Aims

While residual fixed flexion deformity (FFD) in unicompartmental knee arthroplasty (UKA) has been associated with worse functional outcomes, limited evidence exists regarding FFD changes. The objective of this study was to quantify FFD changes in patients with medial unicompartmental knee arthritis undergoing UKA, and investigate any correlation with clinical outcomes.

Aims

To fully quantify the effect of posterior tibial slope (PTS) angles on joint kinematics and contact mechanics of intact and anterior cruciate ligament-deficient (ACLD) knees during the gait cycle.

Aims

The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare length of hospital stay, general health improvement, and satisfaction between rUKA and mTKA.

Aims

The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA.

Anterior cruciate ligament deficiency (ACLD) affects the performance of walking in some patients (non-copers) while copers are able to minimize the effects via proper musculoskeletal compensations. Since many daily activities are more challenging than level walking, e.g., obstacle-crossing, it is not clear whether copers are able to cope with such a challenging task. A successful and safe obstacle-crossing requires not only sufficient foot clearance of the swing limb, but also the stability of the body provided mainly by the stance limb. Failure to meet these demands may lead to falls owing to loss of balance or tripping over obstacles. The purpose of the current study was to identify the motor deficits and/or biomechanical strategies in coper and non-coper ACLD patients when crossing obstacles of different heights for a better function assessment. Ten coper and ten non-coper ACLD patients were recruited in the current study. The non-coper ACLD subjects were those who had not been able to return to their pre-injury level activities, had at least once giving way during the last six months and their Lysholm knee scale was less than 70 [1]. Each subject walked and crossed obstacles of heights of 10%, 20% and 30% of their leg lengths at a self-selected pace. Kinematic and kinetic data were measured with a 7-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The leading and trailing toe clearances were calculated as the vertical distances between the toe markers and the obstacle when the toe was directly above the obstacle. Joint angles of both limbs, and joint moments of the stance limb, were calculated. Peak extensor moments at the knee during stance phase and the corresponding joint angles were extracted for statistical analysis. A 3 by 2, 2-way mixed-model analysis of variance with one between-subject factor (group) and one within-subject factor (obstacle height) was performed (α=0.05). SAS version 9.2 was used for all statistical analysis. Compared with the copers, significantly reduced leading and trailing toe clearances were found in the non-coper group (P<0.05). The non-copers showed significantly decreased peak extensor moments (P<0.05) and flexion angle at the affected knee during the stance phase before leading limb crossing (P<0.05). Distinctive gait patterns were identified in coper and non-coper patients with unilateral anterior cruciate ligament deficiency during obstacle crossing. During the stance phase before the un-affected leading limb crossing, the non-copers showed significantly reduced flexion and peak extensor moments at the affected knee (i.e., quadriceps avoidance), primarily owing to the impaired stability at the affected knee. The significantly reduced leading and trailing toe clearances in the non-coper group indicate that the non-coper ACLD patients are at a higher risk of tripping over the obstacle, and may have difficulty in regaining balance owing to the unstable ACLD knee. Advanced rehabilitation program or reconstruction of the ACL is suggested for the non-coper group

Most patients (95%) with fibular hemimelia have an absent anterior cruciate ligament (ACL). The purpose of this study was to assess the long-term outcome of such patients with respect to pain and knee function. We performed a retrospective review of patients with fibular hemimelia and associated ACL deficiency previously treated at our institution. Of a possible 66 patients, 23 were sent the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire and Lysholm knee score to complete. In all, 11 patients completed the MODEMS and nine completed the Lysholm score questionnaire. Their mean age was 37 years (27 to 57) at review. Five patients had undergone an ipsilateral Symes amputation. There was no significant difference in any subsections of the Short-Form 36 scores of our patients compared with age-matched controls. The mean Lysholm knee score was 90.2 (82 to 100). A slight limp was reported in six patients. No patients had episodes of locking of the knee or required a supportive device for walking. Four had occasional instability with sporting activities.

These results suggest that patients with fibular hemimelia and ACL deficiency can live active lives with a similar health status to age-matched controls.

Introduction: Previous work has shown that fixation of meniscus tears supports healing by preventing tears from gapping. However, an anterior cruciate ligament (ACL) insufficiency might increase the loads especially on the posterior horns of the meniscus. The aim of this study was to test an ACL tear results in wider gaps of longitudinal meniscal tears.

Methods: 3 cm longitudinal tears were artificially set in the posterior horn of the medial menisci in 10 human cadaver knee joints. The medial plateau of the joints was replaced by a translucent copy, under which an arthroscope was positioned to observe the gapping phenomenon of the meniscal tears. The knee specimens were flexed and extended in a motion and loading simulator allowing for all degrees of freedom. The maximum gap width occurring during a flexion-extension cycle was registered.

Results: Longitudinal meniscal tears showed significantly wider gaps after cutting the ACL (p< 0.01). However, refixation of the tears with suture anchors significantly reduced the gap width to much lower values (p< 0.01), still higher then with intact ACL.

Conclusion: The results indicate that medial meniscal tears in the posterior horn are exposed to higher loads in case of an ACL insufficiency. A missing ACL leads to increased anterior instability, which obviously results in wider tear gaps also in case of tear fixation with an implant. This confirms from a biomechanical point of view the clinical finding that meniscus repair is significantly enhanced when combined with ACL reconstruction.

A total of 218 patients with unilateral anterior cruciate ligament deficiency were randomly assigned to one of four groups. In group A an anatomical double bundle anterior cruciate ligament reconstruction was performed; group B were treated by a single bundle using an Endobutton for femoral fixation; in group C by a single bundle using RigidFix cross pins for femoral fixation; and in group D by a single bundle using a bioabsorbable TransFix II screw for femoral fixation. For tibial fixation a bioabsorbable Intrafix interference screw was used for all the groups and the graft was fashioned from the semitendinosus and gracilis tendons in all patients. In all, 18 patients were lost to follow-up. The remaining 200 were subjected to a clinical evaluation, with assessment of the anterior drawer, Lachman’s and the pivot-shift tests, and KT-1000 arthrometer measurement. They also completed the International Knee Documentation Committee, Lysholm knee and Tegner activity scores. At a mean of 29 months (25 to 38) follow-up there were no significant differences concerning time between injury and range of movement and Lysholm knee scores among the four groups. However, the double bundle method showed significantly better results for the pivot-shift test (p = 0.002). The KT 1000 measurements showed a mean difference between the reconstructed knee and the patients’ normal knee of 1.4 mm in the double bundle group and 2.4 mm in the single bundle group; which was statistically significant. The Lachman and anterior drawer tests also showed superior results for the double bundle method. The International Knee Documentation Committee scale showed no significant difference among the groups (p < 0.001). On clinical evaluation the double bundle group showed less laxity than the single bundle groups. However, regardless of the technique, all knees were improved by anterior cruciate ligament reconstruction compared with their pre-operative status

Background: We have devised a modified Pivot Shift test with which to assess ACL deficiency which does not require forced tibio-femoral subluxation. The test is scored on patient reaction to the initiation of the pivot shift without actually having to elicit that ‘shift’ which can be painful. We call the test the Pivot Apprehension test.

Methods: We retrospectively analysed a cohort of 81 patients who were potentially ACL deficient and sought orthopaedic intervention over a period of 3 years and correlate their initial ‘pivot apprehension’ score with the degree of ACL deficiency found at subsequent arthros-copy and/or MRI.

Results: Using contingency tables and Fishers Exact test we calculate that the test has a positive predictive value (for predicting ACL Rupture) of 94% (p=0.026) and a sensitivity of 89% (Specificity 60%). Linear Regression analysis shows a correlation coefficient (r) of 0.47 (p=0.0008).

Conclusion: The data we have collected in this study show that the ‘Pivot Apprehension Score’ is a clinical tool with a high positive predictive value for ACL injury which provides the same information as the Pivot shift test without having to cause painful tibio-femoral sub-luxation thus obviating the clinical need to elicit ‘pivot shift’ in the conscious patient.

The management of medial osteoarthritis of the knee with underlying anterior cruciate ligament deficiency is challenging. Stabilization of the ligament instability at the time of re-alignment osteotomy addresses both components of the disability. We are reporting a retrospective study of thirty-two cases of combined osteotomy and ligament repair between 1995 and 2000. Patients were assessed by questionnaire and clinical examination. Objective measures, using the modified Lystolm score, WOMAC index and SF36 were performed. Radiological examination as well as a survivor-ship analysis were performed. The average age at operation was thirty-six with an average follow-up of five years. Surgery was performed in patients who had complaints of both pain and instability and also had objective findings of Uni-compartmental osteoarthritis and anterior cruciate deficiency. Seventy five percent of patients were classed as good to excellent with only five percent of patients classed as poor. Combined tibial osteotomy and anterior cruciate reconstruction is an effective means to deal with this complex problem

To evaluate the functional outcome after anterior cruciate ligament reconstruction using bioabsorbable femoral cross-pin fixation. 30 patients with chronic anterior cruciate ligament deficiency, treated by arthroscopic reconstruction using hamstring tendon autograft have been reviewed. 3.3mm bioabsorbable (polylactic acid) cross-pins (Rigidfix, Ethicon) were used for graft fixation in the femoral tunnel. Outcome assessment was performed using Lysholm score,Tegner activity level, KT-1000 Arthrometer laxity measurements, single legged hop test and SF-36 evaluation. There were 20 male and 10 female patients with an age between 17 and 45 years(mean 25.1 yrs).The mean follow up was 20.3 months (range12–29 months). The mean Tegner score was 5.5 with a range of 3 to 7. Lysholm scores averaged 88.27 with a range of 74 to 100. The range of movement in the operated knee was comparable to that in normal knee. The single legged hop was 93.4% of the unoperated side. The average KT-1000 side to side difference was 3.2 mm using a 30 lb force and 3.5mm on manual maximal load. Biabsorbable femoral cross-pin fixation offers a viable and safe method of graft fixation in anterior cruciate ligament reconstruction and yeilds a satisfactory functional outcome

Aims: The purpose of this study, we need to identify the balance whether is influenced by proprioception or not? Can those be used as objective measures to predict functional stability?

Materials & Methods: Twelve young adults (10 males; 2 females) with chronic ACL deficiency (6 R’t knee; 4 L’t knee) were included this test (average time from injured to test: 12.8 months). The control group was 13 normal individuals (11 males; 2 females). There were no associated injuries in both group and no significant difference about age, height and body weight. Both groups were tested on computerized balance-testing machine system (self-design), proprioception testing apparatus (self-design) and the Isokinetic Dynamometer (Con-Trex Multi Joint System, Switzerland).

Results: In ACL group, the Lachman score showed 67.7 ± 4.2 points. The difference of joint laxity between injured and uninjured knee was 9± 2 vs 3.7 ± 1.2 using K-T 1000 arthrometer. In single leg hopping test, showed significant difference (p< 0.05) between injured and uninjured leg. In proppriocetion test, the results showed significant time-delay in both TTDPM and RPP in injured knee. The results of balance test showed control group that had better tilting and unsteadiness than ACL group (P< 0.05). Correlation of TTDPM and mean tilting measurement showed significant difference (r=0.52, P< 0.05, y=0.6075x – 0.2072). There was lower correlation between RPP and mean tilting (r=0.19, p> 0.05). There was poor correlation between muscle force and mean tilting (extensor: r=0.20; flexor: r=0.22; p> 0.05). Similarly, time from injury to test correlated poorly with both proprioception (TTDPM: r=0.02; RPP: r=0.132) and balance (mean tilting: r=0.06; unsteadiness: r=0.004).

Conclusion: Loss of proprioceptive sensibility had been proved by authors study, it was rarely indicated balance function in the ACL deficiency. In our study, we had proved positive correlation between proprioception and balance. We do believe poor proproception may cause of imbalance after rupture of ACL. In future rehabilitative program, balance training must be aided for restoration and recreation the proproceptive ability around knee joint.

Introduction: Patellar tendon is one of the main donor sites for graft. Postoperatively, during the healing procedure there are changes, which we recorded and combined them with the clinical image respectively. Material and Methods: During the period 1998–2001 in Sports Injury Unit, we operated for Anterior Cruciate Ligament insufficiency with autologous Bone Patellar Tendon Bone (BPTB) graft 265 patients. We used autologous BPTB graft from the middle third. We got near the two parts after taking the graft and we sewed very well the peritendon fascia. All patients, with few differentiations, followed the same rehabilitation program. Seventy -seven of them (44 men and 33 women ranging from 17 to 44 years -mean: 24,3 years), were imaged postoperative with MRI at specific intervals from the operation between 3–36 months. In the same time we checked the patients clinically. Results: No one study can answer which is the exact time of satisfying or complete healing. Our study shows elements of scar tissue in the middle third of patellar tendon which is decreasing given time. After the 12th month, the proportion between healthy and scar tissue changes and healthy tissue become dominant. But in some cases scar is still existing even after 36 months. The clinical problems such as anterior knee pain are not existed after the 8th postoperative month. Conclusion: In conclusion, we can say that “regeneration” and healing of patellar tendon occurs mainly during the first postoperative year, but it doesn’t stop after this time. So, we couldn’t recommend this donor site for revision reconstruction before the completion of one year postoperatively

Aim: To study the influence of anterior cruciate ligament (ACL) deficiency upon functional outcome after Coventry high tibial osteotomy, four to seven years after the surgery.

Method: One hundred and thirty-five patients (142 knees) each underwent a Coventry high-tibial osteotomy with staple fixation, performed by a single surgeon for medial arthrosis of the knee. During the study period, six patients (seven knees) proceeded to total knee arthroplasty and three patients died from unrelated causes. Nine patients were lost to follow-up. Comparisons were drawn between those patients with an intact ACL (ACLi) and those with ACL deficiency (ACLd).

Results: One hundred and seventeen patients (122 procedures) were available for review (100 males, median age 49 years, range: 29years to 70 years). The median follow up period was 64 months (range 37 to 80 months). The ACLd group was significantly younger (median age was 44 versus 51, p< 0.05) and reported significantly less pain and difficulty with stairs, shopping and rising to stand than the ACLi group. Seventy-eight percent of ACLd patients underwent previous surgical procedures on the affected knee. Ninety-six percent of the ACLd group and 89% of the ACLi group were either enthusiastic or satisfied with the outcome of the surgery. The mean Knee Society Score was 83 and 79 (respectively). All six revisions of the knee arthroplasties were in the ACLi group.

Conclusions: High tibial osteotomy was performed at a younger age for those patients with an absent anterior cruciate ligament. These patients had a subjectively better functional medium-term outcome, despite having had a greater number of surgical procedures prior to the osteotomy and having an ACL-deficient joint.

Tears of the posterior horn of the menisci often call for arthroscopic surgery to the medial or lateral compartments of the knee. In osteoarthritis knees, or when there is anterior cruciate ligament deficiency or joint tightness, using conventional anterolateral and anteromedial portals can be difficult. This is so also in very large adult knees. There is a risk of iatrogenic damage to the articular surfaces and structures of the knee. The establishment of an accessory medial and/or lateral portal for instrumentation makes it easy and safe to perform arthroscopic surgery to the posterior medial and/or lateral compartments. The author used this technique in 103 patients in whom access to the posterior compartments was problematic. The simple but effective technique is particularly useful for the inexperienced surgeon or arthroscopist in training

We performed a prospective, double-blind, randomised, clinical trial to investigate the efficacy of two regimes of rehabilitation for knees with anterior cruciate ligament deficiency (ACLD). Fifty ACLD patients were randomly allocated to one of two treatment groups: a programme of muscle strengthening (T) or a programme designed to enhance proprioception and improve hamstring contraction reflexes (P). An indirect measure of proprioception, the reflex hamstring contraction latency (RHCL), and a functional scoring system were used to record the status of the knee before and after the 12-week course of physiotherapy. Sagittal knee laxity was also measured. There was improvement in mean RHCL and in the mean functional score in both groups after treatment. The improvement in group P was significantly greater than that in group T. There was no significant change in joint laxity after treatment in either group. In both groups there was a positive correlation between improvement in RHCL and functional gain

We examined the menisci in 47 patients at the time of anterior cruciate ligament reconstruction. Twenty-one patients had abnormal menisci at a mean of 34 months after injury, but there was no difference between the Lysholm scores of patients with intact or damaged menisci. Eleven patients had a new meniscal injury between reconstruction and review at a mean of six years later; only 15 patients had both menisci intact nine years after injury. If pivot shift had been cured, the incidence of meniscal injury was reduced, but remained higher than normal. If pivot shift returned after reconstruction there was a significantly higher incidence of meniscal injury. Meniscal lesions appear to be the result of instability and not the cause.

The lateral substitution reconstruction operation described by MacIntosh has been evaluated in 27 patients with chronic anterior cruciate ligament deficiency of the knee. The results, at an average of 11.3 years after operation, have been assessed by a scoring system which allocates a maximum of 25 points each for function and for clinical evaluation. Emphasis was placed on subjective giving way and objective evidence of a positive anterior drawer sign and a positive lateral pivot shift test. A score of 46 to 50 was classified as excellent, 41 to 46 as fair, and less than 41 was a poor result: 52% scored excellent, 26% fair and 22% were poor. Most of those with poor results had had evidence of osteoarthritis at the time of operation. Despite the recorded scores, no less than 75% of the patients at long-term follow-up were subjectively improved, and able to maintain an active life style

Thirty-five patients who had been surgically treated for major symptomatic isolated chronic anterior cruciate ligament deficiency by lateral extra-articular reconstruction alone were reviewed at an average of five years after operation. Seventy-seven per cent of patients reviewed were improved subjectively, and 83% of patients who were examined had objective evidence of only minor instability or none at follow-up. However, only a few patients had "normal" knees and many continued to have minor symptoms of instability with some restriction of activity. Most of the unsatisfactory results were in patients with significant chondral pathology at the time of reconstruction. While an extra-articular pivot-shift repair did not correct all the symptoms and signs completely, most patients were improved subjectively and objectively, and there were few complications