| ACL Study Group 2004 | ||
.jpg) Forte Village Resort, Santa Margherita di Pula, Sardegna, Italy Abstracts and PowerPoint Presentations- 2004 Instructions: Click on the title for the abstract and click on
Download PDF for the PowerPoint Presentations Treatment trends with Anterior Cruciate Ligament, Posterior Cruciate Ligament, Medial Collateral Ligament, and Cartilage Problems. John Campbell, MD. Bozeman Montana. Download PDF file Longterm-Results of ACL-Reconstructions Dr. Med. Dieter Gmur Bern Switzerland Download PDF file Septic Arthritis Following Arthroscopic Anterior Cruciate Ligament Reconstruction: A Retrospective Case-Control Study of Risk Factors and Outcomes. Walter Lowe MD. California Download PDF file Functional Outcome of ACL Revision with 4 years Follow-up. Tom Patt MD. The Netherlands Download PDF file Effectiveness of Bio-Transfix in ACL Reconstruction: a prospective study with three year follow-up. A. Schiavone Panni MD Rome Italy. Download PDF file The Effect of Age on the Histologic Response to ACL Injury. Martha Murray, MD, Minder S. Kocher, MD Boston Mass. Download PDF file ACL Reconstruction in Children and Skeletally Immature Adolescents. Burt Jacobsen MD Aarhaus, Denmark. Download PDF file ACL Reconstruction in the Immature Skeleton, Andrew Unwin, B Sc FRCS Berkshire UK Download PDF file ACL Replacement in Sheep with Open Epiphysis: An Evaluation of Risk Factors. Dr. Seil Download PDF file Timing of Biologic Fixation and Knee Stability After ACL Reconstruction with Hamstring Tendons. Mitsuo Ochi MD Hiroshima Japan Download PDF file Indications for Ancillary Surgery in ACL Deficient Knee. Philippe Neyret MD Lyon France, Download PDF file Comparison of Femoral and Tibial Fixation in ACL Reconstruction. Don Johnson Ottawa Canada. Download PDF file Reproduction of Anatomic ACL Reconstruction in the Sagital Plane: A comparison of Two Endoscopic Techniques. David Chao MD, San Diego California. Download PDF file Prospective evaluation of patellar tendon graft fixation using new interference screws -A comparison of allograft and composite materials Peter Burkart, MD. Innusbruk Austria. Download PDF fileSunday May 30, 2004 PM Endoscopic Reconstruction of the Anterior Cruciate Ligament Using the Quadriceps Tendon Graft and Rigid Fixation: A Randomized Prospective Study with 2 years follow-up. Pietro Randelli MD Milan Itlay. Download PDF file A Novel ACL Reconstruction with Bone-Patellar-Tendon-Bone Graft: A Biomechanical Analysis - Konsei Shino MD Osaka Japan. Download PDF file Tissue Engineering of Xenografts for ACL Reconstruction. Kevin Stone MD, San Francisco CA. Download PDF file Do Femoral Tunnel Positions Affect the Function of the ACL Reconstructed Knee? Volker Musahi MD Pittsburgh PA. Download PDF file Double Bundle Reconstruction of the ACL Using Hamstring Tendons Versus One Bundle Reconstruction: A Biomechanical Cadaveric Study. Guy Bellier MD Paris France.. Download PDF file The Double Graft ACL Reconstruction: Can it restore normal mechanics? Denny Lie MD London England. Download PDF file Posterolateral Corner Injuries - Symposium Russ Warren - Download PDF file Hans Staubli - Download PDF file Don Shelbourne -Download PDF file Hans Passler -Download PDF file Monday May 31, 2004 AM Patellofemoral Symposium The Detection, Prevention, and Control of Arthrosis Following ACL Reconstruction Scott Dye MD, San Francisco. Download PDF file Monday May 31, 2004 PM Neuromuscular Factors for Injury During Tasks Impicated in Non-contact ACL Injuries. T. Sell MD Pittsburgh PA. Download PDF file Proposed Mechanism for Anterior Cruciate Ligament Injury K Don Shelbourne MD Indianapolis IN. Download PDF file Is Phase of Menstrual Cycle Associated with ACL Injury in Alpine Skiers? Bjarne Brattbrack, MD Burlington VT. Download PDF file A Centile Chart of Functional Recovery Following ACL Reconstruction. A Useful Incentive for Patients? Tim Spaulding, MD Warwick UK. Download PDF file Comparison of One-Leg Hop for Distance Scores in the ACL Deficient With a Group of Healthy Controls. Paul Marks, MD, FRCS, Toronto, Canada . Download PDF file Isokinetic Evaluation of Quadriceps, Hamstrings, and Rotational Muscle Strength of the Knee: Comparison Prospective Study of Hamstrings and BTB ACL Reconstruction. Matteo Denti Milan Italy. Download PDF file The Influence of Core Strength on Lower Extremity Performance. M.L. Ireland MD Lexington KT. Download PDF file Applying Conventional Measurements to Modern Modalities: MRI Determination of Tibial Tubercel Lateralization, Patellar Lateralization, Patellar Tilt, and Patella Index in Patients Presenting with Anterior Knee Pain. Ed Bartlett, MD. Download PDF file Risk to Popliteal Vessels in Major Knee Surgery: An Anatomical Study and Survey on Vascular Surgeons. John Barlett MD Heidelberg Australia. Download PDF file Video Informed Consent Improves Knee Arthroscopy Patient Comprehension. James Lubowitz MD Taos NM. Download PDF file An Improved Technique for Open Wedge Osteotomy Using a Biplanar Cut and a new Internal Plate Fixator. Philippe Lobenhoffer, MD. Hanover Germany. Download PDF file Knee Malalignment Corrected by Opening Wedge Osteotomies. Arne Ekeland, Baerum Norway. Download PDF file Tuesday June , 2004 AM Prospective Clinical and MRI Analysis Of Stored Osteochondral Allografts for the Treatment of Knee Cartilage Defects. Riley Williams New York NY. Download PDF file Soft Tissue Healing in Biglycan Knockout Mice. Narimasa Nakamura, Japan. Download PDF file Recellularization and Remodeling of Allografts Used to Replace the Anterior Cruciate Ligament. Variables that have an Influence on these Process. Vicent Sanchis-Alfonso MD PhD, Valencia Spain . Download PDF file Transplantation of Culture Born Myofibroblasts into the Medial Collateral and Anterior Cruciate Ligaments. J Menetrey, MD, Geneva Switzerland. Download PDF file The Effect of Short-term Mechanical Stimulation on Fibroblasts Cultured on Synthetic Scaffolds. David McAllister MD Los Angles, CA. Download PDF file ACL Graft Rupture after Anatomic Reconstruction and Rehabilitation. A Problem of Lack of Reinnervation. Roland Biedert MD Magglingen, Switzerland. Download PDF file Double Bundle ACL Reconstruction. Paulo Aglietti, MD, Florence Italy. Download PDF file Clinical Outcome After Anatomical Reconstruction of the Anteromedial and Posterolateral Bundles of the Anterior Cruciate Ligament. Kazunori Yasuda, MD, PhD, Sapporo, Japan. Download PDF file The Outcome of Anterior Cruciate Ligament Reconstruction Using Quadrupled Semitendinosus Tendon: One-bundle Versus Two-bundle Methods. Taseski Muneta MD Tokoyo Japan. Download PDF file Two-bundle ACL Reconstruction. Guy Bellier MD, Paris France. Download PDF file Outcome of ACL Revision Reconstruction. KP Benedetto, MD Feldrich, Austria. Download PDF file Allograft versus Autograft Patellar tendon for ACL Reconstruction. A 2-year follow-up. Herman Mayr. Munich, Germany. Download PDF file Reconstruction of the Posterolateral Corner. A New Surgical Procedure. BW Jakobsen, Aarhus Denmark. Download PDF file Round Table Discussion - Partial Tears of the ACL in the Young Athlete. K Donald Shelbourne. Download PDF file For Consideration: Can we expect a normal knee after ACL reconstruction? K Donald Shelbourne. Download PDF file Thursday June 2, 2004 AM Why Do We Create a Round Tunnel for a Rectanglar Tendon? Development of a New Technique for ACL Reconstruction Using a Patellar Tendon. Christian Fink MD. Innsbruk Austria. Download PDF file Tunnel Widening After Hamstring ACL is Dependent on the Type of Fixation Used. A Prospective Randomized Study. Peter Fanoe, Randers Denmark. Download PDF file How to Reduce the Tibial Widening in ACL Reconstruction. Tricks and Techniques. V Calvisi MD L'Aguila Italy. Download PDF file The Cross Sectional Area of the Quadruple Hamstring Graft Correlates with the Size of the Donor. AK Aune MD Oslo Norway. Download PDF file Biomechanical Properties of Tibial Hamstring Graft Fixation Techniques for Circumferential Graft Ingrowth. Experimental Roentgen-Stercometric Analysis (RSA) Study. Dieter Kohn MD Homburg Germany. Download PDF file Relationships Between Objective Assessment of Ligament Stability and Subjective Assessment of Symptoms and Function After ACL Reconstruction. Minder S. Kocher. MD Boston Massachusetts. Download PDF file Reducing Invasiveness and Improving Accuracy with Computer Assisted Surgery (CAS) in ACL Reconstruction. Christian Hoser, MD, Innusbruk Austria. Download PDF file Work in Progress: MRI Virtual Arthroscopy of the Knee. Charles Ho. Palo Alta, CA. Download PDF file. Three Years Experience with Computer Navigation-Assisted Positioning of Drilling Tunnels in Anterior Cruciate Ligament Replacement. Jurgen Eichhorn, MD. Staubing Germany. Download PDF file The Influence of Menisectomy or Meniscus Suture on the Stability of the Knee in Computer Assisted Anterior Cruciate Ligament Reconstruction Burt Klos MD. Eindhoven, Netherlands. Download PDF file Reduction of Post-operative Pain Following Arthroscopic ACL Reconstruction Using Low Temperature Arthroscopy Irrigation Fluid. Jon Borrill Melbourne Australia. Download PDF file Integrity of Reconstruction of the Anterior Cruciate Ligament: A Roentgen Sterophotogrammetric Analysis. Rhiodan Thomas MD London England. Download PDF file Arthroscopic Treatment of Avulsion Fracture of Anterior Cruciate Ligaments. Matjaz Veselko MD. Download PDF file Thursday June 2, 2004 PM Effect of Lateral Femoral Tunnel Placement on Knee Stability and Graft Fixation. Yuji Yanamoto MD, PhD Pittsburg PA. Download PDF file The Effect of Tibial Slope on Anterior Tibial Translation in the ACL Deficient Knee. Mark Clatworthy, MD. Auckland NZ. Download PDF file Posterior Tibial Slope Angle and its Association with Anterior Cruciate Ligament Teas in Male and Female Patients. Mark Sherman. MD, Staten Island, New York. Download PDF file Primary Repair of the ACL: Do we need to go there again? John Feagin MD. Download PDF file Alternatives for the Active Individual with Symptomatic Arthritis of the Knee. What would you do? John Bergfeld. Download PDF file Intra-articular Analgesia Using Meperidine/local Anesthesia Combination in Arthroscopic Knee Procedures. John Vander Schilden MD. Little Rock Arkansas USA. Download PDF file Salvage Treatment of Massive Non-structural Osteochondral Lesions of the Knee. The Use of Allograft MegaOATS versus Mosiacplasty. Albert Pearsall IV, MD. New York NY. Download PDF file Articular Cartilage Defects in Children and Adolescents: Treatment with Osteochondral Implantation. Jon Browne MD Kansas City MO. Download PDF file A Prospective Outcome Analysis of Patients Treated with Microfracture Abrasion for Chondral Lesions of the Knee. A Preliminary Review. Russelll Warren MD, New York NY. . Download PDF file Chondral and Meniscal Injuries Associated with Chronic Anterior Ligament Deficient Knee. Arturo Almazan MD, Mexico City DF. Download PDF file Normal Versus Transplanted Meniscii: Evaluation of Extrusion Using MRI and US. A Preliminary Report. Rene Verdonk MD, Gent Belgium. Download PDF file Meniscus Refixation Using the Fast-Fix meniscus Repair Device: A Preliminary Results. Dimitrios Mastrokalos MD Heldelburg Germany. Download PDF file Wound Repair in the Meniscus. New Insights. Cahir McDevitt Clevland OH. Download PDF file Friday June 3, 2004 AM What Can We Learn From In-Vitro Bioamechanical Studies of the ACL? Guiliano Ceruli MD. Perugia Itlay. Download PDF file Tibio-Femoral Kinematics in Normal Knees and Knees Following ACL Reconstruction. A Pilot Study of Weight Bearing Knees Using Dynamic MRI. Andy Williams, London England. Download PDF file Finite Element Modeling and Simulation of Knee Motion. Dereck Bickerstaff, MD. Download PDF file Non-invasive In-vitro Evaluation of the Pivot Shift Using an Electormagnetic Device for the ACL Deficient and Reconstructed Knees. Ryosuke Kuroda, Kobe, Japan. Download PDF file A Pilot Study Presenting New Methodology to Quantify in Vivo Tissue Loads by in-vitro Robotic Reproduction. Cy Frank MD Calgary Alberta, Canada. Download PDF file The Remains of ACL Graft Tension After Cyclic Loading. Markus Arnold MD, Nijmigen Neterlands. Download PDF file Anterior Knee Pain After ACL Reconstruction Arising in the Popliteal Aspect of the Knee. Vicente Sanchis-Alfonso MD Valencia, Spain. Download PDF file The Effectiveness of Reconstruction of the Anterior Cruciate Ligament Using the New Knot/Pressfit Technique: a Cadaveric Study. R. Kilger, Pittsburgh PA. Download PDF file The Tibialis Tendon as a Valuable Anterior Cruciate Ligament Allograft Substitute: In-vitro Properties. Rene Verdonk MD, Ghent Belgium. Download PDF file Hamstring ACL Reconstruction: Is it necessary to sacrifice the gracilis: Alberto Gobbi. Milano, Italy. Download PDF file Angle Osteochondral Grafts - Effects on Articular Contact Pressure. Jason Koh. Chicago IL. Download PDF file Best Practice for Anterior Cruciate Ligament Reconstruction. Do we need standards? Who should set them? Robin Alum MD FRCS Buckinghamstire, UK. Download PDF file Longterm-Results of ACL-Reconstructions Dieter Gmür, MD, FMH für orthopädische Chirurgie OKB (Orthopädische Klinik Bern am Salemspital) Office: Bundesgasse 16, CH 3011 Bern/Switzerland Private: Burgackerweg 23, CH 3047 Bremgarten/Switzerland e-mail: dg.sen@bluewin.ch What happened to patients who have been operated on their ACL-deficient knee 30 years ago (1974) with an intraarticular ACL-reconstruction with either the transplantation of the medial or lateral meniscus or those who have been operated on their ACL-deficient knee with reconstruction of the ACL with a BPTB graft according the method of Bill Clancy 20 years ago (1983). During our ACL Study Group meeting 1986 in Zermatt, I reported about 52 cases of intraarticular ACL-reconstructions, substituting the torn ACL by either the medial or lateral meniscus of the same knee. At that time, they have been operated more than 10 years ago by my predecessor. I could show, that it was a big difference between the view of the patient and the objective view of the examiner: subjective objective very good / good 33 13 fair / poor 19 39 At that time we put to discussion 1. how the then tested knee joints work after another 10 or 20 years and whether 2. ACL-reconstructions with more modern methods like BPTB effectively lead to better longterm results. Therefore I tried to contact all the 52 patients who have been involved in the above mentioned study. Of the 52 patients having undergone the operation 30 years ago I could control 45 personally and 3 by questionaire only. Not astonishing that the 10-years results from 1986 changed in the meantime. subjective objective very good / good 12 18 fair / poor 33 27
At the same time I contacted the 57 patients whom I operated on with the original Clancy method between march 1983 and march 1984. At that time we used the BPTB graft leaving attached to the Hoffa fat pad, believing this would improve the vascularization of the graft. Of the 57 patients whom I operated 20 years ago I was able to control 50 personally and 4 by questionaire. In these patients the overall results have mainly been compromised by patellofemoral problems. These problems existed from the beginning and are – in my opinion – depending on the technical procedure of the operation at that time. Summary Ø I had the opportunity to control 48 patients, operated by my predecessor, 30 years after stabilization of a significant rotatory instability of their knee joint with either the medial or lateral meniscus of the involved knee. Ø As I expected, most of these patients developped significant degenerative changes within about 10 years, but they have been bothered by arthrosis only more than 20 years after the operation. Ø Between 25 and 30 years after the operation more than 30 % needed TKA. Ø At the same time I controlled 54 of my patients 20 years after reconstruction of the ACL with BPTB in the method of Bill Clancy (leaving the ligament attached to the Hoffa fat pad to improve vascularisation of the graft). Ø These patients suffered mainly of patellofemoral problems. Those problems could be significantly reduced, but not quite eliminated, by improving the technical procedure: free graft. Ø Of course, the stability of the knees operated with BPTB is much better than with menisci. But it is very astonishing, that patients have been quite happy with the nowadays abandoned technique. Conclusion Ø 20 – 30 years after stabilizing of a rotatory instability of the knee, overall results in patients and in doctors view are often more depending on concomitant factors at the operation as age of the patient, varus-valgus axis, quality of cartilage and menisci, than on the technical procedure of the operation. Ø Stability does influence the speed of degenerative changes but is not the most important factor. Ø After more than 20 years there are mainly degenerative (postmeniscectomy) changes, which lead to further operations. This is true for both groups and has nothing to do with the technical procedure of the ACL substitution. THE EFFECT OF AGE ON THE HISTOLOGIC INJURY RESPONSE TO ACL INJURY Martha M. Murray, MD, Lyle J. Micheli, MD, David Zurakowski, PhD and Mininder Kocher, MD From The Division of Sports Medicine, Department of Orthopaedic Surgery, Children’s Hospital of Boston, Boston, MA. ABSTRACT Background: New biologically-based techniques are being developed for treatment of the ruptured ACL. The success of these treatments is dependent on the response to injury by the cells in the ligament. This study was designed to determine whether skeletally immature patients had a different response to injury than older patients, and thus might have a different response to biologically-based treatments. Hypothesis: Younger patients have a different proliferative and vascular response to injury than older patients. Methods: Ruptured ACLs were obtained from 48 patients undergoing ACL reconstruction. Seven of the patients were skeletally immature at the time of surgery (immature). This group of seven was compared with two groups: an adolescent group (skeletally mature but younger than 20 years), and adult (older than 20 years). All ligaments had ruptured in the proximal 1/3. The ligaments were removed en bloc, and longitudinal sections analyzed for cell density and vascularity as previously described (Murray et al, JBJS, 2000). The statistical significance was determined using an unpaired Student t-test for cell density, vessel density and nuclear aspect ratio; Mann-Whitney U-test for % SMA positive cells. Results: The ACLs from immature knees had significantly higher cell density and vascularity from those of the adult knees. These differences were most apparent in the first two months after injury. Although the ACLs in the immature group also had a higher cell density than the adolescents, the difference was not found to be statistically significant between these two groups. Conclusions: The histologic response to injury is different in skeletally immature patients. The more vigorous proliferative and vascular response may bode well for enhanced repair techniques in this patient population, as these techniques are dependent on an intrinsic cellular response within the ACL. INDICATIONS FOR ANCILLARY SURGERY IN ACL DEFICIENT KNEE Philippe Neyret, Tarik Aït Si Selmi, Geraldo Schück de Freitas INTRODUCTION To better understand the place of the extraarticular tenodesis combined to an ACL graft we did a prospective randomised study. MATERIAL AND METHODIt ‘s a prospective series of chronic ACL deficient knees without previous surgery. We included two groups statistically comparable: 60 isolated ACL graft and 60 ACL graft combined with an extra articular plasty pre and post operative subjective and objective IKDC evaluation were used. Comparative AP + Lateral Monopodal Stance and Stress XRays were obtained preoperatively. The two groups were preoperatively comparable in terms of : Sexe ratio, Age, Weight, Type/Sport level, Delay injury – op, Meniscal status, Subjective IKDC (75.3% // 72.6%), Swelling, Mobility, Crepitus, X-Rays. 107 patients (89.2%) 51 KJ, versus 56 KJT were available at follow. 92% were reviewed with pre & post-op Stress X-Rays. The follow-up was 16.5 ± months in the KJ group versus 18.5 months in the KJT group. RESULTS93.5% were very satisfied or satisfied in the KJ group versus, 96.3% in the KJT group
DISCUSSIONDraganish demonstrated that isolated extra-articular tenodesis can control some amount of laxity at 30° flexion. However after isolated extra-articular tenodesis without ACL reconstruction, clinical failures are frequent: the anterior tibial translation is not controlled and at long term F.U. the arthrosis is frequent. Frank Noyes underlined the benefits to add an extraarticular tenodesis when an allograft is performed. Failure rate decreased from 16% to 3% and the control of anterior laxity was better. At the contrary several authors (O’Brien, Holmes, Buss) in different retrospective studies found no superiority to add an extra articular tenodesis. Very recently during the French Society, Hulet from Caen in a retrospective study did not find statistical difference between two groups with and without extraarticular tenodesis but the factor ß was unknown and the number of patients in the two groups was not large enough. F Cladiere (Lerat-Moyen) compared in a prospective randomised study two groups with and without extraarticular tenodesis and recommended a lateral complementary procedure when there is a preoperative differential anterior tibial translation measured on the lateral compartment, called “TACE” of more than 8 mm. CONCLUSIONSThe place of extraarticular tenodesis is still discussed. This series encourages us to evaluate this comparison is larger groups and longer Follow-up. Timing of Biological Fixation and Knee Stability after ACL Reconstruction of with Hamstring Tendons Mitsuo Ochi, Yuji Uchio, Nobuo Adachi (Hiroshima, Japan) The Hypothesis The success of anterior cruciate ligament (ACL) reconstruction is considered to be affected by several factors such as surgical skill, graft selection, and the postoperative rehabilitation program. Timing of the graft incorporation within the bone tunnels is considered to be one of the important factors but it has been unclear when a hamstring tendon graft becomes biologically fixed in the bone tunnel after ACL reconstruction. The purpose of this study was to prospectively examine changes over time in the biomechanical properties of the knee and their representation on MRI during the 2-year period after ACL reconstruction and to analyze the factors predicting a poor outcome. Methods: Sixty-four patients were evaluated by serial biomechanical testing, magnetic resonance imaging, and second-look arthroscopy 2 years after surgery. Biologic fixation of the graft was confirmed radiographically by injecting a contrast medium into the femoral bone tunnel. Results: Forty-two stable knees with graft fixation maintained a high stiffness (120% of normal) and showed low signal intensity in an early postoperative magnetic resonance image (12±8 months). Fourteen stable knees without graft fixation had gradually increased anterior displacement with nearly normal stiffness and high signal intensity. Five unstable knees with graft fixation retained low stiffness (70%) and showed late low signal intensity at 20±9 months. Three unstable knees without biologic fixation had rapidly increased anterior displacement, with half the stiffness of a normal knee. Conclusion: Postoperative low stiffness and high signal intensity might indicate late biologic graft fixation, predicting a possibility of postoperative anterior knee instability.
Prospective evaluation of patellar tendon graft fixation using new interference screws -A comparison of allograft and composite materialsBurkart P*, Tecklenburg K+, Hoser C+, Fink C+*St. Anna Hospital, Luzern CH +University Hospital for Traumatology, Innsbruck A Introduction: During recent years metal interference screws for graft fixation in ACL reconstruction. have been continuously replaced by resorbable screw materials. Resorbable screw materials are found to be biologically safe and provide reliable graft fixation. However, degradation rates are highly variable and bony replacement of these screws has not been sufficiently documented. Therefore new screw materials (composites of polylactid and HA) which should enhance bone formation have been investigated and compared to an allograft interference screw. Materials and methods: Three groups of patients have been prospectively evaluated. In all patients ACL reconstruction has been performed using patellar tendon autograft and distal fixation was either (A) Biloc screw (Atlantec) , (B) Bio RCI - HA (Smith&Nephew) or an (C) allograft interference screw (Regeneration).IKDC and subjective IKDC were used preoperative and for follow up. CT scans have been performed post op and at 3, 12 months (24 months) and MRI‘s at 3 months (and 24months). Each group consisted of 19 patients (A: mean age 32,3 ± 10,9 (20-52) , B: 32,2 ± 10,6 (18-55) and C: 31,1 ± 6,6 (21-42) . There was no significant (p>0.05) difference in age, sex and time of follow up. Results: (2 year follow up will be completed February 2004 and presented) One breakage of an interference screw during insertion was encountered intraoperatively in groups A and B. At one year follow up there were no significant differences within the groups with respect to objective and subjective clinical results. IKDC evaluation revealed group A: 13 A, 5 B, 1 C, group B: 13 A, 6 B and group C: 18 A, 1 B.On MRI no inflammatory response could be detected in any of the patients of all groups. CT scans documented no loss of graft fixation, no significant bony resorption, but also no signs of bone ingrowth or replacement in the two groups with composite screws (A and B). At one year the allograft screws (C) remained unchanged without signs of resorption. Discussion: All 3 screw types proved successful in providing adequate graft fixation. Ultimately a resorbable screw has to be replaced by bone in order to facilitate revision surgery. At one year only the screw made out of bone could meet this task. If the composite material will be of any advantage has to been seen with longer follow up. Randomized Clinical Trials of Femoral and Tibial Fixation Devices in ACL Reconstruction. Don Johnson MD, Ottawa Canada STUDY DESIGN: Prospective randomized clinical trial comparing femoral and tibial fixation devices. OBJECTIVES: To investigate the efficacy of femoral and tibial fixation devices in ACL reconstruction. Question - Is BioScrew/EndoPearl equal to Endobutton for femoral fixation in ACL hamstring reconstruction as measured by KT-1000 and IKDC outcome measurements? Question –Is ExtraLok BioScrew equal to Intrafix for tibial fixation in hamstring ACL reconstruction as measured by KT-1000 and IKDC outcome measurements? BACKGROUND: ACL rupture may cause severe problems with recurrent giving way of the knee. In reconstruction of the anterior cruciate ligament, a hamstring or patellar tendon autograft is used to replace the ruptured ligament and is securely fixed to bone tunnels in both the femur and tibia that correspond to the position of the original ligament. Fixation of the graft to the femur is now most commonly performed by interference fit screws or Endobutton. Fixation in the femur has been with interference fit screws, and recently by the use of the Intrafix device. BioScrews are an effective means of fixation but do demonstrate late laxity in a previous 2 year study done at our institution (27% 3-5mm SSD). The recent introduction of continuous loop Endobutton and the Intrafix has improved graft fixation with few reported complications, but it is unknown if they are superior to BioScrew fixation. METHODS: The patients were randomly assigned to femoral fixation with either Endobutton or Bioscrew/Endopearl. The mean age was 29.1 years with a follow up of 2 year. Similarly patients were randomized to either a BioScrew (ExtrLok) or the Intrafix tibial device. RESULTS: There was no significant SSD (side to side difference) in laxity (Endobutton group= 2mm, Bioscrew=2.3mm) at 2 year. Both groups also had a similar percentage falling within the 3-5mm laxity range. Subjective IKDC scores were also similar in both groups. The SSD was similar for the tibial fixation devices at 1 year. CONCLUSION: Fixation of the ACL on the femoral side appears have similar results whether using BioScrew/Endopearl or Endobutton. There are still 30-40% of patients with 3-5mm SSD however, this did not affect the subjective outcome of the patient. Fixation of the graft with either the ExtrLok screw or the Intrafix device provided good stability at 1 year, with a reduction of the 3-5 mm SSD. Reproduction of Anatomic ACL Sagittal Angle: A Comparison of Two Endoscopic Reconstrucion Techniques David J. Chao, MD – San Diego, CA, USA Purpose: Current orthopedic techniques involving ligament reconstruction generally attempt to restore native anatomic structure and form. One method of assessing whether or not an ACL reconstruction accurately reproduces the native ligament’s anatomic orientation involves measuring its sagittal angle. The purpose of this study was to compare the established Magnetic Resonance Imaging (MRI) angle of the anatomic Anterior Cruciate Ligament (ACL) to two endoscopic ACL techniques to determine if one method more accurately reproduced the anatomic sagittal angle of the native ACL. Methods: The sagittal orientation of a reconstructed ACL graft using two endoscopic reconstructive techniques was compared to the native uninjured ACL using two established magnetic resonance imaging (MRI) techniques. The two endoscopic methods, performed by a single surgeon, differed only in the technique used to drill the femoral tunnel. In the first method of reconstruction the femoral tunnel was drilled through the tibial tunnel (transtibial) and in the second method the femoral tunnel was drilled through the medial portal with the knee in maximal flexion. There were a total of thirty patients giving fifteen subjects each reconstructed group. Two separate evaluators recorded two established methods of sagittal angle measurement using MRI scans. These values were then compared to the same measurements obtained from MR images of normal, uninjured ACLs. Results: There was a statistically significant difference when the mean value of the sagittal ACL angles of the transtibial grafts (74.7) were compared to the anatomic ACLs (56.9) (p<0.001). There was also a statistically significant difference between the mean value of the sagittal angles of the transtibial ACL grafts and the medial portal ACL grafts (57.5) (p<0.001). No statistical significance was noted when comparing the sagittal angles of the medial portal ACL grafts to the anatomic ACLs (p<0.8). Conclusions: Endoscopic anterior cruciate ligament (ACL) reconstruction has become the standard of care. When employing this technique, the femoral tunnel can be drilled through the tibial tunnel or via the medial portal with knee in hyperflexion. Based on MRI measurements, the authors conclude that the medial portal technique for drilling the femoral tunnel reproduces a more anatomic ACL reconstruction by producing a more normal sagittal orientation. References: Gentili A, Seeger LL, Yao L. Anterior cruciate ligament tear: Indirect signs at MR imaging. Radiology 1994;193:835-840. Murao H, Morishita S, Nakajima M. Magnetic resonance imaging of anterior cruciate ligament tears: Diagnostic value of ACL-tibial plateau angle. J Orthop Sci 1998;3:10-17. Arnold M, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 2001 Jul;9(4):194-9. ACL RECONSTRUCTION IN THE IMMATURE SKELETON Andrew Unwin BSc FRCS (Orth) Consultant Orthopaedic Surgeon, The Windsor Knee Clinic, Windsor, Berkshire, UK
The ACL-deficient knee in the immature skeleton is a difficult management problem. Left untreated the orthopaedic literature suggests a poor outcome, with loss of sporting potential, regular episodes of instability, recurrent arthroscopic surgery for meniscal tears and osteoarthritic change within the knee at a young age. Our group is of the view that reconstruction of the ACL is appropriate and largely necessary in the presence of symptomatic instability in the immature skeleton, a view which is not uniformly held in the orthopaedic community. We have performed 48 ACL reconstructions in the immature skeleton, 8 under the age of 11 years, 12 at ages 11-14 and 28 in the 15-16 year age group. The decision to proceed to reconstruction is symptomatic instability in the presence of ACL rupture, either as a single ligament deficiency or in combination with other ligament deficiencies. Meniscal repair and articular cartilage surgery is undertaken at the same episode of surgery. Most of our series underwent a preliminary examination under anaesthetic and arthroscopy to assess the degree of laxity and assess intra-articular pathology prior to reconstruction. All reconstructions were performed using ipsilateral medial hamstrings as the graft. Tunnel diameters were on average 7mm to minimise disruption of the growth plate. The quality of hamstring grafts is good in this immature age group, and the grafts are relatively larger than in the adult population. A variety of fixation methods have been used although all have minimised disruption of the tibial and femoral growth plates. Latterly the preferred method of fixation is a bioabsorbable cross-pin proximally with interference screw fixation and a low profile staple distally. All of our cases have been retrospectively reviewed and 23 are on prospective review. We have not had any cases of evidence of growth plate damage and no deformity or significant leg length discrepancy has occurred. There have been no ruptures of any of the reconstructed grafts. All except one retrospective and prospective cases reviewed have scored A or B on the IKDC scoring system. One case has scored D but on analysis this was due to factors other than ACL deficiency, and largely reflected meniscal and chondral pathology within the knee; this case had waited 47 months from the time of injury to reconstruction. There is a trend in our results for better outcome with more prompt reconstruction. Even in the case which scored D, no child or parent regretted the decision to have undergone reconstruction. Although the results of ACL reconstruction in the immature skeleton offer an improved outcome over conservative treatment, the results of reconstruction in this age group are not as successful as in the adult population. We conclude that ACL reconstruction in the immature skeleton is indicated in those children who have symptomatic instability. The results are better than conservative treatment alone although not as good as in the adult population. We have experienced no cases of catastrophic complication such as growth plate-derived deformity or leg length discrepancy. With respect to the pre-pubescent child with symptomatic instability, we do not believe there is a case for waiting until puberty to reconstruct. ACL replacement in sheep with open physes: an evaluation of risk factors. Dr Seil Objective An in vivo sheep model was used to evaluate the risk of different transphyseal ACL reconstruction techniques for growth disturbances. The following potential risk factors were analyzed: (1) the peripheral localization of the femoral tunnel and its relation to the perichondral structures of the growth plate, (2) transphyseal bony bridge formation with respect to different graft diameters and (3) transphyseal graft fixation using a biodegradable interference screw on the tibial side. Methods Unilateral ACL reconstruction using an autologous Achilles tendon graft and rigid button fixation was performed in 24 4-months-old Merino sheep. The tunnel diameter was 5 mm in all groups. In group I (N=6) the transphyseal tunnels were left empty. In groups II, III and IV (N=6 in all groups) ACL reconstruction was performed using either a double-stranded graft with a diameter of 5 mm (groups II and IV) or a single stranded graft with a diameter of 3 mm. In group IV a supplemental transphyseal fixation using a biodegradable interference screw fixation ( 5 mm) was used on the tibial side. The grafts were all tensioned with 40 N. Six months after the procedure, the animals were euthanized. Longitudinal growth was evaluated using X-rays of the operated and nonoperated legs. MRI was used to quantify the physeal injury. Physeal abnormalities and transphyseal bony bridges were analyzed histologically. Results Longitudinal growth was 1.6 (+/- 0.7) cm on the tibial side and 2.5 (+/- 0.7) cm on the femoral side. This corresponded to a longitudinal growth of 9.5 % of the initial length of the tibia and 13.4% of the femur, which was comparable to the expected remaining growth of a 10 year old child. 17/18 knees with ACL replacement (groups II-IV) were stable. Macroscopic analysis revealed one graft failure (group III). Quantification of the physeal injury revealed a lesion of 1.7 (+/- 1.8) % of the surface of the femoral physis and 1.7 (+/- 0.1) % of the tibial physis. In 3 animals of group I (empty tunnels) a significant shortening of the lateral femoral condyle of 7.8 mm in average could be noted (p= 0.02). This corresponded to a valgus deformity of 12.8° (12-14°) and a flexion deformity of the lateral femoral condyle of 8.6° (5-15°). Histology showed a strong bony bridge formation over the physis and an injury to the perichondral structures. In the 3 remaining sheep of group I with an intact perichondral groove, no growth changes could be noted. In groups II-IV (tunnels filled with tendon grafts) the presence of a transphyseal bony bridge did not depend on the graft diameter. These bony bridges were smaller in comparison to those of group I and did not result in growth disturbances, even if the perichondral groove was injured (p<0.05). Transphyseal fixation of the graft with a biodegradable interference screw (group IV) resulted in a dip deformity of the physis (p<0.01), but not in a shortening of the affected tibia. Conclusions Transphyseal ACL replacement in sheep did not cause any clinically relevant growth disturbances. Filling the tunnels with tendon grafts did not always prevent a transphyseal bony bridge formation. However, these bony bridges had no influence on longitudinal growth. Performing a transphyseal fixation of the graft on the tibial side by using a biodegradable interference screw resulted in a deformity of the physis, but did not affect longitudinal growth. Leaving the tunnels empty resulted in major growth deformities on the femoral side if the perichondral structures were injured. These structures, which might be injured either in a transphyseal or in an over-the-top technique for ACL replacement, represent a zone at risk for growth deformities. TWO-BUNDLE ACL RECONSTRUCTION USING HAMSTRING TENDONS : 1 YEAR FOLLOW-UP RESULTS OF A PROSPECTIVE STUDY G.Bellier*,P.Djian*,P.Christel *Cabinet Goethe 3,rue Goethe 75116 PARIS FRANCE email : bellier@genou.net The hypothesis Current techniques do not completely reproduce the anatomy and function of the ACL.They address only the anteromedial bundle,and do not fully reproduce ACL function throughout the range of motion.Current grafts control the anteroposterior stability of the knee in extension.To control the rotatory instability,several authors have suggested reconstructing also the posterolateral bundle.Anatomic two-bundle reconstruction restores knee kinematics more closely to normal than does single-bundle reconstruction. MethodThis nonrandomized prospective study is conducted on 148 patients operated on from January 2002 to July 2003,for an isolated ACL tear.Of them,46 patients (28 male,18 female) were available for 1-year follow-up. Both antero-medial (AM) and postero-lateral (PL) bundles are arthroscopically reconstructed using hamstring tendons,with two femoral sockets and two tibial tunnels.The femoral fixation is achieved with Endobutton® CL, and after cycling the tibial fixation is performed with BioRCI screws under a 50 N tension. The AM bundle is fixed at 20°-30° of flexion while the PL is fixed close to full extension. In addition both bundles are stapled on the tibia.All patients underwent the same postoperative rehabilitation protocol : passive range of motion exercises are immediately begun on CPM,50% partial weightbearing with a knee immobilizer for 1 month (1). ResultsAccording to the IKDC Knee Ligament Evaluation Form (global score), the pre-operative global scores were : 1(2.2%) normal,19(41.3%) nearly normal,20(43.5%) abnormal,6(13%) severely abnormal,the mean score was 60.3+/-2.4 [58-95].At 1 year follow-up, 15 patients (32.7%) are graded as normal ,22(47.8%) as nearly normal,6 (13%) as abnormal, 3(6.5%) as severely abnormal,the mean score is 79.5+/-1.6 [30-100].The improvement is statistically significant (p=0.003).The diminution of the anterior laxity measured with the KT 1000 is also statistically significant (p=0.001). There are only 1 deficit in extension (B) and 5 deficits in flexion (3B,2C).The pivot-shift is absent in 37 patients (80%),scored as B (glide) in 8 patients and C (gross)only in 1 patient. 6 complications occurred : 3 stiffness in flexion which required an arthroscopic lysis of adhesions at 4 month post-op,2 post-op hemarthrosis treated by drainage,1 deep infection treated by lavage and antibiotics. DiscussionThe procedure is validated by a biomechanical study on cadaveric knees (5),and by clinical results (2,3,4). The persistence of the pivot-shift in 20% of cases doesn’t blame the principle of the procedure but probably the graft.The mean diameter of the posterolateral bundle (double stranded gracilis) is only 6mm. The rotational laxity has not been measured in our study.This will be done in a further work using the “Flock of Birds”,technique developped by A.Amis. References
Double Stranded Hamstring Graft For Anterior Cruciate Ligament Reconstruction. Accepted for publication in Arthroscopy
Single versus bi-socket ACL reconstruction using autogenous multiple-stranded hamstring tendons.A prospective study. Arthroscopy,17,2001,801-807.
Rev Chir Orthop 88,2002,691-697.
The Double Graft ACL Reconstruction. Can it restore normal kinematics? DTT Lie,, AA Amis Biomechanics Section, Imperial College, London. Introduction: The pivot shift instability is not always completely abolished after ACL reconstruction. Despite objective restoration of the anterior laxity to intact levels, a residual tibial internal rotation of about 5° may persist (a ‘mini-pivot’). We hypothesised that the double graft (DG) technique would be better able to resist tibial rotation, and thus would be able to abolish this persistent rotation. This experiment was designed to validate whether the DG technique was superior to a typical reconstruction with a single graft (SG), in restoring laxity and kinematics. Material & Methods: 8 cadaver knees were studied; intact, after cutting the ACL and after reconstruction with single and double grafts. Antero-posterior laxity was tested under ±150N, and rotational laxity under 5Nm internal-external torque in an Instron machine. The Flock-of-birds electromagnetic tracking device was used to measure tibio-femoral motion, during the pivot shift and unloaded flexion-extension. Bovine flexor tendons were used to simulate hamstring grafts. In the SG technique, the graft was positioned from the centre of the tibial footprint to a point determined by a 5mm-offset femoral drill guide at the 10:30 or 1:30 position. This position was close to the AM bundle. Laxity-matched pretensions were applied at 90° flexion. In the DG technique the graft was left in-situ to act as the AM bundle, the PL bundle was positioned posterior to the AM bundle on the tibia, and on the femur, about 10mm distal and 5mm posterior to the AM bundle (i.e. 10mm shallower and 5mm lower in a 90o notch view). Laxity-matched pretension was applied at 20° flexion. Results: Anterior laxity was restored by the SG and DG techniques at 60 and 90° flexion. At 20° flexion the DG technique reduced laxity (6.5mm) more (p=0.005) than the SG (7.4mm), compared to the intact (6.7mm). Tibial rotation was significantly reduced (p=0.002) at the above flexion angles, with the DG (range 28-38°) compared to the SG and normal rotation (32-40°). The pivot shift was recreated by applying 54N ilio-tibial band load, 2.9Nm valgus and 1.8Nm internal rotatory torques. Anterior subluxation was reduced by both techniques. The internal rotation during the pivot shift (17.4°) was persistent after the SG technique (8.5°) compared to normal (4.8°). This rotation was abolished or overcorrected by the DG technique (1.3°), significantly different from intact (p=0.02) and SG (p=0.0005). During flexion, tibiae after both SG and DG reconstruction were subluxed posteriorly and rotated internally. Conclusion: The SG technique was adequate if anterior laxity was the only objective test, though residual rotation was present. The DG technique was better able to restore rotational laxity and abolish the pivot shift. This technique appears to be biomechanically superior in vitro. Is phase of menstrual cycle associated with ACL injury in alpine skiers? B Beynnon, R Johnson, M Sargent, A Frodsham, S Braun, B Brattback Department of Orthopaedics and Rehabilitation McClure Musculoskeletal Research Center University of Vermont, Burlington, Vermont Background and SignificanceThe incidence of anterior cruciate ligament (ACL) injury among female athletes has been shown to be 2 to 8 times greater than that of male athletes.1,2,3,4,5,6 Several intrinsic and extrinsic factors for these injuries have been identified.7 Three studies have investigated the association between phase of menstrual cycle and ACL injury risk.6,8,9 Two of these studies8,9 confirmed actual hormone levels and phase of the cycle at the time of injury. Wojtys et al.9 found a higher than expected number of non-contact ACL injuries during the ovulatory phase of the menstrual cycle based on urine samples. Slauterbeck8 found an increased risk of incurring ACL injury during the follicular phase of the menstrual cycle based on saliva analysis of hormone levels. Myklebust6 found a greater risk of ACL injury during the late luteal and menstrual phases based on self-reported menstrual history. While these studies suggest an increased risk of sustaining an ACL injury during certain phases of the menstrual cycle, there are limitations that have not been addressed in this type of investigation. First, none of these studies compared the risk of injury with respect to phase of the menstrual cycle to that of a matched control group that accurately represents the population at risk for ACL injury. Additionally, urinalysis is an indirect technique for the measurement of hormone levels as compared to either saliva or serum-based approaches, and may not be reliable because it is dependent on hydration status. Likewise, self-report has not been shown to be a reliable method of determining phase of menstrual cycle and only one study followed the subjects to verify the onset of next menses,9 a detail which is important for accurately determining the phase of cycle during which the subject was injured. Epidemiological evidence has yet to clearly elucidate the relationship of hormonal factors to ACL injury risk. The purpose of this study was to determine, based on serum hormone levels, if the phase of menstrual cycle has an effect on the risk of ACL injury.Specific Aims and HypothesisThe specific aims of this case-control study were to identify female athletes with ACL disruptions, obtain serum estrogen and progesterone levels, and then correlate these values with the menstrual cycle to determine if incidence of ACL injury is affected by phase of menstrual cycle. These subjects were compared with matched, uninjured control subjects. Our primary hypothesis was as follows: menstrual cycle phase, as documented by serum concentrations of estradiol and progesterone, can be used to identify female athletes at increased risk of anterior cruciate ligament trauma. MethodsThis case-control study was performed at the Sugarbush Clinic (in affiliation with The University of Vermont) during the 2001-2003 ski seasons. Subjects were excluded for the following: history of Grade II or Grade III knee ligament sprain, history of previous surgical procedure involving the knee, history of metabolic disease such as diabetes, presence of a degenerative joint disease such as Juvenile Rheumatoid Arthritis, use of oral contraception, recent or current pregnancy. Female alpine skiers with ACL injuries and uninjured female controls were enrolled. Immediately following injury on the mountain, subjects were transported to the Sugarbush Clinic where the diagnosis of a knee ligament injury was made by an orthopaedic surgeon or sports medicine physician. Determination of an ACL injury was made using the most sensitive clinical testing method, Lachman’s Test, by the treating physician. ACL injuries were then confirmed by arthroscopy or MRI through the use of a questionnaire and follow-up contact via telephone. At the time of the initial diagnosis on the day of injury, serum levels of estradiol and progesterone were measured. Control subjects also provided serum for the analysis of estradiol and progesterone levels. The blood samples were transported to the laboratory for chemiluminescence immunoassay analysis by the investigators. Injured and control subjects completed a questionnaire regarding menstrual history, use of medication, and injury history. Determination of menstrual cycle phase was made based on serum concentrations of estradiol and progesterone. In the normal menstrual cycle, low estradiol (<100 pg/ml) and low progesterone (<2.0 ng/ml) define follicular phase. High estradiol (>100 pg/ml) and low progesterone (<2.0 ng/ml) define ovulatory phase. Moderately high estradiol (>100 and < 300 pg/ml) and high progesterone (>2.0 ng/ml) define luteal phase. The Pearson Chi-Square test was used to compare the proportion of subjects in each phase of the menstrual cycle (follicular, ovulatory, and luteal) between those who suffered ACL injuries and uninjured controls. ResultsAll Injured subjects were alpine skiers. Thirty-seven females with grade III ACL sprains and 41 controls participated. Ninety percent of subjects had the injury confirmed by arthroscopy or MRI. Injured subjects ranged from 15 to 50 years of age (mean ± SD, 37.41 ± 9.22 years) and control subjects ranged from 14 to 50 years of age (33.68 ± 9.17 years). Serum analysis of the injured subjects demonstrated that there were 14 (38% of those injured) subjects in the follicular phase, 12 (32%) in the ovulatory phase and 11 (30%) in the luteal phase. Serum analysis of the control subjects demonstrated that there were 13 (32% of those uninjured) subjects in the follicular phase, 10 (24%) in the ovulatory phase, and 18 (44%) in the luteal phase. There was no significant differences found between injured and uninjured groups with regard to the proportion of subjects in the follicular, ovulatory, or luteal phases of menstrual cycle (x2=1.70, p=0.43). Discussion 1. Arendt E, Dick R: Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med 23:694-701, 1995 2. Gwinn DE, Wilkens JH, McDevitt ER, Ross G, Kao T-C: The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy. Am J Sports Med 28(1):98-102, 2000 3. Ireland ML: Anterior cruciate ligament injury in female athletes: Epidemiology. J Athl Train 34(2):150-154, 1999 4.&nbs |