Therefore, would the patellar tendon be a better graft?

Barrrett had another paper that compared the semi-t vs the patellar tendon in females:

• Semi-t has more B and C on the IKDC scale
  
• Semi-t's had more effusion
  
• Patellar tendon had more quads atrophy and crepitus
  
• The semi-t rehab was slower
  
  

Conclusion: Patellar tendon may be better graft source in active female population

Comment: Woo stated that the endobutton may be the problem in this group

Erickson showed that the females had more quads atrophy than males. Is this do to lack of testosterone?

The effusion may be due to the quads atrophy or the laxity

More collagen in the tunnel provides better healing





Treatment Trends - from ACL study group - John Campbell

John Campbell has sent out a survey to the members of the ACL study group for the past 8 years. These are the results from the last survey done in 1997 of which 57% of the group responded.


Pre-operatively

35% used the IKDC form

Timing of surgery

10% acute
44% -1-3 weeks
47% - >3 weeks

60% use KT-1000 for pre-op evaluation

MRI

• ACL 44%
  
• PCL 51%
  
• Multiple ligament 63%
  
  

Most have no age limit for ACL reconstruction (16% do have an age limit)

Operative Technique

Graft Choice

• PT -76%
  
• HT - 21%
  
• QT - 2.5%
  
• no allografts or synthetics for primary reconstruction
  
  

Screws

• 14% use Bioscrew
  
• 15% endobutton
  
• 53% metal interference fit screws
  
  

12% used an isometer during the operation

75% used endoscopic one incision technique

25% used 2 incision technique

Operative repair of the MCL - isolated -only one person in the group would do a primary repair of the MCL

Outpatient surgery is done by 50% of surgeons in the USA

PCL - only 6% would operate for the isolated PCL

Patellar tendon is the graft choice for most surgeons

Immature athlete - 12 year old with open physis

43% drilled across the physis and used hamstrings

Rehab -

• 96% allowed full extension immediately after ACL reconstruction
  
• 83% allowed full range of motion immediately post op (compared to 39% after PCL reconstruction)
  
• 66% use cryocuff
  
• 50% use continuous passive motion
  
• 66% use closed kinetic chain exercise by 2 weeks ( 45% used at 1 week) 90% used bike by 3 weeks
  
• 90% allowed run by 3 months
  
• sports - 76% allowed return by 6 months (20% by 4 months)
  
• work - 76% allowed return to sedantary work by 3 weeks
  
• labour - 88% allowed return to manual labour by 3 months
  
• Bracing post op - 33% routinely used bracing
  
  

Complications

<!% superficial infection rate

Failure - 80% had a 6% failure rate (>5 mm side to side)

Revision - for a patient who had undergone a patellar tendon graft 24 months previously graft choice

• 43% - autogenous hamstring
  
• 26% - contralateral patellar tendon
  
• 8% - ipsi-lateral patellar tendon - wait 2 years from same site
  
• 8% allograft
  
  

Cartilage -

• 17% do meniscal allograft
  
• 20% do genyzme - chondrocyte transplantation
  
  

Trends that emerge from this 1997 survey

• Patellar tendon still the choice for 76% of the ACL study group
  
• Early surgery leads to arthrofibrosis Immature athlete - hamstring tendon graft, with drilling across the epiphysis
  
• Fixation - interference screw still the most popular fixation
  
• Most surgeons allow full extension early in rehab
  

• Most of the surgeon surveyed do not do isolated PCL reconstruction
  
  

ACL reconstruction - 10 year follow-up - Pierre Chambat

This was a review of the ACL reconstruction using the patellar tendon over the top procedure.

There were 96 patients follow-up for 10 years - reviewed 88 in office and 10 by questionnaire.

all were athletes

rehab was slow

2 had ruptured the graft and one had severe osteoarthritis

10% were grade C by the IKDC rating

KT-1000 evaluation

• 64% <2 mm
  
• 5% were >5 mm
  
  

The Telos showed that 6% were tighter than the normal side, and these had narrowing of the medial joint space

Only 58% had a normal x-ray

There was more degeneration noted in the tighter knees

12% had loss of extension

The menisectomy patients showed a relationship to degenerative change

15% had reduced sports participation

The patellofemoral joint showed the same degenerative change as the medial compartment

There was no patella baja in this series

The female patients were equal to males

Osteoarthritis was due to:

varus alignment
post menisectomy
tight knee




IKDC Committee

This committee has met recently to try and make the IKDC form more user friendly, and thus have more widespread use of the form.

The committee has revised the form to include more PCL and posterolateral corner

In the members of the ACL study group - 35% use the form.

The form has not been validated

A study group produced a position paper that extra-articular reconstruction is not a valid reconstruction. ('87)






ACL Graft Fixation - Lonnie Paulos

Paulos presented his new Linx HT fixation from Innovasive devices - this is non-absorbable implant at present.

This is a summary of the literature of the mechanical properties of grafts and fixation devices.





Endobutton cause tunnel widening, but there seems to be no clinical problem associated with this.

Bioscrew press fits the tendon into the bone, and thus better healing, and no tunnel widening.

A recurrent theme is: Make the tunnels in the correct position and the operation will be successful.

Paulos - hamstring graft rehab is slower, and most of faculty agreed with this.




Precision guide pin placement in ACL reconstruction -arthroscopic and fluoroscopic control - Hans-Ulrich Staeubli

This paper outlines Staeubli's technique to make the tunnels in the correct position. He uses fluoroscopy to check the position of the guide wire. If it is not correct, he will change it.

Xray - femoral tunnel - 25% from the back and 25% down from Blumenstadt's line

Very few people in North America use flouroscopy in ACL, but more people use fluoroscopy for PCL reconstruction.

Someone from the audience suggested that you just need to look up the tibial tunnel with the scope to look for impingement. But, by then it may be too late. All you can do then is to make the notch larger.

Remember: the femoral attachment is high up in the back of the notch

Message: Even Staeubli has to occasionally change his pin placement, based on the fluoroscopy. The outcome of the operation depends on the proper tunnel placement.




Effect of Different Graft Tensioning - Albert Van Kampen

He used 20 and 40 Newtons of tension at the time of ACL reconstruction and compared the outcome.

There was no significant difference in the outcome between the 2 groups.

Conclusion: use 20 Newtons of pull to avoid over constraining the joint




Local Disuse Osteoporosis After Chronic ACL Reconstruction - Torsten Wredmark

The bone mineral content is greater in the femur compared to the tibia on normal side.

The bone mineral content was lower in both the tibia and the femur in the injured side.

The bone loss was greater in the femur.

females had greater loss over males.

Chronic ACL deficiency causes local osteoporosis, more marked in females

This has influence on the graft fixation methods

Even after ACL reconstruction the bone loss does not return to normal. It is better if more walking, running post op to improve the bone density.

Surgery causes 10% bone loss immediately.

Message: Weight bearing exercise in the post op rehab is essential to treat the osteoporosis.