Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction

BACKGROUND: The outcome of revision anterior cruciate ligament reconstruction has only rarely been reported. The purpose of this study was to evaluate the results of revision anterior cruciate ligament surgery with use of an autogenous doubled semitendinosus and gracilis graft in association with an extra-articular procedure. METHODS: Between 1997 and 2003, thirty patients underwent a repeat reconstruction of a previously reconstructed torn anterior cruciate ligament with use of a doubled semitendinosus and gracilis graft combined with an extra-articular reconstruction. Primary reconstruction had been done with an autogenous patellar tendon graft in twenty-six patients and with a prosthetic ligament in four patients; the average time from the primary reconstruction to the revision was five years. Functional outcomes, graft survival, and radiographic outcomes were evaluated at a mean of five years. A graft was considered to have failed when a revision was done or when the side-to-side difference on KT-1000 arthrometer testing was >5 mm and/or the pivot-shift test grade was greater than a trace. RESULTS: One patient underwent another revision reconstruction because of graft failure at three years postoperatively. The mean International Knee Documentation Committee (IKDC) subjective knee score for the remaining twenty-nine patients was 84 +/- 12 points, and the mean Lysholm knee score was 90 +/- 10 points. The side-to-side difference as measured with the KT-1000 arthrometer with maximum manual force was <3 mm in twenty patients (of the twenty-eight who returned for follow-up), between 3 and 5 mm in six patients, and >5 mm in two patients. The result of the pivot shift examination was normal in fifteen patients, slightly positive in eleven patients, and positive in two patients. Twenty-five percent of the patients showed no radiographic signs of degenerative joint disease. CONCLUSIONS: Revision anterior cruciate ligament reconstruction with use of an autogenous doubled semitendinosus and gracilis graft combined with an extra-articular procedure provided satisfactory functional outcomes, with a failure rate of 10%.     

Optimizing anterior cruciate ligament reconstruction: Individualizing the decision-making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.     

Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004

We analyzed the temporal changes in the caseload of primary and revision hip and knee arthroplasty surgeons in the United States between 1990 and 2004. The Nationwide Inpatient Sample was used to identify arthroplasty procedures and the surgeons who performed them. Annual caseloads were analyzed for each procedure; 47% +/- 2% and 39% +/- 2% of hip and knee surgeons performed revisions nationwide. Average revision caseloads increased slightly over time at a rate of 1.2 and 1.4 cases per surgeon per decade for total hip arthroplasty (THA) and total knee arthroplasty (TKA), respectively. The caseload of primary THA and TKA increased by 1.4 and 1.7 cases per surgeon per decade. The caseload for the top 5% of primary THA and TKA surgeons increased from 25 to 45 and 33 to 86, respectively, during this period compared with the median caseload, which increased from 4 to 5 (hip) and 5 to 10 (knee). The revision caseload of surgeons has increased over time, particularly for surgeons with the highest caseloads.     

Association of KT-1000 measurements with clinical tests of knee stability 1 year following anterior cruciate ligament reconstruction.

STUDY DESIGN: Prospective, observational study. OBJECTIVES: To determine the association between KT-1000 measurements with an anterior translation force of 89 N and other measures of outcome (the Tegner activity score, the modified Lysholm score, subjective rating of instability, Lachman test, and pivot-shift test) 1 year following anterior cruciate ligament (ACL) reconstruction. BACKGROUND: Health care professionals often use the side-to-side difference measured with the KT-1000 arthrometer to determine ACL integrity during passive motion. It has been postulated that a 5-mm or greater difference between impaired and nonimpaired knees represents a procedural failure. METHODS AND MEASURES: Ninety patients (46 men, 44 women) with a mean age of 30 +/- 8 years were examined 1 year after surgery. Patients were classified in 1 of 3 groups depending on the amount of laxity between the impaired knee and the nonimpaired knee. Seventy percent of the subjects had a side-to-side difference less than or equal to 3 mm (tight), 13% had a difference of between 3 and 5 mm (moderate), and 17% had a difference greater than or equal to 5 mm (loose) on examination using the KT-1000. RESULTS: Mean Lysholm and Tegner scores did not differ significantly among groups. Side-to-side differences in KT-1000 measurements at 89 N were not associated with the Lysholm score (r = -0.09) or Tegner score (r = 0.02). Lachman tests were related to involved-knee KT-1000 measurements (r = 0.39) but not to side-to-side differences in KT-1000 measurements (r = 0.15). Similarly, pivot-shift tests were related to involved-knee KT-1000 measurements (r = 0.26) but not to side-to-side differences (r = -0.08). CONCLUSIONS: These results suggest that side-to-side KT-1000 measurements obtained with an anterior translation force of 89 N should not be used in isolation to determine ACL reconstruction success or failure 1 year following surgery.     

Revision anterior cruciate ligament reconstruction using the lateral third of the ipsilateral patellar tendon after failure of a central-third graft: a preliminary report on 10 patients

Long-term outcomes were reported for 10 (77%) of 13 cases of revision anterior cruciate ligament (ACL) reconstruction using the lateral third of the ipsilateral patellar tendon as a graft. All primary ACL reconstructions were ipsilateral central-third bone-patellar tendon-bone graft procedures. Mean age at follow-up was 30.7 years, and mean time from revision ACL surgery to follow-up was 42.9 months. At follow-up, average KT-1000 difference between knees was 2.4 mm. All patients had a negative pivot shift, extension within 5 degrees of the contralateral knee, and flexion within 15 degrees. Mean bilateral comparison ratios for isokinetic strength and hop testing were: extension, 83.5%; flexion, 96%; and single-leg hop 96.9%. No patella fractures or tendon ruptures had occurred. All patients had returned to their previous work level, and 8 of the 10 patients could participate in at least "moderate" sports activities (e.g., skiing and tennis). The results were comparable to published outcome reports for both primary and revision ACL reconstruction. The lateral third of the ipsilateral patellar tendon is a good graft option for revision ACL reconstruction.     

Primary- and revision-reconstruction of the anterior cruciate ligament with allografts: a retrospective study including 325 patients

At our institution we have used fresh-frozen allografts for the reconstruction of the anterior and posterior cruciate ligament since 1993. METHOD: In this retrospective study we evaluated the clinical outcome of 325 fresh-frozen allografts (bone-patellar-tendon-bone allografts and Achilles-bone-tendon allografts) for primary and revision ACL-reconstruction. Patients (average age 38 years) were operated between 5/1993 and 2/1998 and mean follow-up was 38 (range 24 to 71) months. Clinical evaluation consisted of a case history, an examination, IKDC, Cincinnati knee score (CKS), KT-1000 testing and standardized X-rays. RESULTS: Overall subjective rating according to the CKS was more than 82 points for both groups. Objective results according to the IKDC were normal or nearly normal in 75.6 % of primary- and 67.0 % of revision-ACL reconstructions. The stability measured with the KT-1000 showed an average maximum side to side difference of 2.1 mm for primary ACL reconstruction and 2.3 mm for revisioners. The total failure-rate (= rerupture-rate + laxity-failures) was 13.7 % for primary and 15.0 % for revision ACL reconstructions. CONCLUSION: Given the increased failure-rate, autograft tissue remains our graft of first choice for primary ACL-reconstruction. We advise to reserve allografts for revision procedures where suitable autogenous tissues have been previously compromised, where a contraindication for autogenous tissue harvest exists or for multiple ligament surgery. No specific complications were observed with the use of allograft tissue.     

Comparing the anatomic single-bundle versus the anatomic double-bundle for anterior cruciate ligament reconstruction: a prospective,randomized, single blind,clinical study

Purpose

The aim of this study was to compare the early results of anatomic single bundle versus double-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

We conducted a prospective randomized study of anatomic single-bundle versus double-bundle ACL reconstruction using the hamstring tendons of 67 patients with unilateral ACL deficiency. The subjects were randomized into two groups. The single-bundle group consisted of 37 patients and the double-bundle group 30 patients. We used the following evaluations: clinical examination, KT-1000 arthrometry, Tegner knee score, modified Cincinnati score, Knee Injury and Osteoarthritis Outcome Scale (KOOS), International Knee Documentation Committee (IKDC) score. Two surgeons performed all operations, and a blinded independent author conducted the clinical follow-up assessments.

Results

The mean follow-up period was 25.8 months. The differences between the preoperative and postoperative clinical examinations and the KT-1000 measurements were statistically different in both groups (p?p?Conclusions This prospective study found no difference between the outcomes of the anatomic single-bundle and the anatomic double-bundle ACL reconstructions. Level of evidence II.     

Age and ACL reconstruction revisited

To determine the age limitations for indicating ACL reconstructions in patients with functional instability, this article reviews the results of anterior cruciate ligament (ACL) reconstructions in 23 patients with an average age of 54 years (range: 49-64 years). Patients were evaluated with the Lysholm and Gillquist knee questionairre, visual analog scale, satisfaction rating, physical examination, KT-1000 testing, and radiographs. Nineteen of the 23 patients were available for follow-up at an average of 24 months after the index procedure. Sixteen patients returned for physical examination and 3 agreed to telephone interviews. The mean Lysholm score was 92, visual analog score 0.5, satisfaction rating 100%, KT-1000 testing 2mm, range of motion 0 degrees to 135 degees. Sixteen of the 19 patients returned to acceptable activity levels. Fifteen patients had excellent or good results, while 4 patients had fair or poor results. Three of the 4 fair or poor results had significant moderate or severe knee arthrosis. Anterior cruciate ligament reconstruction with allograft in 49-64 year-old patients with minimal arthrosis is a safe, minimally invasive procedure that allows for return to a desired level of activity.     

Patient and Surgeon Expectations Prior to Anterior Cruciate Ligament Reconstruction

Background

When discussing potential treatment with patients choosing to undergo surgery for disruption of the anterior cruciate ligament (ACL) and their families, surgeons spend considerable time discussing expectations of the short- and long-term health of the knee. Most of the research examining patient expectations in orthopedic surgery has focused largely on arthroplasty.

Questions/Purposes

The purpose of this study was to quantitatively assess the differences between the patient’s and the surgeon’s expectations before primary anterior cruciate ligament reconstruction (ACLR).

Methods

In this case series, we prospectively enrolled 93 patients scheduled for primary ACLR between 2011 and 2014. Expectations were measured using the Hospital for Special Surgery 23-item Knee Expectations Survey; scores were calculated for each subject.

Results

In all but six categories, patients had expectations that either aligned with their surgeons’ or were lower. The largest discordance between surgeon and patient expectations in which the patient had lower expectations was employment; 75% of patients had similar expectations to the surgeon when asked if the knee would be “back to the way it was before the problem started,” less than 1% had higher expectations, and 17% had lower expectations.

Conclusion

In general, patient expectations align well with surgeon expectations. Patients who are older, have a lower activity level, and who have selected allograft over autograft for ACLR could also be at risk for greater discordance. Understanding these differences, and their predictors, will help guide physicians when they are counseling patients about ACLR and also help them interact with patients after surgery as they assess outcomes.

     

Measurement of anterior-posterior knee laxity: a comparison of three techniques.

Several non-invasive techniques have been developed to assess anterior-posterior (A-P) laxity of the knee, however, their accuracy remains unclear. Roentgen Stereophotogrammetry Analysis (RSA) is a three-dimensional motion analysis method that has been shown to be an accurate tool for evaluating joint kinematics. Thus. RSA provides a means that can be used to evaluate other less invasive techniques. The objectives of this study were to compare A-P laxity values as measured using the KT-1000 Knee Arthrometer, planar stress radiography and RSA, and to determine if they detect similar changes in A-P laxity over time in 15 subjects following anterior cruciate ligament reconstruction with patellar tendon autografts. The A-P laxity values of the injured knee were measured immediately following surgery and at their 3-, 6-, and 12-month follow-up visits. A-P laxity was defined as the A-P translation of the tibia relative to the femur that occurred between the posterior and anterior shear load limits of -90 to +130 N, respectively. The values of A-P laxity across all time points were 11.4 +/- 3.0, 10.2 +/- 3.3, and 6.9 +/- 3.0 mm (mean +/- standard deviation) for the KT-1000, planar stress radiography and the RSA methods, respectively. These values were significantly different from each other (p < 0.001). The two-dimensional analyses techniques (planar stress radiography and the KT-1000) consistently over-estimated the true laxity values that were obtained using the three-dimensional RSA technique. Significant increases in A-P laxity values over time were also detected with the KT-1000 (p = 0.04) and the RSA technique (p = 0.04). However, this increase was not evident when using planar stress radiography (p = 0.89). This study determined that the KT-1000 and RSA document temporal changes in A-P laxity following ACL reconstruction that were not documented by planar stress radiography.     

A new device to measure knee laxity during weightbearing and non-weightbearing conditions.

The Vermont knee laxity device (VKLD) was developed to evaluate anterior-posterior (A-P) displacement of the tibia relative to the femur (A-P laxity) during weightbearing and non-weightbearing conditions. The purposes of this study were to determine the repeatability and reliability of the VKLD measurements of A-P laxity and to compare them with two devices currently in clinical use: the KT-1000 knee arthrometer and planar stress radiography. Two independent examiners tested six subjects with no history of knee injury. A-P laxity was measured on three separate days with the KT-1000 and the VKLD. With the VKLD, A-P laxity was measured in the weightbearing and non-weightbearing conditions. In addition, one examiner measured A P laxity in each subject on each day using a planar stress radiography technique. Similar A-P laxity values were obtained with the KT-1000 and the VKLD; however, the planar stress radiography technique measured less A-P laxity compared to the VKLD (9.2+/-2.2 mm versus 13.3+/-2.9 mm, P = 0.0004). None of the three devices showed significant differences in measuring A-P laxity between days. During weightbearing, A-P laxity was reduced by 65-70% compared to the non-weightbearing condition (P = 0.0001). Future investigations will use the VKLD to study subjects that have suffered injury to the anterior and posterior cruciate ligaments.     

Fibular Collateral Ligament Reconstruction Graft Options: Clinical and Radiographic Outcomes of Autograft Versus Allograft

PurposeTo compare varus knee stability and clinical outcomes between patients who underwent fibular collateral ligament reconstruction (FCLR) or lateral collateral ligament (LCL) reconstruction with autografts versus allografts when undergoing concomitant anterior cruciate ligament reconstruction (ACLR).MethodsAll patients who underwent primary ACLR and concomitant FCLR from 2010 to 2017 performed by a single surgeon (R.F.L.) were retrospectively identified. Clinical characteristics and graft choices for FCLR were collected. Patients with a minimum 2-year follow-up for clinical outcome scores and 6-month stress radiographs were included. Patients with any other ligamentous procedure or revision ACLR were excluded.ResultsWe identified 69 primary ACLR with concomitant FCLR patients who met the inclusion criteria. Fifty patients underwent FCLR with semitendinosus autografts, and 19 with allografts. There were no significant side-to-side differences (SSDs) in lateral compartment gapping on varus stress x-rays between the 2 cohorts (allograft, 0.49 mm; autograft, 0.15 mm, P = .22), and no FCLR failures. There were no significant differences between autograft and allograft groups at minimum 2-year outcomes for 12-Item Short Form mental or physical composite score (SF12 MCS, P = .134; SF12 PCS, P = .642), WOMAC total (P = .158), pain (P = .116), stiffness (P = .061), or activity (P = .252); International Knee Documentation Committee (IKDC) (P = .337), Tegner (P = .601), Lysholm (P = .622), or patient satisfaction (P = .218). There were no significant differences in clinical knee stability between groups at an average follow-up of 3.6 years (P = 1.0).ConclusionThere were no differences in varus stress laxity 6 months postoperatively or clinical outcome scores at ≥2 years postoperatively between patients having FCL reconstructions with either autograft or allograft. This study demonstrates that both hamstring autografts and allografts for FCL reconstructions offer reliable and similar radiographic and clinical results at short-term follow-up.Level of EvidenceIII, retrospective comparative trial.     

Association between hospital and surgeon procedure volume and the outcomes of total knee replacement

BACKGROUND: The annual volume of major cardiovascular and oncologic procedures performed in hospitals and by surgeons has been inversely associated with the rates of perioperative mortality and complications. The relationship between hospital and surgeon volume and perioperative outcomes following total knee replacement has received little study. METHODS: We analyzed claims data for Medicare patients who had elective primary total knee replacement between January 1 and August 31, 2000. Hospital and surgeon volumes were defined as the number of primary and revision total knee replacements performed in the hospital or by the surgeon in Medicare recipients in 2000. We examined the associations between the annual volumes of total knee replacement performed in the hospitals and by the surgeons and the rates of mortality and complications (infection, pulmonary embolus, myocardial infarction, or pneumonia) in the first ninety days postoperatively. The analyses were adjusted for age, gender, comorbid conditions, Medicaid eligibility (a marker of low income), and arthritis diagnosis. Analyses of hospital volume were adjusted for surgeon volume and vice versa. RESULTS: Twenty-five percent of the primary total knee replacements were done by surgeons who performed twelve of these procedures or fewer in the Medicare population annually, and 11% were done in hospitals with an annual volume of twenty-five of these procedures or fewer. Compared with the patients who had a primary total knee replacement in hospitals with an annual volume of twenty-five procedures or fewer, those managed in hospitals with an annual volume exceeding 200 procedures had a lower risk of pneumonia (odds ratio, 0.65; 99% confidence interval, 0.47 to 0.90) and any of the adverse outcomes examined (death, pneumonia, pulmonary embolus, acute myocardial infarction, or deep infection) (odds ratio, 0.74; 99% confidence interval, 0.60 to 0.90). Similarly, patients who had a primary total knee replacement done by surgeons who performed more than fifty such procedures in Medicare recipients annually had a lower risk of pneumonia (odds ratio, 0.72; 99% confidence interval, 0.54 to 0.95) and any adverse outcome (odds ratio, 0.81; 99% confidence interval, 0.68 to 0.98) compared with patients of surgeons with an annual volume of twelve procedures or fewer. CONCLUSIONS: Patients managed at hospitals and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events following primary total knee replacement. Patients and clinicians should incorporate these findings into discussions about selecting a surgeon and a hospital for total knee replacement. These data should also be integrated into the policy debate about the advantages and drawbacks of regionalizing total joint replacement to high-volume centers.     

Comparative study of knee anterior cruciate ligament reconstruction with or without fluoroscopic assistance: a prospective study of 73 cases

INTRODUCTION: Correct placement of both tibial and femoral tunnels is one of the main factors for a favorable clinical outcome after anterior cruciate ligament (ACL) reconstruction. We used an original system of computer assisted surgery (CAS). The system, based on fluoroscopic guidance combined with special graphical software of image analyzing, showed to the surgeon, before drilling, the recommended placement of tibial and femoral tunnel centers. We compared the first anatomical and clinical results of this procedure to the usual one single incision technique. MATERIALS AND METHODS: We conducted a prospective study on 73 patients; 37 patients were operated on with CAS and 36 without CAS, by the same senior surgeon. The mean age was 27 years for both groups. Every patient was reviewed at an average of 2.2 years (range 1-4.5) by an independent observer, using IKDC scoring system, KT-1000, and passive stress radiographs. RESULTS: Time between ACL rupture and reconstruction averaged 30 months for both groups. CAS needed 9.3 min extra surgery time. Clinical evaluation was graded from A to C as per the IKDC scoring system: 67.6% A, 29.7% B, 2.7% C with CAS; and 60% A, 37.1% B, 2.9% C without CAS. IKDC subjective knee evaluation score averaged 89.7 with CAS and 89.5 without CAS. Pre operative KT-1000 maxi manual differential laxity averaged 7. At revision time, all the patients after CAS had a differential laxity less than 2 and 97.7% without CAS. Stress X-rays differential laxity averaged 2.4 mm with CAS and 3 mm without CAS. The area of dispersion of the tunnels' center was smaller on the femoral side using the CAS method. There was no statistically significant difference between both groups using IKDC score, KT-1000 and passive stress radiographs. CONCLUSIONS: The CAS method provided a more accurate and reproducible tunnels placement without clinical significant effect.     

A minimally invasive technique ("healing response") to treat proximal ACL injuries in skeletally immature athletes

This study documents outcomes of athletically active, skeletally immature patients with proximal anterior cruciate ligament (ACL) tears treated with a non-reconstructive technique to promote healing ("healing response"). Between 1992 and 1998, 13 skeletally immature athletes with proximal ACL tears underwent a healing response procedure. Patients with previous ACL injury, other concurrent ligament pathology, and/or complete mid-substance ACL tears were excluded. Average preoperative KT-1000 arthrometer manual maximum difference for all patients was 5 mm (range: 3-10 mm). Preoperatively, all patients had a 1+ or 2+ pivot shift, and all patients reported knee function as abnormal or severely abnormal. Patients were followed prospectively with clinical examinations, KT-1000 testing, and subjective questionnaires. Three (23%) patients had a re-injury 30 to 55 months after the healing response and underwent subsequent ACL reconstruction. Subjective follow-up on the remaining 10 patients at an average of 69 months (range: 26-113 months) postoperatively indicated no patients experienced pain or giving way, and all considered their knee function normal. Average Lysholm score was 96, Tegner score was 8.5 (range: 7-10), and patient satisfaction at follow-up was 9.9 (1=very dissatisfied and 10=very satisfied). Clinical examination at least one year postoperatively was performed on 7 of 10 patients at 35 months (range: 12-63 months). Five patients had a negative pivot shift and 2 had a 1+ pivot shift. KT-1000 measurements improved to 2 mm (range: 0-3 mm). In the athletically active, skeletally immature patient, the healing response procedure can restore stability and knee function, with proper patient selection. In this study group, patients were very satisfied with the procedure and returned to a high level of sports and activities.     

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,¹ and an objective failure rate of 13.7% has been reported for revision ACLR.² Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.     

Total knee arthroplasty for patients 90 years of age and older

This study was done to review the reliability, durability, and safety of primary and revision total knee arthroplasty for patients 90 years of age and older. Because little data exist about the safety or efficacy of total knee replacement in this elderly population some physicians may be hesitant to recommend elective surgery to patients of this age. Fifty-one total knee replacements were done for 41 patients age 90 to 102 years (mean, 92 years). Forty-four primary total knee replacements and seven revision total knee replacements were done. Each patient was followed up until death or for a minimum of 2 years (mean, 4.0 years). The Knee Society pain scores improved significantly for the primary and revision groups from preoperative mean scores of 30 and 29 points to latest followup scores of 86 and 87 points, respectively. One patient died in the early postoperative period of causes related to the operation. The remaining patients have lived an average of 4.4 +/- 2.2 years after the primary knee arthroplasties and 5.7 +/- 2.8 years after the revision knee arthroplasties. No knees have required revision subsequently. Total knee replacement was reliable, durable, and safe in this group of patients older than 90 years. Primary care physicians and surgeons should be aware that primary and revision total knee replacement can be done safely and effectively for patients 90 years and older and result in years of marked pain relief for those patients.     

Editorial Commentary: Is the Key to Successful Revision Anterior Cruciate Ligament Reconstruction Addressing the Anterolateral Complex With a Lateral Extra-articular Tenodesis?

As the overall incidence of anterior cruciate ligament (ACL) ruptures continues to rise, the failure rates in reconstructive surgery remain relatively stable. Despite advances in our understanding of graft selection, anatomic reconstruction, addressing concomitant injuries, and the importance of rehabilitation, we continue to see failure rates in primary ACL reconstructions of up to 15%. Thus as the number of primary ACL reconstructions rises, so too does the number of revision ACL surgeries. This rising need for revision ACL reconstructions presents an even more daunting task because failure rates of up to 25% have been reported. Much of the current literature's focus is on improving outcomes and lowering these failure rates. Could adding a lateral extra-articular tenodesis to revision ACL surgery be the magic bullet we have been searching for to lower our failure rates? We question whether it is that simple.     

保留与不保留残端重建前十字韧带的前瞻性随机对照研究

 目的 评估保留与不保留残端对重建前十字韧带（anterior cruciate ligament,ACL）的意义及临床疗效。方法 2010年1月至2012年10月,收治93例残端存留的ACL损伤患者,前瞻性随机将其分为保留组（保留残端）和不保留组（切除残端）。保留组48例,男34例,女14例;平均年龄30.4岁;左侧25例,右侧23例;损伤至手术时间13.5 d;合并内侧半月板损伤7例,外侧半月板损伤16例,内侧副韧带损伤4例。不保留组45例,男33例,女12例;平均年龄28.8岁;左侧22例,右侧23例;损伤至手术时间14.9 d;合并内侧半月板损伤7例,外侧半月板损伤12例,内侧副韧带损伤2例。两组重建ACL移植物均为自体四股腘绳肌腱。术后两组患者分别行膝关节功能评估、稳定性评估、本体感觉功能测量和二次关节镜手术探查。结果 82例患者完成随访,其中保留组42例,随访时间（25.4±1.9）个月;不保留组40例,随访时间（25.2±1.7）个月。IKDC分级：保留组A级32例,B级9例,C级1例;不保留组A级30例,B级8例,C级2例。Lysholm评分：保留组（95.9±5.2）分,不保留组（95.4±1.7）分。Lachman试验：保留组,阴性38例,1度阳性4例;不保留组,阴性36例,1度阳性4例。轴移试验：保留组,阴性37例,1度阳性5例;不保留组,阴性34例,1度阳性6例。KT-1000测量侧-侧差值：保留组（1.1±1.2） mm,不保留组（1.2±0.9） mm。本体感觉测量关节位置觉侧-侧差值：保留组3.6°±1.8°,不保留组3.9°±2.2°。以上指标两组均无明显差异。二次手术探查移植物滑膜覆盖分型,保留组A型11例,B型6例,C型2例,D型2例;不保留组A型10例,B型5例,C型2例,D型2例。结论 保留较不保留残端并使用自体肌腱移植重建ACL对术后膝关节主观功能、稳定性、本体感觉和移植物滑膜覆盖无促进作用。     

Two surgeons,one patient: The impact of surgeon–surgeon familiarity on patient outcomes following mastectomy with immediate reconstruction

BackgroundMastectomy with immediate reconstruction requires the coordination and expertise of two distinct surgeons. This often results in several different combinations of mastectomy and reconstructive surgeons, but with an unknown impact on patient outcomes. We evaluate the effect of different surgical teams on complication rates following mastectomy and immediate reconstruction.MethodsRetrospective review of consecutive patients that underwent mastectomy with immediate prosthetic reconstruction from 4/1998 to 10/2008 at one institution was performed. Patients of the three highest-volume mastectomy and reconstructive surgeons were stratified by their individual combination of surgeons, resulting in nine different surgical teams. Complications were categorized by end-outcome. Appropriate statistics, including multiple linear regression, were performed.ResultsClinical characteristics were similar among patients (n = 511 patients, 699 breasts) with the same mastectomy surgeon but different reconstructive surgeon. Mean follow-up was 38.4 ± 25.7 months. For each mastectomy surgeon, the choice of reconstructive surgeon did not affect complication rates. Furthermore, the combined complication rates of the three highest-volume teams (n = 384 breasts) were similar to the remaining lower-volume teams (n = 315 breasts). Patient factors, but not the individual surgeon or surgical team, were independent risk factors for complications.DiscussionOur study suggests that among high-volume surgeons, complication rates following mastectomy with immediate reconstruction are not affected by the surgeon–surgeon familiarity. The individual surgeon's expertise, and patient risk factors, may have a greater impact on outcomes than the team's experience with each other. These results validate the efficacy and safety of the surgeon distribution model currently used by many breast surgery practices.