• Pre-pubescent - these are the problems children.
  
• Post-pubescent - these are the largest group, and should be treated as adolescent
  
  

Grafts - soft tissue do not fuse the plates- Arnoczky

No extra-articular repairs are recommended, they may interfer with the lateral aspect of the growth plate.

Patellar tendon is also not recommended due to damage to the tibial tubercle.

Preferred treatment:

• Central tibial tunnel
  
• Femoral tunnel - endo button - double looped tape
  

• Semi-tendinosus graft
  
  

Prospective Review of ACL Reconstructions with Bioabsorbable Screw - Phillip Neyret

MRI measurements on the tunnels were performed on ACL reconstruction with bioabsorbable screws.

The femoral tunnel should be high in the notch.

There was relationship with a soft end point in follow-up and the tunnel placement.

The use of the bioabsorbable screws had no increase in complications.




Hydroxyapatite dowels for fixation of the ACL graft - Herman Mayr

The dowel is used to 'impact fixate' the patellar tendon bone plug, and this was compared to the interference screw.

The pullout strength was less than the screw (50%)




Multiple Ligament Reconstruction - 2-5 year Follow-up - Chris Harner

This study reports on the results of operation for dislocated Knees -30 patients

17 spontaneous reduced - the rest had to be reduced in emergency.

Graft choice:

ACL- patellar tendon allograft

PCL - Achilles allograft

17 acute - within 3 weeks

6 vascular injuries - 3 complete - 3 intimal injuries

when in doubt, get an arteriogram

Also helpful is the ankle brachial ratio< .8 - get arteriogram

Intimal injury is a problem if operating within 24 hours

Summary: pulses normal, doppler normal, indices normal, - no arteriogram

ACL/PCL - medial

ACL/PCL - lateral

Rehab - brace in extension for 4-6 weeks

83% follow-up

IKDC - Subjective / ROM / Stability / overall

A - 9 7 3 0

B 13 13 14 10

C 3 4 8 8

D 0 1 0 7

Operation is generally successful, but return to sports and heavy work is variable

Often does a primary repair of the PCL

Allograft restores stability

MRI helps to evaluate the avulsion injuries and get early repair

EUA is extremely important to make decisions on the repair.




Postero-lateral Instability - Brian Casey

This was an overview of 15 years of observing the postero-lateral corner injury by Casey

Variable intra/extra fibrous response to surgery

Variable degree of ligamentous stability - hyperlax patients are more of a problem.

Variable anatomy of the posterolateral corner


Procedures

• Mueller by pass
  
• Clancy biceps tenodesis
  
• Quads tendon for varus - bone on femoral side
  
• Bony realignment - valgus osteotomy for varus thrust
  

• Patellar olecranization - may have a place
  
  

Treatment of Acute Lateral Ligament Injuries of the Knee - Thomas Klootwyk - Shelbourne

Lateral side needs to be done within 3 weeks with open procedures.

Review the lateral anatomy 1,2,3, layers

Procedure - the injury is distal

Re-attach the lateral mass back to tibia - open

Results 17 patients

Most had ACL/PCL reconstruction




Instability and Arthritis - Osteotomy - G. Puddu

Combined ACL deficiency and medial compartment OA

Uses the open wedge osteotomy held with a plate, and no fibular osteotomy

Cuts the wedge with saw and osteotome, up to 1 cm of lateral side, then pry it open.

Bone graft the defect from the iliac crest

Post up - brace, WB partial 30 days and full at 45 days




Capsuloligamentous Injuries with Chondral injuries- Chrisitan Guier

These injuries were diagnosis with MRI scan - 8X increase in associated fractures in past 2 years

More injuries due to the parabolic skis and the internal rotation injury of Bob Johnson

The tibia will abut against the femur on reduction and cause a transchondral fracture of the femur.

Common to have tibial plateau fractures

Operate for 2 mm of step off




Problems of Donor Site After ACL Reconstruction - Nic Piskopakis

This reviewed 1420 cases

This study divided the ACL reconstruction patients into 2 groups - with and without aggressive rehab

The incidence of patellofemoral pain was 23%, this reduced to 4% with aggressive rehab

Patellar tendinitis was slightly more common in the aggressive rehab program

Muscle weakness same in both groups

Less loss of range of motion with aggressive rehab

The length of patellar tendon was longer in 8% and shorter in 6%




Non contact ACL Mechanism "The Position of No Return" Mary Lloyd Ireland

This study determined that in 82% of ACL were non-contact mechanism.

There is a gender differences - 4X greater in females

She felt that position sense could be improved by training

She showed several basketball injuries that she called the "heart attack" of the knee, and showed the position of no return.

This position of no return is:

Body forward flexed

Hip adducted

Internally rotated

Valgus flexion knee

Tibia externally rotated

Foot pronated

This is a distal deceleration with rotation

Prevention - training - emphasized by Erickson. (Proprioception and strength)

ACL is torn with valgus and rotation - Woo The main control of valgus is the ACL not the MCL.

Off balance jump stop - brain has 'mini-stroke', the hamstrings forget to fire.




The Infuence of Menstrual Cycle on ACL Laxity - Rhidan Thomas

More ACL's during the menstrual cycle - old study from the 60's

Wojits found the highest ACL rate during the ovulatory phase ( more estrogen during this phase)

Estrogne had inhibitory effect on fibroblasts of the ACL

Luteal phase had more a-p displacement measured by the KT-2000

There was no change with the oral contraceptive pill, is this a protective effect.

Conclusions: showed more ACL laxity with menstrual cycle




ACL Injury Rate of Men and Women at the United States Military Academy - Dean Taylor

The injury rate is not different between men and women - 3.5% rate over 4 years

Reasons:

• The natural selection criteria to enter West Point (some weaker high school females are eliminated prior to entry)
  
• The training involved at West Point
  
• Most injuries were in football and rugby (women did not participate)
  
• Women have higher rate for gymnastics
  
  
  

The injury rate at the Navy and Air Force have a higher rate in females, but they play rugby at Navy. The numbers should be combined from all three academies




Distinct Patterns of Scans in Acute and Chronic ACL Deficient Knees - Scott Dye

Daniel's studied the reconstructed knees with scans and showed a higher level of degenerative changes compared to the non-operated knees. This may because they had more menisectomies and some were 'tighter' due to casting post-op.

It is important to understand the concept of the 'load envelope'

1.Zone of homeostasis 2.zone of load acceptance 3.zone of overload

Bone bruise has a scan appearance that is different in the acute and chronic

Acute uptake is in the lateral - anterolateral femoral condyle and posterolateral tibia

Chronic injury uptake is in the medial -90% and only 10% in the lateral




Radiological Comparison of Graft Orientation in Endo vs 2 incision - Gary Losse

The ACL graft position determines the success of the outcome of the operation

Is there a simple xray determination for graft position?

This was a complex measurement of x-rays that favoured his 2 incision technique. The single incision technique was done by another surgeon. ( this weakens the study conclusions)

Xray ap and lateral scanned and reference markers placed

There were differences in the one vs two incisions The endo was a shorter graft

Fuss ( Acta Anat 140:260-268, 1991) felt that the guiding bundle is the isometric bundle, and this is placed in the optimum femoral position - posterior

Outcome: The endoscopic single incision had more laxity in follow-up. Losse does a 2 incision tech

Bone scans have been demonstrated as normal in both groups.