Similar cost-utility for double- and single-bundle techniques in ACL reconstruction.

PURPOSE: The aim was to estimate the cost-utility of the DB technique (n = 53) compared with the SB (n = 50) technique 2 years after ACL reconstruction. METHODS: One hundred and five patients with an ACL injury were randomised to either the Double-bundle (DB) or the Single-bundle (SB) technique. One hundred and three patients (SBG n = 50, DBG n = 53) attended the 2-year follow-up examination. The mean age was 27.5 (8.4) years in the SBG and 30.1 (9.1) years in the DBG. The cost per quality-adjusted life years (QALYs) was used as the primary outcome. Direct costs were the cost of health care, in this case outpatient procedures. Indirect costs are costs related to reduce work ability for health reasons. The cost-utility analysis was measured in terms of QALY gained. RESULTS: The groups were comparable in terms of clinical outcome. Operating room time was statistically significantly longer in the DBG (p = 0.001), making the direct costs statistically significantly higher in the DBG (p = 0.005). There was no significant difference in QALYs between groups. In the cost-effectiveness plane, the mean difference in costs and QALYs from the trial data using 1000 bootstrap replicates in order to visualise the uncertainty associated with the mean incremental cost-effectiveness ratio (ICER) estimate showed that the ICERs were spread out over all quadrants. The cost-effectiveness acceptability curve showed that there was a 50% probability of the DB being cost-effective at a threshold of Euro 50,000. CONCLUSION: The principal findings are that the DB is more expensive from a health-care perspective. This suggests that the physician may choose individualised treatment to match the patients' expectations and requirements.

Pre-operative factors predicting good outcome in terms of health-related quality of life after ACL reconstruction.

The life situation of many patients changes after an anterior cruciate ligament (ACL) rupture and subsequent reconstruction, and this may affect their health-related quality of life in many ways. It is well known that the overall clinical results after ACL reconstruction are considered good, but pre-operative predictive factors for a good post-operative clinical outcome after ACL reconstruction have not been studied in as much detail. The purpose of this study was to identify pre-operative factors that predict a good post-operative outcome as measured by the Short Form 36 (SF-36) and Knee Osteoarthritis Outcome Score (KOOS) 3-6 years after ACL reconstruction. Seventy-three patients scheduled for ACL reconstruction were clinically examined pre-operatively. The SF-36 and KOOS questionnaires were sent by mail to these patients 3-6 years after reconstruction. Predictive factors for health-related quality of life were investigated using a stepwise regression analysis. In conclusion, pre-operative factors, such as pivot shift, knee function, and range of motion, may predict a good post-operative outcome and explain up to 25% in terms of health-related quality of life after ACL reconstruction. Furthermore, it appears that the patients' pre-injury and pre-operative Tegner activity levels are important predictors of post-operative health-related quality of life.

Outcome of anterior cruciate ligament reconstruction with emphasis on sex-related differences.

The aim of this retrospective study was to compare the results after arthroscopic anterior cruciate ligament (ACL) reconstruction using the four-strand semitendinosus-gracilis (ST/G) autograft in male (n=141) vs female (n=103) patients. The patients were operated on between 1996 and 2005, using interference screw fixation and drilling the femoral tunnel through the anteromedial portal. The pre-operative assessments and demographics, apart from age (males 29 years, females 26 years; P=0.02), were comparable at the time of surgery. At 25 (23-36) months post-operatively, no significant differences were found between the study groups in terms of anterior side-to-side knee laxity, manual Lachman test, Tegner activity level, Lysholm knee score, range of motion or donor-site morbidity. Both study groups improved significantly in most clinical assessments and functional scores compared with their pre-operative values. Two years after ACL reconstruction using ST/G autografts, there were no significant differences between male and female patients in terms of clinical outcome or functional scores.

Preconditioning patellar tendon autografts in arthroscopic anterior cruciate ligament reconstruction: a prospective randomized study.

This prospective randomized evaluated the effect of preconditioning patellar tendon autografts before implantation and fixation during anterior cruciate ligament (ACL) reconstruction. Fifty-three patients with a unilateral ACL rupture were included in the study. One group of patients had their patellar tendon autograft preconditioned by passive stretching at a constant load of 39 N for 10 min immediately prior to implantation (group P). The other group underwent no preconditioning before the implantation of the graft (group NP). The follow-up examination was performed by independent observers after 26 months (23-29) in group P and after 25 months (23-30) in group NP (n.s.). At follow-up the KT-1000 laxity test revealed a total side-to-side difference of 2.5 mm (-1.5 to +8.5) in group P and 3.0 mm (-7 to +6.5) in group NP (n.s.). The Lysholm score was 86 points (47-100) in group P and 94 points (44-100) in group NP (n.s.). The Tegner activity level was 6 (2-9) in group P and 7 (3-9) in group NP (n.s.). There was no significant difference between the study groups regarding IKDC classification. Patients who underwent ACL reconstruction using a preconditioned patellar tendon autograft had no advantages in terms of restoration of laxity or clinical outcome at 2-year follow-up.

Evaluation of the reproducibility of the KT-1000 arthrometer.

The aim of the study was to examine whether the KT-1000 arthrometer was reliable when it came to distinguishing between a group of patients with a chronic anterior cruciate ligament (ACL) rupture and a group of patients without an ACL rupture, and to examine the reproducibility of the examination between two experienced examiners. The aim was also to examine whether the KT-1000 measurements were dependent on whether the patients were awake or under anaesthesia. The study comprised 40 patients: Group A consisted of 20 patients who had a chronic unilateral ACL rupture and Group B consisted of 20 patients who were scheduled for arthroscopy due to knee problems other than an ACL rupture. The KT-1000 examination was performed before surgery by two experienced physiotherapists (PT I and PT II). PT II subsequently performed a retest of the patients under anaesthesia. The mean anterior side-to-side laxity difference between PT I and PT II was 0.2 mm in Group A and 1.8 mm in Group B (n.s., P=0.03). The anterior side-to-side measurements of knee laxity revealed significant differences between Group A and Group B, independent of who the measurements were made by when the patients were awake (PT I P=0.011, PT II P=0.001). However, no significant difference (P=0.063) was found when the patients were under anaesthesia. The interclass correlation coefficient (ICC) between PT I and PT II in Group A was 0.55 (P=0.005) for the anterior side-to-side laxity, while it was 0.60 (P=0.002) in Group B. There were no significant differences within Group A or Group B between the measurements made when people were awake compared with those under anaesthesia. The conclusions of the study were that the KT-1000 arthrometer was able to distinguish a group of patients with an ACL rupture from a group without one. The reproducibility of the KT-1000 measurements of anterior knee laxity between two experienced examiners was considered as fair. Furthermore, the measurements were not dependent on whether the patients were awake or under anaesthesia.

Comparison of traditional and subcutaneous patellar tendon harvest. A prospective study of donor site-related problems after anterior cruciate ligament reconstruction using different graft harvesting techniques.

Our goal was to compare the results after anterior cruciate ligament reconstruction using either the traditional one-incision or the subcutaneous two-incision technique to harvest the central third of the patellar tendon, particularly concerning disturbances in anterior knee sensitivity and the patient's ability to walk on his or her knees. One surgeon performed anterior cruciate ligament reconstruction on 124 patients with unilateral ruptures and no history of previous incisions in the anterior knee region. The traditional one-incision graft harvesting technique was used in 58 patients and the subcutaneous two-incision technique was used in 66 patients. At 2 years, the International Knee Documentation Committee classification, Lysholm score, arthrometry side-to-side difference, and single-legged hop test showed no significant differences between groups. The area of insensitivity was a median of 24 cm2 in the traditional harvest group and 0 cm2 in the subcutaneous harvest group. The patients with subcutaneous harvest had a tendency toward fewer problems during walking on their knees than did the patients with traditional harvest. Our conclusion is that the subcutaneous two-incision graft harvesting technique caused less disturbance in anterior knee sensitivity and a tendency of less discomfort during walking on one's knees than the traditional one-incision technique.

Absorbable implants for open shoulder stabilization: a clinical and serial radiographic evaluation.

PATIENTS AND METHODS: Eighteen consecutive patients who had recurrent, unidirectional, post-traumatic shoulder instability were included. All the patients underwent surgery with a standardized open Bankart technique involving absorbable suture anchors. CLINICAL RESULTS: No redislocations occurred during the study period of 31 months (range 25 to 38 months). The Rowe and Constant scores were 86 points (range 61 to 98 points) and 89 points (range 73 to 99 points), respectively. The strength measurements revealed 8.6 kg (range 3.8 to 15 kg) in 90 degrees abduction compared with 9.3 kg (range 2.2 to 16.5 kg) in the control shoulders (not significant). The external rotation in abduction was 65 degrees (range 20 degrees to 90 degrees) compared with 91 degrees (range 80 degrees to 105 degrees) in the control group (P < .001). RADIOGRAPHIC RESULTS: Signs of minor or moderate degeneration were found in 10 of 18 patients on the preoperative radiographs, in 15 of 18 at 7 months, and in 16 of 18 at 33 months (P < .05 before surgery vs 33 months). From the preoperative examination to the 7-month control, 7 of 18 patients had an increase in degenerative changes, and from the 7-month to the 33-month control, an increase was found in 8 of 18 (P = .008, before surgery vs 7 months; P = .005, 7 months vs 33 months). At the 7-month control, 8 of 18 patients had invisible or hardly visible drill holes, and 10 of 18 had visible or cystic drill holes at the site of implantation for the absorbable suture anchors. At the 33-month control, 10 of 18 patients had invisible or hardly visible drill holes, and 8 of 18 had visible or cystic drill holes (not significant, 7 months vs 33 months). CONCLUSION: The method resulted in stable shoulders in 17 of 18 patients. Degenerative changes were present on the radiographs in most of the patients and appeared to increase over time. Visible drill holes or drill holes with cystic changes were seen on the radiographs in a significant number of patients at the 7-month and the 33-month control and did not appear to heal during the follow-up period.

A clinical and radiographic comparison of absorbable and non-absorbable suture anchors in open shoulder stabilisation.

The aim of this study was to compare the clinical and radiographic results using either absorbable or non-absorbable suture anchors in patients with recurrent unidirectional, post-traumatic shoulder dislocations. All patients had a Bankart lesion. One surgeon operated on 33 consecutive patients, 27 males and six females. Group A comprised 15 shoulders and group B 18 shoulders, all of which underwent a standardised open Bankart reconstruction using 3.7-mm TAG suture anchors. In group A, absorbable anchors were used, while in group B, non-absorbable ones were used. There was one re-dislocation in each group. In group A, the Rowe and Constant scores were 89 (69-98) and 89 (76-99) points, respectively. The corresponding values in group B were 87 (44-98) (not significant; NS) and 90 (71-100) points (NS). The strength measurements revealed 8.1 (3.8-12.3) kg in 90 degrees abduction in group A and 10.0 (6.7-12.0) kg in group B. Healthy control shoulders revealed 10.2 (4.5-13.2) kg (NS A and B versus controls). The external rotation in abduction was 70 degrees (40-90) in group A and 80 degrees (40-100) in group B. The value for the controls was 90 degrees (80-120) [P < 0.001 (A versus controls), P < 0.05 (A versus B) and P < 0.001 (B versus controls)]. The radiographs revealed that 9/15 (60%) in group A and 10/15 (66%) in group B had visible drill holes or cystic formations in conjunction with the drill holes (NS). Furthermore, 11/15 (73%) in group A and 10/15 (66%) in group B had signs of minor degeneration (NS). We conclude that, in terms of stability and clinical results, no differences were found between the study groups. Both groups demonstrated a restriction in external rotation as compared with the healthy shoulders in the same cohort. On the radiographs, visible drill holes or cystic formations in conjunction with the drill holes were seen with equal frequency, regardless of whether absorbable or non-absorbable suture anchors were used.

Analysis of subjective, objective and functional examination tests after anterior cruciate ligament reconstruction. A follow-up of 527 patients.

This study included 527 patients (178 female and 349 male) with unilateral anterior cruciate ligament (ACL) rupture who underwent arthroscopic ACL reconstruction using bone-patellar tendon-bone autograft and interference screw fixation. The follow-up examination was performed by independent observers at a median of 38 (21-68) months after the index operation. At the follow-up, the Lysholm score was 86 (14-100) points, the Lysholm instability subscore was 22 (0-25) points and the Lysholm pain subscore was 19 (0-25) points. The Tegner activity level was 6 (1-10). The one-leg-hop test was 91 (0-167)% of the non-injured knee. The difference in the anterior side-to-side laxity as measured with the KT-1000 arthrometer at 89 Newton (N) was 1.5 (-5-13) mm and the total KT-1000 side-to-side difference at 89 N was 2 (-7-11) mm. Using the International Knee Documentation Committee (IKDC) evaluation system, 177 (33.6%) patients were classified as normal (group A), 211 (40%) as nearly normal (group B), 109 (20.7%) as abnormal (group C) and 30 (5.7%) as severely abnormal (group D). The highest correlation coefficients were recorded between the IKDC evaluation system and the Lysholm score (p = 0.66), the patients' subjective evaluation (p = 0.53), the Tegner activity level (p = 0.34), all the laxity tests (p > or = 0.34) and the one-leg-hop test (p = 0.28). The resumption of sporting activities and work as evaluated by the Tegner activity level correlated with the patients' subjective evaluation (p = 0.34) but did not correlate with the laxity tests, i.e., the manual Lachman test (p = -0.06) and the total and anterior KT-1000 tests (p = -0.06). Furthermore, none of the laxity tests correlated with the functional tests or the patients' subjective evaluation. We conclude that the IKDC evaluation system is a reliable and useful tool for evaluating the post-operative outcome after an ACL reconstruction.

Serial magnetic resonance imaging of the donor site after harvesting the central third of the patellar tendon. A prospective study of 37 patients after arthroscopic anterior cruciate ligament reconstruction.

The aim of this prospective study was to follow the development of repair tissue in the donor-site area using serial magnetic resonance imaging (MRI) evaluation and to assess whether the MRI findings were correlated with donor-site morbidity. Thirty-seven consecutive patients with unilateral anterior cruciate ligament injuries undergoing elective reconstruction of the ligament were included in the study. They were aged 27 (range 14-50) years. The graft was harvested through two 25-mm vertical incisions with the aim of protecting the infrapatellar nerve and sparing the paratenon. The tendon defect was left open. The patients underwent MRI evaluation at 6 weeks, 6 months and 27 months postoperatively. A final clinical follow-up was made 25 (range 23-29) months postoperatively. MRI demonstrated that the donor-site gap, i.e. the area corresponding to a pathological non-tendinous-like tissue signal, was 9 (range 4-18) mm at 6 weeks, 5 (range 2-14) mm at 6 months and 2 (range 0-5) mm at 27 months. The size of the donor-site gap had significantly decreased at 6 months compared with 6 weeks (P = 0.0001), as well as at 27 months compared with 6 months (P = 0.0001). We conclude that the patellar tendon at the donor site healed gradually, as expressed by a decrease in the area of non-tendinous-like tissue signal on the serial MRI evaluations.

Arthroscopic and open shoulder stabilization using absorbable implants. A clinical and radiographic comparison of two methods.

The aim of this study was to compare the clinical and radiographic results in patients with recurrent unidirectional, post-traumatic shoulder instability (dislocations/subluxations). All the patients had a Bankart lesion and underwent reconstruction using either an open or an arthroscopic technique and absorbable implants. Thirty-three consecutive patients (36 shoulders) were operated on by one surgeon. Group A comprised 18 shoulders which underwent an open Bankart reconstruction using absorbable 3.7-mm TAG suture anchors. Group B comprised 18 shoulders which underwent a combination of an intra- and extra-articular arthroscopic stabilization using 8-mm Suretac fixators. The median number of dislocations before the reconstruction was 5(0-45) in group A and 4 (0-30) in group B (NS). The follow-up examination was performed by an independent observer after a median of 31 (range 25-38) months in group A and 28 (range 18-46) months in group B (NS). An independent radiologist without any knowledge of the surgical procedure evaluated all the radiographs. There were no re-dislocations in either group. In group A, the Rowe and Constant scores were 86 (range 61-98) and 89 (range 73-99), respectively. The corresponding values in group B were 92 (range 83-98; P = 0.05) and 96 (range 75-100; NS). The external rotation in abduction was 65 degrees (range 20 degrees-90 degrees) in group A and 83 degrees (range 65 degrees-105 degrees) in group B (P = 0.0017). The radiographs revealed that 10/18 (56%) in group A and 4/18 (23%) in group B had visible drill-holes or cystic formations in conjunction with the drill-holes (P = 0.002). In this study the open procedure resulted in a restriction in external rotation more frequently than the arthroscopic procedure. The radiographs revealed visible drill-holes or cystic formations in conjunction with the drill-holes more frequently when TAG suture anchors were used than when Suretac fixators were used. The radiographic changes did, not appear to affect the clinical outcome, however.

Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace.

The aim of this study was to evaluate the effect of a standard postoperative rehabilitation knee brace on function, stability and postoperative complications at the 2-year follow-up after anterior cruciate ligament (ACL) reconstructive surgery. Seventy-eight consecutive patients with a unilateral chronic ACL rupture reconstructed by the same surgeon using the endoscopic "all-inside" technique, patellar tendon autograft and interference screw fixation were included in the study. The rehabilitation followed a standard protocol. Group A included 39 patients who were supplied postoperatively with a knee brace for 4 (range 3-6) weeks. Group B included 39 patients for whom a brace was not used. The median age was 27 (range 16-48) years in group A and 26 (range 14-51) years in group B. The median time period between the injury and the index operation was 24 (range 3-150) months in group A and 18 (range 3-360) months in group B. All 78 patients were re-examined by two independent observers after a median follow-up period of 25 (range 23-28) months in group A and 24 (range 22-27) months in group B. The median KT-1000 total side-to-side difference between the reconstructed and the uninjured knees at 89 N was 3 (range -5.5-11) mm in group A and 3 (range -7-10) mm in group B (NS). When the anterior translation was tested separately at 89 N, the corresponding values were 3 (range -4-13) mm in group A and 3 (range -5-10) mm in group B (NS). The median one-leg hop quotient was 95% (range 50%-167%) of the uninjured leg in group A and 92% (range 64%-119%) in group B (NS). The median Lysholm score was 89 (range 39-100) points in group A and 85 (range 37-100) points in group B (NS). In group A, 27/39 (69%) patients and in group B 21/39 (54%) patients were classified as excellent or good (NS). The median Tegner activity level was 7 (range 3-9) in group A and 6 (range 3-9) in group B (NS). Using the IKDC scale, 27/39 (69%) in group A and 24/39 (62%) in group B were classified as normal or nearly normal (NS). The median sick leave in group A was 62 (range 0-357) days and 59 (range 0-243) days in group B (NS). No serious complications occurred during the first 6 postoperative weeks. Two serious complications were, however, registered after the 6th postoperative week. One patient in group A sustained a rupture of the reconstructed ACL 8 weeks postoperatively (3 weeks after removing the brace), and one patient in group B sustained an undislocated patellar fracture during the 7th postoperative week after a fall. This study indicates that the use of a postoperative rehabilitation brace after an arthroscopic ACL reconstruction did not appear to influence either objective stability or subjective function by the 2-year follow-up.