Between 1993 and 1994, 891 patients underwent primary anterior cruciate ligament (ACL) reconstruction. A total of 48 patients had undergone bilateral ACL reconstruction and 42 were available for review. These patients were matched to a unilateral ACL reconstruction control group for gender, age, sport of primary injury, meniscal status and graft type. At 15-year follow-up a telephone interview with patients in both groups was performed. The incidence of further ACL injury was identified through structured questions and the two groups were compared for the variables of graft rupture or further ACL injury, family history of ACL injury, International Knee Documentation Committee (IKDC) subjective score and activity level.

There were 28 male and 14 female patients with a mean age of 25 years (13 to 42) at the time of first ACL injury. Subsequent further ACL injury was identified in ten patients (24%) in the bilateral ACL reconstruction study group and in nine patients (21%) in the unilateral ACL reconstruction control group (p = 0.794). The mean time from bilateral ACL reconstruction to further ACL injury was 54 months (6 to 103). There was no significant difference between the bilateral ACL reconstruction study group and the matched unilateral ACL reconstruction control group in incidence of further ACL injury (p = 0.794), family history of ACL injury (p = 0.595), IKDC activity level (p = 0.514), or IKDC subjective score (p = 0.824).

After bilateral ACL reconstruction the incidence of graft rupture and subjective outcomes were equivalent to that after unilateral ACL reconstructions.

Cite this article: Bone Joint J 2013;95-B:798–802.

Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial (AM) and trans-tibial (TT) portal femoral tunnel placement techniques on the primary outcome of ACLR graft rupture. Adult patients (>18year old) who underwent primary ACLR between January 2011 – January 2018 were identified and divided based on portal technique (AM v TT). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables. 473 patients were analysed. Median age at surgery was 27 years old (range 18–70). A total of 152/473, (32.1%) patients were AM group compared to 321/473 (67.9%) TT. Twenty-five patients (25/473, 5.3%) sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odds for graft rupture was associated with the AM group, which trended towards significance (OR 2.03; 95% CI 0.90 – 4.56, p=0.081). Older age at time of surgery was associated with a lower odds of rupture (OR 0.92, 95% CI 0.86 – 0.98, p=0.014). There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. There was a trend towards higher rupture rates in the anteromedial portal group

Introduction. It has been contentious whether an anatomic double-bundle technique for anterior cruciate ligament reconstruction (ACLR)is superior to that of a single-bundle technique. It has been hypothesized in the literature that the double-bundle technique could provide function closer to that of the anatomical knee joint. The purpose of this study was to compare the long-term clinical outcomes after single-bundle ACLR versus double-bundle ACLR. We hypothesized that the double-bundle technique would not be superior to the single-bundle technique. Methods. A retrospective, non-randomized, matched-paired comparative study was performed. Patients undergoing primary anterior cruciate ligament reconstruction, using either a double-bundle or single-bundle technique, between 2003 and 2008 were included and matched 1:1. Matching included age, sex, BMI, time from injury to surgery, side of injury and type of sport. Patients who underwent revision procedures, multiligament reconstruction or other ACLR techniques were excluded. Patients were subsequently followed up, noting occurrence of graft rupture and any other complications. Results. A total of 1377 ACLRs were performed during the study period. Seven hundred and fifty-six patients were excluded, leaving 396patients to be included in the matching (198 matched pairs). Mean follow-up time was 176.7 +/− 7.7 months (range, 166–211 months). Overall, 40 patients (10.1%) suffered from a graft rupture which consisted of 22 patients (11.1%) in the single-bundle group and 18patients (9.1%) in the double-bundle group. A multivariate analysis was performed using the Cox model and demonstrated that graft failure had no significant association with the surgical technique (hazard ratio (HR), 0.857(0.457;1.609), p=0.6313). (Figure 1) Five patients (2.5%) in the single-bundle group and 7 patients (3.5%) in the double-bundle group underwent secondary surgery for cyclops syndrome(p=0.5637). Three patients (1.5%) in the single-bundle group and 2 patients (1.0%) in the double-bundle group underwent arthrolysis(p=0.6547). Seven patients (3.5%) in the single-bundle group underwent secondary meniscectomy compared to 6 patients (3.0%) in the double-bundle group (p=0.7630). Conclusion. Double-bundle ACLR is not superior to single-bundle ACLR at long-term follow up. Therefore, orthopaedic surgeons do not need to use a double-bundle technique when performing ACL reconstruction. For any figures or tables, please contact authors directly

After anterior cruciate ligament (ACL) rupture, reconstructive surgery with a hamstring tendon autograft is often performed. Despite overall good results, ACL re-rupture occurs in up to 10% of the patient population, increasing to 30% of the cases for patients aged under 20 years. This can be related to tissue remodelling in the first months to years after surgery, which compromises the graft's mechanical strength. Resident graft fibroblasts secrete matrix metalloproteinases (MMPs), which break down the collagen I extracellular matrix. After necrosis of these fibroblasts, myofibroblasts repopulate the graft, and deposit more collagen III rather than collagen I. Eventually, the cellular and matrix properties converge towards those of the native ACL, but full restoration of the ACL properties is not achieved. It is unknown how inter-patient differences in tissue remodelling capacity contribute to ACL graft rupture risk. This research measured patient-specific tissue remodelling-related properties of human hamstring tendon-derived cells in an in vitro micro-tissue platform, in order to identify potential biological predictors for graft rupture. Human hamstring tendon-derived cells were obtained from remnant autograft tissue after ACL reconstructions. These cells were seeded in collagen I gels on a micro-tissue platform to assess inter-patient cellular differences in tissue remodelling capacity. Remodelling was induced by removing the outermost micro-posts, and micro-tissue compaction over time was assessed using transmitted light microscopy. Protein expression of tendon marker tenomodulin and myofibroblast marker α-smooth muscle actin (αSMA) were measured using Western blot. Expression and activity of remodelling marker MMP2 were determined using gelatin zymography. Cells were obtained from 12 patients (aged 12–51 years). Patient-specific variations in micro-tissue compaction speed or magnitude were observed. Up to 50-fold differences in αSMA expression were found between patients, although these did not correlate with faster or stronger compaction. Surprisingly, tenomodulin was only detected in samples obtained from two patients. Total MMP2 expression varied between patients, but no large differences in active fractions were found. No correlation of patient age with any of the remodelling-related factors was detected. Remodelling-related biological differences between patient tendon-derived cells could be assessed with the presented micro-tissue platform, and did not correlate with age. This demonstrates the need to compare this biological variation in vitro - especially cells with extreme properties - to clinical outcome. Sample size is currently increased, and patient outcome will be determined. Combined with results obtained from the in vitro platform, this could lead to a predictive tool to identify patients at risk for graft rupture

There is no consensus for the appropriate surgical management of chronic ulnar collateral ligament (UCL) injuries of the thumb. A systematic review of Pubmed, MEDLINE, EMBASE and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-analysis (PRISMA) guidelines and formal protocol registered with PROSPERO. Two authors collated data from 10 studies that met strict inclusion criteria, using various surgical techniques in 131 thumbs. Results were heterogenous and metanalysis of results not possible. These data were, therefore, qualitatively assessed and synthesised. Bias was assessed using the ROBINS-I tool. Direct repair, reconstruction with free tendon or bone-tissue-bone grafts and arthrodesis all demonstrated favourable outcomes with Patient Reported Outcome Measures. Direct repair can be safely performed more than two months following injury, with a positive mean Disabilities of the Arm, Shoulder and Hand (DASH) score of 13.5 despite evidence of radiographic osteoarthritis. Arthrodesis should be considered in heavy manual laborers or those at risk of osteoarthritis as it provides significant reduction in pain (Mean Visual Analogue Score of 1.2) when compared to other methods. Free tendon grafting has been criticised for failure rates and poor functional grip strength, however collated analysis of 97 patients found a single graft rupture and mean grip strength of 97% (of the contralateral thumb). Bone-tissue-bone grafting was the least effective method across all outcome measures. Studies included were at high risk of bias, however, it can be concluded that delayed direct repair can be performed safely, while arthrodesis may benefit certain patient subgroups. New findings suggest poor efficacy of bone-tissue-bone grafts, but that free tendon grafting with palmaris longus are in fact safe with good restoration of grip strength. The optimal graft and configuration are yet to be determined for reconstructive methods

Aims. To evaluate graft healing of decellularized porcine superflexor tendon (pSFT) xenograft in an ovine anterior cruciate ligament (ACL) reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared with the preoperative measurements. Methods. A total of 12 sheep underwent unilateral single-bundle ACL reconstruction using pSFT. Two femoral fixation devices were investigated: Group 1 (n = 6) used cortical suspensory fixation (Endobutton CL) and Group 2 (n = 6) used cross-pin fixation (Stratis ST). A soft screw was used for tibial fixation. Functional recovery was quantified using force plate analysis at weeks 5, 8, and 11. The sheep were euthanized after 12 weeks and comprehensive histological analysis characterized graft healing at the graft-bone interface and the intra-articular graft (ligamentization). Results. The pSFT remodelled into a ligament-like structure and no adverse inflammatory reaction was seen. The ground reaction force in the operated leg of the Endobutton group was higher at 11 weeks (p < 0.05). An indirect insertion was seen at the graft-bone interface characterized by Sharpey-like fibres. Qualitative differences in tendon remodelling were seen between the two groups, with greater crimp-like organization and more aligned collagen fibres seen with Endobutton fixation. One graft rupture occurred in the cross-pin group, which histologically showed low collagen organization. Conclusion. Decellularized pSFT xenograft remodels into a ligament-like structure after 12 weeks and regenerates an indirect-type insertion with Sharpey-like fibres. No adverse inflammatory reaction was observed. Cortical suspensory femoral fixation was associated with more enhanced graft remodelling and earlier functional recovery when compared with the stiffer cross-pin fixation

Abstract. Introduction. Anterolateral procedures can reduce the risk of re-rupture after ACL reconstruction in high risk patients however, this effectiveness has never been evaluated in elite athletes. The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis in reducing revision rates in ACL reconstructions in elite athletes. Methodology. A consecutive cohort of elite athletes between 2005 and 2018 undergoing ACLR reconstruction with or without modified Lemaire lateral extra-articular tenodesis were analysed. A minimum of 2 years of follow-up was required. The association between the use of LET and ACL graft failure was evaluated with univariate and multivariate logistic regression models. Results. 455 elite athletes (83% male; 22.5±4.7 years) underwent primary ACL reconstruction with (n=117) or without (n=338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACL reconstruction reduced the risk of graft failure by 2.8 times with 16.5 athletes needing to be treated with LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (RR=0.325; p=.029) as compared to ACL reconstruction alone after controlling for age at ACL reconstruction and gender. Including graft type in the model did not significantly change the risk profile. Conclusion. The addition of LET in elite athletes undergoing primary ACL reconstruction reduced the risk of undergoing revision by 2.8 times

Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Cite this article: Bone Joint J 2023;105-B(7):723–728.

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females’ characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes.

Cite this article: Bone Jt Open 2024;5(2):94–100.

The choice of graft for anterior cruciate ligament reconstruction remains controversial. A systematic review was performed to compare bone-patella tendon-bone and 4-strand hamstring grafts. Medline (1966 onwards), EMBASE (1980 onwards) and the Cochrane database were searched retrieving 6312 possible articles but only 6 studies fulfilled all the inclusion criteria. To be included, the study had to be prospective, randomised or quasi-randomised, comparing 4SHS and central third BPTB autografts, inserted using an arthroscopically assisted technique and have a minimum 2-year follow up for all patients. These studies recruited 526 patients and 475 were followed for at least 2 years with 235 patients receiving a bone-patella tendon-bone graft and 240 receiving a 4-strand hamstring graft. Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased patellofemoral joint pain (p=0.09) with a patella tendon graft. With a 4-strand hamstring graft there is a greater loss of hamstring power (p=0.008) and a trend towards an increased chance of a pivot shift > 1 (p=0.12). There was no difference between the 2 groups in terms of lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications

The choice of graft for anterior cruciate ligament reconstruction remains controversial. A systematic review was performed to compare bone-patella tendon-bone and 4-strand hamstring grafts. Medline (1966 onwards), EMBASE (1980 onwards) and the Cochrane database were searched retrieving 6312 possible articles but only 6 studies fulfilled all the inclusion criteria. To be included, the study had to be prospective, randomised or quasirandomised, comparing 4SHS and central third BPTB autografts, inserted using an arthroscopically assisted technique and have a minimum 2-year follow up for all patients. These studies recruited 526 patients and 475 were followed for at least 2 years with 235 patients receiving a bone-patella tendon-bone graft and 240 receiving a 4-strand hamstring graft. Overall, there was a greater chance of extension loss (p=0.007) and a trend towards increased patellofemoral joint pain (p=0.09) with a patella tendon graft. With a 4-strand hamstring graft there is a greater loss of hamstring power (p=0.008) and a trend towards an increased chance of a pivot shift > 1 (p=0.12). There was no difference between the 2 groups in terms of lachman testing, chance of returning to the same level of sport, clinical knee scores, graft ruptures or other complications

The aim of this longitudinal study is to compare the clinical outcomes of endoscopic ACL reconstruction with either a 4-strand HT or PT autograft over a 5-year period. 90 patients with isolated ACL rupture received PT autograft and 90 received HT autograft were studied annually for 5 years. Assessment included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs. The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, Xray findings, manual ligament KT1000 instrumented testing, graft rupture or contralateral ACL rupture. There was an increasing incidence of fixed flex-ion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at 5 years was significantly higher in the PT group. Endoscopic reconstruction of the ACL utilizing either autograft can restore knee stability and is menisco protective despite a high level of sporting activity. We did find a worrying trend towards an increasing incidence of fixed flexion deformity with time in the patellar tendon group. Kneeling pain also remains a persistent problem in this subgroup

Aim. The purpose of this paper is to report on the results of ACL hamstring reconstruction using a novel fixation device. Patients-Methods. We reviewed a total of 132 patients with anterior cruciate ligament reconstruction, operated between 1998 and 2002, with a mean follow up time of 51 ± 9 months. A uniform arthroscopically assisted surgical technique with an instrument guided impingement free tibial tunnel placement and “over the top” femoral routing was employed. An autologous four strand semitendinosus-gracilis tendon graft in combination with a polyester graft suspension tape and cortical fixation device was used. An accelerated rehabilitation was instructed. All patients were examined in a dedicated Research Clinic on a 6 month basis. IKDC, Lysholm and Tegner scoring were employed to validate the end results. Arthrometric evaluation was performed with the KT 2000 device. Results. The over all analysis showed a mean side to side difference of 2.9 mm ± 1.8 and the International Knee Documentation Committee score rating was 91.6 % normal or nearly normal (121 patients). Complications included one graft rupture, one deep infection and 5 case of loosening. Conclusion. These findings suggest that the described method of anterior cruciate ligament replacement produces good early functional results and restores knee stability

Background: There is limited evidence on long-term outcome following ACL reconstruction. Concern has been raised that degenerative joint disease is common in the long-term and this may be associated with use of patellar tendon autograft. Methods: 162 patients underwent single-surgeon arthroscopic ACL reconstruction (1991–1993) were identified from our prospective database. Patient-centred outcome was by Lysholm and Subjective IKDC score, objective outcome measures were clinical examination, arthrometry and X-rays. Results: 13 year outcome (10–15 years) is known in 115/161 patients (71%). The median subjective scores were 94% (Lysholm) and 90% (IKDC). Ipsilateral graft rupture rate was 4%, with contralateral ACL injury in 8%. Mean manual maximum KT 1000 was 9mm in the grafted knee and 8mm in the contralateral knee. Clinical laxity scores of grade 0 or 1 were found in over 93% patients. Radiographically 66% were normal or near normal (Grade A or B). When compared to the contra-lateral uninjured knee we found no significant difference in the proportion of normal/near normal x-rays (grade A/B) versus abnormal/severe (grade C/D) for the medial, lateral nor patellofemoral compartments. There was no significant difference in the radiological IKDC grades in the medial compartment when compared to the contra-lateral uninjured knee, but there was a difference in the lateral and patellofemoral joints. Conclusions: At 13 years patellar tendon ACLR provides excellent patient satisfaction, with clinically objective knee stability and low risk of re-rupture. Radiographically degenerative change was seen in 34%. There was no significant side to side difference to the uninjured contralateral medial knee joint, but there was a small but significant difference in the lateral and patellofemoral joints. The lateral joint differences may reflect underlying bone bruising at the time of injury. We do not believe that the patellar tendon autograft is the cause of arthrosis after BTB ACLR

Aim: To compare, in a longitudinal study, the clinical outcomes of endoscopic anterior cruciate ligament (ACL) reconstruction with either a four-strand hamstring tendon (HT) or a patellar tendon (PT) autograft over a five-year period, when a similar operative procedure is followed for both groups. Method: Ninety patients with isolated ACL ruptures who had received PT autografts and another 90 who had received HT autografts were studied annually for five years. Fifty patients were randomised as a subgroup. The assessments included the IKDC Knee Ligament Evaluation, KT1000, Lysholm Knee Score, thigh atrophy, kneeling pain, hamstring pain and radiographs. Results: The median Lysholm Knee Score was 96 for the PT group and 95 for the HT group. No significant difference was found for subjective knee function, overall IKDC assessment, X-ray findings, manual ligament KT1000 instrumented testing, graft rupture or contra-lateral ACL rupture. There was an increasing incidence of fixed flexion deformity seen in the PT group. There was no difference in the requirement for subsequent surgery. The incidence of kneeling pain at five years was significantly higher in the PT group. The results of the randomised patients were identical to the sequential patients. Conclusions: Endoscopic reconstruction of the ACL utilizing either type of autograft restored knee stability and was protective of the meniscus despite a high level of sporting activity. We found a worrying trend towards an increasing incidence of fixed flexion deformity with time in the PT group. Pain when kneeling also remained a persistent problem in this subgroup. PT grafts appeared tighter clinically and, with the KT 1000, when assessed up to three years post operatively, compared with HT grafts. Thereafter the results were similar

Introduction: Some authors have suggested that the results of ACL reconstruction in females using hamstring tendon (HS) autograft are inferior to those using patellar tendon (PT) autograft. The purpose of this study was to compare our results of ACL reconstruction in females using both graft types. Material and methods: 80 females who had undergone primary ACL reconstruction using either HS (n=48) or PT (n=32) were evaluated at mean 3.7 year follow-up (2.4 – 5.7). The same surgeon carried out all the reconstructions, using Endobutton femoral fixation and interference screw tibial fixation, and the same rapid rehabilitation protocol was followed by all patients. Independent assessment included IKDC 2000, SF-36, and Cincinnati Sports Activity Score (CSAS) and measurements of anterior knee pain (AKP), kneeling pain and anterior knee laxity (KT-1000). Results: One patient in the PT group sustained a traumatic graft rupture. For the remaining patients there were no significant differences between the two graft types in terms of objective IKDC 2000 or KT-1000. In terms of subjective IKDC the HS group scored significantly higher (PT: 85 pts., HS: 90pts, p< 0.05), as well as for the CSAS (PT:72.8 vs. HS: 82.1, p< 0.01) and for the SF-36 on the Physical Functioning (PT:90 vs. HS:95, p< 0.01) and General Health subscales (PT:79 vs. HS 86, p< 0.05). Although there was no significant difference in AKP between the two groups, there was a significantly greater mean kneeling pain in the PT group (PT:4.1 vs. HS: 2.5, p=0.001). Conclusions: Both PT and HS primary ACL reconstructions appear to provide comparable good objective results in females, but ACL reconstruction with HS showed significantly better subjective results. This finding seems to be related to less donor site problems compared with PT. Our results indicate that a quadruple hamstring autograft is an adequate alternative to a patellar tendon autograft for ACL reconstruction in female patients

Introduction and Aims: This longitudinal prospective study reports the 10-year results of anterior cruciate ligament (ACL) reconstruction in 90 patients with isolated ACL rupture. Method: Three hundred and thirty-three patients undergoing endoscopic ACL reconstruction over a 15-month period using patellar tendon autograft and interference screw fixation were evaluated prospectively. Those patients with an associated ligament injury, chondral damage, previous meniscectomy, excision > 1/3 of one meniscus, an abnormal radiograph or contra-lateral knee, or a compensable injury were excluded. This left 90 patients in the study group. Evaluation was conducted annually for five years, then at seven and 10 years after surgery and included the IKDC Standard Evaluation, Lysholm knee score, kneeling pain, KT1000 testing and weight-bearing radiographs at two, five, seven and 10 years. Results: Repeat ACL injury occurred in a total of 23 patients (26%). There were six cases of graft rupture (7%) and 18 cases of contralateral ACL injury (20%). One patient suffered both a contralateral and graft ACL rupture. Eight patients (9%) underwent surgery for meniscal or chondral symptoms during the 10-year period. Of the 84 patients with intact grafts at 10 years, 75 (89%) were reviewed. On radiological examination at 10 years, 47% displayed mild to moderate evidence of osteoarthritis. The median Lysholm knee score was 95. Ninety-six percent felt their knee was normal or nearly normal. Forty-seven percent were still participating in moderate to strenuous activity after 10 years. Eighty-seven percent reported that their knee did not affect their activity level. Ninety-seven percent had grade 0–1 on Lachman and pivot shift testing. On instrumented testing 81% had < 3mm of anterior tibial displacement. Twenty-five percent displayed loss of extension range when compared to the contralateral limb, however this was < 5 degrees in 20% of patients. Pain on kneeling was present in 56%. On overall IKDC assessment, 77% were normal or nearly normal. Conclusion: Endoscopic ACL reconstruction using the PT autograft and interference screw fixation achieves and maintains excellent subjective results and objective stability. This combined with the low incidence of patients requiring subsequent meniscal or chondral surgery enforces the meniscoprotective function of ACL reconstruction. However, early signs of osteoarthritis are developing at 10 years, as displayed by radiological examination and early loss of extension

Introduction and Aims: Some authors have suggested that, in females, the results of ACL reconstruction using hamstring tendon (HS) grafts are inferior to those using patellar tendon (PT) grafts, while others have suggested that HS grafts may be preferable. This study compared the mid-term results of ACL reconstruction in females using both graft types. Method: Sixty-six females who had undergone primary ACL reconstruction using either HS (n=43) or PT autograft (n=22) were evaluated at a mean 3.7 years follow-up (range 2.6–5.5). All procedures were performed by the same experienced knee surgeon using an arthroscopically assisted, single-incision technique, with Endobutton femoral fixation and interference screw tibial fixation. The same rapid rehabilitation protocol (immediate full extension and weight-bearing; no brace) was used for all patients. Assessment was performed by an independent orthopaedic surgeon and included IKDC 2000, SF-36 and Cincinatti Sports Activity scores and measurements of anterior knee pain (AKP), kneeling pain and anterior knee laxity (KT-1000). Results: The overall results in both groups were good. One PT patient sustained a traumatic graft rupture. The HS patients had higher Cincinnati Sports Activity Scores (HS: 83 vs. PT: 72, p< 0.05), but there was no difference in IKDC subjective scores (HS: 89.6 vs. PT: 85.7). For the SF-36, the HS group scored significantly higher on Physical Functioning (HS: 95.4 vs. PT: 89.8, p< 0.01) and General Health subscales (HS: 87.5 vs. PT: 78.4, p< 0.05), but there were no differences for the other subscales. Although there was no significant difference in AKP between the two groups (HS: 1.3/10 vs. PT: 1.7), there was a significantly greater mean kneeling pain in the PT group (PT: 4.0/10 vs. HS: 1.3, p< 0.001). There was no difference between the groups in side to side difference in anterior knee laxity at 134N (HS: 1.7mm vs. PT: 1.8mm). Seventy percent HS and 71% PT patients had a difference of < 3mm, with all remaining patients having 3–5mm difference. There was no difference in terms of overall IKDC knee examination grade, but the HS group had a lesser (hyper)extension deficit (HS: 1.0° vs. PT: 1.8°, p< 0.05). Conclusion: Both PT and HS ACL reconstructions appear to provide satisfactory results in females, but HS grafts are associated with fewer symptoms, a greater return to pre-injury level of activity and higher quality of life scores

Purpose: We analysed the radiographic course of anterior lumbar interbody fusion achieved via a minimal anterior extraperitoneal approach. Material and methods: From January 1996 to December 2001, we operated 198 patients with this technique. Twenty-one patients were excluded from the analysis (two deaths, three tumours, 16 follow-ups less than 12 months). Mean age of the 177 patients retained for study was 53 years (range 22–78). Mean follow-up was 2.7 years. The 55 post-trauma cases involved essentially thoracolumbar junction. The 122 cases of degenerative lumbar spine included 14 cases of scoliosis, 26 cases of spondylolisthesis, 72 cases of unstable spines after primary posterior surgery, and 10 isolated degenerative discs. Only eight patients did not have posterior fixation. Fusion (globally 360 levels) concerned one disc in 89 patients, two discs in 71, three discs in 17. Cancellous autologous grafts were used with cages. Tricortical grafts were implanted after corporectomy (n=23). Radiological fusion was confirmed by the absence of a mobility chamber around the pedicular screws, the cages or the tricortical grafts, and by searching for loss of sagittal angles (digitalized scans and x-ray, Auto Cad L.T.2000). Results: 1) Early postoperative status. For the post-trauma cases (65 fused levels, 55 patients), a simple callus was observed in 28. For the others, mean correction was 4° per level. 2) Angle loss. For the trauma cases, mean angle loss was 3.9° in 36 cases (29 grafts on a single level). There were two partial expulsions of the tricortical grafts implanted in osteoporotic patients; revision was not attempted. Mean angle loss for the 65 grafted levels was 2°. For the degenerative cases, mean angle loss was 3.7° for 172 fused levels (112 patients). Cage expulsion on a grade 3 spondylolisthesis did not warrant revision. Two cage impactions did not cause significant loss of angle. 3) Anatomic status of the grafts. Fusion was achieved at all levels without cage or tri-cortical graft rupture. We observed a partial but stable lucent line around the case in five cases. Discussion: The rate of fusion reported after anterior lumbar interbody fusion has varied from 55 to 100% in the literature. This technique is an original approach for trauma victims avoiding the need for extensive posterior assemblies and/or the damage caused by a wide anterior approach. For the degenerative spine, the mediocre quality of the bone and the frequency of several level fusions is not a particular problem. Conclusion: Anterior lumbar interbody fusion is an interesting method for reinforcing posterior fixation with a real efficacy in terms of effective fusion