[ACL reconstruction in skeletally immature patients]. / Ersatz des vorderen Kreuzbandes bei Kindern und Jugendlichen mit offenen Wachstumsfugen.

AIM: The treatment of choice for skeletally immature patients with anterior cruciate ligament (ACL) deficiency is an ACL reconstruction. In a retrospective study we analysed the clinical results after ACL reconstruction in skeletally immature patients. MATERIAL AND METHOD: In 55 immature patients the ACL was replaced with a four strand-hamstring graft in an anatomic transepiphyseal origin. The fixation was by means of an extracortical button femoral and a suture washer or staple tibial. Patient mean age at operation was 13 years (8 to 16 years). RESULTS: The mean follow-up was at 3.2 years (1 to 7.5 years) postoperatively. The objective IKDC 2000 score was 90.7 % normal or almost normal values. The mean Lysholm score was 94.1 points (70 - 100), the mean Cincinnati knee score was 93.9 points (76 - 100) and 88 % of the patients went back to normal or almost normal sports according to the Tegner score. Stability testing performed with the KT-1000 arthrometer was 1.0 mm (0 - 4 mm) (preoperative average 5.8 mm). The traumatic re-rupture rate was 5.5 %. In two additional cases a partial rupture of the graft was analysed by arthroscopy. Growth deformities or leg length differences were not seen in any case. CONCLUSION: ACL reconstruction with hamstrings and extracortical fixation showed good results and might be the treatment of choice in immature patients. The complication rate was low and there were no postoperative growth deformities.

[ACL reconstruction in skeletally immature patients]. / Ersatz des vorderen Kreuzbandes bei Kindern und Jugendlichen mit offenen Wachstumsfugen.

AIM: The treatment of choice for skeletally immature patients with anterior cruciate ligament (ACL) deficiency is an ACL reconstruction. In a retrospective study we analysed the clinical results after ACL reconstruction in skeletally immature patients. MATERIAL AND METHOD: In 55 immature patients the ACL was replaced with a four strand-hamstring graft in an anatomic transepiphyseal origin. The fixation was by means of an extracortical button femoral and a suture washer or staple tibial. Patient mean age at operation was 13 years (8 to 16 years). RESULTS: The mean follow-up was at 3.2 years (1 to 7.5 years) postoperatively. The objective IKDC 2000 score was 90.7 % normal or almost normal values. The mean Lysholm score was 94.1 points (70-100), the mean Cincinnati knee score was 93.9 points (76-100) and 88 % of the patients went back to normal or almost normal sports according to the Tegner score. Stability testing performed with the KT-1000 arthrometer was 1.0 mm (0-4 mm) (preoperative average 5.8 mm). The traumatic re-rupture rate was 5.5 %. In two additional cases a partial rupture of the graft was analysed by arthroscopy. Growth deformities or leg length differences were not seen in any case. CONCLUSION: ACL reconstruction with hamstrings and extracortical fixation showed good results and might be the treatment of choice in immature patients. The complication rate was low and there were no postoperative growth deformities.

Multicenter-study of operative treatment of intraligamentous tears of the anterior cruciate ligament in children and adolescents: comparison of four different techniques.

Tears of the anterior cruciate ligament in skeletally immature patients were operated with four different methods and their outcome compared to each other. Sixty-eight patients (33 males, 35 females), mean 12.5 years, were treated in four different centers from 1984 to 2001. Twenty-eight patients underwent the ACL-reconstruction with hamstring grafts, 16 patients with bone-patella-bone autografts, 12 patients with quadriceps grafts and 12 patients with facia lata. The mean follow-up was 32 months. Postoperative evaluation included radiographs, KT-1000/2000 stability measurements, Lysholm score, The Tegner activity scale and IKDC score. Neither leg length discrepancy nor angular deformities were noted. Mean KT-1000 difference was 2.1 mm, mean postoperative Lysholm knee score 93.3, IKDC 87% normal or nearly normal. The Tegner index decreased from 6.6 to 5.7. In total, six patients developed instability due to an adequate trauma 1 year after the index operation. Two patients showed mild arthrotic changes. All but two patients were able to return to the same level of preoperative sports participation. None of the four methods studied showed major differences in outcome compared to the other. No growth disturbance could be noted.

[Anterior cruciate ligament reconstruction with hamstring tendons in the young]. / Die vordere Kreuzbandplastik mit Hamstringsehnen bei Kindern und Jugendlichen.

Regarding the controversial discussion about how and when to operate a patient with an ACL lesion and still open physes,we routinely perform ACL reconstruction in those patients. We evaluated 30 patients with a mean age of 14.2 years at the time of operation (range: 10-18) and a mean follow-up of 30.8 months (range: 13-77). The ACL reconstruction was performed using a four-strand hamstring graft. Fixation was strictly extracortical using an endobutton and a suture washer. The placement of the graft was transepiphyseal. Using the IKDC score, 86.7% were classified as normal or nearly normal. In three cases an ACL insufficiency recurred during the first 12 months postoperatively. There was no growth disturbance. Expecting a poor outcome when treating an ACL lesion conservatively during the growth period and carefully performing the operation, we were able to show that the method provided satisfactory results and should be considered an operative method of choice.

Primary ACL reconstruction with fresh-frozen patellar versus Achilles tendon allografts.

BACKGROUND: In recent years, there has been an interest in the use of allografts as an alternative graft for anterior cruciate ligament (ACL) reconstruction to reduce potential donor-site morbidity resulting from the harvest of autogenous tissue. Nevertheless, in the literature, the use of allografts for primary ACL reconstruction is controversial due to a higher failure rate and the potential risk of disease transmission. METHOD: In this retrospective study, we evaluated the clinical outcome of 251 fresh-frozen patellar vs Achilles tendon allografts for primary ACL reconstruction. Patients (average age 39 years) were operated on between 1993 and 1998, and the mean follow-up was 37.7 months (range 24-74 months). We were able to follow up 225 patients (89.6%). According to the different types of allograft, we divided the patients into two groups: group P with patellar bone-tendon-bone allograft (BTB; n=183) and group A with Achilles bone-tendon allograft ( n=42). Clinical evaluation consisted of a history, an examination, IKDC Score, Cincinnati Knee Score (CKS), Cincinnati Sports Activity Scale (CSAS), KT-1000 testing, and standardized X-rays. RESULTS: According to the IKDC, the outcome was normal or nearly normal in 75.3% in group P and 76.2% in group A. Overall rating according to the CKS was an average of 85 in group P and 82.9 in group A. CSAS was 79.6 in group P and 84.8 in group A. The objective stability measured with the KT-1000 showed an average side-to-side difference of 2.1 mm in group P and 2.0 mm in group A. 4.4% of group P and 2.5% of group A were considered a laxity failure, and 10.4% of group P and 4.8% of group A re-ruptured the reconstructed ACL. In summary, there was a significantly higher failure rate ( p<0.001) in group P compared with group A. CONCLUSION: Satisfactory clinical results can be achieved with the use of allografts for primary ACL reconstruction. Comparing Achilles tendon and patellar BTB allografts, the Achilles tendon-bone allograft seems to be advantageous for ACL reconstruction as the failure rate was significantly lower. Nevertheless, the total failure rate appears to be much higher compared with autogenous ACL reconstruction, indicating that the use of an allograft for routine uncomplicated primary ACL reconstruction offers few advantages. Therefore, autograft tissue remains our graft of first choice for this procedure. We advise reserving allografts for revision procedures where suitable autogenous tissues have been previously compromised, where a contraindication for autogenous tissue harvest exists, or for multiple ligament surgery.

[Primary- and revision-reconstruction of the anterior cruciate ligament with allografts: a retrospective study including 325 patients]. / Allogene Transplantate zur Rekonstruktion des vorderen Kreuzbandes bei Primär- und Revisionseingriffen.

UNLABELLED: At our institution we have used fresh-frozen allografts for the reconstruction of the anterior and posterior cruciate ligament since 1993. METHOD: In this retrospective study we evaluated the clinical outcome of 325 fresh-frozen allografts (bone-patellar-tendon-bone allografts and Achilles-bone-tendon allografts) for primary and revision ACL-reconstruction. Patients (average age 38 years) were operated between 5/1993 and 2/1998 and mean follow-up was 38 (range 24 to 71) months. Clinical evaluation consisted of a case history, an examination, IKDC, Cincinnati knee score (CKS), KT-1000 testing and standardized X-rays. RESULTS: Overall subjective rating according to the CKS was more than 82 points for both groups. Objective results according to the IKDC were normal or nearly normal in 75.6 % of primary- and 67.0 % of revision-ACL reconstructions. The stability measured with the KT-1000 showed an average maximum side to side difference of 2.1 mm for primary ACL reconstruction and 2.3 mm for revisioners. The total failure-rate (= rerupture-rate + laxity-failures) was 13.7 % for primary and 15.0 % for revision ACL reconstructions. CONCLUSION: Given the increased failure-rate, autograft tissue remains our graft of first choice for primary ACL-reconstruction. We advise to reserve allografts for revision procedures where suitable autogenous tissues have been previously compromised, where a contraindication for autogenous tissue harvest exists or for multiple ligament surgery. No specific complications were observed with the use of allograft tissue.

Clinical evaluation of meniscus repair with a bioabsorbable arrow: a 2- to 3-year follow-up study.

In a clinical study with the bioabsorbable Bionx Meniscus Arrow we prospectively evaluated 113 consecutive patients (113 menisci) after all-inside meniscus repair. Repairs were performed in either the medial (80.5%) or lateral (19.5%) posterior horn in the red-red or red-white meniscal zone; 66% of patients underwent concomitant ACL reconstruction. Assessment was based on history, clinical examination, and Lysholm [37] and Cincinnati Knee Scores. After a mean follow-up was 33 months (range 24-43; n=105) 21 (20%) patients showed signs and symptoms consistent with a meniscus tear (16 medial, 5 lateral) and underwent partial meniscectomy. In 11 (52%) of the revised patients concomitant ACL reconstruction was performed; 4 (19%) of revised patients were older than 35 years. In the nonrevised the average Lysholm Score was 92.5 and the average Cincinnati Score 90.4. Two patients showed a distinct femoral cartilage damage. Patient's age did not significantly affect the revision rate. Meniscus repair with the bioabsorbable arrow leads to clinical results comparable to those of traditional suture techniques. When stabilized, patients with concomitant ACL reconstruction showed comparable results to patients without ACL rupture. The simple and time saving all-inside insertion obviates the need for additional incisions and avoids knot tying. A proper tear selection and arrow positioning is necessary and should avoid cartilage damage.

A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: extracortical versus anatomical fixation.

Changes in the femoral and tibial bone tunnel were studied prospectively after arthroscopic ACL reconstruction with quadruple hamstring autograft. To determine whether tunnel enlargement can be decreased by fixing the graft close to the joint line having a stiffer fixation construct we compared "anatomical" (one absorbable interference screw femorally, and bicortical fixation with two absorbable interference screws tibially) and extracortical fixation techniques (Endobutton femorally, and two no. 6 Ethibond sutures over a suture washer tibially). Over a 2-year period we evaluated 60 patients clinically (IKDC scale, Cincinnati Knee Score, KT-1000) and radiographically (confirmed by MRI). The operated knee was radiographed immediately postoperatively and 6 and 24 months postoperatively. The femoral and tibial bone tunnel diameter was measured on anteroposterior and lateral images, and the tunnel area was calculated and compared to the initial area calculated from the perioperative drill size. In the "anatomical" group the immediately postoperative bone tunnel area was 75% larger than the initial tunnel area, after 6 months it was increased another 31%, and between 6 and 24 months it remained basically unchanged. In the "extracortical" group there was no significant enlargement immediately postoperatively, but after 6 months it was 65% larger than the initial area of drill and graft size, and between 6 and 24 months it decreased to 47%. There was no correlation between the amount of tunnel enlargement and clinical scores or KT-1000 measurement. Arthroscopic ACL reconstruction with quadruple hamstring autograft is associated with bone tunnel enlargement. Using a purely extracortical fixation technique thus significantly increased the tibial and femoral tunnel area during the first 6 postoperative months, while it decreased slightly thereafter. The insertion of large interference screws apparently not only compresses the graft in the bone tunnel but also significantly enlarges the bone tunnel itself. The immediate enlargement at the time of the operation is followed by a reduced further enlargement at 6 months and then stabilization. Tunnel widening did not influence clinical outcome over a 2-year period.

A new bicortical tibial fixation technique in anterior cruciate ligament reconstruction with quadruple hamstring graft.

We report a prospective series of 101 patients receiving a four-strand semitendinosus-gracilis autograft for anterior cruciate ligament reconstruction using a new bicortical tibial fixation technique with bioabsorbable interference screws. Patients (average age 32 years) were operated on between November 1997 and Mai 1998, and follow-up was at least 12 months postoperatively. The evaluation consisted of history, clinical examination, IKDC score, Cincinnati Knee Score, KT-1000 testing, standardized radiography and magnetic resonance imaging. One hundred patients were available for follow-up. There were two traumatic reruptures 6 and 11 months postoperatively. By IKDC score 87 patients were in groups A and B, 12 in group C, and 2 with a rerupture in group D. Mean Cincinnati Knee Score was 82 (range 46-100), KT-1000 manual maximum at follow-up showed an average difference of 1.7 mm between the sides. Full extension was rapidly achieved in all cases, and flexion averaged 135 degrees . Considering the enlargement caused by the bioabsorbable interference screws, the incidence of tunnel widening was 6.6% on the femoral side and 1.7% on the tibial side. Tunnel widening did not affect the clinical results. Three patients experienced an effusion after more than 6 months postoperatively. There was one infection, which settled without functional impairment after early arthroscopic lavage and intravenous antibiotics. Otherwise no complications occurred. The described technique for anterior cruciate ligament reconstruction combines the advantage of anatomical graft position with sufficient graft fixation. A short intra-articular graft construct with a strong tendon to bone interface was created. Clinically, 87% of patients had a normal or nearly normal IKDC score at follow-up. Magnetic resonance imaging revealed a considerable increase in tunnel area caused by the insertion of the interference screws. On the other hand, the development of a "fibrous interzone" between the graft and the bone tunnel was prevented in most cases. At short-term follow-up the bicortical tibial fixation proved to be efficient even with an aggressive rehabilitation program.

Ultrasonographically guided needle biopsy of benign and malignant soft tissue and bone tumors.

In 65 patients an ultrasonographically guided needle biopsy was performed for histologic diagnosis of benign and malignant soft tissue and bone tumors. On the basis of the histopathologic findings, a final diagnosis could be made in 54 cases after sonographically guided needle biopsy of the soft tissue tumor component. In addition, tumor grouping was possible in seven cases; however, due to the small volume of the biopsy specimen, further tumor differentiation proved to be unsuccessful. A definite diagnosis was not possible in four patients, who had mainly cystoid tumors; however, malignancy could be ruled out in three of these cases. The decisive advantage of the ultrasonographically guided needle biopsy procedure over what is known as a blind tumor biopsy is that the biopsy needle can be positioned exactly by means of imaging control. The ultrasound screen enables the user to monitor the biopsy procedure; multiple biopsies of different parts of the tumor soft tissue component can be performed using a single needle tract. No complications occurred in our study. Because of the far-reaching consequences of ultrasonographically guided needle biopsy, this type of procedure should be performed only at tumor centers.

[Pseudotumor cerebri caused by Lyme borreliosis]. / Pseudotumor cerebri forårsaget af Lyme-borreliose.

Lyme borreliosis may cause a wide range of clinical symptoms. The two previously described paediatric cases of Lyme borreliosis with symptoms of pseudotumor cerebri were associated with characteristic cutaneous symptoms. A case of seven year-old girl with six weeks of headache, vomiting nausea and fatigue as the only symptoms was shown to suffer from pseudotumor cerebri with papilloedema and increased intracranial pressure caused Borrelia burgdorferi. Specific treatment with intravenous penicillin and later intravenous ceftriaxone (due to development of penicillin allergy) for a total of ten days caused the symptoms to gradually disappear over following three to four weeks. Hence, even if pseudotumor cerebri is the only symptom, it is recommended that testing for Lyme borreliosis should be carried out.

The effect of cisapride and metoclopramide on human digestive and interdigestive antroduodenal motility.

BACKGROUND: To date, there is little information available about the effect of cisapride and metoclopramide on gastroduodenal pressure waves and their space/time orientation. METHODS: Antroduodenal pressures (two antral, three duodenal recording sites) were measured in nine healthy volunteers. Cisapride (10 mg), metoclopramide (10 mg), and placebo were administered intravenously on different days in a randomized manner. RESULTS: During the interdigestive state cisapride increased the motility index significantly in the antrum (p < 0.05) and duodenum (p < 0.005), metoclopramide only in the duodenum (p < 0.01). Antroduodenal coordination was significantly (p < 0.01) improved by cisapride but not by metoclopramide. There is evidence of antroduodenal coordination even during the interdigestive state. After a liquid test meal an increase in the antroduodenal motility index (p < 0.05), in the rate of prograde antroduodenal peristalsis (p < 0.01), and in antroduodenal coordination (p < 0.01) was caused by cisapride but not metoclopramide. Both prokinetics decreased (p < 0.01) retrograde antroduodenal peristalsis. CONCLUSION: Cisapride significantly improves antroduodenal coordination and antroduodenal motility; metoclopramide seems to be less effective.

Myoelectric and manometric patterns of human rectosigmoid colon in irritable bowel syndrome and diverticulosis.

Rectosigmoid electric control activity and intraluminal pressure were measured in the fasting state and after a standard 3040-kJ meal in irritable bowel syndrome (IBS) patients (n = 41), diverticulosis patients (n = 15), and healthy controls (n = 13). Analysis of myoelectric and motor patterns was performed computer-based with home-made software. Spectral analysis (fast Fourier transform) and computer recognition of slow waves emulating visual scoring showed very similar slow-wave frequency patterns in all three groups. Calculation of contractile indices displayed a widely scattered variable of motility in all three groups without significant differences. IBS subgroups with different bowel patterns showed very similar frequencies of basic myoelectric rhythm and a considerable overlap of contractile activity without significant differences among the subgroups and compared with controls. Slow-wave rhythm seems unlikely to be the basis of disturbed motility in IBS and diverticular disease. A specific pattern of contractile activity was not detectable in either condition.

[Antroduodenal coordination]. / Antroduodenale Koordination.

The function of the antro-duodenal segment depends on the spatial and temporal sequence of contractions. This process can be defined as antroduodenal coordination. There is no constantly increased pressure in the antro-duodenal transition zone. During the interdigestive phase a coordination of gastral and duodenal motility, gastric acid secretion and bile-flow into the duodenum can be demonstrated. During phase II of the interdigestive phase a pressure gradient, proximal and distal, is observed in the gastroduodenal transition zone with peak values in the pyloric and duodenal bulb area. Cisapride and metoclopramide stimulate antral and duodenal motility, cisapride causes a significant increase in gastroduodenal coordination.