Comparison of score evaluations and instrumented measurement after anterior cruciate ligament reconstruction

Effects of higher femoral tunnels on clinical outcomes, MRI, and second-look findings in double-bundle anterior cruciate ligament reconstruction with a minimal 5-year follow-up

BACKGROUND

To perform anatomical anterior cruciate ligament reconstruction (ACLR), tunnels should be placed relatively higher in the femoral anterior cruciate ligament (ACL) footprint based on the findings of direct and indirect femoral insertion. But the clinical results of higher femoral tunnels (HFT) in double-bundle ACLR (DB-ACLR) remain unclear. The purpose was to investigate the clinical results of HFT and lower femoral tunnels (LFT) in DB-ACLR.

METHODS

From September 2014 to February 2016, 83 patients who underwent DB-ACLR and met the inclusion and exclusion criteria were divided into HFT-ACLR (group 1, n = 37) and LFT-ACLR (group 2, n = 46) according to the position of femoral tunnels. Preoperatively and at the final follow-up, clinical scores were evaluated with International Knee Documentation Committee (IKDC), Tegner activity, and Lysholm score. The stability of the knee was evaluated with KT-2000, Lachman test, and pivot-shift test. Cartilage degeneration grades of the International Cartilage Repair Society (ICRS) were evaluated on magnetic resonance imaging (MRI). Graft tension, continuity, and synovialization were evaluated by second-look arthroscopy. Return-to-sports was assessed at the final follow-up.

RESULTS

Significantly better improvement were found for KT-2000, Lachman test, and pivot-shift test postoperatively in group 1 ( P >0.05). Posterolateral bundles (PL) showed significantly better results in second-look arthroscopy regarding graft tension, continuity, and synovialization ( P <0.05), but not in anteromedial bundles in group 1. At the final follow-up, cartilage worsening was observed in groups 1 and 2, but it did not reach a stastistically significant difference ( P >0.05). No statistically significant differences were found in IKDC subjective score, Tegner activity, and Lysholm score between the two groups. Higher return-to-sports rate was found in group 1 with 86.8% (32/37) vs. 65.2% (30/46) in group 2 ( P = 0.027).

CONCLUSION

The HFT-ACLR group showed better stability results, better PL, and higher return-to-sports rate compared to the LFT-ACLR group.

Patient reported outcome measures in anterior cruciate ligament rupture and reconstruction: The significance of outcome score prediction

BACKGROUND

Numerous anterior cruciate ligament (ACL) clinical outcome measures exist. However, the result of one score does not equate to the findings of another even when evaluating the same patient group.

AIM

To investigate if statistically derived formulae can be used to predict the outcome of one knee scoring system when the result of another is known in patients with ACL rupture before and after reconstruction.

METHODS

Fifty patients with ACL rupture were evaluated using nine clinical outcome measures. These included Tegner Activity Score, Lysholm Knee Score, Cincinnati Knee Score, International Knee Documentation Committee (IKDC) Objective Knee Score, Tapper and Hoover Meniscal Grading Score, IKDC Subjective Knee Score, Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), Short Form-12 Item Health Survey and Knee Injury and Osteoarthritis Outcome Score. Thirty-four patients underwent an ACL reconstruction and were reassessed post-operatively.

RESULTS

The mean total of each of the nine outcome scores appreciably differed from each other. Significant correlations and regressions were found between most of the outcome scores and were stronger post-operatively. The strongest correlation was found between Cincinnati and KOS-ADLS (r = 0.91, P < 0.001). The strongest regression formula was also found between Cincinnati and KOS-ADLS (R² = 0.84, P < 0.001).

CONCLUSION

The formulae produced from this study can be used to predict the outcome of one knee score when the results of the other are known. These formulae could facilitate the conduct of systematic reviews and meta-analysis in studies relating to ACL injuries by allowing the pooling of substantially more data.

Neither Residual Anterior Knee Laxity Up to 6 mm nor a Pivot Glide Predict Patient-Reported Outcome Scores or Subsequent Knee Surgery Between 2 and 6 Years After ACL Reconstruction

BACKGROUND

A primary goal of anterior cruciate ligament reconstruction (ACLR) is to reduce pathologically increased anterior and rotational laxity of the knee, but the effects of residual laxity on patient-reported outcomes (PROs) after ACLR remain unclear.

HYPOTHESIS

Increased residual laxity at 2 years postoperatively is predictive of a higher risk of subsequent ipsilateral knee surgery and decreases in PRO scores from 2 to 6 years after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From a prospective multicenter cohort, 433 patients aged <36 years were identified at a minimum 2 years after primary ACLR. These patients underwent a KT-1000 arthrometer assessment and pivot-shift test and completed PRO assessments with the Knee injury and Osteoarthritis Outcome Score and International Knee Documentation Committee (IKDC) scores. Patients completed the same PROs at 6 years postoperatively, and any subsequent ipsilateral knee procedures during this period were recorded. Subsequent surgery risk and change in PROs from 2 to 6 years postoperatively were compared based on residual side-to-side KT-1000 arthrometer differences (<-1 mm, -1 to 2 mm, 2 to 6 mm, and >6 mm) in laxity at 2 years postoperatively. Multiple linear regression models were built to determine the relationship between 2-year postoperative knee laxity and 2- to 6-year change in PROs while controlling for age, sex, body mass index, smoking status, meniscal and cartilage status, and graft type.

RESULTS

A total of 381 patients (87.9%) were available for follow-up 6 years postoperatively. There were no significant differences in risk of subsequent knee surgery based on residual knee laxity. Patients with a difference >6 mm in side-to-side anterior laxity at 2 years postoperatively were noted to have a larger decrease in PROs from 2 to 6 years postoperatively (P < .05). No significant differences in any PROs were noted among patients with a difference <6 mm in side-to-side anterior laxity or those with pivot glide (IKDC B) versus no pivot shift (IKDC A).

CONCLUSION

The presence of a residual side-to-side KT-1000 arthrometer difference <6 mm or pivot glide at 2 years after ACLR is not associated with an increased risk of subsequent ipsilateral knee surgery or decreased PROs up to 6 years after ACLR. Conversely, patients exhibiting a difference >6 mm in side-to-side anterior laxity were noted to have significantly decreased PROs at 6 years after ACLR.

Clinical outcome measures in anterior cruciate ligament reconstruction: Clinician vs patient completed knee scores

INTRODUCTION

Clinical outcome measures are important in both the conduct of clinical research and evaluation of knee surgery in every day clinical practice. A wide variety of validated outcome scores are available in the literature. The objective of this study was to investigate if there is a difference between clinician-completed and patient-completed outcome scores in detecting improvement following anterior cruciate ligament (ACL) reconstruction.

METHODS

Fifty patients with ACL rupture were prospectively evaluated using nine clinical outcome measures. Five clinician-completed knee scores included Tegner Activity Score, Lysholm Knee Score, Cincinnati Knee Score, International Knee Documentation Committee (IKDC) Objective Knee Score and Tapper and Hoover Meniscal Grading Score. Four patient-completed knee scores included IKDC Subjective Knee Score, Knee Outcome Survey - Activities of Daily Living Scale (KOS-ADLS), Short Form-12 Item Health Survey (SF-12) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Thirty-four of the 50 patients underwent an ACL reconstruction and were reassessed with all nine outcome scores upon their follow-up review 3 months post-operatively.

RESULTS

A significant longitudinal improvement was observed of all five clinician-completed knee scores including Tegner (3.3-4.1 (p = 0.006)), Lysholm (71.7-85.3 (p < 0.001)), Cincinnati (62.6-75.9 (p < 0.001)), IKDC Objective (Abnormal to Nearly Normal (p = 0.001)) and Tapper and Hoover (Fair to Good (p < 0.001)). However, none of the four patient-completed knee scores revealed a statistically significant improvement post-operatively.

CONCLUSIONS

Results of clinician-completed scores were found to be inconsistent with those of patient-completed instruments. It's important to consider the mode of administering outcome measures either for research or clinical practice as it can have a significant influence on the end results. The use of both a clinician-completed and a patient-completed instrument maybe the more prudent approach to assessing and quantifying ACL injuries and the outcome post-operatively. Ultimately, better methods of objectively evaluating surgical interventions of the knee are required.

Triaxial accelerometer can quantify the Lachman test similarly to standard arthrometers

PURPOSE

To assess the relationship between the KiRA triaxial accelerometer and the KT-1000 measurements in the intact, anterior cruciate ligament (ACL) deficient, and ACL reconstructed knee joint for the quantification of the Lachman test. Moreover, the intra- and inter-examiner repeatability of the KiRA device will be determined. It was hypothesized that the side-to-side difference of the anterior tibial translation as measured by the KiRA device would be equivalent to the one measured by the KT-1000 during the Lachman test.

METHODS

Sixty patients were divided into three groups and have been prospectively included in the present study. Group_A composed of 20 patients with a diagnosis of an isolated ACL tear. Group_B composed of 20 patients who underwent ACL reconstruction with a Single-Bundle Lateral Plasty (SBLP) technique with at least 20 years of follow-up. Group_C was the control group and included 20 patients with no history of ACL lesion. Lachman test has been performed at manual-maximum load on both sides, the involved and the contralateral and analyzed with the two different devices.

RESULTS

The KiRA device in terms of side-to-side difference resulted not statistically different from the measurement of the KT-1000 arthrometer for the three study groups (n.s): Group_A: (4 ± 2 mm KiRA, 4 ± 2 mm KT1000), Group_B: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), Group_C: (4 ± 2 mm KiRA, 4 ± 2 mm KT-1000), an excellent intra- (ICC = 0.88-0.89) and inter-examiner (ICC = 0.79) agreement was found for KiRA measurements.

CONCLUSION

The KiRA (I+, Italy) device offers a valid method to quantify the Lacham test.

LEVEL OF EVIDENCE

II.

Anterior and Rotational Knee Laxity Does Not Affect Patient-Reported Knee Function 2 Years After Anterior Cruciate Ligament Reconstruction

BACKGROUND

While a primary goal of anterior cruciate ligament (ACL) reconstruction is to reduce pathologically increased anterior and rotational knee laxity, the relationship between knee laxity after ACL reconstruction and patient-reported knee function remains unclear.

HYPOTHESIS

There would be no significant correlation between the degree of residual anterior and rotational knee laxity and patient-reported outcomes (PROs) 2 years after primary ACL reconstruction.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

From a prospective multicenter nested cohort of patients, 433 patients younger than 36 years of age injured in sports with no history of concomitant ligament surgery, revision ACL surgery, or surgery of the contralateral knee were identified and evaluated at a minimum 2 years after primary ACL reconstruction. Each patient underwent Lachman and pivot-shift evaluation as well as a KT-1000 arthrometer assessment along with Knee injury and Osteoarthritis Outcome Score and subjective International Knee Documentation Committee (IKDC) scores. A proportional odds logistic regression model was used to predict each 2-year PRO score, controlling for preoperative score, age, sex, body mass index, smoking, Marx activity score, education, subsequent surgery, meniscal and cartilage status, graft type, and range of motion asymmetry. Measures of knee laxity were independently added to each model to determine correlation with PROs.

RESULTS

Side-to-side manual Lachman differences were IKDC A in 246 (57%) patients, IKDC B in 183 (42%) patients, and IKDC C in 4 (<1%) patients. Pivot-shift was classified as IKDC A in 209 (48%) patients, IKDC B in 183 (42%) patients, and IKDC C in 11 (2.5%) patients. The mean side-to-side KT-1000 difference was 2.0 ± 2.6 mm. No significant correlations were noted between pivot-shift or anterior tibial translation as assessed by Lachman or KT-1000 and any PRO. All predicted differences in PROs based on IKDC A versus B pivot-shift and anterior tibial translation were less than 4 points.

CONCLUSION

Neither the presence of IKDC A versus B pivot-shift nor increased anterior tibial translation of up to 6 mm is associated with clinically relevant decreases in PROs 2 years after ACL reconstruction.

Comparison of outcome after ACL reconstruction in terms of subjective assessment of symptoms and function and clinical assessment of ligament stability

BACKGROUND

The knee joint is frequently involved in sports and other injuries with Anterior cruciate ligament being a very common ligament to be injured. The Lachman test, pivot-shift test, and instrumented knee laxity examination are frequently used and reported for evaluation of ACL reconstruction. The aim of this study is to examine and evaluate the relationships between the clinical assessment of ligament stability and subjective assessment of symptoms and function after ACL reconstruction.

METHODS

A total of 50 young and middle aged patients with unilateral knee ACL injury treated with ACL reconstruction using hamstring graft were evaluated for a minimum period of 1 year. Clinical assessment of ligament stability was done through Lachman and pivot-shift examination. Subjective variables of symptoms at follow-up included pain, swelling, instability and locking of knee. Subjective function at follow up included satisfaction with outcome, squatting, ascending or descending stairs, jumping, twisting and Lysholm score.

RESULTS

Lachman Examination at follow-up had no significant (P > .05) relationship with pain, swelling, instability, locking, squatting, ascending or descending stairs, jumping, twisting, satisfaction with outcome and Lysholm score. Pivot-shift examination at follow-up had significant associations with patient satisfaction (P = .04), instability of knee (P = .02), difficulty during twisting (P = .02) and Lysholm score (P = .01).

CONCLUSION

Pivot-shift examination is a better measure than Lachman examination or instrumented knee laxity as far as patients' functional outcome and overall satisfaction is concerned.

Impact of Patient Sex on Clinical Outcomes: Data From an Anterior Cruciate Ligament Reconstruction Registry, 2008-2013

Background:

The Combined Quality Care Anterior Cruciate Ligament registry provides data for clinical research regarding primary anterior cruciate ligament (ACL) surgery.

Purpose:

To explore the data with regard to the clinical outcomes between sexes after ACL reconstruction in a Dutch population.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data involving patients diagnosed with an ACL tear and eligible for surgery were recorded. Isokinetic muscle strength, functional muscle performance, and anterior-posterior translation of the knee joint were documented preoperatively and at 3, 6, 9, and 12 months postoperatively. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner rating scales during each examination using a web-based questionnaire.

Results:

Approximately 90% of ACL injuries occurred during sport activities. The mean (SD) age at surgery was 28 (11) years for both men and women, and the majority of patients were treated with hamstring tendon autografts (94%). Four percent received bone–patellar tendon–bone autografts, and 2% of the patients received other grafts. Preoperatively, the KOOS, Lysholm, and Tegner scores were significantly higher in males. Twelve months postoperatively, both sexes showed comparable isokinetic strength (P = .336), knee laxity (P = .680), and hop test for distance (P = .122) when comparing the injured with the uninjured side. Self-reported knee function was comparable between sexes as assessed by the KOOS (P = .202), Lysholm (P = .872), and Tegner (P = .767) questionnaires during the 12-month follow-up.

Conclusion:

One year after ACL surgery, all patients had improved greatly, showing only minor differences between sexes. The male group showed slightly better results when evaluating self-reported knee questionnaires. Comparable outcomes and knee function between sexes can therefore be presumed with patients who are treated with hamstring tendon autografts in a Dutch population.

Clinical Relevance:

These results can be used during the clinical evaluation of patients who are eligible for ACL reconstruction.

ANALYSIS ON THE MODIFIED LYSHOLM FUNCTIONAL PROTOCOL AMONG PATIENTS WITH NORMAL KNEES

Objective: To evaluate the modified Lysholm protocol among patients with knees that were considered to be normal (without previous complaints or pathological conditions in this region). Method: Between January 2010 and March 2010, a prospective study was conducted on 300 patients with orthopedic complaints in other regions of the body who came to the emergency service of our hospital. The inclusion criterion among these patients was the absence of complaints or previous surgery in the knee that was considered to be dominant. The age range was from 16 to 40 years, with an average of 28.8 years. Our study group consisted of 153 males and 147 females. In the modified Lysholm system, the maximum score is 100 points and this includes functional and objective criteria. Altogether, 50% of the total score is based on symptoms of pain and instability. Results: The average score using the Lysholm protocol was 95 points in the knees that were considered normal. Males had higher scores than females. Conclusion: These patients with knees that were considered normal did not achieve the maximum score when evaluated using the modified Lysholm protocol. This study suggests that this line of research on functional evaluation systems for the knee is open for further evaluations. Moreover, creation and development of new forms of functional assessment for the knee should be investigated in order to achieve a worldwide consensus.

An original clinical methodology for non-invasive assessment of pivot-shift test

Even if pivot-shift (PS) test has been clinically used to specifically detect anterior cruciate ligament (ACL) injury, the main problem in using this combined test has been yet associated with the difficulty of clearly quantifying its outcome. The goal of this study was to describe an original non-invasive methodology used to quantify PS test, highlighting its possible clinical reliability. The method was validated on 66 consecutive unilateral ACL-injured patients. A commercial triaxial accelerometer was non-invasively mounted on patient's tibia, the corresponding 3D acceleration was acquired during PS test execution and a set of specific parameters were automatically identified on the signal to quantify the test. PS test was repeated three times on both injured and controlateral limbs. Reliability of the method was found to be good (mean intra-rater intraclass correlation coefficient was 0.79); moreover, we found that ACL-deficient knees presented statistically higher values for the identified parameters--than the controlateral healthy limbs, averagely reporting also large effect size.

Reabilitação pós-operatória dos ligamentos cruzado anterior e posterior: estudo de caso

As lesões ligamentares do joelho estão entre as principais lesões ocorridas nos esportes, sendo raras as lesões combinadas dos ligamentos cruzados e estas lesões normalmente estão associadas com traumas de alta velocidade. Nesses casos a intervenção cirúrgica é necessária devido ao alto nível de instabilidade funcional. OBJETIVO: desenvolver e aplicar um protocolo de reabilitação para pós-operatório de reconstrução dos ligamentos cruzados e registrar a evolução por meio de avaliações periódicas com questionários de função validados. METODOLOGIA: trata-se de um relato de caso de um paciente que foi submetido à reconstrução dos ligamentos cruzados até o retorno ao esporte. Foram realizadas avaliações da capacidade funcional com o uso de questionários (Lysholm e IKDC); amplitude de movimento (goniômetro), lassidão ântero-posterior (artrômetro KT1000TM), força (dinamometria Isocinética) e análises do movimento (marcha e corrida). CONCLUSÃO: o protocolo foi efetivo para melhorar a capacidade funcional, força e retorno seguro ao esporte.

The long-term effect of 2 postoperative rehabilitation programs after anterior cruciate ligament reconstruction: a randomized controlled clinical trial with 2 years of follow-up

BACKGROUND

There is no consensus regarding the optimal postoperative rehabilitation program after anterior cruciate ligament (ACL) reconstruction.

PURPOSE

The purpose of this study was to examine the long-term outcome of a 6-month neuromuscular exercise (NE) training program versus a traditional strength exercise (SE) training program after ACL reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Seventy-four patients were randomly assigned to either a NE program or a SE program and tested preoperatively and at 6 months, 1 year, and 2 years after ACL reconstruction. Outcome measurements were as follows: Cincinnati knee score, visual analog scale for pain and global function, Short Form 36, functional knee tests, and isokinetic muscle strength tests.

RESULTS

There were no significant differences between the NE and SE programs 1 and 2 years after ACL reconstruction for the primary outcome measurement (Cincinnati knee score). There were significantly improved knee function (global function) and reduced pain during activity for the NE group, compared with the SE group, and significantly improved hamstring muscle strength for the SE group, compared with the NE group, 2 years after ACL reconstruction.

CONCLUSION

On the basis of these results, a postoperative program combining both NE and SE should be included after ACL reconstruction to improve knee function.

Rasch analysis of the Knee injury and Osteoarthritis Outcome Score (KOOS): a statistical re-evaluation

The knee injury and Osteoarthritis Outcome Score (KOOS), based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), is widely used to evaluate subjective outcome in anterior cruciate ligament (ACL) reconstructed patients. However, the validity of KOOS has not been assessed using Rasch analysis. The objective of this study was to evaluate the viability of KOOS as an outcome measure for ACL reconstruction using the partial credit Rasch model. Rasch analysis was applied to 200 KOOS questionnaires completed by patients consecutively tested 20 weeks after ACL reconstruction and subsequent rehabilitation. Rasch analysis showed that of the five proposed subscales in KOOS, only knee-related quality of life (QoL) and sport and recreational related function (Sport/Rec) fulfilled the criteria of a unidimensional measurement scale when applied to these patients. The three subdomains in KOOS extracted from WOMAC did not fulfill these criteria. While the content of KOOS appears to be relevant for knee patients, the psychometric measurement properties of KOOS are insufficient for use on patients 20 weeks subsequent to ACL reconstruction. A new knee measure targeted for these patients could be developed based on the content of KOOS. This study demonstrates that knee measurement instruments constructed for a specific condition cannot necessarily be used on patients with other similar conditions.

Anterior cruciate ligament reconstruction after 10 to 15 years: association between meniscectomy and osteoarthrosis

PURPOSE

To evaluate the stability and arthrosis of the knee 10 to 15 years after arthroscopic-assisted anterior cruciate ligament (ACL) reconstruction with patellar tendon graft.

METHODS

From July 1986 to March 1991, 82 patients underwent arthroscopic-assisted ACL reconstruction with patellar tendon graft. Of these, 62 returned for follow-up evaluation between November 2000 and April 2001. Four different physicians, blinded to each other's examination findings, evaluated the radiologic as well as surgical results according to the International Knee Documentation Committee criteria and the Lysholm knee scoring scale.

RESULTS

There were 47 male and 15 female patients. The mean period between injury and surgery was 16 months (range, 2 weeks to 8 years). Results of radiographs were compared with the finding of meniscal lesions during surgery and with International Knee Documentation Committee test results. A statistically significant association (P < .0001) was found between medial or lateral arthrosis of the knee and meniscal injury. In all patients the presence of tears in both menisci was associated with osteoarthrosis in both compartments (medial and lateral).

CONCLUSIONS

In patients who underwent arthroscopic-assisted ACL reconstruction with patellar tendon graft who also had medial or lateral meniscectomy (or both), arthrosis of the respective compartments developed by 10 to 15 years after reconstruction. Meniscectomy was also associated with poorer results on objective tests of knee function, even with a stable knee joint.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Validation of a new protocol for navigated intraoperative assessment of knee kinematics

BACKGROUND

This study describes a novel method for accurate evaluations of knee kinematics during arthroscopic reconstructions of anterior cruciate ligament (ACL).

METHODS

Quantitative evaluation of knee stability was estimated by experimental validation on 30 volunteers and by statistical analysis of test repeatability.

RESULTS

Proposed method present short learning time, is minimally invasive and thus suitable for arthroscopic techniques. Computed laxity showed a repeatability of 1.5 degrees for varus-valgus, 3 degrees for internal-external, and 2mm for antero-posterior tests.

CONCLUSIONS

This method represents a reliable quantification of knee kinematics in surgery, able to improve present intra-operative assessment of knee stability.

Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial

BACKGROUND AND PURPOSE

The purpose of this study was to determine the effect of a 6-month neuromuscular training (NT) program versus a traditional strength training (ST) program following anterior cruciate ligament (ACL) reconstruction.

SUBJECTS

Seventy-four subjects with ACL reconstruction participated in the study.

METHODS

The study was a randomized, single-blinded, controlled trial. The NT and ST groups were tested preoperatively and at 3 and 6 months. The main outcome measure was the Cincinnati Knee Score. Secondary outcome measures were visual analog scales (VASs) for pain and function, the 36-Item Short-Form Health Survey (SF-36), hop tests, isokinetic muscle strength, proprioception, and static and dynamic balance tests.

RESULTS

The NT group demonstrated significantly improved Cincinnati Knee Scores and VAS scores for global knee function compared with the ST group at the 6-month follow-up. There were no significant differences between the groups for the other outcome measures (ie, hop, balance, proprioception, and muscle strength tests).

DISCUSSION AND CONCLUSION

The results of this study suggest that exercises included in the NT program should be part of the rehabilitation program following ACL reconstruction.

New intraoperative protocol for kinematic evaluation of ACL reconstruction: preliminary results

A real improvement in anterior cruciate ligament (ACL) surgery would be achieved if a global kinematic evaluation of graft performance could be made during surgery. A quantitative evaluation of all residual instabilities would be helpful in the evaluation of graft performances. This paper describes a new protocol for an accurate and extensive computer-assisted in vivo evaluation of joint laxities during ACL reconstruction. Fifteen in vivo kinematic evaluations during ACL reconstruction were performed using an optical localizer and custom software. The capability of the protocol was studied by analyzing the accuracy and repeatability of the results, the ergonomics of the setup, time taken, interactions with the surgical steps, and efficacy of the acquisitions. Repeatability of the tests, at maximum force, remained under 1 mm/2 degrees . Repeatability in tibia position and orientation was lower than 1 mm/4 degrees . Secondary laxities during stress tests remained under 2 mm/3 degrees . Added time to surgery was about 11 min. ACL graft increased joint stability up to 52% with respect to the preoperative level. The simplicity and morbidity of the test procedure and system was minimally invasive and allowed a quantitative evaluation of knee laxities at time zero. The repeatability of the tests opens the way for future research on in vivo evaluation of different ACL reconstruction techniques, which may lead to a better understanding of associated lesions and their role to the global knee stability.

A prospective comparison of bone-patellar tendon-bone and hamstring grafts for anterior cruciate ligament reconstruction in female patients

The aim of the study is to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using central-third, bone-patellar tendon-bone (BTB group) (n = 28) and four-strand semitendinosus/gracilis (ST/G group) (n = 31) autografts in female patients. The type of study was non-randomised prospective consecutive series. A consecutive series of 61 female patients, all with unilateral ACL ruptures, was included in the study. In both groups, interference screw fixation of the graft was used at both ends, and 59/61 (97%) of the patients returned for the follow-up examination after a period of 26 (23-31) months. The pre-operative assessments in both groups were similar in terms of the Lysholm score, KT-1000 measurements, one-leg-hop test, and knee-walking test. At the 2-year follow-up, the knee-walking test was significantly worse in the BTB group than in the ST/G group (P = 0.003). Furthermore, the knee-walking test was significantly worse at follow-up than pre-operatively in the BTB group (P < 0.005). The corresponding finding was not made in the ST/G group. A reduction in knee laxity compared with the pre-operative assessments was found in both groups. No significant difference in the post-operative knee laxity measurement was found between the groups. A significant increase in activity level and subjective scores was found in both groups compared with pre-operative values, without any significant differences between the groups. Two years after ACL reconstruction, the groups displayed no significant differences in terms of functional outcome and knee laxity. However, the use of ST/G autografts rendered significantly less discomfort during the knee-walking test than the use of BTB autografts.

Does anterior cruciate ligament reconstruction restore normal knee kinematics?

This prospective study used magnetic resonance imaging to record sagittal plane tibiofemoral kinematics before and after anterior cruciate ligament reconstruction using autologous hamstring graft. Twenty patients with anterior cruciate ligament injuries, performed a closed-chain leg-press while relaxed and against a 150 N load. The tibiofemoral contact patterns between 0° to 90° of knee flexion were recorded by magnetic resonance scans. All measurements were performed pre-operatively and repeated at 12 weeks and two years.

Following reconstruction there was a mean passive anterior laxity of 2.1 mm (sd 2.3), as measured using a KT 1000 arthrometer, and the mean Cincinnati score was 90 (sd 11) of 100. Pre-operatively, the medial and lateral contact patterns of the injured knees were located posteriorly on the tibial plateau compared with the healthy contralateral knees (p = 0.014), but were no longer different at 12 weeks (p = 0.117) or two years postoperatively (p = 0.909). However, both reconstructed and healthy contralateral knees showed altered kinematics over time. At two years, the contact pattern showed less posterior translation of the lateral femoral condyle during flexion (p < 0.01).

Implications of the pivot shift in the ACL-deficient knee

The Losee repair controls rotational subluxation of the lateral femoral condyle, or pivot shift, but does not reliably eliminate Lachman laxity. Despite this surgical limitation, many patients who were operated on continued to do high-demand activities at the last followup. We hypothesized that Lachman findings alone did not predict poor surgical outcome or progression to osteoarthritis. We report on 87 patients evaluated at an average of 9 years (range, 5-21 years) postoperatively. Prospectively collected examinations and radiographic, subjective, and objective outcome measures were recorded and statistically evaluated. The presence of a postoperative pivot shift or residual varus laxity correlated with poor patient subjective evaluations and poor scoring outcomes. Lachman laxity with an absent pivot shift had no correlation with the outcome measures or onset of radiographic progression to osteoarthritis. Meniscectomy, additional knee surgery, increased valgus or varus laxity, and time from injury until the final radiograph positively correlated with the onset of osteoarthritis. Elimination of the pivot shift was necessary to achieve successful relief of symptoms and functional outcome. In the absence of a pivot shift, Lachman laxity was not solely predictive of poor outcomes.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Les grilles d'évaluations dans la ligamentoplastie du LCA

INTRODUCTION

Recently, results of surgery for anterior cruciate ligament (ACL) have been systematically assessed. Several scales have been developed, but for most rigorous validation is lacking.

METHODOLOGY

We reviewed reports of published scales for ACL surgery and compared their psychometric properties. We searched the MedLine and Cochrane databases with the key words anterior cruciate ligament, surgery, and rating score. A scale was reviewed if its reliability, validity, and responsiveness were reported at least once.

RESULTS

We reviewed four scales (Lysholm and Tegner, Cincinnati, IKDC, and Koos). Test-retest reliability was good, except for the IKDC. For all scales, construct validity could not been ascertained. Responsiveness was acceptable and of the same magnitude for the Lysholm and Tegner, and Cincinnati scales.

CONCLUSION

None of the scales had sufficient psychometric properties and all seemed too complicated for routine use. Validation of a simple scale is needed. Psychometric properties of the last version of the IKDC (IKDC 2000) and the Cincinnati scales should be studied.

Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction

BACKGROUND

Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction have not been established.

HYPOTHESIS

Relationships exist between objective and subjective assessments after anterior cruciate ligament reconstruction.

STUDY DESIGN

Case series.

METHODS

Patients (N = 202) undergoing anterior cruciate ligament reconstruction with 2-year minimum follow-up were studied. Objective variables of ligament stability at follow-up included instrumented laxity, Lachman examination, and pivot-shift examination. Subjective variables of symptoms at follow-up included pain, swelling, giving way, locking, crepitus, stiffness, and limping. Subjective function at follow-up included walking, squatting, stair climbing, running, cutting, jumping, twisting, activity limitation, sports level, activities of daily living level, work level, knee function, sports participation, Lysholm score, and satisfaction with outcome.

RESULTS

Instrumented knee laxity and Lachman examination had no significant (P >.05) relationships with any subjective variables of symptoms and function. Pivot-shift examination had significant associations with satisfaction (P =.03), partial giving way (P =.01), full giving way (P =.01), difficulty cutting (P =.01), difficulty twisting (P =.01), activity limitation (P =.01), overall knee function (P =.03), sports participation (P =.02), and Lysholm score (P =.01).

CONCLUSIONS

The pivot-shift examination may be a better measure of "functional instability" than instrumented knee laxity or Lachman examination after anterior cruciate ligament reconstruction.

Laxity and functional outcome after arthroscopic reduction and internal fixation of displaced tibial spine fractures in children

PURPOSE

The purpose of this study was to evaluate laxity and functional outcome of displaced tibial spine fractures in skeletally immature patients treated with arthroscopic reduction and internal fixation.

TYPE OF STUDY

Retrospective case series.

METHODS

Six patients (mean age, 12.0 years old) underwent subjective, objective, and instrumented knee laxity assessment at minimum 2 years (mean, 3.2 years) of follow-up time after arthroscopic reduction and 3.5-mm cannulated screw fixation of (Meyers and McKeever type III) tibial spine fractures.

RESULTS

Physical examination showed persistent laxity, with an abnormal Lachman examination in 5 of 6 patients and an abnormal pivot-shift examination in 2 of 6 patients. Instrumented knee laxity (KT-1000) showed greater than 3-mm manual-maximum side-to-side difference in 4 of 6 patients. Functional assessment revealed excellent function, with a mean Lysholm score of 99.5 (range, 98-100), mean Marshall score of 49.0 (range, 47-50), and mean Tegner score of 8.7 (range, 7-9).

CONCLUSIONS

Arthroscopic reduction and internal fixation of type III tibial spine fractures in skeletally immature patients results in persistent laxity but excellent functional outcome.

Comparison of outcomes between males and females after anterior cruciate ligament reconstruction

Few studies have specifically addressed the potential differences in outcome from ACL reconstruction between males and females. The present study compared patient-reported outcomes between the sexes after a minimum of 2 years following arthroscopic ACL reconstruction using bone-patellar tendon-bone autograft. Patients were also categorized as acute or chronic based on the time from injury to surgery. Outcome questionnaires were mailed to 638 patients, resulting in 151 eligible respondents included in the analysis. The outcome instruments used were the Cincinnati scale, the ACL-Quality of Life scale, and the Tegner activity rating scale. At an average of 5 years following ACL reconstruction no differences were found between males (n=74) and females (n=77) on the ACL-QOL scale. Females perceived a significantly higher activity level prior to surgery according to the Tegner scale. However, no other differences were identified by gender or stage based on prior, highest, or current Tegner activity levels. Results of the Cincinnati scale for the entire sample showed that females scored an average of 5.7 points lower than males. Analysis of this difference by patient age indicates a trend toward lower scores in females between 12-18 and over 24 years old. Chronicity was not a factor that affected outcome in either males or females. No differences were found in the number of patients who complained of anterior knee pain. We conclude that autogenous bone-patella tendon-bone ACL reconstruction is equally successful in well-matched populations of males and females.

Arthroscopic ACL reconstruction: a 5-9 year follow-up

Arthroscopic ACL reconstruction has a satisfactory functional outcome of up to 90%, but there are few long-term prospective studies. This prospective study presents the outcomes of ACL reconstruction in terms of laxity, function and degenerative change, after a mean follow-up of 7 years. Function was assessed using the Lysholm and Tegner Activity Scores, laxity using the Stryker Knee Laxity Tester, employing maximum manual effort, and degenerative change was assessed as joint line narrowing on standardised radiographs. At latest follow-up, the mean Lysholm score improved from 70 to 87 and the Tegner from 4 to 7 (P<0.001). AP translation also improved (P<0.001). The incidence of early degenerative change was 50% and although this appeared to be associated with a previous meniscectomy, the correlation was not significant (P=0.06). In conclusion, the improved functional scores and laxity are sustained beyond 7 years but the 50% incidence of early degenerative change may be a cause for concern.