The goal of this prospective, randomized study is the long-term evaluation of clinical, functional and MRI results after implant free press-fit ACL reconstruction performed using the bone-patella-tendon (PT) vs. hamstrings (HT) graft.

62 ACL insufficient patients without any concomitant sports injuries took part in a prospective, randomized study (31 PT, 31 HT). All procedures were conducted by the senior author between 10/98 and 09/99. Both surgical procedures were performed without any implants in press-fit technique with intra-operative x-ray control. At a mean FU time of 8.8 years 53 patients (28 PT, 25 HT) were examined by different scores, KT-1000, one leg hop test, kneeling- and knee-walking-test and isokinetic examination. We also performed bilateral MRI to determine the cartilage defects of both injured and uninjured knee. The results were compared with the intra-operative cartilage status. All MRIs were examined by an independent radiologist. For statistical analysis, the Student’s t-test and the chi²–test was used (p< 0.05).

On FU, neither the Tegner nor the Lysholm Score showed any significant results (Tegner 4.86 PT/5.29 HT, Lysholm 87.2/92.47). In the IKDC Score 84% of the PT and 94.4% of the HT group had a normal or nearly normal result (A or B) (p< 0.05), none had a severely abnormal result (D). The KT-1000 stability test and the pivot shift test showed no significance (KT-1000 side-to-side difference of < 3 mm 95.1%/91.7%; pivot glide in 28.0%/17.6%, no cross pivot shift). Isokinetic testing showed nearly normal quadriceps function in both groups (96.0%/96.4%), the hamstring strength was lower in the HT group without reaching statistical significance (100.3%/95.1%). The significant difference of the kneeling- and knee-walking-tests at 1 year FU persisted at year 9 (kneeling: 1.5/1.1; knee-walking: 1.72/1.14 (p< 0.05). Also, the single leg hop test was better in the HT group; however, the results were not significant (95.8%/99.1%).

The MRI results showed no difference in cartilage status grade 0–2 using the ICRS-protocol (69.6%/65.0%), the cartilage status of the uninjured knees showed in both groups a similar distribution. Tunnel measurements did not show any widening of the femoral tunnel (−11.3%PT, −0.4%HT). However, the tibial tunnels were clearly widened in both groups (+16.0%/+15.7%). Also, the Caton Index for patellar height (−0.073/−0.085) as well as the sagittal ACL angle (+1.96°/+2.37°), both compared to the uninjured knee, revealed no significant difference.

The implant free press-fit technique of ACL reconstruction using PT and HT grafts with anatomic graft placement is an excellent technique to preserve the cartilage and meniscal status without any significant differences between the operated and non-operated knees on FU. A significantly lower morbidity was noted in the HT group.

Background: Rehabilitation interventions following anterior cruciate ligament (ACL) reconstruction are key determinants affecting patient return to usual activity levels. Studies show that neuromuscular electrical stimulation (NMES) can counteract loss of strength in the quadriceps and is a beneficial enhancement to traditional forms of therapy.

Purpose: This study compared the effect of adding traditional NMES or garment integrated NMES to a standard postsurgery rehabilitation program. The effect on the strength of the femoral, the ability of patients to perform the single leg hop test (SLH), the shuttle run and other measures of proprioception were assessed.

Study Design: Prospective, randomised, single-blind study in patients undergoing rehabilitation following ACL reconstruction.

Methods: 69 patients were randomly assigned to one of three post-surgery rehabilitation treatment groups. All patients followed a standard rehabilitation program. Additionally, the PS group, (n=29), trained with a traditional NMES device and the KH group (n=33) trained with a garment integrated NMES device with multipath activation, (n=33). The control group (CO, n=34) performed only volitional maximum quadriceps muscle contraction. Functional tests were assessed at baseline and at 6 weeks, 12 weeks and 6 months post operatively.

Results: KH achieved statistically significant results over PS and CO for measurements of the isokinetic strength of the extensors of the injured leg at an angular velocity of 90°/sec in Nm/kg for time effect (p< 0.001), for treatment effect between the groups (p=0.044) and when examination times are considered (p< 0.05). Strength values for KH after 6 months were 30.2% higher than before the surgery, compared with 5.1% (PS) and 6.6% (CO). At an angular velocity of 180°/sec, KH achieves significance (p< 0.05) compared with CO at 12 weeks and 6 months, and compared with PS, achieved significance (p< 0.05) for the entire duration of the study. Strength values for KH were 27.8% higher than before the surgery compared with 5% (PS) and 3.7% (CO). For the SLH with the injured leg, KH achieved significantly better results for the entire period of the investigation compared with PS (p=0.038) and compared with CO (p=0.002). At the times of all three examinations after surgery KH achieved significantly better values (all p< 0.05) than PS CO. Patients in the KH group achieved full weight bearing and return to usual work activities 7 days before either the PS or CO groups.

Conclusions: The results of this study confirm that garment integrated NMES devices, designed for use by patients at home, are a beneficial addition to rehabilitation therapy following anterior cruciate ligament reconstruction, strengthening the quadriceps and accelerating recovery.

Aim: To compare two arthroscopic all-inside methods of meniscal refixation (Fast-FixTM by Smith and Nephew and Clearfix screw by Innovasive Devices Inc.) in a prospective study.

Method: 85 patients (mean age 32.7 years) having 87 meniscal repairs (Group C: 27 with Clearfix screw and Group F: 60 with Fast-FixTM) were included in the study.

Ligament stabilizing procedures were done in 46 (54,1%) patients who had ACL deficient knees (18 reconstructions in Group C and 38 in Group F). Only longitudinal lesions in the red/red or red/white zone were repaired. Follow-up averaged 12.3 months with a range from 6 to 25 months. Only longitudinal lesions in the red/red or red/white zone were repaired. Patients were evaluated using clinical examination, the “OAK” knee evaluation scheme and Magnetic Resonance Imaging. Criteria for clinical success included absence of joint line tenderness, swelling and a negative McMurray test.

Results: 10 out of 87 repaired menisci (11.5%) were considered as failures according to the above mentioned criteria (3 in Group C (11,1%) and 7 in Group F (11,6%)). According to the “OAK” knee evaluation scheme 68 patients (80.%) had excellent or good result (Group C: 20 (80%), Group F: 48 (80%)). Magnetic resonance imaging, however, showed persisting grade III or IV lesions in 41 (47,1%) of 87 patients with successful result (Group C: 13 (47%), Group F: 28 (46,6%)). Postoperatively, we had 10 complications (11,3%) which were not directly associated with the meniscal repair device (Group C: 2 (3,7%), Group F: 7 (11,6%)).

Conclusion: Risk factors for failure of meniscus repair are chronicity of injury, location of tear more than 3 mm from the meniscosynovial junction and meniscus side (medial). At all events, both methods seem to be very promising because of their efficasy, safety and ease to use.

Aim: To evaluate whether a guiding pin for a femoral tunnel could be positioned through the tibial tunnel into the center of the anatomical ACL attachment. Methods: 77 knees underwented arthroscopic ACL reconstruction with hamstrings. The femoral tunnel was drilled through an anteromedial portal at the center of the anatomic insertion at about 10.00 resp.14.00 position. Tibial tunnel (mean diameter 7.55 ± 0.54 mm) was drilled using a guide inserted at 90 degrees of knee flexion. Then, through the tibial tunnel, a 4mm offset femoral drill guide was positioned as close as possible to the femoral tunnel and a 2.5 mm guide wire was drilled. The position of the guide wire was photographed arthroscopically and the deviation was measured as the distance between the center of the femoral tunnel and the guide wire. Results: The mean deviation was 4.50 ± 1.54 mm (p = 0.00000004) In 74 knees (96.1%) the guidewire did not reach the femoral tunnel. Only in 3 knees it reached the superomedial edge of the femoral tunnel. No statistical relationship was found between deviation and tibial tunnel inclination angles or tibial tunnel diameter. Conclusions: Transtibial femoral tunnel drilling does not reach the anatomic site of the ACL insertion, even with larger tibial tunnels (for hamstring grafts up to 8.5 mm). Transtibial tunnel drilling should be replaced by drilling through the anteromedial portal at least for tunnels with diameters < 9 mm.

Aim: Goal of this prospective, randomized study is the functional evaluation of two different techniques of ACL reconstruction by using bone-patellatendon (BPT) vs. hamstrings (ST/G). Methods: 62 ACL-insufficient patients (33 women/29 men) took part in this study. 31 (mean:29,8 y.) underwent ACL-reconstruction using BPT (GI). 31 (mean: 34,2 y.) patients underwent ACL-reconstruction using ST/G (GII). Both techniques were press-fit and implant-free. We used accelerated rehabilitation for both groups. Patients were evaluated by IKDC, Lysholm and Tegner score, KT 1000, one-leg-hop, isokinetics, internal torque, kneeling- and knee-walking-test, 1 day preop., and 3, 6 and 12 months postop. Results: One year results of GII were according to IKDC-score (GII: 30 patients= A and B vs. GI: 24 patients= A and B), Lysholm-score (GII: 95,61 vs. GI: 90,87 (p=0.017) and Tegner-score (GII: 7,07 vs. GI: 6,61 (p=0.00)) better than those of GI. The Evaluation of the strength of hamstrings using isokinetics showed significant differences: GII: 90,34 Nm vs. 99,19 Nm in GI, (p=0.008). However results concerning the internal torque evaluation were not significant. The one-leg-hop comparing injured and non-injured leg resulted in significant differences: GII: 96% vs. GI: 91%, (p=0.012). Results in GI were significantly worse than in GII at kneelling and kneewalking-testings ((p=0.00)(p=0.00)). Conclusion: All scoring, clinical and functional evaluations, except isokinetic hamstring evaluation, showed a hamstring’s supperiority in ACL reconstruction.

Aim: To evaluate activity level and remaining symptoms concerning the donor site morbidity in patients having anterior cruciate ligament reconstruction (ACLreconstruction) with either ipsilateral or contralateral bone-patellar-tendon graft (BPT-graft). Methods: 100 patients aged from 18 to 49 years (mean 34) having an ACL-reconstruction with BPT-graft (with one bone block) from 1997 to 1999 were included in this study. In 52 of them a BPT-graft from the ipsilateral side was used (Group I). In 48 the contralateral BPT was used (Group II). A questionaire, including Cincinnati-, Tegner-activity score and special questions concerning persisting symptoms at the donor site, such as tenderness, numbness, kneeling pain and knee-walking pain, was sent to all patients. Results: The average Cincinnati Scoring was 85,2 in Group I and 86,3 in Group II. There was no statistical significance in Tegner scoring between the two groups. In Group I, 37,5% of the patients refered local tenderness, 59,6% kneeling pain and 82,65% knee-walking pain. According to contralateral leg in Group II, 37,5% of the patients refered local tenderness, 52% kneeling pain and 62,5% knee-walking pain vs. 8,3%, 25% and 25% respectively in the ACL reconstructed knee. Conclusions: This study showed that there are no benefits if the contralateral BPT graft is used, because all symptoms concerning donor site morbidity are shifted from the injured into the healthy knee if the graft is taken from the contralateral side.

Aim: To compare the donor site morbidity after anterior cruciate ligament (ACL) reconstruction using ipsilateral and contralateral bone-patellar-tendon (BPT) autograft.

Patients and Method: 100 patients underwent ACL- reconstruction with autologous BPT graft between 1997 and 1999. ACL-reconstruction was performed using ipsilateral (n= 52) and contralateral (n= 48) BPT-autograft. The average follow-up was 39,2 months. Donor site morbidity was evaluated by using a questionaire, computerised historical data, KT-2000 measurments, Cincinnati- (CKS) and Tegner-Score.

Results: KT-2000 evaluation showed an average side to side difference of 0,6 mm in both groups. There were no significant differences between the two groups concerning CKS or Tegner-Score. In the ipsilateral donor knee, 59,6% of the patients had local tenderness, 69,2% kneeling-pain, 76,9% knee-walking-pain and 75% numbness. In the contralateral donor knee, 58,3% of the patients had local tenderness, 70,8% kneeling-pain, 70,8% knee-walking-pain and 85,4% numbness. In the ACL reconstructed knee 6,3% had local tenderness,6,3% kneeling-pain, 10,4% knee-walking-pain and 64,6% numbness.

There was one rupture of the patellar tendon and one patient with chronic patellar tendinitis.

Conclusion: The contralateral BPT graft appears to present no advantage over the ipsilateral as all symptoms concerning donor site morbidity are shifted from the injured into the healthy knee and return to activity is not more rapid.

Aim: Our aim was to evaluate the accuracy and reliability of both MRI and CT in estimating the patello-femoral alignement with the TT/TG (tibial tuberosity/trochlear groove) distance in 14 healthy probants.

Method: The TT/TG distance has been estimated in 28 healthy knees of 14 probants, 8 women and 6 men (age: 24 – 42) with a) MRI in an Esaote Arthroscan 0,2 Tesla Tomographer and b) CT in a General Electric Tomographer. This parameter was estimated in both imaging devices, first by overprojecting a tibial axial image through the tibial tuberosity onto an axial image through both femoral condyles and then by measuring the distance between the deepest point of the trochlear groove and the most prominent point of the TT. The parameter has been estimated twice by 3 well trained independent observers. The statistical evaluation was done with an unifactorial analysis of variance (ANOVA).

Results: Our results showed a good reproducibility (> 95%) of the TT/TG measurement in both methods: The intraobserver reliability was in CT, 0,008 ± 0,005mm and in MRI 0,03 ± 0,0017mm respectively. The interob-server reliability was 0,046 for the CT and 0,66 for the MRI. Interesting was that the average value of TT/TG by measuring with MRI (14 mm) was 3 mm less than the one measured with CT (17mm).

Conclusion: We concluded that in spite of the difference of the average values between MRI and CT the evaluation of the TT/TG parameter by means of MRI could be a good method for estimating this parameter thus avoiding radiation uptake.

Introduction: The goal of this prospective, randomized study is the functional evaluation of two different techniques of ACL reconstruction by using the bone-patella tendon (BPT) vs. hamstrings (ST/G).62 ACL-insufficient patients without any concommitent sport injuries took part in a prospective randomized study.

Material and Methods: Eighteen men and 13 women underwent ACL-reconstruction with BPT graft (Group I) with average age 29,87 (16–46) years. 31 patients (16 women and 15 men) with average age 34,23 (16–55) years underwent ACL-reconstruction using a quadrupled hamstrings graft (Group II). Both techniques were performed by using a press-fit and implant-free technique. We used the same accelerated rehabilitation protocol for both groups. The patients were evaluated by IKDC, Lysholm and Tegner scoring systems, KT 1000, one leg hop, isokinetics, internal torque, kneeling and knee walking test, 1 day preoperatively (VU), and 3 (NU I), 6 (NU II) and 12 months (NU III) postoperatively.

Results: One year postop.the results of Group II (30 patients classified as A and B) were according to IKDC scoring system better than those in Group I (Group I: 24 patients classified as A and B). We had similar results according to Lysholm-scoring evaluation (Group 11:95,61 points vs. 90,87 in Group I (p=0.017)) and Tegner-scoring (Group II: 7,07 vs. 6,61 in Group I (p=0.00)). According to the KT 1000 stability evaluation, there was no statistical significant difference between injured and uninjured knees in both groups. The evaluation of the strength of the hamstrings by isokinetics in both groups showed statistical significant differences (Group II: 90,34 Nm vs. 99,19 Nm in Group I, (p=0.008)). However, our results concerning internal torque evaluation were not statistical significant. The evaluation of one leg hop by comparing injured and non-injured leg showed a significant difference between group II and group I (Group II: 96% vs. 91% in Group I, (p=0.012)). We had worse results in Group I vs. Group II at kneelling and knee-walking-testings ((p=0.00)(p=0.00)), concerning the anterior knee pain.

Conclusion: From our results concerning IKDC, Lysholm, Tegner, kneeling and knee walking tests it seems that hamstrings can be recommended for ACL reconstruction. The isokinetic evaluation of hamstrings showed a statistical significant deficiency compaired to the BPT-group. But this result could not be confirmed with the internal torque evaluation and “one leg hop”-testing.

Aim of the study: To evaluate whether additional aperture fixation to distal fixation (two-point fixation or 2P) may diminish tibial tunnel enlargement compared to distal fixation alone (one-point fixation or1P).

Methods: Two groups of patients were evaluated. In group 1P (44pts.) the grafts were fixed on the tibial side, using two 4 mm Mersilene tapes tied over a 10 mm bone bridge created in the anterior cortex. In group 2P, an additional fixation, using 1 absorbable cross pin in 27 pts. and 2 absorbable cross pins (Rigid fix, Mitek) in 24 pts., was performed. AP and lateral radiographs as well as patients evaluation were performed 3, 6 and 12 months post-op. Tibial tunnel size was measured at the widest diameter in both AP and lateral radiographs.

Results: Tunnel enlargement occurred in both groups at 3 months post-op, but not thereafter. In the lateral radiographs, tunnel enlargement was significantly less in group 2P compared to group 1P (p< 0.05). No statistical relationship was found between tunnel enlargement and gender, age, IKDC, and KT 1000 side-to-side difference.

Conclusion: Additional tibial graft fixation with cross-pins seems to diminish tibial tunnel enlargement in the sagital plane. This may be explained by the fact that the cross pins inserted in the coronal plane, reduce tibial graft movements mainly in the sagital plane. The study supports the hypothesis that tibial graft micro-movements during the period of tendon healing to bone (up to 3m) play a role in tibial tunnel enlargement after ACL reconstruction using hamstrings.