JBJS | Article

The Journal of Bone & Joint Surgery, Volume 83, Issue 9

Scientific Articles | September 01, 2001

Arthroscopically Assisted Reconstruction of the Anterior Cruciate Ligament : A Follow-up Report

Daniel B. O'Neill, MD

Investigation performed at Christus St. John Sports Medicine Center, Nassau Bay, Texas
Daniel B. O’Neill, MD
Christus St. John Sports Medicine Center, 18100 St. John Drive, Suite 300, Nassau Bay, TX 77058

In support of this research or preparation of this manuscript, the author received grants or outside funding from Dyonics and from Mitek. The author did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

A video supplement to this article is available from the Video Journal of Orthopaedics. A video clip is available at the JBJS web site, www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.

The Journal of Bone & Joint Surgery. 2001; 83:1329-1332

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Abstract

Background: The purpose of this study was to further delineate the outcome of arthroscopically assisted anterior cruciate ligament reconstruction in 125 patients who had previously been followed for two to five years. One of the original 125 patients was excluded from the present study because of insufficient follow-up, and an additional group of 101 patients was added. All 225 patients in the present study were followed for a minimum of six years.

Methods: Patients were randomly assigned to reconstruction with a double-stranded semitendinosus-gracilis graft with use of a two-incision technique (group I), reconstruction with a patellar ligament graft with use of a two-incision technique (group II), or reconstruction with a patellar ligament graft with use of a single-incision endoscopic technique (group III). The groups were compared with regard to the rate of graft failure, the amount of instability, knee strength, radiographic signs of degenerative changes, and functional outcome.

Results: There was no significant difference among the three groups with regard to the rate of graft failure, the amount of knee instability, or the functional outcome. A normal or nearly normal functional outcome was recorded for 208 (92%) of the 225 patients. There were significant differences among the groups with regard to quadriceps muscle-strength deficits: group I had fewer patients with deficits than group III, and groups I and III both had fewer patients with deficits than group II (p = 0.04). There also were significant differences among the groups with regard to hamstring muscle-strength deficits: group III had fewer patients with deficits than group II, and group II had fewer patients with deficits than group I (p < 0.01). Twelve knees (16%) in group I, six knees (8%) in group II, and eight knees (11%) in group III showed radiographic evidence of progressive degenerative changes, but the differences among the three groups were not significant.

Conclusion: Although 11.6% of the 225 knees had radiographic evidence of degenerative arthritis at a minimum of six years after arthroscopically assisted reconstruction of the anterior cruciate ligament, the choice of graft and the technique of reconstruction did not seem to affect the rate of development of these changes.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Reconstruction of a ruptured anterior cruciate ligament of the knee of an active patient is widely recommended to prevent knee instability, recurrent injury, and further intraarticular disease^1-3. Both open and arthroscopically assisted techniques of reconstruction, with use of a variety of grafts, have been successful. The present report is an extension of a previous two-to-five-year follow-up study of 125 patients who were randomly assigned to treatment with one of three arthroscopically assisted techniques for reconstruction of the anterior cruciate ligament². In that report, I found no differences in knee stability or functional outcome when patellar ligament-graft reconstruction was compared with semitendinosus-gracilis tendon-graft reconstruction. I also found no differences between the endoscopic technique and the two-incision technique when a patellar ligament graft was used.

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Fig. 1-A:: Immediate postoperative anteroposterior radiograph of the knee of a forty-three-year-old man who injured the knee while snow-skiing. He had undergone no previous surgical procedures on the knee and had a concomitant partial medial meniscectomy and medial femoral condyle abrasion chondroplasty at the time of the anterior cruciate ligament reconstruction. The contralateral ankle was fused. The patient was 6 ft 8 in (203.2 cm) tall and weighed 280 lb (127 kg).

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Fig. 1-B:: Anteroposterior and lateral radiographs of the knee, made 122 months after the operation, showing severe osteoarthritic changes. The patient participated in no sports. There was no side-to-side difference in knee stability, but the procedure was rated a failure both clinically and radiographically.

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Fig. 1-C:: Anteroposterior and lateral radiographs of the knee, made 122 months after the operation, showing severe osteoarthritic changes. The patient participated in no sports. There was no side-to-side difference in knee stability, but the procedure was rated a failure both clinically and radiographically.

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TABLE I: Postoperative Radiographic Findings

*The values are given as the number of patients.

Compartment Narrowing/Osteophytes/Condyle Flattening	Semitendinosus-Gracilis Graft (Group I)*	Patellar Ligament Graft*
Two-Incision Technique (Group II)	Endoscopic Technique (Group III)
None	63	69	67
Mild (small osteophytes, slight sclerosis or condyle flattening, 1-2 mm of compartment narrowing)	?8	?5	?8
Moderate (2-4 mm of compartment space, £50% narrowing)	?3	?1	?0
Severe (<2 mm of compartment space, >50% narrowing)	?1	?0	?0

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TABLE I: Postoperative Radiographic Findings

*The values are given as the number of patients.

Compartment Narrowing/Osteophytes/Condyle Flattening	Semitendinosus-Gracilis Graft (Group I)*	Patellar Ligament Graft*
Two-Incision Technique (Group II)	Endoscopic Technique (Group III)
None	63	69	67
Mild (small osteophytes, slight sclerosis or condyle flattening, 1-2 mm of compartment narrowing)	?8	?5	?8
Moderate (2-4 mm of compartment space, £50% narrowing)	?3	?1	?0
Severe (<2 mm of compartment space, >50% narrowing)	?1	?0	?0

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From August 1989 to October 1994, 399 patients were examined because of a tear of the anterior cruciate ligament. Of these, eighty-seven patients chose nonoperative management after counseling, eighty declined to be included in the study, three were ineligible for the study because a graft had been previously harvested from the assigned donor site, one died of lymphoma two years postoperatively, and two were lost to follow-up. One hundred and twenty-five patients were included in the previous two-to-five-year follow-up study². One of these patients died from a gunshot wound less than six years postoperatively and therefore was not eligible for the present study. In addition, 101 patients who had had insufficient follow-up for inclusion in the original study were eligible for the present study. Thus, the final analysis included 225 consecutive patients who had been followed for six to eleven years (mean, 102 months) after the procedure. Institutionally approved informed consent to enter the study was obtained from all patients.

Preoperatively, the patients were randomly assigned to one of three groups: reconstruction with a double-stranded semitendinosus-gracilis graft with use of a two-incision technique (group I), reconstruction with a patellar ligament graft with use of a two-incision technique (group II), or reconstruction with a patellar ligament graft with use of a single-incision endoscopic technique (group III).

The male:female ratio in all groups was 2:1, and there were no significant differences among the groups with regard to the mean age, the mean interval between the injury and the index operation, or the mean duration of follow-up (beta < 0.1). There also were no significant differences with regard to the number of previous operations, associated injuries, or concomitant operations (beta < 0.05).

The postoperative regimen, the instrumented testing of laxity with use of the KT-2000 Arthrometer (MedMetric, San Diego, California), and the radiographic and functional evaluations were standard for all three groups. The International Knee Documentation Committee rating system⁴ was used for functional evaluation. According to this scale, a knee with normal function is rated A. The grade becomes lower on the basis of several factors: the patient’s subjective assessment, symptoms, loss of motion, laxity of 3 mm on instrumented testing, a positive pivot-shift sign, the presence of crepitus, narrowing of the cartilage space on radiographs, and a one-leg-hop value of <90% of that on the contralateral side. A knee that has nearly normal function but 3 to 5 mm of laxity is graded B. If there is 6 to 10 mm of laxity, the grade is C (abnormal). A knee with >10 mm of laxity, severe changes seen radiographically, or a one-leg-hop value of <50% of that on the contralateral side is graded D (severely abnormal). Graft failure was documented during subsequent surgical reconstruction of the graft or during instrumented laxity testing.

The t test, analysis of variance, and the Kruskal-Wallis H test were used to analyze the data for the 225 patients in this series. For power analysis, the alpha error was fixed at 5% (the traditional 95% confidence level) and the statistical power or beta error for each comparison was calculated.

Results

Introduction | Materials and Methods | Results | Discussion | References

Six grafts failed in group I, four failed in group II, and five failed in group III. There were no significant differences among the three groups with regard to the rate of graft failure, the time required for return to the preinjury level of athletic activity, the range of motion, evidence of patellar crepitus, or the number of subsequent operative procedures (beta < 0.3).

Testing with the KT-2000 Arthrometer

Testing with the KT-2000 arthrometer at maximum manual force revealed a side-to-side difference of £2 mm in fifty-six patients (75%) in group I, sixty-one patients (81%) in group II, and sixty patients (80%) in group III. These findings were not significantly different (beta < 0.2)

Strength Deficits

Isokinetic testing revealed quadriceps muscle-strength deficits of at least 10% in ten patients (13%) in group I, thirty-one patients (41%) in group II, and twenty patients (27%) in group III. Group I had significantly fewer patients with deficits than group III, and groups I and III both had significantly fewer patients with deficits than group II (p = 0.04). Hamstring muscle-strength deficits of 10% were found in fourteen patients (19%) in group I, ten patients (13%) in group II, and five patients (7%) in group III. Group III had significantly fewer patients with deficits than group II, and group II had significantly fewer patients with deficits than group I (p < 0.01).

Findings on Postoperative Radiographs

Sixty-three patients (84%) in group I, sixty-nine patients (92%) in group II, and sixty-seven patients (89%) in group III showed no radiographic evidence of progressive degenerative changes in the knee (Table 1). In group I, eight patients had mild changes, three had moderate changes, and one had severe changes (Figs. 1-A, 1-B, and 1-C); in group II, five had mild changes and one had moderate changes; and in group III, eight had mild changes. There were no significant differences among the three groups with regard to the radiographic changes over time (beta < 0.3). Furthermore, no significant relationship between meniscal repair, partial meniscectomy, or chondral injury and radiographic signs of progressive degeneration could be found in this series (beta < 0.3).

Functional Testing

In group I, the International Knee Documentation Committee rating was A for forty-eight knees (64%), B for nineteen (25%), C (because of laxity or poor one-leg-hop results) for three (4%), and D (because of failure of the graft or severe radiographic changes) for five (7%).

In group II, fifty-three knees (71%) were rated A, eighteen (24%) were rated B, two (3%) were rated C (because of laxity), and two (3%) were rated D (because of graft rupture).

In group III, fifty-five knees (73%) were rated A, fifteen (20%) were rated B, three (4%) were rated C (because of laxity), and two (3%) were rated D (because of graft rupture).

There was no significant difference among the groups with regard to functional outcome; 208 (92%) of the 225 knees had either normal (grade-A) or nearly normal (grade-B) function.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

No progressive degenerative changes were found on the two-to-five-year radiographs of the 125 patients who were included in the first study². Since then, the study group has been expanded to 225 patients with a longer duration of follow-up (six to eleven years). Although knee stability and functional outcome remained consistent in all of the patients, progressive degenerative changes were seen at the time of the present study. Although no significant differences were noted among the three groups, twelve patients (16%) in group I, six patients (8%) in group II, and eight patients (11%) in group III had radiographic evidence of degenerative changes in the knee, for an overall rate of 11.6%.

Daniel et al.¹ found a greater prevalence of joint abnormalities as seen on bone scans among patients who had open anterior cruciate ligament reconstruction without meniscal surgery than among those who did not have a ligament reconstruction. They also found a greater prevalence of arthrosis among patients who had meniscal surgery. Shelbourne and Gray³ reported poorer functional outcomes among patients who had meniscectomy. In the present study, no significant relationship was found between radiographic degenerative changes and meniscal surgery. Neither the choice of graft nor the arthroscopically assisted reconstruction technique seemed to affect the rate of development of late degenerative changes as seen radiographically.

References

Introduction | Materials and Methods | Results | Discussion | References

Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ,Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med,1994;22: 632-44. 22632 1994 [PubMed][CrossRef]

O’Neill DB. Arthroscopically assisted reconstruction of the anterior cruciate ligament. A prospective randomized analysis of three techniques. J Bone Joint Surg Am,1996;78: 803-13. 78803 1996 [PubMed]

Shelbourne KD,Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations. Am J Sports Med,2000;28: 446-52. 28446 2000 [PubMed]

International Knee Documentation Committee. Knee ligament injury and reconstruction evaluation. In: Aichroth PM, Cannon WD Jr, editors. Knee surgery: current practice. New York: Raven; 1992. p 759-60.

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TABLE I: Postoperative Radiographic Findings

*The values are given as the number of patients.

Compartment Narrowing/Osteophytes/Condyle Flattening	Semitendinosus-Gracilis Graft (Group I)*	Patellar Ligament Graft*
Two-Incision Technique (Group II)	Endoscopic Technique (Group III)
None	63	69	67
Mild (small osteophytes, slight sclerosis or condyle flattening, 1-2 mm of compartment narrowing)	?8	?5	?8
Moderate (2-4 mm of compartment space, £50% narrowing)	?3	?1	?0
Severe (<2 mm of compartment space, >50% narrowing)	?1	?0	?0

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TABLE I: Postoperative Radiographic Findings

*The values are given as the number of patients.

Compartment Narrowing/Osteophytes/Condyle Flattening	Semitendinosus-Gracilis Graft (Group I)*	Patellar Ligament Graft*
Two-Incision Technique (Group II)	Endoscopic Technique (Group III)
None	63	69	67
Mild (small osteophytes, slight sclerosis or condyle flattening, 1-2 mm of compartment narrowing)	?8	?5	?8
Moderate (2-4 mm of compartment space, £50% narrowing)	?3	?1	?0
Severe (<2 mm of compartment space, >50% narrowing)	?1	?0	?0

Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ,Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med,1994;22: 632-44. 22632 1994 [PubMed][CrossRef]

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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Daniel B. O'Neill; Arthroscopically Assisted Reconstruction of the Anterior Cruciate Ligament A Follow-up Report. The Journal of Bone & Joint Surgery. 2001 Sep;83(9):1329-1332.

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