compared with arthroscopy performed within 48 h after imaging, the sensitivity, specificity, and accuracy were respectively 93%, 97%, and 95% for tears of the medial meniscus; 82%, 96%, and 93% for tears of the lateral meniscus; 100%, 100%, and 100% for tears of the posterior cruciate ligament; 98%, 98%, and 97% for tears of the anterior cruciate ligament; and 72%, 100%, and 92% for full-thickness articular cartilage lesions. The examination can be performed within 30-45 min at lower cost than diagnostic arthroscopy. MRI with a 0.2-T magnet is a safe and valuable adjunct to the clinical examination of the knee and an aid to efficient preoperative planning.
Purpose: Reduction in blood loss during surgery stabilizes hemodynamic status and aids in recovery after total knee arthroplasty (TKA). In this study, the authors examined whether different administration routes of tranexamic acid (TNA) might affect the amount of blood loss after TKA. Methods: A total of 150 patients were prospectively allocated to each of the three groups (intravenous, intra-articular, and placebo group) and underwent unilateral TKA. During closing the operative wound, TNA (1.5 g mixed in 100 cc of saline) was administered intravenously or intra-articularly according to the enrolled group, and an equivalent volume of normal saline was administered into the knee joint cavity and intravenously in the placebo group, respectively. The amount of blood loss and transfusion, and changes in haemoglobin levels were documented accordingly. Results: The mean blood loss in the intravenous, intra-articular, and placebo groups were 528 ± 227, 426 ± 197, and 833 ± 412 ml, respectively. About 66 % (intravenous), 80 % (intra-articular), and 6 % (placebo) of each group did not require transfusion for any reason, and the mean amount of transfusion was 273.6, 129.6, and 920.8 ml, respectively. Preoperative haemoglobin values decreased by 1.6 ± 0.8, 1.8 ± 0.8, and 2.0 ± 0.9 mg/dl, respectively. Conclusion: Compared to intravenous administration, intra-articular administration of TNA seems to be more effective in terms of reducing blood loss and transfusion frequency. TNA may improve the general conditions of patients given TKA by maintaining a hemodynamically stable state, aiding in recovery, and reducing the chance of transfusion-associated side effects and complications. Level of evidence: II.
Dear Editor,We read the article entitled “Long-term results after microfracture treatment for full-thickness knee chondral lesions in athletes” with great interest. In this article, the authors analysed the outcome after microfracturing for the treatment of chondral lesions in a selected population from 1991 to 2001 . The results of this study are in accordance with those of other studies published recently [1, 4, 8, 13-15].We agree with the findings of the authors, and we endorse microfracturing as a successful and low-cost technique for treating this type of defect. However, some questions and concerns arose as we read the article:In the Materials and methods, the authors mention that, among other scales, the evaluation form for the International Knee Documentation Committee (IKDC) score was completed by the patients before surgery in 1991-2001. However, the IKDC score in its present form was first published by Irrgang et al. [7] in 2001. The IKDC form is used to evaluate ligament ...
The aim of this study was to report orthopedic surgeons' management of choice for difficult clinical scenarios of shoulder pathologies. A web questionnaire was developed including four clinical scenarios of shoulder pathologies. Subsequently, opinions were solicited from more than 1,000 members of an international association of surgeons specialized in sports traumatology and knee surgery (ESSKA). The response rate was 40% (412 questionnaires). For scenario 1, first anterior dislocation of the shoulder, the most indicated treatment for 71% of respondents was an arthroscopic Bankart repair (P < 0.001). For scenario 2, shoulder arthritis with concentric erosion and cuff tear, 38% chose a shoulder replacement, while 37% preferred a supraspinatus tendon repair in combination with long head of biceps (LHB) tenodesis or tenotomy. For scenario 3, large tendon tears with 70% fatty infiltration of the infraspinatus tendon and lateral LHB instability, 70% of surgeons considered that, among conservative treatments, hyaluronic acid injection was not an appropriate management. Arthroscopic rotator cuff repair, arthroscopic acromioplasty, and LHB tenotomy gained larger consensus (81, 80, and 79% of respondents, respectively). A double-row technique for rotator cuff repair was preferred to a single-row technique (P = 0.02). Scenario 4, adhesive capsulitis, split the respondents equally, with 51% in favor of a surgical approach and 49% in favor of a conservative approach (N.S.). On-line questionnaires have the potential to improve knowledge about current trends in clinical practice and can help orthopedic surgeons to develop guidelines. Cross-sectional; Level V (expert opinion).
The KT-1000 and similar non-invasive arthrometers are used as a complement to clinical examination in the diagnosis of anterior cruciate ligament (ACL) rupture and during the follow-up after surgery. We compared the two methods, KT-1000 and Radiostereometric analysis (RSA), when used to measure anterior-posterior knee laxity (A-P laxity) in patients with ACL rupture, before and after the reconstruction of this ligament, in a prospective, comparative study. Twenty-two consecutive patients (14 men, 8 women) with a median age of 24 years (range 16-41) were studied. All the patients had a unilateral ACL rupture and an intact contralateral knee. The patients were operated on by one experienced surgeon using the bone-patellar tendon-bone (BTB) autograft. Preoperatively and 2 years after the reconstruction, all the patients were evaluated using KT-1000 and RSA measurements of A-P laxity. The side-to-side differences between the injured and the intact knees, that is, total A-P laxity for both knees, are presented. Preoperatively, the median side-to-side differences using the two methods (KT-1000/RSA) were 4.0 (0-10)/7.4 mm (2.2-17.4) (P<0.0001). The total A-P laxity on the injured side was 11.0 (6.0-18.0)/10.9 mm (6.2-19.6) (n.s), while it was 8.0 (6.0-10.0)/3.1 mm (0.2-8.6) on the intact side (P<0.0001). A side-to-side difference of more than 3.0 mm was defined as the cut-off value for indicating ACL rupture. Using the KT-1000, 11 of 22 (50%) patients had a cut-off value above 3.0 mm, while the corresponding figure for RSA was 21/22 (95%) patients. At the 2-year follow-up, the median side-to-side differences using the two methods (KT-1000/RSA) were 0.5 (-1.5 to 4.0)/2.8 mm (-1.8 to 10.7) (P<0.0001). The total A-P laxity on the operated side was 9.5 (7.5-14.0)/6.5 mm (2.4-14.1) (P<0.0001). We conclude that the KT-1000 recorded significantly smaller side-to-side differences than did the RSA, both before and after the reconstruction of the ACL using a BTB autograft. Before it was mainly an effect of larger A-P laxity recordings with KT-1000 on the intact side, and after the reconstruction, the KT-1000 still recorded larger A-P laxity on the intact side and also larger A-P laxity on the reconstructed side than RSA.
The comparison of bilateral dynamic X-rays in passive anterior and posterior drawer with a load of 9 kg, and the arthrometer KT 1000 measurements obtained from 100 patients before anterior cruciate ligament reconstruction, confirms the good diagnostic efficiency of the following methods: (1) radiological measurement of the anterior translation of the medial compartment, as an absolute value and especially as a differential value in relation to the opposite, uninjured knee, the normal value limits being respectively 5 and 2 mm; and (2) arthrometric measurement of the maximal manual translation, also as absolute and differential values, the normal value limits being 10 and 2 mm respectively. These two measurements have a predictive value of 90%. No numerical equivalency exists between the radiological and arthrometric values, but their variations in relation to each other are statistically correlated. The arthrometer, simple to use and totally innocuous, is an excellent test device for consultation, while dynamic X-rays allow separate studies of each compartment to look for lesions of the posteromedial or posterolateral corners.
The KT-1000 was used to measure anterior tibial displacement in three populations: normal subjects (n = 120), patients with unilateral acute anterior cruciate ligament (ACL) disruptions (n = 105), and patients with chronic unilateral ACL disruptions who were scheduled for ACL reconstructions (n = 159). All patients with ACL disruptions were measured with and without anesthesia. Tibial displacement under three loading conditions was measured: 89-N anterior displacement force, manual maximum displacement force, and quadriceps contraction to lift the leg. The measurements of the normal knee in the injured populations were not significantly different from those of the knees in the normal population on any test. The injured knee tested with and without anesthesia was significantly different from the normal knee on all tests. The right-left difference in the normal population as less than 3 mm in 98% of patients in the 89-N test, 97% in the manual maximum test, and 99% in the quadriceps active test. The largest amount of displacement and the greatest difference in displacement between the injured and the normal knee was produced by the manual maximum test. The manual maximum injured-minus-normal knee displacement was 3 mm or more in 99% of patients with chronic ACL disruptions and in 95% of patients with acute ACL disruptions.
The lower limb is placed in a single thermoformed support. The knee is in neutral rotation, so that the patella is facing anteriorly. The knee should be placed, so that the inferior pole of the patella is covered by the lower border of the patellar support. This support exerts a symmetric pressure on the patella during the test, checked by a pressure control. The joint line is palpated and should be located between the thigh support above and the calf support below. An electric actuator exerts increasing loads according to the examiner: 67, 89, 134, 150, or 250 N on the upper aspect of the calf. Surface (EMG) electrodes are placed on the posterior aspect of the thigh to control hamstring muscle relaxation of the tested knee (feedback effect). A displacement sensor records the relative displacement of the anterior tibial tubercle with respect to the patella
Accurate measurement of laxity after anterior cruciate ligament (ACL) rupture is usually performed with the KT-1000 arthrometer, and reproducibility and reliability are discussed. A new arthrometer, the GNRB(®), has been recently developed in an attempt to improve intra- and inter-examiner reproducibility. The aim of this diagnostic study was to evaluate the intra- and inter-examiner reproducibility of the GNRB(®) and the KT-1000. Three protocols were designed to evaluate and compare the two arthrometers. Fifteen physiotherapists conducted tests on 15 subjects with healthy knees. The intra- and inter-reproducibility of the two tests were compared by analysis of variance and the F-test. Measure reproducibility was significantly worst with the KT-1000 than with the GNRB(®) (machine effect, P < 0.001) regardless of operator experience. There was no significant difference between experienced and inexperienced examiners with the GNRB(®) (no 'examiners effect'). Regardless of the machine, there was a 'side effect' with healthy knees. This clinical study demonstrates the superior intra- and inter-examiner reproducibility of the GNRB(®) over the KT-1000. There appears to be some technological advantages to using the GNRB(®) including pressure control of the patella, accuracy of the displacement transducer, control of the load on the calf, and control of hamstring activity. Diagnostic study, Level I.
Two studies were undertaken to evaluate the use of EMG biofeedback to encourage hamstring relaxation during KT-1000 measurement of anterior tibial displacement. In study 1, 60 ACL-deficient patients were studied in three groups using 15 lb and 20 lb in each group: in group 1 the patients were simply retested 15 min after the initial test sequence, in group 2 they were initially retested with EMG biofeedback and then again without, and in group 3 they were retested twice with EMG biofeedback. No significant difference in mean anterior tibial displacement was seen between the initial measurements and retest measurements when no EMG biofeedback was used. A significant increase in mean anterior tibial displacement was seen when the retesting was performed with EMG biofeedback. No further increase was seen with repeated retesting with EMG biofeedback. In study 2, 40 patients were evaluated 4-12 months following ACL reconstruction. KT-1000 measurements of anterior tibial displacement of both the operated and non-operated knees were made at 15 lb and 30 lb with and without the use of EMG biofeedback. EMG biofeedback was associated with a significant increase in unilateral measurement of anterior tibial displacement. When side-to-side differences were compared, there was a small but statistically significant increase in anterior tibial displacement with the use of EMG biofeedback. Although the use of EMG biofeedback to encourage hamstring relaxation does increase unilateral measurements of anterior tibial displacement, it does not appear to have a clinically significant effect on measurement of side-to-side difference. It may have a role in testing patients who have difficulty achieving hamstring relaxation or in aiding inexperienced examiners.
A new simple and portable arthrometer, the Rolimeter, was used to assess the anterior laxity of knees in 20 normal subjects and 18 subjects with chronic anterior cruciate ligament (ACL) deficiency. The subjects were tested by one examiner using maximum manual force. In order to assess the reliability of the device the same subjects were tested with the KT-1000. In ACL-deficient knees the absolute translation and the side-to-side difference did not differ significantly between the devices. In normal knees the Rolimeter measured slightly smaller translations than the KT, but with a high degree of correlation between devices. If a 3-mm or greater side-to-side difference is considered indicative of ACL deficiency, both arthrometers were successful in diagnosing 16 of 18 cruciate ruptures (sensitivity 89%) and 19 of 20 normal knees (specificity 95%). We conclude that the Rolimeter, when compared with the KT-1000, provides a valid measure of anterior knee laxity.
We report on a comparative measurement of anterior knee joint laxity on 30 healthy test subjects and 30 patients with anterior knee joint instability using a new knee testing device (Rolimeter) and the KT- 1000 arthrometer compared to manual assessment of the anterior tibial translation in 30 degrees flexion (Lachman's test). We wanted to establish the reliability of the Rolimeter device compared to manual assessment and to the KT- 1000 arthrometer. The statistical evaluation by means of an analysis of variance (ANOVA) at a significance level of 5% showed no significant difference in the exactitude of measurement between the Rolimeter and the KT-1000 arthrometer, but altogether a significant difference between both instrumental methods compared with manual assessment. Thus the Rolimeter provides an economic, exact and simply operating device for quantifying anterior knee joint instability.
The KT-1000 is widely accepted as a tool for the instrumented measurement of the antero-posterior (AP) tibial translation. The aim of this study is to compare the data obtained with the KT-1000 in ACL deficient knees with the data obtained using a navigation system during "in vivo" ACL reconstruction procedures and to validate the accuracy of the KT-1000. An ACL reconstruction was performed using computer aided surgical navigation (Orthopilot, B-Braun, Aesculap, Tuttlingen, Germany) in 30 patients. AP laxity measurements were obtained for all patients using KT-1000 arthrometer (in a conscious state and under general anaesthesia) and during surgery using the navigation system, always at 30 degrees of knee flexion. The mean AP translation was 14 +/- 4 and 15.6 +/- 3.8 mm using the KT-1000 in conscious and under general anaesthesia, respectively (P = 0.02) and 16.1 +/- 3.7 mm using navigation. Measurements obtained with the KT-1000 under general anaesthesia were no different from those obtained "in vivo" with the navigation system (P = 0.37). In conclusion this study validates the accuracy of the KT-1000 to exactly calculate AP translation of the tibia, in comparison with the more accurate measurements obtained using a navigation system.
The aim of this study was to determine the reliability of bone landmarks for restoring the joint line in revision knee arthroplasty. The relationship of the femoral epicondyles, the tibial tubercle (TT) and the fibular head (FH) to the joint line was measured on 200 magnetic resonance imaging (MRI, 100 females, 100 males), including assessment on intraobserver and interobserver reliability. MRI scans demonstrating chondral lesions and osteoarthritis were excluded, as were patients with immature skeletons or a history of previous knee surgery. Sequences in sagittal, coronal and axial planes were used as well as cross-referencing with the same computer software. In order to account for size differences between patients, each bony landmark measurement was converted to a ratio relative to the femoral or/and tibial width. We found a transepicondylar axis equal to 3.11 degrees (+/-1.9). The average distance from the epicondyles to the joint line was respectively 23 mm on the lateral side and 28 mm on the medial side. However there was a variation of distance from the epicondyles of the joint line up to 11 mm and a significative difference was found between male and female. We determined the distances from the tip of the FH and from the TT to the joint line. The joint line-FH distance averaged 14 mm (range 4.1-22.13) with no gender difference. The joint line-TT distance was averaged 22 mm (range 10.61-32.09). We determined an epicondylar ratio (distance from the lateral epicondyle to the joint line related to the femoral width). We found this ratio averaged 28% with no gender difference (P = 0.09). There is a large variation of bony landmarks depending on the size of the individual. Considering this findings, the FH is not a reliable guide for the joint line in revision surgery. Previous studies have measured the absolute values from various landmarks to the joint line. This study provides a significant advantage, in that the level of the joint line can be determined for each individual by using a ratio to account for gender and size differences.
Although the results of total knee arthroplasty continue to improve, problems related to the patellofemoral joint remain significant. This study examined the factors affecting patellar alignment after total knee arthroplasty and subsequent changes in 56 knees during a postoperative period of 5.3 years. None of the knees examined displayed any clinical complications of the patellofemoral joint; no revision surgeries were necessary, with acceptable patellar alignment on average. The patellar resection angle had a strong influence on patellar alignment. Thinning of the patellar remnant on the medial side can increase postoperative lateral tilt, which leads to a need for lateral retinacular release. Although the changes in patellar alignment were minimal, the tendency that postoperative varus alignment resulted in patellar lateral tilt was observed. As postoperative femorotibial misalignment can lead to patellofemoral problems after total knee arthroplasty, surgeons need to pay scrupulous attention to femorotibial alignment and proper patellar preparation to decrease patellofemoral complications.
Purpose: Researchers from 11 countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their Diagnosis-Related Group (DRG) systems deal with knee replacement cases. The study aims to assist knee surgeons and national authorities to optimize the grouping algorithm of their DRG systems. Methods: National or regional databases were used to identify hospital cases treated with a procedure of knee replacement. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97 % of cases. Five standardized case scenarios were defined and quasi-prices according to national DRG-based hospital payment systems ascertained. Results: Grouping algorithms for knee replacement vary widely across countries: they classify cases according to different variables (between one and five classification variables) into diverging numbers of DRGs (between one and five DRGs). Even the most expensive DRGs generally have a cost index below 2.00, implying that grouping algorithms do not adequately account for cases that are more than twice as costly as the index DRG. Quasi-prices for the most complex case vary between euro 4,920 in Estonia and euro 14,081 in Spain. Conclusions: Most European DRG systems were observed to insufficiently consider the most important determinants of resource consumption. Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. Ultimately, this would contribute to assuring adequate performance comparisons and fair hospital reimbursement on the basis of DRGs.
Isolated meniscus tears with consecutive complete luxation of the meniscus are an exceptional injury especially in children. We report a case of an 11-year-old girl with a complete luxation of the lateral meniscus, injured by a jump from low height. Following clinical examination and magnetic resonance imaging, a surgical refixation of the entire lateral meniscus was performed. Short-time clinical and radiological follow-up was conducted.
Difference between the Tegner Score prior to trauma and at the time of follow-up. Patients from the highest levels of activity (7–8 and 9–10) were also included in the study. No difference in activity loss between the two groups could be proved (P = 0.9)
ACL-reconstruction aims to restore joint stability and prevent osteoarthritis; however, malfunction and osteoarthritis are often the sequelae. Our study asks whether ACL-reconstruction or conservative treatment lead to better long-term results. In this retrospective cohort study, 136 patients with isolated ACL-rupture who had been treated by bone-ligament-bone transplant or conservatively were identified. Twenty-seven of these were excluded because of a revision operation in the 11.1 years follow-up period, leaving 109 patients (60 reconstructions and 49 conservatively treated) for evaluation based on clinical, radiological and internationally accepted knee-scores (Tegner, IKDC, Kellgren and Lawrence). An individual cohort study is classified as EBM level 2b according to the Oxford Centre of EBM. We observed significantly better knee-stability (P = 0.008) but more osteoarthritis (Grade II or higher) after ACL-reconstruction (42% vs. 25%). Physical activity levels were similar in both groups during the follow-up period (P = 0.16). Eleven years after ACL-rupture the physical activity levels are similar for both groups. After ACL-reconstruction, stability is higher as is osteoarthritis, whereby the result is not necessarily perceived as better subjectively. Specifically, this retrospective study yielded a 24% incidence of oseoarthrits 11 years after conservative management of ACL-rupture in patients not needing secondary surgery. The risk of secondary meniscal tears is reduced after ACL reconstruction, which reduces the negative effects of OA after surgery. The ultimate objective would be to achieve a good subjective outcome by conservative treatment followed by a rehabilitation program designed to keep secondary meniscus tears at a low level.
We report results of surgical treatment of ten knees affected by patellar dislocation in six children with Down syndrome. Four knees showed a dislocatable patella (grade III according to Dugdale), two a dislocated reducible patella (grade IV) and four a dislocated irreducible patella (grade V). Symptoms included frequent falls, limping and pain. In all the cases a Roux-Goldthwait-Campbell procedure was performed. Mean age at surgery was 10 years (range 6 years and 6 months to 13 years and 4 months). Patients were reviewed at an average follow-up of 8 years and 8 months (range 3 years and 6 months to 11 years and 5 months). None showed signs of recurrence of the dislocation. The median Lysholm score improved from 57.5 to 91/100. Statistical analysis showed a significant effectiveness of the procedure in improving function, and that surgery was significantly more effective in patients with more severe disability.
Appearance of the regenerative tendon at 12 months. The regenerative tendon appears very similar to the normal one  
a Normal tendon: normal semitendinosus tendon shows compact, longitudinally oriented collagen fibers and thin linear fibroblast nuclei. These are findings peculiar to a normal tendon (HE·400) b Regenerative tendon: histological appearance of the regenerated tendon at 12 months. In comparison with a normal tendon, regenerative tendon shows longitudinally but more irregularly oriented collagen fibers and more spindle-shaped fibroblast-like cell nuclei. There was some variation in the thickness of the fibrous tissues. No evidence of degeneration or necrosis of the tendonous tissue was present (HE·400)  
The purpose of our study is to evaluate whether the hamstring tendons can regrow after harvesting for anterior cruciate ligament (ACL) reconstruction and whether the regenerate tissue can be histologically characterized as tendinous. Eleven of the patients (eight female and three male; mean age, 23 years; range 17-37 years) consented to participate in this study. One year after the ACL reconstruction, surgical biopsy was done. Regeneration of the tendon was detected macroscopically in 9 of the 11 patients. Histologically and immunohistochemically, the regenerated tendons closely resembled normal ones. The results of this study show the hamstring tendons can regenerate after harvesting for the ACL reconstruction.
Gait alterations after ACL reconstruction have been reported in the literature. The current study examined a group of 14 patients who all had an ACL reconstruction with a patellar tendon autograft. Kinetic and kinematic data were obtained from the knee during walking. The flexion-extension deficit (FED) calculated from the angular difference between maximal flexion and maximal extension during the stance phase in the ACL-reconstructed and the normal knee was measured. We investigated whether these alterations in gait are related to quadriceps strength and residual laxity of the knee. It may be that patients modify their gait patterns to protect the knee from excessive anterior translation of the tibia by reducing the amount of extension during stance. On the other hand, persistent quadriceps weakness may also cause changes in gait patterns as the quadriceps is functioning as an important dynamic stabilizer of the knee during stance. Results showed that patients had a significantly higher FED value (4.9+/-4.0) than a healthy control group in a previous study (1.3+/-0.9). This is caused mainly by an extension deficit during midstance. External extension moments of the knee (TZMAX were significantly lower in the current patients group than in a healthy control group (TZMAX -0.27+/-0.19 Nm/kg in patients vs. -0.08+/-0.06 Nm/kg in controls). There were no significant correlations between quadriceps strength and gait analysis parameters. Furthermore no correlation was found between the amount of laxity of the knee and gait. The relevance of this study lies in the fact that apparently the measured gait alterations cannot be explained solely by often used biomechanical indicators such as laxity and strength. The measured gait alterations may be a result of the surgical procedure with subsequent modified motor programming.
This study evaluated telemark injuries in a Swedish ski area in terms of injury ratio, location, and causes over time. During the seasons of 1989-2000 all injured telemark skiers ( n=94) who attended the medical center in Tärnaby, Sweden, within 48 h after the accident were registered and asked to fill in an injury form. A control group of noninjured telemark skiers were interviewed in the season of 1999-2000. The most common cause of injury was fall (70%) and the injury ratio was 1.2. There was a higher proportion of beginners in the injured population, and they had a fall/run ratio of 0.7, compared with 0.3 for average and advanced skiers. Ankle/foot injuries were most common (28% of injuries) followed by knee (20%) and head/neck (17%). The ankle/foot injuries decreased from 35% to 22% in the seasons 1989-1995 to 1995-2000. Beginners had more ankle/foot injuries than skilled participants. The severity of ankle/foot injuries classified as the Abbreviated Injury Scale group 2 or higher decreased from 33% to 21% during the study period. Twenty-seven percent used plastic and 73% leather boots. We found no association between boot material and ankle/foot injuries. The proportion of high boots with two or more buckles was 51%. High boots appeared to be protective against ankle/foot injuries. The proportion of high boots increased from 24% to 67% during the study period. Thus ankle/foot injuries were the most common injury location, but have decreased over time. The severity of these injuries has also decreased. A possible explanation could be the increased use of high boots.
Group 1: pain-free shoulders (n = 53) 
Group 3: painful shoulders with arthropathy (n = 11); concomitant pathology and additional surgery 
The aim of this investigation was to evaluate the long-term outcome of arthroscopic subacromial decompression (ASD) in patients with primary impingement syndrome stage II and early stage III. Ninety-five patients (105 shoulders, 48 female), mean age 54 years (range 26-69), who had undergone surgery between 1996 and 1999, were included. Pain intensity during activity and at rest, patient satisfaction, active range of motion (ROM), muscular strength and shoulder function using the Constant score were evaluated. Fifty-three (50%) shoulders were pain-free (Visual Analogue Scale < or = 10 mm) during activity and 72 (68%) shoulders were pain-free at rest. Sixty-one (58%) patients stated that they were very satisfied and 27 (25%) were quite satisfied with regard to their current shoulder function. Shoulders were divided into Group 1: Pain-free patients (n = 53), Group 2: Patients with shoulder pain and no arthropathy (n = 41) and Group 3: Patients with shoulder pain and arthropathy (n = 11). The groups had average active ROM of 157 degrees, 135 degrees and 117 degrees, respectively, in abduction and 97 degrees, 79 degrees, and 68 degrees in external rotation. The average strength in elevation in the scapular plane was 7.4, 5.8 and 3.9 kg, respectively, whereas the mean value in external rotation was 8.4, 7.9 and 5.3 kg, respectively. The Constant score had a mean value of 87, 69 and 59 points in the three groups, respectively. Eleven shoulders have undergone re-operation, one after a new trauma. We conclude that ASD is a valuable procedure. Patients expressed a high degree of satisfaction with shoulder function 8-11 years after ASD.
We compared the results of microfracture in single versus multiple symptomatic articular cartilage defects in the knee in 110 patients with a median age of 38 years (range 15-60). Cases of reoperation of the cartilage defect were classified as failures. Clinical outcome in non-failures was evaluated by the Lysholm score and grading of knee pain and function of the knee by the use of patient-administered visual analog scales (VAS; 0-100). Data were prospectively collected before the operation and at the 2- to 9-year follow-up. The single lesion or the largest of multiple lesions were located on the medial femoral condyle (n = 62), trochlea (n = 18), lateral tibia (n = 11), patella (n = 10) or lateral femoral condyle (n = 9). We treated one (n = 76), two (n = 27) or three (n = 7) lesions with a median total area of 4 cm(2) (range 1-15). A total of 24 failures (22%) were registered-18% in the single-defect subgroup and 29% in the multiple-defects subgroup. In the remaining group of patients (n = 86), the mean Lysholm score, mean pain-score (0 = no pain; 100 = worst possible pain) and mean function-score (0 = useless; 100 = full function) improved from 51, 52 and 41, respectively, to 71 (P < 0.001), 30 (P < 0.001) and 69 (P < 0.001) at the follow-up. The pain-score was significant lower (P = 0.042), and the function-score significantly higher (P = 0.001) in the group of patients with a single lesion compared to the group with 2 or 3 lesions. The Lysholm score did not differ significantly between the two subgroups (P = 0.06).
Of about 150 cases reported in the literature on pectoralis major ruptures, 108 were selected as presenting enough data to be analyzed for cause, rupture site, injury mechanism, and treatment outcome. We added data on four of our own cases reported here. All patients yet reported have been men. Rupture of the PM occurs most commonly in sports during weight training, weight lifting, or wrestling when the arm is externally rotated and abducted. Most reported ruptures are complete and are located at the insertion to the humerus. Work-related injuries occur more often at the musculo-tendinous junction. The prognosis is related neither to the age of the patient nor to the location of the rupture. Surgical treatment, preferably within the first 8 weeks after the injury, has a significantly better outcome than conservative treatment or delayed repair.
Correlation coefficients between the Lysholm score, and 
The purpose of this study was to determine: (1) the sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score, (2) the relationship between the IKDC form, the Lysholm score and the Cincinnati knee score, (3) the criterion validity of each graded variable included in the IKDC form, and (4) if a functional knee test should be included as a graded variable and part of the final result of the IKDC form. We included in this prospective study 120 subjects who underwent ACL reconstruction with follow-up times of 3 and 6 months, and 1 and 2 years after surgery. Outcome measurements were the graded variables of the IKDC form (IKDC1-4 and IKDC-final), the Lysholm score, the Cincinnati knee score, a visual analogue scale for patient's satisfaction, knee joint laxity measurement (KT-1000 knee arthrometer), and two functional knee tests (the triple jump and stairs hopple tests). The IKDC1, IKDC2, IKDC-final, and the Lysholm score were not sensitive to changes over time. The Cincinnati knee score was highly sensitive to changes over time and showed significantly improved outcome between each follow-up. IKDC1-4 showed high criterion validity, indicating that the IKDC1-4 is a good means of documenting clinical examination at one follow-up, but not of detecting changes over time. The functional knee tests were significant outcome measurements after ACL reconstruction, and should be reported separately.
High tibial osteotomy is a well-established method for the treatment of medial unicompartmental osteoarthritis of the knee. We analysed retrospectively the long-term outcome of open and closing wedge valgisation high tibial osteotomies. Out of 71 patients, 54 (76%) were available for the study. Survival rates and the influence of the osteotomy type were investigated. Secondary outcome measures were the course of radiological leg axis and osteoarthritis as well as score outcomes. During a median follow-up of 16.5 years (IQR 14.5-17.9; range 13-21), 13 patients (24%) underwent conversion to total knee arthroplasty; the other 41 patients (76%, survivor group) were studied by score follow-up as well as clinical and radiological examinations. Osteotomy survival was of 98% after 5 years, 92% after 10 years and 71% after 15 years. Comparison between open and closing wedge high tibial osteotomy showed no significant difference in survival and score outcome. The median Visual Analogue Score (VAS) was 0 (IQR 0-1; range 0-4), the Satisfaction Index was 80% (IQR 63-89; range 30-100), the median Knee Injury and Osteoarthritis Outcome Score was 71 (IQR 49-82; range 9-100) and the median Western Ontario and McMaster Universities Osteoarthritis index was 84 (IQR 66-96; range 9-100). Radiological evaluation showed only a slight progression of the degree of osteoarthritis following the Kellgren and Lawrence classification. In each case, the axis passed through the healthy compartment or at least through the centre of the knee. Open and closing wedge high tibial osteotomies are a successful choice of treatment for unicompartmental degenerative diseases with associated varus in active patients. Survival of both techniques is comparable in our series and is associated with low pain scores, high satisfaction and high activity levels of the survivors.
This study investigated the long-term outcome of common meniscus treatment (meniscectomy, repair). A consecutive series of 30 patients with open meniscus repair were compared retrospectively to 30 patients who had an arthroscopic partial or subtotal meniscectomy. The groups were matched according to sex, age, meniscus lesion, and follow-up time. The patients were aged 13-43 years at the time of operation; all had intact cruciate ligaments, and none had had previous surgery on the knee. Patients were reexamined at a mean of 13 years after the operation. In addition, for a subgroup of 22 matched pairs, data were available from a 7-year follow-up. Four of the repaired menisci did not heal, and another three reruptured during the 13-year follow-up; these menisci were all excised (23%). Meniscal remnant surgery was needed in 6 cases (20%) after initial meniscectomy. At the 13-year follow-up there was no difference between the groups in knee function, subjective complaints, or manual findings. Almost 90% of the patients in both groups had no knee problems during daily activities. At the late follow-up radiographic signs for bone spurs, sclerosis, or flattening of the femoral condyle were found in around half of the cases in each group. Three patients (10%) with initial repair and 8 (27%) with meniscectomy had minor joint space reduction, but no patient had more severe radiographic changes. After 7 years (subgroup) joint space reduction was more common after initial meniscectomy than after repair (P < 0.05). After 13 years the incidence and severity of arthrosis did not differ significantly between the two groups, even when only the successful repairs were compared to meniscectomy (P = 0.06).
The purpose of this study is to describe an arthroscopic-assisted surgical technique for focal resurfacing of medial tibio-femoral compartment and to present the preliminary clinical and radiographic results in a case series of 13 consecutive patients at a mean follow-up of 29 months. All patients were treated with the presented procedure for Ahlback grade 3 medial compartment osteoarthritis. Subjective evaluation was based on a visual analog scale for pain self-assessment. Objective clinical evaluation was based on Hospital for Special Surgery score. Range of motion was evaluated with a manual goniometer. Radiographic evaluation compared hip-knee-ankle angle pre- and post-operatively. Clinical and functional results were satisfactory. Hospital for Special Surgery score and visual analog scale for pain self-assessment showed significant improvements (P < 0.0001 and P = 0.0002, respectively). ROM and axial alignment were not significantly different respect to pre-operative values. Despite the small sample size and short follow-up, this study has shown that an arthroscopic-assisted focal resurfacing of the knee in selected cases can be a viable option for early onset degenerative joint disease, providing satisfactory pain relief and good functional results at 2 years follow-up. Retrospective case series, Level IV.
Many studies have reported successful outcomes less than 10 years after anterior cruciate ligament (ACL) reconstruction. However, longer-term outcomes have not been analyzed. We assessd outcomes 24 years after anterior cruciate ligament reconstruction with iliotibial tract and compared them with shorter-term results in the same patients. Between 1979 and 1981, 45 patients underwent combined intra- and extra-articular ACL reconstruction with iliotibial tract. Follow-up evaluations of these patients were performed at 6, 13, and 24 years after surgery, which included manual and instrumental laxity testing, functional assessments, and radiography. Twenty-six (60%) patients of the original ACL reconstruction cohort participated in all three follow-up assessments. Three patients had undergone meniscectomy prior to ACL reconstruction and 18 underwent meniscectomy together with ACL reconstruction. Eleven patients underwent subsequent meniscectomy. The mean Lysholm score was 96.2, 93.8, and 87.8 at 6-, 13-, and 24-year follow-up, respectively. A significant decrease in mean Lysholm score was found between 13- and 24-year follow-up. The mean KT-1000 side-to-side difference was 3.5 mm at 24-year follow-up. Overall knee laxity did not change significantly during the follow-up period. At 24-year follow-up, 17 (71%) patients had moderate or severe degenerative changes on radiographs although about 50% of the patients participated in regular sports activities and no patient required regular clinical intervention.
To investigate the pre-soaking of hamstring grafts in topical vancomycin, in addition to IV prophylaxis, during anterior cruciate ligament (ACL) reconstruction to reduce the incidence of post-operative infection, and to describe an evidence-based diagnostic and treatment algorithm to facilitate early diagnosis and appropriate management of possible knee sepsis post-operatively after ACL reconstruction. This study is a controlled observational series comprising of 1585 individuals who underwent ACL reconstruction over a 13-year period. All surgeries were performed by a single surgeon at the same hospital. Group 1 consisted of 285 patients who received pre-operative IV antibiotics without topical graft pre-soaking. Group 2 consisted of 1300 individuals who received IV antibiotics and graft pre-soaking in a vancomycin solution of 5 mg/mL. In group 1, a total of four patients suffered a post-operative joint infection (1.4 %). Three out of the four were culture positive for Staphylococcus species. The fourth was culture negative but was managed as an acute infection. Group 2 suffered no post-operative infections (0 %). Statistical analysis of the vancomycin pre-soak with IV antibiotics group, compared with IV antibiotics-alone group, revealed a significantly reduced post-operative infection rate using a Fisher's exact test (P = 0.0011) and Chi-square test with Yates' correction (P = 0.0003). Pre-soaking of hamstrings grafts with topical vancomycin reduced the rate of post-operative infection when compared to IV antibiotics alone. This technique should be utilised by surgeons to reduce the overall incidence of knee sepsis post-ACL reconstruction. III.
We report a very rare association of a physeal fracture of the medial clavicular growth plate with a fracture of the adjacent clavicle in a 14-year-old boy who fell on his shoulder while playing football. Clinical, radiographic and computed tomographic (with three-dimensional reconstruction) features are described. Open reduction, internal fixation of the lateral fracture (with a reconstructive plate) and suture of the periosteum were performed.
To evaluate the long-term clinical outcome after microfracture treatment of focal chondral defects of the knee and to investigate possible early determinants of the outcome. A prospective cohort of 110 patients, treated with microfracture, was evaluated at a median of 12 years (range 10-14) by Lysholm score, VAS of knee function and VAS of knee pain. Pre- and perioperative information was collected, and additional surgery to the same knee during the follow-up period was recorded. Analysis of variance and paired t test were used for comparison of the long-term data to results from the baseline examination and a former 5-year (midterm) follow-up evaluation. Forty-three patients needed additional surgery to the knee including seven knee replacements. Fifty had a poor long-term outcome-defined as a knee replacement surgery or Lysholm score below 64. A poor result was more common in subgroups with mild degenerative changes in the cartilage surrounding the treated defect, concurrent partial meniscectomy, poor baseline Lysholm score or long-standing knee symptoms. The Lysholm score, function VAS and pain VAS all significantly improved from the baseline values to the mean scores of 65 (SD 24), 65 (SD 24) and 31 (SD 24), respectively, at the long-term evaluation. The long-term scores did not differ significantly from the midterm scores. The outcome scores improved significantly from baseline to the long-term evaluation and were not different from the midterm outcome. Still, a normal knee function was generally not achieved, and many patients had further surgery. The results call for more research and, at present, caution in recommending microfracture in articular cartilage defects, especially in subgroups with worse prognosis. Case series, Level IV.
Our medium- and long-term results obtained with the Oxford unicompartmental knee prosthesis for unicompartmental knee osteoarthrosis are presented. Ninety-seven prostheses were evaluated (87 medial, 10 lateral) in 86 patients, with the Hospital for Special Surgery knee score after 2-14 years (mean follow-up: 6 years 9 months). Five prostheses were lost to follow-up. Eight patients died, not related to surgery; none had undergone a revision. Fourteen revisions (of which one bilateral UKP), 11 medial and three lateral, were performed. The mean HSS score of the 69 UKPs was 178.8 (80% excellent, 10% good, 4% fair, 6% poor). These findings confirm the good results reported in other studies, regarding proper patient selection and a consistent operative technique.
Previous studies have reported that Anterior Cruciate Ligament (ACL) reconstruction does not restore normal tibial rotation in patients with chronic instability and repeated episodes of giving way. We hypothesised that early ACL reconstruction, using quadruple hamstring autografts, before the pivoting episodes had occurred, would protect the knee joint from developing abnormal kinematics with increased external tibial rotation during flexion. Fourteen consecutive patients (8 men, 6 women) with a median age of 24 years (18-43), with a complete, isolated unilateral ACL rupture and an intact contralateral knee, were studied. The operations were performed by one experienced surgeon, using quadruple hamstring autografts. We used dynamic radiostereometry (RSA) with tantalum markers inserted in both the injured and the intact contralateral knee to study the pattern of knee motion during active and weight-bearing knee extension. The patients were evaluated pre-operatively and followed for 2 years after the ACL reconstruction. The anterior-posterior laxity was measured using the KT-1000. Before surgical repair of the ACL, the internal/external tibial rotation or abduction/adduction did not differ significantly between the injured and intact knees (P = 0.27-0.91). Separate studies of the anterior-posterior translation of the medial and lateral femoral flexion facet centres (MFC and LFC) relative to a fixed tibia did not reveal any significant differences between the injured and intact knees (P = 0.21-0.59). Pre-operatively, the KT-1000 laxity measurements showed a side-to-side difference of 2.5 (1.0-5.5) mm. At 2 years, the laxity side-to-side difference was 0.5 (0-3.0) mm (P = 0.001), and there were still no significant differences between the injured and intact knees in terms of internal/external tibial rotation and abduction/adduction (P = 0.13-0.60). Nor did the anterior-posterior translation of the flexion facet centres differs (P = 0.27-0.97). During the first 6-8 weeks after the ACL injury, before pivoting episodes had occurred, the kinematics of the injured knee were normal and did not differ from those of the intact contralateral knee. Reconstruction of the ACL within 10 weeks after injury using quadruple hamstring autografts resulted in unchanged knee kinematics for 2 years and no difference compared with the intact contralateral knee. Surgical repair during the early phase after the injury appears to protect the knee from developing abnormal knee motion after an ACL rupture. III.
Open kinetic chain (OKC) knee extensor resistance training has lost favour in ACLR rehabilitation due to concerns that this exercise is harmful to the graft and will be less effective in improving function. In this randomized, single-blind clinical trial OKC and closed kinetic chain (CKC) knee extensor training were compared for their effects on knee laxity and function in the middle period of ACLR rehabilitation. The study subjects were 49 patients recovering from ACLR surgery (37 M, 12 F; mean age=33 years). Tests were carried out at 8 and 14 weeks after ACLR with knee laxity measured using a ligament arthrometer and function with the Hughston Clinic knee self-assessment questionnaire and single leg, maximal effort jump testing (post-test only). Between tests, subjects trained using either OKC or CKC resistance of their knee and hip extensors as part of formal physical therapy sessions three times per week. No statistically significant (one-way ANOVA, p>0.05) differences were found between the treatment groups in knee laxity or leg function. OKC and CKC knee extensor training in the middle period of rehabilitation after ACLR surgery do not differ in their effects on knee laxity or leg function. Exercise dosages are described in this study and further research is required to assess whether the findings in this study are dosage specific.
The femoral attachment of the PCL. Lateral–medial view in a left knee after removal of the lateral femoral condyle. The anterolateral and posteromedial bundles of the PCL, plus anterior meniscofemoral ligament attachments are outlined 
The PCL attaches close to the edge of the condylar articular cartilage. It usually extends from approximately 7.30 to 12.30 o’clock position in a left knee; this example is wider. The aMFL slants across the PCL 
The PCL fibres have been separated into the ALB and the PMB. Posterolateral view of left knee after removal of the lateral femoral condyle 
The posteromedial fibre bundle of the PCL: a it is tight and oriented proximal–distal in the extended knee; b it passes between the ALB and the medial condyle in mid-flexion; and c it is tight and oriented to withstand posterior draw in the flexed knee 
The anterolateral fibre bundle: a it is curved and slack in the extended knee; b it is tight and takes a steeper slope in mid-flexion; and c it wraps against the roof of the intercondylar notch in deep flexion and could be nipped between the bones in hyperflexion ( arrows ) 
This paper describes the anatomy of the posterior cruciate ligament (PCL) and the meniscofemoral ligaments (MFLs). The fibres of the PCL may be split into two functional bundles; the anterolateral bundle (ALB) and the posteromedial bundle (PMB), relating to their femoral attachments. The tibial attachment is relatively compact, with the ALB anterior to the PLB. These bundles are not isometric: the ALB is tightest in the mid-arc of knee flexion, the PMB is tight at both extension and deep flexion. At least one MFL is present in 93% of knees. On the femur, the anterior MFL attaches distal to the PCL, close to the articular cartilage; the posterior MFL attaches proximal to the PCL. They both attach distally to the posterior horn of the lateral meniscus. Their slanting orientation allows the MFLs to resist tibial posterior drawer.
The AMIC procedure. (1) Debridement of injured cartilage; (2) Microfracture is performed by penetrating the subchondral layer with 3–4-mm space between holes; (3) a collagen matrix is sutured to the defect; and (4) fibrin glue is injected under the matrix to improve fixation  
MOCART evaluation of all patients at follow-up 
The purpose of this study is to evaluate clinical and radiological outcomes of patients treated with autologous matrix-induced chondrogenesis (AMIC) for full-thickness chondral and osteochondral defects of the femoral condyles and patella. A retrospective evaluation of clinical and radiographic outcomes of patients treated with AMIC for chondral and osteochondral full-thickness cartilage defects of the knee was performed with a mean follow-up of 28.8 ± 1.5 months (range, 13-51 months). Significant improvements in clinical outcome scores (IKDC, Lysholm, Tegner, and VAS pain score) were noted. The largest improvements were seen in the osteochondral subgroup (mean age 25.9 years), whereas patients treated for chondral defects in the patellofemoral joint and on the femoral condyles improved less. Patients in all groups were generally satisfied with their results. MRI evaluation showed that tissue filling was present but generally not complete or homogenous. AMIC is a safe procedure and leads to clinical improvement of symptomatic full-thickness chondral and osteochondral defects and to regenerative defect filling. The value of AMIC relative to other cartilage repair procedures and to the natural course remains undefined. Case series, Level IV.
The purpose of this study was to assess correlation of soft tissue tension in extension with postoperative extension deficit and valgus/varus instability. Sixty-four osteoarthritic knees that underwent primary total knee arthroplasty were investigated. Soft tissue tension in extension was measured during operation with a balancer/tensor device. Extension deficit was measured, and valgus/varus laxity was assessed by stress radiographs in extension and 30°-flexion 1 year after operation. The extension deficit became larger with an increase of soft tissue tension a year after operation. (P < 0.05) The varus laxity in extension and 30°-flexion and valgus laxity in 30°-flexion became smaller with an increase of soft tissue tension (P < 0.05). Our results demonstrated that soft tissue tension during operation affects postoperative knee extension and stability.
The objective of this study was to compare subjects who sustained an ACL injury during soccer 16 years ago with a control group with regard to knee kinematics and kinetics of gait, step activity and cross over hop. Secondly, in the injured subjects, the purpose was to study the impact on kinematics and kinetics of characteristics such as operative status, meniscal resection, being symptomatic, having knee extensor weakness and of having radiographic knee OA. Data from a 3-dimensional gait analysis system (VICON) were used to calculate kinetics and kinematics during gait, step activity and cross over hop of 12 male subjects who had an anterior cruciate ligament injury 16 years earlier. Twelve uninjured subjects matched for age, sex, BMI and activity level served as controls. No significant differences in knee kinematics and kinetics between the ACL group and the control group were found. The variability of some parameters of step and all parameters of hop activity was generally larger in the ACL injured subjects compared with the controls. The ACL injured subjects had a significantly worse clinical status compared with the controls. Reduced knee extension strength was associated with joint moment reductions especially during step activity and cross over hop. Despite a significantly worse clinical status, as determined by self-report and isokinetic strength testing, no significant differences were seen in knee joint kinetics and kinematics in an ACL injured group 16 years after injury compared with a matched control group. The variation was larger among the ACL injured subjects indicating the need for larger study groups in gait and movement analysis in long-term follow-up of ACL injury.
The purpose of this study was to determine the biomechanical characteristics of 16 arthroscopic knots and to determine if locking knots have superior loop security compared to non-locking knots. Sixteen knot types were tied in arthroscopic fashion and tested on a materials testing system. Knots were cyclically loaded to 30 Newtons (N) for 20 cycles and then loaded to failure at 1.25 mm/s. Ten samples of each knot were tied using both #2 Ethibond and #1 PDS II. Load to ultimate failure, load to clinical failure, post-cyclic stiffness, cyclical elongation, ultimate displacement, loop security, and mode of failure were determined for each knot. Nicky's Knot and the French Knot were most consistently ranked within the top five knot types for each of the biomechanical parameters. Locking knots did not improve loop security over non-locking knots.
Authors have hypothesized that the incidence and the degree of femoral tunnel enlargement after the hamstring ACL reconstruction may be significantly less in the anatomic double-bundle procedure than in single-bundle procedure. The purpose of this study is to test this hypothesis. Seventy-two patients who underwent single-bundle reconstruction (Group S) and 97 patients who underwent anatomic double-bundle reconstruction (Group D) were followed up for 2 years after surgery. The hamstring tendon grafts were used in each procedure. All of the 169 patients were examined with computed radiography, and the standard clinical evaluation methods. In Group S, the incidence of femoral tunnel enlargement was 48.6 and 54.2% in the anteroposterior and lateral views. In Group D, the incidence of femoral anteromedial and posterolateral tunnel enlargement was 36.1 and 23.7%, respectively, in the anteroposterior view, and that of femoral anteromedial and posterolateral tunnel enlargement was 33.0 and 21.6%, respectively, in the lateral view. The incidence of femoral tunnel enlargement was significantly less in Group D than in Group S (P < 0.0133). Concerning the degree of the tunnel enlargement, a similar tendency with statistical significance was observed (P < 0.0001). In each group, there were no significant relationships between the degree of tunnel enlargement and each clinical measure. Both the incidence and the degree of femoral tunnel enlargement after anatomic double-bundle reconstruction with the hamstring tendon grafts are significantly less than those after single-bundle reconstruction with the same graft. Prospective comparative cohort study, Level II.
Purpose: (1) To identify the relationship between anteromedial notch ridging, a recently identified non-contact anterior cruciate ligament injury risk factor, and patient demographics in a general population. (2) To characterize the symmetry of the femoral notch between knees. Methods: The femoral notches of 170 non-arthritic archival skeletal specimens devoid of soft-tissue attachments (n = 79 females, 90 males, 34.3 ± 15.7 years) were measured for notch width, ridge thickness, and outlet stenosis due to ridging. Measurements were compared by race and sex by ANOVA, and Pearson correlations were calculated for all continuous measures. Results: Percent stenosis was associated with increasing age (p < 0.001, r = 0.40). Ridge thickness was similar among men (2.7 ± 1.6 mm) and women (3.1 ± 1.5; n.s.). Women had narrower notches (16.0 ± 2.1 mm) and higher percent stenosis (19.6 ± 9.9 %) than men (p ≤ 0.001; men 19.3 ± 2.4 mm; 14.4 ± 8.7 %). African American men have narrower notches than Caucasian men (20.4 ± 2.5 vs. 18.7 ± 2.3 mm, respectively; p = 0.002) with no difference between women of both races (16.2 ± 2.5 vs. 15.8 ± 1.6 mm, respectively; n.s.). A positive association was observed between height and notch width among men only (18+ years men p = 0.004, r = 0.33; women n.s., r = 0.21). Finally, both total notch width and ridge thickness are symmetric between knees (p < 0.001; r = 0.98 and 0.93, respectively). Conclusions: Women have narrower femoral notches overall and also exhibit greater percent notch stenosis due to anteromedial ridging than men. Anteromedial ridging increases with age, suggesting progressive formation over time. Finally, both notch width and ridge thickness are highly symmetric between knees.
This is a retrospective study of 173 cases of chronic laxity of the knee, surgically treated between May 1985 and December 1988 using the MacIntosh technique (quadriceps-plasty) reinforced with the Kennedy ligament augmentation device (LAD). It involved 171 operations, 113 men and 58 women aged between 15 and 49 years (average 26 years), the majority of whom were active in sports both at competition (51 cases) and at recreational level (119 cases). There were 101 lesions of the medial meniscus (58.4%) and 94 lesions of the lateral meniscus (54.4%); only 41 knees had no meniscal lesion (23.6%). The results at medium term (between 4 and 8 years follow-up) were based on 107 cases (61.8%). The tolerance of the reinforcement was excellent as there were no instances of either acute or chronic synovitis in this series. The anatomical results evaluated using the Lachmann test (maximum manual Lachmann) showed no differential in 24 cases (22.8%), a differential of between 0 and 2 mm in 54 cases (50.5%), of between 2 and 4 mm in 20 cases (19%) and of > 4 mm in 9 cases (8.7%). The functional results evaluated using the Arpège CLAS system showed 83% of results to be satisfactory (score > 23). The radiological results showed that 63 knees (58.9%) had no subclinical or clinical signs of medial or lateral femorotibial osteoarthritis. In total, with an average follow-up of > 5 years (4-8 years), it was found that the MacIntosh quadriceps-plasty reinforced with the Kennedy LAD was not accompanied by any iatrogenic disease.(ABSTRACT TRUNCATED AT 250 WORDS)
Positron-emission tomography (PET) imaging has several advantages over conventional scintigraphy, including a high spatial resolution and the ability to quantify disease progression. Recently, 18F-fluoride PET has been applied to the evaluation of malignant tumors and musculoskeletal disorders. In our current study, spontaneous osteonecrosis of the knee (SONK) was visualized using this technique. We determined whether PET images can reveal SONK lesions, whether there were significant differences in the maximum standardized uptake value (SUVmax) among each of the SONK stages, and finally if there was any correlation between the maximum SUVmax value and size of the SONK lesion measured both by radiography and MRI. Fourteen knees from 13 patients diagnosed with SONK were imaged using a PET scanner. In all cases, PET showed an accumulation of 18F-fluoride in the medial condyle. The SUVmax ranged from 8.6 to 23.7 with an average of 15.1 ± 3.7 and was measured at different disease stages with an average of 12.4 ± 5.9 in Stage 2 (n = 5), 16.3 ± 1.4 in Stage 3 (n = 4), and 16.8 ± 4.3 (n = 5) in Stage 4 lesions. There were no significant differences in these measurements between the SONK stages. However, a significant positive correlation between the SUVmax and lesion size, including the surface area of the lesion (r 2 = 0.692, P = 0.0002) and the condyle width ratio (r 2 = 0.365, P = 0.022), was found. The approximate volumes of the lesions measured by MRI had an average of 4.8 ± 3.1 cm3, and also showed a significant correlation with the SUVmax (r 2 = 0.853, P < 0.0001). Hence, our present results indicate that a high SUV is indicative of a large SONK lesion.
Intraoperative view of MF  
Mean and median lysholm scores over time 
Disposition of ICRS scores, by therapy over time
Cartilage defects occur in approximately 12% of the population and can result in significant function impairment and reduction in quality of life. Evidence for the variety of surgical treatments available is inconclusive. This study aimed to compare the clinical outcomes of patients with symptomatic cartilage defects treated with matrix-induced autologous chondrocyte implantation (MACI or microfracture (MF). Included patients were >or= 18 and <or= 50 years of age with symptomatic, post-traumatic, single, isolated chondral defects (4-10 cm2) and were randomised to receive MACI or MF. Patients were followed up 8-12, 22-26 and 50-54 weeks post-operatively for efficacy and safety evaluation. Outcome measures were the Tegner, Lysholm and ICRS scores. Sixty patients were included in a randomised study (40 MACI, 20 MF). The difference between baseline and 24 months post-operatively for both treatment groups was significant for the Lysholm, Tegner, patient ICRS and surgeon ICRS scores (all P < 0.0001). However, MACI was significantly more effective over time (24 months versus baseline) than MF according to the Lysholm (P = 0.005), Tegner (P = 0.04), ICRS patient (P = 0.03) and ICRS surgeon (P = 0.02) scores. There were no safety issues related to MACI or MF during the study. MACI is superior to MF in the treatment of articular defects over 2 years. MACI and MF are complementary procedures, depending on the size of the defect and symptom recurrence. The MACI technique represents a significant advance over both first and second generation chondrocyte-based cartilage repair techniques for surgeons, patients, health care institutions and payers in terms of reproducibility, safety, intraoperative time, surgical simplicity and reduced invasiveness.
Reported advantages and disadvantages of OWHTO compared with CWHTO n % 
Opening wedge high tibial osteotomy (OWHTO) is a recently described procedure for medial compartment arthritis of the knee in the active, younger population. Despite having a number of advantages over the traditional closing wedge high tibial osteotomy (CWHTO) a potential complication of OWHTO is a high rate of delayed- and non-union. This study reports the occurrence of delayed- and non-union following OWHTO for medial compartment arthritis of the knee. Questionnaires were sent to all current members of the Australian Knee Society (n=45), a special interest group of the Australian Orthopaedic Group. Surgeons were asked primarily to indicate how many OWHTOs they had performed, and how many of these had progressed to union, delayed-union and non-union. All 45 questionnaires were returned, with 21 surgeons (47%) performing OWHTOs. A total of 188 OWHTO cases were reported, of which 182 were complete. Of these complete cases 167 (91.8%) were classed as united, 12 (6.6%) delay-united and 3 (1.6%) non-united. The results of this study demonstrate that the rate of delayed- and non-union following OWHTO for medial compartment arthritis of the knee is relatively low and comparable to that reported for traditional CWHTO.
Rotational knee laxity is an important measure in restoring knee stability following anterior cruciate ligament (ACL) injury, but is difficult to quantify with current clinical tools. The hypothesis of the study is that there is greater tibial rotation (TR) in women than men, and also in ACL-deficient than healthy knees. Sixteen healthy (8 men, 26.8 ± 6.4 years; 8 women, 26.9 ± 3.8 years) and ten ACL-deficient (5 men, 33.6 ± 10.5 years; 5 women, 36.3 ± 10.7 years) subjects received bilateral knee MRI in 15° of flexion using a custom device to apply a constant axial compressive load (44 N). A rotational torque (3.35 Nm) was sequentially applied to obtain images at internal and external rotation positions. T (2)-weighted images were acquired in internal and external rotation. Images were segmented and TR was calculated. To assess reproducibility, six knees were scanned twice on separate days. Group comparisons were made with unpaired t tests, while intrasubject comparisons were made using paired t tests. Healthy women demonstrated greater TR than men (13.6° ± 4.7° vs. 8.3° ± 3.6°; P = 0.001). Male ACL-deficient knees showed greater TR than the contralateral knee (15.7° ± 6.9° vs. 7.7° ± 5.6°; P = 0.003), and compared to male controls (P = 0.002). ACL-deficient women showed greater TR compared to their contralateral leg (15.1° ± 2.3° vs. 10.0° ± 4.3°; P = 0.01). The intraclass correlation coefficient of the TR measurement was 0.913, and the SEM = 1.1°. Kinematic MRI is a reproducible method to quantify total knee rotation. Women have more rotational laxity than men, particularly in the external rotation position. ACL rupture leads to increased rotational laxity of the knee. Retrospective case-control series, Level III.
Top-cited authors
Giuseppe Filardo
  • Istituto Ortopedico Rizzoli
Elizaveta Kon
  • Humanitas University. Istituto Clinico Humanitas IRCCS
Jon Karlsson
  • Institute of Clinical Science
Niek C. Dijk, van
  • Academisch Medisch Centrum Universiteit van Amsterdam
Lars Engebretsen
  • University of Oslo