Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft.

We compared the outcome of anterior cruciate ligament reconstruction using hamstring tendon autograft with outcome using patellar tendon autograft at 2 years after surgery. Patients had an isolated anterior cruciate ligament injury and, apart from the grafts, the arthroscopic surgical technique was identical. Prospective assessment was performed on 90 patients with isolated anterior cruciate ligament injury undergoing reconstruction with a patellar tendon autograft; 82 were available for follow-up. The hamstring tendon autograft group consisted of the next 90 consecutive patients fulfilling the same criteria; 85 were available for follow-up. Clinical review included the Lysholm and International Knee Documentation Committee scores, instrumented testing, thigh atrophy, and kneeling pain. These methods revealed no difference between the groups in terms of ligament stability, range of motion, and general symptoms. Thigh atrophy was significantly less in the hamstring tendon group at 1 year after surgery, a difference that had disappeared by 2 years. The KT-1000 arthrometer testing showed a slightly increased mean laxity in the female patients in the hamstring tendon graft group. Kneeling pain after reconstruction with the hamstring tendon autograft was significantly less common than with the patellar tendon autograft, suggesting lower donor-site morbidity with hamstring tendon harvest.

Long-term osteoarthritic changes in anterior cruciate ligament reconstructed knees.

To consolidate the indications for anterior cruciate ligament reconstruction and clarify the long-term prognosis associated with current surgical and rehabilitation techniques, the incidence of osteoarthritis in arthroscopically anterior cruciate ligament reconstructed knees requires investigation. Seventy-two patients with anterior cruciate ligament ruptures who were active in sports requiring sidestepping and pivoting, or who had recurrent episodes of giving way, underwent arthroscopic bone-patellar tendon-bone anterior cruciate ligament reconstruction. These patients were evaluated for meniscal damage and osteoarthritic changes at the time of surgery and followed up for 7 years. Fifty-three patients underwent radiographic evaluation at 7 years, which included anteroposterior, lateral, skyline, and 30 degrees posteroanterior weightbearing views. Radiographic evaluation was performed by three independent surgeons and graded as per International Knee Documentation Committee criteria. Results revealed that knees with chronic anterior cruciate ligament deficiency, even those with intact menisci before reconstruction, suffered early osteoarthritic changes. More severe changes were seen with meniscectomy. Acute anterior cruciate ligament reconstruction with meniscal preservation was shown to have the lowest incidence of degenerative change. Controversy exists regarding the timing of anterior cruciate ligament reconstruction. This study supports early reconstruction of anterior cruciate ligament deficient knees before episodes of giving way occur in individuals intent on continuing activities that involve sidestepping and pivoting.

Endoscopic reconstruction for isolated anterior cruciate ligament rupture.

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.

Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament.

Anterior cruciate ligament (ACL) reconstruction using four-strand hamstring graft with round-headed, cannulated, interference (RCI) screw fixation requires osteointegration of the tendon graft. This report describes the histology at the bone-tendon junction of two specimens retrieved from patients undergoing revision surgery after traumatic mid-substance ACL graft rupture at 6 and 10 weeks after initial reconstruction. Revision was performed at 12 and 15 weeks. Integration of the graft was evident by observation of collagen fiber continuity between bone and tendon. This histology plus the low incidence of early graft failure suggest that free tendon autograft attached to bone by RCI screw allows adequate osteointegration between 6 and 15 weeks after surgery.