Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction: A 5-year follow-up.

PURPOSE: To compare the long-term results of allograft versus autograft central one-third bone-patellar tendon-bone reconstruction of the anterior cruciate ligament (ACL), 2 groups of 30 patients were evaluated subjectively and objectively at an average follow-up of 63 months (range, 55 to 78 months). TYPE OF STUDY: A prospective nonrandomized study. METHODS: All surgeries were performed endoscopically by a single surgeon using metal interference screw fixation between May 1991 and November 1992. Early aggressive rehabilitation was employed and follow-up visits at 3, 6, 12, 24, and 60 months noted swelling, pain, range of motion, and patellofemoral crepitus, and Lachman test, pivot shift test, and side-to-side arthrometer differences. RESULTS: Results were analyzed using 2-sample t test and chi-square analysis. Average age at surgery for autografts was 25 years (range, 14 to 49) and for allografts was 28 years (range, 14 to 53). The presence of meniscal tears were similar (allografts, 23 tears; autografts, 19 tears). At follow-up, no statistically significant difference was found for the presence of pain, giving way, effusion, Lachman and pivot shift results, or arthrometer measurements. Two patients, 1 allograft and 1 autograft had complete rupture of their grafts. There was no late stretching out of either graft and patients stable at 2 years were stable at 5 years, with the exception of the 1 ruptured graft in each group. CONCLUSIONS: A trend toward a greater incidence of glide on pivot testing was seen in the allografts (4 allografts v 2 autografts) but was present at 2 years and did not change at 5 years. A trend toward greater loss of extension in autografts (2.47 degrees ) than allografts (1.07 degrees ) was seen at 5-year follow-up, not seen at 2 years.

Meniscal allograft transplantation: a 1- to 5-year follow-up of 22 patients.

SUMMARY: Between October 1991 and December 1995, a total of 22 patients (23 knees) underwent meniscal transplantation with nonirradiated, cryopreserved allografts. Implantation was arthroscopically assisted using bone plugs to prevent meniscal extrusion and maintain weight-bearing functional position. Patients were evaluated with an average follow-up of 40 months (range, 13 to 69 months) using the International Knee Documentation Committee, Lysholm, and Tegner scoring systems. The most significant finding was pain reduction after implantation. Lateral and standing anteroposterior radiographs were obtained on all patients at follow-up with an average joint space loss of 0.882 mm (range, 0 to 3 mm). Magnetic resonance imaging was preformed on both knees in 12 of the 22 patients at an average of 24.4 months postoperatively. On average, the allograft meniscus was 63% (range, 31% to 100%) the size of the normal meniscus. Clinical results showed improvement of preoperative pain in all patients. Although patients continue to have good pain relief following their meniscal allograft transplantation, the average shrinkage in the size of the meniscus as shown on magnetic resonance imaging is a concern.

Use of allografts in knee reconstruction: II. Surgical considerations.

The first allograft used in the knee was articular cartilage. The need to use fresh grafts and the absence of proper instruments for shaping and sizing implants have prevented widespread usage of articular cartilage allografts. Patient selection is very important; young, active, well-motivated individuals with defects smaller than 4 cm2 caused by trauma or osteochondritis dissecans have the best results. Failure is evidenced by crumbling of the supporting bone and fragmentation of the graft, a process identical to that seen in osteonecrosis. The use of allografts to reconstruct knee ligaments has gained wider acceptance. The availability of high-quality tissue from modern tissue banks, excellent preservation methods, a decrease in short-term surgical morbidity, and results at 2- to 5-year follow-up that are essentially equivalent to those obtained with autogenous grafts have combined to make allografts an alternative to using the patient's own tissue. However, long-term stability results are needed for comparison with autogenous grafts. Replacing an unsalvageable meniscus with an allograft is an appealing concept, with the potential for restoring normal load distribution, lubrication, and stability in the knee. Healing of the grafts and pain reduction have been reported by several investigators, but concerns about graft shrinkage, central hypocellularity, and long-term functional survival remain.

Use of allografts in knee reconstruction: I. Basic science aspects and current status.

Allografts were first used in reconstructive surgery of the knee early in this century. Their widespread use and acceptance paralleled the development of modern tissue banks and our increased understanding of the immune system. Advantages of allogeneic tissue use include less surgical morbidity, shorter surgical time, smaller incisions, and the wider selection of graft sizes and types of tissue. Disadvantages include the risk of disease transmission, a slower biologic remodeling process, and the potential for a subclinical immune response. Allografts can be obtained in several forms, including fresh, fresh-frozen, freeze-dried, and cryopreserved, each with its own advantages and disadvantages. Graft sterility is most commonly ensured by aseptic techniques of harvest and procurement. Other methods, such as irradiation and chemical sterilization, have the potential to damage the collagen structure of the graft and must be used with care. Surgeons who use allografts should make sure that the tissue bank supplying their graft adheres to any applicable guidelines of the Food and Drug Administration and the American Association of Tissue Banks, and uses top-quality testing procedures. In addition, the physician should thoroughly understand the structural and biologic influence of the preservation technique used for that tissue.

Early season anterior cruciate ligament tears. A treatment dilemma.

An anterior cruciate ligament tear before or early in an athlete's season presents a treatment dilemma: surgically repair the ligament and end the season, or use rehabilitative exercises and bracing to quickly return the athlete to play. We conducted a prospective study of 43 athletes (44 acute tears) over 44 months to determine criteria for early return to play and if an early return is safe. All patients had an acute injury in a previously normal knee, a positive Lachman test, and KT-1000 arthrometry indicating ligament abnormalities. Magnetic resonance imaging of each injured knee showed an interior cruciate ligament tear but no meniscal tear. Thirty patients (31 tears) returned to play with rehabilitation and a brace at an average of 5.7 weeks after injury: Only 12 patients returned to their sports without recurrent buckling of their injured knees; 18 patients (19 knees) had recurrent buckling during play. Thirteen patients could not return to play. Patients were observed until they 1) had ligament reconstruction (29 patients, 29 tears), 2) gave up their sports because of instability but did not elect surgery (3 patients), or 3) returned to play in a brace and declined surgery (11 patients, 12 tears). All who elected reconstruction experienced recurrent knee buckling. We found 23 meniscal tears (17 knees) in the 29 patients undergoing reconstruction.

Autograft versus allograft anterior cruciate ligament reconstruction.

To compare the efficacy of allograft versus autograft central one third patella bone-tendon-bone reconstruction of anterior cruciate ligaments (ACL), subjective and objective criteria were compared between two groups of 30 patients with 2-year follow-up. Over a 15-month period, 60 patients underwent ACL reconstruction with 30 allografts and 30 autografts. One surgeon performed all reconstructions, and interference fit screw fixation was used. An early rehabilitation protocol was instituted. At 3, 6, 12, and 24 months, allograft and autograft groups were compared based on side-to-side arthrometer difference, swelling, pain, range of motion, patellofermoral pain and crepitation, Lachman's test, pivot shift test, and side-to-side thigh circumference difference. Average age in the autograft group was 25 years (range, 15 to 43; standard deviation, 8.1), and in the allograft group was 27 years (range, 15 to 55; standard deviation, 10.9). Thirteen meniscectomies and 12 meniscal repairs were performed at the time of ACL autograft. Fifteen patients in the allograft group had meniscectomies, and 10 had meniscal repairs. There were 15 acute and 15 chronic injuries in the allograft group and 24 acute and 6 chronic in the autograft group. Results were analyzed using a chi-square test, and no statistical differences between groups were shown at 3, 6, 12, or 24 months for swelling, pain, side-to-side arthrometer difference, pivot shift test, range of motion, patellofermoral pain and crepitation, or Lachman's test comparisons. There was a trend for more of the allografts (20%) to have a glide on pivot shift at 24 months than autografts (7%). At 12 and 24 months, there was no difference in patellofermoral crepitus or thigh circumference. Complications included two patients with superficial infections.

Acute atraumatic compartment syndrome in an athlete: a case report.

OBJECTIVE: To present the case of a college football player with acute, atraumatic, exercise-induced compartment syndrome in the leg. BACKGROUND: Acute, atraumatic, exercise-induced compartment syndrome is an infrequently reported cause of leg pain in the athlete. If left untreated, acute compartment syndrome can cause muscle necrosis. DIFFERENTIAL DIAGNOSIS: Chronic exertional compartment syndrome, medial tibial syndrome, stress fracture. TREATMENT: Treatment consists of compartment fasciotomy. UNIQUENESS: This previously healthy, but unconditioned, athlete developed severe anterolateral left leg pain after two days of fall practice in which he was unable to run a mile in 7.5 minutes. Physical examination by the team physician revealed acute compartment syndrome, and an emergency anterolateral compartment fasciotomy was performed. Second-look débridement performed 48 hours later revealed no significant change in the necrotic appearance of the anterior compartment soft tissue. Therefore, the dead muscle was completely débrided, and a free-flap latissumus dorsi graft was used for coverage of the wound. With recovery, strength returned to normal in the lateral compartment but remained 0/5 in the anterior compartment. The patient had persistent sensory loss in the distributions of the superficial and deep peroneal nerves. CONCLUSIONS: Although much less common than the more frequent causes of leg pain (ie, chronic exertional compartment syndrome, medial tibial syndrome, stress fracture), acute compartment syndrome is potentially more devastating. When the increased intracompartmental pressure within a closed tissue space exceeds capillary perfusion pressure, tissue perfusion is decreased, the soft tissue becomes ischemic, and cells die. The most important clinical diagnostic signs of compartment syndrome are pain with passive stretching of the compartment and pain out of proportion to the results of the physical examination.

Deltoid and syndesmosis ligament injury of the ankle without fracture.

Ankle diastasis without fracture is a rare injury with few examples reported. We report on four male patients, aged 16 to 18 years, who sustained this injury playing football. Swelling and tenderness over both the deltoid and syndesmosis ligaments are the most common physical findings. Plain ankle radiographs demonstrated lateral talus subluxation in three patients, and a stress radiograph demonstrated subluxation of the talus in one patient. Treatment consisted of reduction and fixation of the syndesmosis with a screw followed by 6 weeks of cast immobilization. Using the scale developed by Edwards and DeLee, three patients had excellent results and one had a good result. Diagnosis of tears of the deltoid and syndesmosis ligaments without fracture requires a high index of suspicion on the physician's part. In patients whose mortise is more than 1 mm subluxated, reduction and screw fixation will produce good results.

Meniscus replacement with bone anchors: a surgical technique.

Human meniscal replacement with allograft is a new and promising procedure. Heretofore the procedure has required an extensive arthrotomy with direct suture implantation. A surgical technique using a minimally invasive, arthroscopically assisted approach to implantation of the allograft meniscus with attached bone anchors has been developed. Technique development followed extensive review and participation in the open implantation technique, along with cadaveric refinement of the proposed arthroscopic technique. The presented technique includes preparation of the meniscus with attached bone anchors, preparation of the peripheral rim bed, drilling of tibial tunnels for bone anchor placement, passage of the meniscus and bone anchors into the recipient site without detachment of collateral ligaments, securing the bone anchors in the appropriate bony tunnel, and peripheral suturing of the implanted meniscus.

The Dacron ligament prosthesis in anterior cruciate ligament reconstruction. A four-year review.

We studied 40 patients who underwent reconstruction for chronic anterior cruciate ligament deficiency with a Dacron ligament prosthesis using a modified MacIntosh over-the-top technique, augmented with iliotibial band. Thirty patients had undergone at least 1 prior surgical procedure on the affected knee, but only 7 patients had previous anterior cruciate ligament reconstruction. All patients were followed for a mean of 47.5 months. The results at final followup demonstrated an average side-to-side arthrometer difference of 1.0 mm. The Lysholm score improved from 65 preoperatively to 89 at the end of the review; the Tegner activity level score improved from 3 to 5. Objectively, 75% of the patients had a negative Lachman test result and 95.1% of the subjects had negative or trace pivot shift results at review. Mild knee pain was still present with day-to-day activity in 87.7% of the patients. Complications occurred in 27.5% of patients, including five who had implant ruptures and two who had their grafts removed. Synovitis was a significant problem. Based on our failure criteria, 47.5% (19) of the subjects had failed results. In this study, radiologic evidence of tracer separation greater than 1 cm was a criterion of failure. With inclusion of tracer separation, the failure rate increased to 60.0% (24). Multiple previous surgeries of any type had an adverse effect on results. Damage to secondary stabilizers in these cases increased failure rate. Based on the high complication and failure rates, and relatively poor end result in this retrospective review, we cannot recommend this procedure.

Maisonneuve fracture dislocation of the ankle.

Ligamentous injuries of the ankle are usually benign and may be managed satisfactorily by nonoperative measures. This is not true, however, of the Maisonneuve variant. In this paper we present a case report of a high school athlete who sustained a Maisonneuve fracture dislocation of the ankle. The diagnosis was missed initially, because of an incomplete examination. The subsequent physical and radiographic examination revealed the proper diagnosis. Guidelines for the evaluation and appropriate treatment are discussed.

Fungal peritonitis caused by Lecythophora mutabilis.

Fungal peritonitis caused by Lecythophora mutabilis, a mold rarely isolated from humans, is described. A patient on continuous peritoneal dialysis developed clinical, microbiological, and serological evidence for peritonitis due to this fungus. In vitro susceptibility testing of the fungus revealed marked differences in the activities of various antifungal agents. Although initially responding to treatment with oral ketoconazole, intraperitoneal miconazole, and catheter replacement, the patient had a documented relapse. The patient was eventually cured following the removal of a second catheter in association with prolonged imidazole treatment.

Persistent Campylobacter jejuni infection in an immunocompromised patient.

Recurrent bacteremia and enteritis due to a specific serotype of Campylobacter jejuni occurred over a 12-month period in a patient on hemodialysis with systemic lupus erythematosus who was also deficient in serum IgA and IgM. A bactericidal defect in the patient's sera for C. jejuni was shown. A role for immunoglobulins in the host response to C. jejuni is suggested, in that the IgA deficiency may have predisposed the patient to chronic gastrointestinal carriage and because the resolution of the bacteremia corresponded with the delayed appearance in the blood of IgG specific for the infecting strain.

Modified Nicoll-graft treatment of gap non-unions in the upper extremity.

Sixteen gap non-unions (seven in the radius, eight in the ulna, and one in the humerus) in fifteen patients were treated with a full-thickness corticocancellous iliac-crest graft, 1.2 to 2.5 centimeters in length, to replace the bone loss, and with a compression plate to provide stability. Thirteen of the fifteen fractures with adequate follow-up united and the grafts were incorporated in an average of 13.5 weeks, an 87 per cent success rate. The stability achieved by the compression plate allowed early removal of the plaster cast and institution of active exercises. In the two failures, the graft was not resorbed, and it filled the gap in the bone but failed to unite at one end.

Fractures of the tibia through the proximal tibial epiphyseal cartilage.

Thirty-nine fractures of the tibia involving the proximal tibial epiphyseal cartilage were treated at the Campbell Clinic over a twenty-five-year period. Stress roentgenograms were essential in making the diagnosis in three patients. Two patients had disruption of the popliteal artery, and both had posterior displacement of the tibial shaft. The other immediate complications that we encountered were anterior compartment syndrome, peroneal-nerve palsy, and associated ligamentous and meniscal injuries. Of twenty-eight fractures (twenty seven patients) with an average follow-up of 7.1 years, there were satisfactory results in twenty-four. Unsatisfactory results (four fractures) were due to chronic neurovascular insufficiency, growth disturbance, or traumatic arthritis.