Introduction. Anterior cruciate ligament (ACL) reconstructive surgery is one of the most commonly performed surgical procedures. Synthetic ACL repair surgery with the Lars ligament is designed to repair, rather than replace, the torn ACL. Once the ACL is repaired, the level of function, biomechanical attributes and proprioception should be similar to the pre-injury state. All patients in this cohort have undergone surgical repair of the torn ACL with synthetic Lars ligament augmentation. The indications and surgical technique will be outlined. Patients have been assessed at follow-up with KOOS and Marx scores, which reflect the surgical outcome. The preliminary results with a six-month minimum follow-up will be presented. The results reflect previous published studies that show that surgical repair of the torn ACL with Lars ligament augmentation, can reliably and reproducibly stabilise the knee and allow an early return to sport. Complications include one septic arthritis, superficial wound infections and improperly placed bone tunnels. Synthetic ACL repair using the Lars ligament is a reprodicible technique that allows a rapid post-operative rehabilitation and avoids all complications relating to graft harvesting. The indications and the surgical technique are quite specific and must be adhered to in order to achieve the best results

We studied the efficacy of arthroscopic ACL repair for femoral avulsion of the ligament in ten patients (18 to 32 years of age). The tibial attachment and the midsub-stance of the ligaments were intact. We placed 2 mattress sutures with #2 fiberwire. The footprint of the ACL on the medial wall was decorticated and a guide drill was passed from inside-out followed by an endobutton reamer. The sutures were retrieved through the femoral tunnel using a small skin incision and tied over a button in full extension. The rehabilitation included weightbearing with a hinged knee brace in extension, and CPM machine for the first month. The minimum follow-up was one year (mean 14 months). Lachman, Pivot shift, drawer tests, KT-1000 were documented. At 1 year all patients were stable. Sixty percent tested symmetric on KT-1000 and within 2 mm of the controlateral site. Forty percent had Lachman and anterior drawer within 1 grade and KT-1000 scores of > 4mm from the non-injured knee. None of the patients had a positive pivot shift. Our short-term data on arthroscopic ACL repair of a specific tear pattern are encouraging despite the negative outcome of open repair reported in the literature

Introduction

Autologous chondrocyte implantation (ACI) is contra-indicated in a joint rendered unstable by a ruptured anterior cruciate ligament (ACL). We present our experience of ACI repair with ACL reconstruction

Purpose of the study: The isometric position of the femoral tunnel is a critical element for successful anterior cruciate ligament (ACL) repair. An overly wide tunnel can compromise long-term results, requiring revision. The purpose of this prospective study was to evaluate the incidence of femoral tunnel widening on two fixation systems and to determine its impact on clinical outcome.

Material and methods: This prospective study included 80 four-strand hamstring ACL reconstructions. In group A, the titanium cross pinning method was used for fixation (Arthrex, Transfix) 30 mm from the Blumensaat line. In group B, two bioabsorble crossed pins (Mitek, Rigid Fix) were used 13 mm from the «anatomic» fixation. The two groups were similar for age, gender, degenerative disease and type of tibial fixation. Radiographic findings were noted at postop, and 6, 12 and 24 months follow-up. The diameter of the femoral tunnel was measured on the ap and lateral views. The diameter of the tunnel was compared with the drilled diameter. Outcome was assessed with the IKDC score and KT1000 arthrometry.

Results: Two-year follow-up data was available for 66 patients (34 in group A and 32 in group B). Postoperatively, tunnel widening was not significant in either group. At six months, the diameter of the tunnel had increased 62% in group A and 49% in group B. At one year, tunnel diameter decreased 24% in group A and 21% in group B. No significant difference was noted at 24 months. At two years, the tunnel diameter was not correlated with clinical outcome.

Discussion and conclusion: Widening of the femoral fixation tunnel does not alter long-term outcome of ACL reconstructions. While no significant difference was observed for the fixation systems studied in the present analysis, radiographic widening appears to be less for fixations closer to the «anatomic» fixation.

Purpose of the study: The objectives of this study were to measure tension force usually applied to the transplant and analyze its impact on postoperative laxity and joint mobility.

Material and methods: This was a prospective consecutive study. Inclusion criteria were: isolated tear of the anterior cruciate ligament (ACL) more than three months earlier, healthy contralateral knee, radiological anterior drawer measurements (Telos 20 kg) both pre and postoperatively, follow-up greater than six months. ACL reconstruction was achieved with a free bone-tendon-bone patellar transplant using the blind technique. A dynometer was used to measure the traction force applied by the operator using the «usual» method for the tibial fixation. The force applied (2, 4, 6, 9, or 11 kg) was recorded by the assistant and was maintained constant while screwing. Variables studied were: tension force applied to the transplant by four different operators, mobility of the two knees, differential laxity pre and postoperatively (L0 and L1) and relative gain in laxity (real gain/ideal gain).

Results: The study included 22 patients, mean age 26 years. Mean tension force applied was 7.68 kg and varied from 7.3 to 8.1 for each operator. Mean extension and flexion deficit compared with the healthy side was 1.6° and 3° respectively. There was no correlation between loss of mobility and tension applied. Mean laxities (L0 and L1) were 9.2 and 5.4 mm respectively. Mean minimal differential laxity (< 5 mm) was obtained for tension forces of 4 to 6 kg. There was no correlation between tension and L1. The relative gain was greater in the knees with tension at 6 kg. But there was no correlation between these two variables.

Discussion: This study provides the only available data on tension forces applied in routine practice. This tension does not appear to have an impact on the final joint mobility. It would appear however tht laxity would be minimal for tension forces to the order of 7 kg. These data are in agreement with reported in the literature were it is recommended to apply tension to the order of 1.5 to 7 kg.

Conclusion: It would not appear that measuring the force applied to the implant during the tibial fixation provides useful information for routine practice. The force applied in routine practice appears to give the best gain in stability without limiting joint mobility.

The management of medial osteoarthritis of the knee with underlying anterior cruciate ligament deficiency is challenging. Stabilization of the ligament instability at the time of re-alignment osteotomy addresses both components of the disability.

We are reporting a retrospective study of thirty-two cases of combined osteotomy and ligament repair between 1995 and 2000.

Patients were assessed by questionnaire and clinical examination. Objective measures, using the modified Lystolm score, WOMAC index and SF36 were performed. Radiological examination as well as a survivor-ship analysis were performed.

The average age at operation was thirty-six with an average follow-up of five years. Surgery was performed in patients who had complaints of both pain and instability and also had objective findings of Uni-compartmental osteoarthritis and anterior cruciate deficiency.

Seventy five percent of patients were classed as good to excellent with only five percent of patients classed as poor.

Combined tibial osteotomy and anterior cruciate reconstruction is an effective means to deal with this complex problem.

Introduction: Autologous chondrocyte implantation (ACI) is a technique described for treating symptomatic osteochondral defects in the knee. It is contra-indicated, however, in a joint rendered unstable by a ruptured anterior cruciate ligament (ACL). We present our early experience of combined ACL and ACI repair.

Methods: Patients underwent arthroscopic examination and cartilage harvesting of the knee. Chondrocytes were then cultured in plasma and a second operation was undertaken approximately four weeks later to repair the ruptured ACL with hamstring graft and to implant the chondrocytes via formal arthrotomy. Patients then underwent a graduated rehabilitation program and were reviewed at 6 and 12 months. Functional measurements were made using the Bentley functional scale and the modified Cincinnati rating system, with pain measured on a visual analogue scale. All patients also underwent formal clinical examination at each review.

Results: 4 out of the 5 patients reported an improvement in pain as measured on visual analogue scale, with 1 patient reporting no difference. 4 patients had stable knees as determined by negative anterior draw, negative Lachman’s test and negative pivot shift test; one patient showed improvement, but remained pivot shift positive. Improvements in Bentley scores were noted in 3 patients. Cincinnati scores were markedly improved in 3 patients and slightly improved in the remaining 2 patients. The only operative complications were a traction neuropraxia to the saphenous nerve of one patient requiring no treatment and a manipulation under anaesthesia for poor mobilisation in another patient, which was successful in improving range of movement. A further patient required arthroscopic trimming of the cartilage graft which had overgrown; this was also successful.

Conclusion: Symptomatic cartilage defects and ACL deficiency may co-exist in many patients and represent a treatment challenge. Our early results suggest that a combined ACL and ACI repair is a viable option in this group of patients and should reduce the anaesthetic and operative risks of a two-stage repair. More patients and longer follow up will be required to fully assess this technique.

Aims

The purpose of this study was to report the experience of dynamic intraligamentary stabilisation (DIS) using the Ligamys device for the treatment of acute ruptures of the anterior cruciate ligament (ACL).

Objectives

Surgical marking during tendon surgery is often used for technical and teaching purposes. This study investigates the effect of a gentian violet ink marker pen, a common surgical marker, on the viability of the tissue and cells of tendon.

Excessive postoperative opioid prescribing is a significant contributor to the opioid crisis. Prescribing in orthopaedic surgery is often further complicated by high use of opioid-based preoperative analgesia. ‘Opioid PrEscRiptions and usage After Surgery’ (OPERAS) is an international multicentre prospective student- and trainee-led collaborative study which aims to quantify the amount of opioids prescribed at discharge after common orthopaedic surgeries against what is consumed by patients at 7-days, and assess the impact of opioids on patient-reported outcomes. Data is being collected over 6 14-day periods on consecutive adult patients undergoing shoulder arthroplasty, rotator cuff repair, shoulder labral repair, anterior cruciate ligament repair, hip arthroplasty, and knee arthroplasty, with follow-up via telephone call at 7-days after discharge. The primary outcome is the proportion of oral morphine equivalents (OME) of prescribed opioids versus consumed opioids at 7-days post-discharge. This ongoing study is actively recruiting in over 20 countries. Globally, 65 centres are collecting orthopaedic, including 10 New Zealand centres and 17 Australian centres. To date, 284 orthopaedic patients have been prospectively enrolled with complete data (mean age 59.6 ± 16.7 years; 51.6% female). Overall, 77% and 89% of patients were prescribed opioids on discharge in New Zealand and Australia respectively. On average, 60% of prescribed opioids were consumed at 7-days post-discharge globally (150 OME (75-500) vs. 90 OME (15-200); p<0.01). In New Zealand and Australia, 42.1% (285 OME (150-584) vs. 120 OME (6-210); p<0.01) and 63.3% (150 OME (86-503) vs. 95 OME (28-221); p<0.01) of prescribed opioids were consumed at 7-days, respectively. OPERAS will provide the first high-quality global data on opioid prescription and consumption patterns with patient perspectives. These data can inform prescribing practice and inform guidelines. The growing interest in New Zealand and Australia in student- and trainee-led orthopaedic collaborative research, as evidenced by this study should be actively encouraged and fostered

Injury to the anterior cruciate ligament (ACL) is one of the most devastating and frequent injuries of the knee. Surgical reconstruction is the current standard of care for treatment of ACL injuries in active patients. The widespread adoption of ACL reconstruction over primary repair was based on early perception of the limited healing capacity of the ACL. Although the majority of ACL reconstruction surgeries successfully restore gross joint stability, post-traumatic osteoarthritis is commonplace following these injuries, even with ACL reconstruction. The development of new techniques to limit the long-term clinical sequelae associated with ACL reconstruction has been the main focus of research over the past decades. The improved knowledge of healing, along with recent advances in tissue engineering and regenerative medicine, has resulted in the discovery of novel biologically augmented ACL-repair techniques that have satisfactory outcomes in preclinical studies. This instructional review provides a summary of the latest advances made in ACL repair. Cite this article: Bone Joint Res 2014;3:20–31

Introduction: recent studies showed the possibility of spontaneous ACL healing in acute lesion with proper treatment. The goal of our study was to analyze the functional outcome of partial ACL tears treated acutely with suture-repair combined with a bone marrow stimulation (BMS) technique (microperforation). We hypothesized that knee stability could be restored and good functional outcome could be obtained with a simple primary repair technique. Methods: From January 2003 to January 2006, 22 patients (14 males and 8 females – mean age: 23 years) with partial ACL rupture underwent acute primary ACL repair with our technique. Inclusion-exclusion criteria:. anterior instability (confirmed intraoperatively by an isolated ACL tear),. surgery performed within 3 weeks from injury. No grade 4 chondral defect,. no associated pathologies except for meniscal lesion. will to undergo to the same rehabilitation protocol. Parameters analyzed included the standard knee scales (IKDC, Noyes, Lysholm and Tegner), SANE Score, Knee Laxity Analysis and Deep Flexion Tests. In 6 cases, second look arthroscopy was performed. All patients underwent a post-operative MRI. Results: All these patients were available for follow up at 3/6 and final follow up (average of 18 months). Scoring systems revealed: Lysholm 93% (74–100), Tegner 7 (6–9), Noyes 80% (60–100) and Subjective (SANE) 86,22% (60–100). IKDC score demonstrated 55% group A, 36% B, 4% C and 4% D. This last patient didn’t go back to his previous activity level because of subjective apprehension. The knee was stable. Pivot shift test was negative in all the cases. Side to side difference was less or equal to 2 mm in all of our patients. Conclusion: Based on the preliminary results, primary ACL repair with BMS can lead to favourable results in acute partial ACL lesion. However, further prospective randomized studies are recommended at longer follow-up to validate these findings

An important aspect of the governance of surgical services within a Healthcare Trust is the correct coding of elective procedures performed. Within the Trust, treatment codes are banded into specific healthcare resource groups (HRGs), which generate a predetermined income. Accurate coding and grouping of the treatments provided for patients is consequently vital to Trusts to ensure that they receive appropriate financial reward for the care provided, so ensuring they remain economically viable as a department. We present a retrospective study investigating the accuracy of procedure coding, code allocation to HRGs, and the resultant cost consequences for all elective arthroscopic anterior cruciate ligament (ACL) repairs completed by one consultant over one financial year (01/01/2010-31/03/2011). In this period a total of 55 ACL repairs were undertaken by the consultant. Data was available for 43 of these cases, all of which were repairs of traumatic ACL ruptures. The patients had an average age of 26.7 (17–55) years, all were ASA 1 and had no significant comorbidities. They were all booked for identical procedures, except one patient who required an allograft; 12 required meniscectomies. All 43 had an operation note completed by the operating consultant. Within this trust patient and procedural codes were generated from electronic discharge letters (EDLs). We found that all 43 EDLs were completed accurately, contained full details of the procedures undertaken, and included relevant information such as complications, patient comorbidities, length of stay and the prescription of analgesics. These 43 EDLs generated 15 different diagnostic codes and 10 different procedure codes, with a total of 35 different combinations of codes. These were then grouped into six different HRGs. These six HRGs generated income for the Trust, varying from £1880 to £3554 (mean £2670) for the procedures, with a total income of £114,823. We found that patient and procedure details, and the level of doctor completing the EDL did not significantly influence the HRG generated (P = 0.4). Currently within the Trust, and nationally the HRG tariff for a routine ACL repair has not been agreed upon. The maximum possible tariff from an HRG for this procedure for a patient with no significant comorbidities is described as – ‘Reconstruction of intraarticular ligament – Major knee procedure for trauma’, generating an income of £5183 per case. Application of this tariff would have resulted in a total income of £222,869 for the 43 patients included in the present study a potential increase of earnings for the Trust of £108,046, for one elective procedure in one financial year. The findings of this study reveal the potential for limitations in the governance of surgical services through inaccuracies in HRG coding, despite the availability of suitably detailed EDLs. It is suggested that Trusts should audit and, where indicated, ensure effective quality assurance of HRG coding in the interests of the governance of secondary care services

Purpose: Anterior cruciate ligament (ACL) repair is increasingly performed to allow athletes reach their earlier sports performance or higher, leading to the risk of repeated tears. Several grafts can be proposed: the contralateral patellar ligament, hamstring tendons and the rectus femoris tendon. The purpose of this study was to analyse results in a continuous series of repeated tears of the ACL repaired with the rectus femoris tendon. Material and methods: Forty patients underwent surgical repair of the ACL after iterative tears between January 1998 and June 2000. All had had a patellar tendon graft. All were active athletes, 70% at a competition level. The second tear had occurred a mean two years after the first repair. A second graft was indicated because of persistent knee instability. Preoperative laxity was demonstrated with telos at 20 kg showing a mean differential of 12.2 mm with the healthy knee (range 5–25). The arthroscopic technique described by P. Chambat was used. A strand of the rectus femoris tendon was harvested with its bony patellar attachment. The graft was introduced laterally to medially with fixation in the tibial bore hole with a resorbable interference screw. The patellar bone was press fit into the femoral hole. Results: Outcome was assessed in all patients at mean two years (range 1–3) using telos at 20 kg. Two vertical fractures of the patella occurred three months after the ACL repair subsequent to minimal trauma. Only 50% of the patients resumed competition level sports. Two patients out of 40 had a sensation of unstable knee. Mean residual differential laxity was 2.6 mm (range 0–9). Discussion: Repair of the ACL with the rectus femoris tendon appears to provide satisfactory results after repeated tears. The thickness, width and stiffness of the tendon allow satisfactory repair even in case of severe laxity. The surgical technique is not particularly difficult if the prior surgery did not produce bony damage and if the bore holes are positioned correctly. The postoperative period is not different than after first intention ligamento-plasty. Complications are minimal. This type of graft can be used for ligamentoplasty of the central pivot. The major complication is the risk of patellar fracture which can be avoided by careful graft harvesting during the first intention procedure. Control of knee laxity can be improved by inverting the graft and fixing the patellar fragment in the tibia and the proximal tendon in the femur

The December 2022 Sports Roundup³⁶⁰ looks at: Anterior cruciate ligament (ACL) repair with dynamic intraligamentary stabilization or anterior ACL at five years?; Femoroacetabular impingement in mild osteoarthritis: is hip arthroscopy the answer?; Steroids in Achilles tendinopathy: A randomized trial.

Computer assisted navigation is known to improve tunnel placement in ACL reconstruction even compared to use of direct arthroscopic view due to image distorsion by the wide angle optics in the arthroscope. However the earlier software and instrumentation has been relatively cumbersome. The use of new materials and further software elaboration has allowed to increase the navigational precision and to accommodate more different ACL repair techniques. The relevant developments of such an upgrade which in addition allows stability testing before and after the repair are presented

In an animal model we determined the strength of anterior cruciate ligaments (ACL) after section and repair by four different methods and compared it with that of the intact ligament. The standard suturing technique of multiple loops through the ligament stumps was used. Stronger suture material did not give a stronger repair. Wrapping a fine polyester mesh around the ligament or placing it between the bundles before suture increased the strength of the repair. This modification, allied to protective rehabilitation, may reduce the failure rate of acute ACL repairs

Aims

The aim of this study was to compare patient-reported outcomes (PROMs) following isolated anterior cruciate ligament reconstruction (ACLR), with those following ACLR and concomitant meniscal resection or repair.

Previous Anterior Cruciate Ligament (ACL) reconstruction is currently a bar from entry to the Royal Marines and Royal Navy, whilst the British Army allows recruits to join if asymptomatic 18 months post ACL reconstruction. However current Royal Marines policy is to rehabilitate recruits who sustain an ACL disruption in training. We retrospectively analysed the rehabilitation times and pass out rate of Royal Marines who had an ACL disruption during recruit training over an 8 year period. 12 recruits sustained an ACL disruption during recruit training in the study period, giving an incidence of around 1.5/1000 recruits. 9 Patients underwent ACL repairs in training, with 1 patient leaving and rejoining post repair and later successfully passed out. 2 patients were treated conservatively. Of the 12 ACL sustained in training 8/12 (67%) passed out. None of the patients treated conservatively passed out. The mean time out of training for successful recruits was 51.6 weeks (95% CI 13.1) mean rehabilitation time post ACL reconstruction for successful recruits was 36.7 weeks (95% CI 12.5). Mean time to discharge for unsuccessful recruits 63.2 weeks (95% CI 42.4). In the operative group 1/10 left due to failure to return to training and 1/10 left through unrelated reasons. Current costing for recruit training is £1800 per week per recruit. ACL injuries are not common in Royal Marine Training, and reconstruction is not a bar to completing Royal Marine basic training. We estimate that it costs around £100,000 per-injured recruit, to maintain a policy of rehabilitating ACL injured recruits in Royal Marines training. Further research into the long-term employability or Royal Marines sustaining an ACL injury in training is required