To determine the relationship between advancing months from ACL rupture and the incidence of intra-articular meniscal and chondral damage. From a prospectively collected database 5086 patients undergoing primary ACL reconstruction, using hamstring graft, carried out between January 2000 and August 2010 were identified. Data collected included the interval between injury and surgery, type and location of meniscal tears (requiring meniscectomy) and location and severity of chondral damage (ICRS grading system). Patients were grouped according to time interval and age. The median time from ACL injury to ACL reconstruction was 3 months (range 0.25 to 480). Overall, an increasing incidence of medial meniscal injury and chondral damage occurred with advancing chronicity of ACL deficiency. The incidence of medial meniscal injury requiring meniscectomy increased from 18% of patients undergoing ACL reconstruction within 4 months of injury to 59% of patients if ACL reconstruction was delayed more than 12 months (p<0.001). The incidence of lateral meniscal tears did not increase significantly over time. The increasing incidence of secondary pathology with advancing chronicity was more pronounced in the younger age groups. The risk of a medial meniscal tear requiring resection was significantly less if surgery was performed before 5 months in the <17 years group (Odds Ratio 2) and 17–30 years group (OR 1.9), but less so in the 31–50 years group (OR 1.5) and >50 years group (OR 1.5). Advancing age was associated with a greater incidence of chondral damage and medial meniscal injury, but not lateral meniscal injury. Males had a greater incidence of lateral meniscal tears (34% vs. 20%), but not medial (28% vs. 25%) or chondral damage (35% vs. 36%), compared to females. The incidence of chondral damage and medial meniscal tears increases with advancing time after ACL injury. Particularly in younger patients, ACL reconstruction should be performed within 4 months of ACL injury in order to minimise the risk of irreversible damage to meniscal and chondral structures

The purpose of this study is to assess the long term results of combined ACL reconstruction and unicompartmental knee replacements (UKR). These patients have been selected for this combined operation due to their combination of instability symptoms from an absent ACL and unicompartmental arthritis. Retrospective review of 44 combined UKR and ACL reconstruction by a single surgeon. Surgeries included both medial and lateral UKR combined with either revision ACL reconstruction or primary ACL reconstruction. Patient reported outcomes were obtained preoperatively, at one year, 5 years and 10 years. Revision rate was followed up over 13 years for a mean of 7.4 years post-surgery. The average Oxford score at one year was 43 with an average increase from pre-operation to 1 year post operation of 15. For the 7 patients with 10 year follow up average oxford score was 42 at 1 year, 43 at 5 years and 45 at 10 years. There were 5 reoperations. 2 for revision to total knee arthroplasty and 1 for an exchange of bearing due to wear. The other 2 were the addition of another UKR. For those requiring reoperation the average time was 8 years. Younger more active patients presenting with ACL deficiency causing instability and unicompartmental arthritis are a difficult group to manage. Combining UKR and ACL reconstruction has scant evidence in regard to long term follow up but is a viable option for this select group. This paper has one of the largest cohorts with a reasonable follow up averaging 7.4 years and a revision rate of 11 percent. Combined unilateral knee replacements and ACL reconstruction can be a successful operation for patients with ACL rupture causing instability and unicompartmental arthritis

The treatment of medial knee osteoarthritis (OA) in conjunction with anterior knee laxity is an issue of debate. Current treatment options include knee joint distraction, unicompartmental knee replacement (UKR) or high tibial osteotomy with anterior cruciate ligament (ACL) reconstruction or total knee replacement. Bone-conserving options are preferred for younger and active patients with intact lateral and patello-femoral compartment. However, still limited experience exists in the field of combining medial UKR and ACL reconstruction. The aim of this study is to retrospectively evaluate the results of combined fixed-bearing UKR and ACL reconstruction, specifically with regard to patient satisfaction, activity level, and postoperative functional outcomes. The hypothesis was that this represents a safe and viable procedure leading to improved stability and functional outcome in patients affected by isolated unicompartmental OA and concomitant ACL deficiency. Fourteen patients with ACL deficiency and concomitant medial compartment symptomatic osteoarthritis were treated from 2006 to 2010. Twelve of them were followed up for an average time of 7.8 year (range 6–10 years). Assessment included Knee Osteoarthritis Outcome Score (KOOS), Oxford Knee score (OKS), American Knee Society scores (AKSS), WOMAC index of osteoarthritis, Tegner activity level, objective examination including instrumented laxity test with KT-1000 arthrometer and standard X-rays. Wilcoxon test was utilized to compare the pre-operative and follow-up status. Differences with a p value <0.05 were considered statistically significant. KOOS score, OKS, WOMAC index and the AKSS improved significantly at follow-up (p < 0.05). There was no clinical evidence of instability in any of the knees as evaluated with clinical an instrumented laxity testing (p < 0.05). No pathologic radiolucent lines were observed around the components. In one patient a total knee prosthesis was implanted due to the progression of signs of osteoarthritis in the lateral compartment 3 years after primary surgery. UKR combined with ACL reconstruction is a valid therapeutic option for young and active patients with a primary ACL injury who develop secondary OA and confirms subjective and objective clinical improvement up to 8 years after surgery

Young, active patients with end-stage medial osteoarthritis (OA) secondary to anterior cruciate ligament (ACL) deficiency present a treatment challenge for surgeons. Current surgical treatment options include high tibial osteotomy (HTO) with or without ACL reconstruction, unicompartmental knee arthroplasty (UKA) with ACL reconstruction, and total knee arthroplasty (TKA). A recent systematic review reported a much higher rate of complications in HTO combined with ACL reconstruction than with UKA-ACL (21.1% vs 2.8%), while survivorship between the two procedures was similar. UKA offers several advantages over TKA, namely faster recovery, lower blood loss, lower rate of postoperative complications, better range of motion, and better knee kinematics. However, UKA has classically been contraindicated in the presence of ACL deficiency due to reported concerns over increased incidence aseptic loosening tibia. However, as a majority of patients presenting with this pathology are young and active, concerns about implant longevity with TKRA and loss of bone stock have arisen. As a result, several authors have described combining ACL reconstruction with medial UKA to decrease the tibiofemoral translation-related stress on the tibial component, thereby decreasing aseptic loosening-related failures. The purpose of this study was to compare the functional outcomes and survivorship of combined medial UKA and ACL reconstruction (UKA-ACL) with those of a matched TKA cohort. We hypothesized that UKA-ACL patients would have better functional outcomes than TKA patients while maintaining similar survivorship. Material and Methods. We conducted a case-control study establishing UKA-ACL as the study group and TKA as the control group by a single senior surgeon between October 2005 and January 2015. We excluded patients who were over the age of 55 at the time of surgery and those who had less than two-year follow-up. A total of 21 patients (23 knees) were ultimately included in each group. Propensity matching was for age-, sex-, and body mass index (BMI)-matched control group of TKA cases. Surgical technique. UKA-ACL. This patient's had an arthroscopy to allow for tunnel preparation in the standard fashion and then the graft was passed and fixed on the femoral side. An MIS medial incision was then made to allow for insertion of the Oxford mobile-bearing unicompartmental prosthesis (Zimmer Biomet, Warsaw, IN). Primary choice of ACL graft was autogenous ipsilateral semitendinosus and gracilis tendons, which was available I and 6 of the cases were revision from previous Gore-Tex synthetic ligament reconstruction. Results. Preoperatively, baseline questionnaires demonstrated that the TKA group had scored significantly lower on the symptom subscore of the KOOS. There was no difference between the groups in the rest of the KOOS subscores, (the UCLA, and the Tegner. All scores (UCLA, and Tegner – TBC post stats) improved significantly after surgery in both groups. Improvement in each subscore of the KOOS surpassed the minimal clinically important difference in both the UKA-ACL and TKA groups. At latest follow-up, there was no significant difference between the groups on the KOOS, UCLA or Tegner, showing that our UKA-ACL patients fared as our TKA patients. This confirms that UKA-ACL is an important tool in dealing with young patients with end-stage medial OA and ACL deficiency and offers an option that leads to less bone loss and potentially easier future revision. For any figures or tables, please contact authors directly

Background. The cruciate ligaments are important structures for biomechanical stability of the knee. For total knee arthroplasty (TKA), understanding of the exact function of the (PCL) and anterior (ACL) cruciate ligament during walking is important in the light of recent designs of bicruciate TKAs. However, studies evaluating in vivo function of the PCL during daily activities such as walking are scarce. We aimed to assess the role of the PCL during gait by measuring kinematics and kinetics of individuals with PCL deficiency and compare them with individuals with ACL deficiency and healthy young adults. Methods. Individuals with unilateral PCL deficiency (PCLD; n=9), unilateral ACL deficiency (n=10) and healthy young adults performed (n=10) 10 walk trials (5 for each leg) in which they walked over a force platform. Motion analysis (Vicon Motion Capture System) was used to calculate joint angles and internal moments around the knee, hip and ankle in the sagittal plane. Joint angles and moments of the injured knee (in PCLD and ACLD) or left knee (in HYA) were compared between groups at weight acceptance, mid-stance and push-off phases (see Fig. 1). Clinical assessment included passive knee laxity (Kneelax) for anterior (in 20–30° knee flexion) and posterior tibia translation (in 70–90° knee flexion) and Lysholm questionnaires. Results. Lysholm scores were significantly lower in PCLD and ACLD individuals compared to HYA (p's ≤ .001). PCLD subjects had more passive anterior (p = .001) and posterior tibia translation (p = .041) compared to HYA, but no significant differences were found in both directions between ACLD and HYA (p's > .10). During gait, knee angles at weight acceptance, late stance and around toe-off were not significantly different between the PCLD and HYA, and between ACLD and HYA (all p's > .06). However, the knee extension moment during mid-stance was significantly lower in the PCLD group when compared to the HYA group (p = .001; Fig. 2). Interestingly, the knee moment in the PCLD group remained positive (i.e. extension moment) throughout the stance phase, whereas HYA and ACLD groups created a substantial flexion moment around the knee at this instant. We did not observe any significant differences in hip and ankle joint angles and moments between groups. Discussion. We observed a difference in gait pattern in individuals with PCL deficiency compared to HYA, that was confined to an absence of knee flexion moments during the mid-stance phase. We hypothesize that this difference reflects a compensation strategy employed by individuals with PCL deficiency to avoid external knee (hyper)extension moments. Gait adaptations related to PCL deficiency might also have implications for design of total knee prosthesis and calls for careful evaluation of gait patterns after TKA with a specific focus on the role of the PCL. For any figures or tables, please contact the authors directly

Purpose. Patients with anterior cruciate ligament (ACL) deficiency and symptomatic medial compartment osteoarthritis (OA) present a challenge in management. These are often younger than typical primary OA patients and aspire to remain athletically active beyond simple ADLs. Combined ACL reconstruction and valgus tibial osteotomy (ACLHTO) is a well documented surgical option for patients deemed wither too young or too active for total knee arthroplasty. Unicompartmental knee arthroplasty (UKA) is an established surgical treatment for symptomatic medial osteoarthritis of the knee refractory to conservative management. A commonly cited contraindications is symptomatic ACL deficiency because of previous reports detailing premature failure through loosening of the tibial component. Improved results and endoscopic ACL reconstructive procedures have led to an enticing concept of combining ACL reconstruction with medial unicompartmental knee arthroplasty (ACLUKR) for those ACL-deficient medial osteoarthritic (OA) knees. We sought to compare the outcomes in 2 cohorts of patients who underwent either ACLHTO or ACLUKR for this clinical problem. Method. Patients presenting with symptomatic bone on bone medial compartment OA and concomitant ACL deficiency (clinical or asymptomatic) were evaluated for surgery after exhausting non operative management. Patients who were under 40 or had plans to return to high impact loading sports and/or who had more moderate OA were offered combined ACL – medial opening wedge tibia osteotomy as a surgical procedure of choice. Patients were considered for combined ACL Oxford replacement if they were primarily seeking pain relief and were not engaged or aspiring to return to high impact or pivoting sports. All cases but one were concurrent ACL with either HTO or UKR with autogenous hamstring grafts used in all but 2 cases. Results. Thirty of 34 consecutive cases were available for follow-up for a rate of 88%. The median ages for 14 cases of ACLUKR was 51 (range 43 60) whereas 16 patients with ACLHTO had median age 43.4 (range 32 −59). Median FU was 4.65 yrs with minimum 2 year follow up (range 2–8.3). Three of the cases were revision ACL cases all from previous Gore-Tex reconstructions. All but the first patient had concomitant ACL and Oxford unicompartmental knee replacement at 1 surgical sitting and are the subject of this report. The first patient had an autogenous patella bone tendon bone graft performed 6 months prior to the UKA. There were similar change scores for patients in both groups. For ACLUKR, WOMAC pain improvements from 48.1 10.2 SD preoperatively to 79.0 17 SD postop. For ACLHTO, WOMAC improvements from 55.1 13.2 SD preoperatively to 85.0 17 SD postop. To date there have been no cases of infection or bearing dislocation in the ACLUKR group. One patient in the ACLHTO group was revised to TKR for ongoing pain and postoperative flexion contracture. Patient activities ranged from ambulation to vigorous hiking, tennis, and downhill skiing in the UKR group whereas a few in the ACLHTO group were also running mid distances. Overall satisfaction was similar in both groups. Conclusion. ACL reconstruction can safely be combined with medial UKR. The procedure has been used in younger patients with a view toward bone preservation while anticipating need for future revision. Both cohorts showed similar improvements and can be considered. The choice should be geared toward patient athletic demand. While short term results are encouraging though longer term data are necessary to thoroughly evaluate the role of this procedure in patients with medial compartment osteoarthritis and ACL deficiency

The options for treatment of the young active patient with isolated symptomatic osteoarthritis of the medial compartment and pre-existing deficiency of the anterior cruciate ligament are limited. The indications for the unicompartimental knee prosthesis are selective. Misalignment femoral-tibia, varo-valgus angle more than 7°, over-weight, and knee instability were considered to be a contraindication. The potential longevity of the implant and levels of activity of the patient may preclude total knee replacement, and tibial osteotomy and unicompartmental knee arthroplasty are unreliable because of the ligamentous instability. Therefore, we combined reconstruction of the anterior cruciate ligament first and unicompartmental arthroplasty of the knee. We included in this study six patients, three males and three female, mean age 53.6 years, that presented only osteoarthritis of medial femoral condyle and ACL deficiency. In the first group included 2 patients, we performed arthroscopy ACL reconstruction with hamstring and unicompartimental knee prosthesis one-step, and in the second group included 4 patients, we performed the same surgical procedure in two-step. The clinical and radiological data at a minimum of 1.5 years at follow-up. We evaluated all patients with KOOS score, and IKDC score. At the last follow-up, no patient had radiological evidence of component loosening, no infection, no knee remainder instability. The subjective and objective outcome assessed with the scale documented satisfactory average results, both in patients of first group and in those of second group. ACL deficiency induced knee osteoarthritis for incorrect knee biomechanics, and all patients could be submit a total knee replacement. What method for preventing it? This combined surgical treatment seems to be a viable treatment option for young active patients with symptomatic arthritis of the medial compartment, in whom the anterior cruciate ligament has been ruptured. Future developments and more data are necessary for standardised surgical approach

Introduction. The management of degenerative arthritis of the knee in the younger, active patient presents a challenge to the orthopaedic surgeon. Surgical treatment options include: high tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The aim of this study was to examine the long-term survival of closing wedge HTO in a large series of patients up to 19 years after surgery. Methods. Four hundred and fifty-five consecutive patients underwent lateral closing wedge HTO for medial compartment osteoarthritis (MCOA) between 1990 and 2001. Between 2008-2009, patients were contacted via telephone. Assessment included: incidence of further surgery, current body mass index (BMI), Oxford Knee Score, and British Orthopaedic Association (BOA) Patient Satisfaction Scale. Failure was defined as the need for revision HTO or conversion to UKA or TKA. Survival analysis was completed using the Kaplan-Meier method. Results. High tibial osteotomy survival was determined on 413 patients (91%) and, of the 397 patients who were alive at the time of final review, 394 (99%) were contacted for follow-up via telephone interview. The probability of survival for HTO at 5, 10 and 15 years was: 95%, 79% and 56% respectively. Multivariate regression analysis showed that age < 50 years (p=0.001), BMI < 25 kg/m. 2. (p=0.006) and ACL deficiency (p=0.03) were associated with better odds of survival. Mean Oxford Knee Score was 40/48 (range 17-48). Overall, 85% of patients were enthusiastic or satisfied and 84% would undergo HTO again at mean 12 years follow-up. Conclusion. High tibial osteotomy can be effective for periods longer than 15 years. However, results do deteriorate over time. Age < 50 years, normal BMI and ACL deficiency were independent factors associated with improved long-term survival of HTO

INTRODUCION. Appropriate soft tissue balance is an important factor for postoperative function and long survival of total knee arthroplasty(TKA). Soft tissue balance is affected by ligament release, osteophyte removal, order of soft tissue release, cutting angle of tibial surface and rotational alignment of femoral components. The purpose of this study is to know the characteristics of soft tissue balance in ACL deficient osteoarthritis(OA) knee and warning points during procedures for TKA. METHODS. We evaluated 139 knees, underwent TKA (NexGen LPS-Flex, fixed surface, Zimmer) by one surgeon (S.A.) for OA. All procedures were performed through a medial parapatellar approach. There were 49 ACL deficient knees. A balanced gap technique was used in 26 ACL deficient knees, and anatomical measured technique based on pre-operative CT was used in 23 ACL deficient knees. To compare flexion-extension gaps and medial- lateral balance during operations between the two techniques, we measured each using an original two paddles tensor (figure 1) at 20lb, 30lb and 40lb, for each knee at a 0 degree extension and 90 degree flexion. We measured bone gaps after removal of all osteophytes and cutting of the tibial surface, then we measured component gaps after insertion of femoral components. Statistical analysis was performed by t-test with significant difference defined as P<0.05. RESULTS. (1) There were 90 ACL remaining knees and 49 deficient knees. Each group's preoperative FTA was 184±4.4 degrees, 187±6.3 degrees, postoperative FTA was 174±2.7 degrees, 173±3.1 degrees, preoperative knee extension was −12.8±7.5 degrees, −14.5.±3.1 degrees, flexion was 122.4±13.7 degrees, 110.7±20.2 degrees, post-operative β angle was, 88.1±2.5 degrees, 88.5±2.5 degrees. Comparing bone gap, medial gap and lateral-medial gap at a 30lb flexion were significantly different(P<0.05). (2) Comparing component gaps using modified gap techniques (group G) and anatomical techniques (group A) in ACL deficient knees, extension of medial and lateral gaps at 30lb and 40 lb in anatomical technique was bigger. The lateral-medial gap at 30lb was bigger in anatomical techniques. (P<0.05). DISCUSSION. The present results showed that ACL deficient OA knee were looser at medial side compared with ACL remaining OA knees. It indicates that we performed medial rerelease carefully in ACL deficient TKA. When we used gap techniques, medial loosening caused malposition of femoral components, and when we used anatomical techniques, extension gap was bigger than using gap techniques because generally smaller femoral components were chosen. It is reported that lateral gaps are bigger in severe varus deformity OA than slightly deformed OA knees and the soft tissue on the medial side is not shorter. It is also reported the correlation of lateral thrust with ACL deficiency and the progression OA, and when OA is developed, lateral side becomes loose. Our study indicated that ACL deficient OA knee progress rotational instability, in addition to antero-posterior instability, and subsequent medial loosening and development of medial osteophyte. Medial preserving gap technique is recommended

INTRODUCTION. In native knees the anterior cruciate ligament (ACL) plays a major role in joint stability and kinematics. Sacrificing the ACL in contemporary total knee arthroplasty (TKA) is known to cause abnormal knee motion, and reduced function. Hence, there is growing interest in the development of ACL retaining TKA implants. Accommodation of ACL insertion around the tibial eminence is a challenge with these designs. Therefore, a reproducible and practical test setup is necessary to characterize the strength of the ACL/bone construct in ACL retaining implants. Seminal work showed importance of loading the ACL along its anatomical orientation. However, prior setups designed for this purpose are complex and difficult to incorporate into a standardized test for wide adoption. The goal of this study was to develop a standardized and anatomically relevant test setup for repeatable strength assessment of ACL construct using basic force-displacement testing equipment. METHODS. Cadaver knees were positioned with the ACL oriented along the loading axis and being the only connection between femur and tibia. 15° knee flexion was selected based on highest ACL tensions reported in literature. Therefore, the fixtures were adjusted accordingly to retain 15° knee flexion when the ACL was tensioned. The test protocol included 10 cycles of preconditioning between 6N and 60N at 1mm/s, followed by continuous distraction at 1mm/s until failure (Fig. 1). Eleven cadaveric knees (4 male, 7 female; 70.9 yrs +/−13.9 yrs) were tested using this setup to characterize a baseline ACL pullout strength (peak load to failure) in native knees. RESULTS. The average ACL pullout strength was 935.6N +/−327.5N with the extremes ranging from a minimum of 346N to a maximum of 1425N. There were five failure modes observed: [1] ACL avulsion from the femur with bony attachment (one knee), [2] ACL pull-off from the femur w/o bony attachment (two knees), [3] ACL tear (three knees), [4] ACL pull-off from the tibia w/o bony attachment (one knee), [5] ACL avulsion from the tibia with bony attachment (three knees). One knee showed a combined failure mode of 2 & 4, meaning part of the ACL was pulled off the femur and part pulled off the tibia. CONCLUSION. There was a large variation in failure load between specimens. The knee with the minimum failure load had severe arthritis, osteophytes and signs of ACL deficiency. The average failure load (935.6N +/−327.5N) is in line with those published in literature for a comparable age group. This indicates that failure loads and modes obtained with more complex setups could be reproduced by using standard uniaxial load frames and simple fixtures. The failure modes in our experiment were evenly spread between mid-substance, and insertions (either femur or tibia). This test could be used as a standardized method to investigate the strength of the ACL complex following procedures such as ACL reconstruction, partial- and total knee arthroplasty. In particular, this setup provides a reliable mechanism for evaluation of the ACL-bone construct in bi-cruciate retaining (BCR) TKA, which is likely required for regulatory pathways

Purpose. The majority (73%) of orthopaedic surgeons in Canada prefer using semitendinosus-gracilis (STG) autograft for ACL reconstruction. However, there is large variation in tendon size between individuals which makes pre-operative estimation of graft size unpredictable. Inadequate graft size may require an alternative source of graft tissue that should be planned prior to surgery. The purpose of this study is to determine if clinical anthropometric data and MRI measurements of STG tendons can be used to predict hamstring graft size. Method. One-hundred and fourteen patients with ACL deficiency awaiting reconstruction using hamstring autograft were retrospectively evaluated. The following information was obtained from patient charts: height, weight, body mass index (BMI), age, and gender. Cross-sectional area (CSA) of gracilis (G) and semitendinosus (ST) tendons were determined from pre-operative MRI scans using NIH ImageJ analysis software. Actual STG graft diameters were obtained from operative reports. Correlations between patient height, weight, BMI, age, gender, ST-CSA, G-CSA, STG-CSA and intraoperative graft size were calculated to determine the association between these variables. Multiple stepwise regression was performed to assess the predictive value of these variables to intraoperative graft diameter. In addition, three investigators with no radiological experience made independent measurements of the ST and G tendons to determine the inter-rater reliability (ICC) of MRI measurements. Results. All variables were independently correlated with intraoperative graft size (p<0.001). However, based on multiple stepwise regression analysis, only models including STG-CSA (r2=.212; p<.001); STG-CSA and sex (r2=.285; p<.001); and STG-CSA, sex and weight (r2=.294; p<.001) were found to be significant predictors of graft size (when co-variation in other factors was controlled). Inter-class correlation coefficients demonstrated very high agreement between raters for measurements of the ST, G and STG (.816, .827, .863, respectively). Conclusion. Measurement of tendon CSA from MRI images is very reliable. A model including STG-CSA, sex and weight was found to be strongly predictive of hamstring graft diameter for ACL reconstruction. This model may enhance our ability to predict adequate graft size and identify instances that other graft tissues may be a better option. The results of this study may improve pre-operative planning for ACL reconstruction