Magnetic resonance imaging measurement of the contralateral normal meniscus is a more accurate method of determining meniscal allograft size than radiographic measurement of the recipient tibial plateau.

PURPOSE: The purpose of this study was to develop and validate magnetic resonance imaging (MRI) scanning of the contralateral meniscus as a more accurate method of determining the needed size of a meniscal allograft than the traditional method of inferring meniscal size from radiographic measurement of the ipsilateral tibial plateau. METHODS: Tissue bank meniscal size records from the left and right knees of 500 meniscal donors were analyzed for symmetry. The menisci of 10 cadaveric knees were then sized indirectly via the radiographic tibial plateau method and directly via MRI and actual physical measurement. The MRI and radiographic methods were then compared. Statistical analysis was carried out to determine error rates for each imaging method by comparison to the physical meniscal measurements. RESULTS: Of the 500 pairs of menisci, 97% were found to be within 3 mm of each other in both the anterior-posterior and medial-lateral dimensions. In the cadaveric study MRI measurement predicted actual meniscal size significantly better than the radiographic tibial plateau method. CONCLUSIONS: Human knee menisci are bilaterally symmetric in size. Direct MRI measurement of the contralateral intact meniscus better predicts actual meniscal size than estimation of size indirectly from measurement of the tibial plateau on which it is located. We, therefore, propose contralateral MRI meniscal measurement as a new gold standard to size menisci before transplantation. LEVEL OF EVIDENCE: Level II, diagnostic study of consecutive patients with a universally applied gold standard.

A meta-analysis of stability after anterior cruciate ligament reconstruction as a function of hamstring versus patellar tendon graft and fixation type.

PURPOSE: Four-strand hamstring graft (4HS) is stronger than 10-mm bone-patellar tendon-bone graft (BPTB) and has equal tunnel pullout strength, but is believed by some to produce lower rates of stability after anterior cruciate ligament reconstruction (ACLR). Our purpose was to test the hypothesis that 4HS ACLR with modern fixation would produce equal or greater stability than BPTB ACLR. TYPE OF STUDY: Meta-analysis. METHODS: A computer search was used to find all published reports of ACLR series using HS and/or BPTB. Inclusion criteria were minimum 24-month follow-up, stratified presentation of arthrometric stability data, and at least 30-lb arthrometric testing force. Twenty-four 4HS, 8 2-strand hamstring (2HS), and 32 BPTB series met these criteria and were subdivided into groups according to fixation type. We used the International Knee Documentation Committee classification of a side-to-side instrumented Lachman test difference of < or = 2 mm as normal stability, and > 5 mm difference as abnormal stability. Series with at least 80% normal and at most 3% abnormal stability were designated as high-stability. Meta-analytic methods were used to determine group level differences. RESULTS: Total 4HS had a higher normal stability rate than total BPTB: 77% versus 66%, P < .001; and lower abnormal stability: 4.4% versus 5.9%, P = .029. The 4HS ACLR using the EndoButton (Smith & Nephew Endoscopy, Andover, MA) and second-generation tibial fixation (EB2-4HS) had higher normal stability (80%) and lower abnormal stability (1.7%) than all other subgroups, including BPTB with 2 interference screws (70% normal, 5.0% abnormal) P < .001; 84% of the series in the EB2-4HS group were high-stability series. No more than 33% of the series from any other group were high-stability. CONCLUSIONS: The recent literature would suggest that 4HS ACLR produces higher stability rates than BPTB, that 4HS stability rates are fixation dependent, that aperture fixation offers no stability advantage, and that EndoButton with second-generation tibial fixation produces consistently high stability rates. LEVEL OF EVIDENCE: Level IV.

Posterior mini-incision technique for hamstring anterior cruciate ligament reconstruction graft harvest.

PURPOSE: This study presents a new approach to hamstring graft harvest. The hypothesis tested was that this approach, the posterior mini-incision technique, would result in (1) consistent semitendinosus (ST) and gracilis (Gr) tendon identification, (2) consistent identification and sectioning of the accessory semitendinosus tendon, (3) virtual elimination of the risk of cutting hamstring grafts short, (4) excellent safety, and (5) a small anterior incision with excellent cosmesis. TYPE OF STUDY: Surgical technique. METHODS: Two-hundred three consecutive primary hamstring anterior cruciate ligament reconstructions were performed in skeletally mature patients using this technique. Of these, 185 were located and 175 were clinically evaluated. Follow-up was 24 to 113 months. Ninety patients completed a brief cosmesis questionnaire. Seven fresh-frozen knees were dissected. The locations of the ST and Gr tendons were identified in the popliteal fossa along a medial-to-lateral axis for purposes of incision placement. The location of the accessory ST was documented and the distance from the posterior incision to the popliteal artery was measured. RESULTS: There were no complications referable to graft harvest. No tendon was cut short. The posterior graft harvest mini-incision and the anterior tibial fixation/tibial tunnel mini-incisions were each usually about 1 inch in length. Cosmesis evaluation showed that 80% of patients thought their incisions looked better than the incisions of others they had seen who had had anterior cruciate ligament reconstruction. None thought them worse. Cosmesis was important to a majority of patients. CONCLUSIONS: The posterior mini-incision technique facilitated safe, rapid hamstring graft harvest and virtually eliminated the risk of cutting tendons short. Cosmesis was excellent, and was important to patients. LEVEL OF EVIDENCE: Level V.

Stability results of hamstring anterior cruciate ligament reconstruction at 2- to 8-year follow-up.

PURPOSE: The purpose of this study was to test the hypothesis that hamstring (HS) anterior cruciate ligament (ACL) reconstructions using EndoButton (Smith & Nephew, Andover, MA) femoral and whipstitch/screw tibial fixation can produce a high rate of objective stability in a population of reconstructed patients with low morbidity. TYPE OF STUDY: Case series. METHODS: We retrospectively reviewed 153 consecutive primary HS ACL reconstructions in skeletally mature patients without other ligament reconstructions. All knees had EndoButton femoral and whipstitch/screw tibial fixation; 139 patients were located and 133 were tested. Thirteen were geographically distant and tested subjectively only. Evaluations included KT-1000 testing; radiographs; and Noyes, Lysholm, and Single Assessment Numeric Evaluation (SANE) ratings. Follow-up was 24 to 104 months (mean, 54.4 months). RESULTS: There were no graft failures. No patient had rupture of an implanted graft. No patient had repeat surgery for instability; 96.9% of reconstructions had maximum manual side-to-side differences of < or =3 mm, 85.7% had < or =2 mm; 3% of the knees had a 4-mm difference; none had > or =5-mm difference. There was no objective stability difference between male and female patients and no deterioration in results with increasing follow-up time. Median ratings were: Noyes, 94; Lysholm, 94.5; and SANE, 90. Radiographs showed that no EndoButtons had migrated. No EndoButton or tibial screw had to be removed due to symptoms from the implant. One hundred eighteen of 120 patients had full extension; the other 2 patients had a 2 degrees flexion loss. One patient required repeat arthroscopy for arthrofibrosis but had full range of motion at follow-up. There were no deep knee infections. One patient had a superficial wound infection requiring intravenous antibiotics. One patient had a calf deep vein thrombosis that resolved with treatment. CONCLUSIONS: Hamstring ACL reconstructions can produce (1) reliable, durable stability in both males and females with no graft failures, (2) good clinical ratings, (3) excellent range of motion, and (4) low morbidity, without hardware problems. LEVEL OF EVIDENCE: Level IV, Case Series.