Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

The potential harm to the growth plate following reconstruction of the anterior cruciate ligament in skeletally-immature patients is well documented, but we are not aware of literature on the subject of the fate of the graft itself. We have reviewed five adolescent males who underwent reconstruction of the ligament with four-strand hamstring grafts using MR images taken at a mean of 34.6 months (18 to 58) from the time of operation. The changes in dimension of the graft were measured and compared with those taken at the original operation. No growth arrest was seen on radiological or clinical measurement of leg-length discrepancy, nor was there any soft-tissue contracture. All the patients regained their pre-injury level of activity, including elite-level sport in three. The patients grew by a mean of 17.3 cm (14 to 24). The diameter of the grafts did not change despite large increases in length (mean 42%; 33% to 57%). Most of the gain in length was on the femoral side. Large changes in the length of the grafts were seen. There is a considerable increase in the size of the graft, so some neogenesis must occur; the graft must grow

Aim. To assess the ten year subjective knee function and activity level following four-strand semitendinosis and gracilis (STG) anterior cruciate ligament reconstruction. Methods. 86 patients underwent anterior cruciate reconstruction by two knee surgeons in the year 1999. 80 patients meet the inclusion criteria of STG reconstruction by a standard operative technique. Patient evaluation was by completion of a Lysholm Knee Score and Tegner Activity Level Scale at a minimum of ten years from reconstructive surgery. This was by initial postal questionnaire and subsequent telephone follow-up. Results. 80 patients underwent anterior cruciate reconstruction with average age 30.9 years +/− 8.8 (15 to 58 years). There was a 77.5% (62 patients) response at ten years to the questionnaire. The mean Lysholm Knee Score at ten years was 78.4 +/− 12.8 (39 to 90). The mean activity level had decreased from 8.3 to 5.3 at ten years according to the Tegner Activity Scale. 11 patients required medial and lateral partial menisectomies at the time of original reconstruction. This group of patients had a Lysholm Knee Score of 67.6 +/− 19.1 and Tegner Activity Scale of 3.9 at ten years following reconstruction. 17 of the 80 patients (21.25%) required re-operation because of further knee symptoms, with 4 patients requiring revision of the anterior cruciate following re-rupture. Conclusion. Anterior Cruciate Ligament Reconstruction with four-strand STG hamstring graft provides a reliable method of restoring knee function with a 5% revision rate for re-rupture at ten years. Combined partial medial and lateral menisectomy at the time of the initial reconstruction is a poor prognostic indicator for function at ten years

Aims. To examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes. Materials and Methods. A search was performed without language restriction on PubMed, EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials (CENTRAL) databases from their inception to April 2015. We identified 147 infected hamstring grafts across 16 included studies. Meta-analysis was performed using a random-effects model to estimate the overall graft salvage rate, incorporating two different definitions of graft salvage. Results. The graft salvage rate was 86% (95% confidence intervals (CI) 73% to 93%; heterogeneity: tau. 2. = 1.047, I. 2. = 40.51%, Q = 25.2, df = 15, p < 0.001), excluding ACL re-ruptures. Including re-ruptures as failures, the graft salvage rate was 85% (95% CI 76% to 91%; heterogeneity: tau. 2.  = 0.099, I. 2. = 8.15%, Q = 14.15, df = 13, p = 0.36). Conclusions. Arthroscopic debridement combined with antibiotic treatment can lead to successful eradication of infection and graft salvage, with satisfactory functional outcomes in many cases of septic arthritis following ACL reconstruction. Persistent infection despite repeat arthroscopic debridements requires graft removal with the intention of revision ACL surgery at a later stage. Take home message: Arthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608–15

Purpose. Investigate the functional outcome of medial patellofemoral ligament (MPFL) surgery for patella instability. Compare functional outcome of direct MPFL repair and reconstruction using hamstring graft. Methods. All patients that underwent MPFL surgery for patella instability between 2007-2010 were retrospectively identified from operative records. Patients were divided based on whether they underwent direct repair of MPFL, or reconstruction using hamstring graft. The Kujala scoring questionnaire for patellofemoral disorders (max score 100) was used to assess their functional outcome following surgery. Results. 33 patients were identified, 11 were not suitable for inclusion in the study. The remaining 22 patients had a total of 25 operations for patella stabilisation (3 bilateral). Average age of patient at time of surgery was 21 (15-33), 15 male and 7 female. 17 had direct repair of MPFL, 8 had reconstruction using hamstring graft. Of the 8 reconstructions 6 were primary procedures and 2 were for failed direct repair due to further traumatic injury. Mean follow-up period was 17 months (6-43). Mean Kujala score overall 91.6, mean score for reconstruction group 93.2, direct repair score 90.7. Total number of further patella dislocations in the repair group was 1/17 (5.9%). No patients in the reconstruction group reported any further patella dislocations following their surgery. Conclusion. Both direct repair and reconstruction of MPFL for patella instability demonstrate high functional outcome at short/mid-term follow up. Our high success rate in direct MPFL repair, good functional outcome and low re-dislocation rate is better than that quoted in the current literature

This study was performed to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction in children with open physes. Between 2001 and 2009, 31 knees in 29 patients with a mean age of 14.1 years (10-16) underwent transphyseal, arthroscopic ACL reconstruction using an autogenous four-strand hamstrings graft. The technique was identical to that used in the adult population in our unit, except that care was taken to ensure fixation did not cross the physes. The patients were followed up to the point of physeal closure at skeletal maturity. The mean length of follow up was 25 months. The primary outcome measure was graft survival. Functional outcome was measured using Lysolm scores, International Knee Documentation Committee (IKDC) scores and the Tegner activity scale. Post-operative clinical examination and radiological findings were also recorded. There were two cases of re-rupture following a further sports injury, one 12 months post-operative and one at six years. Both patients later had successful revision ACL reconstructive surgery. The re-rupture rate in this case series was 6%. Two patients underwent repair of a concomitant lateral meniscal tear at the time of surgery. The mean post-operative Lysolm score was 88 and the mean IKDC score was 88.1. The mean Tegner activity scale was 7.95. There was no evidence of growth disturbance radiologically or leg length inequality clinically. There was one case of deep infection which was successfully treated with two subsequent arthroscopic washouts. This study demonstrates that transphyseal arthroscopic ACL reconstruction using hamstrings graft and an ‘adult’ technique, in skeletally immature patients, provides good functional outcomes, has a low revision rate and is not associated with physeal growth arrest or disturbance

We sought to determine whether smoking affected the outcome of reconstruction of the anterior cruciate ligament. We analysed the results of 66 smokers (group 1 with a mean follow-up of 5.67 years (1.1 to 12.7)) and 238 non-smokers (group 2 with a mean follow-up of 6.61 years (1.2 to 11.5)), who were statistically similar in age, gender, graft type, fixation and associated meniscal and chondral pathology. The assessment was performed using the International Knee Documentation Committee form and serial cruciometer readings. Poor outcomes were reported in group 1 for the mean subjective International Knee Documentation Committee score (p < 0.001), the frequency (p = 0.005) and intensity (p = 0.005) of pain, a side-to-side difference in knee laxity (p = 0.001) and the use of a four-strand hamstring graft (p = 0.015). Patients in group 1 were also less likely to return to their original level of pre-injury sport (p = 0.003) and had an overall worse final 7 International Knee Documentation Committee grade score (p = 0.007). Despite the well-known negative effects of smoking on tissue healing, the association with an inferior outcome after reconstruction of the anterior cruciate ligament has not previously been described and should be included in the pre-operative counselling of patients undergoing the procedure

We present the results of 17 children of Tanner stage 1 or 2 who underwent reconstruction of the anterior cruciate ligament between 1999 and 2006 using a transphyseal procedure, employing an ipsilateral four-strand hamstring graft. The mean age of the children was 12.1 years (9.5 to 14). The mean follow-up was 44 months (25 to 100). Survival of the graft, the functional outcome and complications were recorded. There was one re-rupture following another injury. Of the remaining patients, all had good or excellent results and a normal International Knee Documentation Committee score. The mean post-operative Lysholm score was 97.5 (. sd. 2.6) and the mean Tegner activity scale was 7.9 (. sd. 1.4). One patient had a mild valgus deformity which caused no functional disturbance. No other abnormality or discrepancy of leg length was seen. Measurements with a KT1000 arthrometer showed no significant difference between the normal and the operated legs. In this small series, transphyseal reconstruction of the anterior cruciate ligament appeared to be safe in these young children

This prospective study used magnetic resonance imaging to record sagittal plane tibiofemoral kinematics before and after anterior cruciate ligament reconstruction using autologous hamstring graft. Twenty patients with anterior cruciate ligament injuries, performed a closed-chain leg-press while relaxed and against a 150 N load. The tibiofemoral contact patterns between 0° to 90° of knee flexion were recorded by magnetic resonance scans. All measurements were performed pre-operatively and repeated at 12 weeks and two years. Following reconstruction there was a mean passive anterior laxity of 2.1 mm (. sd. 2.3), as measured using a KT 1000 arthrometer, and the mean Cincinnati score was 90 (. sd. 11) of 100. Pre-operatively, the medial and lateral contact patterns of the injured knees were located posteriorly on the tibial plateau compared with the healthy contralateral knees (p = 0.014), but were no longer different at 12 weeks (p = 0.117) or two years postoperatively (p = 0.909). However, both reconstructed and healthy contralateral knees showed altered kinematics over time. At two years, the contact pattern showed less posterior translation of the lateral femoral condyle during flexion (p < 0.01)

Delayed rather than early reconstruction of the anterior cruciate ligament is the current recommended treatment for injury to this ligament since it is thought to give a better functional outcome. We randomised 105 consecutive patients with injury associated with chondral lesions no more severe than grades 1 and 2 and/or meniscal tears which only required trimming, to early (< two weeks) or delayed (> four to six weeks) reconstruction of the anterior cruciate ligament using a quadrupled hamstring graft. All operations were performed by a single surgeon and a standard rehabilitation regime was followed in both groups. The outcomes were assessed using the Lysholm score, the Tegner score and measurement of the range of movement. Stability was assessed by clinical tests and measurements taken with the KT-1000 arthrometer, with all testing performed by a blinded uninvolved experienced observer. A total of six patients were lost to follow-up, with 48 patients assigned to the delayed group and 51 to the early group. None was a competitive athlete. The mean interval between injury and the surgery was seven days (2 to 14) in the early group and 32 days (29 to 42) in the delayed group. The mean follow-up was 32 months (26 to 36). The results did not show a statistically significant difference for the Lysholm score (p = 0.86), Tegner activity score (p = 0.913) or the range of movement (p = 1). Similarly, no distinction could be made for stability testing by clinical examination (p = 0.56) and measurements with the KT-1000 arthrometer (p = 0.93). Reconstruction of the anterior cruciate ligament gave a similar clinical and functional outcome whether performed early (< two weeks) or late at four to six weeks after injury

Purpose. The purpose of this study was to assess radiologically the absorption of a poly L-lactide bioabsorbable interference screw used in anterior ligament reconstruction. Methods. A case series of ten sequential patients undergoing anterior ligament reconstruction with a four-strand hamstrings technique were assessed with MRI scans at one, two, four, seven and ten years postoperatively. The scans were reported by an independent radiologist, with respect to resorption of the screw and post resorption changes in the bone. Fixation of the graft in ACL surgery is varied from metal interference screw, resorbable screws made of PLLA, and staple fixation. The advantage of resorbable screws allow imaging of the knee postoperatively, and the perceive benefit of screw resorption and replacement with host bone. Results. No resorption had occurred after 4 years in any of the patients. By seven years screw absorption was complete in seven patients and progressive in three. Five patients displayed new bone formation within the tibial tunnel. Of the five patients with no demonstrable new bone formation, a fluid collection was present within the tibial tunnel. In one of these patients, MRI revealed formation of a ganglion beyond the limit of the tunnel. We will present the final data after ten years. Conclusions. This study has shown that the bioabsorbable screws take longer to resorb than initial in vitro data. It is unclear as to whether any ganglion formation is related to the resorption, or the presence of the hamstring graft in the tunnel. The theoretical advantages of bio-absorbable screws must be weighed against these findings

AIM. We aim to identify whether meniscal repair at the time of ACL reconstruction was associated with a better outcome than meniscectomy. Method. We prospectively collected data on 233 consecutive patients undergoing ACL reconstruction in our unit. A four strand autologous hamstring graft was used with suspensory femoral fixation, and a tibial interference screw. At surgery the presence and location of chondral and meniscal injuries was noted, and whether the meniscal lesion was resected or repaired. Patients were reviewed and scored by a specialist physiotherapist practitioner pre-operatively, and at 6, 12, and 24 months. Tegner, Lysholm, and Cincinatti knee scores were used. Results. At surgey 58% of patients had a meniscal injury, of which 51% were medial and 36% were lateral. 13% had injury to both medial and lateral menisci. 26% of these were repaired. 23% of patients had an associated chondral injury of which 55% involved the medial femoral condyle. The presence of a meniscal injury did not correlate with a worse outcome (Tegner, Lysholm and Cincinatti). There was no difference in outcome whether a meniscal tear was repaired or resected. Lateral meniscus injuries were associated with a worse outcome at 2 years than medial meniscus injuries (Lysholm p= 0.013). Chondral injury was associated with a worse outcome at 2 years. Age over 40 years was associated with a higher incidence of chondral injury (51%) and with a worse outcome. Conclusion. We found that lateral meniscal injury was associated with poorer outcome when compared to medial meniscal injury. This was found to be statistically significant. We found that associated chondral injury at the time of surgery to be a better predictor of poor outcome than meniscal injury. Meniscal repair did not seem to confer a discernable improvement in outcome at 2 years over meniscectomy

A total of 60 children and adolescents with rupture of the anterior cruciate ligament (ACL) was seen between 1980 and 1990. Observation of the 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee. Associated meniscal tears were present in 15 knees. Three osteochondral fractures occurred and osteoarthritic changes developed in ten knees. In 1990 therefore we introduced reconstruction of the ACL with a four-strand hamstring graft using an anatomical placement with transphyseal tunnels and anchorage well away from the growth plate. Over a period of nine years, 47 knees underwent reconstruction. The mean follow-up was 49 months (12 to 96). No child suffered physeal damage or leg-length discrepancy. The results were satisfactory in 77% and there was little difference between patients treated before the adolescent growth spurt and those treated during or after this time. These results, however, were not as good as those seen in adults during the same period

We randomised 31 patients with acute tears of the anterior cruciate ligament (ACL) to receive either early (within 2 weeks) or delayed (8 to 12 weeks) reconstruction using a quadruple hamstring graft in order to determine if there was any functional advantage to early reconstruction. Outcome measures included return of knee movement, muscle dynamometry, International Knee Documentation Committee (IKDC) scores and Tegner activity levels. Two cases of symptomatic deep-venous thrombosis occurred in the early group. The mean range of movement was significantly greater at two weeks in the delayed group. Quadriceps muscle power was significantly better in the delayed group at 12 weeks (p < 0.05). These trends were evident at later time points, but were not statistically significant. One patient in each group had clinically significant knee stiffness at 52 weeks. IKDC scores and Tegner activity levels were not significantly different at 52 weeks. We conclude that there is no functional advantage to be gained by early reconstruction of the ACL

The early surgical management of the anterior cruciate ligament (ACL) tears in children remains controversial. The argument for nonoperative treatment is driven by concerns about the risk of growth arrest caused by a transphyseal procedure. On the other hand, early surgical reconstruction is favoured because of poor compliance with conservative treatment and increased risk of secondary damage due to instability. This paper reports a series of 39 very young children who had an ACL reconstruction using a transphyseal procedure with a hamstring graft. Patients were followed to skeletal maturity or for a minimum of three years. Only those patients with either a chronological age less than 14 years or with a Tanner stage of 1 and 2 of puberty were included in the study. Thirty children were Tanner 1 or 2 and nine were Tanner 3-4 but were younger than 14. The mean age at operation was 12.2 years (Range 9.5-14.2, Median 12.4). The mean follow up was 60.7 months (range 36-129, median: 51) months. Thirty four patients had attained skeletal maturity at the last follow up. The mean Lysholm score improved from 72.4 pre-operatively to 95.86 postoperatively (p<0.0001). The mean Tegner activity scale was 4.23 after injury and it improved to 7.52 after operation (p<0.0001)) which was a reasonable comparison to the pre- injury score of 8.0. One patient had a mild valgus deformity with no functional disturbance. No other growth related abnormalities including limb length discrepancy were noted. There has been one re-rupture but all others had good or excellent outcome. This is one of the largest series reporting the long term results of ACL reconstruction in very young children. Most other studies include children up to the age of 16. Based on our results we can conclude that transphyseal ACL reconstruction modified for very young patients is a safe procedure

Aims

MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation.

Aims

The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective.

Aims

The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort.

Aims

Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft.

Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis.

Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis.

This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients.

Cite this article: Bone Joint J 2017;99-B:159–70.