ORTHOPEDICS April 2011;34(4):276.

Posterior Reattachment of a Radial Tear in the Posterior Root of the Medial Meniscus

by Kyung Wook Nha, MD; Kook Hyun Wang, MD; Gautam M. Shetty, MD; Chang Soo Lee, MD; Jong In Kim, MD

The new posterior vertical mattress suture technique is technically easier to perform and provides more secure fixation than the arthroscopic simple or horizontal stitch techniques and may contribute to restoring function of the medial meniscus.

Cover illustration © Scott Holladay

The meniscus is known to have a role in shock absorption and dispersing load transmission, thereby protecting and enhancing stability of the knee joint. A radial tear at the posterior root of the medial meniscus is not uncommon. A root tear has been defined as a radial tear that occurs within 1 cm of the posterior horn insertion.¹ Recent studies have shown a relatively high incidence of complete posterior medial meniscus root tear, especially in east Asia.² A complete posterior medial meniscus root tear leads to a loss of hoop tension, resulting in a reduction of contact surface, thereby increasing contact pressure within the joint and leading to accelerated degenerative changes.³

Several reports have concluded that radial tears of the meniscus have a clinically different outcome when compared to other types of meniscal tears.⁴ Meniscectomy in these patients does not seem to prevent acceleration of osteoarthritis. Recently, an arthroscopic pullout suture technique has been described in the literature as a mode of surgical treatment for complete posterior medial meniscus root tear.^5,6 However, in this technique, a simple suture is placed along the direction of the circumferential collagen fibers within the meniscus, and hence is liable to failure when increased tensile forces are present.⁴ This article describes a more secure fixation method to restore the function of the meniscus by posterior reattachment using a vertical mattress suture.

Materials and Methods

From May 2004 to December 2008, a prospective study was performed in 25 patients with 31 meniscal tears who underwent meniscal repair and partial menisectomy at 1 institution. We reviewed the records of these patients after Institutional Review Board approval. Inclusion criteria were complete posterior medial meniscus root tear and a minimum 2-year follow-up. Patients with considerable articular cartilage degeneration defined as Kellgren-Lawrence⁷ grade >2; with associated ligament injury; who underwent additional procedures such as microfracture, chondroplasty, and synovial shaving; and with <2 years of follow-up were excluded. Surgery was performed when the remnant tissue of the posterior medial meniscus root tear was insufficient to direct repair (<3 mm).

Four men and 21 women had a mean age of 53.4 years (range, 23-70 years). Mean follow-up was 38 months (range, 27-60 months). Duration of symptoms preoperatively was <3 months in 21 patients (84%) who presented during the early phase and varied from 3 to 10 months for the remaining 4 patients (16%). All patients reported knee joint pain with no history of trauma or with trivial trauma. Of the patients, 9 (36%) had a history of a popping sound that preceded the onset of symptoms.¹ On physical examination, all patients were found to have medial or posteromedial joint line tenderness, a positive McMurray test for the medial meniscus, restriction of deep flexion, and an inability to squat. Joint aspiration was done in patients presenting with an effusion. Blood-tinged joint fluid,¹ confirmed by joint aspiration, was detected in 11 patients who presented in the early phase. Each radiograph was graded from 0 to 4 for osteoarthritis by the original criteria of Kellgren and Lawrence.⁷ All patients were evaluated with magnetic resonance imaging (MRI) preoperatively, and the complete posterior medial meniscus root tear was confirmed by arthroscopic examination (Figure 1).

Figure 1: Preoperative MRI showing complete posterior medial meniscus root tear (arrow) in the coronal section (A). Intraoperative arthroscopic image showing complete radial tear of the posterior horn of the medial meniscus (arrow) (B).

The complete posterior medial meniscus root tear was repaired by a posterior reattachment using vertical mattress sutures, and partial menisectomy was performed in 6 patients combined with meniscal horizontal tear. No additional procedures such as microfractures, synovial shaving, or chondroplasty were performed. Intraoperatively, arthroscopic evaluation and grading of the articular cartilage damage to the medial compartment of the knee joint were performed with the Outerbridge grading system.⁸International Knee Documentation Committee (IKDC) and modified Lysholm knee scores⁹ were obtained to evaluate knee function preoperatively and at last follow-up. Evaluation consisted of McMurray test and assessment of joint line tenderness, swelling, and blocking. Statistical analysis was performed with SPSS software version 12.0 (SPSS, Inc, Chicago, Illinois). A 2-tailed t test was used for comparison of pre- and postoperative IKDC and Lysholm scores, with significance determined to be <.05.

Surgical Technique

All procedures were performed with the patient under spinal or general anesthesia. Arthroscopy was performed through a routine anterolateral and anteromedial portal. First, arthroscopic examination identified a complete posterior medial meniscus root tear. The patient was turned over to the prone position. A 10-cm curved incision was made over the popliteal fossa, and dissection was performed between the semimembranosus and the medial head of the gastrocnemius (Figure 2A). The medial head of the gastrocnemius was retracted laterally, and care was taken to protect the popliteal artery and nerve (Figure 2B). The posterior aspect of the proximal tibia near the posterior cruciate ligament attachment was palpated to identify the posteromedial capsule. A longitudinal incision of approximately 3 cm was made over the posterior capsule to expose the torn posterior horn of the medial meniscus (Figure 3). The capsule was separated from the medial meniscus and the posterior aspect of the proximal tibia. The posterior tibial condyle around the posterior horn was decorticated using a curette to improve the healing process of the bone to the meniscus.

Figure 2: A 10-cm curved incision is made over the popliteal fossa (A). The medial head of the gastrocnemius (GCM) is retracted laterally, and care is taken to protect the popliteal artery and nerve (B).

Figure 3: Intraoperative view showing a complete posterior medial meniscus root tear (arrow) and K-wire being used to create bone tunnels on the posteromedial aspect of the proximal tibia. Figure 4: Photograph showing the 2 tibial tunnels with wire loops passed to help deliver the suture threads.

Two tunnels 5 mm apart were drilled from the posterior aspect of the proximal tibia using 2.0-mm K-wires, to exit just below the inferior aspect of the medial meniscus. Two wire loops were then passed through each of the tunnels to exit at the inferior surface of the meniscus (Figure 4). A nonabsorbable suture (Ethibond No. 2; Ethicon, Somerville, New Jersey) was first passed from the undersurface of the medial meniscus to its posterior aspect, which is perpendicular to the direction of the circumferential fibers. Another suture was then passed again from the posterior aspect of the meniscus to the undersurface of the medial meniscus so that there were 2 sutures on the undersurface of the meniscus (Figure 5). The sutures were then pulled out through the tibial tunnels with wire loops and tied to each other over the posteromedial surface of the proximal tibia, thereby recreating a posterior attachment site of the meniscus (Figure 6). By this technique, the posterior horn of the medial meniscus was rigidly fixed over the posterior aspect of the proximal tibia using a nonabsorbable suture material.

Figure 5: Schematic diagram showing the vertical mattress suture and posterior reattachment technique for posterior medial meniscus root tear. Abbreviations: Lat, lateral; MM, medial meniscus; MTC, medial tibial condyle.

Figure 6: Photograph (A) and schematic diagram (B) showing the suture threads delivered out through the tibial tunnels from the posteromedial aspect of the proximal tibia after securing the meniscus.

The procedure was performed with the knee in 30° of flexion. The wound was closed in layers, and an above-knee splint was applied with the knee in 30° of flexion. Quadriceps-strengthening and straight-leg raising exercises were started postoperatively. Range of motion exercises were started on postoperative day 3. The patient was allowed partial weight bearing and crutch walking for 6 weeks postoperatively. From postoperative weeks 6 to 10, crutch walking with 50% weight-bearing exercise was allowed. After 10 weeks postoperatively, the patient was instructed to walk bearing full weight.

The advantages of the new technique are (1) a shorter lever arm is used as compared to the arthroscopic tibial pullout suture technique, and (2) the meniscus is rigidly fixed due to a double vertical suture, which renders it a more anatomical fixation as compared to other arthroscopic fixation methods.

Results

All 25 patients had complete posterior medial meniscus root tear confirmed by MRI and arthroscopy and underwent meniscal repair by a posterior reattachment using vertical mattress sutures. Partial menisectomy was performed in 6 patients with meniscal horizontal tear. Seven patients (28%) had normal articular cartilage (Outerbridge grade 0), 13 (52%) had Outerbridge grade I articular cartilage, and 5 (20%) had Outerbridge grade II articular cartilage on the medial compartment of the knee joint. The mean preoperative Lysholm score, which averaged 68 points (range, 61-79 points), significantly increased to an average 89 points (range, 83-97 points) at last follow-up (P<.01). The IKDC scores improved significantly from an average 66 points (range, 60-77 points) preoperatively to an average 88 points (range, 81-96 points) postoperatively (P<.05). All patients had good to excellent IKDC scores at last follow-up (excellent, 90-100; good, 80-89; fair, 70-79; poor, <70). The change in Lysholm score and IKDC score at last follow-up as compared with preoperative values according to Outerbridge grading is summarized in the Table. At last follow-up, when we evaluated standing knee radiographs for evidence of osteoarthritis progression, 1 patient (4%) showed progression of degeneration from Kellgren-Lawrence grade 0 to 2, and 24 patients (96%) showed no progression (Figure 7).

Figure 7: One-year postoperative MRI showing healed posterior medial meniscus root tear without subluxation and bone tunnel on the posteromedial aspect of the proximal tibia (white arrow).

Discussion

The complete posterior medial meniscus root tear is a recently described entity wherein there is loss of hoop stress with extrusion of the meniscus, causing accelerated degeneration of the knee joint. It is reported to be biomechanically equivalent to a total meniscectomy.³ The complete posterior medial meniscus root tear occurs frequently in degeneration of the meniscus. The radial tear occurs perpendicular to that of the circumferential fibers of the meniscus and is thereby morphologically different from other types of meniscal tears; it can be either a partial or full-thickness tear extending from the inner margin to the periphery.⁴ A narrow medial joint space and overlooking the site of the tear are possible obstacles that may prevent the surgeon from recognizing it.² Their high incidence in east Asia is thought to be due to the lifestyle of squatting and sitting on the floor with legs crossed and folded, wherein maximal knee flexion is needed in activities of daily living.²

Definitive surgical treatment for complete posterior medial meniscus root tear has not yet been identified. The preservation of the meniscus seems to prevent the progression of degenerative arthritis. The ideal treatment option in a complete posterior medial meniscus root tear would be a primary suture, which restores meniscal hoop tension to its preinjury state.⁴ However, it is difficult to perform primary suturing within approximately 3 to 5 mm of the remnant tibial end of the meniscus. Even if it is possible, the risk of retearing is high when the joint is loaded.

Ahn et al⁵ and Kim et al⁶ described an arthroscopic pullout suture technique wherein a simple stitch was passed through an anterior transtibial tunnel using a posterior transseptal portal. The technique is difficult due to narrow space in the knee joint and liable to failure of the pullout suture due to the simple suture method.

In a biomechanical cadaveric study, Tejwani and Harner¹⁰ compared different meniscal repair techniques in complete posterior medial meniscus root tear, using 2-0 braided suture in a tibial tunnel technique with an Endobutton (Smith & Nephew, Memphis, Tennessee). The horizontal mattress stitch (91 N) had less pullout strength than the modified Kessler stitch (132 N) but more strength than a simple stitch (70 N).

Conclusion

Our new posterior vertical mattress suture technique is technically easier to perform and provides more secure fixation than the arthroscopic simple or horizontal stitch techniques. We performed this new technique on 25 knees and followed them for at least 2 years. Most patients’ symptoms improved postoperatively. However, longer follow-up is needed, and osteoarthritis changes should be evaluated in simple radiograph and MRIs.

For further information: http://www.orthosupersite.com/view.aspx?rid=81579

ARTHROSCOPY

Posted on the ORTHOSuperSite January 17, 2011

Age and symptoms important factors for hip arthroscopy referral

KOLOA, Hawaii — An in-place protocol for referring patients for hip arthroscopy will increase the odds of having better results with the procedure, according to an orthopedic investigator here.

Dean K. Matsuda, MD, said at Orthopedics Today Hawaii 2011 that age, symptoms, imaging and clinical factors are used to determine the prime candidates for hip arthroscopy.

Dean K. Matsuda

“Who do we refer for hip arthroscopy? In general it is patients who are in pain, or those who have mechanical symptoms thought to be from the hip,” he said. Potential hip arthroscopy patients should not have responded to conservative measures, such as activity changes and physical therapy, and should have minimal or no osteoarthritis (OA).

New indication

Pain coming from the hip is a relatively new indication, Matsuda said. “We used to think that deep groin pain was a result of intra-articular hip pathology, but we are seeing now that trochanteric pain may also be from an intra-articular hip problem.”

Symptoms signaling a referral include: moderate-to-severe hip pain that is worsened by flexion activities, such as squatting or prolonged sitting, that significantly limits activities and a positive impingement signon clinical examination — pain elicited with 90° of flexion and internal rotation and adduction of the femur.

There are also exceptions to these, he noted. “You should consider even mild pain, especially in the deep groin or lateral hip. Also, positive FADIR [flexion adduction with internal rotation] and FADER [flexion adduction with external rotation] may also see you picking up some other patients.”

In terms of age, he said, adolescent patients should be skeletally mature with documented closure of growth plates, and adult patients should be too young to be considered appropriate candidates for total hip arthroplasty or other reconstructive hip surgery — usually younger than 55 years. “But I can tell you this,” Matsuda added, “patients as young as 11 or 12 years old can benefit from this procedure, as well as people older than 60 years.”

Imaging

Imaging data should also be used in the decision. Morphology indicative of cam or pincer-type femoroacetabular impingement, such as pistol-grip deformity, femoral head-neck offset with an alpha angle greater than 50°, a positive posterior wall sign, acetabular retroversion (overcoverage with crossover sign), coxa profunda or protrusion, or damage of the acetabular rim.

He said that referrals should be made sooner rather than later to avoid irreversible third body wear. “Some insurers say 3 months of failed conservative care before referral. Early referrals are also starting to be supported in the literature and the insurers are starting to get on board with that.”

Matsuda stressed the importance of knowing when not to refer for hip arthroscopy and provided the following examples: cases of advanced OA; patients with moderate-to-severe dysplasia; patients who have not undergone the sufficient course of conservative treatment, especially in snapping hips. Physicians should also avoid referring patients for hip arthroscopy if there are no experienced hip arthroscopy surgeons in their referring area.

For further information: http://www.orthosupersite.com/view.aspx?rid=79500

SPORTS MEDICINE

Posted on the ORTHOSuperSite December 29, 2010

Shorter jump training program could lower risk of knee injury in female basketball players

An abridged, focused “jump training” program may help lower the risk of knee injuries in female basketball players, according to a study in the December issue of The Journal of Strength and Conditioning Research.

The program yields “similar positive effects on landing strategies and functional performance” compared to longer, more complex training programs – and thus may be more “user friendly” to coaches and athletes, the authors wrote.

In the jump training program, athletes received coaching and feedback on appropriate landing technique. The specific goal of the training was to decrease the knee valgus angle upon landing from jumps, as landing with the knee in the valgus position is believed to increase the risk of knee injury.

The training program

The study looked at 15 competitive female basketball players who completed the 4-week training program with three sessions per week. Knee valgus angles during two different landing tasks – a drop-jump and a jump-shot test – were compared before and after training. The women were also assessed on a crossover hop test to assess hop distance.

The results of the training showed significant improvements in proper landing technique, the study noted. On both tests, the women landed with reduced valgus angles. Landing from the jump shot, the valgus angle was reduced by an average of 4.5º on the left leg and 4.3º on the right leg.

On the crossover hop test, distance jumped increased by nearly 75% after jump training. The authors wrote that this indicates increased strength and stability of the knee, likely helping to protect against injury.

Still work to be done

The authors noted that female basketball players appear to be particularly prone to knee injuries, especially in ACL injuries Previous studies have shown that jump training programs can improve knee valgus angles in female basketball players and lead to reduced rates of ACL injuries, but most of these jump programs are intensive, feature a variety of other training elements and last 6 to 8 weeks.

“It remains unclear if it is jump training that makes the difference or a combined strength, flexibility, and jump-training program,” stated author Lee Herrington, PhD, MCSP, CSCS, in a press release.

While the study shows that a 4-week jump training program can significantly improve landing technique and improve knee strength and stability in female basketball players, the authors noted that a larger study would be needed to show a significant effect on knee or ACL injures.

Still, they wrote, the results show a significantly shorter program can produce results comparable to those of much longer and complex mixed-training programs. Shorter and more focused training programs may offer coaches, trainers and athletes a simpler – but still effective – way of reducing knee injury rates in female basketball players.

For further information: http://www.orthosupersite.com/view.aspx?rid=78923

© 2010 The Journal of Bone and Joint Surgery, Inc.

Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures

A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation

Kevin Willits, MA, MD, FRCSC¹, Annunziato Amendola, MD, FRCSC²,Dianne Bryant, MSc, PhD³, Nicholas G. Mohtadi, MD, MSc, FRCSC⁴,J. Robert Giffin, MD, FRCSC¹, Peter Fowler, MD, FRCSC¹,Crystal O. Kean, MSc, PhD¹ and Alexandra Kirkley, MD, MSc, FRCSC⁵

¹ WOLF Orthopaedic Biomechanics Lab (C.O.K.), Fowler Kennedy Sport Medicine Clinic (K.W., J.R.G., and P.F.), 3M Centre, The University of Western Ontario, London, ON N6A 3K7, Canada. E-mail address for K. Willits: kwillit@uwo.ca. E-mail address for J.R. Giffin: rgiffin@uwo.ca. E-mail address for C.O. Kean: ckean@unimelb.edu.au. E-mail address for P. Fowler: pfowler@uwo.ca
² University of Iowa Sports Medicine, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242. E-mail address: ned-amendola@uiowa.edu
³ Orthopaedic Division, Department of Surgery, Elborn College, Room 1438, The University of Western Ontario, London, ON N6G 1H1, Canada. E-mail address: dianne.bryant@uwo.ca
⁴ University of Calgary Sport Medicine Centre, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada. E-mail address: mohtadi@ucalgary.ca
⁵ Deceased

A commentary by Michael S. Aronow, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.

Investigation performed at the Fowler Kennedy Sport Medicine Clinic, London, Ontario, and the University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from PhysiciansServices, Inc. (PSI) and Aircast, Inc. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

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Background To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In all but one study, the limb was immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functionalrehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.

Methods Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent anaccelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupturerate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength.Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury.

Results A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.

Conclusions This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. Allmeasured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.

For further information: http://www.ejbjs.org/cgi/content/abstract/92/17/2767?etoc

KNEE

ORTHOPEDICS November 2010;33(11):832.

Graft Selection in Anterior Cruciate Ligament Surgery

by Matthew R. Poulsen, MD; Darren L. Johnson, MD

The ideal graft for ACL surgery should have similar anatomic and biomechanical characteristics to the native ACL, provide for strong initial fixation, allow for prompt biologic incorporation, and have minimal donor site morbidity for a particular athlete.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly-performed orthopedic surgeries in this country. As ACL reconstruction techniques have evolved and improved dramatically over the past few years from nonanatomic to anatomic, controversies regarding graft selection remain. While conclusions drawn from past studies regarding graft choice in ACL surgery have resulted from predominantly nonanatomic surgical techniques, there are useful guiding principles that can be followed when determining which type of graft to use in ACL reconstruction.

Graft selection in ACL surgery should be individualized for each patient. It should be athlete-specific, male- and female-specific, and sport-specific. Desired timing for return to play and length of rehabilitation are other important considerations for the surgeon. Other variables to consider include donor site morbidity, graft fixation options, and differences in length of time required for graft incorporation and healing with subsequent return to play.

The ideal graft for ACL surgery should have similar anatomic and biomechanical characteristics to the native ACL, provide for strong initial fixation, allow for prompt biologic incorporation, and have minimal donor site morbidity for a particular athlete. It is generally believed that no one graft source optimally possesses all these characteristics for each patient. Thus, it is imperative that surgeons and patients discuss risks and benefits of all graft types, and then select a graft that is best for each particular clinical scenario.

Graft Options

There are multiple autograft and allograft options for ACL reconstruction. The most common autografts used are bone–patellar tendon–bone and quadrupled-hamstring (gracilis and semitendinosus tendons). Common allograft tendons used include hamstring (usually semitendinosus), Achilles (with or without a bone block), bone–patellar tendon–bone, anterior tibialis, and posterior tibialis. Quadriceps tendon autograft or allograft, with or without a patellar bone block, may also be used.

When selecting a graft for ACL surgery, there are important biologic and scientific concerns to consider. These include bone versus soft tissue healing in bone tunnels, incorporation of allograft versus autograft tissue, ideal fixation options for a particular graft, and ultimate return to play and at what competitive level.

Bone–Patellar Tendon–Bone Autograft

Bone–patellar tendon–bone autograft has been considered the gold standard for ACL reconstruction for many years. One reason is that bone–patellar tendon–bone autograft has the most peer-reviewed data in the literature, with the longest follow-up (compared to other types of ACL grafts). Another reason is that bone-to-bone tunnel healing seen with bone–patellar tendon–bone autograft is more optimal than soft-tissue-to-bone healing seen with most other types of grafts. Also, rigid initial fixation seen with bone-to-bone fixation is superior to other fixation techniques used with all soft tissue grafts (autografts and allografts). With bone–patellar tendon–bone grafts, fixation points are closer together than those seen in suspensory soft tissue fixation, which enhances overall graft stiffness, an important variable that prevents early and late stretching of the graft during the incorporation process.

Furthermore, many studies advocate possible earlier return to play with use of a bone–patellar tendon–bone autograft. Multiple studies have also shown an increased frequency of return to preinjury level of activity after use of bone–patellar tendon–bone autograft, particularly in young athletes who participate in Level 1 sports year round. In a recent study by Mascarenhas et al¹ comparing bone–patellar tendon–bone autograft to bone–patellar tendon–bone allograft, twice as many autograft patients were able to return to very strenuous (jumping or pivoting) activities without the sense of instability.

Additionally, instrumented laxity measurements in bone–patellar tendon–bone autograft patients have shown less laxity than those for allograft patients.² And in a recent metaanalysis by Prodromos et al³comparing stability of autograft to allograft tissue after ACL reconstruction, allograft resulted in significantly more knee laxity compared to autograft. In this study, abnormal stability was 2 to 3 times more frequent after allograft ACL reconstruction.

However, potential disadvantages to using bone–patellar tendon–bone autograft exist. These generally relate to donor site morbidity and include anterior knee pain, patella fracture, decreased knee extension, and a potential adverse effect on the extensor mechanism of the knee.^4-6 Patients who have low pain tolerance, are nonmotivated, or are too busy to participate in vigorous postoperative rehabilitation may have increased morbidity if bone–patellar tendon–bone autograft is used. The majority of the donor-site morbidity issues with this graft are a nonissue in a patient that is well-engaged in the rehabilitation process and achieves normal knee range of motion and patellar mobility within 6 weeks of the index operation.

Hamstring Autograft

Quadrupled-hamstring autograft is frequently used in ACL surgery. It has been shown to be the strongest of all grafts in the laboratory, if equal tension can be applied to each strand.⁷ Also, it is generally considered to have less donor site morbidity compared to bone–patellar tendon–bone autograft. However, tendon-to-bone graft incorporation is slower than bone-to-bone healing (approximately 4 weeks longer). Other potential disadvantages include graft laxity, tunnel osteolysis, and hamstring weakness (particularly with terminal knee flexion).⁶

Both bone–patellar tendon–bone and hamstring autografts for ACL reconstruction have shown adequate clinical results in the literature for the majority of patients. However, in a recent systematic review of the literature by Reinhardt et al,⁸ hamstring autograft was found to result in graft failure more often than bone–patellar tendon–bone autograft. In this study, results were combined from 6 randomized controlled trials comparing bone–patellar tendon–bone and hamstring autografts. There were 11 failures out of 153 bone–patellar tendon–bone autograft reconstructions (7.2%), and 26 failures out of 165 hamstring autograft reconstructions (15.8%) (P=.02).

In addition, Kim et al⁹ recently showed that in patients with excessive joint laxity, including hyperextension, bone–patellar tendon–bone autograft performed better than hamstring autograft at 2-year follow-up. This was especially true in women. In this study, testing of anterior tibial translation with a KT-2000 arthrometer (MEDmetric, San Diego, California) showed significantly increased anterior laxity after use of hamstring autograft. Lysholm clinical scores were also significantly better for bone–patellar tendon–bone patients. These results should be strongly considered when selecting appropriate ACL grafts in female athletes with knee hyperextension, especially those involved in high level sports at high risk for ACL injury (eg, soccer, basketball, volleyball, field hockey, and softball).

Allograft

Allografts are commonly used in primary and revision ACL surgeries. The use of allograft tissue in primary ACL surgery has become more common than in the past, largely because of increased availability, better safety of tissues, and no donor site morbidity.

It is important to understand that use of different allograft tissue types may produce different clinical results. This has not been adequately discussed in the orthopedic literature. The majority of the published literature discussing allograft tissue use in ACL surgery relates to bone–patellar tendon–bone allograft, not all-soft-tissue allograft. Currently, more all-soft-tissue allografts are being used for ACL surgery than bone–patellar tendon–bone allografts. Surgeons must be careful not to “lump” all allograft tissue results as the same. It is imperative that each orthopedic surgeon know what is written in the literature regarding a particular type of allograft tissue selected for ACL reconstruction in a particular patient for which allograft is being considered.

The use of allograft tissue in ACL surgery has been shown to yield adequate clinical results in certain patients. However, a high allograft failure rate after ACL surgery has been demonstrated in young active patients.^10-12 Additionally, Borchers et al¹³ recently showed a significantly higher ACL reconstruction failure-rate after use of allograft, and also after return to a higher activity level. In patients with both characteristics (ie, allograft was used and they returned to higher activity levels), failure of ACL reconstruction was even more significant.

Furthermore, a study by Singhal et al¹² showed an unacceptably high failure rate of an all-soft-tissue allograft (anterior tibialis), particularly in young patients (<25 years).And, as mentioned previously, increased knee laxity has been demonstrated after allograft ACL surgery, compared with the use of autograft.^2,3

The secondary sterilization processing of allograft tissue is important to reduce the incidence of disease transmission and eliminate infection, but many of these processes decrease mechanical properties. For example, Rappe et al¹⁴ showed a significantly higher failure rate with Achilles allograft that had been irradiated with 2 to 2.5 Mrad (2.4% failure rate for nonirradiated grafts, and 33% failure rate for irradiated grafts).¹⁴

Sterilization processes vary tremendously among tissue banks and distributors, and thus surgeons must be familiar with those used by the American Association of Tissue Banks-certified musculoskeletal tissue banks they select. The surgeon is the ultimate tissue bank for the patient. Much remains to be learned about these companies’ proprietary sterilization processes and resultant effects on biologic graft incorporation. Basic science data is severely lacking in this respect, particularly as it relates to animal and human studies with Level 1 evidence.

Conclusion/Authors’ Recommendations

It is imperative to match length of rehabilitation and timing for return-to-play to the biology of the graft incorporation process and timeline (for whichever graft is selected for ACL surgery). Rehabilitation-specific guidelines should be graft-specific. Bone–patellar tendon–bone autograft provides optimal graft incorporation because of bone-to-bone healing. Thus, rehabilitation and return-to-play are optimized with bone–patellar tendon–bone autograft. If soft tissue autograft is used, graft incorporation takes longer because soft-tissue-to-bone tunnel healing is required. Rehabilitation should be lengthened in this scenario, particularly within the first 12 weeks, which is critical for soft tissue healing in a bone tunnel. In addition, rehabilitation and return to play should also be extended if allograft tissue is used, because of the extended graft incorporation time required when compared to autograft tissue.

Young, active patients (<22>

For patients younger than 40 years, who are active but not involved in highly competitive athletics year round, we prefer hamstring autograft (quadrupled gracilis and semitendinosus tendons). In our experience, hamstring autograft has been extremely successful in these patients.

In patients older than 40 years, we feel that allograft and hamstring autograft both produce excellent results. If a patient older than 40 years is highly active, we prefer hamstring autograft. However, based on patient preference and clinical scenario, we have experienced good results with both allograft and hamstring autograft in this age group. In addition, we prefer allograft tissue for revision ACL reconstruction as well as multi-ligamentous knee surgery.

Finally, the most important variable control led by the surgeon in ACL surgery is anatomic graft placement. Anatomic techniques must be used (ie, the femoral and tibial tunnels must be properly positioned) (Figure).¹⁵ If nonanatomic techniques are used; it makes no difference which type of graft is used, the risk of graft failure is highly increased.

Figure: AP and lateral radiographs showing tunnel placement after bilateral ACL reconstructions (each performed by a different surgeon). Tunnels were placed anatomically for the right knee (A, B), while nonanatomic and vertical tunnels were used for the left knee (C,D).

For further information: http://www.orthosupersite.com/view.aspx?rid=76738

Countrywide Campaign to Prevent Soccer Injuries in Swiss Amateur Players

1. Astrid Junge, PhD (astrid.junge@kws.ch)

1. FIFA–Medical Assessment and Research Centre (F-MARC), Schulthess Clinic, Zurich, Switzerland

1. Markus Lamprecht, PhD

1. Lamprecht & Stamm, Sozialforschung und Beratung AG, Zurich, Switzerland

1. Hanspeter Stamm, PhD

1. Lamprecht & Stamm, Sozialforschung und Beratung AG, Zurich, Switzerland

1. Hansruedi Hasler

1. Schweizerischer Fussballverband (SFV), Bern, Switzerland

1. Mario Bizzini, PhD

1. FIFA–Medical Assessment and Research Centre (F-MARC), Schulthess Clinic, Zurich, Switzerland

1. Markus Tschopp, MD

1. Bundesamt für Sport, Magglingen, Switzerland

1. Harald Reuter, Dipl Psych

1. Institut für Sozial- und Präventivmedizin, University Zurich, Zurich, Switzerland

1. Heinz Wyss

1. Schweizerische Unfallversicherungsanstalt (SUVA), Luzern, Switzerland

1. Chris Chilvers

1. Schweizerische Unfallversicherungsanstalt (SUVA), Luzern, Switzerland

1. Jiri Dvorak, MD, PhD

1. FIFA–Medical Assessment and Research Centre (F-MARC), Schulthess Clinic, Zurich, Switzerland

Abstract

Background: In Switzerland, the national accident insurance company registered a total of 42 262 soccer injuries, resulting in costs of approximately 145 million Swiss francs (~US$130 million) in 2003. Research on injury prevention has shown that exercise-based programs can reduce the incidence of soccer injuries.

Purpose: This study was conducted to assess the implementation and effects of a countrywide campaign to reduce the incidence of soccer injuries in Swiss amateur players.

Study Design: Cohort study; Level of evidence, 3.

Methods: All coaches of the Schweizerischer Fussballverband (SFV) received information material and were instructed to implement the injury prevention program “The 11” in their training of amateur players. After the instruction, the coaches were asked to rate the quality and the feasibility of “The 11.” Before the start of the intervention and 4 years later, a representative sample of about 1000 Swiss soccer coaches were interviewed about the frequency and characteristics of injuries in their teams. Teams that did or did not practice “The 11” were compared with respect to the incidence of soccer injuries.

Results: A total of 5549 coaches for amateur players were instructed to perform “The 11” in the training with their teams. The ratings of the teaching session and the prevention program were overall very positive. In 2008, 80% of all SFV coaches knew the prevention campaign “The 11” and 57% performed the program or most parts of it. Teams performing “The 11” had an 11.5% lower incidence of match injuries and a 25.3% lower incidence of training injuries than other teams; noncontact injuries in particular were prevented by the program.

Conclusion: “The 11” was successfully implemented in a countrywide campaign and proved effective in reducing soccer injuries in amateur players. An effect of the prevention program was also observed in the population-based insurance data and health-care costs.

For further information: http://ajs.sagepub.com/content/early/2010/10/16/0363546510377424.abstract