Deficiency of the anterior cruciate ligament (ACL) is a common disorder which can lead to changes in lifestyle. We followed 59 patients who had had arthroscopic reconstruction of the ACL using a central-third patellar-tendon autograft for seven years to assess the long-term effectiveness of recent advances in reconstruction of the ACL. The standard criteria for evaluation of the International Knee Documentation Committee, the Lysholm knee score and measurements using the KT 1000 arthrometer all showed satisfactory results. Deterioration in the clinical performance after seven years was associated with osteoarthritic changes and correlated with chronic ligament injuries and meniscectomy. There were three traumatic and three spontaneous ruptures.

We believe that the procedure can be successful, but remain concerned about failure of the graft and osteoarthritis. The results raise questions about the best time to operate and suggest that early surgery may reduce the risk of osteoarthritis.

Aims

The traditional transosseus flexor hallucis longus (FHL) tendon transfer for patients with Achilles tendinopathy requires two incisions to harvest a long tendon graft. The use of a bio-tenodesis screw enables a short graft to be used and is less invasive, but lacks supporting evidence about its biomechanical behaviour. We aimed, in this study, to compare the strength of the traditional transosseus tendon-to-tendon fixation with tendon-to-bone fixation using a tenodesis screw, in cyclical loading and ultimate load testing.

Objectives. This study investigated the biomechanical performance of decellularized porcine superflexor tendon (pSFT) grafts of varying diameters when utilized in conjunction with contemporary ACL graft fixation systems. This aimed to produce a range of ‘off-the-shelf’ products with predictable mechanical performance, depending on the individual requirements of the patient. Methods. Decellularized pSFTs were prepared to create double-bundle grafts of 7 mm, 8 mm, and 9 mm diameter. Femoral and tibial fixation systems were simulated utilizing Arthrex suspension devices and interference screws in bovine bone, respectively. Dynamic stiffness and creep were measured, followed by ramp to failure from which linear stiffness and load at failure were measured. The mechanisms of failure were also recorded. Results. Dynamic stiffness was found to increase with greater graft diameter, with significant differences between all groups. Conversely, dynamic creep reduced with increasing graft diameter with significant differences between the 7 mm and 9 mm groups and the 8 mm and 9 mm groups. Significant differences were also found between the 7 mm, 8 mm, and 9 mm groups for linear stiffness, but no significant differences were found between groups for load at failure. The distribution of failure mechanisms was found to change with graft diameter. Conclusion. This study showed that decellularized pSFTs demonstrate comparable biomechanical properties to other ACL graft options and are a potentially viable option for ACL reconstruction. Although grafts can be stratified by their diameter to provide varying biomechanical properties, it may be more appropriate to alter the fixation technique to stratify for a greater diversity of biomechanical requirements. Cite this article: Bone Joint Res 2019;8:518–525

The purpose of this study was to report the outcome of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with anatomical endoscopic reconstruction using hamstring tendon autograft at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive men and 100 consecutive women with ‘isolated’ ACL rupture underwent four-strand hamstring tendon reconstruction with anteromedial portal femoral tunnel drilling and interference screw fixation by a single surgeon. Details were recorded pre-operatively and at one, two, seven and 15 years post-operatively. Outcomes included clinical examination, subjective and objective scoring systems, and radiological assessment. At 15 years only eight of 118 patients (7%) had moderate or severe osteo-arthritic changes (International Knee Documentation Committee Grades C and D), and 79 of 152 patients (52%) still performed very strenuous activities. Overall graft survival at 15 years was 83% (1.1% failure per year). Patients aged < 18 years at the time of surgery and patients with > 2 mm of laxity at one year had a threefold increase in the risk of suffering a rupture of the graft (p = 0.002 and p = 0.001, respectively). There was no increase in laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture using this technique shows good results 15 years post-operatively with respect to ligamentous stability, objective and subjective outcomes, and does not appear to cause osteoarthritis

A total of 218 patients with unilateral anterior cruciate ligament deficiency were randomly assigned to one of four groups. In group A an anatomical double bundle anterior cruciate ligament reconstruction was performed; group B were treated by a single bundle using an Endobutton for femoral fixation; in group C by a single bundle using RigidFix cross pins for femoral fixation; and in group D by a single bundle using a bioabsorbable TransFix II screw for femoral fixation. For tibial fixation a bioabsorbable Intrafix interference screw was used for all the groups and the graft was fashioned from the semitendinosus and gracilis tendons in all patients. In all, 18 patients were lost to follow-up. The remaining 200 were subjected to a clinical evaluation, with assessment of the anterior drawer, Lachman’s and the pivot-shift tests, and KT-1000 arthrometer measurement. They also completed the International Knee Documentation Committee, Lysholm knee and Tegner activity scores. At a mean of 29 months (25 to 38) follow-up there were no significant differences concerning time between injury and range of movement and Lysholm knee scores among the four groups. However, the double bundle method showed significantly better results for the pivot-shift test (p = 0.002). The KT 1000 measurements showed a mean difference between the reconstructed knee and the patients’ normal knee of 1.4 mm in the double bundle group and 2.4 mm in the single bundle group; which was statistically significant. The Lachman and anterior drawer tests also showed superior results for the double bundle method. The International Knee Documentation Committee scale showed no significant difference among the groups (p < 0.001). On clinical evaluation the double bundle group showed less laxity than the single bundle groups. However, regardless of the technique, all knees were improved by anterior cruciate ligament reconstruction compared with their pre-operative status

We compared the strength of fixation of a biodegradable screw with that of two metal screws in a bone-patellar-tendon-bone (BPTB) graft in the bovine knee. We used 33 fresh BPTB specimens with a circular tibial bone plug of 9 mm in diameter which were anchored in a tibial metaphyseal bone tunnel with either an interference screw (n = 11), an AO cancellous screw (n = 11) or a fibrillated, self-reinforced biodegradable poly-L-lactide screw (n = 11). The mean force to failure (+/- SD) in the three groups was 1358 +/- 348 N, 1081 +/- 331 N and 1211 +/- 362 N, respectively. There was no significant difference in the groups with regard to the linear load or the elastic moduli of the fixation. We conclude that the biodegradable screw is as good as either of the two metal screws in the fixation of a BPTB graft in the bovine knee and can be recommended for ACL reconstruction using this type of graft

A total of 90 patients with an isolated rupture of the anterior cruciate ligament (ACL) had a reconstruction using the ipsilateral patellar tendon secured with round-headed cannulated interference screws. Annual review for five years showed three failures of the graft (two traumatic and one atraumatic); none occurred after two years. Ten patients sustained a rupture of the contralateral ACL. At five years, 69% of those with surviving grafts continued to participate in moderate to strenuous activity. Using the International Knee Documentation Committee assessment, 90% reported their knee as being normal or nearly normal and had a median Lysholm knee score of 96 (64 to 100). Most patients (98%) had a pivot shift of grade 0 with the remaining 2% being grade 1; 90% of the group had a Lachman test of grade 0. The incidence of subsequent meniscectomy was similar in the reconstructed joint to that in the contralateral knee. Radiological examination was normal in 63 of 65 patients. Our study supports the view that reconstruction of the ACL is a reliable technique allowing full rehabilitation of the previously injured knee. In the presence of normal menisci there is a low incidence of osteoarthritic change despite continued participation in sporting activity

We treated 90 patients with an isolated injury to the anterior cruciate ligament (ACL) by reconstruction using a patellar tendon autograft and interference screw fixation. Of these, 82 (91%) were available for review at 24 months. Two grafts and two contralateral ACLs had ruptured during sport and there was one case of atraumatic graft resorption. Using the assessment of the International Knee Documentation Committee (IKDC), 86% of the remaining patients were normal or nearly normal. The median Lysholm knee score was 95/100 and 84% of patients were participating in moderate to strenuous activity. All had grade-0 or grade-1 Lachman, pivot-shift and anterior-drawer tests. Measurement with the KT1000 arthrometer gave a side-to-side difference of < 3 mm of anterior tibial displacement in 90%. Sixty-six radiographs were IKDC grade A and one was grade B. Pain on kneeling was present in 31% and graft site pain in 44%. At 24 months after operation all patients had excellent knee stability, a high rate of return to sport and minimal radiological evidence of degenerative change. Our series therefore represents a basis for comparison of results using other techniques and after more severe injuries

In a two-centre study, 164 patients with unilateral instability of the anterior cruciate ligament were prospectively randomised to arthroscopic reconstruction with either a patellar tendon graft using interference screw fixation or a quadruple semitendinosus graft using an endobutton fixation technique. The same postoperative rehabilitation protocol was used for all patients and follow-up at a median of 31 months (24 to 59) was carried out by independent observers. Four patients (2%) were lost to follow-up. No significant differences were found between the groups regarding the Stryker laxity test, one-leg hop test, Tegner activity level, Lysholm score, patellofemoral pain score, International Knee Documentation Committee (IKDC) score or visual analogue scale, reflecting patient satisfaction and knee function. Slightly decreased extension, compared with the non-operated side, was found in the patellar tendon group (p < 0.05). Patients with associated meniscal injuries had lower IKDC, visual analogue (p < 0.01) and Lysholm scores (p < 0.05) than those without such injuries. Patients in whom reconstruction had been carried out less than five months after the injury had better final IKDC scores than the more chronic cases (p < 0.05). We conclude that patellar tendon and quadruple semitendinous tendon grafts have similar outcomes in the medium term. Associated meniscal pathology significantly affects the final outcome and early reconstruction seems to be beneficial

Aims

The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

Aims

The best surgical strategy for the management of displaced bucket-handle (BH) meniscal tears in an anterior cruciate ligament (ACL)-deficient knee is unclear. Combining meniscal repair with ACL reconstruction (ACLR) is thought to improve meniscal healing rates; however, patients with displaced BH meniscal tears may lack extension. This leads some to advocate staged surgery to avoid postoperative stiffness and loss of range of motion (ROM) following ACLR.

Aims

The aim of this prospective study was to assess the long-term clinical, radiological, functional, and quality of life (QoL)-related outcome of patients treated with the synthetic Ligament Advanced Reinforcement System (LARS) device for anterior cruciate ligament (ACL) rupture.

Aims

The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture.

Aims

The purpose was to evaluate early clinical, patient-reported, and radiological outcomes of the scapholunate ligament 360° tenodesis (SL 360) technique for treatment of scapholunate (SL) instability.

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

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.

Aims

Acute distal biceps tendon repair reduces fatigue-related pain and minimizes loss of supination of the forearm and strength of flexion of the elbow. We report the short- and long-term outcome following repair using fixation with a cortical button techqniue.

Cite this article: Bone Joint Open 2020;1-11:706–708.

Objectives

Bioresorbable orthopaedic devices with calcium phosphate (CaP) fillers are commercially available on the assumption that increased calcium (Ca) locally drives new bone formation, but the clinical benefits are unknown. Electron beam (EB) irradiation of polymer devices has been shown to enhance the release of Ca. The aims of this study were to: 1) establish the biological safety of EB surface-modified bioresorbable devices; 2) test the release kinetics of CaP from a polymer device; and 3) establish any subsequent beneficial effects on bone repair in vivo.

Aims

The aim of this study was to compare the osseous reactions elicited by all-suture, polyetheretherketone (PEEK), and two different biodegradable anchors used during rotator cuff repair.

Aims

The success of anterior cruciate ligament reconstruction (ACLR) depends on osseointegration at the graft-tunnel interface and intra-articular ligamentization. Our aim was to conduct a systematic review of clinical and preclinical studies that evaluated biological augmentation of graft healing in ACLR.

Aims

The aim of this study was to evaluate cartilaginous patellotrochlear congruence and patellofemoral alignment parameters after deepening trochleoplasty in severe trochlear dysplasia.

Aims

To compare radiographic failure and re-operation rates of anatomical coracoclavicular (CC) ligament reconstructional techniques with non-anatomical techniques after chronic high grade acromioclavicular (AC) joint injuries.

Aims

Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture.

Graft-tunnel mismatch of the bone-patellar tendon-bone (BPTB) graft is a major concern during anatomical anterior cruciate ligament (ACL) reconstruction if the femoral tunnel is positioned using a far medial portal technique, as the femoral tunnel tends to be shorter compared with that positioned using a transtibial portal technique. This study describes an accurate method of calculating the ideal length of bone plugs of a BPTB graft required to avoid graft–tunnel mismatch during anatomical ACL reconstruction using a far medial portal technique of femoral tunnel positioning.

Based on data obtained intra-operatively from 60 anatomical ACL reconstruction procedures, we calculated the length of bone plugs required in the BPTB graft to avoid graft–tunnel mismatch. When this was prevented in all the 60 cases, we found that the mean length of femoral bone plug that remained in contact with the interference screw within the femoral tunnel was 14 mm (12 to 22) and the mean length of tibial bone plug that remained in contact with the interference screw within the tibial tunnel was 23 mm (18 to 28). These results were used to validate theoretical formulae developed to predict the required length of bone plugs in BPTB graft during anatomical ACL reconstruction using a far medial portal technique.

Cite this article: Bone Joint J 2015;97-B:324–8.

We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale.

At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities.

This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities.

Cite this article: Bone Joint J 2015;97-B:353–7.

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.

The records of patients aged 50 years or over who underwent primary reconstruction of the anterior cruciate ligament between 1990 and 2002 were reviewed. There were 35 knees in 34 patients that met the inclusion criteria. The mean age of the patients was 57 years (50 to 66) and the mean clinical follow-up was for 72 months (25 to 173). A total of 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The mean pre-operative knee extension was 1° (−5° to 10°) and flexion was 129° (125° to 150°) and at follow-up these values were 0° (−5° to 5°) and 135° (120° to 150°), respectively. Pre-operatively there were 31 knees (89%) with a Lachman grade 2+ or 3+. Post-operatively, 33 knees (94%) were Lachman grade 0 or 1+. The mean pre- and post-operative International Knee Documentation Committee scores were 39 (23 to 72) and 90 (33 to 100) respectively. The mean pre- and post-operative Lysholm scores were 50 (18 to 68) and 92 (28 to 100) respectively and the mean University of California Los Angeles activity scores were 8.5 before injury (4 to 10), 4.3 (3 to 6) after injury and 8.3 (4 to 10) post-operatively. There were three graft failures (8.6%) requiring revision.

We conclude that reconstruction of the anterior cruciate ligament in carefully-selected patients aged 50 years or over can achieve similar results to those in younger patients, with no increased risk of complications.

Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown.

The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures.

In this paper we review the management of ACL tears in skeletally immature patients.

Cite this article: Bone Joint J 2013;95-B:1562–9.

Objectives

Our aim was to assess the use of intra-operative fluoroscopy in the assessment of the position of the tibial tunnel during reconstruction of the anterior cruciate ligament (ACL).

Femoroacetabular impingement causes groin pain and decreased athletic performance in active adults. This bony conflict may result in femoroacetabular subluxation if of sufficient magnitude.

The ligamentum teres has recently been reported to be capable of withstanding tensile loads similar to that of the anterior cruciate ligament, and patents with early subluxation of the hip may become dependent on the secondary restraint that is potentially provided by the ligamentum teres. Rupture of the ligamentum may thus cause symptomatic hip instability during athletic activities.

An arthroscopic reconstruction of the ligamentum teres using iliotibial band autograft was performed in an attempt to restore this static stabiliser in a series of four such patients. Early clinical results have been promising. The indications, technique and early outcomes of this procedure are discussed.

The August 2015 Knee Roundup360 looks at: Two days as good as three in TKA; Bilateral TKA: minimising the risks; Tranexamic acid in knee arthroplasty: everyone should be using it, but how?; Initial follow-up for knee arthroplasty?; Navigation finds its niche?; Another take on navigation?; Multimodal care for early knee osteoarthritis; ACL graft fixation methods under the spotlight

This paper describes the current views on the pathology of lesions of the tendon of the long head of biceps and their management. Their diagnosis is described and their surgical management classified, with details of the techniques employed.

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

Posterolateral rotatory instability is the most common type of symptomatic chronic instability of the elbow. In this condition the forearm complex rotates externally in relation to the humerus, causing posterior subluxation or dislocation of the radial head. The lateral ligament complex, radial head and coronoid process are important constraints to posterolateral rotatory instability, and their disruption is involved in the pathogenesis of this condition. The diagnosis relies on a high index of clinical suspicion, active and passive apprehension tests, and examination under anaesthesia. Surgical treatment has given consistently successful results. Open reconstruction of the lateral ligaments with a tendon graft has been the procedure of choice, with arthroscopic techniques emerging as a potential alternative.

We evaluated two reconstruction techniques for a simulated posterolateral corner injury on ten pairs of cadaver knees. Specimens were mounted at 30° and 90° of knee flexion to record external rotation and varus movement. Instability was created by transversely sectioning the lateral collateral ligament at its midpoint and the popliteus tendon was released at the lateral femoral condyle. The left knee was randomly assigned for reconstruction using either a combined or fibula-based treatment with the right knee receiving the other. After sectioning, laxity increased in all the specimens. Each technique restored external rotatory and varus stability at both flexion angles to levels similar to the intact condition. For the fibula-based reconstruction method, varus laxity at 30° of knee flexion did not differ from the intact state, but was significantly less than after the combined method.

Both the fibula-based and combined posterolateral reconstruction techniques are equally effective in restoring stability following the simulated injury.

This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb.

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.

We used immediate post-operative in vivo three-dimensional computed tomography to compare graft bending angles and femoral tunnel lengths in 155 patients who had undergone single-bundle reconstruction of the anterior cruciate ligament using the transtibial (n = 37), anteromedial portal (n = 72) and outside-in (n = 46) techniques.

The bending angles in the sagittal and axial planes were significantly greater but the coronal-bending angle was significantly less in the transtibial group than in the anteromedial portal and outside-in groups (p < 0.001 each). The mean length of the femoral tunnel in all three planes was significantly greater in the transtibial group than the anteromedial portal and outside-in groups (p < 0.001 each), but all mean tunnel lengths in the three groups exceeded 30 mm. The only significant difference was the coronal graft- bending angle in the anteromedial portal and outside-in groups (23.5° vs 29.8°, p = 0.012).

Compared with the transtibial technique, the anteromedial portal and outside-in techniques may reduce the graft-bending stress at the opening of the femoral tunnel. Despite the femoral tunnel length being shorter in the anteromedial portal and outside-in techniques than in the transtibial technique, a femoral tunnel length of more than 30 mm in the anteromedial portal and outside-in techniques may be sufficient for the graft to heal.

Cite this article: Bone Joint J 2014;96-B:743–51.