Purpose of the study: The purpose of this retrospective multicentric analysis was to study the functional and radiological outcomes at more than 20 years of 89 arthroscopic lateral menisectomy procedures performed on stable knees.

Materialandmethod:The series included 89 arthroscopic lateral meniscectomies performed on knee with intact anterior cruciate ligaments (ACL). Mean follow-up was 22±3 years; 56 male, mean BMI 25±4, mean age at meniscectomy 35 years, mean age at last follow-up 57 years. Most of the injuries were vertical (41%), complex (22%) and radial (20%) lesions. The middle segment was involved in 79%. The meniscectomy removed more than one-third of the meniscus in 67%. All patients were reviewed by an independent operator for subjective assessment KOOS (100% normal) and IKDC, and for objective clinical and radiological measurements (IKDC). P< 0.05 was considered statistically significant. There was no independent control group.

Results: Revisions were performed for 16% of the knees. Intense or moderate activity was maintained by all patients. The subjective IKDC score was 71.1±23, comparable with an age and gender matched population. The mean KOOS score was 82% for pain, 80% for symptoms, 85% for daily activities, 64% for sports, and 69% for quality of life. The rate of of osteoarthritis was 56%, and 44% of patients had a difference between the two knees for osteoarthritis. The incidence of osteoarthritis was 53% and shift to valgus on the arthritic side was significantly associated with osteoarthritis, while the opposite side was well aligned. The knee was pain free in 27% of patients. Significant factors for good prognosis were age less than 38 years at first operation, moderate BMI, and minimal cartilage damage (grade 0 or 1).

Conclusion: After the first postoperative year after arthroscopic lateral meniscectomy on a stable knee, the results remain stable and satisfactory for more than 22 years. Nevertheless, patients aged over 40 with a high BMI and cartilage damage at the time of the first operation have a less encouraging prognosis.

Purpose: To define the positions of the attachments of the anteromedial (AM) and posterolateral (PL) bundles of the ACL facilitating accurate tunnel placement during two-bundle reconstruction.

Methods: The positions of the femoral and tibial attachments of the AM and PL bundles was determined in 7 fresh-frozen, unpaired, cadaveric knees by 6 independent observers, using landmarks visible at arthroscopy. This included, on the tibia, the retro-eminence ridge (lying just anterior to the PCL), a bony landmark that could be reliably identified arthroscopically. Tantallum beads were then inserted so that the bundle attachments could be clearly identified on a plain lateral radiograph of the knee. The position of the centres of the AM and PL attachments were described relative to Amis and Jakob’s line on the tibia and Bernard’s grid on the femur.

Results: The AM femoral attachment lay high and deep in the notch with the most posterior fibres 1.8 mm anterior to the “over–the-top” position. The PL femoral attachment was low and shallow in the notch with the most anterior fibres 2.8 mm from the border of the articular cartilage. The centres of the bundles were 8.2 mm apart. The position of the bundles relative to Bernhard’s grid is shown in figure 1.

On the tibia, the centre of the AM attachment was located 18 mm anterior to the Retro-eminence ridge (RER). The centre of the PL bundle lay 8.4 mm posterior to the centre of the AM bundle. These positions were at 35% and 52% along Amis and Jacob’s line

Conclusions: This study details the morphology of the AM and PL bundle attachments and demonstrates reliable arthroscopic techniques to assist with accurate tunnel placement in reconstruction surgery. In addition, it provides reference data for radiographic evaluation of tunnel placement.

Purpose of the study: Failure of anterior cruciate ligament (ACL) ligamentoplasty is a major surgical challenge. Over the last decade, failures have been related to the use of synthetic material, but at the present time, most of the failures observed are related to an inappropriate position for the graft. The purpose of this work was to report a prospective cohort of 44 consecutive patients where the objective and subjective results of revision surgery were recorded.

Material and methods: Between January 2000 and January 2004, 44 patients with a healthy contralateral knee were included in this study: 26 males and 18 females, mean age 30 years (range 20–53 years). The majority of the initial grafts were patellar (57%), hamstring tendons had been used for 26%. The time from the first ligamentoplasty to revision reconstruction was 38.7±28.3 months. This was a first revision for 38 patients and six patients had had multiple revisions. The preoperative IKDC scores were: subjective 51.7±16.2; overall: 1B, 19C, 24D. The maximal manual differential laxity measured with KT1000 was 8.6±3.1 mm. In 70% of cases, the cause of failure was related to an inadapted position of the graft. At revision, grade 2 or 3 cartilage lesions were observed in 50% of knees. Reconstructions were performed with autografts: patellar tendon (39%), hamstring tendons (31%), or quadricipital tendon (29%), combined with lateral ligamentoplasty in 78% of the cases.

Results: Mean follow-up in this series was 14.7 months, minimum 12 months. At last follow-up, the IKDC scores were: 73.8±13.9 for the subjective assessment and 9A, 12B, 17C, 6D for the overall assessment. 67.7% of patients were satisfied or very satisfied. The maximal manual differential laxity measured with KT1000 was 4.3±3.5 mm. All variables exhibited statistically significant improvement. Grade B or C radiologial modifications were noted in 32% of cases.

Discussion and conclusion: Complete analysis of the clinical findings searching for combined laxity as well as a precise preoperative radiological work-up is the key to a successful operative strategy. Data provided by this series confirmed that outcome is less satisfactory after revision reconstruction of the ACL than first-intention ligamentoplasty. Most of the knees involved however present cartilaginous and meniscal lesions with associated peripheral injuries. Short-term cartilage degradation is a worrisome problem and emphasizes the importance of correctly positioning the ACL graft at the primary surgery.

Purpose: The purpose of this study was to compare the reliability and reproducibility of anterior knee laxity measurements made with the KT1000 arthrometere (Medmetric) and radiographically with Telos. The Telos measurement was taken as the standard system.

Material and methods: Inclusion criteria were preoperative anterior laxity differential less than 10 mm, a healthy contralateral knee, and intra-articular surgery. Between January 2001 and December 20001, 147 patients underwent surgery for free graft repair of anterior laxity. Both measurement methods, KT1000 and Telos were used to measure both knees before surgery and at mean 16 months postsurgery. KT1000 measurements were taken at 67N, 89N, 134N and maximum manual force. Telos was measured at 150 N as recommended by the manufacturer. A differential laxity measured at more than 3 mm was considered pathological for KT1000 and greater than 5 mm for Telos. We also determined the intrao-bserver reproducibility (experimented operators) with both methods on the 147 healthy knees considering the measurements taken preoperatively and postoperatively.

Results: Mean preoperative differential laxity was 4.2±2.4 with KT1000 at 89N and 6.3±3.1 mm at maximal manual force. It was 7.7±3.4 mm with Telos. The mean postoperative differential laxity with KT1000 was 2.1±2.2 mm at 89N and 2.6±2.5 mm at maximal manual force. With Telos it was 3±3.6 mm. The Telos values showed a wider distribution than the KT1000 values (p< 0.03). The sensitivity with Telos was 72% with 28% false negatives. With KT1000, the sensitivity improved with greater traction. It was 65% at 89N, 73% at 134N and 92% at maximal manual force. For the healthy knee, the anterior laxity measurements taken by an experimented operator were reproducible with KT1000, p=0.04, kappa = 7.8.

Discussion: The sensitivity and reproducibility results as well as the narrow distribution of the values show that KT1000 is a reliable method for the measurement of anterior knee laxity. Its use can be recommended in routine practice due to the good benefit-cost ratio. The low sensitivity is a drawback of the Telos method due to the high percentage of false negatives. Its use in routine practice should be revisited.

Purpose: Autologous osteochondral grafts using the Mosaicplasty(r) technique have been employed for more then a decade for the treatment of osteocartilaginous tissue loss in weight-bearing zones. The advantage is to repair damage using a hyaline cartilage. Application of this technique to the talar dome is more recent and has been inspired by the good results obtained at the knee level. The purpose of this retrospective analysis was to determine outcome in 36 patients presenting tissue loss of the talar dome who underwent surgery between June 1997 and September 2001 using the method described by L. Hangody and to determine the contribution of the malleolar osteotomy.

Material and methods: Patients, aged 17 to 53 years, complaining of ankle problems were managed in three centres. Surgery was performed by three senior surgeons experienced with knee Mosaicplasty(r). The Acufex Mosaicplasty(r) instrumentation furnished by Smith-Nephew was used in all cases. The ankle was rarely opened by direct arthrotomy. Osteotomy of the medial or lateral malleolus was preferred. Bone grafts were harvested, with the patient’s consent, from a non-weight-bearing articular zone of the homolateral knee. The International Cartilage Repair Society (ICRS) chart, modified for the ankle, was used to assess outcome. Epi-Info 6.0 was used for statistical analysis.

Results: The deep lesions were all ICRS grade III or IV and involved dissecting osteochondritis (n=21), chondral or osteochondral avulsion (n=13) and dome necrosis (n=2). Osteotomy of the medial malleolus was required to access the lesions in 27 ankles; a lateral osteotomy was used in six ankles. After a mean follow-up of 18 months, outcome was considered excellent or good in 81% (ICRS grade I and II). Mild knee pain was reported by 14 patients. All malleolar osteotomies healed without complication. None of the cases worsened.

Discussion: This technique is to be reserved for young symptomatic patients. Despite the more traumatic technique compared with the traditional method, Mosaicplasty(r) enables repair with hyaline cartilage giving more satisfactory short- and mid-term results. Use of a medial or lateral osteotomy does not create any major problem. This is the only was to obtain good lesion exposure, particularly for more posterior lesions. Morbidity at the donor site, though not significantly proven in this series, should be examined in more detail.

Conclusion: Autologous osteochondral grafts using Mosaicplasty(r) is a validated technique for ankle repair. Malleolar osteotomy has been found to be important to achieve proper repair. A long-term study will be needed to evaluate the persistence of these results, and possible donor site morbidity, as well as the preventive effect against osteoarthritis.

Purpose: The anterior cruciate ligament (ACL) is composed of two strands, the anteromedial (AM) and the posterolateral (PL). Each strand has a distinct biomechanical role. The classical techniques for reconstruction of the ACL using a one-strand graft cannot replace the AM strand of the ligament. Control of knee laxity after graft reconstruction with a single strand cannot restore physiological laxity.

Material and methods: This study was performed on 16 matched cadaver knees randomised for reconstruction technique. Anterior tibial dislocation was measured with the Rolimeter arthrometer using manual traction on the intact knee, after section of the ACL, and after arthroscopic reconstruction of the ACL using a 2-strand or 4-strand hamstring method at 20°, 60°, and 90° flexion. Changes in the length of each reconstructed strand were measured.

Results: For the 16 intact knees, anterior laxity was measured at 20°, 60° and 90°. After section of the ACL, laxity increased significantly at all angles studied. Statistical parametric and non-parametric tests demonstrated a significant difference between laxity after ACL section and after ACL reconstruction (one-strand) at 20°, 60° and 90° flexion. There was a significant difference between intact ACL and reconstructed ACL at 20° flexion, the residual laxity was greater after one-strand reconstruction. Conversely, at 60° and 90°, there was no difference in anterior displacement of the tibia for intact and reconstructed ACL. There was a statistically significant improvement in laxity between sectioned and reconstructed (two-strand) ACL at 20°, 60° and 90° but no difference in anterior dislocation between the intact ACL and the reconstructed ACL at 2°, 60°, and 90° flexion.

Conclusion: Two-strand reconstruction of the ACL provides laxity comparable with that of the intact ACL at 20°, 60°, and 90° flexion while one-strand reconstruction only re-establishes physiological laxity at 60° and 90°.

Purpose: We present the results obtained in a consecutive series of 48 patients who underwent surgical repair for chronic posterior knee laxity between 1995 and 2000.

Material and methods: The series included 33 men and 15 women, men age 29 years at the time of trauma. Mean duration of knee laxity before surgery was 32 months: 26 patients had undergone different procedures but without reconstruction of the posterior cruciate ligament (PCL). Preoperative physical examination revealed direct posterior laxity (DPL in 17 knees, posteroposterolateral laxity (PPLL) in 17, posteroposteromedial laxity (PPML) in 6, global posterior laxity (GPL) in one, and complex anteroposterier laxity (APL) in 7. The PCL was reconstructed arthroscopically using a two-strand graft using either the patellar tendon for the oldest cases (n=22) or the quadriceps tendon (n=26). Peripheral involvement was repaired by tension, reinforcement, or reconstruction with an autologous tendon graft. In the event of associated genu varum, a tibial osteotomy for normo-correction was also performed prior to the ligamentoplasty. Outcome was assessed with the IKDC 93 criteria and posterior laxity was measured on the stress x-rays.

Results: All patients were followed at least one year. Mean follow-up was 24 months. There were no postoperative complications. The principal results for the first three types of laxity, DPL, PPLL, and PPML, were as follows. Preoperative subjective evaluation for the entire series: 12C, 36D; symptoms: 6B, 10C, 32D; global score: 9C, 39D; laxity: 11.4±4.3 mm. DPL: subjective evaluation: 4C, 13D; symptoms: 2B, 2C, 12D; global score: 4C, 14D; laxity 9.9±3.3 mm. PPLL subjective evaluation: 7C, 10D; symptoms: 2B, 6C, 9D; global score: 3C, 14D; laxity 11.7±4.6 mm. PPML subjective evaluation: 6D; symptoms: 1B, 5D; global score: 6D; laxity 13.0±3.7 mm. At last follow-up for the entire series, subjective evaluation: 9A, 27B, 12C; symptoms: 6A, 26B, 14C; global score: 1A, 25B, 21C, 1D; laxity: 5.0±3.0 mm, giving a 62% gain. DPL subjective evaluation: 6A, 8B, 3C; symptoms: 5A, 10B, 2C; global score: 1A, 10B, 6C; laxity: 4.0±2.0 mm, giving a 62% gain. PPLL subjective evaluation: 2A, 11B, 14C; symptoms: 3A, 10B, 4C; global score: 4B, 12C, 1D: laxity: 5.7±3.5 mm, giving a 54% gain. PPML subjective evaluation: 6B; symptoms: 6B; global score: 5B, 1C; laxity: 5.9±3.0 mm, giving a 61% gain. For all parameters considered, category D disappeared at last follow-up in almost all knees. This improvement over the preoperative status was statistically significant (p=0.001).

Discussion: Reconstruction of the PCL with a two-strand graft combined with compensation of peripheral laxity and axial deviations provides significant correction in laxity similar to that obtained for the anterior cruciate ligament. Despite these satisfactory results, posteroposterolateral laxity has a less favourable prognosis than the other types of laxity.