Anterior cruciate ligament (ACL) injuries have been increasing, especially amongst adolescents. These injuries can increase the risk for early-onset knee osteoarthritis (OA). The consequences of late-stage knee OA include structural joint change, functional limitations and persistent pain. Interleukin-6 (IL-6) is a pro-inflammatory biomarker reflecting knee joint healing, and increasing evidence suggests that IL-6 may play a critical role in the development of pathological pain. The purpose of this study was to determine the relationship between subjective knee joint pain and function, and synovial fluid concentrations of the pro-inflammatory cytokine IL-6, in adolescents undergoing anterior cruciate ligament reconstruction surgery. Seven youth (12-17 yrs.) undergoing anterior cruciate ligament (ACL) reconstruction surgery participated in this study. They completed the Pedi International Knee Documentation Committee (Pedi-IKDC) questionnaire on knee joint pain and function. At the time of their ACL reconstruction surgery, synovial fluid samples were collected through aspiration to dryness with a syringe without saline flushing. IL-6 levels in synovial fluid (sf) were measured using enzyme linked immunosorbent assay. Spearman's rho correlation coefficient was used to determine the correlation between IL-6 levels and scores from the Pedi-IKDC questionnaire. There was a statistically significant correlation between sfIL-6 levels and the Pedi-IKDC Symptoms score (-.929, p=0.003). The correlations between sfIL-6 and Pedi-IKDC activity score (.546, p = .234) and between sfIL-6 and total Pedi-IKDC score (-.536, p = .215) were not statistically significant. This is the first study to evaluate IL-6 as a biomarker of knee joint healing in an adolescent population, reported a very strong correlation (-.929, p=0.003) between IL-6 in knee joint synovial fluid and a subjective questionnaire on knee joint pain. These findings provide preliminary scientific evidence regarding the relationship between knee joint pain, as determined by a validated questionnaire and the inflammatory and healing status of the patient's knee. This study provides a basis and justification for future longitudinal research on biomarkers of knee joint healing in patients throughout their recovery and rehabilitation process. Incorporating physiological and psychosocial variables to current return-to-activity (RTA) criteria has the potential to improve decision making for adolescents following ACL reconstruction to reduce premature RTA thereby reducing the risk of re-injury and risk of early-onset knee OA in adolescents

There is increasing evidence that patients with ACL reconstruction using ipsilateral graft harvest are at greater risk of rupture (12.5%) on their contralateral compared to their surgical side (7.9%). The purpose of this study is to re-evaluate patients from a previous study comparing ipsi- versus contralateral graft harvest to compare ACL rupture rate at a minimum 10 year follow-up. An attempt to contact all participants from a previously published study was made to invite them to return for a follow-up. The assessment included an International Knee Documentation Committee Knee Clinical Assessment (IKDC), isokinetic concentric knee flexion and extension strength testing, as well as the ACL-Quality of life (ACL-QOL). A chart review was conducted to identify or confirm subsequent ipsi- or contralateral knee surgeries. In patients with ipsilateral graft, 3/34 (8.8%) re-ruptured and 3/34 (8.8%) had contralateral rupture. In the contralateral group, 1/28 (3.6%) re-ruptured and 2/28 (7.1%) had contralateral rupture. The relative risk (RR) of re-rupture with ipsilateral graft was 2.47 compared to using the contralateral site (p=0.42). RR of rupture on the contralateral side when ipsilateral graft was used was 1.23 compared to the alternate approach. Current contact information was unavailable for 21 patients. Of the 47 remaining, 37 were consented (79%). No difference in the ACL-QOL between groups (ipsilateral 68.4±24.4, contralateral 80.1±16.0, p=0.17) was observed. There were no differences in knee flexion strength between groups (peak torque flexion affected leg: ipsilateral 77.8nm/kg±27.4, contralateral: 90.0 nm/kg±35.1; p=0.32; Unaffected leg: ipsilateral: 83.3 nm/kg±30.2 contralateral 81.7 nm/kg±24.4; p= 0.89). This study suggests that using the contralateral hamstring in ACL rupture is not associated with an increase in ACL rupture on either side. The risk of ACL injury was low in all limbs; therefore, a larger study would be required to definitively state that graft side had no impact

The purpose of this study was to evaluate the results of selective anatomic augmentation of partial anterior cruciate (ACL) ligament tears in 36 consecutive patients with mean 3years follow-up. Our hypothesis is that this selective augmentation of partial ACL tears could restore knee stability and function. In a consecutive series of 314 ACL reconstructions, 40 patients in which intact ACL fibers remained in the location corresponding to the anteromedial or posterolateral bundle were diagnosed perioperatively. All patients underwent selective augmentation of the torn bundle, while keeping the remaining fibers intact using autogenous hamstring graft. 38 patients (28 males, 10 females) were available with minimum 3 year follow- up. 26 cases had AM bundle tears and 12 cases had PL bundle tears respectively. Patients were assessed with International Knee Documentation Committee (IKDC) 2000 Knee Evaluation Form, Lysholm score; instrumented knee testing was performed with the arthrometer (KT 2000). Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. At 3 year follow-up, 12 (31.6%) patients were graded A, 25 (65.8%) graded B and 1 C (2.6%) at IKDC objective evaluation. Lysholm's score and mean side to side instrumental laxity improved significantly. The results of anatomic single bundle augmentation in partial ACL tears are encouraging with excellent side to side laxity

Purpose. To evaluate the results of quadrupled hamstring tendon autograft anterior cruciate ligament reconstruction with four fold Hamstring Tendon Graft using Transfix and Bioabsorbable Interference Screw Fixation. Study Design. Retrospective review. Methods. Sixty-five patients (66 knees) were retrospectively identified by chart review as having undergone quadrupled hamstring tendon autograft anterior cruciate ligament reconstruction, with four fold Hamstring Tendon Graft, using Transfix and Bioabsorbable Interference Screw Fixation. All patients underwent a minimum two-year follow-up. Results. Data were collected on 48 knees in 47 patients (73%) at an average 30.2 months (range 24 to 43) after surgery. Thirty-six patients (37 knees) returned for clinical evaluation (56% return) and subjective follow-up only was obtained in 11 patients (17%). The mean Lysolm knee score was 91 (range, 45 to 98), with a mean of 97 for the uninvolved knee. The mean Tegner activity score was 5.7 (range 3 to 7). The KT-1000 arthrometer mean side-to-side difference for manual maximum displacement was 2.03 mm (range -1 to 8). The mean International Knee Documentation Committee knee score was 83 (range 47 to 100). Patients who underwent associated partial meniscectomy or meniscal repair had significantly lower International Knee Documentation Committee scores than patients without associated procedures (P < 0.01). Conclusions. Quadrupled hamstring tendon autograft anterior cruciate ligament reconstruction with bioabsorbable interference screw fixation is comparable with other methods of anterior cruciate ligament reconstruction in terms of patient satisfaction, knee stability, and function

Anterior cruciate ligament (ACL) injuries are being seen with increasing frequency in children. Treatment of the ACL deficient knee in skeletally immature patients is controversial. To determine the outcome of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years after surgery. Between 2007–2008, 16 prepubescent skeletally immature patients underwent anatomic transphyseal ACL reconstruction using soft tissue grafts. All patients were tanner stage 1 and 2 and all had open growth plates. Outcomes were assessed at a minimum of 2 years after surgery and included: limb alignment, limb length, instrumented testing with KT-1000 and International Knee Documentation Committee (IKDC) score. Mean age at the time of surgery was 12 years (8–14). Graft choices included: living-related donor hamstring tendon allograft (n=14), hamstring tendon autograft (n=1) and fresh frozen allograft (n=1). Mean IKDC subjective score was 96 (84–100). Sixty-two percent of patients had <3mm side-to-side difference on instrumented KT-1000 testing and 88% had a negative pivot shift. At 2 years after surgery, all patients had returned to strenuous activities and normal or nearly normal overall IKDC score was documented in 94% of patients. There were no cases of limb malalignment or growth arrest. We present a large series of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years following surgery. Excellent clinical outcomes were obtained with high levels of return to desired activities. Importantly, no growth disturbances were seen in this series of patients

Background:. Different surgical approaches have been proposed for the treatment of chondral lesions. However surgical management of osteochondral defects of the knee joint involving subchondral bone are still under debate. Purpose:. The aim of this prospective non-randomized uncontrolled clinical investigation is to confirm the effectiveness of a commercially available biomimetic osteochondral scaffold in regenerating cartilage and subchondral bone of severe osteochondral lesions of the knee joint with one step surgery. Methods:. The biomimetic scaffold has a multilayer structure consisting of a combination of type I collagen and type I collagen/hydroxyapatite, mimicking the osteochondral connective tissue of the knee joint. From 2009 to 2011, sixty-one patients affected by grade III or IV osteochondral lesions of the knee, according to Outerbridge Classification, were admitted to three centers and received the biomimetic scaffold. Four-nine patients were evaluated using the International Knee Documentation Committee (IKDC), Tegner and VAS scores, and MRI at 1-, 2- and 3-year follow-ups. Biopsies were carried out in 5 patients at an average time of 19.2 months to histologically evaluate the quality of the newly-formed tissue. Results:. All patients tolerated the surgery well; no major adverse events were observed in the early postoperative period. Clinical evaluation of the 49 patients showed a statistically significant improvement in all scores at 1- 2- and 3-year follow-ups as compared to preoperative baseline scores. Improvement in the scores and functional recovery seemed to reach a plateau after 2 years; no significant improvement was seen between the 2- and the 3-year follow-up. Conclusions:. A synthetic biomimetic scaffold used in one-step surgery for the treatment of severe osteochondral knee lesions significantly improved symptoms and joint function, as demonstrated by subjective and objective scoring system evaluation. Furthermore, the athletic subpopulation exhibited a significantly better outcome than the non-athletic subpopulation

Bioabsorbable screws for anterior cruciate ligament reconstruction (ACLR) have been shown to be associated with femoral tunnel widening and cyst formation. To compare a poly-L-lactide–hydroxyapatite screw (PLLA-HA) with a titanium screw with respect to clinical and radiological outcomes over a 5 year period. 40 patients were equally randomized into 2 groups (PLLA-HA vs titanium) and ACLR performed with a 4 strand hamstring graft with femoral tunnel drilling via the anteromedial portal. Evaluation at 2 and 5 years was performed using the International Knee Documentation Committee assessment (IKDC), Lysholm knee score, KT 1000 arthrometer, single-legged hop test. Magnetic resonance imaging was used to evaluate tunnel and screw volume, ossification around the screws, graft integration and cyst formation. There was no difference in any clinical outcome measure at 2 or 5 years between the 2 groups. At 2 years, the PLLA-HA femoral tunnel was significantly smaller than the titanium screw tunnel (p=0.015) and at 5 years, there was no difference. At 2 years the femoral PLLA-HA screw was a mean 76% of its original volume and by 5 years, 36%. At 2 years the tibial PLLA-HA screw mean volume was 68% of its original volume and by 5 years, 46%. At 5 years, 88% of femoral tunnels and 56% of tibial tunnels demonstrated a significant ossification response. There was no increase in cyst formation in the PLLA-HA group and no screw breakages. The PLLA-HA screw provides adequate aperture fixation in ACLR with excellent functional outcomes. It was not associated with femoral tunnel widening or increased cyst formation when compared with the titanium screw. The resorbtion characteristics appear favourable and the hydroxyapatite component of the screw may stimulate osteoconduction, contributing to these results. The PLLA-HA screw is a good alternative to a titanium screw in ACLR, which may aid revision procedures and allow for imaging without artifact

Introduction. Anterior cruciate ligament (ACL) rupture is a common sporting injury, often managed surgically with patella-tendon or hamstrings autograft. Surgeons are under increasing pressure for open transparent assessment of their performance. Scoring systems can be used to assess outcome. More than 50 different scoring systems have been identified to assess the ACL deficient knee. Aims. The survey is investigating the use of ACL scoring systems between knee surgeons in the United Kingdom as a method of assessing performance. Method. 134 knee surgeons in the United Kingdom, performing ACL reconstruction, were asked to complete a written questionnaire regarding their use of scoring systems & outcome measures. Written questionnaires were sent and responses were received by post. Results. 81 (60%) surgeons responded to the questionnaire by stating their preferred scoring system. 40 (49%) surgeons routinely use ACL scoring systems versus 41 (51%) surgeons who do not. The Lysholm (I and II) knee scoring scale (80%) and Tegner activity score (67.5%) were most commonly used (57.5% both of them) followed by the Knee injury and osteoarthritis outcome score (KOOS) (30%), International Knee Documentation Committee (IKDC) subjective knee score (22.5%), Medical Outcome Study 12 Item Short Form (SF12) (20%), the Medical Outcome Study 36 Item Short Form (SF 36) (12.5%), Cincinnati Knee Scoring System (10%), and ACL Quality of Life scoring system (7.5%). Recommendations. The routine use of ACL scoring systems by 49% of surgeons raises the question - should all surgeons be using scoring systems in their ACL practice? This would be relatively easy to do as most patients are followed up post operatively for 6 months. This will help to adopt a transparent assessment of the performance of every consultant to the procedure they perform

The question of whether to reconstruct an ACL-deficient knee as early as possible following injury or to delay surgery remains unanswered. Early reconstruction potentially reduces the risk of secondary damage. However, there is also concern regarding the risk of arthrofibrosis if surgery is undertaken too soon. The aim of this study was to investigate whether injury-to-surgery delay determines ACL-reconstruction outcomes at up to 2years post-operatively. A retrospective analysis of prospectively collected data from 211 knees with isolated primary ACL ruptures was performed. Patients were examined preoperatively, at 6months, 1 year, and 2 years post-operatively using International Knee Documentation Committee (IKDC) and Lysholm scores. Side to side differences in knee laxity were also measured with a KT1000 arthrometer. Spearman's rho correlations were used to associate injury-to-surgery delay with outcome scores. Outcomes scores significantly increased for both IKDC (p<0.05) and Lysholm (p<0.05) questionnaires. Significant positive correlations (p<0.05) were also found between injury-to-surgery delay and IKDC and Lysholm subjective scores. Strongest correlation coefficients were noted at the 2yr follow-up for both IKDC and Lysholm scores (r = 0.79 and 0.8 respectively). Side-to-side laxity measures also showed significant positive correlations with injury-to-surgery delay at 1 year (r = 0.17) and 2 year (r = 0.41) follow ups. The positive correlation suggests that delayed surgery is positively related to subjective outcomes, as well as objective measures of knee laxity. However, this relationship also suggests that other factors such as the patient's functional status at time of surgery may play a role in their post-operative function. For example, those who can compensate for the ruptured ligament may function well following delayed surgery. These findings highlight the need for more detailed investigation of the interaction between functional status, injury-to-surgery delay and post-operative recovery

Aim. To assess the efficacy and ease of use of the Oxford Knee Score (OKS) in soft tissue knee pathology. Method. In a prospective study, we compared the OKS against the International Knee Documentation Committee 2000 (IKDC) and the Lysholm Scores (Lys). We also assessed the OKS with retrograde (Reversed OKS: 48=worst symptoms, 0=asymptomatic) and antegrade (as currently used in Oxford) numbering. All patients completed 3 questionnaires (OKS, Lys, and IKDC, or RevOKS, Lys, and IKDC) stating which was the simplest from their perspective. We recruited 93 patients from the orthopaedic and physiotherapy clinics. All patients between the ages of 15 and 45 with soft tissue knee derangements, such as ligamentous, and meniscal injuries were included. Exclusions were made in patients with degenerative and/or inflammatory arthritidis. Patients who had sustained bony injuries or underwent bony surgery were also excluded. Results. The distribution of the soft tissue injuries was: Meniscal tears (35%), anterior cruciate ligament injuries (23%), anterior knee pain (22%), other injuries (12%), and collateral ligament damage (8%). Linear regression analysis revealed no significant difference between all 3 scores (R squared=0.7823, P<0.0001). The OKS correlated best with the IKDC (r=0.7483), but less so with the Lys (r=0.3278). The reversed OKS did not correlate as well (R squared= 0.2603) with either the IKDC (r= -0.2978) or the Lys (r=-0.2586). ANOVA showed the OKS to be significantly easier than Lys to complete (p<0.0001), but not significantly easier than IKDC (p>0.05). Conclusion. The OKS is patient friendly and reliable in assessing soft tissue knee injury. This is particularly useful if the OKS is already in use within a department for assessment of degenerative disease. The Oxford Knee score should be used in an antegrade fashion (with a score of 48/48 corresponding to maximum symptoms) to give the best results in objective assessment

Subchondral drillings for articular cartilage repair give functional improvement that peaks at 24 months after surgery. We postulate that intra-articular injections with autologous peripheral blood stem cells (PBSC) and hyaluronic acid (HA) following subchondral drillings can improve the repair process. Thirty-four patients with full thickness chondral defects of the knee joint underwent subchondral drillings. The operated knees were then placed on continuous passive motion for a period of two hours per day for four weeks, with partial weight-bearing for the first six weeks. PBSC were harvested by apheresis and divided into aliquots which were cryopreserved. One week after surgery, weekly intra-articular injections of 2.5 mLs PBSC mixed with 2 mLs of sodium hyaluronate were given for five weeks after surgery. Patients were followed up for an average of 11 months (range 6–20) and assessed using serial MRI scans. Second look arthroscopy and chondral biopsies were obtained in five patients. International Knee Documentation Committee (IKDC) scores were compared with previous microfractures results from the Mithoefer cohort study using linear interpolation to generate time-based predicted values. The difference was compared using a two-tailed, one-sample T-test against a value of zero. Serial MRI scans showed healing of subchondral bone and evidence of cartilage regeneration that was confirmed on arthroscopy with good integration into surrounding cartilage with no delamination. Biopsy specimens showed attributes typical of hyaline cartilage with good cellular morphology, abundant proteoglycans and Type II collagen. No oedema or degenerative changes were seen. The IKDC data was on average 12.8 points (95% CI 6.5-19.1) higher than the Mithoefer group with p=0.0002. Intra-articular injections of PBSC and HA following subchondral drillings resulted in good repair tissue based on MRI, arthroscopic, and histological criteria, with IKDC scores superior to standard microfracture surgery

Thirty-three knees in thirty-three patients who underwent ACLR using four-strand semitendinousus and gracilis tendon in our hospital were included in this study. In 17 knees, we use a fluoroscopic-based navigation system (Vector Vision ACL, BrainLab. Inc.) for positioning of the tunnels (Group 1). In the remaining 16 knees, positioning of the femoral and tibial tunnels was done without navigation (Group 2). In navigation operation, anteroposterior and lateral images of the knee were taken with a fluoroscope and captured into the computer. The optimal target points for bone tunnels were semi-automatically calculated and displayed on the screen. Femoral placement was determined based on the quadrant method. The target for tibial tunnel was set at 43% of tibial plateau AP length. Intraoperatively, positions of the drill guides were decided referring to both navigation image and arthroscopic image. We evaluated Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Lachman test and pivot shift test at 1 year after operation and calculated bone tunnel position on the postoperative lateral x-ray films and expressed them as relative values against total AP length of the Blumensaat's line and of the tibia plateau. Lysholm score, IKDC subjective score, Lachman test and pivot shift test were not significantly differed between the groups. The femoral tunnels were 74.2±3.3% in Group 1 and 71.7±6.0% in Group 2 along and the tibial tunnels were 42.1±1.4% in group 1 and 43.0±4.6% in group 2 along the tibia plateau. Although femur and tibial tunnel positions were not significantly differed between the groups, variation of bone tunnel position was significantly smaller in Group 1, indicating a good reproducibility. One pin tract infection occurred in Group 1. This case successfully treated with debridment and antibiotics containing cement filling. Fluoroscopic navigation system is quite helpful for precise and reproducible creation of both femur and tibial tunnel. The results encourage us to use this system for double-bundle anatomical ACLR. However, a special care must be taken to avoid complication caused by tracker pin placement

Purpose. No knee-specific outcome measures have demonstrated reliability, validity or responsiveness in patients with multiligament knee injuries. Furthermore, the content validity of existing questionnaires has been challenged and remains unknown for patients with concomitant neurovascular injury. As a first step in developing a disease-specific outcome measure, the objective of this study was to identify items from existing knee questionnaires pertinent to patients with multiligament knee injuries using established a priori criteria. Method. Eighty-five consecutive patients from a level one trauma centre were mailed a questionnaire comprising 124 items from 11 knee-specific instruments. They rated the frequency and importance for each item on a five-point Likert scale. Criteria for item selection included a mean importance rating (MIR) ≥ 3.5 and frequency < 30% for the response never experienced. The World Health Organization International Classification of Functioning, Disability and Health (ICF) framework was used to support the content. Results. The average age of the 60/85 respondents (70.6%) was 34.7 years and most were male (n=45). Average time from injury was 845 days. Using the Schenck classification, 19 patients were KD I, two were KD II, 39 were KD IIIL or IIIM, and nine were KD IV. Nineteen had peroneal nerve injury and five had a vascular injury. Forty-four patients were treated surgically, six nonoperatively and 10 are pre-operative. Sixty-one of 124 questionnaire items met the a priori inclusion criteria. Based on the ICF, 22 of the retained items were physical impairments (PI), 15 items were emotional impairments (EI), 18 items were activity limitations (AL), and six items were participation restrictions (PR). The 10 items with the highest MIR included six EI, one PI and three PR. Twenty-four items (PI=6 EI=13, AL=2, PR=3) of the Anterior Cruciate Ligament Quality of Life Questionnaire (ACL-QoL) satisfied the a priori criteria and this instrument also endorsed the most items within the EI and PR constructs. The Knee Osteoarthritis and Injury Outcome Score (KOOS) had 21 items (PI=7, EI=2, AL=11, PR=1) which satisfied the a priori criteria and also had the most items within the PI and AL constructs. The International Knee Documentation Committee (IKDC) Subjective Knee Form had 12 items (EI=0, PI=3, AL=9, PR=0) meeting criteria while the remaining questionnaires contained 11 items with concepts redundant to above. Combining the ACL-QoL and KOOS resulted in representation of 41/61 of the retained items (PI=13, EI=13, AL=12, PR=3). No existing instrument includes content that may result from neurological or vascular injury. Conclusion. This work has identified over sixty pertinent items across the various ICF domains relevant to patients with multiligament knee injuries. The ACL-QoL and KOOS together address over two thirds of these items. Patient and clinician focus groups will be conducted to address missing content and to further refine the questionnaire items

Purpose. Isolated fractures of femoral condyle in the coronal plane (Hoffa fracture) is rare and is surgically challenging to treat. 44 patients were operated between 2004–2014. The aim was to retrospectively assess the fracture patterns, fixation done and functional outcome. Methods. All injuries resulted from direct trauma to the knee out of which 36 were due to road traffic accidents.38 were closed injuries and the rest open.35 involved lateral condyle, 8 involved medial condyle and one was bicondylar type. All were anatomically reduced with fixation decided based on preoperative radiographs, CT scan and intra-op observation. Early passive motion and isometric exercises were started but kept non-weight bearing for 6–8 weeks. The mean follow up period was five years. Outcomes were measured using Neer's scoring system and International Knee Society Documentation Committee (IKDC) Functional Score. Results. 26 patients had excellent outcome, 14 had satisfactory and 4 had unsatisfactory outcome which corresponded with the specified fracture severity pattern. Uniformly excellent results were obtained in all simple pattern fractures, whereas comminuted fracture patterns were more challenging to treat with variable outcomes. Conclusion. In our retrospective observational study, we found that each fracture had specific pattern which dictated the treatment plan and the prognosis. Subsequently we grouped the fractures and proposed a classification system that would specify the pattern of fracture and dictate the type of fixation preferred. We conclude that therapeutic outcome is significantly affected by the amount of articular surface comminution, posterior cortex comminution, attainment of anatomical reduction and stable fixation