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Poster Abstracts

        Poster 1. Mechanisms of pain in tendons, ligaments and joint capsules

        Paul W. Ackermann, Mahmood Ahmed, Andris Kreicbergs
        2001 ISAKOS Poster Abstracts
        Purpose: Pain is one of the main indications for orthopedic surgery. Yet, very little is known about the basic mechanisms of pain originating from the locomotor system, especially chronic pain. The objectives of the present study on tendons, ligaments and joint capsules were (a) to investigate the neuronal occurrence of endogenous opioids, i.e., enkephalins, by immunohistochemistry (IHC) (b) to investigate the occurrence of opioid receptors by IHC; (c) to quantify enkephalins by radioimmunoassay (RIA). Method: In normal male Sprague-Dawley rats the Achilles tendon, medial collateral ligament and knee capsule were dissected bilaterally. IHC was performed according to the avidin biotin method for four different enkephalins (ME, LE, MEAP, MEAGL) and the delta-(DOR), kappa-(KOR) and mu-(MOR) opioid receptors. RIA was used to assess the levels of MEAP. Results: Nerve fibers immunoreactive to the four enkephalins tested were identified in all tissues studied. They predominantly occurred in the paratenon, epiligament and the loose connective tissue, and were mostly perivascular. The opioid receptors, DOR, KOR and MOR were found in all tissues, mostly in nerves in blood vessel walls and the tendo-muscular junction. In the ligaments and tendons MEAP concentrations were six and two times higher than in the capsules, respectively. Conclusion: This study shows that opioids, i.e., enkephalins, and opioid receptors are present in tendons, ligaments and joint capsules of the rat and that opioids can be quantified. The existence of enkephalins in these tissues presumably reflects an antinociceptive function, where differences in tissue levels may reflect a differentiated susceptibility to injury. Significance: It may prove that the opioid system demonstrated in the connective tissues is a useful target for pharmacological therapy in painful and degenerative conditions of tendons, ligaments and capsules.

        Poster 2. Sensory neuropeptides in achilles tendinosis

        Paul W. Ackermann, Per Renström
        2001 ISAKOS Poster Abstracts
        Purpose: The pathomechanisms leading to chronic pain and degeneration in Achilles tendinosis are unclear. Little inflammation has been shown in tendinosis, but lately animal studies have suggested that neuroinflammation may play a role in degeneration as well as in nociception. The objective of the present study on Achilles biopsies was to investigate the neuronal occurrence of sensory neuropeptides in tendinosis compared to normal tendon tissue, by immunohistochemistry (IHC). Method: In patients subjected to Achilles tendinosis surgery, biopsies were taken from the tendinosis tissue and from normal tendon tissue. IHC was performed according to the avidin biotin method for substance P (SP), calcitonin gene related peptide (CGRP) and a nerve marker (PGP-9.5). Results: Nerve fibers immunoreactive to SP and CGRP were commonly identified in the tendinosis tissue and mostly localised in blood vessel walls. Conversely, in the control tendon tissue there were no nerve fibres, although some SP- and CGRP-positive fibres for were found in the paratenon. Conclusion: This study shows that sensory neuropeptides, i.e., SP and CGRP are commonly found in the proper tendinosis tissue but not in the control tendon tissue. SP and CGRP have in rabbits been shown to decrease growth factor mRNA levels and increase proteinase mRNA levels. The existence of SP and CGRP in the proper tendinosis tissue may reflect pathomechanisms leading to decrease in matrix synthesis and increase in matrix degradation, in addition to a nociceptive function. Significance: It may prove that sensory neuropeptides demonstrated in the tendinosis tissue may be contributing factors in the pathogenesis of pain and degeneration of the Achilles tendon.

        Poster 3. No signs of inflammation but high amounts of the neurotransmitter glutamate in common tendinopathies: An investigation using microdialysis and immunohistochemical techniques

        Hakan Alfredson, Kim Thorsen, Sture Farsgren, Ronny Lorentzon
        2001 ISAKOS Poster Abstracts
        Purpose: To investigate the in vivo concentrations of prostaglandin E2 (PGE2) and the neurotransmitter glutamate in tendons, and the occurrence of glutamate NMDAR1 receptors in tendon tissue samples, from patients with chronic painful Achilles tendinosis, Jumper’s knee (patellar tendinosis), Tennis elbow, and in normal (pain-free) tendons. Material/Method: Twenty patients (mean age 46 years) with chronic Achilles tendinosis at the 2-6 cm level and 12 controls (mean age 37 years), 6 patients (mean age 28 years) with chronic patellar tendinosis and 6 controls (mean age 33 years), 4 patients with tennis elbow (mean age 41 years) and 4 controls (mean age 36 years) were included. Microdialysis technique was used to study concentrations of PGE2 and glutamate, and immunohistochemical analyses was used to study the occurrence of glutamate NMDAR1 receptors in tissue samples. The local concentrations of PGE2 and glutamate were registered under resting conditions. A standard microdialysis catheter was inserted into the Achilles, patellar and extensor carpi radialis brevis (ECRB) tendons under local anesthesia. Samplings were done every 15 min during 2 hours, and tendon-biopsies were taken. Results: The results showed significantly higher concentrations of glutamate (μmol/L [mean ± SD]) in tendons from all patient groups compared to normal tendons: (Achilles tendon 154 ± 70 vs. 59 ± 42 p<0.001, patellar tendon 172 ± 88 vs. 52 ±27 p<0.05, ECRB tendon 215 ± 30 vs. 69 ± 28 p<0.001). There were no significant differences in the concentrations of PGE2 between tendons from the patient groups and normal tendons. Immunohistochemical analyses showed glutamate NMDAR1 receptors in painful and pain-free tendons. Conclusion: In these three relatively common chronic tendinopathies there were high concentrations of the excitatory neurotransmitter glutamate, but no signs of chemical inflammation (normal PGE2 levels). Significance: Glutamate may be involved in chronic tendon pain.

        Poster 4. Ultrastructural features of achilles tendinopathy in athletes

        F. Benazzo, N. Maffulli, M. Mosconi, G. Zanon
        2001 ISAKOS Poster Abstracts
        We used transmission electron microscopy (TEM) to study the ultrastructural features of Achilles tendinopathy from biopsies of 31 consecutive athletes operated for chronic tendinopathy. All biopsies showed different degree of alterations, and a variety of ultrastructural abnormalities could be detected. When areas which macroscopically we classified as mildly degenerated were examined, myofibroblasts (resembling those found in Dupuytren’s contracture), large proteoglycanic molecules, and collagen fibrils with large interfibrillar spaces were present. In areas of medium to high degeneration, the collagen fibrils were totally disorganised, with notching and indentation of their surfaces. Proteoglycan filaments were small and interspersed among the fibrils. Marked fibril degeneration was evident, with loss of banding characteristics, fragments of fibrils with round lysosome-like bodies randomly distributed in the matrix, and cellular debris. One or more of these features were appreciated at various degrees of severity in different areas within the same tendon, indicating that the histopathological process of tendinopathy is not homogeneous along the whole path of the tendon, but different degrees of tendinopathy may simultaneously coexist. These high-resolution histopathological findings would correlate with imaging, which usually shows elongated areas of signal abnormality along the tendon at different sites.

        Poster 5. Inferior limb stereoradiography: Technique and applications in clinical practice

        Eric Berthonnaud, Ignaki Benareau, Franck Chotel, Johannes Dimnet, Jean Luc Lerat, Bernard Moyen
        2001 ISAKOS Poster Abstracts
        Purpose: To develop a new system of three-dimensional radiographic reconstruction of bones and to validate this technique through a comparison with direct measurements. Methods: The principle is to take two successive x-rays with two different radiographic incidences. The new stereoradiographic technique requires only X-ray source and one plate. The main problem with the successive exposures is that the patient must keep the same posture while X-rayed. In the new system the patient stands up upon a numerical balance integrated to the turning plateau. This balance gives the location of the global center of mass of the subject. The second exposure is taken when the position of the center of mass of the subject is the same as that in the first one. The two projections of anatomical axes and landmarks are then tracked upon each digitized film. The use of epipolar lines correlated with the tracking of projections of anatomical axes makes it possible to accurately reconstruct anatomical landmarks and axes in space. Anatomic specimen are directly measured by contact feeling using a measuring 3D robot and compared with that obtained from 3D radiographic reconstruction. A series of CT scans are performed so as to measure the axial rotation of the femur in the horizontal plane. Results: The linear and angular differences are within 0.7 mm and 0.8 degree respectively. The results relative to the values of axial rotation of the femur are more accurate when using stereoradiographic technique (16.6°) than that obtained from CT scans (12°). The reference value (17.1°) is given by a measuring 3D robot. Conclusion: This study confirms the accuracy and the reliability of the three dimensional reconstruction of bones from two different radiographic incidences. Then, this technique will be used for clinical applications and more particularly for osteotomies and the total knee replacements.

        Poster 6. Histopathologic assessment of healed osteochondral fractures

        Cengiz Yilmaz, Mehmet S. Binnet, Ilksen Gürkan, Atac Karakas
        2001 ISAKOS Poster Abstracts
        The general principle of management of detached acute osteochondral fractures is reattachment of the fragment by internal fixation, but the opinions on the quality and structure of the healed tissue that will be obtained after treatment is controversial. This cohort study aims to assess the histopathologic features of this tissue in order to define its biological and biomechanical properties after internal fixation. The study includes 13 patients with acute osteochondral fractures who were treated arthroscopically and had surgical fixation providing joint surface congruity. Patients with osteochondral fractures too small for fixation or with the overlying cartilage frayed and patients with associating injuries were excluded from the study. Mean age of patients was 17 (9-24). In 2 cases the fractures were localized at medial, in 7 at lateral femoral condyles, and in 4 at the patella. Internal fixation materials were Kirschner wires for one case, Herbert screws for 3 and mini spongious screws for 9. The mean follow-up period was 6.3 years (3-13). On the second-look arthroscopy congruity of the joint surfaces and healed fractures were observed in all cases. Besides removal of the implant, punch biopsies were performed extending to the osteochondral junction. Biopsies were taken from the junction of the articular margin of the fragment and the edge of the remainder of the articular surface. On histologic examination of these specimens, presence of scarce mature chondrocytes among regenerative stroma, which dyed more eosinophilic than the basophilic chondral stroma and which had a chondrocyte-like appearance were seen. Maturation of histologic architecture to hyaline or articular cartilage was not recorded in any of these cases. The clinical results did not correlate with the histological findings.

        Poster 7. Two novel imaging tools for human knee meniscus: CM and OCT

        Vanessa Campo-Ruiz, MD (a, b – Lucid Inc.), Dinesh Patel, MD, Brett E. Bouma, PhD, Salvador Gonzalez, MD, PhD
        2001 ISAKOS Poster Abstracts
        Objective: To examine the architectural pattern of freshly-excised human meniscus with near-infrared reflectance confocal microscopy (CM) and optical coherence tomography (OCT). Methods: Twenty-six freshly-excised human menisci were imaged with CM and OCT. Two CM systems (1064 nm Nd:YAG and 830 nm diode lasers) and an OCT system (1300 nm laser) were utilized in this study. Images were compared with companion histopathology stained sections. Results: CM (fig.A) revealed a fibrous top surface with narrow striae. Beneath this superficial network, a highly-cellular layer was elucidated, followed by a more fibrous interior. Meniscal cells were imaged isolated, in grouplets and in piles. Circumferential and radial fibers were also clearly seen. A zebra pattern was identified, consisting of refractile (bright) and non-refractile (dark) striae. This may be consequence of the collagen bundles three-dimensional disposition. Vessels were also identified with CM, which were not always found in companion histology sections. OCT (fig.B) achieved a greater depth of imaging with less cellular detail, supporting CM findings. OCT images showed a difference in optical density between the upper cellular layer and the deeper fibrilar interior. Conclusions and Significance: CM and OCT provide real-time three-dimensional images of the tissue without any processing or damaging of the specimen, that correlate well with those of classical histology and with previous literature. CM and OCT are thus potential useful adjuncts to standard histopathology for both basic and clinical research. Future applications may include assessing the results of tissue engineering, establishing in vivo morphology during surgical interventions, etc.

        Poster 8. High intensity exercise training can reverse age-related reduction of paravalbumin in rats

        Dong Qing Cai, Ming Li, Kai Ming Chan
        2001 ISAKOS Poster Abstracts
        Purpose: To investigate the exercise effects in skeletal muscle soluble proteins during aging using proteomics strategy. Method: S.D. rats of 3, 18 and 24 month ages were used. The extensor digitorum longues (EDL, fast twitch muscle) and soleus (SOL, slow twitch muscle) muscles were isolated from both hindlimbs. The aqueous proteins were extracted at 4T. The high resolution two-dimensional electrophoresis technique (2-DE) was applied to monitor the temporal expression pattern of skeletal muscle aqueous proteins during aging. The age-related proteins were identified by automated Edman degradation sequencing. To investigate the trained effects in age-related proteins, high intensity training in treadmill was applied. Results: One protein spot (St3) was detected consistently in EDL muscles but not in SOL muscles. The N-terminal sequence of St3 was determined. The N-terminal sequence (1-19 AA) of St3 is MSMTDLLSAEDIKKAl. It was found to be 100% homologous with that of parvalbumin. It was further documented that parvalbumin expression was downregulated over age in EDL muscle. However, high intensity exercise could rescue this age-related change. Conclusion: This study demonstrates that parvalbumin expression was downregulated in elderly fast-twitch skeletal muscle. However, high intensity exercise could rescue this age-related change. Significance: It has recently been proposed that parvalbumin may act as a Ca2+ buffer in the relaxation phase of fast twitch muscle. Our findings may explain why young fast-twitch muscles are able to contract and relax much faster than their older counterpart. Moreover, we also demonstrated that high intensity training could up-regulate parvalbumin expression in aged EDL muscles. These findings suggested that the ability of exercise to maintain parvalbumin expression is one of the factors contributing to the improvements seen in trained-old muscles.

        Poster 9. Oxidative stress in immobilized muscle during remobilization – an esr study of the effect of a purified extract of chinese medicine on moderating the production of free radicals

        Kai Ming Chan, Ming Ju Liu, Jing Xian Li, Ling Qin, Simon K.W. Lee
        2001 ISAKOS Poster Abstracts
        Purpose: The aims of this study were to detect the production of free radicals signals in the muscle during remobilization by electron spin resonance (ESR) technique and to examine the effect of verbascoside, a purified extract of Chinese medicine on the moderation of production of free radical in remobilization of muscle. Method: A total of 8 adult New Zealand white rabbits were randomly divided into three groups, control (N=2), immobilization with verbascoside treatment (N=3) and immobilization with placebo treatment group (N=3). The rabbits of verbascoside group were administrated with 3.2 mg.kg-1day-1 twice a day by intramuscular injection for 3 days before remobilization. The rabbits in placebo group were administrated with normal saline equal to the volume used in verbascoside group. The electrical pulses (9V, 66Hz, with 3msx 1000, 2TPS) were used to induce contraction of the gastrocnemius for 40 min. The samples of gastrocnemius from contralateral and immobilized limb were taken for ESR study (Bruker ESP-300 ESR spectroscopy). The instrument conditions were set at microwave power 1mw; modulation amplitude 4.9 G; central magnetic field 3360 G, X band, temperature –196°C. Results: Following remobilization, the amplitude of free radicals signals was significantly higher than those observed in the control and placebo group. Signal amplitude in the samples from verbascoside group was significantly lower than those observed from placebo group. The results indicated that remobilization induced an increased production of free radicals in the immobilized muscle. Pre-treatment with verbascoside could significantly moderate the oxidative stress in immobilized muscle during remobilization.

        Poster 10. Bone mineral density of the proximal tibia in normal population

        Robert Wen-Wei Hsu
        2001 ISAKOS Poster Abstracts
        The bone mineral density (BMD) can be measured by dual energy X-ray absorptiometry (DEXA) accurately and precisely. BMD measurements of proximal tibia, where the structure is dominantly trabecular bone, were made on 45 normal women, aged 24-91 (52.0±14.2) years, and on 46 normal men, aged 20-71 (53.7±15.5) years. The precision of BMD measurements of proximal tibia, expressed as the coefficient of variation, was smaller than 4%. Throughout this cross-sectional study, the following results were acquired. The mean BMD in male is higher than that in female. The BMD show a decrease with age at different rates in women and men. The BMD in both genders is found to increase with body weight. A positive correlation is found between the BMD and body height in women, not in men. In right proximal tibia, the BMD of medial regions are higher than that of lateral regions significantly. Our study also demonstrates that the excellent symmetry of the BMD of the bilateral proximal tibias in both genders, but not in men with age less than 50 years old. Through the study of BMD in proximal tibias using the DEXA, it may reflect the bone reactions to many factors, such as age, sex, body weight & height, and weight bearing, etc. Such a kind of study might be an useful adjuvant tool to assess the bone remodeling around the knee joint following the different surgical procedures such as total knee arthroplasty or high tibial osteotomy and might predict the future surgical outcomes.

        Poster 11. Effect of the hyaluronic acid in osteoarthritis

        Dong Chul Lee, MD, PhD, Sung Hee Lee, MD
        2001 ISAKOS Poster Abstracts
        Objective: To evaluate efficacy of intra-articular injection of hyaluronic acid in patients with pain and dysfunction. Methods: Thirty patients with knee osteoarthritis were evaluated. Hyruan® (Sodium Hyaluronate: 25mg/2.5ml, 1000KDa) was given once a week for 5 weeks intra-articulary. Clinical efficacy was evaluated with visual analogue scale (VAS) for pain, Algofunctional index (AI) for function, and Tegner activity score (TAS) for activity. The patients were evaluated at every injection, 9th week, 13th week and 21st week after initial intra-articular injection. ANOVA was used as a statistical method. Results: (1) Responsiveness to pain and function was the most prominent at 3rd week (43%), 4th week (27%) and 2nd week (20%) in order of frequency. There was no response in 3 cases (10%). (2) Good responsiveness to hyaluronic acid was related with the severity of radiologic classification (Kellgrene). The patients with grade II and III osteoarthritis were sufficiently improved in pain and activity. There was little responsiveness in grade IV osteoarthritis. There was a tendency of functional improvement in Algofunctional index but no significant difference. (3) With respect to efficacy according to weight bearing femorotibial alignment, the patient with neutral alignment was more effective than that with varus deformity. (4) Complications were pain at injection site in 6 cases (20%) and effusion in 3 cases (10%). Conclusion: Sodium hyarulonate was efficacious in mild and moderate stage of knee osteoarthritis (grade II and III of Kellgrene classification). But there was little response on severe stage (grade IV). Intra-articular injection of hyarulonate may help to decrease pain and disability and to increase knee function in osteoarthritis.

        Poster 12. ABO blood groups and achilles tendon rupture in the Grampian region, Scotland

        N. Maffulli, J. Reaper, S. W. Waterston, R. Ahya
        2001 ISAKOS Poster Abstracts
        We tested whether the association between blood groups and Achilles tendon rupture reported in some Scandinavian countries and in Hungary was present in our region using a prospective study design. We included in our study 78 patients treated at Aberdeen Royal Infirmary for an Achilles tendon rupture in the period 1990 to 1996, and 24501 blood donors typed at the Blood Transfusion Centre during the same period. Overall, 47 of 78 (60%) of patients with an Achilles tendon rupture belonged to blood group O, compared with 51% of the population as a whole. Only 22 (28%) of the Achilles tendon rupture patients belonged to blood group A, whereas 35% of the general population were members of this group (NS). The A/O ratio was 0.47 for the tendon rupture patients, compared with 0.68 for the general population (NS). We could not demonstrate any significant association between the proportions of ABO blood groups and ATR in the Grampian Region of Scotland. The findings in other studies could be due to peculiarities in the distribution of the ABO groups in genetically segregated populations.

        Poster 13. Distal course of the sural nerve and its clinical significance at the lateral part of the ankle joint: An anatomic study

        Ercan Olcay, Adnan Ouml;ztürk, Zafer Ari, Kayihan Sahinoglu
        2001 ISAKOS Poster Abstracts
        The sural nerve is a superficial nerve that takes place at the lateral part of the ankle joint. Recently, the significance of this area in young population during either traumatic or surgical interventions is much more increased. Although the course of the sural nerve is well-known in peripheral nerve surgery, the detailed knowledge regarding this nerve is not included in text books. In this study, it is intended to investigate the distal course of the sural nerve and to emphasize the relationship between the nerve and some principal anatomical points by means of reviewing. Material and method: 24 feet of 12 cadavers treated with formol were included in the study. 4 of the cadavers were women and 8 of the cadavers were men. The cadavers having deformities at their feet or other traumatic problems were excluded. 6 principal points at the lateral part of the ankle joint were indicated before beginning to dissection. Taking these points into consideration performed the dissection. These principal points having clinical significance were 8 cm proximal part of the lower end of fibula (A), 4 cm proximal part of the lower end of fibula (B), the posterior of the lower and of fibula (C), the lower end of fibula (D), The base of the fifth metatarsus (E), 3 cm above of the Achilles tendon insertion (F). The distances of the branches of the sural nerve and itself to these principal points were recorded by measurement with an electronic compass. Results: Subsequent to measurements, the average distances of the sural nerve to these points were found as following: 2.6±0.2 cm to A, 2.0±0.1 cm to B, 2.1±0.1 cm to C, 1.9±0.1 cm to D, 1.4±0.2 cm to E and 1.8±0.1 cm to F. Discussion and conclusion: The studies conducted in the cases by using sural nerve as a graft showed that symptomatic neurinoma about 16% and sensitivity loss reaching to 40% caused problems in the patents. The functional significance of the sural nerve during walking was also emphasized in specifically conducted studies. According to our results the sural nerve took our attention in the region of the lower end of lateral malleolus, the base of the fifth metatarsus and Achilles tendon and it was thought that this nerve could be damaged in unplanned surgical interventions of these areas and especially in sportive traumas.

        Poster 14. Hyper cellularity and collagen degradation in patellar tendinosis

        Christer Rolf, Sai Chuen Bruma Fu, Wen Wang, Hon Man Anson Pau, Kai Ming Chan
        2001 ISAKOS Poster Abstracts
        Objective: The current studies assessed tissues from 12 patients operated for clinically and radiologically well defined chronic patella tendinosis, and from 13 matched controls using patella tendon grafts from patients undergoing ACL reconstruction. The patients had rested from sports and undergone physiotherapy for more than six months. Methods: Standard immunohistochemistry, in situ zymography and cell culture techniques were used to assess proliferation and collagen degradation in the tissue. Results: An increased cellularity (p<0.001) was found in patellar tendinosis, as well as a higher proliferative index (p<0.001) associated with an increased expression of PDGFRb (p<0.001). Cultured cells showed higher proliferation rate (p<0.001), maintained under various serum and PDGF supplementation. Increased gelatinolytic activities with an elevated expression of MMP1 (p<0.001) and decreased level of TIMP1 (p<0.001) concertedly demonstrated a predominant collagen degradation. The collagen type I production did not match demands (NS), while hsp47 which helps procollagen folding and secretion was significantly increased (p<0.001). Conclusion: Chronic patellar tendinosis tissues show an ongoing collagen degradation associated with an increasing number of hyperactive cells, the interaction not being fully understood. The cells preserve their destructive activities over cell cycles, which may explain the well experienced recurrency after non radical surgical excision. The new findings render further investigations before a complete understanding of the origin of tendinosis is reached.

        Poster 15. Adolescent sports injury and height growth stage predicted by using neural network

        Eiichi Suzuki, Ryohei Takeuchi, Tomoyuki Saito, Tomihisa Koshino
        2001 ISAKOS Poster Abstracts
        Purpose: We had reported that take-off age, peak-height age, and final-height age can be predicted accurately (mean error: 0.5 years old) by using the growth in height at 6-11 years and development stage can be estimated at the age of twelve. The purpose of this study is to prevent the injuries at sports like Osgood disease at the age of twelve, by making clear the relation between sports injury frequency and growth development stage using this neural network system. Method: Orthopaedic medical check was performed on 87 soccer players (average age was 12.5 years old) whose height data from 6 to 11 years old was obvious and we prevented their growth height curve from height data from 6 to 11 years old using 3 layered neural network. We estimated their growth development stage at the age of twelve. Moreover, the relation between frequency of sports injury and growth development stage was examined. Growth development stage was divided into four phases: Phase I-IV. Results and conclusion: Frequency of lower back pain was found peak at the latter part of phase II. Frequency of Osgood disease was found during the middle part of phase II, and 80% of these were concentrated at one year before and after peak height age. Sever’s disease was started to find after phase I, and about 70% of these were concentrated before phase II. Significance: When this system is established, and spread in sports coaching field, we can preserve sports injury, determine training program more simply and accurately, and we can prevent sports injury, get skills more effectively.

        Poster 16. Mechanoreceptors of the ligament with Ho-YAG laser irradiation in a long term follow-up

        Toshiaki Takahashi, MD, Yukihisa Wada, MD, Norio Yamanaka, MD, Hiroshi Yamamoto, MD
        2001 ISAKOS Poster Abstracts
        Purpose: No studies have reported what changes in mechanoreceptor following laser treatment. The purpose of this study was to investigate detailed shortening of the ligament during and after irradiation, and mechanoreceptors quantitatively in a long-term follow-up period. Materials and Methods: A total of 35 Japanese white rabbits were used in this study. Ho-YAG Laser irradiation was applied on the surface of the ligament. We irradiated on the ligament proximal, middle and distal rows for 3 spots each. We continuously recorded the length of the ligament using a DVRT-100 starting from before irradiation until after a time at which the length did not change. The following served as quantitative assessments of the shrinkage of the ligament, 1). ratio of the shrinkage of the ligament between before and after irradiation, 2). comparison of the ratio of shrinkage at proximal, middle and distal site, 3). comparison of the ratio of shrinkage at the starting site of the irradiation. The middle of the ligaments at 15 mm were stained according to a modified gold chloride method. Serial sections were studied under light microscopy. Pacinian corpuscles, Ruffini corpuscles and free nerve endings were counted after being identified morphologically. We investigated the total number of each type of sensory nerve ending per ligament for the irradiated and control ligaments. Results: The shortening of ligaments was on average 15% immediately at after radiation, and recovered by 1.8% within 10 minutes after irradiation. The ratios of shortening showed no significant differences among three groups as proximal, middle, or distal. In comparison of order of irradiation, the first row was 48%, second row was 25%, and the third row was 28%. There was significant shortening in the first irradiated row. At two weeks after treatment, the number of mechanoreceptors of irradiated ligaments was less than that of intact ligaments. However, there were Pacinian and Ruffini corpuscles in the irradiated and intact patellar ligaments at one year and 6 months after the treatment. A total number of Pacinian and Ruffini corpuscles was on average 3.0 in the irradiated, and 4.2 in the intact ligaments. There was no significant difference between irradiated and intact ligaments. Conclusion and Significance: The first row of irradiation showed the most effective shortening of the ligaments. The number of mechanoreceptors in the irradiated ligaments was diminished compared to that of intact ligaments at two weeks after treatment. However, there was no significant difference in the number of mechanoreceptors between both groups. Therefore, mechanoreceptors after irradiation are thought to have regenerated.

        Poster 17. Quadriceps and hamstring muscle fiber pennation angles after ACL reconstruction

        Yoshitsugu Takeda, Shinji Kashiwaguchi, Tetsuya Matsu-ura, Takahiro Sasa
        2001 ISAKOS Poster Abstracts
        Purpose: Geometric arrangement of muscle fibers, i.e., muscle architecture (pennation angle and length of fibers, cross-sectional area) considerably affects the manner in which muscle force is transmitted to the tendons and bones. Recently, a technique has been developed to determine the muscle architecture in humans in vivo using ultrasonography. The purpose of this study was to investigate with measuring fiber pennation angles in vivo whether the muscle architecture of the vastus lateralis (VL) and semimembronosus (SM) are changed by the ACL rupture and reconstruction. Subjects and Results: Twelve males and eight females (age 15 to 32 yr) participated in the study. The subjects were subdivided into the four groups consisted of 5 subjects each as follows; 1) ACL-deficient, 2) ACL reconstructed with STG, 3) ACL reconstructed with BPTB, and 4) Control (intact ACL) group. A real-time ultrasonic apparatus (SSA-340A, 8MHz, Toshiba, Japan) was used. Longitudinal ultrasonic images of the VL and SM at a level 50% of the thigh length were obtained. In the ultrasound image, the echoes from the interspaces of fascicles and from the superficial and deep aponeuroses were visualized. The pennation angle was defined as the angle between the fascicles and the deep aponeurosis for the VL and the superficial aponeurosis for the SM. The measurements were repeated five times in the same image, and three measurements excluding the largest and smallest values were averaged. The three measurements of fascicle angles did not differ significantly with the coefficient of variation (CV) ranging from 0 to 3.1% for the VL and from 0 to 6.5% for the SM. Ultrasonic measurement was performed within 6 months after ACL reconstruction. During measurement, the subject was lied on supine for the VL and on prone for the SM on a testing table of an isokinetic dinamometer (MYORET, Asics, Japan) with the hip joint at 0° of flexion. The knee joint angles were changed every 30° from full extension to flexion at 90°, and at each joint angle, ultrasonic measurement was performed. After the measurement of the VL and SM in the relaxed condition, measurement were carried out while the subject performed isometric knee extension and flexion with 10% of the maximum torque of the uninjured knee (10% MVC) for each joint angle. The subject could flex and extend the knee joint at 10% MVC, with a visual aid of the torque displayed with the target torque on a monitor screen. Side to side difference of the pennation angles (Pennation angles of the VL/SM in the uninjured knee - those in the ACL deficient/reconstructed knee) for each angles in relaxed and tensed condition were compared among the groups. Statistical analysis was performed using one-factor ANOVA and Tukey-Kramer test. A significant difference was defined as p<.05. Results: The pennation angles of the VL increased during knee extension at relaxed and tensed condition in every group, while those of the SM increased during knee flexion. For the side to side difference of the VL, a significant difference was observed only between the control vs. BPTB/STG groups at 30° and 90° in relaxed condition (-0.7°, 2.7°, 2.1° at 30° and -0.8°, 2.1°, 2.0° at 90° respectively). For the SM, the side to side difference of the pennation angles in the STG group was significantly greater than that for the ACL-deficient at 0° and 90° in the tensed condition (4.1°, -0.5° at 0° and 5.4°, 0° at 90° respectively). Those values in the STG were also greater than those in the BPTB at 90° (-2.2°) and in the control at 30° (-1.3°) in the tensed condition, but there was no significant difference among those values for the groups in the relaxed condition. Conclusion and Significance: The pennation angles of the SM in the ACL reconstructed knee with the STG were not significantly different from those in the contra-lateral knee in the relaxed condition, but those were significantly smaller with contraction of the 10% maximum torque of the SM in the contra-lateral knee. The results suggested that the SM in the knees that have been reconstructed with the STG tendon could transmit their contraction force to the tendon and bone more effectively in order to compensate the decrease of the flexion strength due to the STG harvesting.

        Poster 18. Etiological difference of bone-cartilage lesion between osteochondral dissecans and osteochondral fracture in the patello-femoral joint

        Taisuke Tomatsu, Seiji Saito, Shigeki Momohara, Mariko Horikoshi, Kazunori Irie
        2001 ISAKOS Poster Abstracts
        Purposes: Osteochondritis dissecans (OCD) and osteochondral fracture (OCF) is popular osteochondral lesion among young people. But their etiology still remained obscure. To clarify the etiological difference of osteochondral lesion between OCD and OCF in the patello-femoral joint, we studied the clinical cases of OCD and OCF. Materials and Methods: Twenty cases (28 lesions) of OCD and thirty-seven (40 lesions) of OCF in patello-femoral joints were examined about age, gender, history of trauma, shape of patella, hypermobility of patella and location of the lesion. Results: Among items above mentioned, there was difference in gender, shape of patella, location of the lesion between OCD and OCF in patello-femoral joint. Males were dominantly found in OCD, although females were dominantly observed in OCF. According to Baumgurtl’s classification of patella shape, type 3, 4 and hunter’s cap, which were often observed in patello-femoral malalignment disorders, were more often found in OCF than those in OCD. Osteochondral lesions of OCF were mainly located medial and central in patella but those of OCD were central and lateral in patella. Conclusion: These clinical data indicate the different mechanism of the osteochondral lesions. From the viewpoint of the location of the lesions, OCD were supposed to be produced on the way of lateral shift of the patella, and OCF on the way back from the lateral dislocation over the central ridge.

        Poster 19. The effect of running shoes on running biomechanics

        William Workman, MD, Sylvia Ounpuu, MSc, Katharine Bell, MS, Peter DeLuca, MD
        2001 ISAKOS Poster Abstracts
        Background: Much is known about the mechanics of distance running. However, studies to date have mainly been performed in runners wearing shoes. Therefore, little is known about the effect of running shoes on a runner’s biomechanics. Running biomechanics can be analyzed by viewing the lower extremities as springs, which move the center of mass vertically and horizontally. Mechanical energy is absorbed and generated by the muscles and tendons during each landing and take-off. The differences in mechanical energy absorption at the knee and ankle between barefoot and shoe running was the focus of this study. Methods: Twenty runners (13 women and 7 men) were included in this single-blinded controlled experiment. The protocol was carried out in a sophisticated motion analysis laboratory. Six motion and video cameras surround a fifty foot running track with embedded forceplates. Data was collected on kinematics and kinetics of the lower extremity. Results: There were significant differences in the mechanical energy absorption and generation in the knee and ankle between barefoot and shoe running. Of note, there was approximately 26% greater group average in energy absorption at the knee while running in shoes (p=.00001), and 55% less ankle dorsiflexion (p=.00001). Conclusions: In this representative cross section of runners statistically significant differences exist in running biomechanics between shoe and barefoot running. The clinical effect of this difference remains to be determined. Clinical Relevance: The results indicate that closer examination of the effect of running shoes on biomechanics should be undertaken and may indicate a need for modification of shoe design to better approximate the barefoot state.

        Poster 20. Conservative and functional treatment for recent ruptured achilles tendon

        Yvan Arlettaz, F. Chevalley, G. Cremion, P. F. Leyvraz
        2001 ISAKOS Poster Abstracts
        Introduction: The treatment of the recent ruptured Achilles tendon is still controversial. Surgical procedures are commonly considered to restore excellent functional capacity and suffer low rerupture rates. Recent studies report excellent results with a functional and conservative treatment. Our purpose is to evaluate prospectively this new method without discrimination of people. Material and Method: Between March 1998 and June 1999, 4 women and 14 men of an average age of 45 (34-76) underwent a functional and conservative treatment for a recent ruptured Achilles tendon. After an immobilisation with a cast in equinus for 10 days, the patients were authorised to walk progressively in full bearing protected by a commercial orthesis. The angle of equinus of this orthesis was progressively modified in order to reach the normal angle after 6 weeks. During the following 2 weeks, the system allowed a mobilisation of the ankle ranged between 0° and 30° of plantar flexion. After 8 weeks, the patients were able to walk without any contention. All the patients but 3 underwent a clinical examination and muscular testing with a Cybex at 6 and 12 months. Results: Sedentary workers returned to work within 10 days, heavy workers within 49 days. We observed one rerupture (6%). There were no other complications. In comparison with the healthy leg, after one year, there was no difference in the motion of the ankle and no calf amyotrophy proving the absence of muscular deficiency. Conclusion: This kind of treatment must be considered as a safe technique in terms of complication rates and functional results. This is a cost-effective procedure with a short delay before returning to work.

        Poster 21. Acute repair of transections of the biceps brachii muscle belly

        Carl J. Basamania, MD, John F. Kragh Jr. MD, Daniel Gordon, MD
        2001 ISAKOS Poster Abstracts
        Objective: We determined the outcome of direct biceps muscle fiber repair regarding strength, appearance, and satisfaction. We confirmed imaging accuracy with surgery. Methods: We conducted a prospective, controlled study of surgical repairs of acute traumatic closed transection of the biceps brachii muscle bellies in paratroopers. All paratroopers had the same muscle injured by the same mechanism. We included nine patients with more than 1.5 years follow-up. Follow-up of acute repairs averaged 2 years (1.6-2.2). Illustrations detail suturing muscle fibers and epimysium using running interlocking and Mason-Allen stitches. We measured supination torque, appearance, and satisfaction. Uninjured arms served as internal controls. The historical control was the external control of conservatively treated complete transections. In the complete conservative group, follow-up averaged 10 years (2-15). Results: Comparing the repair group to the conservative group, we found that the repair group had better supination torque (7.7 newton-meters v. 6.0 N · m, p=0.007), appearance (cosmetic visual analog scale 4.8 cm v. 3.0 cm, p = 0.0000007), and satisfaction (all excellent v. all satisfactory, p=0.02). The repair group averaged 75% supination torque at 6 months compared to the uninjured arm while the conservative group averaged 63% at ten years. The imaging accurately located and predicted the extent of transection in each of seven ultrasounds and six MRIs. Conclusions and Significance: We illustrate a muscle repair technique and demonstrate functional improvements compared with conservative treatment. Ultrasonography and MRI are accurate in detailing muscle tissue direct trauma. Our repair patients had significant improvements in strength, appearance, and satisfaction.

        Poster 22. Sports activity following knee dislocation

        Karl Peter Benedetto, Wolfgang Hackl, Christian Fink, Christian Hoser
        2001 ISAKOS Poster Abstracts
        Complete dislocation of the knee – complete rupture of ACL and PCL associated with rupture of secondary restraints – is reported in literature to be caused by high energy trauma in traffic injuries as well as during sports activity. The damage of the various knee ligaments leads to different directions of instability which influence the incidence of neurovascular complications. To determine the main pathology in global knee instability meticulous clinical examination and x-ray screening is necessary and examination under imaging intensifier may be helpful. MRI sonography and angiography are necessary for documentation of vascular complications. The goal of the study was to evaluate the outcome following of operative treatment of knee dislocation with respect to sports activity level. Material and method: 19 patients (18 male, 19 female), age 20 - 50 years were followed 3 - 10 years postoperative personal clinically and radiologically. IKDC and Innsbrucker knee sports rating scale were used.
        Figure thumbnail gr1a
        Figure thumbnail gr1b
        Conclusion: Operative treatment of complete knee dislocation leads to good and fair results and the outcome is mainly influenced by neurovascular complications, by associated injuries as femur and tibia fractures and cartilage damage. Sports activity can be regained if stability and nearly free range of motion is restored and cartilage damage is absent. The type of sports activity is changed from high to low and non risk pivoting sports.

        Poster 23. Enforced detraining due to intramedullary nailing induces changes to intramuscular architecture of the quadriceps

        R. Bleakney, N. Maffulli
        2001 ISAKOS Poster Abstracts
        We monitored the effects of enforced detraining due to trauma on the intramuscular architecture of the quadriceps using high-resolution real-time ultrasonography (HRRTU) in 13 skeletally mature male patients (43.2 years, range 16 to 82 years), with an isolated unilateral diaphyseal fracture of the femur or of the tibia. All patients had undergone interlocked intramedullary nailing (IIN). Using HRRTU, the pennation angles and muscle fibre lengths of vastus lateralis, the cross-sectional area (CSA) of the rectus femoris, and the quadriceps muscle layer thickness (MLT) were measured in the injured and the normal contralateral limb. Repeated measurements showed the technique of measurement of the variables used in this study to be highly reproducible. There was a significant difference in the angle of pennation of the vastus lateralis in the nailed (15.4°) and the unnailed limb (21.2°), documenting that muscle atrophy causes a change to muscle architecture that results in a significant decrease in pennation angle (p=0.0002). The muscle fibre length was significantly different (p=0.002), and there was a significant correlation between pennation angle and muscle fibre length (r=-0.51, p=0.001). There was also a significant difference in the quadriceps MLT (p=0.001) and CSA of the rectus femoris (p=0.0004), implying that the whole of the quadriceps muscle is affected.

        Poster 24. Mechanisms of ACL injury

        Barry Boden, MD, G. Scott Dean, MD, John Feagin, MD, William E. Garrett, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Despite the explosion of information on the anterior cruciate ligament (ACL), little attention has been focused on the mechanisms of ACL injury. The purpose of this study was to identify the various mechanisms that lead to a complete rupture of the ACL. Methods: In the first part of the study, using a comprehensive, standardized questionnaire, 89 athletes (100 knees) were interviewed about the events surrounding their ACL injury. In the second phase of the study 28 videotapes of athletes who sustained an ACL disruption were reviewed. The videotapes are currently undergoing digital video analysis. Results: The questionnaire revealed a noncontact mechanism in 71 (72%) knees and a contact injury in 28 (28%) knees. The most common activities at the time of the injury included basketball (25%), football (22%), and soccer (20%). A variety of mechanisms were identified. Most of the injuries were sustained at foot strike with the knee close to full extension. Review of the videotapes confirmed that most noncontact injuries occurred with the knee close to extension during a sudden deceleration prior to a change in direction or a landing maneuver. The center of gravity was behind the knee and the foot was flat or pronated in the majority of injuries. Most contact injuries occurred as a result of lateral knee contact with valgus collapse. Discussion: Because the knee is in a position to allow the extensor mechanism to strain the ACL and maximum, eccentric muscle force conditions usually apply, the quadriceps may play an important role in ACL disruption. Preventive programs, in which the athlete is trained to make ground contact on the forefoot with the center of gravity over the knees, and the hamstrings active, may reduce the incidence of noncontact ACL injuries.

        Poster 25. Functional outcome following patellar tendon transfer for the painful patella alta

        John C. Cameron
        2001 ISAKOS Poster Abstracts
        The relationship between patella alta and patello-femoral chondromalacia has been described by Lancourt (JBJS 1975) and the relationship to osteoarthritis by Ahlback (Acta Radiol 1978). There is no study in the English literature on the role of distal tibial tubercle transfer for the painful non-dislocating patella alta. The purpose of the paper is to describe a group of patients who suffer from anterior knee pain related to patella alta without symptomatic instability. This is a retrospective study of twenty-nine knees in twenty-four patients with minimal follow-up over 2 years. All patients had pre-operative arthroscopy assessment of the articular cartilage lesions using the Outerbridge classification. All patients had significant pain with activities of daily living. Comparison was made with sex and age-matched controls. Eighty-eight percent of patients had good to excellent results. Clinical assessment was carried out in addition to radiographic assessment using the Insall-Salvati technique. Pre-operative assessment tools included the Kujala patello-femoral score and the modified Lysholm score. Post-operative assessment tools also included the WOMAC index and the SF-36. The typical pattern of patellar chondromalacia is in the infero-lateral aspect of the patella with painful patella alta. Patients with less severe chondromalacia had better post-operative function. Routine arthroscopic examination in cases of painful patella alta should be considered prior to tibial tubercle transfer.

        Poster 26. Mini invasive day surgery brostrom technique in ankle instability

        Gian Luigi Canata, MD
        2001 ISAKOS Poster Abstracts
        We evaluated a mini invasive Brostrom technique in regional or local anaesthesia. Material and Methods: 17 patients, 14 males and 3 females (the mean age being 25.9 years, 12-62 years) were operated on using the Brostrom technique for instability due to chronic post-traumatic calcaneofibular ligament laxity. The mean time from surgery was 53 months (6-145 months). All cases showed painful ankle instability with a pathological talar tilt. All cases were treated in Day Surgery: 11 in regional and 4 in local anaesthesia. After surgery a functional bracing was prescribed. Weight bearing was allowed after 15 days. Results were evaluated with the Ogilvie Harris scale and the Kaikkonen scale. In all cases an isokinetic evaluation was made. The mean follow-up was 31 months (16-46 months). The results were analysed statistically (paired Student’s t test). Results. The Ogilvie Harris scale showed 12 excellent and five good results. The Kaikkonen scale showed 17 excellent results. No difference between regional or local anaesthesia was evidenced. Side to side isokinetic evaluation did not show significant differences. All subjects resumed their previous sports activities in the third month after surgery. Conclusions and Significance. The Brostrom technique can be performed in Day Surgery with excellent results.

        Poster 27. Orthopedic lesions in soccer

        Moises Cohen, Rene Jorge Abdalla, Benno Ejnisman, Joicemar T. Amaro
        2001 ISAKOS Poster Abstracts
        Soccer is the most popular sport in the world, but we did not find researches about the epidemiology and soccer injuries. The authors studied 124 professional soccer players of the 8 leading Brazilian teams during more than 2 years. The athletes were all male, with a mean age of 22.4 years. All injuries analyzed occurred in official and exhibition matches. The purpose was to identify the frequency of injuries in Brazilian professional soccer. Results showed that the highest incidence of injuries were in midfield and forward players. Injuries were usually of the non-contact type and were more frequent in the lower extremities. Muscle injuries were more frequent, soccer lesions are in general light and most of them allowed for resumption of the activity within a week.

        Poster 28. Musculoskeletal injuries in bodybuilding and power lifting

        Moises Cohen, Fabio A. Caporino, Rene Jorge Abdalla, Laira Campello
        2001 ISAKOS Poster Abstracts
        The authors accomplished a retrospective study of musculoskeletal injuries in 247 bodybuilders. Their objective was to evaluate the incidence of the main injuries in this sport, time of removal from the activity, use of nutritional supplements or drugs among athletes and professional orientation during the training sessions. They observed that the most frequent injuries were in the lumbar area (23.7%), shoulder (21.1%) and wrist (13.9%). The mean time of removal from the activity was 27.6 days. The use of nutritional supplements or drugs among the athletes happened in 25.9% and only 6.1% was medically prescribed. Athletes received professional orientation in 90.3% of the cases.

        Poster 29. Surgical management of tennis elbow

        Debashis Das, Nicola Maffulli
        2001 ISAKOS Poster Abstracts
        We report the long-term results of a longitudinal study of surgical release of the common extensor origin for the management of recalcitrant tennis elbow in 111 patients (125 elbows). Seventy-one of 111 patients were females, the most prevalent age group being 40 to 50 years, with the dominant arm being affected in 75% of cases. The average period of trial of conservative management was 20 months, and the average number of steroid injections per elbow was 3.1. Surgery was mostly performed on a day case basis, and the procedure most commonly performed was release of the common extensor tendon. The minimum follow-up period was two years, with an average follow-up period of 52.8 months, and 75% of patients had excellent or good results, with 73% of them being satisfied with the results of surgery. The elbow was back to normal in 84% of patients, 62% thought their grip strength was back to normal, and 70% of the operated elbows had no residual pain. However, most patients took up to six months to regain their pre-injury level of function. Release of the common extensor origin at the elbow is a relatively simple operation, and is an acceptable surgical procedure for tennis elbow provided that a correct diagnosis has been made and a trial of conservative management failed to resolve symptoms.

        Poster 30. Ulnar stress fracture of the nondominant arm in a tennis player using a two-handed backhand

        Bruno Fragniere, Michel Landry, Olivier Siegrist, Gérald Gremion
        2001 ISAKOS Poster Abstracts
        Introduction: Stress fractures during sports activities are common on the lower limbs. In the case of the tennis player the stress fracture of the ulna always occurs on the nondominant forearm. The five cases reported in the literature concern each time players using a two-handed backhand. The pathological mechanism is clear, seems to be a repetitive torsional stress caused by pronation of the forearm during the ball-strike and follow-through phases. Case Report: A 24-year-old professional tennis woman, right-handed, presented with the complaint of 4 weeks of gradually worsening left wrist pain when she used the two-handed backhand. Physical examination demonstrated pain at the resisted flexion of the wrist and diffuse tenderness was noted over the distal ulna. Imaging Results: X-rays are normal. Bone scan shows linear monocortical uptake on the distal ulna. MRI shows on T2-weighted periosteal and medullary edema, there is no real fracture picture. On the x-rays 8 weeks after the beginning of the symptoms there is no periosteal apposition. Treatment: Avoiding two-handed backhand during 4 weeks allowed her to return to high level of tennis without pain. Discussion: The physical examination, the x-rays and the bone scan lead to incomplete diagnosis of periostitis. However the MR imaging brings additional information, the periosteal and the medullary edema allowed us to classify this lesion as a stress fracture, grade II, according to the Fredericson classification. This grading system, according to Zwas, may assist in determining the rest necessary to obtain the healing of the lesion. Grades I and II need 3-4 weeks rest though 6 weeks for grades III and IV.

        Poster 31. Scapular dyskinesis as a possible cause of painful throwing shoulder: The dynamic radiographic study

        Minoru Yoneda, MD, PhD, Sunao Fukushima, MD, Shigeyuki Wakitani, MD, PhD, Atsushi Yokota, MD
        2001 ISAKOS Poster Abstracts
        Purpose: It is very important to evaluate the exact function and the role of scapula to solve the shoulder problems. In this study, we analyzed the scapular abduction motion using the dynamic radiographs to clarify that the scapular dyskinesis is a possible cause of painful throwing shoulder. Patients and Methods: Scapular plane dynamic radiographs were taken in painful throwing athletes group (10 patients), non-throwers group (10 patients), and the dominant side 10 healthy volunteers. All the patients had a painful arc sign, and no limited motion or inferior laxity of the joint. They raise the arm from 0 degrees to maximum abduction actively in the thirty-degree interval. The scapular abduction angle (ABD), scapulo-thoracic angle (STA), and gleno-humeral angle (GHA) were measured in each position. And the scapular abduction ratio (STA/ABD) was calculated. The Mann-Whitney U-test for unpaired groups was used for statistical analysis. Results and Discussion: The increase of the scapular abduction ratio from 30 to 60 degrees and from 60 to 90 degrees were significantly small in the painful throwing athletes group (P=0.028, 0.037) compared with healthy control group. Scapular plane dynamic radiographs can be one of the diagnostic tools that demonstrate the abnormal motion of scapula. Conclusion: Significant difference in early phase of scapular abduction motion can diagnose the existence of scapular dyskinesis in painful throwing athletes.

        Poster 32. Effects of three bracing conditions on functional performance in subjects with ACL reconstruction – an objective and subjective evaluation

        Wu Kin Hey Gloria, Lam James Joseph, MBBS, FRCS, Ng Yin Fat Gabriel, PhD, Mak Fuk Tat Arthur, PhD
        2001 ISAKOS Poster Abstracts
        This study compared the performance in running, jumping, isokinetic tests and static joint angle repositioning in subjects with ACL reconstruction under three conditions of (1) no brace, (2) ACL functional knee brace (Donjoy, Legend), and (3) mechanically placebo knee brace. The mechanically placebo brace was made with similar materials and shape as the functional knee brace except the mechanical hinges were substituted. Twenty-nine subjects with ACL reconstruction at least five months prior to testing were recruited. The study consisted of objective and subjective evaluation. Objective tests included running along a 22-meter figure-of-eight runway for 10 laps, single leg jumping and turning internally with the affected side and then landing on a floor mark, isokinetic performance at 60°/sec and 180°/sec, and joint angle repositioning. The tests were conducted under all three conditions at random testing order. A subjective questionnaire was asked after each test to indicate which condition being felt to be most comfortable, which could enhance or hinder their performance. Objective data were analysed with repeated measures MANOVA and ANOVA, and the level of significance was set at 0.05. Significant results were further analysed by post-hoc contrasts. Results showed that subjects ran and turned faster in condition 1 than both conditions 2 and 3 (p<0.05). There was no significant difference in the jumping and isokinetic test among the three conditions (p>0.05). For the joint repositioning test, subjects performed better in both conditions 2 and 3 than condition 1 (p<0.05), but there was no difference between the two bracing conditions. Subjective data were summarised with the SPSS crosstab function. 75.9% subjects reported they felt most comfortable in condition 1 and being hindered by condition 2 and/or 3 during the running test. For subjects had their reconstruction less than 9 months significantly felt that condition 2 and/or 3 were enhancing their jumping performance. These results suggested that functional knee brace had not improved the motor performance of people with ACL reconstruction. The use of a knee brace had actually deterred the running and turning performance in these subjects; despite subjects with more recent reconstruction felt the brace were enhancing functional performance. The only improvement observed with the brace was the static knee position sense, but the improvement was not due to the mechanical hinge of the brace. It could be the cutaneous sensory stimulation of the brace, which had led to the improvement. Based on the above findings, the use of a ACL functional knee braces to enhance function in subjects with ACL reconstruction needs further justification.

        Poster 33. Efficacy of radial shock wave therapy in the chronic patellar tendonitis

        Gérald Gremion, Ch. Gobelet, Olivier Siegrist; , P. F. Leyvraz
        2001 ISAKOS Poster Abstracts
        Since the beginning of this year 1999 we gathered experience with the application of radial extracorporal shock waves of varying intensity in chronic orthopedic diseases. A controlled study was performed in sportive patients suffering of chronic patellar tendonitis (jumpers knee) since more than six months, who unanimously reported severe pain symptoms. All the previous and usual treatments had demonstrated a lack of efficiency. Admission criteria for this study were: - Complaints lasting more than 6 months - At least two unsuccessfully completed conventional therapies - Age between 18 and 55 Patients were treated in a maximum of 7 sessions. 2000 impulses were applied per session at the frequency of 4 Hz. The energy flow density during treatment was progressive from 2 to 3.8 bar in function of the improvement of the pain. Follow-up examinations took place 4 and 8 weeks after final treatment session. Subjective improvement was observed in 80% of the 45 treated patients with this new system and each of them could again take part in their physical activities without limit and pain. In 5 patients no improvement could be demonstrated and a severe pain was always reported. The authors consider that : - this new device seems to be useful for the treatment of chronic orthopedic diseases; - more investigations are necessary to improve the knowledge about application of this therapy, especially concerning the possible side effects.

        Poster 34. Findings with a new ultrasound examination of athletes with chronic pelvis related pain

        Per Hölmich, MD, Michael Bachmann Nielsen, MD, PhD
        2001 ISAKOS Poster Abstracts
        Objective: The aim of this study was to describe the new possibilities of advanced ultrasound examination in the diagnosis and treatment of athletes with chronic pelvis related pain. Method: During an 18-month period 29 consecutive athletes with chronic pelvis related pain underwent a standardized clinical examination and a standardized ultrasonographic examination. Pelvic x-ray and bone scan was also performed. Results: Ultrasound pathology was present in all but 2 patients; 10 patients had more than one ultrasonographic finding. The findings were located as follows: Distal iliopsoas tendon (11), adductor longus tendon insertion (11), biceps femoris tendon (1), gluteus maximus muscle (1), adductor magnus tendon (1), abdominal wall muscles (2), hip joint (1). When clinically indicated ultrasound guided steroid injections was performed with success. In 10 patients ultrasound found an (incipient) inguinal hernia. One patient had a stress fracture and one patient had an osteoid osteoma, which of cause could not be seen by ultrasound. Conclusion: We describe a new type of ultrasonographic changes in athletes with pelvis related pain. Ultrasound seems to be an important tool in distinguishing the different conditions associated with chronic pain in the groin and pelvis. It can be a helpful instrument in the planning of treatment. Indications for surgery may depend on the ultrasound findings especially in the case of incipient hernia.

        Poster 35. Isokinetic assessment of patello-femoral pain syndrome

        Robert Wen-Wei Hsu
        2001 ISAKOS Poster Abstracts
        The patellofemoral joint (PFJ) malalignment is one of the most common disorders of the knee joint. Beside the skeletal factors, the extensor mechanism play a very important role in this disorder. Dynamic and static elements control the patellar alignment. The balance between the vastus medialis obliquus (VMO) and vastus lateralis (VL) was defined as the main dynamic factors. Some authors suggested a good balance between the hamstring and quadriceps is essential for a normal knee function. Deficiency of vastus medialis obliquus (VMO) is often detected and considered to contribute to laterally subluxated patella. Clinical assessment of the functions of vastus medialis and lateralis is difficult and debated. There were many articles depicting the concentric Hamstring/Quadriceps balance status, but only a few stated the “Eccentric” balance conditions. The purpose of this study was to assess the concentric and eccentric contraction muscle strength and balance of the knee joint using isokinetic machine (Kin-Com dynamometer) in normal and also in PFJ malalignment patients. Fifty patients, meeting the criteria for PFJ malalignment, were collected as the testing group. A match control fifty control subjects will be recruited for the comparison. In normal subjects, the males have the greater muscle torques, either concentric or eccentric contraction, than females (p<0.05). Among the patients, the males demonstrated the greater muscle torques over both types of contraction in right side knees than females. The normal controls had a greater muscle torques in both side knee than the patients. A reverse relationship was noted between the testing velecity and muscle torques. The painful knees has a weaker muscle torque than the non painful knees. Strengthening of the muscle strength must be firstly tried for the management of patellofemoral pain syndrome before proceeding the surgical intervention.

        Poster 36. Throwing form correction for baseball shoulder and elbow

        Yusuke Iwahori, MD, PhD, Hiroshi Honjo, MD, PhD, Keiji Sato, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: The effect of throwing form correction for baseball shoulder and elbow was evaluated. Method: Eighty-seven baseball players with throwing pain in shoulder or elbow were examined. All were males aged 10 to 33 years (mean 22.4), with the duration pain on throwing of 40 months in average (range 2 weeks to 17 years). There were 52 pitchers, 9 catchers, and 26 fielders. The throwing motions were recorded by a digital video camera and were evaluated whether there were any problems on throwing form. The throwing form was corrected and the grade of pain relief and return to pitching was inquired. Result: Seventy-eight of 97 cases (90%) had one or more problems on throwing form. Problems on throwing arm in 64 of 78 cases (82%), on trunk or lower extremities motion in 59 cases (76%) and on opposite arm in 58 cases (74%) were observed. Remarkable or moderate pain relief in 53 cases (64%) and complete return to pitching in 32 cases (41%) were gained by throwing form correction. The outcomes were worse, as the age was older or the pain duration was longer. Conclusion: This study shows inadequate throwing form results in the baseball shoulder and throwing form correction worthwhile for this condition. Hypothesis: We should pay attention on opposite arm, lower extremities, and trunk motion as well as throwing arm motion, when we check throwing form.

        Poster 37. Somatosensory evoked potentials in the injured posterior cruciate ligament

        Junji Iwasa, MD, Mitsuo Ochi, MD, PhD, Yuji Uchio, MD, PhD, Kenzo Kawasaki, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To detect somatosensory evoked potentials (SEPs) of injured posterior cruciate ligaments (PCL) by direct electrical stimulation. Method: We studied 21 knees in 21 patients (average age 29 years, ranged 14-44 years) who had given informed consent to intraoperative monitoring of SEPs. All isolated PCL injuries were confirmed by arthroscopy. The PCL was electrically stimulated using a bipolar electrode probe during arthroscopy under general anesthesia. The position sense of the knee was tested by examining the ability of patients to reproduce an angle at which the joint had been placed before being moved. At the same time, the total knee laxity was examined with the knee flexed at 70° under a force of 133 N applied posteriorly and anteriorly to the tibia using the KT-2000 knee arthrometer. The correlation between the SEP and the position sense, the correlation between the SEP and instability, and the correlation between the SEP and the time after injury were statistically analysed. Results: The SEP was detectable in 9 out of 21 cases. The mean side-to-side difference of the total knee laxity in the SEP-positive group was less than 10 min. The time after injury was significantly longer in the SEP-positive group than in the SEP-negative group (p<0.05). It seemed that the SEP-positive group had better position sense than the SEP negative group (p=0.07). Conclusion and Significance: Our findings showed that the electrically stimulated SEPs in injured PCL were related to their stability and position sense.

        Poster 38. Use of cannulated screws in jones fractures – a clinical and biomechanical study

        Christopher Kaeding, MD, Alan S. Litsky, MD, Keri Reese
        2001 ISAKOS Poster Abstracts
        Purpose: To review the long-term clinical results of cannulated screw fixation of Jones fractures as well as to perform biomechanical testing of various screws: Cannulated vs. solid; stainless steel vs. titanium, and small (4 mm) vs. large (6.5-7.3) Methods: In the clinical study 21 patients who had undergone cannulated screw fixation of a Jones fracture were evaluated for: Time to full weight-bearing, average time to painless gait, time to full activity, intra-operative/post-operative complication, and AOFAS midfoot scale. The average follow-up time was greater than 2 years. As part of the biomechanical study the following screws were fatigue tested under cyclic loading of 250 newtons to a maximum of 201,000 cycles: 4 mm cannulated steel, 4 mm solid steel, 7 mm cannulated steel, 6.5 mm solid steel, 4 mm cannulated titanium, and 7.3 mm cannulated titanium. Results: The clinical study yielded the following results. Average time to full weight-bearing: 1.75 wks. Average time to painless gait: 4 weeks. Average time to full activity: 7 weeks. All patients showed radiographic union and returned to prior level of activity. Average AOFAS midfoot scale: 94. No intra/post operative complications or broken screws were reported at average follow-up of over two years. The biomechanical study yielded the following results. Cycles to failure: 4 mm cannulated steel - 22,012; 4 mm solid steel - 44,820; 7 mm cannulated steel - 195,959; 6.5 mm solid steel - 201,000; 4 mm cannulated titanium - 4,308; 7.3 mm cannulated titanium - 201,000. Conclusions: Clinically all patients demonstrated excellent short- and long-term results. Biomechanical testing of screws showed that for fatigue resistance: Solid > cannulated; stainless > titanium; and large > small. The advantage of greater fatigue strength vs. higher modulas of elasticity warrants further study.

        Poster 39. Achilles tendon rupture in young female athletes

        Aasha Sinha, DVM, Christopher Kaeding, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Complete rupture of the achilles tendon is a devastating injury that typically affects males in the third to fourth decade of life participating in occasional sports. Rarely, spontaneous achilles tendon rupture may occur in young athletic females. In this study we describe the features of complete achilles tendon rupture in a group of elite young female athletes. The aims of the study were to describe the clinical features, elucidate potential risk factors, and examine treatment and outcome of achilles tendon rupture in this unique patient population. Methods: Female athletes participating in competitive / professional sporting activities who had sustained a complete subcutaneous achilles tendon rupture during athletic activity when 31 years of age or less, were selected for study. These patients were contacted by telephone and administered a detailed questionnaire to obtain information on their injury, competition and training habits, treatment and rehabilitation, as well as aspects of their nutrition, medical and family history. To date, fourteen patients have been interviewed for this study. Results: Mean age at injury was 21.4 years (range 17-31 years). There were 9 gymnasts (1 Olympic team, 8 varsity with full scholarship), 2 freestyle skiers (Olympic squad), and 3 professional dancers (2 modern, 1 ballet). Mean time to follow-up was 49.2 months after injury (range 9-120 months). The average duration of sports training and participation prior to injury was 14.6 years (range 8-21 years). Patients trained on average 23.1 hours per week (range 6-48 hours). In all patients, tendon rupture occurred during landing or takeoff for a two-footed jumping maneuver. Five patients had a prior diagnosis of achilles tendonitis, mean duration 10.3 months (2 wk - 24 mo). One of these had received an injection of corticosteroid in the tendon sheath 4 months prior to achilles rupture. Four patients reported vague pain in the affected achilles for a variable time prior to rupture. Past medical history was significant for oligomenorrhea in 4 patients. Eight patients were taking NSAIDs at the time of injury for non specific complaints. Four patients reported O blood group, 2 A, 1 AB, 7 unknown. One patient had a family history of achilles rupture. Mean BMI at injury was 21.8 (range 19.2-23.9). Surgical repair was performed in all patients on average 4.1 days after injury (range 0-14 days). Return to unrestricted training activities occurred on average 7.1 months after surgery (range 5-14 months). Twelve patients were able to return to competition at the same or an increased level. Two gymnasts returned to the same level but decreased their degree of difficulty due to persistent problems with pain and tightness. At the time of follow-up 5 patients rated the function of the affected achilles/ankle/calf as normal, 9 as nearly normal. No patient retired from competition due to their injury. Conclusions: We conclude that achilles tendon rupture is a rare but significant injury in elite female athletes. Despite a long period of rehabilitation, the prognosis for return to elite competition is good and these athletes do not appear to be predisposed to chronic problems such as tendinitis. While all injuries occurred during jumping/tumbling, we did not identify any specific features that may indicate increased risk for tendon rupture in this population. The presence of clinical tendinitis before rupture does not appear to predict a poor outcome. The disproportionately large number of gymnasts in our study, in contrast to studies of males, where ball sports predominate, prompts further investigation.

        Poster 40. Endoscopic release of the tibialis posterior and soleus muscles for medial tibial stress syndrome

        Makoto Kawakubo, MD, Takahiro Koyanagi, MD, Masanori Takahashi, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To introduce an endoscopic release for medial tibial stress syndrome. Materials and method: Twenty-four patients with medial tibial stress syndrome were treated between 1997 and 1999. All patients complained of excise-induced pain along the posterior-medial border of the tibia, and had tried various conservative treatment. Among them, 5 patients with medial tibial stress syndrome, resistant to conservative therapy, were treated by the operation. Three patients were basketball players, one was volleyball player and one was runner. In all 5 patients, subcutaneous releases of the tibialis posterior and soleus muscles origin were performed by endoscopic technique using ECTRAII (Dyonics®). Results: All patients were able to return to original sports within 6 weeks after operation. Of the five patients with medial tibial stress syndrome, four were completely free of pain after operation, but one had still slight pain during vigorous sporting activity. Conclusion: The medial tibial stress syndrome can be treated conservatively, in most patients. However, if the conservative treatment can not accomplished, endoscopic release, which is minimum invasive method, can diminish the symptoms. Significance: Endoscopic release should be performed if complete relief from pain cannot be accomplished conservatively.

        Poster 41. Open reduction and internal fixation of 59 intra-articular distal femoral fractures: A 14-year follow-up study

        Gino M.M.J. Kerkhoffs, MD (a – Academic Medical Center, Dept. of Ortho. Surg.), Maarten Rademakers, MSc, Frank van Bommel, MD, Rene K. Marti, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: Evaluation of the functional and radiological outcome of osteosynthesis of intra-articular distal femoral fractures. Method: Fifty-nine patients with an operated intra-articular distal femoral fracture were included in the study. This abstract describes the results of the first 22 patients seen at our clinic for recent follow-up. At follow-up physical examination and radiographic evaluation was performed, and the Neer score and the HSS knee score were evaluated. The mean age at follow-up was 52 years. The average follow-up period was 14 years (range 6 to 22 years). Condylar blade plates were used in 6, plates + screws were used in 11, and screws were used in 5 patients. Results: Eighteen patients (82%) had a good or excellent result on the Neer score, and 21 patients (95%) had a good or excellent result on the HSS knee score. Seven patients (32%) developed osteo-arthritis (grade 2 or 3 according to Ahlback). Four of these patients (57%) had a good or excellent functional result. Patient satisfaction at the latest follow-up was 86% (n=19). There is no significant correlation between fracture type and the development of osteoarthritis (p=0.5), nor between the type of internal fixation and development of osteoarthritis (p=0.8). Conclusion and Significance: We achieve excellent long-term results with ORIF of intra-articular distal femoral fractures (86% patients satisfied). Although there is a high percentage of osteo-arthritis after the use of osteosynthesis, these patients tolerate this late complication well. Final conclusions will be drawn after analysis of the results of the remaining 37 patients of this group.

        Poster 42. Achilles tendon rupture in sports: 25 years experience

        Gino M.M.J. Kerkhoffs, MD (a – Academic Medical Center, Dept. of Ortho. Surg.), Peter A.A. Struijs, MSc, Rene K. Marti, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the outcome of functional postoperative treatment for Achilles tendon ruptures in athletes. Method: Ninety-six athletes with an Achilles tendon rupture were included in the study. Eight-nine of these were seen at our clinic at a recent follow-up, four had died and three were lost to follow-up. At follow-up, we analysed the complications, patient satisfaction, hospital stay and the period to return to sports. All patients were treated with the three-tissue-bundle technique and subsequent 6 weeks cast. From 1990 onward, half of all patients were treated with a wrap instead of cast; these results were analysed separately using the independent T-test and the Chi-square test. Results: The average hospital stay was 9.7 days; full-weight bearing was possible after a mean period of 9.9 weeks. Seventy-five patients returned to pre-injury sports level within 6 months, one patient required 8 months. The other patients stopped doing sports or switched sports, but the Achilles tendon rupture was never their reason. Eighty-two patients (92%) were completely satisfied with their treatment. Postoperative complications occurred in 7 patients: 4 suffered from a re-rupture, 3 from a delayed wound healing. Post-operative management with an elastic wrap does allow a statistically shorter hospital stay (p<0.05) as well as a shorter period until full-weight bearing (p<0.01). Conclusion and Significance: Postoperative treatment with an elastic wrap is safe and provides significantly less hospital stay and a shorter rehabilitation period. Subsequently, the period until return to sports is most probably shorter in the wrap group, but the series is still too small to allow final conclusions.

        Poster 43. A study of factors delaying the accelerated rehabilitation programme after ACL reconstruction

        Tatsuo Kobayashi, MD, Kyosuke Fujikawa, MD, M.Phil., Yoshihiro Sasazaki, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Recently rehabilitation programme after ACL reconstruction has been accelerated. However patients’ accomplishment rate of accelerated rehabilitation has hardly evaluated / discussed. In this study we analyze whether patients can follow the accelerated rehabilitation programme which is made from the doctor’s side and what factors make it delay. Method: Subjects were 67 patients (male: 37, female: 30) with mean age of 22.7 (SD5.6) years at the operation. ACL reconstruction was performed using Leeds-Keio artificial ligament. It was planned for them to start ROM-ex. on CPM, quadriceps setting and SLR exercise from the 1st day. On the 5 to 7th day they started cybex exercise and allowed to bear total weight on the operated leg. Jogging was allowed 6 to 8 weeks after operation, participation in sports was allowed 8-10 weeks after operation. We studied the resuming rate of jogging 8 weeks after operation, of sport activities 10 weeks postoperatively. As delaying factors we investigated gender, stability using KT-2000, ROM, atrophy of quadriceps, hydrops and synovitis of the knee. Results: The resuming rate of jogging was 71.6% and that of sport was 49.3%. Significant inhibiting factors were hydrops and synovitis of the knee, restriction of flexion and quadriceps atrophy. Conclusion and Significance: Not the all patients after ACL reconstruction, even when using LK artificial ligament, could follow the accelerated rehabilitation. Now that accelerated rehabilitation has prevailed all over the world, we should consider how efficiently we make the patients perform it. From our study it was suggested that arthritis persisting after operation delays the progress of rehabilitation plan. We had better delay the rehabilitation plan in case with arthritis at the operation.

        Poster 44. Isokinetic muscle performance after anterior cruciate ligament reconstruction: Middle-term result and analysis of predicting factor

        Atsushi Kobayashi, MD, Hiroshi Higuchi, MD, Fumiaki Kobayashi, MD, Kenji Takagishi
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the middle-term isokinetic muscle performance after ACL reconstruction using autogenous bone-patellar tendon-bone (BTB) graft. The predicting factors that influence to the recovery of muscle strength were also analyzed. Materials and Methods: Subjects were consisted of 36 patients (11 men, 25 women) who underwent ACL reconstruction with autogenous patellar tendon. The clinical evaluation was performed at a minimum of 2 years postoperatively. Muscle strength was postoperatively measured using the Biodex dynamometer at 1, 6, 12 and 24 months. Quadriceps and hamstrings isokinetic strength were assessed during concentric contraction at 60 deg/s and 180 deg/s. We also analyze a correlation between predicting factors (age, sex, athletic activity level, anterior tibial laxity, and anterior knee pain) and the isokinetic muscular performance. Results: Muscle strength of the quadriceps at 60 deg/s was postoperatively recovered to 33.1% at one month; 6 months was 63.2%, 12 months was 72.9%, 24 months was 89.1%. No correlation could be found between several factors (age, sex, athletic activity level, and anterior tibial laxity) and isokinetic muscular performance. Anterior knee pain was risk factor to recover the quadriceps muscle performance. There were significant differences between the anterior knee pain positive group and the negative group. Conclusions: This data showed that muscle strength of the quadriceps favorably restored in minimum 2 years postoperatively. In the patients with anterior knee pain, however, the recovery of muscle strength was delayed in these periods. ACL reconstruction with autogenous BTB graft had good clinical results, however, some problems were made clear in the recovery of muscle performance.

        Poster 45. Olecranon stress injury in throwing athletes: Diagnosis and treatment

        Jason L. Koh, MD (a – Cleveland Clinic), Mark Schickendantz, MD, Charles P. Ho, MD, PhD, Louis Kepler, MD
        2001 ISAKOS Poster Abstracts
        Introduction: We describe 9 professional baseball players with olecranon stress injury successfully treated with a progressive rehabilitation program. Materials and Methods: Nine athletes gradually developed posterior-medial elbow pain during acceleration and follow-through. Exam demonstrated pain with valgus/extension stress, and posteromedial olecranon tenderness. MRI demonstrated high signal consistent with bone edema and stress reaction in the proximal-medial ulna and olecranon. Other findings: Chronic UCL injury(2), posteromedial OA(2). Three had prior injury, including ORIF(1). Treatment: All patients underwent progressive rehabilitation, consisting initially of rest and an orthosis at 200 degrees of flexion, followed by light wrist/forearm progressive resistance exercises at 2 weeks, and elbow exercises at 4 weeks. Functional rehabilitation was initiated at 6 weeks, followed by an interval throwing program at 8 weeks progressing to full throwing by 12 weeks. Results: Mean 4 years follow-up (2-7), 6 patients were able to resume play at their previous level. All players had no symptoms at rest following treatment. Repeat MRI demonstrated resolution of increased signal in the olecranon. 2 underwent UCL reconstruction, one after reinjuring the elbow. Discussion: Stress fractures of the elbow in throwing athletes have been previously documented by X-rays and tomograms. In this study, we were able to diagnose and treat olecranon stress injuries prior to the development of a frank stress fracture. If these injuries are recognized and treated appropriately, resolution of bone edema and symptoms can occur, and permit the athlete to return to a previous high level of play.

        Poster 46. MRI in the early diagnosis and treatment of olecranon stress injury in professional throwing athletes

        Jason L. Koh, MD (a – Cleveland Clinic), Mark Schickendantz, MD, Charles P. Ho, MD, PhD, Louis Kepler, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Stress fractures of the olecranon in throwing athletes have been described using radiography and tomography. We describe the use of MRI to diagnose earlier stress injury to olecranon to assist management before development of discrete stress fractures in elite throwing athletes. Method/Materials: 9 professional baseball players underwent imaging for posteromedial elbow pain in the throwing arm that developed over 2-12 weeks. Exam demonstrated pain with valgus/extension stress and posteromedial olecranon tenderness. 3 had prior injury, including a stress fracture. Results: Initial plain film demonstrated no fractures. Tomography demonstrated 1 stress fracture. MRI demonstrated high signal of bone edema consistent with stress injury/response in the proximal medial ulna and olecranon. Additional findings included chronic UCL injury(2), ulnar neuritis(2), and posteromedial OA (2). Rehabilitation consisted of initial rest followed by gradual progression to full throwing by 12 weeks. 6 patients were able to return to baseball at their previous level. All had complete resolution of symptoms at rest. Repeat MR demonstrated resolution of increased signal in the olecranon. 2 players subsequently underwent UCL reconstruction. Conclusions: Stress injuries from repetitive high loads to the elbow in throwing athletes have been previously documented by X-rays and tomograms. This study demonstrates that MRI may detect the bone edema of olecranon stress injury/response to assist diagnosis and management before the later radiographic findings of discrete stress fractures develop. If these injuries are promptly recognized and treated appropriately, resolution of the edema and symptoms can occur, and permit a more rapid return to play.

        Poster 47. Treatment of cartilage defects of the talus using autologous osteochondral grafting

        Dov Kolker, MD, Emanuel Gautier, MD, Roland P. Jakob, MD
        2001 ISAKOS Poster Abstracts
        Purpose: We present a follow-up study including a standardized outcome analysis to help further develop our understanding of both the management and prognosis of osteochondral defects of the talus treated with the use of autologous, osteochondral grafting. Methods: The cases of eleven patients surgically treated with open talar autologous osteochondral grafting for symptomatic chondral or osteochondral defects of the talar dome between 1996 and 1999 were retrospectively reviewed. The mean age of men and women was 34.2 and 25.9 years, respectively, with a mean time to follow-up of 24 months. Results: Functional outcome results were prospectively obtained, for both the ankle and knee, using the MODEMS™ AAOS Foot and Ankle follow-up questionnaire and Hannover scores for the ankle, and the lKDC subjective and objective knee evaluation forms and the modified Cincinnati and HSS scores for the knee. Overall excellent results were obtained for the knee, with good to excellent results obtained for the ankle. There were no cases of arthritic changes of the knee, however there were three cases of mild degenerative changes present in the ankle with a CT finding of partial graft resorption in a select case. Pain, ankle stiffness, swelling and decreased ankle range of motion were less frequently seen. Conclusion: We believe that the technique of autologous osteochondral grafting presented is valuable and should he considered an option for the patient with a symptomatic osteochondral defect of the talus.

        Poster 48. Treatment of symptomatic recalcitrant retrocalcaneal exostoses: A new surgical technique

        Dov Kolker, MD, Anthony Teebagy, MD
        2001 ISAKOS Poster Abstracts
        Purpose: A new surgical technique is presented to treat symptomatic recalcitrant retrocalcaneal exostoses which consistently affords complete resection of the retrocalcaneal exostosis in addition to the Haglund’s deformity, if present, by completely detaching the terminal Achilles tendon from its insertion. Methods: The results of eight patients who underwent surgical treatment of their symptomatic recalcitrant retrocalcaneal exostoses between 1996 and 1999 were reviewed with a mean follow-up of fifteen months. Surgical management for all patients consisted of excision of the retrocalcaneal exostosis through a single para-Achilles longitudinal incision with complete subperiosteal detachment of the Achilles tendon to allow access for complete resection of the retrocalcaneal bony prominence. The terminal tendon was then reattached to the calcaneus with two reinforced GII Mitek bone anchors. The postoperative regimen included a six week course of short leg casting in equinus followed by a foot and ankle rehabilitation program. Results: Functional outcome results were obtained using the MODEMS™ AAOS Foot and Ankle follow-up questionnaire with overall good to excellent results. In the two patients with a postoperative follow-up of over three years, isokinetic Cybex testing indicated better strength in the operated side compared to the uninvolved side. There were no instances of postoperative Achilles tendon rupture, prominence recurrence or wound problems. Conclusion: We believe this technique to be valuable and should be considered for the patient with a symptomatic recalcitrant retrocalcaneal exostosis.

        Poster 49. Local flap coverage for soft tissue defects following open repair of achilles tendon rupture

        S. M. Kumta, N. Maffulli
        2001 ISAKOS Poster Abstracts
        We examined the long-term clinical and functional results following local flap coverage in 11 patients (mean age: 40.7 years, range 28 to 61 years) who developed wound complications after open repair of a ruptured Achilles tendon. In the period 1990-1997, we used the medial plantar flap with no additional reinforcement of the Achilles tendon repair in six patients. The peroneal reverse flow island flap was used in four patients, three of whom received a reinforcement of the original repair with the peroneus brevis tendon. The posterior tibial reverse flow flap was used in one patient, whose Achilles tendon was reinforced with the plantaris tendon. In all cases, the donor area was skin grafted from the ipsilateral thigh. At the latest follow-up, all but three patients had achieved a good result, having returned to their pre-injury activities. All patients were able to stand on tiptoes unaided, and were able to walk without any aids. In all patients, the maximum calf circumference was decreased, ranging from 2.5 to 1.3 cm less than the non-affected contralateral leg. However, none reported a subjective sensation of weakness in their calf muscles. In our hands, local flaps have proven to be a reliable means of dealing with skin defects following open repair of Achilles tendon ruptures.

        Poster 50. Lateral retinacular syndrome

        Robert P. Langen, MD
        2001 ISAKOS Poster Abstracts
        Lateral retinacular syndrome is a post traumatic condition of the knee. Scarring causes a progressive painful snapping of the lateral retinaculum. A palpable and visible lump appears with extension of the knee and disappears with flexion. As the patella moves laterally with extension, the retinacular scar is forced out of the patellofemoral joint into a position of prominence. As the knee flexes, the patella moves medially pulling the retinacular scar into the patellofemoral joint, and the prominence disappears. Three case histories are presented illustrating the typical history and physical findings. Lateral release was found to be an effective treatment in all three cases. The pathologic mechanism is demonstrated by cadaveric dissections.

        Poster 51. Musculoskeletal injuries in track and field athletes

        Cristiano F.S. Laurino, MD, Moises Cohen, MD, Rene J. Abdalla, MD, Alexandre Lopes, PT, Karina Mano, PT
        2001 ISAKOS Poster Abstracts
        The objective of the present study is to evaluate 103 athletes, of which 69 (67%) were males and 34 (33.0%) females, practicing amateur and professional track and field, in the State of Sao Paulo, in 1998. The presence and behavior of pain and musculoskeletal injuries due to training or competition in relation to sex, age, race and practiced modality were studied. The presence of pain was reported by 79 (76.7%) athletes, of which 54 (68.4%) were males and 25 (31.6%). females Among the evaluated athletes, 78 (75.7%) reported lesions, of which 54 (69.2%) were males and 24 (30.8%) females. Most of the lesions (82.2%) involved the lower limbs. The most common regions were: Thigh (39.8%), knees (22.1%), ankle (11.5%), leg (8.8%), lumbar region (7.1%), shoulder (6.2%) and others (4.5%). Sprints and hurdles races were responsible for 43.3% of the lesions, followed by 30.8% in the jumping events, 13.3% in the throwing events, 7.5% in the middle distance (800 m and 1500 m) and 5.0% in the long distance running. Lesion patterns varied in relation to the modality practiced. The results of this study showed that track and field athletes present a high risk of musculoskeletal injuries mainly in the inferior limbs.

        Poster 52. Sports-specific training improves muscle strength and reduces overuse tendinitis: A longitudinal follow-up of a group of elite sport climbers

        Wilson Li, MBBS, FRCS, Francis Lau Y.K., MBChB, FRCS, Jocelyn Cho, M.Phil., Timothy Y.C. So, MBBS, FRCS
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the effects of a muscle-specific conditioning programme among a group of elite sport climbers in terms of muscle strength and incidence of overuse finger tendinitis after a electromyographic study on simulated climbing movements. Method: Two groups of sport climbers in Hong Kong were surveyed biennially for sport-related injuries. Special attention was paid to overuse flexor tendinitis of the fingers, a condition specific to the sport. In the 1996 & 1998 studies, we observed a consistently higher prevalence of flexor tendinitis among the elite group at 72% (climbing experience averaged 5.6 years, practicing average of 12 hours a week and 112 days a year) than the recreational group (climbing experience averaged 3.5 years, practicing 5.6 hours per week, 39 days a year) at 28%. We therefore carried out an electromyographic study on the elite climbers’ group in 1998, in line with a study from the Duke University published in 1995, in which four climbing muscles were tested for activity during a consecutive pull-up exercise simulating the climbing movement. A specific strengthening programme aimed at the most highly activated muscles (FDS & BR) at the electromyographic study was carried out in 1999. 18 of the 20 elite climbers completed the project. Results: Survey on flexor tendinitis in 2000 showed a reduction in incidence (to 50%) among these 18 climbers. Objective strength testing with the Jamar Power Grip and pinch grasp tests also showed improvement in maximum strength and endurance over the pre-structured-training study. Conclusion and Significance: This is the first longitudinal study among a specific group of sportsmen on the effect of sport-specific training programme on overuse disorders. Specific muscle strengthening programmes seemed to have a beneficial impact on the prevention of overuse injuries.

        Poster 53. Painful proximal tibio-fibular synostosis (case report)

        Lukas G. Lorez, Niklaus F. Friederich, Lucas Kaelin
        2001 ISAKOS Poster Abstracts
        Proximal tibio-fibular synostosis not associated with generalized disorders or deformities like genu vaIgum, proximal tibio-fibular joint and difference of leg length, are extremely uncommon. Only 8 cases have been reported in the literature so far. It is believed that the synostosis occurred after epiphyseal closure. We present a case of a 34-year-old former athlete who presented with pain in the left proximal tibio-fibular joint after long-distance jogging (>3 km). He had no history of trauma. After the resection of the adjacent exostosis and some physiotherapy, the patient had only little pain relief. An osteotomy of the proximal fibula is now planned to avoid the mechanical stresses to the joint transmitted from the foot.

        Poster 54. Quality of life assessment in elite collegiate athletes

        David R. McAllister, MD, Ali Motamedi, MD, Sharon L. Hame, MD, Matthew S. Shapiro, MD
        2001 ISAKOS Poster Abstracts
        Objective: The primary objective of this study was to establish baseline SF-36 health survey data in Division collegiate athletes and to determine the effects of injury severity and training time on the various scores of the SF-36. Methods: All athletes (N=562) participating in Division I collegiate athletics at a major university were evaluated prior to participating in their respective sports. All athletes were evaluated with the SF-36 Health Survey, and answered questions pertaining to exercise time, sport, and injury. Mean scores for the 8 SF-36 domains: Role Physical (RP), Physical Function (PF), Bodily Pain (BP), Social Function (SF), General Health (GH), Vitality (VT), Mental Health (MH), Role Emotional (RE) as well as Physical Component Summary Scale (PCS) and Mental Component Summary Scale (MCS) were determined. Regression analysis was performed to identify factors that were predictors of these scores. Results: 333 males and 229 females with a mean age of 19.6 years participated in the study. PCS and MCS scores are listed in the table below. There was a trend for decreased SF-36 component scores and summary scores with increased injury severity in both males and females. However, when comparing males without injury to the norm group, there was a significant increase in RE (P<.015) in our study group. In females there were significant increases in MCS (P<.001), PF (P<.002), RE (P<.001), MH (P<.001), and VT (P<.001) in females without injury when compared to the previously established norms. Serious injury was a predictor of lower scores in the MCS, PCS and all eight component SF-36 scores, while minimal injury was predictive of lower PCS, RP, BP, SF, and GH scores. Increased exercise was predictive of higher MCS, RP, VT, and GH. Conclusions: When compared to previously established normative data, Division I collegiate female athletes scored higher in 4 SF-36 component scores and 1 summary score, while males scored higher in 1 SF-36 component score. Injury was a strong predictor of lower scores in all domains, and increased exercise time was predictive of higher scores in 3 SF-36 component scores and 1 summary score.
        Tabled 1SUMMARY SCORES
        PCS InjuryMCS Injury
        GroupNoneMin.Ser.AllNoneMin.Ser.All
        Female53.750.345.852.049.951.549.750.2
        Male54.150.044.752.851.452.248.051.3
        All53.950.145.352.550.851.949.050.9

        Poster 55. The isokinetic avaliation of the patients with tear of the anterior cruciate ligament

        Zartur Menegassi, Benedito Silva, Idemar Palmar
        2001 ISAKOS Poster Abstracts
        Purpose: This study was initiated for evaluation isokinetic of the patients with anterior cruciate ligament (ACL) tears associated or not with meniscus tear. Type of Study: It was a prospective and randomized trial. Method: Sixteen patients with clinic suspicion of ACL tear associated or not to meniscus tear, were studied by using the isokinetic method (Cybex 6.000). All the lesions were confirmed with surgery (ACL reconstruction). The average age was 28 years old (19 to 38), all the patients were white males who played soccer. All the clinical examinations and surgeries were done by the same surgeon. Results: All the 16 patients (100%) had ACL tears in which seven (43.75%) of them had medial meniscus tears associated. The average of the extensor mechanism deficit was 23.56% in the knee with lesion and the flexor mechanism was 13.43%. In the cases of meniscus tear associated, the extensor mechanism deficit was 27.0% and the flexor mechanism deficit was 15.4%. At the cases without meniscus tear associated the extensor mechanism deficit was 20.8% and flexor was 11.8%. The statistic analyses with the T Student test (p≤5%) confirmed the extensor mechanism deficit that was bigger than the flexor mechanism. Conclusion: The patients with tear had a deficit in the extensor and flexor knee mechanism and the extensor mechanism deficit is bigger than the flexor mechanism.

        Poster 56. Rules of follow during rehabilitation after posterior cruciate ligament reconstruction

        Marta Milewska, PT, Jacek Manka, PT, Robert Smigielski, MD, Grzegorz Adamczyk, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study is to make you more familiar with the rules we follow during rehabilitation after arthroscopic double-bundle Posterior Cruciate Ligament (PCL) reconstruction. Material: There were three (3) patients observed after PCL reconstruction: One woman and two men (average age: 27 years). All patients were operated with arthroscopic double-bundle PCL reconstruction with using of autogenic graft from quadriceps muscle tendon. Method: Patients were diagnosed and prepared to the operative PCL reconstruction by arthroscopy. This is why we divided our procedure to two main stages: Stage I - preoperative (before reconstruction), Stage II - postoperative (after reconstruction). In the first stage we paid our attention to the mass of quadriceps muscle, prioreception and prevention of pain coming from patello-femoral joint. The second stage of rehabilitation was compliant with main rules of postoperative care and with rules of biomechanics. We also put particular attention to active graft protection, to early patient mobilization and to strengthen of muscle mass. We also recommended full extremity weight bearing (to pain border). Progress and way of conducting rehabilitation were determined by graft re-building. Results: Our patients showed motion activity and knee joint stability compliant to our anticipation. Conclusion: Patients preparation to postoperative rehabilitation turned out to be right. Showing target and idea of procedure to the patients and making good contact with them helped in faster and easier rehabilitation after PCL reconstruction.

        Poster 57. Relationship between the flexibility and the injuries in collegiate sumo wrestlers

        Yasuaki Nakagawa, MD, Yoshitaka Matsusue, MD, Takashi Nakamura, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To clarify the relationship between the injuries and the flexibility of joints and muscles in collegiate sumo wrestlers. Methods: Fifty-six collegiate sumo wrestlers, who belonged to the major league, were examined as a medical check in September 1999. We assessed aspects of their physique such as height, weight and body mass index (BMI), past history, the ability of “matawari” (special training of sumo) and the flexibility test. Past history divided into 4 subgroups; injuries occurred for all periods (TI), injuries occurred for collegiate periods (CI), joint injuries (JI) and muscle injuries (MI). The flexibility tests involved seven joints (shoulder, elbow, wrist, spine, hip, knee and ankle) and five muscles (paravertebral, iliopsoas, quadriceps, hamstrings and gastrocnemius). We statistically compared their physique and flexibility with the injuries, using an unpaired t-test. Results: Their mean height was 176.1 cm, weight 111.3 kg and BMI 35.9 kg/m2. There were no relationships between flexibility and injuries in TI and CI. There were 30 sumo wrestlers (54%) who had JI. They decreased quadriceps muscle flexibility than the others. Seven wrestlers (20%) who couldn’t do “matawari” existed, and they were significantly less flexible paravertebral muscle and hamstrings than the wrestlers who could do “matawari.” There was no relationship between the ability of “matawari” and the injuries. Conclusion: One of the risk factors of JI was the decreasing of quadriceps muscle flexibility in collegiate sumo wrestlers. Significance: In order to decrease sport injuries, the investigation of the relationship between the flexibility and the injuries is significant.

        Poster 58. Relationship between the mobility of the hip joint and non-contact ACL injuries

        Yasumitsu Ohkoshi, MD, PhD, Shinya Nagasaki, MD, Ryosuke Ishida, PT, Shigeru Yamane, PhD
        2001 ISAKOS Poster Abstracts
        Introduction: Subjecting the knee to excessive rotation (ER) is one of the main causes of non-contact ACL tears. Rotation of the lower extremity occurs mainly in the hip joint. Our hypothesis is that a restricted range of rotation of the hip joint correlates with non-contact ACL tears due to ER. A case-control study was performed to test this hypothesis. Methods: Fifty consecutive patients had ACL injuries, all from non-contact mechanisms due to ER (ACL group). The control group consisted of 65 subjects. There were no statistical differences in the background factors (age*, gender, activity level, etc.) between the two groups (*; statistical power>0.8). The range of rotation of the hip joint was measured with a special photogrametric method which excluded measuring bias. In the ACL group, the contra-lateral hip was measured. All data were analyzed by an independent observer in a blind fashion. Statistical analysis was performed between the two groups (Student’s t-test). Results: The mean angle of maximum internal rotation was 40.5 ± 12.9° in the control group and 32.4± 10.9° in the ACL group (P<0.05). The mean angle of maximum external rotation was 61.1 ± 7.7° in the control group and 56.5 ± 10.4° in the ACL group (P<0.05). Discussion & conclusion: Our results show that the range of rotation of the hip joint is significantly smaller in the ACL group. These findings thus prove our hypothesis. We conclude that restricted range of rotation of the hip joint is a predisposing factor for non-contact ACL tears due to ER.

        Poster 59. Bilateral atraumatic quadriceps and patellar tendon ossification: Case report

        Ercan Olcay, Tarik Sener, I. Haci Kutlu, Kahraman Öztürk
        2001 ISAKOS Poster Abstracts
        Ectopic patellar tendon ossification is a complication which may be seen in Osgood-Schlatter disease, following the traumas including the lower end of patella, total knee prosthesis and intramedullary nailing of tibial fractures. Heterotopic ossification both in patellar tendon and quadriceps tendon without any trauma is a rare condition. Case report: A heterotopic ossification with unknown etiology was seen in bilateral patellar tendons and quadriceps tendons of a 48 years old male patient. Ectopic calcification was seen along the patellar tendon and the quadriceps tendon when X-ray and computerized tomography investigations of the patent were done. Quadriceps atrophy 3 cm in right knee and 1 cm in left knee was determined in the physical examination. An average 10° extension loss and 0-130° range of motion in both knee and difficulty in stepping down and presence of pain were noticed. A wide osteochondrosis appearance in medial femur condyles of both knees was determined during arthroscopic evaluation of the case. Because of these findings of a rare case the literature was discussed by a review.

        Poster 60. The significance of the patella morphology in the assessment of patients with patella-femoral pain

        Ercan Olcay, Ömer Selim Yildirim, Murat Bülbül, Tarik Sener
        2001 ISAKOS Poster Abstracts
        The anatomy of the patella and the length of the patellar tendon plays rather an important role in the assessment of patella-femoral pain. 263 patents (104 men and 159 women) with patella-femoral pain were included in this prospective study. Following radiological examination of these cases, the Insall-Salvati indexes and the Blackburne-Peel indexes were assessed and the difference between men and women was compared. The morphology of the patella was also examined during radiologic examination and the differences between men and women were compared. The relationship between patella-femoral pain and types of patella determined after radiological examination were investigated. The Insall-Salvati index was found to be a mean value of 1.01 ±0.13 in men and 1.05 ±0.10 in women. It was observed that the difference between men and women were statistically significant. The Blackburne-Peel index was found to be 0.81 ±0.8 for men and 0.83 ±0.11 for women. The difference was once again observed to be statistically significant. It was interesting that of the patella type cases 75.3% (198) were type 1, 13.3% (35) were type 2, and 11.4% (30) were type 3. In the statistical assessment carried out in these groups it was seen that type 2 patella was observed more frequently in men, that type 3 patella was more common in women (p<0.05) and also that patella pain was more severe especially in type 2 and type 3. The conclusion that has been reached, considering patella morphology as well as classical indexes when assessing patients with patello-femoral pain, and paying special attention to this in radiological examination, is important for diagnosis and treatment.

        Poster 61. Ruptures and avulsions of hamstring muscles

        Sakari Orava, MD, PhD, Jussi Rautanen, MD, PhD, Ilmo Helttula, MD, Juhana Leppilahti, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the diagnosis, timing or operation and final results of patients treated surgically due to tear or avulsion of hamstring muscles near ischial tuberosity. Method: A retrospective clinical series of 40 consecutive patients treated surgically during years 1981 - 1999. Results: There were 32 males and 8 females in the series. The mean age of them was 35 years (range 18 - 60 years). The injury occurred during sports activities in 32 cases. The operation was done in less than two weeks after the injury in 9 cases, in less than three months after the injury in 17 cases and later than that in 14 cases. The longest delay from the injury to surgery was 7 years. The operation technique was as follows: Suturation of the proximal hamstring muscles in 8 cases, suturation through drill holes of ischial tuberosity in 3 cases and suturation with help of Mitek’s or other achors 29 cases. The follow-up time was from 1.2 years to 16 years (mean 5.5 years). There were postoperative complications in 12 patients. Most of the complications were minor and did not disturb the final healing. The final result was excellent or good in 26 patients, moderate in 8 patients and poor in 6 patients. Conclusions: Proximal tear or avulsion injury of hamstring muscles is a rare injury. The diagnosis is often delayed. By repeated clinical examination and by ultrasound echography or MRI examination the diagnosis should be done in time. Early operative treatment gives good results. The surgery can be done also late with good or moderate result.

        Poster 62. Surgical treatment for chronic achilles tendinopathy. A prospective 7-month follow-up study

        Mika Paavola, MD, Pekka Kannus, MD, PhD, Sakari Orava, MD, PhD, Matti Pasanen, MSc, Markku Järvinen, MD, PhD
        2001 ISAKOS Poster Abstracts
        This 7-month prospective follow-up study assessed the short-term results of surgical treatment of chronic Achilles tendinopathy and compared the subjective and functional outcome of patients with Achilles tendinopathy without a local intratendinous lesion (group A) with that of similar patients with such a lesion (group B). 42 of the initial 50 patients could be examined at the study entry (before the surgery) and after the 7-month follow-up. The evaluation protocol included an interview, subjective evaluation, clinical tests, and a performance test protocol. At the follow-up, physical activity was fully recovered in 28 of the 42 patients (67%), and 35 patients (83%) were asymptomatic or had only mild pain in strenuous exercise. In clinical tests, significant improvements were observed in the climbing up and down stairs and in the rising-on-toes test. Using the total performance test protocol as the criterion, the surgical treatment also seemed successful since at the follow-up total test score was excellent or good in 35 patients (83%), compared that preoperatively the total test score was excellent or good in one patient (2%) only. Patients in the group A managed better than those in group B, evaluated by whether the recovery of physical activity after surgery (88% vs. 54%), or a complication rate (6% vs. 27%). The results of this 7-month follow-up showed that surgical treatment of chronic Achilles tendinopathy gives good and acceptable short-term results. A somewhat lower complication rate and a trend to better recovery was observed in patients with pure peritendinous adhesions than in those with peritendinous adhesions combined with an intratendinous lesion.

        Poster 63. Patellar tendinopathy in athletes

        Alfredo Schiavone Panni, Mario Tartarone, Nicola Maffulli
        2001 ISAKOS Poster Abstracts
        We report the results of conservative and operative management of patellar tendinopathy in 42 athletes who presented with Blazina’s Stage 2 (26 patients) or Stage 3 (16 patients) disease. All patients were initially managed conservatively with NSAID, physical therapy and a progressive rehabilitation program based on isometric exercises, stretching, and eccentric exercises. After six months, 33 patients showed symptomatic improvement, and were able to resume their sports. In the nine patients presenting with Blazina’s Stage 3 disease conservative measures failed, and surgery was undertaken. This consisted of removal of the degenerated areas of the tendon, multiple longitudinal tenotomies, and drilling of the lower pole of the patella at the site of tendon attachment. Histology of the excised tendon tissue showed areas of necrosis and mucoid degeneration, and alterations of the bone-tendon junction. After a mean follow-up of 4.8 years, clinical results were excellent or good in all patients. In the group treated nonoperatively, results were better in the patients presenting with Stage 2 disease than in those with Stage 3.

        Poster 64. Gender specific differences in school sports accidents

        J. Kelm, F. Ahlhelm, W. Pitsch, T. Regitz, C. Engel, D. Pape
        2001 ISAKOS Poster Abstracts
        Purpose: A specific gender analysis and thereby the influence of sex on predilection of sport injuries may help to reduce sport accidents. This gender specific analysis should allow to draw conclusions for physical education. Method: In this study 213 accidents during school sport lessons had been prospectively investigated. Beneath diagnosis, the localization of injuries and the adequate therapy as well as the duration of the sick leave had been documented and statistically elaborated. Results: For boys and girls (predilection age: 13 years) most common injuries had been distortions, contusions and fractures. Main reasons for the accidents had been faults in basic motor trainings like running, jumping and catching. The majority of injuries could be observed in team games. Gender specific differences could be demonstrated in the kinds and in the reasons of injuries. No gender specific differences could be shown for the localization of injuries. Playing soccer and basketball is the most frequent reason for sport injuries. The upper extremity is more frequently invoked than the lower extremity. Conclusion: Sport injuries have a predilection during or at the beginning of puberty. At this time boys and girls differ in their spare time sport activities. This fact beneath differences in physical constitution and motor skills may be responsible for different reasons of injuries. By considering this fact it should be possible to reduce sport accidents.

        Poster 65. Inline skating accidents – sports medical and sports sociological aspects

        J. Kelm, F. Ahlhelm, W. Pitsch, T. Regitz, C. Engel, D. Pape
        2001 ISAKOS Poster Abstracts
        Purpose: Was to determine injury patterns and localization of damages, to evaluate the causes for accidents and to analyse accident preservation by the use of special protecting clothes, to investigate the influence of the social status and readiness to use the special protecting clothes. Method: 76 inline skating accidents had prospectively been analysed. Beneath the diagnosis, the exact modes of injuries as well as the localization of the injured part of the body has been documented. Data were statistically analysed using the x2-test and the one factorial variance analysis. Results: The most frequent injuries had been fractures (51.3%) and distortions (17.1%). The preferred localization was the distal forearm (39.4%), the fingers (10.5%) and the wrist (9.2%). Most of the accidents took place on the sidewalk and on the streets (47.3%). The most dangerous skating techniques were sliding and spinning (64.4%). The terrace profile had been planar in 44.7% of all injuries; the lane generally was tarred (47.3%). The most common protective clothes were kneepads (68.4%) and helmets (64.4%). The mostly applied protective suits were kneepads (43.4%) and elbow pads (34.2%). 59.2% of children had wrist pads but only 28.9% used them. A higher social status is tendentious (p<0.1) combined with the higher readiness to use protective clothes. Conclusion: We could show that there is quite a big difference concerning possession of protective cloths and the readiness to use it. The modality of most accidents may be important for injury prevention. Special teaching courses and providing special skating tracks may help to prevent injuries.

        Poster 66. Sports injuries, sports damages and diseases of world class athletes practicing modern pentathlon

        J. Kelm, F. Ahlhelm, W. Pitsch, T. Regitz, C. Engel, D. Pape
        2001 ISAKOS Poster Abstracts
        Purpose: Was to evaluate typical injury patterns and diseases resulting from trainings or competitions of world-class athletes practicing modern pentathlon and to analyse methodical aspects of training behaviour as prophylaxis. Method: 108 world-class athletes (54 males, 54 females) practicing modern pentathlon had been interviewed about their sports related injuries, damages and diseases in the competition year 94/95. Statistical significance was achieved for p<0.05. Results: The mean number of national and international competitions athletes made was 9. Their training extent was about 25 hours per week, especially concerning swimming and running. Mean number of health threatening incidents of each athlete had been 2 (41% diseases, 23% injuries and 33% damages). Most of the diseases had been otitis and pharyngitis, most of the damages were tendonitis and periostitis. Contusions and distortions were the most frequent kinds of injuries. Training efforts were the most frequent reasons for health threatening incidents (84%), such as diseases and damages. Most of the injuries happened practicing horse riding 9% during competitions. Conclusion: The incidence of health threatening incidents concerning world-class athletes practicing modern pentathlon is quite low. Especially running and swimming combined with a high training extent predispose to suffer from damages and diseases. Horse riding with quite a low training extent is less predilective for injuries. As a consequence the training extent should not be too extended. Due to a high number of diseases the training sequence should also be considered combined with being in attendance of an inner medicine physician.

        Poster 67. Arthroscopic treatment for proximal patellar tendonitis in athletes

        Alberto Pienovi, MD, Luciano Quevedo, MD, Eduardo Ottolenghi, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Anterior knee pain is a very frequent symptom among young athletes. Proximal patellar tendonitis is one of the causes of this syndrome and many authors have proposed different treatments. The purpose of this study is to describe the arthroscopic treatment and the evaluation of medium and long-term results in this lesion. Method: Twenty-one patients with a diagnosis of chronic tendonitis of the patellar tendon were evaluated. All patients underwent previous medical treatment and physical therapy. Eleven patents had a previous MRI evidencing a thickening of the tissues with hypertrofic synovitis. Arthroscopy was performed with local anesthesia and through two portals, proximal and distal to the lesion, creating a space for the endoscopic treatment. Fasciotomy, bursectomy and longitudinal opening of the tendon were performed. This study describes the surgical technique. The knee was immobilized with a brace for two weeks and a return to sports was allowed after two months. Results: Twenty-one patients who underwent surgery were studied, presenting symptoms for an average of 8 months (5 to 23). Eighteen were male and three female. They all were amateur athletes and practiced contact or jump sports. Results were excellent or very good in 15 patients (71.43%), fair in 4 patients (19.05%) and poor in 2 patients (9.52%) maintaining or worsening the symptoms. Discussion: Anterior knee pain is one of the causes for chronic tendonitis and is very frequent among contact or jump sports. Several treatments have been described with different results. This study presents a simple arthroscopic technique with effective results. It is considered that arthroscopic treatment is each time more useful for this pathology.

        Poster 68. Isokinetic strength of the quadriceps and hamstrings and functional ability of the knee after ACL reconstruction with different techniques and grafts

        Uwe Pietzner, MD, Katrin Giese, MD, Britta Schmidt, MD, Dirk Ganzer, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To compare the symmetry of the quadriceps and hamstrings after ACL reconstruction with different techniques and autologous grafts. Method: Forty-five patients with a traumatic rupture of the anterior cruciate ligament (ACL) underwent an arthroscopically assisted reconstruction. We performed this ACL reconstruction in three different techniques with 15 patients each group: I transtibial technique with a BPTB-graft, II all-inside technique with BPT-Graft (without a patellar bone plug) and III transfix-technique with quadrupled hamstrings. A standard rehabilitation program was used for all patients after surgery The patients were evaluated 3, 6 and 12 months postoperatively measuring subjective complaints and muscular atrophy. We also used the KT-1000 arthrometer and the LIDO isokinetic dynamometer. With the LIDO system we compared the hamstrings and quadriceps of the operated and healthy leg using a speed of 90 and 180 degrees s-1. The variables including total work output and explosive power were registered and a statistical analysis was performed. Results: The KT-1000 examination showed an instability (≥ 3 mm) in 28% group I, 25% group II and 35% group III after one year. In all groups didn’t return the strength of either the hamstrings or the quadriceps to the level of the contralateral normal limb after 12 months postoperatively. The strength of hamstrings and quadriceps was always higher in group II than in group I (groups using patellar tendon as graft). Three months after surgery the strength of the quadriceps of the all-inside group was also higher as of the group using quadrupled hamstrings. But the patients in this group (III) got better results than the patients in group I. The weakest group for the strength of the hamstrings was group III. Conclusion: The results showed that the postoperative strength of the quadriceps and the hamstrings is influenced by the kind of used graft for the ACL reconstruction. It also suggested that using patellar tendon without a patellar bone plug improves the results regarding muscle strength and stability. Asymmetries between operated and healthy leg in all groups after 12 months may reflect either incomplete rehabilitation or inability to regain full isokinetic strength after ACL reconstruction. Significance: The rehabilitation after ACL reconstruction and the selection of the graft and the reconstruction technique are very important for the success of the operation including a return of the strength of quadriceps and hamstrings to normal level.

        Poster 69. Peroneus brevis tendon transfer in fresh and neglected subcutaneous tears of the achilles tendon. A comparative cohort study

        E. Pintore, V. Barra, R. Pintore, N. Maffulli
        2001 ISAKOS Poster Abstracts
        We present the results of a single centre, single surgeon longitudinal study in which patients with a fresh (four women and 23 men, mean age 43.6 years ± 8.8) or a neglected (one woman and 21 men, mean age 41.3 years ± 7.4) Achilles tendon rupture were operated upon using the tendon of the peroneus brevis as an autologous graft. After definitive removal of the plaster cast, patients were assessed during the sixth post-operative week and during the sixth post-operative month. Patients were discharged within one year from the operation and were reviewed at an average of 53 ± 13 months from surgery. Patients were generally satisfied with the procedure, but those with a neglected rupture tended to have a greater post-operative complication rate, greater loss of isokinetic strength variables at high speeds, and greater loss of calf circumference. The management of acute and neglected subcutaneous tears of the Achilles tendon by peroneus tendon transfer is safe but technically demanding, which affords good recovery, even in patients with a neglected rupture of six weeks’ to nine months’ duration. Patients with a neglected rupture are at a slightly greater risk of post-operative complications, and their ankle plantar flexion strength can be reduced.

        Poster 70. Clinical signs and anatomical correlation of patellar tendinitis

        Ehud Rath, MD, John C. Richmond, MD
        2001 ISAKOS Poster Abstracts
        Objectives: The clinical diagnosis of patellar tendinitis is based on tenderness to palpation at the inferior pole of the patella. It has been suggested that the tenderness is maximal when the knee is extended and the quadriceps relaxed. Bending the knee to 90 degrees decreases the tenderness dramatically. The objectives of this study were to assess 2 clinical signs for patellar tendinitis and to demonstrate the pathoanatomic correlation. Materials and Methods: 10 consecutive patients with a positive sign as described had an MRI that showed focal abnormality in the tendon. The location of the MRI finding corresponded to the region of tenderness. The patients were reevaluated to assess the sensitivity of the standing active quadriceps sign. The patellar tendon was palpated along its course while the patient stands and the point of maximal tenderness identified. The patient was then asked to stand only on the involved extremity with 30 degrees of knee flexion and the tendon was re-palpated. Visual analog scale was used to describe the tenderness on each phase of the exam in both tests. A cadaveric dissection was made to explore the pathoanatomic correlation for the physical signs. Results: Both tests showed significant decrease in tenderness at the inflammation region when the patellar tendon was under tension. The cadaveric study showed that when the knee is flexed to 90 degrees or when the quadriceps is tensioned the deep fibers did not deform under anteriorly applied pressure. Discussion: The two clinical signs presented in the study are based on palpation of the patellar tendon in a relaxed and in tensioned positions. The cadaveric study showed that tenderness to palpation diminishes at the tensed phase of each test as the anterior fibers of the patellar tendon “protect” the deep fibers from irritation. We suggest using these tests routinely in the evaluation of patients with anterior knee pain.

        Poster 71. Aggressive and accelerated rehabilitation after osteochondral autograft transfer: A 3 years follow-up clinical assessment

        Michel Rousseaux, MD, Dirk P.M. De Clerq, MD, Koenraad L.A. Verstraete, MD, PhD, Wouter C. Huysse, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To present the clinical results of patients who underwent an aggressive and accelerated rehabilitation program after an Osteochondral Autograft Transfer (OATS) for treatment of posttraumatic focal chondral lesions of the knee. Method: A retrospective evaluation of 31 patients is presented. The outcome is based on a clinical assessment using the cartilage standard evaluation form as proposed by the international cartilage repair society. In addition an isokinetic muscle strength test was performed (Biodex Dynamometer). Results: Clinical assessment:
        • 1.
          Normal: 7%
        • 2.
          Nearly normal: 32%
        • 3.
          Abnormal: 43%
        • 4.
          Severely abnormal: 18%.
        There is a good correlation between the patient subjective functional assessment (71% normal and nearly normal) and a postoperative normalised hamstrings/ quadriceps ratio. Conclusion: Better standardisation of the pre-, per- and postoperative rehabilitation program (relying upon radiological & MRI assessment) must allow further improvement in clinical outcome. Significance: An essential point in the clinical outcome after OATS seems to be an aggressive rehabilitation with emphasis on restoring muscle strength.

        Poster 72. Early clinical outcome of an acelerated and aggressive postoperative rehabilitation program after a surgical ACL reconstruction technique with a double-looped gracilis and semitendinosus tendon autografts

        Michel Rousseaux, MD, Dirk P.M. De Clerq, MD
        2001 ISAKOS Poster Abstracts
        A. Introduction: The combination of an arthroscopic ACL reconstruction by endoscopic fixation of double-looped gracilis and semitendinosus autografts and an accelerated, aggressive postoperative rehabilitation program is successful to lead athletes to an earlier and more reliable return to sports activities. B. Material: An evaluation of a series of 30 patients at 4 months postoperatively will be presented. C. Methods: The results are based on the International Knee Documentation Committee (IKDC). D. Results: IKDC final score:
        • 1.
          Normal: 36.7%
        • 2.
          Nearly normal: 50%
        • 3.
          Abnormal: 13.3%
        • 4.
          Severely abnormal: 0%
        E. Discussion: A double-looped hamstrings autograft in combination with strong fixation devices (Bone Mulch screw and tibial Washer-lock) seems to be the new “Gold” standard for ACL reconstruction. F. Conclusion: The standardisation of the post-operative rehabilitation program must allow further improvement in clinical outcome.

        Poster 73. Anterior knee pain after ACL reconstruction

        Sahir Shaikh, MD, Peter Dobson, FRACS, Kevin Angel, FRACS, Peter Lewis, FRACS
        2001 ISAKOS Poster Abstracts
        Objective: Anterior knee pain is the most frequent complication of ACL reconstruction. Although the occurrence of this anterior knee pain has been well established, the causes remain unknown. The influence of shape of bone plug on the incidence of anterior knee pain in ACL reconstruction using autogenous patellar tendon has not been previously documented. Our purpose was to compare the incidence and severity of anterior knee pain after ACL reconstruction using patellar tendon autografts with cylindrical and trapezoidal bone plugs. Methods: 479 patients were contacted and asked to complete a subjective questionnaire. 296 patients replied of which 157 patients had cylindrical bone plugs while 139 had trapezoidal bone plugs. Each of the six variables were analysed separately by an unbalanced three factor analysis of variance, with age used as a covariant. The factors were shape of bone plug (trapezoid vs. cylindrical), gender (male vs. female) and operated knee (left vs. right). Results: Cylindrical group reported slightly more symptoms during sporting activities and kneeling. Anterior knee pain with daily activities was found to be less for males than for females therefore to decrease with increasing age. Total incidence of anterior knee pain in cylindrical and trapezoidal group was similar (23%) for all other activities except kneeling. Kneeling activities reported slightly higher incidence in cylindrical group (85%) as compared to trapezoidal group (80%). Conclusion: Anterior knee pain after an ACL reconstruction with bone tendon bone autograft is not related to shape of bone plug. Morbidity of donor site should be taken into account in patients who regain kneeling and squatting, as part of daily activity such as occupation, e.g., tilers as well as sporting activity. The use of hamstring graft may be better in this particular group.

        Poster 74. Qualitative and quantitative evaluation of the injured anterior talo-fibular ligament with MRI

        Yoshiki Shiozaki, MD, Shuji Horibe, MD, Tomoki Mitsuoka, MD, Konsei Shino, MD
        2001 ISAKOS Poster Abstracts
        Introduction: To restore the stability for the chronic lateral ligamentous instability, either grafting of fascio-tendinous tissue, advancement of the residual tissue or capsulorrhaphy is performed. Since choice of surgical treatment is based on the quality of the residual ligamentous tissue, qualitative and quantitative evaluation of the tissue has been desired preoperatively. The purpose of this study was to assess how accurately MRI describes the structure of the injured anterior talo-fibular ligament (ATFL). Materials & methods: From 1997 to 2000, 12 patients with chronic ankle instability underwent preoperative MRI evaluation and subsequent ligament surgery. There were 5 males and 7 females with an average age of 25 years. MR imaging was performed on a 0.3-T unit (AIRIS, Hitachi Medico). For evaluation of the ATFL, axial T1 -weighted SE sequences and T2-weighted FSE sequences (3-mm section thickness, 0.5-mm intersection gap) was performed with the ankle kept in neutral position. Results: Abnormal signal intensity in ATFL was found in all cases. Five showed irregular thickening of the ligaments accompanied by increase signal intensity, while the other seven had the thin and wavy ligaments. These MRI findings were verified by the subsequent macroscopic and histological evaluations after surgery. CONCULSION: MRI evaluation is useful to preoperatively evaluate the residual ligamentous tissue following injury.

        Poster 75. Lesions in unión rosarina de rugby (rosario rugby union) in 1999

        Daniel Slullitel, MD, Sergio Luscher, MD, J. Carlos S. Begnis, MD, Adrián Blasco, MD, Carlos Nasio, MD
        2001 ISAKOS Poster Abstracts
        Objective: The aim is to search avoidable lesions in rugby. Method: During 1999, 35% of the declared accidents in the official games of the URR were assisted at “Dr. Jaime Slullitel” Orthopaedic and Trauma Institute, due to an agreement between both organizations. This value arises from the comparison between assisted patients and declared lesions in the official game. The sample is random and unbiased for it represents statistically significant general data. In a prospective study patients were asked about the time of the game when the lesion took place, the field conditions, the training routine and others. Results: 60% of the lesions occurred at 20-60 minutes of the game. Regular and bad conditions of the field markedly increase the incidence of lesions. The teams with less replacement of players also have an increase of lesions. No difference were found between play-off and regular seasons. Conclusion and Significance: Rugby is a contact sport, lesions must be avoided by improving field conditions and changing the rules that allow playing in the rain or in muddy fields. Players’ fatigue must always be avoided and players must be replaced on a regular basis even if they are essential to the team.

        Poster 76. Rehabilitation after autologous osteochondral grafting modifications of the program depending on different surgical techniques

        Robert Smigielski, MD, Jacek Grabowski, PT, Renata Jopek, PT, Grzegorz Adamczyk, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the functional rehabilitation programme after autologous osteochondral autograft treatment. Method: Outerbridge articular cartilage defects were treated by open approach, mini approach or arthroscopic autograft procedure. Defect size ranged from 7 mm to 45 mm. Differences in protocol were consequences of understanding of healing of soft tissues and bones. We improved the functional protocol with early assisted exercises in 31 patients divided into 3 groups in average age 38 (range 16 to 58) with full thickness grade IV. I group contained patients (3 causes) after open cartilage repair worn the extensive brace and were not allowed to make contractive exercises for three weeks. II groups contained 15 patients operated by mini-open approach through a small incision, at the mirror site for the area of damaged cartilage without disruption of the vastus medialis. Quadriceps exercises began within 48 hours. III group included 14 patients after arthroscopically assisted procedure had the same protocol as II group. Results: 19 patients finished rehabilitation at the activity level as before the injury. 12 patients are still continuing rehabilitation (due to rehabilitation after surgical treatment of other concomitant injuries like anterior cruciate ligament injury). Rehabilitation program resulted in very good therapeutic outcomes. In one case of osteochondral autologous knee cartilage transplantation, graft did not heal. Conclusion: Early assisted movement exercises of the knee with eliminated weightbearing is the main goal of successive rehabilitation protocol after autologous osteochondral grafting. Significance: IV° degree chondral surfaces defects in the knee are common findings during arthroscopic investigations. Optimalization of the rehabilitation programme leads to the effective results of the surgical treatment and finally save the knee joint from the early degeneration.

        Poster 77. Retrograde nailing for femoral fractures and its effect on knee function

        D. Suva, MD, J. Menetrey, MD, R. E. Peter, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: Retrograde femoral nailing is an efficient technique for the ORIF of distal femoral fractures. Secondary effects on the knee joint remain controversial. The aim of this prospective clinical study is to evaluate the healing of the fracture and the knee function, after distal femoral nailing with a solid titanium implant. Methods: 10 patients were enrolled in this study, age averaged 44.5 years (20-80). Fracture was supra-condylar in 5 (33A1-A3) and diaphysal in 6 patients. There were 5 cases with a floating knee and 3 femur fractures were open. Associated neck and shaft fractures were present in one patient. The nails were inserted through a medial parapatellar arthrotomy using the AO DFN system after closed reduction under fluoroscopy. Proximal and distal interlocking was routinely performed. An antegrade, unreamed tibia interlocking nail was inserted through the same incision in all floating knees. The patients were assessed at a mean follow-up of 13 (3-29) months. The function of the knee was evaluated with the Noyes and Lysholm scoring systems as well as clinical examination. Standard radiographs were obtained and posterior laxity was evaluated using dynamic axial view with PCL press. Results: Bone union of the femoral fracture was obtained primarily in all patients. Recurvatum deformities <100 were observed in 3 patients. The mean shortening of the femur was 6.2 mm (0-20 mm). In isolated femur fractures, the average Noyes and Lysholm score were 280 (124-495) and 59 (32-93). In floating knee injuries, values were respectively 245 (182-341) and 45 (33-64) (p>0.05). Eight patients complained of either significant anterior knee pain, an effusion of the knee, a stiffness of the knee or instability. Mean ROM was 137° (120-170). A mean posterior laxity of 5.3 (1-10) mm and a clinical lateral laxity were noted in 4 and in 3 patients respectively. Conclusion: DFN is an efficient alternative in the treatment of femoral shaft and supra-condylar fractures. Most of the patients presented an impaired knee function. Scores, however, appeared to be related to the severity of the initial trauma (floating knee).

        Poster 78. Studies of surgical outcome after achilles tendinopathy: Clinical significance of methodological deficiencies and guidelines for future studies

        C. Tallon, N. Maffulli, K. M. Khan, B. D. Coleman
        2001 ISAKOS Poster Abstracts
        Little is known on the long-term outcome of surgical management of overuse injuries of the Achilles tendon. We reviewed 24 articles reporting the outcome of the surgical treatment of 1492 Achilles tendon overuse injuries, with an average follow-up time of 36 months (with a mean success rate of 82%). Each article was given a methodology score of between 0 and 100 according to the 10 criteria assessed. The duplicate methodology scores were found to be highly reproducible (r=0.98, p<0.01), with a mean of 36.7. The methodology score was correlated using Pearson’s correlation coefficient (r) with the percentage success rate and year of publication to examine trends in methodology over time. There was a significant negative correlation between methodology score and reported success rate (r=0.63, p<0.05). The mean methodology scores were compared to the maximum attainable score for each of the criteria. We identified common methodological deficiencies including type of study, subject selection, diagnostic certainty and outcome assessment. We propose suggestions as to how these common methodological problems may be overcome and present guidelines for future surgical studies on this subject.

        Poster 79. Back pain in collegiate rowers

        Carol C. Teitz, MD, John W. O’Kane, MD, Bonnie K. Lind, MS
        2001 ISAKOS Poster Abstracts
        Surveys were sent to 4680 former intercollegiate rowing athletes who had graduated between 1978 and 1998 from 5 schools with strong rowing programs. 2165 surveys were returned (46%).The surveys included questions concerning back pain prior to intercollegiate rowing, during intercollegiate rowing and subsequent to graduation. For purposes of the study, back pain was described as pain that lasted at least one week. The questions addressed training methods and types of equipment both in the training room and in the boat. Coxswains were included in the overall survey but were omitted from the multivariate analyses. Subjects who had back pain before college rowing and those older than 45 were omitted from the analysis leaving 1698 subjects. Bivariate associations were assessed using t-tests and chi-squared analyses. Multivariate associations were assessed using logistic regression analysis. P<0.05 was considered significant. 526 of 1698 subjects (32%) developed back pain during intercollegiate rowing. In bivariate analysis, the factors significantly associated with back pain during college included current age, starting to row before age 16, using a hatchet type of oar, training in an indoor tank, with free weights, or with weight machines; training with an ergometer, duration of ergometer training sessions greater than 30 minutes, and position of the ergometer cable. College back pain was also associated with a higher mean college weight and height in both men and women. In multivariate analyses, type of oar and duration of ergometer sessions were significant predictors of back pain for men, whereas duration of ergometer sessions and height were significant predictors for women. Prevalence of back pain in intercollegiate rowing has increased over the last 25 years. This may reflect increased intensity of training as well as a change in type of equipment. In addition, the percentage of subjects who began rowing prior to age 16 has increased significantly in the last 10 years as has the average height and weight of female rowers. The last 10 years have produced larger rowers who start rowing at an earlier age, train more intensely, and develop more back pain during college than their predecessors. Additional analyses are under way to determine whether this back pain resolves or persists after intercollegiate rowing.

        Poster 80. Closed treatment of patellar fractures using a polyester tow instead of metal implants. Immediate restoration of active knee movements and full weight bearing

        Ioannis Valavanis, MD, PhD, Antonis Tsangalis, MD, Athanasia Kitsios, MD, Stratigoula Valavanis, MS
        2001 ISAKOS Poster Abstracts
        Objective: Evaluation and presentation of closed surgical treatment of patellar fractures using a specially designed bone reduction clamp and a newly developed polyester tow. Introduction: Fractures of the patella are usually treated surgically through an open incision, the results depending upon the stability of the fixation achieved. Sliding Osteosynthesis is a new method providing immediate post-op full weight bearing and mobilization of the knee. It can be performed either through an open incision or by a closed method with the use of a specially designed Patella Reduction Clamp. Description of the method: Reduction of bone fragments is achieved with the use of the Patella Reduction Clamp inserted through two pairs of small skin incisions, above and below the patella. Closing of the clamp results in reduction of bone fragments and alignment of intermediate parts. A Force Transmission Frame (FTF) using a polyester tow is built in between the most proximal fragment of the patella and the tibia. The FTF is inserted blindly and acts as media for the transmission of all tension forces from the site of the fracture and as guiding rails for intermediate fragments to be kept in place. Material: The method has been used for the surgical treatment of a total of 63 patients, 30 of which completed a minimum of 3 up to 6 years of follow-up (mean 4+8). Sex distribution refers to 16 male and 15 female, their age ranging from 17 to 81 years (mean 42.6). Fractures were classified as transverse (18), distally comminuted (9) and totally comminuted (4). Results: Operation time ranged from 12 to 29 minutes (mean 17). Post op hospitalization ranged from 2 to 5 days (mean 3.1). No patellectomies were performed. All patients were able to full weight bearing immediately after surgery, regained 90° of flexion and full extension of the knee joint within the first two and four post op weeks respectively and a full range of movements within a period of two months. There were no infections or pseudarthroses. Clinical examination at follow-up showed normal range of movements of the patellae with minimal, if any, signs of discomfort. Conclusions & Significance: Sliding Osteosynthesis of the Knee Extending Mechanism (SOKEM), as performed blindly with the use of the patella reduction clamp and the insertion of a strong flexible media, is a new method providing immediate restoration of the functional continuity of the extending mechanism of the knee: Allows immediate post-op full weight bearing and active mobilization of the knee joint. It can be easily performed without an open incision and there is no need for removal of implanted material. Patellectomy is avoided in all cases. Patients are able to the fastest rehabilitation regime, compared to other established methods, making it possible for them to participate in sports or labor activities the soonest possible. Hopefully it could turn out to be a “method of choice” in the treatment of such fractures.

        Poster 81. Patellar fractures: Immediate restoration of the knee extensor mechanism with the sokem technique using a polyester tow instead of metal implants

        Ioannis Valavanis, MD, PhD, Ioannis Hadjikomninos, MD, Mili Konstandinidis, MD, Stratigoula Valavanis, MS
        2001 ISAKOS Poster Abstracts
        Objective: Evaluation and presentation of the new SOKEM technique used successfully in the surgical treatment of patellar fractures for the last 10 consecutive years. Introduction: Patellectomy is a “salvage procedure” applied in cases when good reduction and/or stable osteosynthesis of patellar fractures cannot be accomplished. Sliding osteosynthesis of the knee extensor mechanism (SOKEM) restores its functional continuity with preservation of the patella so that a firm bony union can take place resulting in a fastest possible restoration of sufficient mechanical resistance against distraction forces. The fractured area is neutralized with the use of a Force Transmission Frame (FTF) put in between the proximal part of the patella and the tibial tubercle. Material: The SOKEM technique has been used for the surgical treatment of 77 cases of patellar fractures in 75 patients (48 female and 27 male). The age of patients ranged from 15 to 80 years. The 77 fractures were classified as transverse (37), distally comminuted (23) and totally comminuted (17). Results: The patella was preserved in all 77 cases, regardless of the type of fracture or the magnitude of fragmentation. The SOKEM method resulted in immediate restoration of the functional continuity of the extending mechanism of the knee, allowing full-weight bearing and active movements of the knee immediately post op. All patients regained active flexion of 90° and full extension of the knee by the end of the second post op week and full flexion of the knee within two months from the operation. The use of an absolutely bio-compatible artificial polyester tow for the formation of the Force Transmission Frame lead to a “permanent cure” since there was no need for removal of any implanted material. Follow-up ranges from 1 to 10 years. Function of the extending mechanism of the knee as well as the shape and function of the articulating areas of the patella, had been restored as proved by clinical, x-Ray and/or CT evaluation. Conclusions & Significance: Sliding Osteosynthesis of the Knee Extending Mechanism is a promising new technique for the surgical treatment of patellar fractures, results in immediate restoration of knee function succeeding, at the same time, in preservation of the patella even in cases of severe comminution. There is no need for removal of implanted material while patients are able to the fastest rehabilitation regime, compared to other established methods, making it possible for them to participate in sports or labor activities the soonest possible. Hopefully, it could become a “method of choice” in the treatment of patella fractures, especially the comminuted ones.

        Poster 82. Tendo calcaneus ruptures; immediate restoration with the new dynamic tendon gripping (DTG) suturing technique (new method)

        Ioannis Valavanis, MD, PhD, Antonis Tsangalis, MD, Lykourgos Kollintzas, MD, Stratigoula Valavanis, MS
        2001 ISAKOS Poster Abstracts
        Objective: Evaluation and presentation of the new Dynamic Tendon Gripping technique used successfully in the treatment of Tendo Calcaneus ruptures for the last 10 consecutive years. Introduction: Suturing techniques of tendo calcaneus ruptures do not result in immediate functional restoration of the ruptured tendon since sutures tend to slip through the tendon fibers making it mandatory for post operative immobilization. The Dynamic Tendon Gripping (DTG) is a new technique, developed for the surgical treatment of major tendon ruptures; it provides immediate functional restoration at the site of the rupture and full weight bearing abilities of the injured limb while the process of healing takes place. Description of the technique: The ruptured tendon is being approached through a midline posterior longitudinal incision. A polyester tow is used instead of ordinary sutures; it is of great strength and thicker than ordinary suture material so that cutting-through-the tendon phenomena are avoided. The polyester tow is interwoven around the proximal tendon stump, thus forming a dynamic net of variable gripping strength and is anchored through the os calcis. No post-operative immobilization is applied; loosening or re-rupturing probabilities are greatly reduced since distraction forces lead to an increase of the net’s gripping power. Method, Material & Results: The Dynamic Tendon Gripping technique has been used in 39 consecutive cases of tendo calcaneus ruptures. All patients but two were male with a mean age of 42+7 (min. 32, max. 78). Surgery was performed within three hours to four days from injury. Post-op hospitalization ranged from two to five days (mean 3.1 days). Patients were allowed to immediate post-op initiation of active movements while full weight bearing was encouraged as soon as tolerated. Full range of movement was restored within two months post-op. Follow-up ranged from 1.2 to 9.6 years. There were no inflammations or re-ruptures. Participation in sports (soccer, tennis, skiing, etc.) became possible within two months post-op. Conclusions: Dynamic Tendon Gripping technique has been developed after the mechanical principles of the “Chinese finger trap” so that distraction of the tow results in constriction of the net while release leads to a relevant loosening of its loops. Healing process is being accomplished without mechanical interference. Passing of the suturing material around instead of within the tendon preserves blood flow while preservation of the peritendon aids into the same principle. Patients were able to the fastest rehabilitation regime compared to other established methods, making it possible for them to participate in sports or labor activities as soon as possible. The DTG technique is a promising new method for the surgical treatment of major tendon ruptures providing excellent results with no need for any kind of post-operative immobilization. Significance: Dynamic Tendon Gripping technique proved to be a method of extreme importance for the treatment of Achilles tendon ruptures, overcoming the main disadvantage of post operative immobilization of all the well established methods. Hopefully, it could turn out to be a “method of choice.”

        Poster 83. Anterior knee pain and flexor hallucis longus impingement: A close relationship

        Jacques Vallotton, Vinciane Dobbelaere-Nicolas
        2001 ISAKOS Poster Abstracts
        Anterior knee pain (AKP) is common in athletes and a muscular dysbalance is frequently involved as an etiological factor. A flexor hallucis longus (FHL) dysfunction is rarely involved or searched. However, it can be determined during the physical exam and gait analysis. Materials and method: 50 patients with AKP were included in a prospective study and treated with the same rehabilitation protocol. FHL dysfunction was present in all cases. AKP was related to retro or peripatellar pain (100% of cases), patellar tendonitis (10%), semi-tendinosus tendonitis (40%), ilio-tibial friction syndrome (30%). Patients with patellar instability, ligament injuries or arthritis were excluded from the study. Morphotype analysis and muscular testing were performed by the authors following the same protocol. Specific attention was directed to the FHL tracking. Gait analysis was performed on the Footscan PR 4.4 platform and running on a travelling band was recorded on videotape. Results: A specific footprint pattern was observed during gait according with FHL impingement. Changes were noted after treatment and improvement of AKP occurred in all cases. Conclusion: Specific attention should be directed to the FHL in cases of AKP. FHL dysfunction is often the “primum movens” of a patellar syndrome, ITB or 1/2 T tendonitis. Specifically treated with mobilization of the subtalar joint and stretching exercises, a normal tracking of the FHL can be restored and improvement of symptoms and gait occurs in most cases.

        Poster 84. Treatment of localised avascular necrosis of the talar dome by retrograde drilling

        Edwin Van Ovost, MD, Peter Burssens, MD, PhD, René Verdonk, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: Clinical evaluation of the results of retrograde drilling of the talar dome for osteochondral lesions. Method: A series of 15 patients with documented osteochondral lesions of the talar dome were treated by arthroscopic evaluation of the chondral surface of the talus and tibia. If the chondral surface was not damaged they were treated with retrograde drilling using a cannulated 3.5 mm burr, filling the defect with autologous spongious bone from the distal tibia. Each patient had a standard rehabilitation scheme of 3 months prohibition of weight bearing using a patella tendon bearing brace. The mean follow-up is 31.5 months (range 15-59). We used the classification as proposed by Berndt and Harty (JBJS 1959, 41A;988-1020). We used the Clinical rating system for the ankle-hindfoot, midfoot, hallux and lesser toes as proposed by Kitaoka e.a. (Foot and Ankle, 1997; 187-188). Results: Two patients required arthrodesis of the ankle joint. One patient had a score of 20/100. Three patients had a mean score of 76.3/100 (range 72-85). Subjectively these patients scored themselves as good but not excellent. Nine patients were extremely satisfied with a mean score of 93.1/100 (range 82-100). Conclusion: This is a valuable therapy which we recommend for the treatment of stage one and two osteochondral lesions with good to excellent results in the majority of the cases. More severe cartilage lesions do not respond very well to this type of therapy.

        Poster 85. Avulsion fractures of the apophisis ring (“limbus”) posterior superior of the l5 vertebra, associated with pre-marginal hernia in athletes: Two cases studies

        Marcelo Wajchenberg, Eduardo Barros Puertas, Moises Cohen, Mario Neia Isoldi
        2001 ISAKOS Poster Abstracts
        The number of sport related injuries has raised with the increasing number of adolescents practicing in competitive sports. Lumbar pain is a frequent complaint among the young athletes. It is usually related to the contractors of the paravertebral musculature and fractures (spondylolysis) caused by excessive training and incorrect techniques. However, other etiologies can cause lumbar pain, Such as infectious processes, tumor and fractures. Avulsion fractures of the apophisis ring are uncommon lesions which rarely happen in the posterior superior area of the L5 vertebra. The literature shows that the most susceptible place to injuries is the posterior inferior area of the L4 vertebra. The article presents two cases of young athletes with this unusual lesion. The objective of this work is to discuss the possible etiology, the best diagnostic and treatment methods of this pathology.

        Poster 86. Early rehabilitation of athletes by hydrotherapy after surgical treatment of lumbar disc hernia: A report of three cases

        Marcelo Wajchenberg, Leonardo Pires, Reynaldo C. Rodrigues, Moises Cohen
        2001 ISAKOS Poster Abstracts
        The authors evaluated 3 male athletes submitted to surgical treatment for lumbar disc hernia, to assess the outcome of a rehabilitation protocol based on hydrotherapy. This method allowed for early rehabilitation of the athletes, who presented evidence of improvement as early as the first postoperative week. Analogic visual scales (ranging from 0 to 10) with 4 parameters were used in the assessment: Frequency of sports practice, level of sports activity, daily life activities, and pain intensity. Athletes were evaluated in the preoperative period and during four months after surgery. Mean initial pain was 83% of the maximum intensity. Pain was completely eliminated in two athletes. The third case presented, in the fourth month, 1.3% of the maximum intensity. Mean daily life activity in the preoperative period was 21.6% of the maximum intensity, reaching 99.3% in the fourth month. Mean frequency of sports practice was 10% of the intensity in the preoperative period, and in the fourth month the athletes were able to practice sports activities with a frequency of 84.6% of the normal. The level mean initial of activity sports was 10% of that established by the athletes before the symptoms arose, reaching 88.3% in the fourth month. The authors conclude that the athletes presented improvements in all parameters analyzed, specially with respect to pain, since in the fourth month 98.7% of the symptoms did improve. Therefore, hydrotherapy was found to be an effective and tolerable method in the early rehabilitation of athletes submitted to surgery for disc hernia.

        Poster 87. Injury stress of sacroiliac joint in marathon runners: Relate of 3 cases

        Marcelo Wajchenberg, Moises Cohen, Eduardo Barros Puertas, Paulo Satoro De Souza
        2001 ISAKOS Poster Abstracts
        Low back pin is common in individuals engaged in athletic sports. The related of pars arthicularis lesion is not unusual in athletes, but the stress reaction of the sacroiliac joint are considered very rare. We propose to describe three cases of marathon runners with stress reaction of the sacroiliac joint. These athletes reported back pain without sciatica, which stopped their sports practice. All this cases was studied with CT scan images, because we had limitations to detect stress lesions of the sacroiliac region with plain radiographs. This type of injury can result in abnormal stress to the lower extremities, which have a relationship with the marathon efforts. We consider these lesions an important cause of low back pain in athletes, but the sacroiliac joint dysfunction with stress reaction is largely unstudied in the medical literature. This information may be useful for clinicians who treat marathon runners and elite athletes.

        Poster 90. High tibial osteotomy – fixation with one screw

        Gilberto Luis Camanho, MD, PhD, Marco Martins Amatuzzi, MD, PhD, Arnaldo José Hernandez, MD, PhD, Márcia Uchôa de Rezende, MD, PhD, Rogerio Olivi, MD, M.Sc
        2001 ISAKOS Poster Abstracts
        Purpose: To present a method of high tibial osteotomy (HTO), dome shaped with osteotomy of the middle third of the fibula and fixation with one oblique oriented screw. Method: Thirty-one patients (26 men and 5 women), were submitted to HTO to correct the varus knee deformity. The technique consists of an anterior longitudinal incision of the knee and the exposition of the proximal third of the tibia. A dome tibial osteotomy is carried out with a delicate osteotome. Subsequently an osteotomy of the middle third of the fibula is done through a lateral incision and the correction of the deformity is achieved under fluoroscopy. This correction is fixed with a cannulated screw introduced obliquely from the laterally and proximally towards medially and distally to the osteotomy. A long leg cast was kept until healing of the osteotomy. Results: All cases maintained the correction obtained at surgery and healed in an average time of 8 weeks. In two cases, overcorrection was obtained and kept since surgery without complaints of pain or dysfunction. Conclusion: HTO, dome shaped fixed with a single oblique screw is a simple, safe and reproducible technique. Significance: This technique is of easy accomplishment with stabilization that allows the maintenance of correction obtained not putting difficulties in the way of an associated ACL reconstruction.

        Poster 91. Opening wedge high tibial osteotomy for posterior knee instability

        Annunziato Amendola, MD, Douglas Naudie, MD, Peter J. Fowler, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study was to assess the functional outcome of opening wedge high tibial osteotomy in a relatively young and active group of patients with posterior instability and malalignment rather than osteoathritis. Method: The results of 17 opening wedge osteotomies in 16 patients with posterior or posterolateral knee instability and malalignment were evaluated. Patient demographic data and surgical technique were determined from retrospective chart review. Patients were assessed for functional results, complications and other surgeries. Functional results were evaluated according to the Tegner and Lysholm activity score and with visual analogue scales evaluating change in stability and satisfaction. Full length staining anteroposterior and lateral radiographs taken pre-operatively and 1 year postoperatively were analyzed to determine changes in femorotibial axis alignment, tibial slope and patellar height. Results: The mean patient age was 27 years (14-41). Mean follow-up time was 39 months (24-83). There was an average increase of 1.6 points in the postoperative Tegner Lysholm activity score with an improvement in activity in 15 of 17 patients. Subjectively, 16 of 17 patients felt that their knee stability had improved. Four patients underwent delayed posterior cruciate ligament reconstruction; 2 required hardware removal; 2 underwent revision of a displaced tibial tubercle osteotomy. Sixteen of the 17 patients were satisfied with the surgery and would have it again in the same circumstances. Change in alignment averaged 6°, change in posterior tibial slope averaged 8° and patellar height ratio was decreased an average of 0.17. Discussion and Significance: The results of this review suggest that opening wedge high tibial osteotomy can produce good functional and radiographic results in selected patients with chronic posterior or posterolateral knee instability and malalignment.

        Poster 92. Comparison of medial parapatellar and midvastus approach for total knee arthroplasty – patient comfort and function of the knee

        John R. Ashwell, MBBS, FRACS (a – Northern Rivers Institute of Health & Research), David Liu, MBBS
        2001 ISAKOS Poster Abstracts
        Objective: To compare two popular approaches to the knee joint for total knee replacement with regard to patient comfort and return of knee function. Method: A randomly selected prospective trial in which 66 consecutive patients underwent either a medial parapatellar or midvastus approach for knee replacement. All patients received the same type of knee prosthesis with surgery under the guidance of the same surgeon. A comparison was made of operative time, number of soft tissue releases, days to reach 60 degrees and 80 degrees of flexion, time to achieve straight leg raise and time to discharge. A subgroup of 34 patients who had the same type of anaesthesia (spinal and femoral nerve block) and used the same type of post-op analgesia, were compared for pain in the first 48 hours following surgery. Results: A one way analysis of variance techniques was used to compare numerical parameters and chi-square analysis for categorical data. The two groups were similar for age, weight, gender and diagnosis. The midvastus approach was shown to be significantly better at earlier straight leg raising but demonstrated only an indication of improvement with other parameters such as operation time, and days to reaching 80 degrees. Conclusion: This trial has shown that the midvastus approach for knee arthroplasty allows an earlier ability to straight leg raise postoperatively. It also showed a trend towards improvement in the operative time, and earlier recovery of movement when compared with the medial parapatellar approach.

        Poster 93. Allograft-prosthesis composite & extracortical bone bridging

        Muharrem Babacan, Tahir Ogut, Tahsin Beyzadeoglu
        2001 ISAKOS Poster Abstracts
        In applying total knee arthroplasty in tumour surgery there have been many different kinds of problems occurring while providing reconstruction after soft tissue and bone resection procedures . Wide resection loads extreme stress upon prosthesis and bone. Local stress that occurs at the fixation point of prosthesis upon the bone strains the mechanical limits of the implant and stability. The bone fixation place of prosthesis is usually the diaphyseal part of the bone. As this part of bone is smooth and flat, not spongious in structure, stabilization with cement is not effective with itself alone. Early breakage and loosening of prosthesis usually takes place at this part. Many different techniques and searches are investigated to decrease the stress in this area even to supply the physiological dimension limits. In stabilizating the implant to the bone with cement porotic part of bone is supported with bone allografts , that is extracortical bone bridging. Over 4 years we have been trying to create extracortical bone bridging at the contact area of prosthesis and bone in order to provide reconstruction of the defect after tumour resections. In 22 patients this procedure is applied.2 of them are ewing sarcoma, 6 have osteosarcoma at the distal femur, 4 have giant cell tumour at the distal femur, 2 have paraosteal osteosarcoma, and 8 have different kinds of malign bone turnours. Average follow-up period is 3 years.

        Poster 94. Comparing TMTS with “kinematic rotating hinge” prosthesis

        Muharrem Babacan, Rifat Erginer, Mustafa Hakan Ozdemir
        2001 ISAKOS Poster Abstracts
        In applying total knee arthroplasty modular segmental replacement system has many different specialties to prolong the survival time of knee prosthesis. The hinge part of prosthesis that is capable of doing kinematic rotation provides the stability and decreases the stress involving stem to a great degree. It is used widely all over the world since 1981. Generally loosening of prosthesis and insufficiency in prosthesis are seen at the stem of prosthesis. Mechanical stability is absolutely needed in tumour resection procedures in knee as the whole soft tissue that provides stability are all extracted. The hinge part of prosthesis provides stability and rotating part allows rotation in a great manner. This finally decreases the stress upon the stem. When we consider the first and normal hinge prosthesis (TMTS), the stress in cemented part of bone decreases into a great degree in kinematic rotating hinge prosthesis. Therefore, loosening and breakage of this part is seen more rarely. Our first prosthesis applications are fixed hinge prosthesis such as Stanmoore, Kotz and TMTS. We have usually observed stem fracture and loosening in these prosthesis. To avoid this complication, we have started to use hinge prosthesis allowing rotation for 3 years. We have applied this kind of prosthesis in 6 patients, who had benign or malign tumour at distal part of femur. The patients are followed averagely for 2 years. Out of 6, 2 have osteosarcoma at the distal part of femur, 2 have giant cell tumour at the distal part of femur, 1 has fibrosarcoma and 1 has a loosening of total knee arthroplasty. We compare the results of both two kinds of prosthesis.

        Poster 95. Distal external femoral rotation in osteoarthritic knees: A CT-scan study

        Philippe Boisrenoult, Patrice Scemama, Laure Fallet, Philippe Beaufils
        2001 ISAKOS Poster Abstracts
        Introduction: Femoral component rotational malalignment in total knee arthroplasty (TKA) may lead to many complications ranging from posteromedial alterations of the tibial insert to patellofemoral complications. Femoral component rotational alignment is directly linked to the distal femoral rotation (DFR), which is difficult to assess during surgery whatever the method. The aim of this prospective study was to measure DFR by CT scan and to find a correlation between DFR and X-ray measures. Material and Methods: Thirty-eight patients with varus osteoarthritic knee deformity were evaluated preoperatively (75 knees). The mean age was 70.4 years (39-87). There was 13 men and 25 women. HKS, HKA and epiphysis varus angles (EVA) were measured on X-ray. DFR was defined as the angle between the bicondylar posterior line and the epicondylar line. DFR and X-ray measures were compared by a Pearson’s correlation test, and a Student t-test to study the relation between DFR and sex or affected side. Results: Mean DFR was 5.36° (SD 1.87) ranging from 0° to 9°. No statically significant correlation was noted with sex, affected side, HKS or EVA. HKA angle proved a significant correlation but could not allow a clinical application. Conclusion: Our results confirmed the large variability of individual DFR and showed the absence of an indirect method to assess DFR preoperatively. Significance: DFR is an important but very variable parameter in TKA planification. Our findings suggest that DFR should be measured by CT scan before performing TKA.

        Poster 96. Analysis of radiolucent lines in uncemented mobile bearing TKA. A study of 567 cases with 2-15 year follow-up

        Jens Boldt, MBBS, Teroyuki Kashiwagi, MD, Peter Keblish, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To investigate cementless fixation and clinical results of 567 consecutive mobile bearing Low Contact Stress (LCS) cementless total knee arthroplasties (TKA). Method: 567 of 709 cases with 2 to 15 year follow-up (mean: 5.7) entered the study. The same femoral design and two different tibial designs with full porous coating were utilized. Results: 94% of the cases had excellent or good clinical results. Radiolucent Lines (RLL) analysis in 16 zones revealed less than 2 mm RLL in 563 cases (99.4%). There were no RLL larger than 2 mm seen in any of the 165 resurfaced patellae and in less than 1% of the femoral components. Four (0.6%) tibial components revealed 2 mm RLL in more than two zones at the bone-component interface and had to be revised for fixation failure. Three (6.8%) failures occurred in the three-fin design group and one (0.2%) in the cone design group. RLL of less than 2 mm were classified in stable, unchanged or improved, and appear to represent natural bone remodeling over time. Isolated RLL in one or two zones (usually peripheral) were noted in a small number of cases and were technique related and/or inconsequential. Conclusion: Cementless fixation with the mobile bearing LCS tibial component (tapered cone) is highly successful with over 99% survivorship. The three-fin design (ACL/PCL retaining) represented the majority of failures, where 3 of 44 (6.8%) cases required revision surgery. This component is not generally recommended for cementless fixation. Significance: RLL zonal analysis is an accepted method of evaluating fixation in TKA.

        Poster 97. Arthrofibrosis in TKA. Influence of femoral component rotational alignment

        Jens Boldt, MBBS, Jose Romero, MD, Jochen Hodler, MD, Urs Munzinger, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To analyze the relationship of arthrofibrosis (AF) and rotational mal-alignment of the femoral component in TKA. Method: Arthrofibrosis is a complex and ill-defined entity that may occur after any kind of knee surgery or injury. Arthrofibrosis can lead to impaired range of motion of the knee joint and further invasive management. From 2811 mobile bearing TKA 21 (0.9%) cases with AF were analyzed and compared with two control groups of 10 cases each (average and excellent TKA with clinical follow-up). The majority of AF cases required surgical intervention including both arthroscopic and open debridement and synovectomy. All AF cases underwent radiographic and CT investigations, aspiration of synovial fluid, duplex sonography, and histopathological investigation of fibrotic synovial tissue. Results: There has been an increased incidence of femoral component rotational mal-alignment (CT) and/or tibial mal-alignment (X-rays) in the AF group compared with the control groups. Most cases with AF revealed increased internal rotation of the femoral component taking the transepicondylar axis as reference point. Conclusion: There appears to be a correlation between the presence of AF and rotational mal-alignment of the femoral component in TKA. Computer assisted navigation instruments will contribute to improved alignment measures in the future. Significance: The results emphasize and stress the importance of meticulous implantation of all TKA components, especially femoral rotation. Correct implanted TKA components appear to reduce the incidence of arthrofibrosis in TKA.

        Poster 98. Results of revision TKA: About a series of 69 cases

        M. Bonnin, G. Deschamps, P. Neyret, P. Chambat
        2001 ISAKOS Poster Abstracts
        Purpose of the study: To analyze the results of revision TKA performed for aseptic failure. Material and method: 69 revision TKA were performed between 1990 and 1997 for mechanical failure. It was 30 aseptic loosening (L), 14 instability (I), 11 stiffness (S), 6 patello femoral complications (PF) and 8 unexplained pain (P). We used 56 postero stabilized and 13 hinged TKA. 59 patients were available for clinical exam and X-rays with a mean delay of 37 months. Results: 12 patients (17%) had complications: 4 infections (treated with 2 arthrodesis and 2 hinged TKA), 2 decease in postoperative period, 4 persistent pain needing new revision, 1 tibio femoral dislocation treated by open reduction and 1 stiffness treated surgically. The mean IKS score at follow-up was 72.5+-17 for “knee” and 59+-30 for “function.” The scores in the different groups are mentioned in the table. The mean knee score was 66.9+-17 for PS TKA, 83+-8 for hinged TKA (p=0.002) and 77.3+-18 when an osteotomy of the anterior tuberosity was performed (14 cases, P<0.5).
        Tabled 1
        IKSLISPFP
        Knee score75±772±975±1759±2035±16
        Function score57±1563±1568±1646±3652±21
        Mobility degree101±1897±1373±40106±1576±17
        Pain (on 40)33±1128±839±1322±515±10
        Conclusion: Revision TKA is a difficult procedure with a high rate of complication. The prognosis is mainly influenced by the etiology of the failure. We do not recommend revision of an unexplained painful TKA.

        Poster 99. The long-term results of unicompartmental knee arthroplasty

        Klaus Buckup, MD, Jörg Runge, MD, Bernd-Dietrich Katthagen, Prof
        2001 ISAKOS Poster Abstracts
        90 patients have been treated by a medial unicompartmental arthroplasty for degenerative osteoarthritis 1984 in our hospital. All components were cemented. Non metal backed tibial components were used. Forty-seven knees were available for follow-up examination that was performed 10.8 to 12.7 years postoperatively (mean, 11.5 years). The patients were examined clinically and by x-ray with regard to pain, walk distance, correction of the leg axis, range of motion and loosening of the components. In addition they were also examined with regard to perioperative complications and revision rate. The revision rate was 14.9% for a septic loosening. Five patients required a revision of the unicompartmental arthroplasty, one patient a “uni” on the lateral side of the same knee and another one a total knee prosthesis. We feel that our results indicate unicompartmental arthroplasty being an appropriate procedure for medial osteoarthritis of the knee. Important factors are adequate bone stock, thickness of polyethylene and alignment without overcorrection.

        Poster 100. Autologous posterior condyle transfer: Clinical and biomechanical results

        Andreas Burkart, (a – Orto Maquet GmbH), Andreas Imhoff, Ulrich Schreiber, Florian Dinsamer
        2001 ISAKOS Poster Abstracts
        Introduction: We examined the biomechanical and clinical effects after the autologous posterior condyle transfer for treating great osteochondral defects. Methods: In 8 knee specimens we performed pressure measurements using pressure-sensitive film before and after resecting the medial posterior femoral condyle (PCT). In 2 specimens we performed a high tibial osteotomy (HTO) because of a varus morphotype. The quadriceps force was simulated with hanging weights. Between 7/1996 and 8/1999 we performed 12 autologous posterior condyle transfers in 12 patients ranging in age from 21 to 43 (mean age, 31.2 years). The cartilage defects averaged 9.1 cm2 (range 6 cm2 to 20 cm2). The follow-up was at an average of 24 months (range 12-43 months). Results: In all of the specimens the contact area decreased in the side of the PCT, beginning at 30° of flexion (27% decrease) and most remarkably at 60° (48% decrease). In the lateral compartment there was virtually no change. After performing an HTO and PCT, the contact area in the medial compartment decreased at 30° to 46%, in 60° to 74%. In all specimens we noted an increase of pressure in the medial compartment at the edge of the posterior condyle after PCT. The Lysholm score improved from 36.9 (range 12-57) points preoperatively to 90.1 (range 59-100) points one year postoperatively. In the MRI all transferred condyles were incorporated, the cartilage was restored. Conclusion: Despite the reduction of the contact area in 30° and 60° of flexion, we couldn’t observe any worsening clinically. According to our biomechanical results in a varus morphotype one should perform an HTO.

        Poster 101. Total knee replacement arthroplasty in rheumatoid arthritis – mid-term follow-up

        Hyun-Kee Chung, MD, Chung-Hyeok Choi, MD, Young-Joon Choi, MD, Jong-Heon Kim, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the mid-term results of clinical, radiological and patient satisfaction degree of the total knee replacement arthroplasty in rheumatoid arthritic patients retrospectively. Materials and Methods: Between Oct. 1989 and May 1995, 184 total knee replacement arthroplasties were performed in 109 patients with rheumatoid arthritis. Of these, 21 patients (39 knees) were lost to follow-up, so 145 knees in 88 patients were available for the follow-up evaluation at a mean 8.2 years (5-10.3 yrs.). There were 83 women, 5 men. The age at the operation ranged from 23 to 71 years old (average 49.1 years). The American Knee Society clinical rating system and roentgenographic evaluation scoring system were used for the assessment of the results. We used fluoroscopic guided roentgenogram for the accurate radiolucency score. Results: The flexion contracture was corrected 29.1° preoperatively to 4.9° postoperatively. The R.O.M. was improved average of 93.2° preoperatively to 116.0° at the final follow-up. The knee score and the functional score were increased from a mean of 37.7 and 7.3 preoperatively to 90.8 and 85.6 at the final examination respectively. The radiolucency score was average 1.32 (1-9) point on roentgenographic evaluation. There were 4 complication: 1 delayed infection, 1 subsidence and loosening of tibial component, 1 supracondylar fracture and 1 patella clunk syndrome. Conclusion: In rheumatoid arthritis patients with severe pain, deformity and limitation of motion, the total knee replacement arthroplasty offered good results of relieve pain, increase range of motion, restore the function and patients’ good satisfaction with few complications in minimum 5 years follow-up.

        Poster 102. Retrospective study on surgical treatment of lateral meniscal cysts

        Patrick Djian, Frederic Bussiere, Pascal Christel
        2001 ISAKOS Poster Abstracts
        A retrospective study of factors influencing the clinical results of the surgical treatment of lateral meniscal cysts & the incidence of radiological lesions in the long term. From 1969-1988, 42 patents underwent arthroscopy in 23 cases & arthrotomy in 19 cases. Among the arthroscopy for the excision of the lateral cyst, 8 undergoing a complementary extraarticular approach. There were no traumatic antecedents in 25 cases; 7 had sprains; 4 had a simple cyst puncture & 3 had a previous partial external meniscectomy. A horizontal tear in the lateral meniscus was the most frequent lesion (64% of 27). The anterior horn of the meniscus was involved in 21 cases, the medium part in 34 cases and the posterior horn in 5 cases. There was no bilateral lesions. All the patients had X-Rays and arthrography or MRI before the intervention. The mean follow-up was 130 months (24-370 m) with 13 lost to follow-up. Results: Twenty-four patents were re-examined after 10 years and were evaluated using the IKDC and radiology; 5 patients responded to a telephone questionnaire. 12 patients had a follow-up over 8 years. According to the IKDC, 26 (89%) of patients were satisfied or very satisfied (16a, 10b, 2c, 1d). No clinical factors (sex, side, type of sport, traumatism, initial lKDC score) had significant influence on the functional result. For X-Rays, the external compartment was normal in 7 cases (29.2%); articular relief in 3 cases; a narrowing of <50% in 8 patients & >50% in 6: Corresponding to a 58.3% prevalence of arthritic lesions after 10 years. There was a 54% difference in prevalence between the two knees, with the incidence of arthritis being 50%. Conclusion: There is a correlation between the presence of cartilaginous lesions post-operatively & arthritic signs after longer follow-up (p=0.019). Total meniscectomy has influenced the return of arthritis (p<0.01). The functional & subjective results are satisfactory (79% & 89% good & excellent results), but there is no correlation between clinical results and radiology.

        Poster 103. A complication after high tibial osteotomy: Patella baja, a retrospective study

        Mehmet Rifat Erginer, MD, Aksel Seyahi, MD, Tahsin Beyzadeoglu, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To investigate the incidence of patella baja in patients treated with HTO for varus gonarthrosis. Method: Between 1990 and 2000 116 knees of 98 patients underwent HTO. The same author performed all of the procedures. Three staples were used for internal fixation in most cases. Early continuous passive motion was begun immediately. Clinical and radiological details have been evaluated retrospectively for 85 knees of 70 patients. The average follow-up was 73 months. The preoperative and postoperative Insall-Salvati index (ISI) and Blackburne-Peel index (BPI) and HSS, Hokkaido and Lysholm knee scores were used for radiological and clinic evaluation. Results: The average ISI was 1.055 and BPI 0.805 preoperatively and 0.986 and 0.763 postoperatively, respectively. Two cases had patella baja postoperatively with ISI 0.72 and 0.79. One patella baja had been detected according to BPI (0.51). Two Patella alta were also detected during measurements. In all of the other cases the two indexes were in normal ranges. The Student’s t test was used to compare the changes in patellar height between preoperative and postoperative measurements and the difference was statistically significant for two indexes (ISI: P<0.001) and (BPI: P<0.01). In the clinical evaluation the average HSS score increased from 51.25 to 82.64, Hokkaido score from 50.2 to 80.74 and Lysholm score from 51.04 to 83.39. Conclusion: In our series of middle to long terms follow-up although average patellar height lowered patella baja was rare. The decrease in the average height of the patella had no appreciable effect on the clinical results of the osteotomy.

        Poster 104. The vastus lateralis snip for exposure of the lateral compartment of the knee

        John A.L. Hart
        2001 ISAKOS Poster Abstracts
        Purpose: Joint resurfacing in the knee such as autologous chondrocyte implantation (ACI) has created new challenges in gaining access to affected areas. An approach has been developed to gain access to the posterior aspects of the lateral femoral and tibial condyles. TECHNIQUE:
        • 1.
          The patient is positioned supine on a clear top table with image intensifier available.
        • 2.
          The operation is performed under a high thigh tourniquet.
        • 3.
          Universal lateral incision (Müller, W.: The Knee. Springer-Verlag, Berlin. 1983:166).
        • 4.
          Incision of tensor fascia lata and lateral capsule distally to Gerde’s tubercule.
        • 5.
          Oblique division of the vastus lateralis tendon just distal to the musculotendinous junction allows, medial subluxation or dislocation of the patella.
        • 6.
          Flexion of the knee exposes the lateral femoral condyle.
        • 7.
          The figure of 4 position exposes the lateral tibial condyle.
        • 8.
          In very posterior tibial lesions, detachment of the anterior horn of the lateral meniscus may be necessary.
        • 9.
          All structures are repaired anatomically.
        • 10.
          If biomechanical correction is required to unload the lateral compartment, an opening wedge supracondylar osteotomy using a toothed plate can be performed through the same incision.
        This approach has been used successfully to suture periosteal flaps to lesions on the posterior aspect of the femur and the tibia. The approach is also useful when a combined intra-articular and lateral approach is required for other procedures such as supracondylar femoral fractures.

        Poster 105. Unicomipartmental knee arthroplasty with dependent cut technique

        Kensaku Hashiba, MD, Katsuhiko Kitaoka, MD, Kotaro Yamakado, MD, Ryuichi Nakamura, MD
        2001 ISAKOS Poster Abstracts
        Objective: To introduce a method for unicompartmental knee arthroplasty (UKA) adopting the concept of the dependent cut technique. Surgical technique & subjects: We take Miller-Galante UKA prosthesis (Zimmer Inc.) and use custom-made spacers; each spacer is increased 7mm as thickness of femoral components. The first step consists of pre-cutting of the distal femur. Pre-cutting is minimal so as to fix the osteotomy jig to the distal femur. After pre-cutting, osteotomy of the posterior aspect of the femur is performed. The posterior femur is cut to a depth of 7mm to match the thickness of femoral component. The second step involves measurement of the joint gap in 0 and 90 degrees of flexion with custom-made spacers. Ordinarily, the spacer selected in 90 degrees of flexion is thicker than that in 0 degrees, then the amount of bone to be cut from the distal femur is decided. Finally, osteotomy of the distal femur and posterior chamfer is performed. Since 1998, we have performed UKA on eight knees with this technique. There were two men and six women with an average age of 70 years. All patients were resurfaced medial compartments. The average follow-up was 15 months. Results & conclusion: All patients had excellent results at the time of follow-up about knee score and alignment. UKA contains an inherent problem because it specifies changing the alignment of the lower extremity while maintaining ligamentous balance in spite of that the component itself does not have stability as seen in total knee arthroplasty. We have offered one solution for this problem here.

        Poster 106. Plain radiographic, CT and MR imaging after autologous osteochondral transfer in the knee

        W. C.J. Huysse, K. L. Verstraete, MD, PhD, D. DeClercq, MD, M. Rousseaux, MD
        2001 ISAKOS Poster Abstracts
        Objective: To determine the spectrum of imaging findings of AOT on plain radiography, CT and MRI. Methods: Twenty-eight patients were examined with plain radiography, CT-scan and MRI, six to thirty-six months after arthroscopic repair of focal chondral defects with osteochondral plugs, transferred from non-weight-bearing donor areas in the same knee. Results: On plain radiographs 43% of the 46 grafts were detected at the acceptor site. Donor sites were identified in 50%. CT and MRI showed 96% of all acceptor areas. Size and alignment were assessed. Cortical alignment was perfect in 39% of the grafts, 37% showed depression, 16% elevation and 8% were irregular. The chondral alignment was perfect in 79%. 21% showed slight depression. The incorporation of the osseous component was complete in 47%, 16% had small cysts and 37% had larger trabecular defects. Donor sites showed no (25%) or limited (73%) reossification. Cavities were filled with bone marrow or fluid. Sometimes scar tissue or fibrocartilage was visible. 3 donor areas showed complete reossification. Other findings were metallic artifacts, bone marrow edema and loose bodies. Conclusion: After AOT, cartilage is adequately evaluated on MRI. Osseous incorporation and loose bodies are best seen on CT. Plain radiographs are of no value.

        Poster 107. New advances in computer and robot assisted total knee replacement

        Francesco Iacono, M. Marcacci, L. Nofrini, A. Malvisi, S. Zaffagnini
        2001 ISAKOS Poster Abstracts
        Purpose: Computer assisted procedure consisting of three steps: A detailed computerized preoperative planning based on CT images, an intraoperative registration phase and a robot-assisted bone resection. Material: Identification of the limb mechanical axis in the CT images of the patient, and assessment of prosthesis size and placement. Fixation of the femur and the tibia with Orthofix long and short arms, acquisition of anatomy with a digitizer and registration between the CT model and the intraoperative set of points, based on ICP algorithm. The resections are performed using a milling machine, held by the system in the correct position. Results: Tests done using the system on 10 patients by 3 surgeons showed an accuracy of automatic values during planning of 0.6 mm, with repeatability of 2 mm/1°. The registration showed accuracy of <2.5 mm/2° and repeatability of 2 mm/2°. Cutting evaluation showed accuracy of positioning and orientation of <1 mm/2° and resection roughness of 0.245 mm. Conclusion: The average difference between the planned implant and the one realised with the robot-assisted technique is less than 2 mm/2°. Benefits of this new methodology are the improved accuracy of resection and implant and the reduced risk of intraoperative mistakes.

        Poster 108. Tendon excursion and moment arm of the knee extensors in preoperative and TKA operated limb

        Masao Ishimura, MD, Naohide Tomita, MD, PhD, Takashi Habata, MD, Vince Kish
        2001 ISAKOS Poster Abstracts
        Purpose: “To clarify the differences in the knee extensors tendon excursion and moment arm between preoperative and TKA operated knee.” Method: The TKA systems used were our original model and one of the features is deep facies patellaris in the femoral component. Five fresh frozen cadaveric limbs were used for this study. A special apparatus enabled to continuously measure the knee flexion angles and quadriceps tendon excursions at the same time. An average of four measurements in each subject was used for the analysis. Instantaneous tendon moment arms were calculated according to radian concept. Results: The quadriceps tendon excursion of postoperative knee was apparently smaller than that of preoperative knee throughout every flexion angles of the knee. The excursion during 100 degrees of knee flexion in the preoperative limb was same as that during 120 degrees of knee flexion in the postoperative limb. The instantaneous moment arms of the postoperative knee were smaller at every knee flexion angles below 80 degrees and larger at every knee flexion angles over 90 degrees than those of preoperative knee. Conclusion: The elongation rate of the knee extensors in the TKA operated limb was smaller than that in the preoperative knee. The decrease rate of the knee extensors moment arm in the postoperative limb was less than 20%. Significance: Our original TKA systems may supply convenient floor life for most patients with severe osteoarthritic knee.

        Poster 109. Computer-assisted total knee prosthesis implantation

        Jean-Yves Jenny, MD (a – Aesculap, Tuttlingen (FRG)), Cyril Boeri, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Computer-assisted total knee prosthesis implantation should ensure a higher technical quality in comparison with classical, surgeon-controlled instrumentation. Methods: The authors have implanted 30 total knee prostheses with a computer-assisted instrumentation (Orthopilot®, Aesculap, Tuttlingen - Group A), and compared the quality of implantation with a control group of 30 total knee prostheses of the same type implanted with a classical, surgeon-controlled instrumentation (Group B). Control group was selected out of a previous series of 200 cases and matched to the study group with respect to age, gender, body mass index and preoperative radiological frontal deformation. X-rays were studied according to the Knee Society Radiological Scoring System. Results: An optimal mechanical femorotibial angulation (3° of valgus to 3° of varus) was obtained by 85% of the patients in group A and 72% of the patients in group B (p > 0.05). Same differences were seen in the frontal and coronal orientation for both tibial or femoral prosthesis. 62% of the patients in group A and 30% of the patients in group B had an optimal prosthesis implantation for all studied criteria (p < 0.01). Conclusion: Computer-assisted implantation is more accurate and reproducible than classical surgeon-controlled implantation. Long-term outcome of such implanted prostheses could be improved.

        Poster 110. Routine postoperative drainage after total knee prosthesis implantation is not necessary

        Jean-Yves Jenny, MD (a – Aesculap, Tuttlingen (FRG)), Cyril Boeri, MD, Sébastien Lafare, MD
        2001 ISAKOS Poster Abstracts
        Purpose: There is little support to routine postoperative drainage after knee prosthesis implantation. The authors performed a prospective randomized clinical study to assess the respective complication rates after total knee prosthesis implantation with or without postoperative drainage. Methods: 60 consecutive patients were operated on for primary gonarthrosis. Implantation was performed with tourniquet release before wound closure. Each patient was randomly allocated to drainage or no drainage postoperative course. Postoperative hospital stay was considered as the main criteria, as it is a combination of all possible postoperative events. Clinical follow-up measurements included serial visual analogic pain, wound healing evaluation, range of knee motion and knee circumference. Biologic follow-up measurements included serial hemoglobin concentration and hemotacrit level. Complications such as homologous blood transfusions, wound healing problems or revision surgery were recorded. Data were compared with a Student t-test with a 0.05 level of significance and a power of 0.80 to detect a minimal difference of 2 days of postoperative stay. Results: All patients were followed up to the third postoperative month. Mean postoperative stay duration was 9.5 days in patients with drainage and 9.2 days in patients without drainage. There was no significant difference in the other recorded data for the drained or not drained patients. Conclusion: Routine drainage after total knee prosthesis implantation brings no benefit in all studied criteria, but higher costs. The authors advocate no routine drainage after knee prosthesis implantation.

        Poster 111. Arthroscopic knee arthroplasty with AF flowable polymer – a technical possibility

        Uffe Jorgensen, MD, Lars Engebretsen, MD, Torbjorn Grontved, MD, Grethe Hortemo, MD, William Arnold, MD, Gve Fasting, MD
        2001 ISAKOS Poster Abstracts
        Purpose: 1. To develop a technique for arthroscopic restoration of the medial tibial plateau with a floatable polymer in patients with osteoarthritis. 2. To test the effect on pain and function. Method: After development of a floatable polymer and animal testing 12 patients, who were on a waiting list for total knee replacement, were offered to participate in this ethically approved project. A standardised method for alignment and calculation of the degree of correction of these 12 varus knees were performed by application of a flowable polymer after debridement of the knee. The polymer was placed in the medial chamber on the tibial plateau. After one minute the knee was extended and the patient had a brace until next day, whereafter weight bearing was allowed. Results: A significant relief of pain was observed in all patients (WOMAC). All had significant improvement in knee society score, and all had significant increase in activity level (WOMAC). After mean 6 months the results decreased with swelling and an increase in pain, a decrease in activity level and within one year 6 of the 12 patients had a total knee reconstruction. Conclusion: Arthroscopic restoration of the medial tibial plateau is possible with flowable polymer. Possible explanation for later problems could be the quality of the polymer, wear particle reaction, and mechanical dysfunction. The chosen patient population was already candidates for total knee replacements and a natural course with increase in the degenerative changes in the lateral and the patella femoral compartment could also explain the return of symptoms. Next step is to test the procedure in patients with unicompartmental disease.

        Poster 112. Bursae around the osteoarthritic knee: MR imaging

        Tamiko Kamimura, MD, Yoshiaki Ishii, MD, Kunihiko Andoh, MD, Akihiro Kotani, MD, Takeo Korenaga, MD
        2001 ISAKOS Poster Abstracts
        Objective: We observed the distribution and frequency of bursae around the 84 osteoarthritic knees of 7 patients (mean age, 66.2 years), who had clinical symptoms of the medial compartment of the knee, to establish their Magnetic Resonance findings and examine the relationship between osteoarthritis and the distribution and frequency in bursae. Methods: MR imaging for osteoarthritic knee was performed prospectively in 84 knees in 74 patients in our hospital. The patients had clinical symptoms in the medial compartment of the knee as medial joint pain, and the medial joint space narrowing, subchondral sclerosis of the medial compartment and development of osteophytes on X-rays. None of the patients had surgical treatment. The patients’ ages ranged from 40 to 86 (mean, 66.2 years). There were 31 knees in 27 males and 53 knees in 47 females, consisting of 34 right and 50 left. All patients were examined with a 0.3-T magnetic resonance imager using a permanent magnet with an imaging protocol consisting of coronal and saggital T1- and T2-weighted Spin Echo sequences with a slice thickness of 4.0 mm, and sagittal STIR with 5.0 mm slices. Results: One to 4 bursae in 74 of the 84 knees were observed (88.1%). No knees were found with more than 5 bursae. There was no relation between the numbers of bursae and patients’ ages. The distribution and frequency of bursae were as follows: Deep infrapatellar bursa was found most frequently, in 61 knees (72.6%); tibial collateral ligament bursa was found in 21 knees (25.0%); bursa under the gastrocunemius medial head was found in 18 knees (21.4%); gastrocunemio-semimenbranosus bursa was found in 11 knees (13.1%); bursa under the gastrocunemius lateral head was found in 9 knees (10.7%); pes anserine bursa was in 7 knees (8.3%); and protrusion of the posterior capsule was found in 6 knees (7.1%). Conclusions: Bursae were found with high frequency in osteoarthritic knees (88.1%), and the main distribution was divided into two resions, distal insertion of patellar tendon and posteromedial (88.7%). It is concluded that deep infrapatellar bursa and bursae in posteromedial region may be related to a pathological condition such as inflammation in the knee joint and varus deformity caused by a shifted anatomical axis in osteoarthritic knee.

        Poster 113. Recovery of muscle strength after high tibial osteotomy with percutaneous drillings

        Tateo Kawazoe, MD, Toshiaki Takahashi, MD, Hiroshi Yamamoto, MD
        2001 ISAKOS Poster Abstracts
        Purpose: There are only a few reports of muscle strength measurements after a high tibial osteotomy (HTO) for patients with osteoarthritis of the knee. In this study, to assess muscle strength after HTO with percutaneous drillings, we prospectively evaluated isometric and isokinetic muscle torque of the thigh before and after the operation over time. Materials and Methods: We evaluated 24 joints of 23 patients with a mean age of 66 years. The mean varus deformity was 4.1 degrees, the mean preoperative range of motion was 119 degrees preoperatively. All operation was performed with the dome-shaped HTO using multiple percutaneous drillings. The mean valgus angle was 12.2 degrees and the mean ROM was 129 degrees postoperatively. We measured the isometric muscle torque at 50, 80 degrees of flexion and isokinetic muscle torque at an angular velocity of 30 and 90 degrees per second. Measurement were taken before and 3, 6, 12, and 18 months after the operation. The muscle torque/weight after the operation was evaluated in relation to the preoperative torque. Results: The muscle strength at extension after 3 months tended to decrease. However, there was no significant difference between before and after 6 months. There was no significant difference with age of patients in the recovery of muscle strength. In a comparison of the groups with varus angles greater or less than 5 degrees before the operation, there was no significant difference in muscle strength at any degree of flexion. However, in extension, the group with a varus angle at 5 degrees or more decreased in isometric torque and isokinetic torque postoperatively. In both flexion and extension, the recovery in muscle torque of the group with adequate correction was greater than that of the group with undercorrection. Conclusion and Significance: Postoperative alignment of the leg strongly affected the recovery of muscle strength. It is important to ensure an appropriate correction angle for obtaining good recovery of muscle strength.

        Poster 114. Popliteus tendon release in total knee arthroplasty of the varus knee

        Katsuhiko Kitaoka, MD, Kensaku Hashiba, MD, Kotaro Yamakado, MD, Ryuichi Nakamura, MD
        2001 ISAKOS Poster Abstracts
        Popliteus tendon (PT) release is generally required in total knee arthroplasty (TKA) of the valgus knee. However, we have encountered some patients with varus deformity required PT release to correct ligament balance in flexion with spacer in place. The purpose of this study was to examine what kind of varus knee required PT release in TKA. Between March 1994 and August 1997, 20 patients (25 knees) had varus deformity (over 8 degrees) and were corrected with TKA. All knees were implanted using the Maxim knee system (Biomet, Inc., Warsaw, IN). Twelve knees (Group A) required no PT release and had correct ligament balance in flexion and extension. Thirteen knees (Group B) were laterally tight in flexion after medial release and were corrected by PT release. These two groups were compared as to femorotibial angle (FTA), flexion contracture (over 10 degrees) and lateral deviation of the tibia (over 5mm) before surgery. Preoperative FTA did not differ significantly between Group A (average 185.2 degrees) and Group B (average 187.9 degrees). Preoperative flexion contracture (over 10 degrees) was observed more frequently in Group B (61.5%) than in Group A (25.0%), but this difference was not statistically significant. Lateral deviation of the tibia (over 5mm) was found in 8 of the 13 knees (61.5%) from Group B, while it was not found in any knee from Group A. The prevalence of this deviation differed significantly between the two groups (P<0.01). In this study it was considered that PT release is required for some patients with varus deformity and lateral deviation of the tibia.

        Poster 115. Short term evaluation of tibial and femoral opening wedge osteotomies using puddu osteotomy plates

        P. J.C. Kapitein, T. V.S. Klos, J. H.J.M.P. Kortmann
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the short term results of the Puddu opening wedge osteotomy system. Method: Twenty-four consecutive opening wedge osteotomies performed between September 1997 and November 1999 were evaluated retrospectively. There were 20 tibia osteotomies (14 for medial osteoarthritis, 5 for instability and 1 correction of overcorrection in an earlier osteotomy) and 4 femoral osteotomies (3 for lateral osteoarthritis and 1 for osteonecrosis). Mean age was 58 (range 17-72), 10 male and 14 female. Osteoset bone substitute was used in wedges larger than 7.5 mm. Patients were allowed to walk with crutches, non-weight bearing, until signs of consolidation on radiography. Radiographs taken directly postoperative, after 6 weeks and after three months were evaluated for consolidation, maintenance of correction and complications. In the next weeks patients will be invited to our outpatient clinic for clinical evaluation using the American knee society knee score, the Hospital for Special Surgery Knee Rating and the IKDC score. Results: Mean time until full weight bearing was 11 weeks, consolidation on radiographs was found after a mean of 8 weeks. There were no deep wound infections. Three patients had a superficial wound infection, which was successfully treated with oral anti-biotics. In one patient one of the screws failed after 6 months, two patients had a screw that migrated medially without interference with consolidation. During two procedures there was a fracture of the contra-lateral cortex, on follow-up this did not result in loss of correction. There were two tibia plateau fractures, one during operation without dislocation and no need to change the postoperative management, the other because of repetitive trauma with loss of correction. Ten out of twenty-four osteotomy plates had been removed at time of follow-up. Conclusion: The opening wedge osteotomy plate technique offers a simplified method utilizing a single saw cut. No fibula osteotomy is necessary. The method preserves bone stock and offers a higher degree of precision with the ability to change the wedge intra-operatively without additional steps. Consolidation occurs without loss of correction within an acceptable period. Forty-two percent of the plates had to be removed because of irritation due to the superficial position of the plate.

        Poster 116. New operative technique and jig for high tibial osteotomy

        Yoshio Koga, Go Omori, Hiroyuki Segawa, Tatsuya Kikuchi
        2001 ISAKOS Poster Abstracts
        Background: High tibial osteotomy is well accepted as a good procedure if postoperative alignment is suitable valgus. New instrumented procedure and technique of osteotomy were developed. Operative procedure: The first guide pin is inserted parallel to the joint line just distal to the Gerdy tubercle. The second guide pin is inserted at a planned angle to the first pin which is guided by a special jig. The first osteotomy is made along the second pin. The second osteotomy is made at the tibial tuberosity to remove a small wedge at anterior cortex. The third osteotomy is done at the posterior point of the first osteotomy and perpendicular to it. The posterior and anterior cortical osteotomies are completed by a curved chisel. By these osteotomies the distal fragment is completely free from the proximal fragment at the first osteotomy level. After the jig is reattached to guide pins, gentle manipulation is applied until the second pin slides on the plate of the jig to be parallel to the first pin. A simple tension band wiring fixation technique guided by the jig is applied to fix the fragment. Discussion: All osteotomies of this technique are safely carried out from lateral to medial to avoid complication. The distal fragment is surrounded by the proximal fragment which will provide good stability, easy union and less bleeding after osteotomy. Significance: This jig controls the angle of fragment displacement not the osteotomy angle, which is essential to create better clinical results.

        Poster 117. Evaluation of risk factors of knee osteoarthritis by 21-year epidemiological survey

        Yoshio Koga, Go Omori, Hiroyuki Shiozaki
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the prevalence and risk factors of knee osteoarthrosis (OA), a prospective, population-based epidemiological survey was studied. Method: An epidemiological study focused on knee OA was conducted in 1979 In Matsui Town, on subjects aged 40 to 65 years. The same group of individuals was re-examined by same observers every seven years in 1986, 1993 and 2000. Data were collected by questionnaire, physical examination and anteroposterior standing radiographs of both knee. Radiographs were graded according to a modified Kellgren score. Joint space and femorotibial angle were measured. Results: The percentages covering the population survey were always over 80% (more than 1,400 subjects).The prevalence of radiographical knee OA increased with age. 30% of female subjects over 70 years of age had grade II or more OA changes, however about 40% of the same age group had no OA changes. The risk factors of knee OA are female, obesity and related factors are varus deformity and lateral thrust in gait. Discussion: From this 21 year survey in the early stages of knee OA, medial joint space narrowing tends to be combined with lateral joint space widening, which is related to the joint laxity of female subjects who demonstrated lateral thrust. The laxity and obesity and weakness of muscle power are the factors which create varus deformity and knee OA in females. Significance: For the increasing elderly population, indication and assessment of treatment of knee OA should be based on a longitudinal prospective study.

        Poster 118. The measured resection technique revisited

        Stephen D. Lucey, MD, Giles R. Scuderi, MD, Michael A. Kelly, MD, John N. Insall, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the usefulness of the balanced bone resection/measured resection technique in relationship to the surgical epicondylar axis technique in properly rotating the femoral component in total knee arthroplasty. Method: We performed 50 consecutive total knee arthroplasties using the surgical epicondylar axis technique to guide the rotation of the femoral component. We identified the epicondylar axis and measured the posterior condylar angles. We measured and recorded the bone cuts from the distal and posterior femoral condyles. All flexion and extension gaps were measured and balanced as determined by a tensor. After tabulation of the results, we analyzed the data to determine how often it would have been mathematically possible to use the balanced bone resection or measured resection technique. Results: We performed 50 total knees in 37 consecutive patients. There were 16 women and 21 men. There were 42 varus knees averaging 6.7 degrees of anatomic varus deformity and 8 valgus knees averaging 12.1 degrees of anatomic valgus alignment. The posterior condylar angle averaged 2.98 degrees. After measuring all bone cuts, our analysis showed that the balanced bone resection technique could have worked in 12 of 50 (24%) cases if given a 2mm margin of error. Conclusion: Strictly following the measured resection technique would have been accurate in rotating the femoral component in only 24% of cases, which is unacceptable. Our data supports our hypothesis that the measured resection technique is not consistently reproducible. Significance: The balanced bone resection technique should not be used over other techniques to guide in rotation of the femoral component.

        Poster 119. Medial opening wedge high tibial osteotomy combined with anterior cruciate ligament (ACL) arthroscopic reconstruction - simultaneous procedures

        Luiz R.S. Marczyk, MD, Joao L. Ellera Gomes, MD, Roberto P. Ruthner, MD
        2001 ISAKOS Poster Abstracts
        Objective: To present 10 cases of simultaneous arthroscopic ACL reconstruction and open wedge high tibial osteotomy. Method: All 10 patients were submitted to arthroscopic ACL reconstruction with the doubled semitendinosus and gracilis tendon. Those grafts were chosen because the same incision was easily used for graft oblation and tibial osteotomy. Besides that, once the osteotomy technique was open wedge, a patellar tendon graft would weaken the proximal tibial plateau through the excision of the bone fragment of its anterior cortical, increasing the chance of a plateau fracture. The osteotomy was simultaneously performed in 6 patients to improve medial compartment arthrosis. In the other 4 patients, it was performed to treat an associated varus instability and so prevent stretching of the lateral compartment soft tissue repair. All patients used a removable splint for 3 weeks. Partial weight bearing was allowed after 3 weeks and full weight bearing after 45 days. Results: Though there was a significant improvement of the level of activity of all patients after surgery, only 4 patients return to same sports activities they had prior the beginning of the orthopaedics problem. All patients confirmed that they would do the surgery again after comparing their situation prior and after the procedures. Conclusion and Significance: Though not a routine procedure, the low level of morbidity of both techniques allowed its simultaneous use without great discomfort and risk for the patients. The high tibial opening wedge osteotomy technique, with “Puddu wedge plate” was fundamental for the practice of this approach.

        Poster 120. Effect of cryotherapy after total knee arthroplasty

        Hideo Matsumoto, MD, PhD, Yasunori Suda, MD, M.Phil., Toshiro Otani, MD, Yasuo Niki, MD
        2001 ISAKOS Poster Abstracts
        Purpose: “To analyze effect of cryotherapy after total knee arthroplasty (TKA) by measuring changes in temperature and blood-flow both in the knee joint and on the skin surface.” Method: Five cases (one male and 4 females; average age: 60) who underwent a successful TKA were involved. During the operation, sensors of a thermometer and a blood-flow analyzer were set both in the suprapatellar pouch of the knee joint and on the anterior skin surface. Cryotherapy was started immediately after the operation using a continuous cooling system. On the third postoperative day when the postoperative bleeding and inflammation subsided, the cooling was stopped temporally until the joint temperature became constant, and then it was restarted. The measurement was carried out continuously for 40 minutes after the cooling was restarted. Results: Skin temperature decreased by 2.6°C at 40 minutes after the cooling restarted, and its blood-flow gradually reduced to 69.1% of that before the cooling. Only a minimal change in temperature (within 0.1°C) and not a uniform change in the blood-flow were observed in the joint. Conclusion: Both temperature and blood-flow were reduced by cryotherapy on the skin surface. However, no obvious effect could be observed in the joint, which may be because the postoperative biological reaction was too strong with the TKA to detect the changes in temperature and blood-flow with a short-term measurement (i.e., 40 minutes). Significance: Postoperative cryotherapy can reduce the blood-flow, but a long term investigation is required for further confirmation.

        Poster 121. The consolidation in the knee arthrodesis with external fixation

        Zartur Menegassi, Benedito Silva, Idemar Palmar
        2001 ISAKOS Poster Abstracts
        Purpose: This study was initiated for evaluation of consolidation in the knee arthrodesis with external fixation. Type of Study: It was a prospective and randomized trial. Method: Eight patients underwent knee arthrodesis for different reasons (4 Total Knee Arthroplasty infection (TKA), 1 mechanical failure of TKA, 1 rupture of extensor mechanism associated with infection in TKA, 1 quadriceps weakness caused by poliomyelitis, and 1 post traumatic osteoarthritis in a young girl), with a biplanar external fixation using a Charnley compressor in the coronal plane and a tubular fixator and sagittal plane. Results: All knees fused with good function and low rate of complications in the average of 5.37 months (ranging from 3 to 7 months). The average time was longer in the older patients with failure of TKA due to bone loss and infection, but even in those patients biplanar external fixation has proved to be useful in obtaining knee fusion. Conclusion: This method is a good option to obtain knee arthrodesis.

        Poster 122. Autologous platelet gel (APG) administration in pain control, range of motion, and targeted length of stay in total knee arthroplasty

        Pekka Mooar, MD (b – Medtronic Corporation), Michael J. Gardner, Paul R. Klepchick
        2001 ISAKOS Poster Abstracts
        Introduction: Total knee arthroplasty (TKA) is a procedure that leads to extensive tissue disruption and inflammation. APG, prepared intraoperatively by volume expansion technique and low speed centrifugation, was applied to exposed cut bone surfaces, synovium, and the lining of the wound at closure, after tourniquet release and hemostasis, to promote wound healing, reduce inflammation, and decrease both blood loss and narcotic requirements. Purpose: To evaluate the effectiveness of APG in decreasing postoperative Hgb loss, intravenous and oral narcotic requirements, and in achievement of functional postoperative ROM. Methods: One hundred and six TKA performed by 2 surgeons were evaluated retrospectively for efficacy of APG administration (see table). Results: Patients receiving APG required less IV (17.0 mg/day vs. 34.5 mg/day) and oral (1.84 pills/day vs. 2.72 pills/day) narcotics, achieved higher functional ROM (78.2° vs. 72.1°) an average of 1 day earlier and had less drop in Hgb (2.68 g/dl vs. 3.12 g/dl) than their control counterparts when evaluated with a one-tailed T-Test. Conclusions: APG exhibits a broad spectrum of beneficial effects leading to earlier functional ROM, decreased IV and oral narcotic requirements, and lower drop in Hgb when used in TKA. Patients who received APG achieved the target clinical pathway length of stay of 4 days.
        Tabled 1
        IV mg/dayOral pills/dayHgb (g/dl)Max ROM (°)Days
        Platelet Gels17.0 (n=52)1.84 (n=50)2.68 (n=54)78.2 (n=55)4.04 (n=57)
        Std. Dev.16.41.681.1415.71.04
        Controls34.5 (n=39)2.72 (n=27)3.12 (n=34)72.1 (n=40)5.07 (n=42)
        Std. Dev.43.12.461.0714.32.14
        p value0.0160.0570.0280.0680.003

        Poster 123. Treatment of patellofemoral osteoarthritis by carbon-fibre implant – minimum over-5-year follow-up

        Yujiro Mori, MD, PhD, Akihiko Fujimoto, MD, Hiroyuki Okumo, MD, Hiroshi Takagi, MD
        Purpose: To evaluate the implanted a matrix support prosthesis made of carbon fibre for the treatment of patellofemoral osteoarthritis. Method: From August 1990 to September 1992, the patellofemoral P-F joint of 15 osteoarthritis knees were resurfaced using carbon-fibre implant MEDICARB mesh and rods. The age of patients at surgery was 44 to 75 years old; mean follow-up time was 6.1 years. The mean hospitalization period was approximately 4 weeks. Clinical evaluations were performed using JOA (Japanese Orthopaedic Association) Knee Score. X-ray examination was also performed. Results: Pain and crepitus of the P-F joint diminished or decreased in all patients soon after surgery, and desired effect of treatment continued at follow-up. The mean preoperative JOA knee score of 70.1 ± 8.1 points improved to 87.5 ± 4.1 at 5 years after surgery. X-ray examination revealed that 3 of 15 knees regained joint space on the skyline view. Half of the patients were no change. No major complications were found but moderate joint effusion of one knee was noted. The knee needed several aspirations and stabilized at one year after surgery. Conclusion: Our encouraging clinical results showed that this procedure, P-F resurfacing using MEDICARB mesh and rods, is a good indication for treatment of elderly patients with P-F osteoarthritis. Significance: There is no long followed clinical report concerning carbon-fibre implant in P-F osteoarthritis.

        Poster 124. Patella resurfacing in metal-backed rotating bearing total knee arthroplasty. A 2 to 14 year evaluation

        Urs Munzinger, MD, Jens Boldt, MBBS, Peter Keblish, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate 235 Low Contact Stress (LCS) TKA with utilization of a metal backed rotating polyethylene bearing and to analyze management of patella complication. Method: This study evaluated 235 Low Contact Stress (LCS) TKA with utilization of a metal backed rotating PE bearing. Those cases with a follow-up of less than two years were not calculated for statistical analysis but were included in post-operative complications. The mean follow-up was 4.2 years (range: 2 to 10). Results: Of the 235 cases 94.7% scored excellent or good results. Patello-femoral tracking was analyzed on axial radiographs in all cases and revealed perfect tracking in 96%. Revision surgery related to patella complications was required in 7 (3%) of 235 cases and included one infection, one patella necrosis, two PE bearing spin-outs, one PE bearing breakage, one patella mal-tracking, and one traumatic patella component loosening. Four of 7 patella complications were related to patello-femoral mal-tracking. Conclusion: The results in this study are similar to better compared with those reported in the literature. Patella related complications appear to occur more frequently in cases with less than ideal patello-femoral tracking and in cases with poor aligned patellar bone resection. Significance: Patella related complications remain a major concern and have frequently caused secondary intervention, independent whether resurfaced or not. Common modes of failures are increased PE wear, PE fractures, component dissociation, and patella fractures.

        Poster 125. The results of femoral shaft osteotomy for OA varus of the knee following femoral fracture malunion

        Aradhyula N. Murty, John Ireland
        2001 ISAKOS Poster Abstracts
        Purpose: The management of disabling osteoarthritis of the knee following ipsilateral femoral fracture malunion may be difficult. This study presents the results of seven such patients treated by femoral shaft osteotomy in the fracture region and with locked intra-medullary nail fixation. Material and Methods: Seven patients with malunited femoral shaft fractures presenting with knee symptoms between 1992 and 1999 were treated by femoral shaft osteotomy. The presenting knee symptoms and function were graded from 0-4. All patients underwent open femoral shaft osteotomy at the apex of the deformity and fixation was by locked intra-medullary nailing. The patients were followed up until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function. Results: There were six males and one female. The mean age at presentation was 55 years and the mean time from fracture was 27 years (range 13-35 years). The mean knee alignment angle pre-operatively was 5.6° of varus (range 0-12°). The mean time to osteotomy union was 28 months. The mean knee alignment angle post-operatively was 1.4° vaIgus (range 5° varus - 6° valgus) and the mean post-operative improvement in the knee score was 4 points (range 2-7). One patient had a serious vascular complication and now has a stiff but pain-free knee. One patient had very advanced osteoarthritis and underwent uncomplicated total knee replacement soon after osteotomy union and nail removal. Conclusions: These patients usually presenting with severe disability at an age that would be worryingly young for knee replacement, are difficult to manage. Five out of seven of this small series were symptomatically improved so that knee replacement could be delayed for most by at least 5 years. Their eventual knee replacement is likely to have been made less difficult as a result of their alignment correction.

        Poster 126. The functional outcome following total knee replacement with or without patella resurfacing

        Richard Nutton, Christine Myles, Phillip Rowe, Colin Walker
        2001 ISAKOS Poster Abstracts
        We conducted a prospective, randomised and double-blinded study to observe the recovery of knee function in 50 patients undergoing knee replacement with or without patella resurfacing. Patients were assessed pre-operatively, at four months and a minimum 19 months after surgery using three scoring systems, the Knee Society Clinical Outcome Score, WOMAC and the SF-36 health questionnaire. In addition the active range of knee movement when weight bearing was measured using an electrogoniometer. Patients were asked to undertake 11 standardised activities including level walking, stair climbing and getting into and out of low chairs. Patients were randomised at the time of surgery into receiving a knee replacement with or without patella resurfacing. Forty-two patients, (18 with patella resurfacing, 24 with no resurfacing) completed assessments at all time intervals. All patients in the study demonstrated an improvement in terms of pain relief and function by four months after knee replacement with a further but less significant improvement by 18 months. The active range of knee movement measured by electrogoniometry recovered to the pre-operative range for all activities but there was no increase in knee movement. Patients who had patella resurfacing had a significantly lower (p<0.02) score on the Knee Society Clinical Outcome function score at 18 months compared to patients without patella resurfacing. There was no significant difference (p>0.05) in the active range of knee movement with or without patella resurfacing, although patients with patella resurfacing in general had slightly poorer range of movement particularly for activities that required knee flexion beyond 70 degrees. We concluded that in this study knee function was not improved by patella resurfacing when compared to a matched group of patients without resurfacing. As patients’ recovery stabilises by 19 months it appears that the final functional outcome following knee replacement is not enhanced by patella resurfacing.

        Poster 127. Intra-operative monitoring of knee motion in total knee arthroplasty

        Go Omori, Yoshio Koga, Toyohiko Hyashi
        2001 ISAKOS Poster Abstracts
        Purpose: Pre- and post-operative knee motion of total knee arthroplasty (TKA) have been investigated intensively. Its intraoperative analysis, however, has yet to be attempted We developed a high resolution linear CCD camera based photostereometric system, to apply an intra-operative monitoring of 3-dimensional knee motion during TKA. Method: A total of eight LEDs were rigidly mounted on both femoral and tibial trial components in 2 sets of 4. The position of all LEDs were detected in three-dimensions by 2 sets of 3 linear CCD cameras. Interface proximity was evaluated by the distance between every point of the surface of the tibial insert and the closest point of opposing femoral surface. This motion can be displayed 10 frames per second. Clinical Application: Nine knees of 8 patients were studied successfully. Mean measuring time was 10 minutes and average operating time was 80 minutes. The joint levels before and after TKA were also recorded roentgenographically. Results: Posterior movement of the near-contact region was observed during flexion in 5 cases, while in other cases, the region moved anteriorly in early flexion. Discussion: Two patterns of knee motion seemed to be related new joint line after TKA. Especially the elevation of the tibial joint line showed posterior motion of the tibia. The change of the joint line may relate to PCL tension. Significance: Intra-operative monitoring of knee motion in TKA will give the surgeon useful information about proper position of the joint line and proper tension of the soft tissue balance.

        Poster 128. A ten-to 20 year follow-up observation of high tibial osteotomy using tension band wiring fixation in medial knee osteoarthrosis

        Go Omori
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the long term clinical results of high tibial osteotomy (HTO) using tension band wiring fixation in medial osteoarthrosis (OA). Method: Forty-five patients (female: 35, male: 10) were evaluated. Preoperative diagnosis was medial compartment knee osteoarthrosis in all cases. Mean age at surgery was 58 (45 to 75) and the follow-up period ranged from 10 to 20 years (average, 15.5 years). At surgery, closed wedge osteotomy with tension band wiring fixation was performed. All patients were directly examined, and Japanese Orthopedic Knee Rating Score (JOA score: 100 points was defined as full marks) was used for the clinical evaluation. Results: The average of the JOA score was 45.5 preoperatively and 77 at the follow-up. Preoperative femorotibial angle (FTA) ranged from 182 to 196 degrees (average, 188 degrees) and ranged from 165 to 173 degrees (average, 168 degrees) at the follow-up. One patient had bone graft for the delayed union of the osteotomy site, and three patients had total knee arthroplasty due to re-deterioration of the medial OA. Conclusion: High tibial osteotomy using tension band wiring fixation showed excellent long-term clinical results. This method of fixation is safe, less invasive than plate, and the one of good options for the high tibial osteotomy. Significance: This study indicates that the tension band wiring fixation is effective procedure in high tibial osteotomy.

        Poster 129. Total or partial knee arthroplasty? Tension flow study

        José Ricardo Pécora, MD, PhD, Marco Martins Amatuzzi, MD, PhD, Arnaldo José Hernandez, MD, PhD, Márcia Uchôa de Rezende, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To compare the tension flow changes on the distal femur and proximal tibia due to cemented total (TKA) and unicompartmental knee prosthesis (UCP). Method: Ten pairs of human cadaver knees were studied. Nine landmarks to evaluate superficial deformation with strain gauges (femur-5; tibia-4) were determined in each knee. A mechanical device was developed in order to analyze the tensions under axial compression. Using a KRATOS 5002 machine axial load was applied to the non-operated knee. Subsequently, a medial UCP was done on the right knee and a TKA (preserving the LCP) was done on the left knee. After the implant the compression tests were repeated. Results: Right and left knees before arthroplasty showed no statistical significant difference in respect to superficial microdeformations. Comparing the same knees, before and after the implants, there was a significant increase of the compression load on the medial (p=0.03), and anteromedial femoral cortex (p=0.002) and of the tension load of the lateral femoral cortex (p=0.015) with UCP. There were no differences of the tension flow of the distal femur with the TKA. Both prosthesis increased the compression load of the posteromedial cortex of the tibia (p=0.023). Conclusions: 1- TKA does not alter the tension flow on the distal femur. 2 - UCP increases the compression load of the medial cortex and tension load on the femoral lateral cortex. 3 - There are no differences in proximal tibial tension flow between total and partial knee prosthesis. Significance: TKA reproduces more physiologically the tension flows of the knee.

        Poster 130. Fully constrained knee arthroplasty as a treatment option for comminuted intraarticular distal femoral fractures in elderly

        K. Sampathkumar, FRCS, M. S. Bhamra, FRCS(Orth)
        2001 ISAKOS Poster Abstracts
        Objective: To evaluate the role of constrained knee arthroplasty in the treatment of distal femoral fractures in elderly. Method: A retrospective analysis of 9 patients (average age 85 yrs) who underwent constrained knee arthroplasty for comminuted intra-articular fractures of distal femur. All patients had concomitant medical problems, evidence of osteoporosis and osteoarthritis of the affected knee. The results were analyzed in relation to post-operative complications, length of stay in acute surgical ward, returning to pre-op mobility and evidence of loosening at follow-up. Results: Two patients died of unrelated causes to surgery. Seven remaining patients had a mean follow-up of 4 yrs (2-5). Post-operatively two patients had acute confusion and one patient had chest infection. The average time before returning to pre-injury level of activity was 17 days and the mean inpatient stay was 18 days. The range of movement at follow-up was 10-100. All patients had good pain relief and there was no evidence of loosening at follow-up. Conclusion: Comminuted intra-articular fracture of distal femur in elderly is a difficult problem to treat because of coexisting osteoporosis, medical conditions and osteoarthritis. Conservative treatment is prolonged and painful. Internal fixation is difficult because of osteoporosis. Though constrained knee replacement has the inherent risks of surgery in elderly, pain relief and reduced inpatient time are the main benefits. The risk of early loosening with this type of implant is reduced by limited mobility in this age group of patients. Significance: Fully constrained knee replacement could be considered as an option in the treatment modalities of distal femoral fractures in the elderly.

        Poster 131. Tibial osteotomy coincident with long stem total knee arthroplasty – a surgical technique

        Pascal A. Schai, Richard D. Scott
        2001 ISAKOS Poster Abstracts
        In certain patients requiring total knee arthroplasty, tibial deformity secondary to previous fracture or osteotomy requires corrective osteotomy. This can be performed in two stages or coincident with the arthroplasty. The concept of coincident tibial osteotomy and total knee arthroplasty has been previously published but details of the complicated surgical technique are lacking for the surgeon embarking on this procedure for the first time. This report shares such an experience, detailing the pre-operative planning involved and the intra-operative technique utilized.

        Poster 132. Comparison of dynamic in vitro measurements of tibiofemoral contact stress after TKA with clinical and radiographic findings

        C. Stukenborg-Colsman, S. Ostermeier, C. J. Wirth
        2001 ISAKOS Poster Abstracts
        Objective: The study’s purpose was to compare the tibiofemoral contact stress and bearing contact area of fixed and mobile bearing inlays under dynamic loading. The results were compared to clinical and radiographic findings. Method: The prostheses (with three different inlay types: Standard, high conformity, and meniscal bearing) were implanted into the right knee of five fresh frozen specimens. The specimens were mounted in a knee simulator for biomechanical testing. The tibiofemoral peak contact stress and the tibiofemoral bearing area were measured using resistive ink, 0.1-mm-thin pressure sensors (Tekscan, Boston). Clinically prospective multicenter studies were introduced for the standard prosthesis with fixed bearings in 1991 and for the mobile bearing inlay in 1996. Results: Average max. peak contact stress was 35 MPa (+/-20) for the Standard, 12 MPa (+/-5) for the High Conformity, and 10 MPa (+/-5) for the Meniscal Bearing inlay. Contact stress on the meniscal bearing inlay was consistently lower than that of the fixed bearing inlays and did not vary with knee flexion angle. The meniscal bearing inlay showed the greatest contact area with 140 mm2. Explanted inlays during revision surgery were examined and showed polyethylene wear in the same areas as measured on the vitro inlays. Conclusion and Significance: This study shows a significantly lower tibiofemoral contact stress and greater contact area with the meniscal bearing inlay under dynamic conditions compared to fixed standard and high conformity inlays. These features reduce the likelihood of cold flow and stress-peak damage and supports the longevity of the polyethylene.

        Poster 133. Modified weber technique for high tibial osteotomy

        Tahir Ogut, MD, Tahsin Beyzadeoglu, MD, Fahri Erdogan, Asst. Prof., Yuksel Tenekecioglu, Prof
        2001 ISAKOS Poster Abstracts
        Purpose: A modification of Weber technique for high tibial osteotomy and its advantages were evaluated. Method: High tibial osteotomy with a modification of Weber technique was attempted on 40 knees of 39 patients (35 female, 4 male) for varus deformity of the knee, between May 1997 and January 2000. The median age of the patients was 52.5 (25-67) years. A semitubuler plate and a long cortical screw were used instead of the original Weber instrumentation. The plates were bent approximately 30 degrees for the oblique application of the screws along the tibial diaphysis performing static compression of the closed wedge osteotomy. Mean follow-up time was 18.5 (5-37) months. Results: The patients were allowed for weight bearing as soon as they could tolerate their pain and all of them could perform the half body weight bearing using a walker in one week. At the end of the three weeks, all could walk with one crutch and in six weeks’ time, full body weight was tolerable for them. No pseudoarthrosis or displacement of the osteotomy were observed. Conclusion: High tibial osteotomy is a preferable choice of treatment for varus deformity of the knee for accurate selected patients. Closed wedge osteotomy of the proximal tibia is favourable with its stability and rare pseudoarthrosis incidence. However the surgeon has many alternatives for the fixation of the osteotomy, an instrumentation performing a rigid fixation, preventing the limitations at the early postoperative period and decreasing the complication rate is the ideal one. And in our opinion, Weber fixation technique for high tibial osteotomy is a good choice because of providing the stability, statically and dynamically.

        Poster 134. High tibial osteotomy using the natural knee system

        Subash Tandon, FRCS(Orth), Peter Dobson, FRCS(Orth), Peter Lewis, FRCS(Orth), Kevin Angel, FRCS(Orth)
        2001 ISAKOS Poster Abstracts
        Objectives: To assess the satisfaction, function and clinical outcome of patients who have undergone closing wedge HTO using the Natural Knee System from Sulzer, and to compare our results with those of the system’s originator Aaron Hofmann. Methods: 63 HTOs (in 54 patients) were reviewed from the Wakefield Orthopaedic Clinic and The Queen Elizabeth Hospital, with a follow-up clinical assessment of 48 patients (94%) at a mean of 36 months after operation. Outcome measures were patient satisfaction, complications, measured ROM, assessment of joint laxity, the Oxford knee score and SF-12. Detailed radiographic measurements post-op, at 6 weeks and at latest follow-up were calculated. Results: 26 patients claimed their results were good or excellent, 10 satisfactory, 7 were unchanged and 4 were worse. Mean ROM was 6-123 degrees or greater. Although lateral laxity was present on examination in 14 only one had symptomatic instability. Radiographically there was a tendency to slightly under correct the femorotibial alignment (mean 6.5 degrees) but this was unchanged from post-op to latest follow-up. The posterior tibial slope decreased from 6 to 3 degrees. Although the mean patella tendon measurements were unchanged, there were 3 knees with an Insall/Salvati ratio of <0.8 indicating patella baja. 4 patients from the study group had been revised to a TKR at a mean of 26 months, giving a 90.5% 3-year survival. There were 16 wound complications including infections and haematomata, 4 technical problems (2 intra-articular fractures, 2 anteriorly placed screws), 1 non-union requiring bone graft, 2 pulmonary emboli and 1 septic arthritis on metal removal. Conclusion: This is a precise but fairly demanding system for HTO that gives good early results, but not equivalent to Hofmann. In particular there was a tendency to under-correction, a small incidence of instability and patella baja and a much higher complication rate in our series. Because of the wound infections prophylactic antibiotics are now given and the incision altered. We also now anticoagulate this group of patients. In the 4 revised to a TKR there were no operative problems in this subsequent procedure.

        Poster 135. Late recurrence of varus deformity after high tibial osteotomy

        Masanori Terauchi, Kenji Shirakura, Hiroshi Higuchi, Kenji Takagishi
        2001 ISAKOS Poster Abstracts
        [Objective] The purpose of this study was to analyze retrospectively the relationship between the axial parameters of lower limb alignment and the recurrence of varus deformity which observed over a period of years after high tibial osteotomy (HTO). [Methods] We studied 33 knees. The average duration of follow-up was 88 months (range, 60-120 months). Recurrence of varus deformity was defined as greater than a 3° increase in the femoro-tibial angle compared with that obtained 6 months after the operation. The angle between the axis of femur and the tangent to the femoral condyles (FC-FS) was measured. The angle between tibial plateau and the horizon (TP-H) was also measured. [Results] There were 4 knees with the recurrence of varus deformity. They had larger FC-FS angle than those without varus recurrence. These results indicated that knees with a relatively varus inclination of the distal femur had a tendency for the recurrence of varus deformity. The FC-FS angle correlated with the TP-H (R=0.60). The large femoral shaft-femoral condylar angle accompanied those with the larger tilt of tibial articular surface towards the horizon. [Conclusion and Significance] The combination of a large varus inclination of the distal femur with a greater horizontal obliquity of the joint surface was observed. This excessive obliquity of the tibial joint surface towards the horizon prevents the shift of the weight bearing area to the lateral compartment, and causes the recurrence of varus deformity after HTO.

        Poster 136. Indications for cementless total knee arthroplasty

        Jacques Van Overschelde, MD, Cottenie Dominique, MD
        2001 ISAKOS Poster Abstracts
        Since more than 10 years we use in our department of orthopaedic surgery systematically cementless total knee prostheses. We have used different types of prostheses with the same basis characteristics and possibilities for osseo-integration. At first cementless techniques were only indicated in younger patients but soon this was expanded to all ages and we rarely see contra-indications. Because of our good results in cementless techniques we diminished our indications for osteotomy in favor of the unicondylar technique. In most cases the latest knee prosthesis permits us to keep the patella unchanged. We will discuss about 850 cases in which we used the cementless technique in over 95%.

        Poster 137. Assessment of osteochondral autografts of the knee with CT, conventional MRI, dynamic gadolinium-enhanced MRI and cartilage-thickness images

        K. L. Verstraete, MD, PhD, W. C.J. Huysse, D. Steines, P. Lang, MD, M. Rousseaux, MD, D. DeClercq, MD
        2001 ISAKOS Poster Abstracts
        Objective: To assess the value of CT and MRI for evaluation of osseous incorporation, cartilaginous thickness and alignment of osteochondral autografts of the knee. Methods: 30 patients were examined with CT-scan and conventional MRl 3 days to 3 years after autoIogous osteochondral transplantation (AOT) in the knee. Five also underwent dynamic Gd-enhanced MRI. Parametric images displaying cartilage thickness were created. Results: Immediately after arthroscopic transplantation CT images showed good impaction of the osseous component of the graft in file acceptor area. In the next months, CT showed further complete incorporation or appearance of small peripheral resorption cysts. MRI showed bone marrow edema, that was moderate within the first days and increased within the first weeks, to finally disappear progressively in the next months. Alignment of cartilage was best evaluated on 3-D, gradient-echo images. Dynamic gadolinium-enhanced MRI showed no enhancement in the graft immediately after transplantation, followed by moderate peripheral enhancement within the next months, indicating incorporation. Color-encoded, parametric ‘cartilage thickness’ images display the restoration of the damaged area, and can also be used preoperatively to find the best donor area. Conclusion: Both CT-scan and MRI provide useful information for early and late follow-up of AOT.

        Poster 138. The oxford unicompartmental knee prosthesis: A 5-year follow-up

        Peter Vorlat, MD, René Verdonk, MD, PhD, Hans Schauvliege, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To assess the medium-term results of the Oxford unicompartmental knee prosthesis for unicompartmental osteoarthrosis. To evaluate and discuss the procedure in this series in comparison to earlier literature. Method: Thirty-eight medial and three lateral prostheses were placed in 39 patients. After an average of 58 months, they were evaluated using the Hospital for Special Surgery knee score. Results: Three revisions are noted. The average score is 87. Of the remaining 36 patients 29 patients have an excellent result, 3 a good, 2 a moderate and 2 a poor one. In 2 of the 3 revisions and in 2 of the 4 poor and moderate results, the indications for the procedure can be debated. Conclusion: This series confirms some earlier good results reported in the literature, and demonstrates the importance of adhering to strict indications to reduce the number of poor results.

        Poster 139. Clinical results of cemented total knee arthroplasty using bioceramic YMCK prosthesis for patients with rheumatoid arthritis

        Kazuyoshi Yamamoto, MD, PhD, Tomihisa Koshino, MD, PhD, Tomoyuki Saito, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To investigate the clinical results of total knee arthroplasty using YMCK prosthesis (ceramic femoral and tibial components, cemented without screw fixation, posterior cruciate ligament retained). Method: Eighty-seven knees of 65 rheumatoid patients were evaluated using the knee score system of the Knee Society and radiographically. There were 5 men (5 knees) and 60 women (82 knees) with a mean age of 58.6±9.9 years, excluding one knee with the prostheses retrieved. The mean follow-up duration was 39.1±10.1 months ranging from 24 to 64. Results: The greater part of the patients obtained relief of pain and improvement of walking ability. The knee score improved from 34.5±18.2 points preoperatively to 79.6±12.9 points postoperatively, and the function score improved from 28.4±20.8 points to 52.5±31.1 points. The arc of motion improved from 100.8±32.1 degrees to 106.9 ±18.1 degrees. The flexion contracture improved from 12.8±14.5 degrees to 1.4±5.1 degrees. The standing FTA was 172.1±8.6 degrees before and 171.8±5.2 degrees after arthroplasty. A radiolucent line with a thick of two millimeters was identified adjacent to tibial component in one knee. Complication was a fracture of the femoral condyle during surgery in one knee. Conclusion: These results showed that the clinical evaluations at three years were satisfactory after cemented total knee arthroplasty using YMCK prosthesis. Significance: Cemented total knee arthroplasty using ceramic knee prosthesis is of low friction and useful for rheumatoid patients.

        Poster 140. Clinical evaluation of alumina ceramic condylar prosthesis in total knee arthroplasty

        Kazunori Yasuda, MD, PhD (a – Kyocera Co. Ltd.), Hirotaka Azuma, MD, Hiroko Tanioka, BS, Noboru Miyagi, MD, PhD, Akio Minami, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To review the short- to mid-term results of posterior cruciate ligament retaining TKA utilizing an alumina ceramic condylar prosthesis. Methods: We originally developed a TKA system composed of an alumina ceramic femoral component, a titanium tibial tray and a UHMWPE insert in 1992. In a prospective study, 128 consecutive cemented TKAs were performed. Four patients died and 6 patients were lost to follow-up. Six patients were excluded from the final evaluation because of their general disease. The remaining 110 knees of 86 patients were reviewed clinically and radiographically. The mean follow-up was 46 months (24 to 77 months). The average age was 66 years at the time of arthroplasty. Results: Two revisions were performed at 3 years postoperatively; one for breakage of the tibial tray and one for late infection. There was one knee with patellar dislocation. In the other knees, no components were loose radiographically. In these knees, the average HSS knee score was 88 in the osteoarthritic knees (n=51), and 84 in the RA knees (n=59). The average range of knee motion was 115 degrees in the osteoarthritic knees, and 110 degrees in the RA knees. Radiographically, femoral radiolucencies were not present in any adequate lateral views, while three knees demonstrated a radiolucent line beneath the tibial tray. There were no cases of osteolysis or obvious wear of the insert. Conclusion: Excellent short- to mid-term results were obtained after TKA with alumina ceramic condylar prosthesis. Significance: This is the first report that alumina ceramic can be successfully utilized for condylar TKA retaining the posterior cruciate ligament.

        Poster 141. The problem of femoral extrarotation in TKA

        Claudio Zara, Stefano Albanelli, Antonio Pelati
        2001 ISAKOS Poster Abstracts
        Objective: Our aim was to evaluate the methods to determine the femoral extrarotation in order to establish the most accurate one. Methods: There are 4 methods to determine the femoral extrarotation: 1) TransEpicondylar Axis, 2) Whiteside’s Line, 3) Posterior Condylar Line, 4) Extrarotation after Ligament Balancing. The Whiteside’s Line gives no guarantee in excessive valgus knees and in Trochlear Dysplasia, the Posterior Condylar Line differs in a normal knee and it becomes unreliable in a varus or valgus osteoarthritic knee, the 4th method is an indirect technique, as mentioned by Insall, and thus obsolete. We believe only the TransEpicondylar Axis is the reliable technique as it is based on the survey of the medial epicondyle sulcus and the lateral epicondyle prominence being them landmarks clearly discernible and present in all situations even the most complex. All this is necessary because an incorrect femoral extrarotation is correlated with lateral tracking, patellar tilting, patellar subluxation and early patellar dislocation or late patellar prosthesis failure. Results: Over the last 3 years we have implanted 226 NexGen prostheses with Epicondylar Instrumentation; it is obviously not possible to indicate results at a shorten follow-up time but our choice was supported by the good results in the extension and flexion stability, in the range of knee movement and in the total lack of pain, following the evaluation criteria of Knee Score Society. Conclusions: The most reliable technique is undoubtedly the use of the TransEpicondylar Axis as it determines the native neutral rotational orientation of the femoral component during TKA.

        Poster 142. Tibial tubercle transfer: Quantitative effect on patellar tracking

        Anthony Bull, PhD, Marios Katchburian, FRCS(Orth), Fred Heatley, FRCS, Andrew Amis, D.Sc
        2001 ISAKOS Poster Abstracts
        Purpose: To quantify the effect of tibial tubercle medialisation on patellar tracking intraoperatively. Method: Ten patients undergoing distal realignment (Elmslie-Trillat) and lateral release of the extensor mechanism were recruited. The operations were performed by a single surgeon using a standardised technique. An electromagnetic tracking device with a single transmitter and three sensors was used to measure the relative motion between the patella, femur, and tibia. The sensors were fixed to the femur and patella using sterilised mounting blocks designed to slide over two Kirschner wires which were drilled into the bones. The third receiver was fixed to the tibia using a clamp. Clinical motions were induced and measured pre- and post distal realignment: Medial/lateral patellar mobility, and knee flexion/extension combined with tibial internal/external rotation. Post processing was conducted to calculate output in terms of patellar tilt, rotation, flexion, and shift. Results: Patellar rotation and flexion were not consistently affected by the tibial tubercle transfer. The patellar tilt and shift were significantly affected by the medialisation of the tibial tubercle. The magnitude of change in shift and tilt varied between subjects. Conclusion: Electromagnetic sensors allow subtle knee kinematics to be measured and quantified in clinically relevant ways. Significance: This intra-operative technique allows assessment of surgery which, combined with surgical planning tools, may help the surgeon to achieve greater accuracy of correction of joint kinematics. Other applications include the assessment of restoration of tibio-femoral kinematics with ACL reconstruction.

        Poster 143. Ultra-low velocity knee dislocation

        Frederick M. Azar, MD, Jason C. Brandt, MD, Barry B. Phillips, MD, Robert H. Miller III MD
        2001 ISAKOS Poster Abstracts
        Objective: Complete knee dislocation is an uncommon, but potentially devastating, injury, most often associated with high-energy trauma or athletic activity. Few reports in the literature have documented low-velocity knee dislocations sustained in activities of daily living (ADL) and the prevalence of neurovascular injury and permanent disability with these injuries is unclear. To determine the outcomes of these injuries, we reviewed our results in 14 patients. Methods: Fourteen patients had complete knee dislocations sustained during everyday activities. The average age of the 8 females and 6 males was 30.2 years (range 19 to 59 years). Their average body mass index (BMI) was 47.68 (range 30.8 to 66.7). A BMI of 30 is considered obesity, 35 severe obesity, and 40 or more very severe obesity. Eleven dislocations were anterior, 2 were posterior, and 1 was lateral. Only one patient had an associated injury, a contralateral elbow dislocation. Seven of the 14 patients had vascular (popliteal) injuries, all of which were surgically repaired. Six had injuries to either the peroneal nerve alone (4) or to both the peroneal and tibial nerves (2). All 14 dislocations were closed injuries, and closed reduction was successful in all. Six of the 14 knees had surgical repair of ligaments; the other eight were immobilized with crossed pins (6), external fixation (1), or splints (1). The average hospitalization was 10.7 days. Standardized knee scoring systems (IKDC, HSS, Lysholm, Tegner), physical examination, and isokinetic testing (Kin-Com) were used to evaluate outcome at an average follow-up of 3 years (minimum follow-up of 1 year). Results: Two patients with nerve and vascular injuries required above-knee amputations because of tissue ischemia, one patient died of cardiac arrest 7 days after knee dislocation, and 3 were lost to follow-up. Of the 8 remaining patients, 3 had nerve palsies, which resolved in 1 and persisted in 2. Results on all four evaluation systems were poor in 0 patients, but those patients with surgical repair of ligaments had better results than those without. Six of the 8 patients were employed at the time of injury; four returned to the same type of work. Conclusions and Significance: Although the patient population is small, in general these ultra-low-velocity injuries were more severe, produced more nerve and vascular damage, and had poorer results than those reported after most high-velocity knee dislocations and low-velocity dislocations in athletes. The predominance of anterior dislocation (11 of 14) suggests a hyperextension mechanism indicative of high-energy dislocation. That all of these patients were obese and most were severely obese points to a correlation between obesity and a risk of knee dislocation with ADL. The frequency of neurovascular injury also increased as the BMI increased. Although the limited mobility of these obese patients before injury makes postoperative evaluation difficult, it appears that surgical reconstruction with emphasis on early posterolateral corner repair can improve subjective and objective results.

        Poster 144. The use of calcium phosphate cement and minimal internal fixation in the management of tibial plateau fractures

        James Bidwell, FRCSEd(Tr&Orth), John Keating, FRCS, Carol Hajducka, RCN
        2001 ISAKOS Poster Abstracts
        Methods: A carbonated apatite cement with a high compressive strength was used in the treatment of tibial plateau fractures. There were 41 patients and all patients had isolated tibial plateau fractures. Once initial reduction and fixation were carried out, the void under the elevated plateau was filled using calcium phosphate cement. A buttress plate was used in one case, screws or K-wires in 33 cases and calcium phosphate cement alone in 7 cases. Patients were mobilised partially weight bearing and allowed full weight bearing at 6 weeks. Results: Reductions were anatomic (<2 mm displacement) in 32 (78%) cases, satisfactory (3–5 mm displacement) in 7 (17%) cases and imperfect (>5 mm) in 2 (5%) patients. Extrusion of some calcium phosphate cement into surrounding soft tissue occurred in one case. This material resorbed with no adverse effects. Loss of reduction was observed in 6 (15%) cases. There were no other significant complications. Thirty-seven patients (90%) had more than 120 degrees of knee flexion at 6 months. Discussion: Calcium phosphate cement is an alternative to the use of bone grafting in any area of cancellous subject to compressive load. It is ideal for use in tibial plateau fractures with compressed subchondral bone after elevation. It obviates the need for buttress plating and bone grafting and there is no bone graft donor site morbidity. Patients are able to mobilise more rapidly and early discharge is facilitated. Conclusion: Calcium phosphate cement may be more effective in maintaining reduction that standard methods of fixation and grafting.

        Poster 145. 5-Year multicenter outcome of autologous chondrocyte implantation of the knee

        Jon E. Browne, MD (a – Genzyme Biosurgery), Christoph Erggelet, MD, PhD, Freddie H. Fu, MD, Bert R. Mandelbaum, MD, Lyle J. Micheli, MD, J. Bruce Moseley, MD
        2001 ISAKOS Poster Abstracts
        Introduction: The multicenter experience with autologous cultured chondrocyte implantation (ACI) for the repair of focal chondral lesions now extends to more than 1,300 patients at 300 centers. This paper reviews the results for the first cohort of patients to reach 5-year follow-up. Methods: Patients were prospectively followed and evaluated pre-operatively and at annual intervals using a standardized knee examination and the modified Cincinnati Score. Adverse events, including treatment failures, were collected using standardized forms. Results: Five-year follow-up data will be available at the meeting. These results represent currently available 4-year outcome data for the same patient cohort. Forty-seven patients were evaluated 4 years following ACI. Mean age was 38 years (range: 15-55). 65% had undergone previous surgery to the affected knee, including 35% who failed a previous marrow stimulation procedure. Mean defect size 6.2cm2, median 4.0cm2, 88% = 2.0cm2. 36 patients had defects isolated to the medial or lateral condyles or trochlea, and 11 patients had defects located on the patella and/or tibia. Results for all lesions at 48-months demonstrate improvement in 71% of patients by clinician evaluation and 70% by patient self-evaluation. Mean improvement in Cincinnati score seen at two years was unchanged or improved at 4 years. Results were best in patients with defect/s located on the femur, where 85% and 81% (by clinician and patient evaluation, respectively) were improved. Overall clinician Cincinnati Score demonstrated a greater increase for femoral lesions (+4.5) versus all treated locations (+3.5). 4% of patients reported an adverse event related to ACI and required operative intervention. Conclusion: These multicenter results are consistent with assessments at earlier time points and support the continued durability of the repair.

        Poster 146. A controlled study of autologous chondrocyte implantation versus debridement for full-thickness articular cartilage lesions of the femur: Results at 3 years

        Jon E. Browne, MD (a – Genzyme Biosurgery), Christoph Erggelet, MD, PhD, Freddie H. Fu, MD, Bert R. Mandelbaum, MD, Lyle J. Micheli, MD, J. Bruce Moseley, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Results of autologous cultured chondrocyte implantation (ACI) for articular cartilage lesions of the knee (femoral condyle or trochlea) generally demonstrate effectiveness in 80-85% of cases. However, no studies have compared these results to those of a control group. This is the first prospective, concurrently controlled study to directly compare ACI to an alternative treatment. Methods: Patients were prospectively followed and evaluated preoperatively and at 3 or more years post-treatment using the modified Cincinnati Score. Adverse events, including treatment failures were collected using standardized forms. Failures were included in the analysis and scored as a “2” with all symptoms present. Results: 86 (debridement) and 36 (ACI) patients were assessed. Mean age 37 (debridement) and 36 (ACI) years. Mean total defect area 4.1 cm2 (debridement) and 4.8cm2 (ACI). l9% (debridement) and 28% (ACI) had multiple lesions. 23% (debridement) and 39% (ACI) had failed prior abrasion/drilling/microfracture. Overall results at 3 years indicate improvement in 55% of debridement and 89% of ACI (p<0.001). Overall clinician score at follow-up (±SD): 5.8±2.2 (debridement) vs. 7.6±2.5 (ACI), p<0.001. Overall Cincinnati score decreased with increasing lesion size in debridement patients but was unchanged to improved in ACI: ≤3cm2=6.0 vs. 7.3, >3cm2 - <6cm2=5.9 vs. 7.5, ≥6cm2=5.2 vs. 8.0. Adverse events or continued symptoms required reoperation in 23% of debridement and 14% of ACI. Discussion: ACI is more likely to result in improvement, and produces a higher level of function and greater probability of return to sport than debridement alone. These differences are greatest in patients with larger lesions.

        Poster 147. Bicondylar hoffa fracture associated to extensor mechanism lesion

        Jaume Calmet, Antonio Vicente, Ramon Huguet, Josep Gine
        2001 ISAKOS Poster Abstracts
        We present two cases of a bicondylar Hoffa fracture associated to lesion of the extensor apparatus in two polytraumatized patients. Case 1: A 19-year-old man was admitted to hospital after a traffic accident with a grade II open bicondylar Hoffa fracture of the left knee associated with a sectioned patellar tendon at the level of the inferior pole of the patella and fracture of the distal epiphysis of the radius of the left wrist. It was treated initially with debridement and osteotaxis. Eight days after the accident it was openly reduced and osteosynthesis was carried out with 4 lag screws. The patellar tendon was reinserted into the inferior pole of the patella. Three months later an intra-articular arthrolysis was required. Two and a half years after the intervention the functional result is excellent and the range of motion is 0.0.125. Case 2: A 24-year-old man was admitted to hospital after a traffic accident with a grade II open bicondylar Hoffa fracture of the right knee associated with a sectioned quadricipital tendon at the level of the superior pole of the patella, transversal fracture of the middle third of the ipsilateral femur. He was treated with immediate debridement, open reduction and internal fixation with 4 lag screws. Dyaphiseal fracture was treated by open reduction and internal fixation with a plate. The quadricipital tendon was repaired to the superior pole of the patella. One and a half years after the intervention, the functional result is excellent and the range of motion is 0.0.120. We discuss the pathogenesis and treatment of this exceptional lesional association in the knee.

        Poster 148. Arthroscopic autologous osteochondral transplantation (aots) for treatment of focal chondral defects of the knee – a 3 years follow-up study

        Dirk P.M. De Clerq, MD, Michael J. Rousseaux, MD, Koenraad L. Verstraete, MD, PhD, Wouter C. Huysse, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the results within the first three years after AOTS. Method: A retrospective evaluation of 31 patients is presented. The mean follow-up was between 1 week and 3 years (mean: 22.8 months). The outcome is based on: 1. Clinical assessment: The cartilage standard evaluation form as proposed by the international cartilage repair society. 2. Radiologic assessment: Including plain radiography, CT, MR. Results:
        • 1.
          Clinical assessment:
        • 1.
          Normal: 7%
        • 2.
          Nearly normal: 32%
        • 3.
          Abnormal: 43%
        • 4.
          Severely abnormal: 18%
        • 5.
          Radiologic assessment: complete incorporation: 47% resorption cysts: -small (<2 mm) 16% -large 37% alignment of osseous component: -perfect 39% -graft protuberance: 16% -graft depression: 37% -irregular cortex: 8% alignment of cartilage: -perfect 79% -depression 21% -protuberance: 0% loose bodies: -on CT 46% -plain radiography: 21% -MR: 7% granulation tissue: MR 7%
        • 1.
          Harvest site: Intense enhancement
        • 2.
          Graft site: Mild peripheral enhancement
        Bone Marrow edema: More extensive at the graft site than at the harvest site. Conclusion: This study correlates the clinical outcome with a spectrum of imaging findings consisting of plain radiography, CT and MR. There is a good correlation between the chondral alignment (perfect in 79%) and the patient subjective functional assessment (71% normal and nearly normal). Significance: Endoscopic osteochondral autograft transfer has a important learning curve. The results of this technique seams to give a good patient subjective functional assessment and chondral replacement.

        Poster 149. Patellar tenoplasty with gracilis and semitendinosus

        Roberto Dórea, Cristiano Jodicke
        2001 ISAKOS Poster Abstracts
        Purpose: This presentation demonstrates a new technique to give support to the recovery of the lesioned patellar tendon, maintaining the original strength and function, with the return to the usual activities, letting the blood supply of the strengthener tendon (gracilis and semitendineous). Method: A central incision from the patella to tile tibial tuberosity is made, the tendon lesion is identified and the debridement of the injured edges of the patellar tendon is performed. The approximation of the edges with suture is realized, using Ethibond no2. Another incision is done on a level with gracilis and semitendinosus distal insertion, a tendon’s extractor is utilized to take off the gracilis and semitendinosus tendons, holding the distal insertion of both, leaving their blood supply intact. The transposition to the patellar tendon is realized, where it will be fixed with a zig-zag suture, strengthening the previous patellar tendon’s suture. Results: On the 48th day after surgery the patient presented full extension of the knee, with 180° and flexion degree of 140°. He returned to his sports activities, partially, after 4 months and completely, after 6 months, in combination with an intensive physiotherapy support. Conclusion: This procedure demonstrates to be an effective method to correct the patellar tendon lesion, maintaining the original strength and function, permitting the return to sports activities with the same intensity.

        Poster 150. Patellar distal realignment with mini-incision in recidivating luxation of the patella

        Roberto Dórea, Cristiano Jodicke
        2001 ISAKOS Poster Abstracts
        Introduction: This technique originally appeared in 1888 when it was described by Roux, and consisted of performing by means of a large incision, the transplantation of the tuberosity of the tibia, medially, and lowering it when necessary. The technique was improved by Hauser in 1938 and in 1989. Roberto Dorea attempted to improve on the technique once again by markedly diminishing the size of the incision and fixing the tuberosity of the tibia with two small fragment screws which provided greater stability and dispensed post-operatory immobilization. Purpose: This presentation demonstrates the realignment with mini-incision technique which provided greater stability and dispensed post-operatory immobilization. Technique: A incision measuring approximately 3.5 cm is made on the distal portion of the patellar tendon. The tendon is separated of the subcutaneous cellular tissue without the use of a cutting instrument, extending to the patella. The lateral part of the tendon is carried out. After partially disengaging of the distal insertion of semitendineous, gracilis and semimembraneius muscles, a new bone attachment is formed. The removal of the patellar tendon with the bone block centralized and temporarily attached onto the new site is then completed. After verifying if the patella centralization is satisfactory it can be fastened in a definitive manner. The distal portion of semitendineous, gracilis and semimembraneius muscles is then reinserted. The closing is done by planes and after that a compressive bandage is used. Results: In the period comprised of December 1989 to December 1999, thirty surgeries were performed with this technique, 27 with good results (90%), 2 with regular (6.6%) and 1 with bad result (3.3%). Conclusion: This procedure is technically easier and a more effective method for recidivating luxation of the patella, with an excellent post-operatory recovery and great esthetic appearance.

        Poster 151. Acute knee dislocation - evaluation and treatment at ullevaal hospital

        L. Engebretsen, T. C. Ludvigsen, S. Johansen
        2001 ISAKOS Poster Abstracts
        As a level I trauma hospital, OOU receives an increasing number of knee dislocations. This study evaluates acute knee dislocations seen at OOU from May 1, 1996, through August 15, 1999. Patients and methods: 26 patients with 27 dislocated knees were admitted in the period. All patients were students or working prior to the injury and all had a high functional level. 12 dislocations occurred in conjunction with major traffic accident – 10 of the 12 were motorcyclists, while the remaining injuries were sustained during sports. 2 patients had a complete injury of the peritoneal nerve on admittance, while an additional 4 had decreased motor strength and/or sensory dysfunction. None of the patients in this group had a vascular injury. On admittance the patients underwent a diagnostic exam in the emergency room. All the patients then had an MRI. The patients were then placed in a brace and on a CPM 2 hours times a day for 7 days, and the vascular status was monitored closely. After 7-10 days the patients underwent surgery including arthroscopic reconstruction of the ACL and PCL with auto or preferably, of available allograft. Conclusion: We have designed a treatment protocol for this difficult patient group. So far the complication frequency has been low. With one exception, the patients have returned to their previous studies or work.

        Poster 152. The autologous chondrocyte transplantation in retropatellar cartilage lesions

        Andreas Göbel, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Is the autologous chondrocyte transplantation (ACT) able to improve painful discomfort in young patients with retropatellar cartilage lesions? Method: From 01.12.1998 - 01.11.1999 we performed ACT in 5 patients with deep retropatellar chondral lesions. Pre- and postoperative status are fixed in commonly used clinical scores (Tegner, Lysholm, HSS and DGKKT). Results: The 5 patients (4 w, 1 m) with complete retropatellar cartilage damage (2 traumatic, 3 degenerative) had a mean age of 31.6 years (24-39) at the time of operation. They tolerated 3.6 (3-6) operations before the ACT. 3 patients reached Tegner score 1, 2 Tegner score 0. All five patients were out of work because of their knee pain. All patients ranged poor in Lysholm and in the DGKKT score (German score to evaluate cartilage damage) before ACT. Nearly one year (11.8 months, 7-18 months) after ACT all patients are fit in work. 1 patient reached Tegner score 4, 3 patients Tegner score 3. 3 patients obtained excellent, 2 good results in Lysholm and in the DGKKT score. All reached excellent in the HSS score after ACT. Conclusion: All patients in this group improved after ACT because of deep retropatellar cartilage lesion in all medical and social aspects. Significance: In respect of these early results ACT may be helpful in the treatment of young patients suffering from retropatellar cartilage damage.

        Poster 153. Two cases of proximal tibia fracture in sportive patients 6 months after fulkerson osteotomy

        Stefan Gödde, MD, Stefan Rupp, MD, Michael Dienst, MD, Dieter Kohn, MD, PhD
        2001 ISAKOS Poster Abstracts
        Introduction: The Fulkerson procedure has proved reliable for the therapy of patellofemoral pain associated with patella malalignment and degenerative changes. After fractures of the proximal tibia were described within the first 13 weeks under early weight bearing the postoperative regimen was adapted. Initial 8 weeks of non- or protected weightbearing are recommend, full weight bearing is allowed after the osteotomy has completely healed. Jogging is discouraged for 6 months. We report about two sportive patients sustaining proximal tibia fractures 6 months after a Fulkerson procedure. Case Series: Two patients underwent anteromedialization of the tibial tuberosity for chronic femoropatellar pain. Both had subluxation-type malalignment and patellofemoral osteoarthritis. Surgery was carried out as described by Fulkerson. The postoperative physiotherapy regimen corresponded to current concepts. The transverse, non-dislocated fractures of the proximal tibia occurred 6 months after surgery during jogging and in a stumble and fall respectively. The fractures were located at the inferior border of the osteotomy. Results: The two fractures were treated conservatively and healed without further complications. Results were excellent (95/100 points) and good (85/100 points) according to a Lysholm Knee score modified for the evaluation of patellofemoral pain. Both patients had free range of motion and were satisfied with the clinical result. Conclusion: The impact of the oblique osteotomy on biomechanical properties of the proximal tibia outlasts the process of bony healing. Compliance with a weightbearing restrictive rehabilitation regimen is important in both the early and late postoperative period after a Fulkerson procedure especially in the sportive patient.

        Poster 154. Distal realignment with adductor magnus tenodesis for patellar dislocation

        Sadafumi Ichinohe, MD, Masaaki Yoshida, MD, Akiko Koyama, Toshiki Akasaka, Takehisa Honda
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of the current study was to introduce the surgical technique of distal realignment with adductor magnus tenodesis for patients with uncontrollable patellar dislocation only distal realignment, and to report preliminary clinical results. Methods: Three cases of 3 knees diagnosed with habitual patellar dislocation and 3 cases of 5 knees with recurrent patellar dislocation were employed in the current study. The average age at surgery was 24-years-old. There were 2 right knees and 4 left knees. A mean follow-up period from the last surgery was 34 months. Surgical procedure of our distal realignment was as follows: 1) oblique osteotomy from medial anterior to lateral posterior was performed on the tibia, 2) the distal fragment was moved to the antero-medial and fixed by 4 or 5 screws, 3) the Q-angle was reduced under 15 degrees, and 4) lateral release was always performed. Additional adductor magnus tenodesis was performed in a modified technique of Avikainen. General joint laxity, Q-angle, Tegner’s activity scale, and history of patella dislocation were studied. Results: Additional adductor magnus tenodesis just after the surgery of distal realignment was performed on all knees of habitual patellar dislocation and two knees of recurrent patellar dislocation. Additional adductor magnus tenodesis was performed on one knee of recurrent patellar dislocation after recurrence of the surgery of distal realignment. There was one general joint laxity case. Thirty-two degrees of preoperative mean Q-angle was decreased to 13 degrees at follow-up. Tegner’s activity scale was evaluated 5 cases that had more than one year follow-up periods. The preoperative mean 3.6 points on Tegner’s activity scale was increased to 5.8 points. There was no patellar dislocation after additional adductor magnus tenodesis. Conclusion: Additional adductor magnus tenodesis is an excellent procedure for patients with uncontrollable patellar dislocation after distal realignment.

        Poster 155. Is there a donorsite for autologeous bone-cartilage-transplants without damaging the weight-bearing area of the knee?

        Joerg Jerosch, Tim Filler, Elmar Peuker
        2001 ISAKOS Poster Abstracts
        Background: Within the last few years autologeous cartilage-bone-grafting is becoming an established standardized procedure in joint surgery. One significant disadvantage of this technique is the harvesting of the bone plugs from the weight-bearing area of the knee joint. Purpose: The tibiofibular articulation is located close to the knee joint that is operated on. This articulation is covered with cartilage. The purpose of this study was to evaluate the question, whether this joint is suitable as a donor site for bone-cartilage transplants. Material & Methods: 10 human knee specimen were freed of all soft tissues around the proximal calf. The age of the specimen ranged between 58 and 79 years. Next the tibiofibular articulation was identified and the ligaments as well as the capsule were removed. After opening up the joint the tibial sided and fibular sided joint surfaces were inspected and measured. Results: In all specimen the articular surfaces showed good cartilage coverage. Only in one single joint the cartilage was macroscopically degenerative. In all other joints the cartilage surface was in a surprisingly good condition, especially in face of the old age of the specimen. The average diameter of the cartilage surface at the tibial side was 1.7 ± 0.26 x 1.9 ± 0.22 mm and at the fibular side 1.6 ± 0.31 x 1.8 ± 0.32 mm. This results in an area of cartilage for transplantation of 3.23 cm2 at the tibia and of 2.88 cm2 at the fibula. The total area for cartilage transplantation is 6.11 cm2. Clinical relevance: The tibiofibular joint contains cartilage, which may be a reasonable donor site even for the elderly patient. Harvesting the graft from this area may avoid iatrogenic damaging of intraarticular weight bearing cartilage of the knee joint.

        Poster 156. Localized pigmented villonodular synovitis of the knee

        Jose Hernandez-Hermoso, Jaume Calmet, Francisco Jimeno, Josep Gine
        2001 ISAKOS Poster Abstracts
        Localized pigmented villonodular synovitis (LPVS) is a rare lesion that can affect any joint but which is most frequently found in the knee. Clinically it is difficult to diagnose and plain roentgenograms are usually within normal limits. We present a series of nine cases of LPVS of the knee. The patients were seven men and two women of an average age of 36.8 (minimum 23 - maximum 49). In seven cases, the right knee was affected and in two, the left. In four cases, the nodule was found in the fat pad, in three in the posterior compartment behind the posterior cruciate ligament, in one in the meniscocapsular junction of the anterior horn of the external meniscus, and in another in the intercondylar notch region. The mean time from the onset of symptoms to diagnosis was 2.25 years (minimum 6 months - maximum 10 years). In four cases the predominant symptoms were mechanical block while in the other five there was nonspecific diffuse pain in the anterior aspect of the knee. Magnetic Resonance Image (MRI) showed hypointense nodular images on T1- and T2-weighted images which helped make the correct diagnosis in all cases. Resection assisted by arthroscopy in five cases and by arthrotomy in the four cases in which it was located in the fat pad gave an excellent functional result and after a mean follow-up of 2.9 years (minimum 6 months - maximum 7 years) there were no signs of recurrence.

        Poster 157. Optimization of MRI techniques for the evaluation of osteochondral autografting (mosaicplasty) for the treatment of articular cartilage defects

        Jason L. Koh, MD (a – Cleveland Clinic), Michael Recht, MD, Damon Petty, MD, John A. Bergfeld, MD
        2001 ISAKOS Poster Abstracts
        Introduction: MRI can provide a non-invasive, independent, and reproducible method to evaluate articular cartilage repair. We describe the optimization of the MR evaluation of mosaicplasty, the description of MR features of post-operative repair tissue, and the correlation of MR findings with clinical outcome. Method/Materials: 25 mosaicplasty patients were evaluated using the ICRS scoring system. Twelve MR examinations 13-40 months postoperatively. MR sequences were optimized on the first 3. Consensus evaluation of images was performed by four musculoskeletal radiologists. The remaining 9 were evaluated with optimized sequences. The following features were evaluated: Repair tissue signal intensity and surface integrity, congruity of bone-bone interface, bone plug incorporation, bone marrow edema, donor site appearance, and metallic artifact. Results: The optimal sequences were determined to be a fast spin echo (FSE) sequence with TR/TE/ETL/IES of 3000/43/7/14.4 with a matrix size of 252/256 and a fat suppressed T1 weighted spoiled gradient echo sequence with TR/TE/FA = 50/11/450. Repair tissue and bone plugs demonstrated increased signal intensity. Donor sites were filled with repair tissue consistent with fibrocartilage. MRI criteria were statistically analyzed for correlation with clinical outcome. Greater than 2/3 fill and minimal surface irregularity were associated with better clinical outcomes. Conclusions: FSE and fat suppressed T1 weighted gradient echo sequences were successfully optimized to evaluate the morphology and signal characteristics of repair tissue following mosaicplasty. These techniques minimized metallic artifact from the procedure, and the accurate evaluation of cartilaginous repair tissue. Greater than 2/3 defect fill and minimal surface irregularity were associated with better clinical outcomes.

        Poster 158. Osteochondral autografting of articular cartilage defects: Clinical and MRI evaluation

        Jason L. Koh, MD (a – Cleveland Clinic), Damon Petty, MD, Michael Recht, MD, John A. Bergfeld, MD
        2001 ISAKOS Poster Abstracts
        Objective: We describe clinical and MR results of 26 patients undergoing osteochondral autografting of the knee. Methods: Patients meeting strict selection criteria were treated with osteochondral grafts harvested by tubular chisel and press-fit into drilled sites. Rehabilitation was 6 weeks NWB and immediate ROM followed by gradual progression to FWB. 81% had previous failed surgery. OCD(8), osteochondral fracture(7), chondrosis(11). Mean age 30 (14-52); mean defect 250 mm2 (range 40-700). Location: MFC(17), LFC(4), Trochlea(5), patella(2). Two had 2 defects. The average number of grafts 4.5 (1-9); the most common size was 4.5 mm. Four had concomitant procedures: HTO(2), patella realignment(1), ORIF patellar osteochondral fracture(1). Follow-up (mean 2 years, range 12-39 mo) consisted of physical examination, MRI, IKDC and pain and satisfaction evaluation. Results: Pain, function, and patient satisfaction significantly improved (p<0.001). IKDC pain improved from 4 to 2.3, and activity from 3.4 to 2.2; Normal 9%, nearly normal 27%, abnormal 45%, poor 18%. MRI demonstrated persistent graft viability and maintenance of graft height. The cartilage margin surrounding the grafts appeared filled with fibrocartilage. Metal artifact was common. No infectious complications were noted. No patient complained of pain at the donor sites. 1 developed a new medial meniscal tear, 2 had persistent pain. All grafts appeared intact and stable with fibrocartilage filling the interstices of grafts at second-look. Donor sites were well-filled with bone and fibrocartilage. Conclusions: Two year results of osteochondral autografting in salvage patients are encouraging. There are significant improvements in pain and functional level, with minimal donor site morbidity.

        Poster 159. Patello-femoral joint pressures after femoral trochlear osteotomy

        Rysouke Kuroda, MD, Helen Kambic, PhD, Antonio Valdevit, MSc
        2001 ISAKOS Poster Abstracts
        Hypothesis: Anterior osteotomy of the lateral femoral condyle was designed for the treatment of recurrent patellar dislocations associated with either patella alta or with hypoplasia of the femoral trochlea. This study was designed to test the hypothesis that anterior femoral trochlear osteotomy will significantly elevate contact pressures of the patellofemoral joint. Methods: In six cadaver knees, contact pressure and area determination was performed using pre-scale Fuji pressure film and a static model invoking quadriceps and hamstrings muscle contraction. Peak pressures, average contact pressures and contact areas of the patellofemoral joints were calculated on native intact knee specimens and after anterior osteotomy of the lateral condyle. Results: The results of our study showed that average contact pressure significantly increased at 10 mm elevation at 15° and 45° of flexion (p<0.01). No significant changes were detected in peak contact pressure at 15° of flexion (p>0.05). At 45° of flexion, peak contact pressure significantly increased at 6 mm (p<0.05) and at 10 mm of elevation (p<0.01). Conclusion and Significance: Our results indicate that anterior osteotomy of the lateral femoral condyle can significantly elevate patellofemoral contact pressures in cases of excessive elevation. This procedure should be used with caution in the presence of articular cartilage damage of the patellofemoral joint.

        Poster 160. Intra-joint pressure from tubercle transfer: Caution with over-medialization

        Rysouke Kuroda, MD, Helen Kambic, PhD, Antonio Valdevit, MSc
        2001 ISAKOS Poster Abstracts
        Hypothesis: Medial transfer of the tibial tubercle has been used for treatment of patella dislocation and patellofemoral malalignment. Methods: In six cadaver knees, contact pressure and area determination were performed using pre-scale Fuji pressure film. A static model invoking quadriceps and hamstrings muscle contraction was used to reproduce tubercle transfer conditions; intact, clinically medialized and over-medialized. Q-angle as well as peak and average contact pressures and contact areas for the patellofemoral and tibiofemoral joints were calculated for each condition at 15° and 45° of flexion. Results: Clinical medialization (return to normal Q-angle) of the tibial tubercle did not significantly affect the tibiofemoral peak and average contact pressure at 15° and 45° of flexion. At 15° of flexion, further decreases in Q-angle, or over-medialization, significantly decreased the average pressure in the lateral tibiofemoral compartment (p<0.05) while significantly increasing the average pressure in the medial compartment (p<0.05). The patellofemoral joint displayed significant increases in peak pressure due to over-medialization at 15° of flexion (p<0.01), but no statistically significant differences were detected at 45°. Conclusion and Significance: The physiologic limits of mechanical stress upon articular cartilage are still not understood. Increased average contact pressures of the medial tibiofemoral compartment compounded by decreased average contact pressure laterally (due to over-medialization) lend biomechanical evidence to understanding the complication of medial joint arthrosis following medialization of the tibial tubercle. Over-medialization of the tibial tubercle can alter joint loading and thus caution should be used when performing transfers in cases of a pre-existing normal Q-angle.

        Poster 161. Arthrolysis results for treatment of post-traumatic knee stiffness

        Ivano Loreti, S. Zaffagnini, F. Iacono, E. Kon, F. Morici
        2001 ISAKOS Poster Abstracts
        Purpose: Evaluate the results of extended knee arthrolysis for severe joint stiffness at long term follow-up. Material: 33 cases (mean age 26), were clinically evaluated at a mean follow-up of 6 years (min.2-max.12). Grade IV stiffness was present in 13 cases, grade III in 7, grade II in 9, and grade I in 4 according to Blauth classification. 27 cases were related to closed fracture of mid and distal femur, 3 had tibial plateau and femur fracture, and 3 had sequele of femur infection. Mean pre-op. range was 52°. Time between trauma and arthrolysis was 19 months. In 11 cases hardware removal was performed, in 3 cases an osteotomy. Mean intraoperative range obtained was 0 degrees for extension, and 125° for flexion. Results: The results were 58% excellent, 21% good, 15% fair, and 6% bad. The mean range at follow-up was +1° for extension, and 110° for flexion. Articular range was higher for early treatment and lower for infection sequele. In all cases, improvement of range of motion was obtained. In 12% a second arthrolysis was necessary and 21% required manipulation under anesthesia in post-op rehabilitation. Conclusion: Extended arthrolysis of the knee guarantees an improvement of pre-operative range of movement. Time of surgery, etiology, intraoperative range, and aggressive post-operative rehabilitation influences the final outcome.

        Poster 162. Autologous chondrocyte implantation for treatment of cartilage defect in the knee

        T. C. Ludvigsen, A. Knopp, L. Engebretsen
        2001 ISAKOS Poster Abstracts
        Material and methods: From December 1997 to July 1999 24 patients underwent 25 autologous chondrocyte implantations. Mean age was 28 years (16-44). There were 10 females and 14 males. 14 of the patients had OCD, 9 had lesions of traumatic origin related to sports activity. All had lesions Outerbridge 3 or 4 with mean size 5.1 cm2 (1.8 cm2 - 10 cm2). 75% of lesions were located to MFC, 17% LFC and 4% patella. 19 patients (83%) were previously operated in their knee due to the chondral lesion. 2 patients underwent rearthroscopy before 6 months follow-up due to pain and swelling. Results: There no complications. The first three months all patients had swelling of the knee, but at six months this was noticed only in five cases and at twelve months in two. Eleven patients complained of pain at six months, one of them severe. At twelve months ROM was normal for all patients and 50% were pain-free. MRI findings showed tissue with normal signals in the defect in 50% at three months, 36% at six months and 57% at twelve months. A combination of hypo- and hyperdens signals described as fibrous tissue in 43%, 64% and 43% at respectively three, six and twelve months. In one patient the defect seemed empty without any tissue filling in. This patient had been treated with a simultaneous ACL reconstruction and was asymptomatic at follow-up. Clinical results at 12 months showed 81% excellent and good. 24 months rescopes and histology showed 81% excellent and good. 24 months rescopes and histology showed variable ingrowth and primarily fibrous cartilage. Conclusion: Chondrocyte transplantation seems clinically promising, but histological results at 2 years are variable.

        Poster 163. Osteochondral autograft transfer for full thickness articular surface defects of the knee – minimal two years follow-up

        Hsiao-Li Ma
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the results of osteochondral autograft transfer for full thickness articular surface defects of the knee with minimal two years clinical and histological follow-up. Methods: Twelve patients with cartilage defect of the knee were treated with OATS (Osteochondral Autograft System). The average age of them was 29 years old (from 16 to 57 years). All of those lesions were full thickness defect which included osteochondral fracture in 7, OCD in 4 and focal osteonecrosis in 1. Eleven defects over the femoral condyle and one defect over the tibial plateau. The average areas of the defects were 2.9 cm2 (from 1.5 to 4.5 cm2). The additional procedures were ACL reconstruction in 3 knees. Seven of them received second-look arthroscopies and 5 of them received MRI examination during the period of follow-up. Graft biopsy was done in 2 patients at 6 months and 3 years respectively and demonstrated normal hyaline cartilage, subchondral bone and viable chondrocytes. The average follow-up was 31.3 months (from 24 to 40 months). Results: The average preoperative Lysholm score was 48 (from 35 to 60), while the postoperative score was 92 (from 78 to 100). Eleven of them demonstrated good to excellent results and they also satisfied the procedure. Discussion: There are many limitations of this procedure, and do have some tricks and pitfalls of the technique. It is too early to determine whether the transplanted surface will maintain functional and structural integrity over time. However, the results from at least two years follow-up suggest this technique may provide a satisfied alternative for the treatment of isolated chondral or osteochondral lesions of the knee.

        Poster 164. Modified elmslie-trillat technique for treatment of objective patellar instability

        Maurilio Marcacci, S. Zaffagnini, F. Iacono, I. Loreti, F. Morici
        2001 ISAKOS Poster Abstracts
        Purpose: Evaluate the efficacy of medial patellar tendon transposition plus Elsmlie-Trillat procedure in severe patellar instability at a mean f-up of 4 y. Material: 15 cases (mean age 25, M/F 7/7) with severe objective patellar instability, were treated with distal realignment plus medial patellar tendon transposition due to insufficient achieved stability after distal realignment. In 3 cases deepening trochleoplasty was also performed. Kujala score was used for clinical evaluation. AP, LL and Merchant X-ray at 30° was also utilized. Results: Clinical evaluation showed 12 excellent results, 2 good and 1 bad. X-ray evaluation showed normalization of patellar parameters. No recurrent dislocations were observed. In 1 case a medial sub-luxation was observed. Range of motion was complete in all cases but one. No hardware removal was necessary. Conclusion: Medial patellar tendon transposition joined to distal realignment allows to control the functional instability often observed intra-operatively after distal realignment alone. This procedure can be take in consideration for adjunctive procedure for severe instability with no deleterious effect on clinical and radiographical outcome at medium long term f-up.

        Poster 165. Extensive exposure for intraarticular knee fractures: A new technique

        Sefa Muezzinoglu, MD, Hakan Gundes, MD, Kaya Memisoglu, MD, Levent Buluc, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To define a new extensive exposure for intraarticular knee fractures. Method: We describe an extensive exposure for complex tibial plato fractures in which one of the fracture lines is in close proximity to tibial tubercle. A straight mid-line incision to patellar tendon was done, extending to mid-patella and 3 cm distal to tibial tubercle. Half of the tuberositas tibia opposite to the fracture side elevated as similar to the technique used in anterior cruciate ligament reconstruction. Patellar tendon splitted along its fibers with scissors. A bone piece from patella attached to the tendon fibers opposite to the free tibial tubercle piece was cut with oscillating saw. Predrilling the patellar side with 2.7 mm drill made it easy to fix it back. After elevating both tendon halves with bone pieces on one end, one can continue to expose the joint extensively without any obstruction like patellar tendon. Bone piece on the patellar side was fixed with a mini-cancellous screw to its bed and bone on the tibial side was fixed with staples. Patellar tendon and paratenon repaired. Early passive motion was begun immediately as the main fracture allows to. After bone healing on each side of the tendon, it was secure enough to resist against forces. Conclusion: Complete elevation of the tubercle for exposure of the complex tibial plato fractures may make these fractures totally unstable. Instead, we took half of the patellar tendon off with the uninjured side of tubercle and the other half with a piece of bone from patella. This gives an excellent exposure without fixation and healing problems.

        Poster 166. Levels of carbon dioxide in sterile view helmet systems

        Edmund F. Newman, Penny H. Reilly, Chris Frampton
        2001 ISAKOS Poster Abstracts
        Sterile View isolation units are being used extensively by orthopaedic surgeons to protect theatre staff and the patient from infection during joint replacement surgery. A recent study by Rudman et al looked at the connection between symptoms experienced by surgeons and helmet carbon dioxide levels. These symptoms include fatigue, diaphoresis, nausea, headaches and irritability. It had previously been thought that these symptoms were a result of the mental stress associated with orthopaedic surgery or possibly the discomfort of wearing the helmet. The authors measured the level of CO2 in four helmets from three different manufacturers during light exercise designed to approximate the exertion of an orthopaedic operation. They found that ten of the eleven helmet configurations resulted in a mean concentration of carbon dioxide that was higher than the recommended exposure limit (5000 parts per million or 0.5 percent of room air). We measured CO2 levels in the helmet on the surgeon and his scrub nurse during joint replacement surgery. Heart rate was also measured using a Rozin Cardiac holter monitor and oxygen by ear pulse oximetry with a Nonin 850M oximeter. CO2 levels were raised in only 17% of recordings and these were found in only one individual on one particular operating list. The electrocardiogram detected no abnormalities apart from heart rate increasing with exertion as expected. The occurrence of headache and diaphoresis was minimal with the other symptoms not reported. Surgeons and theatre staff who have normal acid-base balances should be able to cope with the occasional slight increase in CO2 concentration1. Orthopaedic surgery is a very physically and mentally demanding specialty, which may be the cause of any headache and diaphoresis symptoms rather than raised carbon dioxide levels in helmet systems. Rudman et al. Levels of Carbon Dioxide in Helmet Systems used during Orthopaedic Operations. JBJS. 80-A (9) 1998.

        Poster 167. Information about knee injuries on the internet

        S. Rose, J. Bruce, N. Maffulli
        2001 ISAKOS Poster Abstracts
        We explored the volume and accessibility of information about anterior cruciate ligament (ACL) and meniscal injuries on the Internet. One hundred patients attending orthopaedic outpatient clinic were surveyed to determine Internet use and to identify the terms that the patients used to describe their injuries. These search terms were used to conduct an extensive Internet search on five search engines for information about ACL and meniscal injuries. Forty percent of patients attending outpatient clinic had searched the Internet. Over half of this patient group (58%) stated they would consider using the Internet to retrieve information about their medical condition. A total of 5947 web pages were accessed and categorised according to content. Only 393 (7%) pages contained information relevant to ACL and meniscal injuries. The number of patients using the Internet to retrieve information on their condition is increasing. As patients usually have no skills in information retrieval and the amount of information retrieved using layman’s terms is negligible, their access to reliable and valid web sites containing medical information should be facilitated.

        Poster 168. Hydroxyapatite as a bone graft substitute in tibial plateau fractures

        Etsuo Shoda, Yasuo Iida, Tsukasa Kuroda, Tomoya Sho
        2001 ISAKOS Poster Abstracts
        Purpose: “Bone defects of displaced tibial plateau fractures were necessary to be filled with cancellous bone or some other materials. The purpose of this study was to examine the relative efficacy of hydroxyapatite and cancellous autograft as graft materials for bone defects in tibial plateau fractures.” Methods: Forty six tibial plateau fractures were treated surgically between 1990 and 1998. Sixteen cases (11 male, 5 female, average age: 49.8 years-old) were filled with hydroxyapatite (HA group) and 10 cases (2 male, 8 female, average age: 55.3 years-old) were filled with cancellous autograft (CA group) for bone defects. Of 16 patients in HA group, 1 case was A0 type B-2 fracture, 13 were B-3, and 2 were C-3. Of 10 patients in CA group, 7 cases were B-3, 2 were C-1, and 1 was C-3. Anatomical and clinical assessments using HohI’s rating system were evaluated at follow-up periods averaging 12.2 months in HA group and 24 months in CA group. Results: Anatomical assessments at final follow-up showed 11 cases were excellent and 5 were good in HA group. Otherwise 3 cases were excellent, 6 were good, and 1 was fair in CA group. Clinical assessments showed 10 cases were excellent, 5 were good and 1 was fair in HA group, while 5 were excellent, 4 were good and 1 was fair in CA group. Anatomical assessments showed better results in HA group. However, clinical assessments showed no significant difference between in both group. Conclusions and Significance: Hydroxyapatite is an effective alternative to autogenous cancellous bone for the filling of bone defects associated with tibial plateau fractures.

        Poster 169. Articular cartilage paste grafting: Two to nine-year follow-up

        Kevin R. Stone, MD (a, b, d, e - Crosscart, Inc.; c - DePuy-Orthotec);, Ann Walgenbach, RN, NP, MSN
        2001 ISAKOS Poster Abstracts
        Objectives: Newer techniques of cartilage transplantation require harvest of weight-bearing cartilage or expensive in vitro growth of cells followed by open surgery. This study was designed to evaluate an arthroscopic technique which required full-thickness fracturing of an arthritic lesion to create a robust healing response followed by grafting of the fracture site with a paste of cancellous bone and articular cartilage. The paste was harvested from a notchplasty. This prospective study presents the results of a two- to nine-year follow-up of 57 patients receiving an articular cartilage paste graft for arthritic lesions. Methods: This study reports on 36 males and 21 females with an average age of 43 years and average time from first knee injury to this surgery of 8.8 years. Of these 57 patients, 27 had previously failed procedures including microfracture, chondroplasty, and debridements. The mean size of the defects was 228 mm2 (range 21-1400 mm2). The surgical technique, shown in the figures below, included chondroplasty of fragmented articular cartilage followed by morselization of the defect until bleeding occurred. Articular cartilage was then harvested from the intercondylar notch using a trephine and formed into a paste of articular cartilage and cancellous bone using a bone graft morselizer. The paste was then impacted into the defect and maintained at the defect site by clot formation. Post-surgical rehabilitation included four weeks of non-weight bearing and continuous passive motion for six hours nightly. Thirty-four patients have undergone second-look arthroscopy with core biopsy for histologic analysis and collagen typing of the grafted defect. Follow-up for this study was obtained at a mean of 5.6 years (0.5 to 9 years).
        Figure thumbnail gr2a
        Figure thumbnail gr2b
        Results: Pre- to post-operative pain scores improved from an average grade of 2.2 to 1.2 (scale of 0-3, 0-no pain, p≤0.05). Significant positive increases in activity levels were also seen pre- to post-surgically. Follow-up lesion appearance was generally smooth with color varying from grayish translucent to normal white. To date, the histologic appearance of the biopsies is consistent with immature hyaline cartilage without fibrocartilage in 12 of 34 biopsies, a mixed hyaline and fibrocartilage appearance in 14, and predominantly fibrocartilage in 8. Collagen typing has revealed a mixture of Type I and II collagen by qualitative gel electrophoresis and immunohistochemical labeling. Conclusion: The paste graft composite of articular cartilage and cancellous bone appears to provide a supportive matrix for repair cartilage formation in arthritic knees, whether or not the patients have undergone previous efforts at treatment. The procedure is inexpensive and pain relief is good with overall results linked to careful surgical technique and a well-defined rehabilitation program. Further studies are planned to prospectively compare this technique to other cartilage repair procedures.

        Poster 170. Rotational deformity of the femoral condyle in juvenile recurrent patellar dislocation

        Shinro Takai, MD, PhD, Nobuyuki Toshino, MD, PhD, Yasusuke Hirasawa, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: In recent biomechanical studies, transepicondylar axis (TEA) which passes through the origins of the medial and lateral collateral ligaments was proven to be the optimal flexion axis of the knee. Therefore, the purposes of this study were to assess the 3-dimensional alignment and the morphology of the femoral condyle in juvenile recurrent patellar dislocations by CT using TEA as a landmark of the distal femur. Materials and Methods: Dislocation group consisted of 39 knees in 26 patients who had episode of patellar dislocation. Control group consisted of 24 knees in 12 patients who had no symptom around knee. CT images of femoral neck, distal femur, proximal and distal tibia were obtained. The anterior twist angle (ATA) between TEA and the line connecting the anterior limits of the femoral trochlea was measured. The posterior twist angle (PTA) between TEA and posterior condylar line was measured. The whole twist angle (WTA) between the line connecting the anterior limits of the femoral trochlea and posterior condylar line was also measured. Results: Anteversion of the dislocation group was larger than that of the control group (p<0.05). ATA of the dislocation group was larger than that of the control group (p<0.05). WTA had no significant difference between two groups. PTA of the dislocation group was larger than that of the control group (p<0.05). Conclusions: While TEA of the dislocation group was proven to locate more externally than that of the control, the femoral insertion sites of the medial collateral ligament and lateral collateral ligament in the juvenile recurrent patellar dislocation locate externally to the normal insertion sites. Therefore, the tibia is obliged to be valgus positioned and tibial tubercle sites laterally during knee flexion. Significance: This is the first study assessing the rotational deformity of the femoral condyle in juvenile recurrent patellar dislocation using TEA as a landmark of femoral condyle.

        Poster 171. Subchondral bone reaction after repair of deep cartilage lesion with chondrocyte transplantation

        A. Vasara, MD, M. Hyttinen, MD, M. Lammi, PhD, P. Lammi, MD
        2001 ISAKOS Poster Abstracts
        The objective of this study was to develop a goat model for autologous chondrocyte transplantation and to study the histological properties of the subchondral bone after the procedure. A deep cartilage lesion (diameter 6 mm) not extending through the subchondral bone was created to the medial femoral condyle of the left knee joint of 13 adult goats. In the second operation propagated autologous chondrocytes were implanted under a periosteal flap (n=5) or in a poly-L,D-lactide composite matrix (n=4). Four goats had untreated lesions. The experimental design was approved by the Animal Care and Use Committee of the University of Kuopio. After three and six months the tissue sections were studied with quantitative microscopy. Collagen network was quantitated with polarised light microscopy. Proteoglycans were analysed after safranin-O staining. Type-Il collagen and HABR were shown immunohistochemically. Matrix was evaluated with toluidiniurn blue staining and TEM. The repair tissue formation was variable due to the frequent delamination of the periosteum. Only two lesions were filled with hyaline like cartilage tissue. Subchondral bone resorption and remodeling was seen in 7 of the 13 lesions. There were areas with small spherical cells showing strong toluidinium blue and safranin-O staining in the intercellular matrix and also staining for collagen type II in the subchondral bone. This phenomenon has not been described previously, and the cause of the reaction is not known, but altered loading conditions are among the possible explanations. Further investigation is needed to clarify the relationship between subchondral bone reaction and cartilage repair process.

        Poster 172. Cross-cultural adaptation and validation of an Italian version of the activities of daily living scale of the knee

        Mario Tartarone, MD, Emilio Romanini, MD, Raffaele Iorio, MD, Alfredo Schiavone Panni, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To perform the cross-cultural adaptation and validation of an Italian version of the Activities of Daily Living Scale of the Knee (Irrgang et al. 1998). Introduction: Health Related Quality of Life (HRQoL) measures progressively replaced traditional physician-derived scores for the evaluation of musculo-skeletal conditions. A great number of questionnaires have been validated, but in order to be able to compare surgical results, it is very important to use standardised outcome instruments. Practice variations analyses emphasized the need to compare outcomes of treatment beyond single nations, promoting multi-cultural research projects; such studies should always include appropriate health status measures and if validated version in all languages are not available, it is mandatory to cross-culturally adapt them in other than the source one (usually English). Method: The Activities of Daily Living Scale of the Knee, a regional outcome assessment tool, proved to be a reliable, valid, and responsive instrument for the assessment of functional limitations that result from a wide variety of pathological disorders and impairments of the knee. The self-administered questionnaire was selected because of its sound properties, and a process of cross-cultural adaptation and validation of an Italian version was performed on a series of patients before and after ACL reconstruction, following criteria suggested by Guillemin in 1993. Results: Our data suggest that the Italian adapted version of the Activities of Daily Living Scale of the Knee is a reliable, consistent and valid instrument for measuring health status and physical functioning in patients with ACL deficiency and reconstruction surgery. Conclusion: The Italian adapted version is comparable with the original one and this will allow confrontation of data and metanalysis in knee surgery.

        Poster 173. In-vivo anterior cruciate ligament strain behaviour during rapid deceleration

        Giuliano Cerulli, MD, Daniel Benoit, MSc, Auro Caraffa, MD, Mario Lamontagne, PhD, Alfredo Schiavone Panni, MD
        2001 ISAKOS Poster Abstracts
        Introduction: The mechanism of ACL injury is still unclear. To gain this insight, knowledge of the mechanical behaviour of the healthy anterior cruciate ligament during activities believed to be stressful must be investigated in-vivo. The goal of this research is to measure ACL strain in-vivo during rapid deceleration, a sport type movement that has been previously shown to precede injuries to the ACL [2] in healthy subjects. Material and Methods: A group of 4 young male subjects with no previous knee joint injuries volunteered after informed consent. The strain guage device (DVRT MicroStrain Systems) was calibrated and surgically implanted in the antero-medial band of the intact ACL [3]. The subject was then transported to the lab for data collection. The zero strain position of the ACL was determined using the slack-taut technique [1]. The subject hopped for speed from a distance of 1.5 m to the target, an X taped at the centre of a force plate (Bertec model 4060), landing with the instrumented left leg and stopping in the landed position. The entire collection window was 5 seconds at 1000 Hz. A total of three rapid deceleration trials were collected and averaged. The slack-taut test was then repeated to ensure proper operation of the strain guage and the reliability of the results. Results and Discussion: The average peak strain of the ACL during the instrumented Lachman test was 1.763+/-0.175%. The average peak strain of the ACL during rapid deceleration task was 4.24+/-0.293%. This first subject data indicates that the deceleration caused a considerable increase in peak ACL strain. This technique may be used in further sport-specific movements to gain insight into ACL injury mechanics. References: [1] B.C. Fleming, B.D. Beynnon, P.A. Renstrom, R.J. Johnson, C.E. Nichols, G.D. Peura, B.S. Uh (1999) Arthroscopy. 15(2): 185-191. [2] J. Feagan (1985). [3] B.D. Beynnon, J.G. Howe, M. II. Pope, R.J. Johnson, B.C. Fleming (1992) Int Orthop. 16: 1-12. Acknowledgments: The authors wish to thank Prof. Ejnar Eriksson for his guidance.

        Poster 174. A new sign for the diagnosis of acute posterior cruciate ligament injuries

        Myles Coolican
        2001 ISAKOS Poster Abstracts
        A new and previously undescribed sign in the diagnosis of acute posterior cruciate ligament (PCL) injuries is presented and its reliability documented. In the presence of an acute isolated Grade I - III PCL injury, active resisted knee flexion at or close to 90 degrees reliably produces popliteal pain as the tibia abnormally translocates posteriorly. This pain is often accentuated if resisted active knee flexion is combined with active ankle plantar flexion allowing the gastrocnemius muscle to act as a secondary knee flexor. When the manoeuvre is repeated whilst actively dorsi flexing the ankle and co-contracting the gastrocnemius-soleus complex with tibialis anterior, the pain is reduced or abated as a result of the co-contracted gastrocnemius acting as a mechanical barrier to posterior drawer. The sign is particularly useful in patients with considerable pain in whom examination may elicit much discomfort and protective spasm. A validity study of this physical sign has been conducted amongst blinded registrars and knee surgeons, comparing the results of this physical sign with MRI as a goal standard. The test is highly specific with two false positives and no false negatives in 50 consecutive evaluations of MRI proven Grade I - III posterior cruciate ligament injuries.

        Poster 175. ACL reconstruction as day surgery

        Peter Faunoe, MD
        2001 ISAKOS Poster Abstracts
        From December 1999 to June 2000 we have performed 75 ACL reconstructions as day surgery. One week before planned surgery patients are instructed by physiotherapists how to use splint and crutches and by nurses how to use analgesics. All patients were operated with Semi-T technique mainly in spinal anaesthesia. No drainage was used. In recovery room all patients received one or two injections of morphine. All operations took place in the morning and the patients were discharged between 3 and 5 pm with 8 500 mg panodil, 4 tablets of 600 mg ibuprofen and 6 tabl with 5 mg Ketogan. The patients were instructed to use cryo compression the first three days. Knee splint is used for 2 weeks full weight bearing with crutches was allowed from first day. The patients were seen one and two weeks after surgery. Each of the first three days a nurse called the patient at home to assess the pain and use of analgesics, further the patients were asked to fill out a form 2 weeks after surgery in order to assess patient satisfaction. Results: Two out of 75 patients could due to pain not be discharged the day of surgery. The rest (73) were satisfied with the day surgery procedure and all patients would go through a similar procedure if necessary. In average the patients used 4 (0-8) panodil, 3 (0-4) ibuprofen and 1 (0-5) ketogan. On a visual analog pain scale (0-10) the patients scored first post op day 4 (1-8) second day 3 (0-7) and third day 2 (1-6). Conclusion: The patients are very satisfied with our setup for day surgery. There has to be a possibility for letting the few patients with high pain score staying overnight at the hospital.

        Poster 176. Are patients over 40 years of age suitable for ACL reconstruction?

        Guillermo Arce, MD, Pablo Lacroze, MD, Fernando Barclay, MD, Enrique Pereira, MD
        2001 ISAKOS Poster Abstracts
        Introduction: ACL reconstruction in patients who are more than forty years old remains controversial. Delay in graft integration, higher incidence of articular rigidity and a difficult rehabilitation have been described in this age population. Objective: To evaluate our results in ACL reconstruction in the over forty population using patellar tendon (PT) autograft and quadrupled semitendinosus and gracilis (ST/G) autograft. Method: Fifty-four patients (56 knees) with ACL reconstruction were retrospectively reviewed. The average age at surgery was 43.3 years (range 40-57). Mean follow-up was 41.2 months (12-96). Twenty-two knees (39.2%) had an isolated ACL lesion; thirty-four (60.7%) had associated lesions. Thirty-seven males and seventeen females were operated on; PT was used in 37 knees, and ST/G in 19. Selection criteria were age, gross clinical instability, high functional demands, and minimum follow-up of twelve months. Subjective and objective results were analyzed with the use of Lysholm and Guillquist and International Knee Documentation Committee (IKDC) scores. Results: Assessment with Lysholm score averaged 92 points; 91% of the evaluated patients were considered normal or nearly normal when assessed with the IKDC. The complication rate (10.7%) was similar to that observed in younger patients. Conclusions and Significance: Arthroscopically assisted ACL reconstruction is a predictable procedure in patients over forty years old who have severe knee instability, high functional demands and want to continue with intense sport activity. This group of patients could be reconstruct with good and excellent outcomes and similar results than younger population.

        Poster 177. Anterior cruciate ligament reconstruction: A comparison of 2 techniques

        Guillermo Arce, MD, Santiago Butler, MD, Pablo Lacroze, MD, Fernando Barclay, MD
        2001 ISAKOS Poster Abstracts
        Objective: The purpose of this PROSPECTIVE RANDOMIZED study was to determine the efficacy of ACL reconstruction and compare the results using two different autografts: Double looped semitendinous and gracilis graft (DLSTG) and bone patellar tendon graft (PTG). Methods: Forty-seven patients were operated on using bone patellar tendon graft (PTG) and forty-five using double looped semitendinous and gracilis graft (DLSTG). Age, sex distribution, duration from injury to surgery, and preoperative laxity were not significantly different between both groups. All patients were operated on by the same surgeon. The PTG was fixed with two interference screws; we used femoral cross pin fixation and two staples for the DLSTG. The mean follow-up was 42 months (24 to 144 months). Functional results were evaluated using the Lysholm test, IKDC score. Results: Assessment with Lysholm score averaged 94 points for PTG group and 92 for DLSTG group. Ninety-three percent (93%) of PTG and 90% of DLSTG were considered normal or nearly normal when assessed with the IKDC. Both grafts proved to be successful in achieving knee stability (Lachman test and pivot shift test) and return to sports activity (Tegner score). The PTG group proved to have better objective stability in the long-term assessment, although patellofemoral symptoms and donor site morbidity were higher. Conclusions: No significant differences were revealed between the two groups. Based on this data, we routinely use PTG as first choice. DSLTG is specifically indicated in selected cases where either older patients are involved, patients with preexisting patellofemoral problems, or those with failed patellar tendon grafts.

        Poster 178. Isometric measurement of medial patellofemoral ligament reconstruction for recurrent dislocation of patella

        Shintaro Asahina, Masamitsu Tsuchiya, Masaki Okuda
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the change of the distance between patellar and femoral insertion of medial patellofemoral (MPF) ligament in MPF ligament reconstruction. Methods: Length change of MPF ligament was measured intraoperatively in 18 knees of 17 patients, whose patella was recurrently dislocated or subluxed. Isotac and isomeric positioner (Acufex) was used. Isotac was anchored at just distal of the adductor tubercle of femur. Isometric positioner was inserted Into the drill hole, which was created at distal one third of the patella. Knee was flexed from full extension to 120 degree flexion, and the length change was recorded at 30 degrees interval. Two dimensional X-rays were also taken, and the location of an isotac was evaluated. Results: The pattern of length change was classified into three groups: 1) the distance was getting longer as the knee was flexed deeper, 2) the distance was getting longer, as the knee was extended, and 3) the distance got longer both at near terminal extension and flexion. The relationship between these groups and position of isotac was highly correlated. At the first trial of isotac anchoring, the maximum change ranged from 0.5 to 9 mm. In all cases, maximum change could be improved to less than 5 mm, by changing the position of isotac. For example, when the length pattern belongs to group 1, an isotac should be moved more distally. Conclusion: These results demonstrated the distance between femoral and patellar insertion of MPF ligament was eliminated less than 5 mm determining the femoral insertion site carefully. Significance: Isometric measurement was an essential procedure in MPF ligament reconstruction.

        Poster 179. The double semitendinosus and gracilis tendon graft as for the anterior cruciate ligament. A rigid connection technique

        Niso Eduardo Balsini, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To present a technique for the LCA reconstruction using the semitendinosus and gracilis tendon graft with high load capacity and small elongation device. To discuss about important details to achieve a good performance in the LCA reconstruction, when using this technique. Method: The authors analyse the rapid advance observed in the use of the semitendinosus and gracilis grafts as a substitute for the LCA in the latest years. This is due to the motivation of surgical modifications techniques, the most the complications with the patellar tendon graft are better known. They show their personal experience with the technique using a femoral plate (similar to EndoButton) to the femoral fixation and a little cancellous screw to the tibial fixation, after 5 years of use and with 186 cases done, up to September the year 1999. The effectiveness was proved with comparative study in surgeries carried out with the patellar tendon for the same authors, that showed similar results to the ones described in the literature and are published in the Revista Brasileira de Ortopedia, vol. 35, no. 4, May, this year 2000. However, based on authors’ research, as John To, Morgan, Ishibashi, Arnoczky, Rodeo and Pinczewski et al., improvements were done in the fixation complex, to allow early physical therapy and more stable joints, when using the double semitendinosus and double gracilis tendon graft. They relate the modification in the femoral fixation, for a rigid connection technique, with high load capacity and small elongation device. In this technique, the tendon graft is directly connected to an inox metal device directly attached to the cortical femoral bone, removing intermediaries and improving this way the rigidity of the connection. Results: 25 knee surgeries were done with the new technique up to May this year 2000. At the pretensioning graft, different results are achieved: One cm or less of graft elongation before the rigid connection and the maximum 0.4 mm with the new technique. Early physical therapy with the accelerated protocol was allowed, even though, with the higher stiffness of the fixation complex, limited ROM of the joints could appear in the results. Conclusion: They consider the increasing of rigidity of the fixation complex, the most important factor to achieve more stable joints. The rigidity graft fixation goes on in wide steps towards its improvement, and must be in the future, a large differential among the most used techniques. Significance: The importance of the rigidity of the fixation complex is now well known and must be considered when we are involved in the LCA reconstruction. Using a rigid connection technique, we are able to achieve better results and more stable knees.

        Poster 180. Patellar tendon versus doubled semitendinosus and gracilis tendons in the LCA reconstruction

        Niso Eduardo Balsini, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The authors propose a comparative evaluation between the two methods, based upon a hundred (100) chronic knees operated, then fifty from July 1991 to September 1994 using the bone patellar tendon (BPT) and fifty from November 1994 to February 1997, using doubled semitendinosus and gracilis tendons (D/St/Gr). Method: All the surgeries were done by arthroscopy in an out-patient system, always by the same surgeon indistinctly for active patients, male or female and also independent of the activity, recreational or professional sport. The rehabilitation was guided by the same protocol. The exception was that there was no hurrying on recovering the final extension in the patients D/St/Gr in the three first weeks. Results: On the subjective evaluation and return to daily activities, pointed 88% for BPT and 90% for D/St/Gr. As for return to sport, 79% for BPT and 81% for D/St/Gr. The presence of final extension limitation was more frequent in BPT (16% and 2% of D/St/Gr). The patello femoral crepitation was noted in 12% of BPT and 2% of D/St/Gr. The determination of laxity carried out by manual maneuvers (Lachman, anterior drawer in external rotation and Pivot Shift) and they observed the knees more loosen but subjectively stable in D/St/Gr cases, with progressive improvement the moment they carried out the pretensioning graft (Lachman +/22%/BPT and Lachman +/24%/D/St/Gr). They did not observe significant loss of strength in the extensor mechanism on those knees appropriately treated in the rehabilitation, neither significant loss of strength of flexors under the same conditions. Conclusion: The search lead us to the conclusion that the two methods are good for the final figures when done by arthroscopy. Improvements must be done in the fixation complex of the D/St/Gr to achieve more stable joints. Significance: Both grafts can be used by the surgeon to the LCA reconstruction. Considerations on increasing the graft fixation stiffness must be done, when using the D/St/Gr tendon graft.

        Poster 181. Patella fracture complicating arthroscopic anterior cruciate ligament reconstruction

        Guy Bellier, Patrick Djian
        2001 ISAKOS Poster Abstracts
        Patella fracture is either an infrequent or underreported complication after arthroscopic reconstruction of the anterior cruciate ligament-deficient knee using the middle third of the patellar tendon. Thirteen cases of isolated patella fracture after ACL reconstruction were reported in the literature. Seven of all were postoperative complications and 6 occurred during surgery. The postoperative fractures were Y-shaped stellate and occurred as the result of a direct blow to the patella. We reported 3 cases of patella fractures occurred respectively within 6 weeks, 2.5 months and 3 months after surgery. These three fractures were operated on with reduction and using K-wires and cerclage compression. One of these fractures must be reoperated with bone graft because of a pseudarthrosis. The physiotherapy has been done immediately after surgery. Complete healing was obtained between 2 to 3 months. Hardware removal was made between 3 to 6 months in all cases. The mean follow-up was 12 months. Results based on IKDC system showed no difference with a non-complicated group. This was a complication but final results were good. Primary bone grafting of the patellar region is recommended as a simple and safe solution especially if a graft wider than 10 mm is taken. This fracture is close to stress fracture of the patella in athletes.

        Poster 182. Radiological location site of ACL femoral insertion. Proposal for a new method of x-ray location

        Ignaki Benareau, Eric Berthonnaud, Jean Luc Besse, Jean Luc Lerat, Johannes Dimnet, Bernard Moyen
        2001 ISAKOS Poster Abstracts
        Purpose: In order to develop an useful X-rays method available intraoperatively a cadaveric and X-ray study was performed, in order to evaluate the femoral ACL location. Methods: 13 cadaveric knees have been dissected free and the femoral insertion outlined. A 2 mm metallic ball was positioned at the center of the ACL femoral insertion. For each knee, 3 X-rays were taken: True lateral, and a 15° internal and external rotation views. The marker location was compared to the quadrant method of Hertel and circle method of Amis. A new technique of X-ray location was developed using a triangle method. Results: On true lateral view the linear distance between the metallic marker and the supposed ACL center indicated by the Hertel method is 3.5±2.1 mm, and is 6.9±2.3 mm by the Amis method. These distances in case of internal or external rotation increase for the Amis method. The new triangle method use the length of the femoral condyle along the Blumenstaat line. The perpendicular to this line located at 32±4.4% from its most posterior part (a). This line crosses the femoral condyle at the tip of the triangle. The marker is located on this perpendicular at 30±2.5% from its base (b). If we use this triangle method the mean distance between the center of the ACL and the supposed ACL center determined by this technique is only 1.9±1.1 mm. Conclusion: The new method gives a more precise location of the center of the ACL femoral location and can be used as radiological landmarks during ACL reconstruction.
        Figure thumbnail gr3a
        Figure thumbnail gr3b

        Poster 183. Anatomic onlay posterior cruciate ligament reconstruction

        John Bergfeld, MD, David R. McAllister, MD, Richard Parker, MD
        2001 ISAKOS Poster Abstracts
        The posterior cruciate ligament (PCL) is the primary restraint to posterior translation of the tibia in the intact knee. There is evidence that certain grade III injuries to the PCL and those PCL injuries associated with other capsuloligamentous injuries will progress to symptomatic chronic, abnormal laxity and/or post traumatic arthritis. PCL reconstruction is the preferred surgical treatment, however the results are inconsistent. Studies performed in our biomechanics laboratory demonstrate less posterior knee laxity with the anatomic tibial onlay technique when compared to a tibial tunnel technique. We believe methods of PCL reconstruction utilizing a tibial tunnel may be responsible for the variable results following PCL reconstruction. In this instructional video, we show our technique of anatomic onlay PCL reconstruction.

        Poster 184. The surgical treatment of ACL deficient knee associated with varus deformity: Long-term results of a randomized perspective study

        Massimo Berruto, Eugenio Uderzo, Alberto Tassi, Eva Usellini
        2001 ISAKOS Poster Abstracts
        Objectives: The goals of the present study were to evaluate prospectively the long-term clinical and radiographical results of the surgical treatment of ACL chronic deficiencies associated with varus deformity (double or triple according to Noyes’s classification) and to relate those data to two different surgical procedures (HTO vs. HTO+ACL reconstruction). Methods: Between 1987 and 1995 27 ACL deficient knees associated with varus deformity (double varus) were observed in our Dept. All were male ranged in age between 21 and 46 years (mean 31 years). Patients with double varus equal or less than 10° and degenerative changes grade 2-4 Fairbank were included in the study; an isolated closing wedge HTO (12 cases) or a closing wedge HTO associated with ACL arthroscopic reconstruction (15 cases) was randomly performed. A control group of 14 ACL reconstruction performed in the same period homogeneous for age and sex distribution was considered. 39 patients (11 HTO, 14 HTO+ACLR, 14 ACLR) were prospectively evaluated at a mean follow-up of 7.3 years (4-11 years). Patients were divided into three groups: G.1: HTO (11 cases); G.2: HTO + ACLR (14 cases); Gr.3: ACLR (14 cases) and were evaluated subjectively (pain and stability according to IKDC), objectively (Lachman, Pivot shift, KT-1000), functionally (one-leg-hop and Tegner) and radiographically (Standard views and Rosenberg views). Unpaired t-test and paired t-test were used to evaluate statistically the results (p<0.001). Results: Subjectively pain has significantly improved (p<0.001) from 9% to 72% in Gr.1 and from 28% to 72% in Gr.2 but the results were significantly less good (p<0.001) if compared with those of the control group (90% of normal or nearly normal). Objectively Lachman was negative in 18% in Gr.1 , 57% in Gr.2 and 70% in Gr.3, while Pivot shift was negative in 45% in Gr.1, 71% in Gr.2 and 80% in Gr. 3. Those differences between groups were statistically significant (p<0.001). Functionally the results of the control group (Gr.3) were significantly better at one leg hop test and in terms of activity level. With lKDC score the results were graded normal or nearly normal in 72% in Gr.1, 78% in Gr.2 and 90% in Gr.3. Radiographically we did not observe significant worsening of degenerative changes in both groups and in the control group. Conclusions: The results of the surgical treatment of ACL deficient knee associated with varus deformity are subjectively good but are significantly worse in terms of function restoring if compared with ACLR in normal knees. Closing wedge HTO associated with ACLR showed better results than isolated HTO . The results of the present study confirm that in varus knees it is necessary to treat ACL insufficiency as early as possible . The surgical treatment of an ACL deficient double varus knee needs to be considered a salvage procedure.

        Poster 185. Anterior cruciate ligament reconstruction in patients over the age of fifty: Medium to long term follow-up

        Mark Blyth, FRCS (Orth.), Marminder Gosal, FRCS (Orth.), Wendy Peake, B.Manip. Physio., John Bartlett, FRACS
        2001 ISAKOS Poster Abstracts
        The medium to long term results of a prospectively followed group of patients over the age of fifty at the time of anterior cruciate ligament reconstruction are presented. Thirty-one consecutive patients with a mean age of 54.7 years (range 50-66) underwent 32 procedures between October 1995 and May 1999. All patients were interviewed and examined at a mean follow-up time of 47 months (range 12-173). Patients were evaluated using the Lysholm and Gillquist, Cincinnati and International Knee Documentation Committee (IKDC) scores, with activity levels assessed using the Tegner activity scores. Side-to-side differences in ligament laxity were measured using the KT-1000 arthrometer. For patients with a normal contra-lateral knee, isokinetic testing of knee flexion and extension strength was carried out and the torque ratio of the strength of the reconstructed knee against the normal knee calculated. The mean Lysholm score improved from 62 (range 32-95) preoperatively to 93 (range 76-100) at review. Similar improvement was seen with the Cincinnati score from 48 (range 18-73) to 89 (73-100). 81% of knees were considered normal or nearly normal according to their IKDC score. Six knees were abnormal with no severely abnormal results. Tegner Activity levels improved from a preoperative value of 3.6 (range 1-7) to 5.2 (range 3-8) at review. The mean side-to-side difference measured by the KT-1000 at maximal manual pressure was 2.9 mm (range 2-7). There were three patients with a measured difference greater than 5 mm. The mean torque ratio for isokinetic flexion strength was 102% (range 74-146) and for extension strength 95% (range 46-126). Poor results as determined by the three scoring systems were mainly associated with advanced articular degenerative changes (Outerbridge 3 or 4) seen at the time of reconstruction. Despite this all patients reported an improvement in the stability and overall function of their knee. Degenerative change itself was associated with increased time to surgery from injury, an increased preoperative re-injury rate and a mild reduction in terminal flexion at review.

        Poster 186. Aetiologic and clinical features of tears of the menisci with mucoid degeneration

        Hakan Boya, MD, Halit Pinar, MD, Zeynep Gülay, MD, Erdener Özer, MD
        2001 ISAKOS Poster Abstracts
        Objective: Tears of the menisci with mucoid degeneration have been more common than mentioned in the literature. The pathology deserves special interest as it may lead to loss of the meniscus even in a very young individual. The aetiology and clinical features of mucoid degeneration of the meniscus have not been well understood. The purpose of the present study is twofold: A) to investigate the role of four proposed factors in the aetiology of mucoid degeneration of the menisci - age, repetitive trauma, bacterial infection and genetic factors, and b) to analyze the clinical features of torn menisci with this pathology. Methods: Meniscal samples obtained from 27 patients during arthroscopic resection of the torn menisci thought to be due to mucoid degeneration were sent for pathologic and microbiologic investigation. The samples were scored according to the light microscopic criteria of Copenhaver; 24 menisci (23 patients) with grade 2-3 mucoid degeneration comprised the study group. The average age of 14 men and 9 women was 36 years (range, 16-68 years). 17 patients’ ages were less than 40 years. Magnetic resonance imaging obtained in 11 patients typically revealed increased intrasubstance signal intensity that extended to one of the meniscal surface. Wide spectrum polimerase chain reaction (PCR) primers that can recognize protected sequences on bacterial 16 S rRNA gene were used to assess the presence of bacteria. Tissue typing could be done in 18 patients and compared to 27 control subjects. X2 and Fisher’s tests were used for statistical analyses. Results: 13% (3/24) of the knees had no history of trauma. 39% of the patients were active in some kind of athletic activity; Tegner activity levels ranged between 1 and 7 (average 4). The duration of symptoms was average 11.6 months (range, 1-36 months). Pain was the most frequent symptom (n=22). Joint line tenderness and McMurray’s test were present in 22 and 16 knees, respectively. Medial meniscus was affected in 16, and lateral meniscus was affected in 8 knees. Meniscus cyst and incomplete discoid meniscus were present in 5 and 2 of the lateral menisci, respectively. All the torn menisci were degenerated and yellow in color. As for HLA typing, DR17 (p=0.0203) and DQ3 (P=0.03668) antigenes were statistically significantly more frequent in the study group. PCR study revealed no presence of bacteria. Conclusion: Bacterial infection has no role in the etiology of mucoid degeneration of the meniscus. It is not related to the aging process, either. Genetic factors are probably important. Clinical findings of such torn menisci are insidious when compared to traumatic tears. Lack of history of trauma may delay the diagnosis. Significance: Mucoid degeneration is a disease of the meniscus. Future studies should aim at a better understanding of the structural defect and at the treatment of this disease before it leads to loss of meniscus.

        Poster 187. ACL reconstruction using human allograft

        Jens Buelow, Rainer Siebold, Ludwig Boes, Andree Ellermann
        2001 ISAKOS Poster Abstracts
        Introduction: The morbidity associated with autograft harvest has increased the interest in allografts. However, the decrease in tensile properties with sterilization and preservation as well as risk of inflammatory reaction has been a concern. Methods: We evaluated the clinical outcome (IKDC, CKS, KT-1000, standardized x-rays) of 325 fresh-frozen allografts (BTB n=265, Achilles tendon n=60) for ACL Reconstruction. There were 224 (69%) primary reconstructions (Group P) and 100 (31%) revisions (Group R). Patients (average age 38 yrs) were operated between 5/1993 and 2/1998. Mean f/u was 38 months (24-74). Results: Overall rating with the CKS of 84 in group P and 82 in group R showed a high subjective acceptance of the procedure among the patients, with a high rate of return to pre-injury activity level. According to IKDC 76% of group P and 67% of group R were in group A and B. Manual maximum KT-1000 side to side difference at f/u was 2.1 mm in primary reconstructions and 2.3 mm in the revisions. Full extension was rapidly achieved in all cases and flexion averaged 135 degrees. There were 21 reruptures (9%) in group P and 9 (9%) in group R (83% of these traumatic). No significant difference in clinical results could be seen between Achilles tendon and BTB grafts. There were no inflammatory reactions. Discussion and Conclusion: Our study shows that favourable results can be obtained with Achilles tendon and BTB allografts and their use can be justified when the surgeon and patient choose this approach.

        Poster 188. ACL reconstruction with hamstrings

        Gilberto Luis Camanho, MD, PhD, Rogerio Olivi, MD, M.Sc., Arnaldo José Hernandez, MD, PhD, Márcia Uchôa de Rezende, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To present the experience of ACL reconstruction with hamstrings fixed with “Endobutton” in 145 cases with minimum follow-up of 2 years. Method: The authors present the follow-up of 145 cases of ACL injury reconstructed endoscopically with hamstrings between 1995 and 1998. The casuistic showed a 3 men to 1 woman ratio. Average age of 27.4 years. Sports related trauma in 42% of the cases. The fixation was done by the use of an “Endobutton” of the femoral side and screw/washer on the tibial side. Postoperatively the patients used a rehabilitation brace for 3 weeks followed by progressive rehabilitation protocol (not accelerated). All cases were operated and analyzed by the same team of surgeons according to the Cincinnati score and to a subjective evaluation. Results: Two years of minimum follow-up revealed 89% good results (Cincinnati) and 94% of good results according to a subjective evaluation based on the return to the activities of daily living and to sports. Conclusion: ACL reconstruction with hamstrings fixed with “Endobutton” is reliable. Significance: The authors present a method of ACL reconstruction with hamstrings fixed with “Endobutton” that reproduces the good results obtained by conventional methods considered as “gold standards.”

        Poster 189. Management of medial collateral ligament laxity

        John C. Cameron
        2001 ISAKOS Poster Abstracts
        The relationship between the axial alignment of the knee and the symptomatic instability of medial collateral ligament (MCL) laxity is very important. Understanding the biomechanics of the knee will help in the management of these complex ligamentous injuries. The conservative management of grade I and II sprains and the surgical management of grade III sprains of the acute isolated MCL injury is generally accepted. More controversy exists regarding the treatment of combined injuries involving the anterior cruciate ligament (ACL) and MCL, with some favouring the conservative management of both ligament injuries and others advocating non repair of the MCL in conjunction with augmented ACL repair. This paper presents a rationale for management of the chronic or late MCL injury. The vaIgus knee with MCL laxity is much more symptomatic than the varus knee with the same degree of laxity. The gait pattern of the patient with valgus alignment and MCL laxity demonstrates a distinct medial thrust on load bearing as seen in Figure 1. Biomechanical studies have shown that the MCL carries as much as 81% of the ligamentous load during vaIgus loading. The patient generally describes this medial thrust as his or her “instability.” Traditional surgical techniques, such as the pes anserinus transplant, have proven to be highly successful for late construction of the MCL in the normal knee but have been generally unsuccessful in the vaIgus knee. The reconstructed MCL gradually stretches, and the symptomatic instability recurs. Only by defunctioning the ligament by changing the axial alignment of the knee can one avoid this recurrence.

        Poster 190. Medial meniscal cyst: A report of three cases

        Jaime Catalan, Ronald Schulz, Carlos Infante, Patricio Erskine
        2001 ISAKOS Poster Abstracts
        Medial meniscal cyst is a rare condition. Only a few studies about this lesions have been published. We present the experience with three patients, 2 females and 1 male, average age 44 years, who developed a painful mass at the medial side of their knees. The mass had an elastic consistency and the MRI and ultrasonography study showed a direct relation with the medial meniscus. All three patients underwent arthroscopic surgery. The arthroscopic examination confirmed that the cyst mass was continuous with the medial meniscus. The cyst was arthroscopically removed in all cases and also a partial meniscectomy was performed in them because of a meniscus tear. No postoperative complications were found and there was an excellent functional outcome at an average follow-up period of 12 months. Since 1995 we have operated more than 1500 patients at our department. These 3 cases described before are a very rare diagnosis and arthroscopic treatment has good results.

        Poster 191. The lars ligament for salvage of PCL and combined deficiencies of the knee

        Amit Chandratreya, FRCS(Orth), Paresh Sonsale, FRCS(Orth), Ian Forster, FRCS
        2001 ISAKOS Poster Abstracts
        The object of this study was to see whether the artificial polyester Lars ligament (Ligament Advanced Reinforced System) is a salvage option in the management of PCL and combined instabilities of the knee. The advantages are no donor site morbidity, immediate strong and functional ligament, stable fixation, decreased operative time and early rehabilitation. Since 1995, we have treated 28 such patients (30 knees). The mechanism of injury was RTA: 18, sports: 10. Previous history: PCL reconstruction 21%; ACL reconstruction 8%; Open dislocation 8%; Polytrauma 17%; Primary repair 8%. The average age of the patient was 33.16 years (19 to 53). Additional ACL reconstruction was required in 8 (26%). A HTO was performed in 2 patients. LCL was reconstructed only in highly unstable knees (18%). All patients were braced for 4-5 weeks. All patients were reviewed. They were independently assessed using the IKDC form, HSS score & SF-36 questionnaire. The average follow-up was 2.6 years (0.7-5 years). Results: IKDC: Group A 3%; Group B 27%; Group C 40%; Group D 30%. HSS scores: Good-Excellent 30%; Fair+ 30%; Fair- 10%; Poor 30%. 50% of patients required another operation. 35% continued to have giving way and 50% still had some pain. 75% of the patients were satisfied. Only 20% were able to return to original sports. We have found that the artificial LARS ligament to be a safe graft, with good results in these highly unstable injuries.

        Poster 192. A radiological comparison of bone-patella-bone and hamstring ACL reconstructions by way of the telos system

        V. Chassaing, F. Combelles, Y. Julien, J. Lemoine, J. E. Perraudin
        2001 ISAKOS Poster Abstracts
        A number of investigators have compared ACL reconstructions utilizing bone-patellar tendon-bone (B-T-B) and hamstring grafts. Radiological evaluations can supplement the physical examination. The purpose of this study has been to study the Lachman test radiologically via the Telos system. The study is retrospective and includes two series of reconstructions performed between October 1996 and October 1998. The inclusion criteria for both series were identical: Age greater than 18, unilateral ACL surgery, and minimum follow-up of 1 year. There were 39 patients with B-T-B and 115 with hamstring grafts. The surgery consisted of an arthroscopically assisted reconstruction utilizing either the central third of the patellar tendon or 4 strands of the pes tendons. Rehabilitation protocols were identical for all cases. All patients were evaluated with the Telos system both pre- and postoperatively (25 Kg force). The healthy side was used as a control. Preoperatively, patients in both series featured a similar differential between injured and healthy side: 10.1 mm for the B-P-B and 10.2 for the hamstring group. Postoperatively, the differential had dropped to 6.6 mm for the B-P-B group and to 4.8 mm for the hamstring group. This represents an improvement of 33.7% for the B-T-B group and 51.3% for the hamstring group. This was statistically significant (p=.0053). There was no correlation with gender, meniscal lesions, fixation mode, or supplementary extra-articular reconstruction. In this study, correction of the anterior drawer was better addressed by way of the hamstring graft relative to the B-T-B graft. This finding is contrary to previous studies that have utilized the KT-1000 as the measure of laxity. Although our study was not prospective, the results obtained in two different series by the precise and operator-independent Telos system are noteworthy.

        Poster 193. Hypertrophy of the anterior cruciate ligament

        Sung-Do Cho, MD, PhD, Tae-Woo Park, MD, Seoung-Oh Yang, MD, Sung-Sook Kim, MD
        2001 ISAKOS Poster Abstracts
        Objective: To propose the diagnosis, “hypertrophy of the anterior cruciate ligament (ACL),” and its clinical, radiological and pathological characteristics. Methods: Since Dec. 1995, we have experienced 10 patients (12 knees) with “hypertrophy of the ACL” which we named. There were 2 men and 8 women, and the age of the patients ranged from 35 to 67 years. Characteristics of clinical, radiological and pathological findings were analysed and summarized. Results: The chief complaint was insidious onset of dull pain on the knee which became worse with activity. The constant physical finding was painful limitation of full extension of the knee. Sagittal MR images showed diffuse swelling of the ACL, similar finding that could be seen in acute ACL tear. Arthroscopically, noted was a marked enlargement of the ACL causing notch impingement. Biopsies of the hypertrophied ACL showed increased collagenous tissue with variable degrees of myxoid degeneration. With partial excision of the hypertrophied ACL with or without notchplasty, the symptoms improved in all. Conclusion: Hypertrophy of the ACL, a newly proposed diagnosis, should be considered in determining the cause of the painful knee, and further study should be done about its pathogenesis.

        Poster 194. ACL reconstruction with double-looped hamstring graft: Comparison of two different fixation construct

        Daniele Comba, Massimo Berruto, Eugenio Uderzo, Giulia Sandrucci
        2001 ISAKOS Poster Abstracts
        Objectives: The goal of the present study was to compare at a mean follow-up of two years the results of ACL reconstruction with double-looped semitendinosis and gracilis graft using two different fixation methods: Bone-Mulch and washer-lock (Arthrotek Inc., USA) and Absorbable Bioscrews (Linvatec, USA). Methods: Between 1995 and 1997 34 ACL reconstructions using hamstring graft were performed: In 19 a bone-mulch for femoral fixation and a washer-lock for tibial fixation of the graft were used; in 15 the graft fixation was performed by bioscrew for both femoral and tibial side. The patients were divided into two groups, Gr.1 (bone-mulch) and Gr.2 (bioscrew) homogeneous for age (Gr.1: 23.6; Gr.2: 22.6), sex, activity level and interval time between injury and surgery (mean 10 months in both groups) and were evaluated at time of operation (procedure duration), postoperatively (pain , blood-loss) and at two years follow-up (Lachman test, Pivot shift, KT-1000, one leg hop, lKDC, Tegner). A control group of 12 ACL reconstructions with BPTB graft performed in the same period homogeneous with the hamstrings groups was considered. All the evaluations were performed from examiners different from surgeons. Unpaired t-test and paired t-test were used to evaluate statistically the results (p<0.001). Results: Intraoperatively and postoperatively we did not record any differences between groups Subjectively results were normal (A) in 74% of Gr.1, 53% of Gr.2 and 58% of control group. In terms of pain, swelling and giving-way the results were not statistically different between groups but were better in Gr.2 than in Gr.1. Lachman test was negative in 84% in Gr.1, in 93% of Gr.2 and in 83% of control group. Pivot shift was negative in 100% of Gr.2 and in 84% of Gr.1. The mean side to side difference at manual maximum test with KT-1000 was 1.4 in Gr.1, 1.3 in Gr.2 and 1.1 in control group. The results of the one leg hop test were normal (>90%) in 93% of Gr.2, in 79% of Gr.1 and in 83% of control group. The mean pre-injury Tegner scale was 7.2 in Gr.1, 7.6 in Gr.2 and 7 in control group. At time of follow-up we have recorded a decreased activity level in all groups: 6.6 in Gr.1, 6.9 in Gr.2 and 6.4 in control group. With lKDC the results were graded normal in 36% of Gr.1, 40% in Gr.2, 33% in control group and nearly normal in 74% of Gr.1, 53% in Gr.2 and 67% in control group. Only one case of Gr.2 was graded as abnormal. Conclusions: The present study confirms that the results of ACL reconstruction with double looped hamstring grafts fixed with reliable fixation hardware are similar to the so-called “golden standard” BPTB graft. Between the two different fixation constructs which have been compared, the results of bioscrews in terms of stability and function restoring seem to be better. Although the bone-mulch / washer-lock construct results were reliable, this technique has demonstrated to be little more demanding in terms of learning curve, and the big hardware used need to be removed in some cases.

        Poster 195. Patellar fractures following cruciate ligament reconstructions with central one-third of the patellar tendon

        Matias Costa-Paz, MD, Maximiliano Ranalletta, MD, Arturo Makino, MD, Miguel Ayerza, MD, D. Luis Muscolo, MD
        2001 ISAKOS Poster Abstracts
        Introduction: The patellar tendon is the autogenous graft mostly used for arthroscopic reconstruction of cruciate ligaments. Patella fracture following the use of this graft is a rare complication. In this paper we present four cases of displaced patella fractures and their final outcome, occurring after cruciate ligament reconstructions using bone-patellar tendon-bone autografts. Material and Methods: The authors retrospectively reviewed 1058 cruciate ligament reconstructions using bone-tendon patellar-bone autograft between 1986 and 1998. There were four displaced patella fractures in donor knees (three males, one female), yielding an incidence of 0.37%. Immediate rigid internal fixation was performed, allowing early mobilization. Mean age of the patients was 31 years (range 25-36 years), with the fracture occurring at an average of 63 days after primary reconstruction (range 50-160 days). Patients were assessed with the Lysholm knee scoring scale and anterior tibial translation side-to-side difference was evaluated with KT-1000 arthrometer. Results: Patients were followed up at an average of 42 months. All patients had asymptomatic patellofemoral crepitus. Average Lysholm score was 90 points. Side-to-side difference was less than 3 mm in all patients with KT-1000 arthrometer. Discussion: Based on the complication described here, we recommend that the graft be harvested in a bullet shape avoiding transversal cuts. Also bone grafting in the patella defect and the correct rehabilitation may prevent this fracture. Although the patella fracture did not affect the stability of the knee in these four cases, the final outcome in them appears less satisfactory than in those patients without this complication.

        Poster 196. Surgical treatment of the postero-lateral injuries

        Ramón Cugat, J. C. Monllau, X. Cusco, M. Garcia
        2001 ISAKOS Poster Abstracts
        Results presented in this study were obtained from patients injured Jan. 1990 - Dec. 1998 + with Isolated/ Combined PL corner injury. Group comprised 20 patients (age 17-52): Athletes, soccer players and non-athletes. Injured anatomic elements were: 9 PL corner 6 PL corner + PCL 5 PL corner + ACL Treatment: Acute corner: Isolated: Suture of the corner’s elements (A). With Peroneal Nerve lesion: A + reconstruction with nerve graft + transposition of Posterior Tibialis tendon Chronic corner: Medialization of bone block of the femoral insertion of PT and LCL fixed with screw + washer (B). Chronic corner + PCL: B + PCL arthroscopic reconstruction with B-PT-B autograft fixed with 2 cannulated interferential screws. Chronic corner + ACL: ACL arthroscopic reconstruction with B-PT-B auto/allograft fixed with 2 cannulated interferential screws + by open surgery, reconstruction of the LCL with B-PT-B auto/allograft fixed with 1 staple or 1 screw in fibula head and with 1 staple or 1 cannulated interferential screw in femur. Surgical Details: The femur block is divided at its center and through the face of the cancellous bone tissue without touching the tendinous part in order to perform the hinge effect on its intraarticular passage which is facilitated by a hook acting as reflection tackle. The hook of the femoral guidewire is introduced through the IM centering it on PCL antero-lateral fibers. The graft is fixed with knee flexed at 60-70° and posterior drawer reduced. Results: Lysholm Test: Preop: Average: 54 Postop: Average: 93 Gravitatory X-ray: Posterior Drawer Test: Preop: 10-20 mm Postop: 66%: <5 mm, 33%: 5-10 mm Bone Scan: Preop: 1+, 8++, 1+++ Postop: 9+, 1++

        Poster 197. Arthroscopic reconstruction of the ACL: Comparative study between 2 tibial fixation methods for ACL double-looped gracilis and semitendinosus tendons autografts

        Dirk P.M. De Clercq, MD, Michel M.J. Rousseaux, MD
        2001 ISAKOS Poster Abstracts
        Objective: A comparative retrospective evaluation of two series of 30 patients using a different tibial fixation is presented. In all the cases we performed an arthroscopic reconstruction of ruptured anterior cruciate ligament by endoscopic fixation of double-looped autograft gracilis and semitendinosus tendons on the femoral side with a cross-pin fixation and bone compaction. On the tibial side; in the first serie the fixation was performed with a classic tendon washer and screw outside the tibial tunnel; in the second serie the fixation was performed with a washer-screw fixation inside the tibial tunnel. Methods: The retrospective evaluation was performed by an independent observer. The results were based on the knee ligament standard evaluation form and designed by the International Knee Documentation Committee (IKDC: 1995) in order to compare with results of other studies. The Telos radiological evaluation and KT-1000 were used. The follow-up range:
        • first serie: Tendon washer and screw fixation: From 6 months to 1 1/2 year.
        • second serie: Washer lock and screw fixation: From 3 to 6 months.
        Because several studies had shown that knee motion stability does not change between 3 months and 2 years after surgery; the subjects were evaluated from 4 months postoperatively on. Results: IKDC final score:
        • 1.
          First serie: 56% good results. Normal 13%: Nearly normal 43%; Abnormal 35%; Severely abnormal 9%.
        • 2.
          Second serie: 87% good results. Normal 37%; Nearly normal 50%; Abnormal 13%; Severely abnormal 0%.
        Conclusion: The results of the tibial fixation with washer lock and screw inside the tibial tunnel were significantly better than the fixation with a classic tendon washer and screw.

        Poster 198. Prospective randomized comparison between patellar tendon and quadruple semitendinosus tendon graft in ACL reconstruction, a two-center study with minimum two year follow-up

        Karl Eriksson, Per Anderberg, Per Hamberg, Torsten Wredmark
        2001 ISAKOS Poster Abstracts
        Objective: Utilizing the central third of the patellar tendon as autologous graft in anterior cruciate ligament reconstruction has been considered the “gold standard” procedure for more than two decades. Various reports have, however, speculated in lower donor site morbidity with alternative graft materials, mainly hamstrings tendon grafts. The main questions about hamstrings tendon grafts have been possible elongation of the graft over time, fixation technique and if early motion postoperatively should be restricted. Thus, the aim of the study was to prospectively in a randomized fashion compare bone-patellar tendon-bone (BTB) autograft with quadruple semitendinosus tendon (ST) autograft with a minimum follow-up of two years after anterior cruciate ligament reconstructive surgery. Methods: In a two-center study 164 patients with unilateral chronic anterior cruciate ligament instability were prospectively randomized to arthroscopic reconstruction either with BTB graft fixed with interference screws or quadruple ST graft, fixed with endobutton proximally and screws and washers distally. The same postoperative rehabilitation protocol was used for all patients under follow-up, at median 32 (24-59) months, was performed by score according to Werner, Tegner activity level, Lysholm score, IKDC score and visual analogue scale (VAS), reflecting patient satisfaction and knee function. The study was approved by the ethics committee at Karolinska Institutet. The groups were compared with conventional statistics and the level of significance was set to p<0.05. Results: There were no differences between the groups regarding Tegner activity level, Lysholm score, IKDC or VAS preoperatively, 160 patients (98%) were available for follow-up. Among these 5 patients (2 BTB and 3 ST) had sustained graft ruptures and one patient (ST) was re-operated with osteochondral grafting due to a chondral lesion postoperatively. Thus 154 patients (74 ST och 80 BTB) were examined according to the follow-up protocol. No statistical differences were found between the groups regarding Tegner activity level, Lysholm score, patellofemoral pain score, IKDC or VAS. Neither were there any differences in Stryker laxity test, one leg hop test or thigh circumferential difference. Slight decreased extension as compared to the non operated side was found in the BTB group, p<0.05. Conclusion: BTB and ST give equal results in medium to long term follow-up. Both methods provide good stability and surgery significantly improves knee function and activity level. Thus, both BTB and quadruple ST could be considered as “gold standard” procedures. However in this non biased observer follow-up, patient satisfaction and objective findings according to VAS and IKDC show impairment to a greater extent than most other studies.

        Poster 199. Understanding medial meniscal injuries: The concept of structural failure of peripheral fibers

        Martin Franz Fischmeister
        2001 ISAKOS Poster Abstracts
        Hypothesis: One of the functions of meniscal tissue is the transmission of forces from the femoral condyle to the tibia. The function of the menisci depends not only on the their preserved anatomic shape but also on the integrity of the peripheral fibers. Structural failure of these peripheral fibers (SFPF) is one of the main reasons for meniscal tears. Pathomorphology: The following findings support this concept of SFPF:
        • 1.
          Avulsion injuries of the dorsal horn of the medial meniscus
        • 2.
          Transverse tears at the attachment area of the medial meniscus and the medial collateral ligament
        • 3.
          Horizontal tears of the medial meniscus in the posterior segment can be explained as structural failure of the peripheral fibers.
        • 4.
          Centrifugal dislocation of the torn meniscus in the posterior segment
        • 5.
          Central chondral damage in the medial compartment of the knee as consequence of the altered biomechanical state.
        • 6.
          The pillar deformity of the posterior horn
        • 7.
          The club in the box dislocation of flap tears.
        • 8.
          The central and collateral flag dislocation of flap tears.
        Which consequences follow from such an hypothesis? It adds to our understanding of the vast diversity of meniscal tears and makes the following new questions possible: Does it make sense to suture a torn meniscus in situations of SFPF? Does it make sense to transplant menisci without addressing the biomechanical function? Is it possible to address SFPF through new therapeutic approaches? The main value of this concept could be seen in the opening of new ideas in the therapy of medial meniscal injuries.

        Poster 200. Anatomic fixation in ACL reconstruction with quadriceps tendon

        Francesco Franceschi, Giacomo Rizzello, Alain Mulap, Vincenzo Denaro
        2001 ISAKOS Poster Abstracts
        Objective: The central third of the quadriceps tendon could be an interesting alternative choice in ACL reconstruction because of its strength, stiffness and wide cross sectional area but above all because of its minimal donor site morbidity. Using this graft it is possible to perform an anatomic fixation. Patients and Methods: We performed 24 ACL arthroscopic reconstruction using the central third of the quadriceps tendon, fixing the tendon end into the femoral tunnel by a reabsorbable screw and the osteotendineous junction of the patellar side at the tibial plateau level by another bio-screw. The patients were followed-up with IKDC score, KT-1000 arthrometer, and seriated MRI scan. Results: The mean follow-up was 15 months. We have found improvement of IKDC scores. The anterior tibial translation side to side difference was 1.8 mm. No patients after 6 months complain about harvest site pain. MRI showed perfect integration of the tendon inside the tunnel. Conclusions & significance: The quadriceps tendon could be an ideal graft for primary and revision ACL surgery with minimal donor site pain. Anatomic fixation of the graft could eliminate tunnel widening and allows an aggressive rehabilitation.

        Poster 201. Reharvesting of the patellar tendon for arthroscopic revision ACL reconstruction: A study of 17 cases

        A. Frank, M. Ouaknine
        2001 ISAKOS Poster Abstracts
        Purpose: To report the functional results of ACL revision surgery reharvesting the same donor site after a failed patellar tendon autograft reconstruction. Material and Methods: 17 patients underwent a revision arthroscopic ACL reconstruction using the same homolateral patellar tendon autograft than during the primary procedure. The patellar tendon was reharvested more medially removing the revision graft with corresponding bone blocks from the patella and tibia. Mean age was 31 years. For all patients the complaint leading to ACL revision was either sole instability or instability associated with pain. Partial meniscectomy before or during the revision surgery was frequent (11 cases). All patients were evaluated using the Lysholm-Tegner and IKDC scores and KT-1000 arthrometer measurements after a 19 months mean follow-up. Results: Final results using the IKDC functional score were: 2A, 10B, 4C and 1D. 14 patients had a side to side laxity difference less or equal than 5 mm at Maximum Manual Traction. Pain was the main complaint but was usually mild occurring only during strenuous activities. Patellar tendon tenderness was present at 6 months in 11 cases but only in 2 cases after 1 year follow-up. Conclusions: Results were satisfactory considering the cartilage and meniscus status at the revision surgery. A slight difference was noticed comparing the results to a primary procedure population. Residual laxity and patellar tendon tenderness were not significantly more frequent in this small series. Significance: Excellent results can be expected after reharvesting the patellar tendon for an ACL revision reconstruction.

        Poster 202. Spontaneous healing of the anterior cruciate ligament (ACL) injury – nonoperative treatment of acute ACL injuries in a selected group of patients

        Eisaku Fujimoto, MD, PhD, Yoshio Sumen, MD, PhD, Mitsuo Ochi, MD, PhD, Yoshikazu Ikuta, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the capability of spontaneous healing of acute anterior cruciate ligament (ACL) injuries in the selected patients. Methods: Conservative treatment was applied to a selected group of 31 patients, who have low athletic demand and continuous ACL magnetic resonance imaging (MRI) from the original femoral attachment through the tibial attachment (high intensity was detected in the substance of ACL). These injured knees were treated just with extension block soft brace for 2-3 months. KT-2000 and MRI examinations were carried out during the follow-up. Results: Twenty-three knees (74%) were revealed as stable by the follow-up with an average of 16.1 months after initial injuries. The KT-2000 side-to-side differences of the 20 knees were less than 3 mm, and those of the other 3 knees were more than 3 mm and less than 5 mm. MRI confirmed that 21 injured ACL out of 23 knees were connected to femoral attachment through tibial attachment and showed low intensity gradually, and that the positions of the other 2 injured ACLs’ femoral attachments were different from the original femoral attachment: One attached to the posterior cruciate ligament and the other was located at the lateral femoral condyle anteriorly to the original femoral attachment. Eight knees (26%) had to have ACL reconstructions due to their instabilities. Conclusion and Significance: This study indicates that nonoperative management of acute ACL injury can yield satisfactory results in a group of the individuals who have low athletic demand and continuous ACL appearance on MRI, provided the patients are willing to accept a slight risk of late ACL reconstruction and meniscal injury.

        Poster 203. ACL reconstruction with a quadrupled bone-semitendinosus graft – a prospective study

        Alberto Gobbi, MD, Stefano Santamaria, MD, Sanjeev Mahajan, MS, Milco Zanazzo, Ph.T
        2001 ISAKOS Poster Abstracts
        Purpose: Aim of the study was to verify if a bone semitendinosus construct can combine a faster bone to bone healing of the graft and a low donor site morbidity for ACL reconstruction. Methods: 50 patients of isolated ACL injuries, operated by same surgeon with the same rehabilitation program were prospectively evaluated at 2 years. Patients with previous operation, associated ligament injury or grade 4 chondral damage were excluded. Results were analysed on the basis of X-Ray, CT or MRI, computerized stability analysis, isokinetic and functional assessment tests. Scoring was done with subjective and standard knee evaluation scales. Results: Total surgical time was 85 min., graft preparation required 15 min. Noyes knee scale scored 86, Lysholm 92, Tegner 6.7, IKDC standard revealed 90% normal or nearly normal. Subjective evaluation resulted 85/100. Kneeling test was positive in only 6% of these patients. Computerized stability analysis revealed 90% within 3 mm side to side difference. lsokinetic tests showed lower hamstring muscle strength at 3 months but equal at 12 months. No internal external rotation deficit of the involved leg was found. MRI showed good osteo integration of the graft at 3 months. Conclusion: The use of a quadrupled bone-semitendinosus autograft is a valid alternative in ACL reconstruction, because of its strength, faster healing and low donor site morbidity.

        Poster 204. Middle-term results of modified macintosh fascia lata graft reconstruction for chronic ACL insufficiency

        L. Balabaud, P. Meyer, M.Y. Jeung, Pierre Hamon, MD
        2001 ISAKOS Poster Abstracts
        Purpose: We evaluated the middle-term results of a modified MacIntosh fascia lata graft repair for chronic ACL insufficiency. Method: In a consecutive series, we reviewed 72/94 patients (77%), who underwent in 1992. The average length of follow-up was 5.5 years. The mean interval from injury to surgery was 44.4 months. The average age at surgery was 28.8 years. 25 patients had had previous surgery. At surgery, 26 patients (36%) had articular cartilage damage, and 37 (51%) meniscus lesion. The postoperative rehabilitation program was identical. Evaluation included detailed history, physical examination, functional testing, KT-1000 arthrometer measurements (preoperative, 3, 6, 12 months, and 5.5 years), multiple scoring systems, and radiographs. Results: At follow-up, clinical examination demonstrated that 39% had a positive Lachman test; 4% had a positive pivot shift. The KT-1000 arthrometric evaluation revealed a mean maximum manual difference of 1.6 mm; 87% of the patients had a maximum manual difference of ≤3 mm. The IKDC, Lysholm and ARPEGE scores resulted in good or excellent results in 83%, 85% and 72% of the patients, respectively. The Lysholm and Tegner scoring scale were 93.2 and 6.7, respectively. 68 patients (9%) resumed athletic activity and 34 (47%) in competitive sport. Radiographs showed mild degenerative changes or osteoarthritis in 15 patients (25%). The pejorative significant factors were constituted by long interval from injury to surgery, raised preoperative laxity, preoperative radiographic degenerative changes and articular cartilage damage at surgery. Conclusion: We consider this procedure as a well-tolerated and effective method of treating chronic anterior cruciate ligament insufficiency.

        Poster 205. Tunnel enlargement 3-5 years after ACL reconstruction titanium versus bioabsorbable interference screw fixation

        Irene Hof, MD, Marco Zanetti, MD, Christoph Marti, MD, Jose Romero, MD
        2001 ISAKOS Poster Abstracts
        Objective: To compare the results of ACL reconstruction using patellar BTB graft in relation to tunnel enlargement between titanium and bioabsorbable interference screw fixation. Methods: 26 knees (follow-up 58 ms.) of group I (titanium screw) were compared with 19 knees (follow-up 46 ms.) of group II (bioabsorbable screw) for clinical results (EMC, Lysholm score), laxity measurements (KT-2000) and tunnel enlargement. Imaging included anteroposterior and lateral x-rays and MR studies. Results: lKDC (p=0.371) and KT-2000 measurement (side-to-side difference of group I 2.4±2.4 mm and of group II 1.3±1.5 mm; p=0.257) revealed no significant differences between the two groups. Tunnel enlargement was more frequent at the tibial than at the femoral site. The mean relative tunnel enlargement was 26.2% (10.0-94.3%) in group I and 18.2% (3.3-57.4%). The following tunnel enlargement patterns were found: Cylinder, trumpet, cavernous. MRI revealed only one case with fluid within the tunnel enlargement. Conclusions: Tunnel enlargement was found to be more frequent in ACL reconstructed knees which had graft fixation with a titanium screw than with a bioabsorbable screw. However, stability seems not to be affected by tunnel enlargement. Cystic transformation of the tunnel was only found in one case, the other tunnels were filled with fibrous tissue.

        Poster 206. Autogenous semitendinosus tendon as a meniscus substitute after total lateral meniscectomy

        Shuji Horibe, MD, Yukiyoshi Toritsuka, MD, Norimasa Nakamura, MD, Tomoki Mitsuoka, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study was to explore the possibility of an autogenous semitendinosus tendon as a meniscus substitute after total isolated lateral meniscectomy. Methods: From 1998 to 1999, six patients with the mean age of 21 years underwent meniscal transplantations with an autogenous semitendinosus tendon under arthroscopic control. The inclusion criteria were patients with symptomatic isolated lateral meniscus tears which were totally excised. After total resection of torn lateral meniscus, two 6 mm tibial drill holes were made at the anterior and posterior horns. Semitendinosus tendon (13-15 cm length) graft was fixed through drill holes with buttons and multiple vertical stacked sutures to the joint capsule. The patients were immobilized for three weeks and not allowed to full weight bearing until six weeks postoperatively. MRI was taken at one week, three months and six months after operation. Second look arthroscopy was performed after six months postoperatively. Results: Transplanted graft was triangular shape with low signal intensity at one week and became high with time on MR findings. At second look arthroscopy, all patients became asymptomatic. Second look arthroscopy revealed that the transplanted tendon was flat shape with synovial covering and that the articular cartilage surface did not deteriorate. Both anterior and posterior anchors to the tibial bone tunnels looked normal, and the graft sutured to the capsule was completely healed in all cases. Conclusion: Since the transplanted autogenous semitendinosus tendon remodeled with time, it is considered to be one the graft materials as a lateral meniscus substitute.

        Poster 207. Primary repair of the medial collateral ligament in complete combined tear of the MCL and ACL

        Tung-Fu Huang, Hsiao-Li Ma, Wai-Hee Lo
        2001 ISAKOS Poster Abstracts
        From June 1994 to June 1997, we had 20 cases who underwent acute surgical intervention for complete combined injury of medial collateral ligament and anterior cruciate ligament. Primary repair of the MCL was performed while the torn ACL was treated non-surgically. Combined anteromedial instability was reduced to an isolated problem of the torn ACL. As a result of this treatment, the condition of 16/20 knees improved and were stable after an average follow-up of 2 years and 9 months. The residual 4 knees had functional instability and they received ACL reconstruction. In conclusion the treatment of an immediate repair of MCL in the cases of combined tear of MCL and ACL is practical and effective.

        Poster 208. A new technique for reconstruction of the medial patellofemoral ligament using endobutton

        Hiroo Ikeda, Takeshi Muneta, Kazuyoshi Yagishita, Kenichi Shinomiya
        2001 ISAKOS Poster Abstracts
        Purpose: We will introduce a new technique for medial patellofemoral ligament (MPFL) reconstruction using Endobutton to treat patellar instability. Operative technique: To harvest the hamstring tendon, a skin incision is made over the posteromedial region along skin crease where the tendon can be easily harvested and the scar is not conspicuous. A second incision (2.5 cm long) is made along the medial border of the patella. The medial soft tissue consist of 3 layers. A Kocher clamp is inserted between the MPFL in the second layer and the third layer from the incised medial aspect of the patella to the adductor tubercle. A third incision of 1.5 cm is made at the tip of the Kocher clamp around the adductor tubercle. Graft was fixed by Endobutton on the lateral femoral cortex, and graft was passed between the second layer and the deepest layer. Finally, the graft is sutured to medial periosteum of the patella and the surrounding medial retinaculum with the knee in 90 degree of flexion. The MPFL was reconstructed in 12 patients using this method since 1997. The medial stability was reestablished in all and the efficacy of the method was reaffirmed. Significance: Among the ligaments investing the patella, the MPFL is reported to have the greatest strength. Therefore, reconstruction of the MPFL is thought to be the most reasonable method for treating patellar instability. We introduced less invasive technique for MPFL reconstruction using Endobutton than that with a long medial incision and graft fixation using staple.

        Poster 209. Anterior cruciate ligament reconstruction using achilles tendon allograft and interference screws fixation: A comparative two-year minimum follow-up study

        Pier Francesco Indelli, MD, Michael Dillingham, MD, Gary Fanton, MD
        2001 ISAKOS Poster Abstracts
        Objective: Achilles tendon allografts have been widely used in anterior cruciate ligament (ACL) reconstruction with good results. Interference screw is a popular method used to secure the graft. This study compared the efficacy of the bioabsorbable poly-L-lactid acid (PLLA) interference screw to that of the washer or double staples for ACL reconstruction. Methods: Fifty consecutive patients underwent arthroscopic primary ACL reconstruction using fresh frozen Achilles tendon allografts. Twenty-five patients received a PLLA interference screw (Phantom, Mitek, Westwood, Ma) at both ends of the graft. Twenty-five received a metallic femoral interference screw and a soft tissue washer or double staples on the tibial side. Identical postoperative rehabilitation was performed. A two-year minimum follow-up study (range, 2 to 4 years) was conducted in all of the patients according to the IKDC score system. Rosemberg view radiographs were performed in each patient. Results: The overall outcome was normal or nearly normal in 96% of the patients. There were no statistical differences in knee stability between the two groups. A second surgery for removal of painful hardware was required in 20% of the subjects. The average allograft tibial tunnel enlargement registered at the widest level in the Rosemberg view was 1.7 mm (0 to 5 mm) in the bioabsorbable group and 2.8 mm (0 to 5 mm) in the other group. The difference was statistically significant (p<0.001). Conclusion: Our results suggest that re-operation for removal of prominent hardware continues to be the primary source of postoperative morbidity. A more anatomic graft fixation, which is possible with bioabsorbable interference screws, may lead to smaller bone tunnel expansion.

        Poster 210. Tibial tunnel enlargement in anterior cruciate reconstruction using hamstring tendons. Does immobilisation make a difference?

        Aradhyula N. Murty, John Ireland
        2001 ISAKOS Poster Abstracts
        Purpose: Radiographic Tunnel enlargement following anterior cruciate ligament reconstruction has been observed. The purpose of this study was to determine the effects of immobilisation on tunnel appearances and clinical results. Materials and Methods: This study comprised twenty-eight patients. All underwent anterior cruciate reconstruction using four strand hamstring tendons. Fourteen knees were immobilised for two weeks and the other fourteen went through an accelerated rehabilitation programme. At one year post-reconstruction, all patients underwent clinical and radiological assessment. The AP and lateral diameters of the tunnel were measured at points 0.5 mm below the tibial articular surface and 5 mm proximal to the distal end of the tibial tunnel. The x-ray magnification factor was calculated from the size of the femoral fixation staple. The increase in tunnel diameter was thus calculated from the drill size used at operation. The increases were graded as insignificant, significant and marked, according with enlargement of <15%, 15-34%, >35% of the original tunnel diameter. The increases were studied in relation to clinical outcome, arthrometer measurements, Lysholm score, Tegner activity level and IKDC rating. Results: Both groups were well matched for age, Tegner activity level, and presence of associated lesions. The tunnel enlargement was cone shaped in most cases. The tunnel enlargement was significantly greater in the immobilised group (t test p<001). However, there was no significant correlation between tunnel enlargement and clinical outcome at one year and at a mean follow-up of five years. Conclusions: The aetiology of tunnel enlargement is not well understood. The greater increase in tunnel diameter tended to occur at the articular end of the tibial tunnel suggesting a mechanical cause. Significantly greater enlargement was observed in the immobilised cases where better tendon bone healing and thus less enlargement, might have been expected.

        Poster 211. Symptomatic medial plica – problem in child athletes

        Ernest Irha, MD, Javor Vrdoljak, MD
        2001 ISAKOS Poster Abstracts
        Objective, question or hypothesis: To establish how much significance has to be paid to the medial synovial plica of the child knee as the etiologic factors of joint problems. Methods: In the period between 1996 and 1999, arthroscopic excision of a symptomatic medial synovial plica was performed in 7 patients, 4 girls and 3 boys, ranging in age from 12 to 16 years. The medical charts and video recordings of 58 arthroscopies done in the children’s knees during the same period but due to other indications, were also retrospectively analyzed. Results: The medial plica was found in 45 (77%) patients. Different anatomical variations of the plicae were not shown to be the cause of complains. All symptomatic plicae were classified in type B according to Sakakibara and Iino classifications. Conclusions and Significance: All children with a pathological plica were actively competing athletes. The clinical presentation of plica syndrome appeared to be dependent not from the plicae morphology than of the sports activity. The most frequent etiology, in that group of patients, differentiate from that which happens in adults. The medial patellar plica may not come into direct contact with either the patella or the medial condyle, but the tethering effect of medial plica may interfere with the function of the quadriceps and subsequently lead to pain, which is produced by traction of the nerve endings or local synovitis. Overuse in pivoting and cutting during the sports activities is the main cause of tethering effect. Synovial plica syndrome is an uncommon pathologic entity in children, occurring far too often in child athletes.

        Poster 212. Radial tear next to the posterior horn of the medial meniscus

        Yasunobu Iwasaki, MD, Masahiro Kurosaka, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To describe the characteristics of radial tear next to the posterior horn of the medial meniscus. Introduction: Radial tear next to the posterior horn of the medial meniscus occurs in elderly population with an episode of minor trauma in daily activity. This particular type of meniscus tear causes severe pain that disturbs walking. The clinical characteristics of this tear are different from those of degenerative tear that generally occurs in elderly population. Materials and Methods: Twelve cases of this lesion were diagnosed and treated under arthroscopy. The average age was 62. Six cases were injured during daily activity, such as twist on stairs or floor. Five cases were injured during sports activity. One case couldn’t recall the episode. Most cases required crutches or cane for transportation after the injuries. MRI is often difficult to show this lesion. Only one or two slice of coronal view could show the tear. 42% were false negative in MRI. Arthroscopy is also difficult to find this lesion, because the tear is too close to the posterior horn. Results: Partial meniscectomy of the lesion gave early pain relief. All patients were able to return to previous activity level within 3 months. Conclusion: This type of meniscus tear could occur with minor trauma in elderly population. The typical symptom is severe pain. The diagnosis of this lesion is difficult in both MRI and arthroscopy. Significance: Radial tear next to the posterior horn of the medial meniscus should be taken into account in elderly population.

        Poster 213. The long-term follow-up of endoscopically assisted BPTB ACL reconstruction

        Simon Jennings
        2001 ISAKOS Poster Abstracts
        Purpose: To assess the radiological changes related to the medium term follow up of ACL reconstruction. Method: A prospective outcome study of fifty patients with chronic ACL injury undergoing reconstruction by a single surgeon were reviewed at a mean of 62 months (range 48 to 95 months) post operation. All patients had instability either precluding participation in sport at the desired level or in normal daily activity. Independent review included clinical examination including Lachman, anterior draw, and pivot shift measurement both pre and post operatively, augmented by KT-1000 measurement. Plain X-rays were reviewed using the Ahlbäck system. Subjective assessment included Tegner activity score and Lysholm score. Results: Surgery was considered a failure if the pivot shift was 2+ and/or symptoms of instability persisted. There were 2 failures (4%). Clinical examination showed improvement in all parameters in all patients except the two failures. There were three Arthrometric failures. Using the Ahlbäck rating system there was a 76% incidence of grade 1 changes in ACL damage with meniscal injury and 19% in the remainder of the series. There was an excellent or good result with post-operative Lysholm score in 94%. The Tegner score had improved by a mean of 3.4. Subjectively the average overall patient satisfaction was 90.4% compared to the normal knee. Conclusion: Our results show a good medium-term outcome for this reconstructive method but we demonstrate a high incidence of asymptomatic early arthritic changes on radiographic examination in patients with associated meniscal injury. Significance: Our results confirm the reliability of this reconstruction procedure in the medium term. While minor degenerative changes are seen in asymptomatic patients it confirms that meniscal injury significantly increases the incidence of degenerative change.

        Poster 214. Two-year results on double-looped semitendinosus and gracilis grafts fixed with a bioabsorbable soft tissue interference screw

        Don Johnson, FRCS, Ari Pressman, FRCS, Moreno Morelli, MD, Geoff Dervin, FRCS, Ross Wilkinson, FRCS
        2001 ISAKOS Poster Abstracts
        A prospective evaluation of 60 patients treated between August 1997 and January 1998 with a double-looped semitendinosus and gracilis graft for anterior cruciate ligament reconstruction was undertaken. Grafts were secured with bioabsorbable interference soft tissue screws (Bioscrew; Linvatec, Largo, FL) made of polyL-lactic acid. Patients were followed for a minimum of two years (average 2.31±0.27 years). Tegner and Lysholm scores were used to determine pre and post-operative knee function and IKDC scores were calculated at the two-year follow-up. The average IKDC score was 84.8±13.9 at the final follow-up. A pivot shift was absent in all but two patients at the final follow-up. With exception of meniscal status at the time of reconstruction, no single independent variable had a statistically significant impact (by group comparison using nonparametric testing and correlation coefficients) on the final IKDC score; including KT scores, use of a larger screw, use of secondary tibial fixation (over a button), age at surgery and sex. Despite the clinical success as determined by patient based subjective outcome and the IKDC score – the distribution of KT scores were less than optimal. Although the average score at KT maximum manual side-to-side difference was 1.96±2.24 mm; a difference of <2 mm was obtained in 59.1%, 2-5 mm in 36.4% and >5 mm in 4.5%. Although this degree of laxity has been experienced in some series with other methods of fixation such as the Endobutton (Acufex Microsurgical, Mansfield, MA), we felt that this represented substantially more laxity that had been experienced with our bone-to-patellar tendon-bone cohort of ACL reconstruction fixed in the same manner during the same period of time. The latter group had an average laxity of 1.96±1.46 mm with 79% <2 mm, 20% 2-5 mm and 2% >5 mm. Although no problems occurred with the polyL-lactic acid interference screws, it is possible that this laxity represents differences in the graft materials, or bone fixation. These results behoove us to work towards improvements in fixation in order to minimize the observed side-to-side laxity. The data does support the effectiveness of Bioscrew fixation on the double looped gracilis and semitendinosus graft for ACL reconstruction.

        Poster 215. Retensioning or retensioning with augmentation in chronic posterior cruciate ligament injury

        Yong Bok Jung, Suk Kee Tae, Dong Ryul Yang, Jae Won Jung
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the outcome of retensioning of posterior cruciate ligament (PCL) with and without augmentation. Method: Sixteen patients who underwent retensioning (3 patients) or retensioning plus augmentation with hamstring tendons (13 patients were evaluated at average 12 months (range: 6-29) after operation. Retensioning was performed by distal transfer of tibial attachment of PCL through a posterior approach in supine position with the operation table to be tilted down as much as possible toward affected side and the hip in abduction and external rotation. Augmentation was performed with 4 bundles of semitendinosus and gracilis tendons. The results were assessed by stress radiographs, maximal manual test with KT-1000 arthrometer, IKDC grading and OAK knee score. Results: Average side to side difference in push view with Telos stress device decreased from 10.4 mm to 2 mm. Difference in maximal manual test with KT-1000 also decreased from 6.7 mm to 2.2 mm. Final IKDC grading was A in one patient, B in two, C in ten and D in three, which was B in one patient, C in five and D in 10 preoperatively. Average OAK score improved from 66.5 to 81.3. Conclusion: The above results show favorable outcome after retensioning rather than sacrificing the remaining fibers in reconstructive surgery for chronic PCL injury. Significance: This technique of retensioning and augmentation seems to improve clinical result by restoring proprioceptive function and two bundle effect of normal PCL.

        Poster 216. Relationship between chondral damage, meniscal tears and ACL injury – a review of 1,005 anterior cruciate ligament reconstructions

        Christopher Kaeding, MD, Lawrence Kusior, MD, Aasha Sinha, DVM, Joseph Hanna, MD
        2001 ISAKOS Poster Abstracts
        Objective: Concerns of an ACL deficient knee include: 1) functional loss 2) risk of meniscal tear and 3) articular cartilage damage. The purpose of this study was to examine the relationship between articular cartilage damage, meniscal tears, and chronicity of ACL injury. We also examined the effect of gender and age on these relationships. Methods: Intra-articular findings were documented at time of surgery in 1,005 ACL reconstructions. Location, size, and severity of chondral injury, as well as size and location of meniscal tears were documented for each case. Affected side, gender, activity at time of injury, age at time of injury, age at time of reconstruction, chronicity of the ACL deficiency, prior surgery, and associated ligament injuries were also tabulated. Exclusion criteria of associated instability other than an incomplete MCL tear, prior arthrotomy or ligament reconstruction produced a database of 911 patients. Correlations between articular cartilage damage, meniscal tears, chronicity, gender, and age were evaluated. Definitions - Chronicity: Acute ≤ 3 months, chronic > 12 months. Meniscal Tears (MT): Meniscal injury requiring meniscal resection or repair. Articular Damage (AD): Any grade 3 or 4 lesion or any grade 2 lesion larger than 2 cm2. Age at time of injury: Young ≤ 20 and old > 30. Statistical analysis was performed by a full time faculty statistician. Results: Gender: 331 females, 580 males. Side: 456 right, 455 left. Lateral meniscal tears were more common in acute injuries (lateral 40%, medial 24%) whereas medial tears were more common in chronic cases (lateral 45%, medial 66%). Gender had no affect on MT in acute injuries. Chronicity of the ACL injury correlated positively with MT. Location and size of MT correlated strongly with AD. Chronicity also had a positive correlation with AD. Chronicity and MT are additive risk factors for AD. Gender played a minor influence with males having a tendency toward greater intra-articular injury. Average age at injury was 24. The young group was evenly split between males (48%) and females (52%) whereas the old group was predominantly male (63%) and female (37%). Age at time of injury did not correlate with meniscal tear (young 54% - old 49%), but did with articular damage (young 46% - old 75%). Gender had no affect on the incidence of AD in the “old” patient group. Conclusions: Articular cartilage damage in ACL deficient knees correlated strongly with location/size of meniscal tears and chronicity of injury. Male gender and older age at time of injury were less powerful risk factors. All risk factors were additive. Gender made no difference in injury pattern in acute injuries. Note: This is an observational study not a natural history study.

        Poster 217. Intra-articular ACL reconstruction versus combined intra- and extra-articular ACL reconstruction: A comparative study

        Izumi Kanisawa, MD, Hideshige Moriya, MD, Anne Z. Banks, MS, Scott A. Banks, PhD, Akihiro Tsuchiya, MD, Frank F. Cook, MD
        2001 ISAKOS Poster Abstracts
        Objective: The purpose of this study was to compare the clinical results and kinematics of intra-articular anterior cruciate ligament (ACL) reconstruction using the hamstring tendons and combined intra- and extra-articular ACL reconstruction using the iliotibial tract. Methods: Thirty-nine patients participated In a prospective, randomized study. Nineteen patients received ACL reconstruction using the hamstring tendons (Group 1), and 20 patients received ACL reconstruction using the iliotibial tract (Group 2). One-year follow-up results were evaluated using the IKDC evaluation form. Weight bearing knee kinematics in six subjects from Group 1 and in five subjects from Group 2 were measured. The step up-down activity was recorded using lateral fluoroscopy and knee kinematics were determined using a three-dimensional measurement technique. Results: Although the final evaluations were similarly satisfactory in both groups, Group 1 showed better results in symptoms, knee extension range, and anterior translations in female patients, and Group 2 showed a better result in the pivot shift test. In the kinematic study, both the normal and the reconstructed knees exhibited condylar rollback and internal tibial rotation with knee flexion, consistent with previous reports of normal kinematics. The reconstructed knees of Group 2 exhibited a trend towards smaller lateral translations. Conclusions and Significance: Both groups showed clinically satisfactory results. However, the reconstruction using the hamstring tendons seems less invasive and resulted in better range of motion and symptoms. Combined intra- and extra-articular reconstruction may have advantages with regard to restricting anterolateral rotatory instability, but it also may restrict the normal motion of the lateral femoral condyle.

        Poster 218. Functional outcome of anterior cruciate ligament reconstruction in recreational and competitive athletes

        Jon Karlsson, Lars Ejerhed, Sveinbjörn Brandsson, Ragnar Jerre, Anders Wallmon
        2001 ISAKOS Poster Abstracts
        Purpose: The aim of this study was to compare the functional, subjective and objective outcome after anterior cruciate ligament reconstruction in recreational and competitive athletes, with a minimum follow-up of two years. Method: Forty-nine patients (24 males and 25 females), who at the time of the index injury were classified as recreational athletes (Tegner level 2-5, Group A), were compared with 226 patients (61 females and 165 males) who at the time of the index injury were classified as competitive athletes (Tegner level 9-10, Group B). Results: At the follow-up, the competitive athletes revealed a significantly higher reduction of the Tegner activity level than the recreational athletes. Otherwise, no significant differences between the study groups were found in terms of the Lysholm score, IKDC evaluation system, one-leg-hop test and KT-1000 laxity measurements. The same thing was found for the patients’ subjective opinion of their anterior knee pain, and evaluation and expectation of the results. Conclusion: We conclude that low pre-injury activity level is not a contraindication for anterior cruciate ligament reconstruction.

        Poster 219. Motion analysis of the knee with posterior cruciate ligament injury

        Masayoshi Katayama, MD, Masashi Kimura, MD, Kenji Shirakura, MD, Naoki Fukasawa, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study is to better the safety of the rehabilitation for the conservative treatment and the reconstruction of posterior cruciate ligament (PCL) injury. Materials and Methods: 11 knees with PCL injury were examined using CA4000 (knee goniometer) and Biodex (knee dynamometer), and compared with that of contralateral (normal) side by the anterior-posterior instability in passive motion (PM) and in active motion (AM). Results: In PM, the tibia of injury side was translated about 5 mm posterior from that of normal side in almost all range of motion. In AM, during the knee extended the tibia of injury side was moved to the anterior, and placed in the same one of normal side. During the knee flexed 40-90 degrees the tibia of injury side was translated to posterior from that of normal side. From the result in PM, it suggests that after PCL reconstruction the grafted ligament is strained in almost all range of motion. From the result in AM, it suggests quadriceps make a relief of the strain to the ligament and hamstrings add a load to the ligament during the knee flexed in 40-90 degrees. Conclusion: In the conservative treatment and the reconstruction of PCL, it is more safety by passive motion than by active motion to obtain the range of motion of the knee.

        Poster 220. MRI evaluation of combined MCL injuries in the ACL injured knees

        Tsuyoshi Kato, Takeshi Muneta, Hiroo Ikeda, Kazuyoshi Yagishita
        2001 ISAKOS Poster Abstracts
        Purpose: How to treat medial collateral ligament (MCL) injury in conjunction with anterior cruciate ligament (ACL) injury is not to be established yet. The purpose of this retrospective study, therefore, is to evaluate type of MCL injury, to analyze MCL instability semi-quantitatively using MR image and to compare MR findings with clinical findings before ACL reconstruction. Materials and Methods: In 156 ACL injured knees, we examined pre-operative MR images of combined MCL injuries; grades, injured areas and the distances from the bone surface to MCL. Then, we compared those MR findings with clinical laxity on 50 random sampling knees one by one. Results and Discussion: In 60 knees (38.5%) we found MCL injuries with MRI. Most injuries were found in femoral site. The bone-MCL distances in the cases of grade I, grade II+III and intact MCL, determined based on continuity of MCL, were 5.2 mm, 6.9 mm and 3.1 mm, respectively. The difference was significant at P<0.01. In 23 normal MCL knees with MR imaging, no valgus instabilities were clinically examined except 1 knee. In 14 grade I knees, 3 positive, 3 unclear and 8 negative, and in 13 grade II+III knees, 9 positive, 1 negative valgus instabilities were indicated. The longer the distance extended, the greater instabilities were examined. Thus, we can use MRI effectively to evaluate the severity of the MCL injuries and to have quantitative expectation of the medial instabilities in ACL injured knees. Conclusion: We can use MRI effectively to evaluate the MCL injuries semi-quantitatively. It will help managing combined MCL injuries with ACL reconstruction.

        Poster 221. The enhanced anterior drawer test

        Basil Kaufman, MBBCh, FRCS, Shmuel Israeli, MD
        2001 ISAKOS Poster Abstracts
        Performance of the Anterior Drawer Test has been the cornerstone of detection of damage to the Anterior Cruciate Ligament. The test is generally, easily performed and reliable. However, in very muscular patients or apprehensive patients, hamstrings muscular contraction prevents execution of the test properly. Occasionally, conflict arises as to whether the Tibia is moving forward from neutral to anterior or whether it is being brought forward from posterior to neutral as in PCL injuries. By placing the thigh flat of the examination couch with the knee bent over the edge and the ankle supported between the knees of the examiner, the “hamstring effect” is completely eliminated and the anterior translocation of the Tibia is greatly enhanced. In some cases, the Tibia can be brought so far forward, so as to produce a dislocation of a damaged posterior horn of meniscus with a visible and audible click. This maneuver has as yet not been documented. A significant number of patients were examined in a) regular way, b) using the KT-1000 apparatus and c) as described above. The results of the analysis show that the enhanced method is very reliable and adds to the accuracy of the diagnosis. The paper presents the method and the analysis of the results and recommends that this method be taught as a standard method of ACL examination.

        Poster 222. ACL reconstructions using allograft bone screws (advantages and complications)

        Kevin J. Kessler, MD (b – Regeneration Technology, Inc.; c, e – Arthrotek; d – Arthrotek, Biomet), Jesse Zinholtz
        2001 ISAKOS Poster Abstracts
        Numerous methods of fixation have been used to secure ACL reconstructions. Graft fixation is a primary concern in surgical reconstructions of the anterior cruciate ligament. We present the advantages, disadvantages and early experience of allograft bone interference screws in fixating endoscopically reconstructed anterior cruciate ligaments. Early results of 25 anterior cruciate ligament reconstructed knees using allograft bone interference screws are presented. Advantages include no retained hardware, no postoperative interference with MRIs and incorporation of allograft to the host bone. Immediate postoperative and six-month follow-up CAT scans were studied. Surgical technique is important in avoiding interoperative complications. Twenty-five consecutive ACL reconstructions using allograft bone interference screws were studied. There were 18 males and 7 females. Ages range from 17 to 40 years old. All cases were done endoscopically. There were 16 allograft bone patella bone tendons and 9 autograft BTB used. Proximal fixation used 7 mm diameter by 20 mm long screws. In 3 patients, we obtained immediate postoperative CAT scans and follow-up CAT scans at six months postoperative to assess radiographic incorporation of the allograft interference screw into the host bone. There were 22 excellent results and 3 good results. There were no poor results or failures. Initially we had three screws break upon insertion. There was one postoperative superficial infection and one prolonged knee effusion, but no long-term postoperative complications. The potential benefits of allograft bone interference screws in endoscopically ACL reconstructed knees include: Lack of interference with future MRIs, incorporation of allograft screw, preservation of bone stock and no painful residual hardware or need for secondary removal of screws.

        Poster 223. A prospective study for joint space narrowing after two-route ACL reconstruction

        Yoshiaki Kurihara, MD, Takeshi Muneta, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate early degenerative changes after two-route ACL reconstruction by investigating the narrowing of joint spice in 45 flexion posteroanterior radiograph prospectively. Method: One hundred and fourteen posteroanterior weight-bearing radiographs of the knee at 45 degrees of flexion were taken before and after two-route ACL reconstructions using hamstring tendon. Among those 67 could be evaluated. The measurement of joint space narrowing was performed by tracing the image of the injured knee and overlapping it to the opposite side. The most different width was measured in medial and lateral joint space separately in 0.5 mm increment. The cases in which joint space narrowing had progressed 1 mm or more were defined as the progressed one and the rate and the degree of narrowing were examined. In addition, sex, age, preoperative period, meniscal injuries and cartilage damages at operation and Lysholm’s score, knee stability at follow-up were compared between the progressed cases and the others. Results: Progress of narrowing was found in 4% in medial FT joint space and in 15% in lateral FT joint space. Progress of 2 mm or more was found in 1% in medial, and 3% in lateral. In medial joint space, there were no significant differences in all parameters above mentioned between the progressed cases and the others. All of the progressed cases had MM injury at operation. In lateral joint space, preoperative period tended to be longer and rate of positive pivot shift was significantly higher in the progressed cases (p<0.05). Conclusion: There were few cases in which joint space narrowing had progressed in short term and extent of the area was small. A little more progress was found in lateral joint space though it was not significant. The progress might have related to accompanying injuries. Significance: Joint space narrowing have not progressed in short term after two-route ACL reconstruction. Early reconstruction for ACL injured knee may prevent articular cartilage damage due to the procedure.

        Poster 224. Bone tunnel remodeling at site of biodegradable interference screws used for ACL reconstruction; 5 year follow-up

        Georg Lajtai, MD, Günther Schmiedhuber, MD, Franz Unger, MD, Gernot Aitzetmüller, MD, Markus Klein, CM, Ernst Orthner, MD
        2001 ISAKOS Poster Abstracts
        The purpose of this prospective study was to review by expanded clinical assessment tools the long-term results of the local effects of a bioabsorbable interference screw (copolymer 85/15 D, L lactide/glycolide) in ACL (Anterior Cruciate Ligament) reconstruction at the Wels Hospital, Austria. This prospective study was initiated in May of 1993. The inclusion criteria for patient selection was: Rupture of the ACL in athletic patients without involvement of the collateral ligaments, arthroscopic ACL reconstruction using middle third of the ligamentum patella, MRI and plain radiograph examinations of the knee joint during the follow-up. Between May 1993 and October 1994, 32 patients were enlisted in the study. 48 patients did not fit the inclusion criteria. There were 25 men, 7 women. The average age was 29.1 years (range, 19 to 50 years). There were 21 right knees and 11 left knees. The follow-ups were made by one operator independent examiner. 28 were available for follow-up at medium of 5.2 years (min 4.1 to max: 6.4 years). The evaluation included various system (OAK, IKDC, Lysholm) as well as MRI (Magnetic Resonance Imaging) and plain radiograph studies to investigate the longevity of the implant and potential adverse effects of this new bioabsorbable material. The clinical results were good. The OAK-score (Orthopädische Arbeitsgruppe Knie) showed 93% excellent and good results, 7% fair results. The IKDC score showed 92%, the Lysholm score 96% good and excellent results. The MRI showed bone remodeling and new bone formations at the site of the implant in the femoral as well in the tibial bone tunnel at follow-up. No dystic or osteolytic changes were seen in MRI as well as in plain radiograph studies. This study showed the correlation between the histology and the MRI. Indicating that there was minimal surgical site edema, minimal reaction to this material, and complete replacement by new bone formation of the previous site of this implant. At five years, this bioabsorbable interference screw appeared clinically safe and effective for fixation of bone blocks during ACL reconstruction while MRI showed complete absorption and replacement with new bone.

        Poster 225. Serial magnetic resonance imaging evaluation of a bioabsorbable interference screw and the adjacent bone

        Georg Lajtai, MD, Klaus Humer, MD, Gernot Aitzetmüller, MD, Franz Unger, MD, Ernst Orthner, MD
        2001 ISAKOS Poster Abstracts
        The purpose of this prospective study was to review, using expanded clinical assessment tools, the initial use of a bioabsorbable interference screw (copolymer 85/15 D, L lactide/glycolide) in anterior cruciate ligament (ACL) reconstruction at the Wels Hospital, Austria. The study enlisted 32 patients of whom 28 were available for follow-up at minimum of 2.5 years. Since the implant material was new and the screw would not show on plain film radiographs, the clinical assessment was expanded beyond the usual historical and physical findings. The evaluation included opportunistic knee joint aspiration and repeat magnetic resonance imaging (MRI) studies to investigate the longevity of the implant and potential adverse effects of this new bioabsorbable material. The knee joint aspirations showed no infection. Serial MRIs showed the physical presence of the screw to remain intact for 4 months and disappear in 6 months. The MRIs showed minimal collection of edema around the bone tunnels that resolved by 12 months. There were no symptoms or adverse clinical result correlated with the MRI evidence of edema. There was temporary bone tunnel expansion. The clinical results were good. The OAK-score (Orthopädische Arbeitsgruppe Knie) showed 89.5% excellent and good results, 7% fair results and 3.5% poor results. The average score was 90.7 points (range, 63 to 10 points). The knee joint stability measured with the KT-1000 arthrometer showed 93% to have a 3-mm or less difference compared with the unoperated knee. This bioabsorbable interference screw appeared safe and effective for fixation of bone blocks during ACL reconstruction while producing no occult infection or adverse clinical response during the degradation process.

        Poster 226. Factors for arthritis after ACL reconstruction – a bone spect study

        Beom Koo Lee, In Ho Sung, Jang Suk Choi
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the factors for arthritis after ACL reconstruction with bone patella tendon bone with single photon emission computed tomography. Method: 19 bone SPECT was done for the 16 cases of ACL reconstruction with bone patella tendon bone. Hot uptake seen at bone SPECT was evaluated in 5 subdivided articular compartment, that is, patello-femoral, antero-medial, anterolateral, postero-medial and postero-lateral compartment. Factors evaluated were type of bone bruise, meniscus injury, anterior instability defined by more than 3 mm side to side difference by KT-2000 at maximum manual test. Result: The percentage of hot uptake was 100% for geographic bone bruise, 80% for meniscectomy site. For the unstable cases, hot uptake was seen in patello-femoral joint in 71.4% and medial tibiofemoral joint in 28.6% and lateral tibiofemoral joint in 14.3%. Conclusion: Geographic bone bruise at injury, meniscectomy and anterior instability were important factors for arthritis in order.

        Poster 227. MRI evaluation of ACL reconstruction using quadriceps tendon autograft

        Myung Chul Lee, Sang-Cheol Seong, Hunchul Jo
        2001 ISAKOS Poster Abstracts
        Purpose: To determine MRI as a useful modality for evaluating ACL reconstruction using quadriceps tendon autograft. Method: Twenty-six MRI were performed in 24 patients after arthroscopic ACL reconstruction with quadriceps tendon autograft. The postoperative interval ranged from 6 months to 12 months (average 6.5 months). Fat saturated proton density sagittal images and T2-weighted oblique coronal images were obtained. MRI findings of the ACL grafts were grouped according to the two criteria; the location of the low signal intensity (toted, proximal, distal, nonvisual) and signal intensity compared to the patella tendon of the same patient (definitely same, slightly increased, nonvisual). MRI findings were then compared to the clinical results. Results: Low signal were seen 19 patients in total length, 2 patients in proximal portion only, 2 patients in distal portion only, and in 2 patients low signal were nonvisual. In one patient, low signal was seen in both proximal and distal portion. The signal intensity compared to the patellar tendon were definitely same in 17 patients, slightly increased in 7 patients, and nonvisual in 2 patients. There was no correlation between the low signal location or intensity and clinical stability except the 2 nonvisual cases where anterior drawer test and pivot shift test revealed instability over grade II. Conclusion: Most quadriceps tendon autograft showed low signal intensity through the whole length. Regardless of the location, e.g., total length, proximal, or distal, the presence of the low signal imply the clinical stability. But in nonvisual cases, the clinical instability is suspected.

        Poster 228. ACL arthroscopic reconstruction using autologous bone-patellar tendon bone autograft over 40 years: A study of 42 cases

        N. Lefevre, A. Frank, P. Beaufils, P. Hardy
        2001 ISAKOS Poster Abstracts
        Purpose: To compare the results of ACL reconstruction before and after 40 years. Material and Methods: 42 patients underwent an arthroscopic ACL reconstruction using a patellar tendon autograft between 1995 and 1999. Mean age was 44 years (40 to 51). All patients were evaluated using the IKDC score and KT-1000 arthrometer or Telos laxity measurements after a 21 months mean follow-up. In 32 cases a sport trauma was involved in the ACL lesion. The ACL reconstruction was indicated because of an unstable knee during sports activity (14 cases) or daily activity (28 cases). Results: Final results using the IKDC functional score were: 9A, 26B, 6C and 1D. 26 patients recovered full sports activity. Meniscal lesions were frequent (51%) depending on the delay between trauma and the ACL reconstruction. Complications seemed slightly more frequent in this series of over 40 years patients with 2 Cyclop syndromes and 3 contracture reflex syndromes. 85% of the patients had a side to side laxity difference less than 5 mm. Pain was the main complaint (52%) but was usually mild occurring only during strenuous sports activity. Conclusions: Results are satisfactory after 40 years with no significant difference compared to the younger population. Nevertheless sports activity and delay between the trauma and the surgical procedure are the main factors affecting the results. Significance: Excellent results can be expected after ACL reconstruction using a bone-patellar tendon-bone autograft in patients over 40 years.

        Poster 229. Preoperative sf-36 outcome evaluation study in patients with anterior cruciate ligament lesion

        Luciano Lucania, MD, Stefano Lupparelli, MD, Alessandro Beccarini, MD, Sergio Cecconi, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Evaluating health status in patients with an anterior cruciate ligament tear using the MOS 36-item short-form health survey (SF-36). Materials and Method: There were 59 patients (37 males; 22 females) with a mean age of 30.42 ± 9.94 SD years, affected by anterior cruciate ligament lesion as confirmed by arthroscopy. All patients were treated with arthroscopically assisted anterior cruciate ligament reconstruction. The Lysholm score and SF-36 were administered preoperatively. The SF-36 preoperative scores were compared with an age-matched healthy normative control group (n = 367) as published in the literature. Each SF-36 domain was correlated with Lysholm score. T-test and Spearman correlation were used for statistics (P<0.05). Results: Mean preoperative Lysholm score was 66.76 ± 16.40. The mean preoperative domain scores were: PF 74.83 ± 21.47; RF 42.37 ± 40.00; BF 59.22 ± 22.60; GH 73.49 ± 18.17; VT 59.66 ± 17.19; SF 66.56 ± 23.68; RE 50.41 ± 42.91; MH 63.52 ± 19.64. All domain scores but GH (P<0.321) significantly differed from an aged-matched healthy normative control group (P<0.000). No significant correlations were found preoperatively between the Lysholm score and the SF-36 domains (P<2.00). Conclusion: Patients with anterior cruciate ligament lesion exhibit a significant worsening of their general health status in the absence of any other comorbidity factor. Whether this aspect might lead us to extend our surgical indication remains to be determined in future studies. The absence of correlation between the SF-36 domains and Lysholm score would suggest to include the SF-36 in our outcome evaluations tools.

        Poster 230. Peripheral nerve block safety and effectiveness as an anesthetic technique in anterior cruciate ligament reconstruction

        Luciano Lucania, MD, Stefano Lupparelli, MD, Francesco Tosti, MD, Sergio Cecconi, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Evaluating the safety and effectiveness of peripheral nerve block in performing arthroscopically assisted anterior cruciate ligament reconstruction (ACLR). Materials and Methods: Between January 1998 and May 2000 an arthroscopically assisted ACLR was performed in 224 patients. Out of the 224 patients, 198 underwent peripheral nerve block. The anesthetic procedure consisted of the sciatic (using Labat’s technique modified by Winnie, femoral (using perivascular inguinal technique) and obturator nerve block with a peripheral nerve stimulator. 2% mepivacaine was used for anesthesia at the mean dose of 9.8 mg/kgbody weight. All patients were premedicated 1 hour before surgery with fentanyl 0.1 mg. In the remaining 26 patients general anesthesia was administered in 7 patients, epidural anesthesia in 13 patients and spinal anesthesia in the other 6. In the peripheral nerve block group there were 165 males and 59 females. Mean age was 28.28 ± 7.90 SD years. The right knee was involved in 107 cases, the left one in 91. A bone patellar tendon bone graft was employed in 176 patients, double looped semitendinosus and gracilis graft being used in the remaining 22 patients. Associated lesions were lateral meniscus tears in 30 patients, medial meniscus tears in 35 patients and bilateral menisci tears in 10. In all cases an arthroscopic selective meniscectomy was performed. The mean operative time was 76.84 ± 15.21 SD min. The criterion used to assess safety of the peripheral nerve block was the ratio between patients who showed anesthesia-related neurological, vascular and/or general complications and those who did not (safety ratio, RS). The effectiveness of the anesthetic procedure was evaluated with the ratio between the patients who did not require intraoperative conversion to general anesthesia and those who did (effectiveness ratio, RE). A further differentiation between patients who received intraoperative parenteral analgesia and those who did not was carried out (ratio intraoperative analgesia/no intraoperative analgesia). Patients satisfaction about the block procedure was also assessed. Results: Neither neurological nor vascular nor general anesthesia-related complications were observed intra or postoperatively (safety ratio RS: 0). Conversion to general anesthesia was required in 10 out of 198 patients (effectiveness ratio, RE: 19.8). In 83 out of the 188 patients who were not converted to general anesthesia an intraoperative analgesia was administered (ratio intraoperative analgesia/no intraoperative analgesia: 0.4). Intraoperative analgesia used a mean fentanyl dose of 0.2 mg in 48 patients. In 35 patients fentanyl was associated with a benzodiazepine (diazepam or midazolam). In 10 patients only a benzodiazepine (diazepam or midazolam) was employed. One hundred sixty-two patients expressed their satisfaction about the anesthesiological procedure. Conclusion: In our experience the peripheral nerve block is a safe and effective anesthetic technique in ACLR, which we prefer to general anesthesia since it allows a prompt institution of active perioperative rehabilitation.

        Poster 231. ACL rconstruction with hamstring tendon autograft and AO screw & spiked washer fixation. 9-38 Months follow-up

        Abbas Madani, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Hamstring grafts have been used with increasing frequency for anterior cruciate ligament reconstruction. Adequate fixation of these grafts is necessary for early rehabilitation. This study evaluates the results of ACL reconstruction using four strands of hamstring tendons with A0 screw and spiked washer fixation. Patient and method: From 1995 to 1998, fifty consecutive patients underwent ACL reconstruction with a four strand hamstring tendon graft. Average follow-up was 14.5 months. The graft fixed by A0 screw and spiked washer to supracondyle of femur. After completion of a brace free, intensive rehabilitation program, clinical evaluation was performed using the IKDC scoring system. Results: 46 patients (92%) considered their knee function normal or near normal. 31 patients (62%) return to their preinjury activity level. One leg hop were >90% of opposite side in 24 patients (48%) and >76% in 16 patients (32%). In ligament examination group of IKDC 8 patients (16%) were graded A and 38 patients (76%) B. An overall IKDC assessment 45 (90%) were considered normal or nearly normal. Knee function and return to preinjury activity level had no correlation with ligament examination tests (x2=3.19, p>0.05) (x2=1.64, p>0.05), but had a significant correlation with IKDC score (x2=21.42, p<0.001), (x2=19.8, p<0.001). Return to preinjury activity level had a significant correlation with one leg hop (x2=19.8, p<0.001) . Conclusions: These results indicate that endoscopic ACL reconstruction using 4 strand hamstring tendon graft and AO screw and spiked washer fixation achieves acceptable knee stability and function, with a high rate of return to preinjury activity level. Knee function mostly correlated to one leg hop and IKDC score, and return to preinjury activities have significant relationship with IKDC score .

        Poster 232. Original hamstring ACL reconstruction. Results at minimum five years follow-up

        Maurilio Marcacci, S. Zaffagnini, F. Iacono, A. Vascellari, F. Morici
        2001 ISAKOS Poster Abstracts
        Purpose: Evaluate at minimum 5 years f-up the results of an original intra- and extra-articular ACL reconstruction with hamstring tendons, with resumption of sport allowed at 3-4 months. Method: 50 young (mean age 25 years) sport practicing patients (40 male, 10 female) underwent ACL reconstruction with hamstring tendons. 17 were professional soccer player, 33 were collegiate or recreational athletes in high risk sports. The tendons lived attached distally were passed over the top and fixed to the femur. The redundant part of the graft was used to perform a lateral plasty fixed to the Gerdy’s tubercle passing under fascia. Partial weight bearing was allowed from 3rd day, full weight bearing at 15 day post-op, and resumption of sport at 3-4 months. No brace was used. IKDC, Tegner score, and KT-2000 were used for clinical evaluation. X-rays were taken to evaluate tunnel enlargement. Linear regression analysis, correlation coefficient and Kruskal Wallis test were used for statistical analysis. Results: IKDC showed 94% of normal or nearly normal knees, 4% abnormal knees and 2% severely abnormal knees. Mean Tegner score was 8.1 (min.5-max.10). KT-2000 showed 94% of cases with differences between operated and healthy knee below 5 mm. Anterior knee pain was present in 8% of the cases. No extension deficit was observed. 40% of the cases resumed sport at 3-4 months, the other 40% between 4-6 months. Statistical analysis showed a significant correlation between early resumption of sport and knee stability (p.0.003). Acute cases had significantly better stability respect to chronic cases. Conclusion: Our intra- and extra-articular ACL reconstruction has demonstrated very low morbidity, with highly satisfactory results in sport practicing patients at high level. The stability obtained also at long term follow-up is satisfactory, and has been found to be significantly influenced by early resumption of activity, and acute reconstruction. Hamstring technique with extra-articular plasty and preservation of tibial insertion allows aggressive rehabilitation by preservation of the extensor apparatus, reducing the risk of complication, with no adverse effect on graft viability and knee stability at long term follow-up.

        Poster 233. Anterior cruciate ligament reconstruction. An economic outcome study comparing autografts to allografts

        David F. Martin, MD, Gary G. Poehling, MD, Walton W. Curl, MD, Adam Ginn, MD
        2001 ISAKOS Poster Abstracts
        Multiple reconstructive techniques for anterior cruciate ligament (ACL) injuries have been proposed, and multiple studies have compared the outcomes of these techniques. This study is unique in that it compares the health-related quality of life and medical charges of two types of anterior cruciate ligament reconstruction, 1) bone-tendon-bone autograft and 2) freeze dried Achilles tendon allograft. The purpose of this study was to compare the clinical status, health-related quality of life, and medical charges related to the ACL surgery of the patients in groups. Between November 1994 and April 1999, 170 patients enrolled in this study at the Wake Forest University Medical Center. The patients were divided into two groups, 1) autograft patients (117 patients of two surgeons) and 2) allograft patients (51 patients of one surgeon). The patients’ health-related quality of life was evaluated using the Rand 36-Item Health Status Profile, the McGill Short-Form Pain Questionnaire, and a knee function form based on the IKDC. Patients in the allograft group tended to be five years older in age than autograft patients, and more allograft patients were employed in professional and managerial positions. Patients in the autograft group averaged twenty-five years of age and included more students and student athletes. The baseline health-related quality of life of the autograft patients documented their reports of more leg problems and more severe pain with ambulation than was reported by patients in the allograft group. At baseline, patients in the autograft group also reported lower energy levels and greater fatigue than the patients in the allograft group. At six weeks after surgery, the autograft patients reported more overall pain than patients in the allograft patients. At later follow-up visits (3 months, 6 months, one year, and 3 years after surgery), the health-related quality of life data and range of motion was similar for both groups. Medical charge data demonstrated that the autograft ACL procedure cost three thousand dollars more than the allograft procedure. After these charges were analyzed, the major areas of difference between the two procedures were that the autograft procedure required longer operating room time, and therefore, more anesthesia services. In addition, most autograft patients were admitted to the hospital for an overnight stay in contrast to allograft patients who returned home after surgery. The charges for physical therapy were approximately two thousand dollars more for the autograft patients than the allograft patients. The autograft patients tended to receive therapy almost twice as long as the allograft patients.

        Poster 234. The effect of cytokines on the proliferation of human meniscal cells

        V. Martinek, MD, D. Pelinkovic, MD, A. B. Imhoff, MD, F. H. Fu, MD, J. Huard, PhD
        2001 ISAKOS Poster Abstracts
        Introduction: Current treatment options for meniscal tears in the avascular area are inadequate. Since the discovery of growth factors in the healing process, several research efforts have focused on characterizing a variety of cytokines to promote meniscal healing in animal models. Until now, detailed information about the effect different growth factors have on human fibrochondrocytes was lacking. We investigated the effect of various growth factors on the proliferation of different populations of human meniscal fibrochondrocytes. Methods: Large meniscal biopsies from 6 patients undergoing arthroscopic partial medial meniscectomy were obtained and placed into culture medium. Outgrowing superficial cells and the stationary deep meniscal cells were separated and transferred on 6-well plates (100,000/well) after the second passage. After 24 hours, insulin-like growth factor-1 (IGF-1), transforming growth factor a (TGF-a) and vascular endothelial growth factor (VEGF) were added at six different concentrations (0, 0.01, 0.1, 1, 10 and 100 ng/ml) and cell counts were performed after 96 h. Results: Superficial and deep fibrochondrocytes demonstrated differential responses to the evaluated growth factors.
        Figure thumbnail gr4a
        Figure thumbnail gr4b
        While TGF-a had a significant dose-dependent effect on the proliferation of both meniscal cell populations, IGF-1 did not stimulate the proliferation of the meniscal fibrochondrocytes (Figures). VEGF had only a significant effect on the deep meniscal cell population. There was a significant difference in stimulation of the superficial fibrochondrocytes by TGF-a in comparison to the deep cell population. Conclusions: The identification of cytokines that stimulate fibrochondrocytes in the avascular zone of the human meniscus provides useful information for possible new treatments of central meniscal tears. For the first time, different responses to a variety of cytokines were demonstrated for deep and superficial human meniscal fibrochondrocytes. TGF-a is a strong stimulator of meniscus cell proliferation and may be used for healing of the meniscus. The potential of VEGF in the avascular zone of the meniscus should be further investigated.

        Poster 235. Clinical results of RCI screw fixation for multi-sirand hamstring tendons in ACL reconstruction

        Yoshitaka Matsusue, MD, Yasuaki Nakagawa, MD, Takashi Nakamura, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To clarify over 2 year-results and problems of RCI screw fixation for multi-strand hamstring tendons in ACL reconstruction. Method: Fifty knees in 49 patients who underwent ACL reconstruction using multi-strand hamstring tendons fixed with an RCI screw were enrolled in this study. There were 25 males and 24 females. The follow-up period ranged from 2 to 4 years and 6 months (mean: 3 years). The RCI screw was used only on the femoral side and the tibial side was fixed with double stapling using an artificial ligament. The enlargement of the bone tunnel was assessed by serial radiographs and classified as no change, sclerosis and significant enlargement. The side-to-side difference of anterior translation was measured using a telos-SE at 20 and 90 degrees of flexion. Statistical analysis was performed for various parameters that would affect the postoperative instability. Results: Two patients suffered rupture of the reconstructed ligament due to re-injuries at 7 and 9 months after operation. respectively. Post-screw fixation was added in 1 knee because of insufficient fixation with an RCI screw. The side-to-side difference at 20 degrees of flexion was 1.9 mm in all cases, 2.2 mm in the right knees and 1.7 mm in the left knees. There was no significant difference in the value of the side-to-side difference between the right and left knee. No radiographical change around the screw was noted in 30 knees (60%) and a slight sclerosis was found in 17 knees (34%). A significant enlargement of bone tunnel was detected in 3 knees (6%). However, there was no significant difference in the value of the side-to-side difference among the radiographical findings. Conclusion: Screw fixation of hamstring tendons may jeopardize the integrity of the tendon structure, but no apparent damage to the substitute was found in this series. Although a significant enlargement of the bone tunnel was observed in a small number of cases, no radiographic change was found in 60%, suggesting that a direct fixation of the tendon to the bone can be achieved with this technique. Significance: RCI screw fixation gave a satisfactory clinical result, the value of the side-to-side difference of anterior translation being the same as that of the other fixation technique for hamstring tendons.

        Poster 236. Loss of motion following ACL reconstruction – reasons and outcomes

        Hermann Otto Mayr, MD, Thomas Weig, Ernst-Otto Muench, MD, Wolfgang Plitz, MD, PhD
        2001 ISAKOS Poster Abstracts
        Question: What are the reasons for a loss of motion following ACL reconstruction? What are the long-term outcomes of arthrolysis? Material and methods: From 1990 to 1998 we performed arthrolysis on 372 patients. 223 took part in this randomized, retrospective study. Mean time interval arthrolysis/follow-up examination was 4.29 years. We recorded timing of surgery, additional injuries, irritation, pain, ROM, type of rehabilitation, severeness and etiology of stiffness, time between ACL reconstruction and revision and course of development after arthrolysis. Follow-up examination consisted of clinical examination and X-ray. Instruments: KLT (laxity), VAS (pain), IKDC-form. For statistical analysis we used the Pearson-test, Exact-Fisher-test, Wilcoxon-test and Mann-Whitney-U-test (SPSS) with statistical significance p<0.05. Results: 68% of the patients were primarily operated with a knee showing limited ROM or irritation (p<0.001). 65.6% were operated during the first 4 weeks after injury. All of these patients had a pre-op limited ROM or irritation. Physiotherapy was painful in 76.7% (p=0.028). A sympathetic reflex dystrophy was found in 15.2%. After arthrolysis, 4.0% had an extension deficit >5°, and a extension deficit >10° was seen in 2.2%. IKDC results: 3.1% normal, 26.0% nearly normal, 46.2% abnormal, 22.9% severely abnormal. 75.3% showed radiographical signs of DJD. The grade of DJD was highly correlated to remaining loss of motion (p=0.002). Conclusion: The risk of developing arthrofibrosis following ACL-reconstruction depends mainly on the pre-op irritation and the pre-op ROM. There was no proof of this complication being only dependent on the time interval injury/reconstruction. Avoid pain during post-op rehabilitation. Outcome of arthrolysis depends mainly on achieved ROM.

        Poster 237. Stability and isokinetic strength after ACL reconstruction using different autografts

        Wolfgang Miehlke, MD, Jens Boldt, MBBS, Mario Bizzini, PhT, Urs Munzinger, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study was to compare knee stability and peak knee extensor/flexor torque after ACL reconstruction with two different autografts. Method: 153 consecutive patients that had undergone ACL reconstruction with either semitendinosus (ST), or bone-patella-ligament-bone (BPLB) autograft were investigated 9 to 12 months postoperatively. Ventral translation was examined with the Kneelax arthrometer and peak torque with the Biodex Multi Joint System 2. Results: In the BPLB group mean ventral translation was 1.9 mm greater than in the healthy knee. In the ST group ventral translation was significantly (p<.0001) higher (mean: 2.7 mm). The peak extensor torque of the operated compared with the healthy leg was -11.7% in the BPLB group and -14.9% in the ST group. In contrast, peak flexor torque was significantly greater in the BPLB (12%) group than in the ST group (-10.4%). Conclusion: BPLB grafts in ACL reconstruction appear to provide more translational stability compared with ST autografts and are, therefore, preferred in athletes with higher demands. Significance: Clinical comparison of two different ACL grafts with preference of BPLB grafts in athletes with higher demands.

        Poster 238. “one step” (Howell) guide for ACL surgery – technical and comparative analysis of the first 30 cases

        Claudio Horacio Mingo Saluzzi, Miguel A. Monges Luces
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the intraarticular position of the ACL graft by using the Howell guide as compared to the same position obtained by using the PCL reference guide. Method: 30 ACL surgery were performed by using BTB patellar tendon graft with the Howell guide (group A) and 30 surgery were performed by using the PCL reference guide (group B). The following measurements in the lateral roentgenogram of the fully extended knee were made:
        • Knee extension (K.EX.)
        • Intercondilary roof angle (I.R.A.)
        • Tibial tunnel position (T.T.P.) calculated by measuring the distance from its intersection at the tibial joint line to the anterior end of the tibial plateau and the result expressed as a percentage of the length of the tibia plateau
        • Tibial tunnel angulation (T.T.A.)
        Results:
        Tabled 1
        GROUPK.EX.I.R.A.T.T.P.maxminT.T.A.max.min.
        A-5.3°36.63°41.71%50.94%38.8%31.13°49°25°
        B-4.6°38.72°47.69%50.05%42.18%38.25°45°33°
        Conclusion: The Howell guide allows to place the graft in an intraarticular position similar to the PCL reference guide (7 degrees more vertical and 6% forward in group A). In spite of the fact there were no statistical differences , the analysis of the rise of extreme values obtained in group A could be related to the degree of extension of the knee and obliquely of the intercondilary roof allowing to place the graft back and parallel to the roof avoiding the impingement and minimizing the roof platy.

        Poster 239. Computer-assisted ACL reconstruction navigation system: Rationale and preliminary results

        Frederic Picard, MD, Anthony DiGioia, MD, James Moody, MD, Freddie H. Fu, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Although Anterior Cruciate Ligament (ACL) reconstruction is a routine procedure, accurate and reproducible graft placement and tensioning remain difficult tasks. The purpose of this study was to compare the efficacy and precision of the placement of the graft tunnels using a computer-assisted navigation system (KneeNav) versus the traditional surgical technique. Methods: KneeNav, a CT-based surgical navigation system, tracks the position of the tibia, femur and guide-pin assembly using optical technology. A randomized study on sawbones was performed to compare the accuracy of KneeNav (Group 1) with a traditional arthroscopic technique (Group 2). Two surgeons experienced in ACL reconstruction, but inexperienced in computer-assisted systems, performed twenty procedures each. Each surgeon preoperatively marked their ideal location of entry and exit holes for ACL tunnels on the tibia and femur on the knee model. These reference knees became the preoperative plan and goals for the surgeon during the experiment. Results: Tibial tunnel and femoral graft site locations were measured from two traditional radiographs and then in 3D coordinates using the navigation system. The “surgical error” was defined as the distance between the preoperatively marked ideal location and the surgically performed femoral and tibial holes. Surgical error was 4.6 mm (SD = +/-2.7 mm) for the KneeNav Group 1 and 6.8 mm (SD = +/-1.69 mm) for the traditional procedure Group 2 (p<0.05). Only four computer-assisted procedures were sufficient for both surgeons to become familiar with the technique. This difference was significant (p<0.05). Standard radiographs used to routinely measure post-operative alignment were not accurate in determining the true 3D orientation of the bone tunnels. Conclusion: The computer-assisted ACL navigation system may reduce surgical error and variation for optimal graft alignment. Standard planar x-rays are not reliable in measuring post-op positioning. Subsequent studies will focus on improved interfaces and clinical use.

        Poster 240. Arthroscopic anterior cruciate ligament reconstruction with central quadriceps tendon or central quadriceps tendon-patellar bone autograft

        Mario Morbidi, Andrea Vitullo, Alfredo Moriconi
        2001 ISAKOS Poster Abstracts
        Bone patellar tendon-bone and the hamstring tendon have been generally used in surgical reconstruction of ACL. In this study we describe an alternative graft: The quadriceps tendon CQT and the quadriceps tendon - patellar bone CQTPB autograft for arthroscopic ACL reconstruction. Methods: The quadriceps tendon autograft was used in 4 patients and CQTPB in 4 patients with acute ACL-injury. In two patients the CQT was fixed with Transfix technique and staple for tibial site and the other two cases we used interferential reabsorbable screws for the autograft fixation. CQTPB autograft was implanted with the bone part in tibial tunnel and fixed with interferential reabsorbable screw Arthrex. The femoral fixation was performed by using reabsorbable pins Rigid fix. Results: After 14 to 20 months of follow-up the clinical outcome for those patients have been encouraging. According to IKDC rating system all patients had normal or nearly normal ratings. Seven patients could return to the level of preinjury activity. Recovery of quadriceps strength muscle was 90% of the normal knee. MRI control have been performed at 12 months. Conclusion: Advantages: 1) the graft is langer and stronger than the patellar tendon (H.U. Staubli 1999), 2) The take off graft may be done by a second surgeon during the arthroscopic technique of notchplasty or meniscectomy. 3) Morbidity of technique and donor site is less than patellar tendon graft. 4) quicker return to sport activity. Disadvantages: Take off graft surgical techniques is demanding for the surgeon because of the risk to opening the suprapatellar punch. (J.P. Fulkerson 1995). CQT and CQTPB is a good alternative technique for ACL reconstruction in selected cases where grafts are not suitable.

        Poster 241. Femoral and tibial bone tunnel enlargement after bone-patella tendon-bone press-fit anterior cruciate ligament reconstruction

        Volker Musahl, MD, Peter Hertel, MD, Andreas Fussan, Heinrich Hornung, MD, Bjoern Stumpenhausen, MD
        2001 ISAKOS Poster Abstracts
        The objectives of this study are to quantify and qualify femoral and tibial bone tunnels after ACL reconstruction. Four major mechanisms for bone tunnel enlargement are presently considered: Mechanical, toxic, immunologic and thermic mechanisms. Methods: We developed a retrospective protocol for this study in which 40 patients were followed up on between 3 and 9 years after ACL reconstruction. We used a bone-patellar tendon-bone press fit technique on both the femoral and patellar side (Hertel, 1990). We present data for the first 16 patients. After 6 days postoperatively and a follow-up of 8.6 years (8.2-9.1) a CT scan of the ACL reconstructed knee was performed. In coronal planes, the size of tibial bone tunnels were measured in a.p.- and transverse diameter. For the femoral bone tunnel, we developed a scale to qualify the bone plug and cyst formation. Objective and subjective clinical findings were obtained using defined outcome scores (IKDC, KT-1000, Tegner and Lysholm). Results: Tibial tunnels increased in a.p. diameter on average by 3.5% (-38.0 - +50.3) and decreased in transverse diameter on average by 15.9% (+6.2 - -48.1). The femoral tunnel showed no significant enlargement. Clinical results for the IKDC Score at the time of follow-up showed A/B in 87% and C in 13%. Conclusion: In this study, tunnel enlargement could not be described as previously reported. Nine years after bone-patella tendon-bone press-fit ACL reconstruction only two patients showed a bone tunnel enlargement of 25% or more. However, bony defects, cysts or holes do occur in 23% of the cases when using press-fit spongiosaplasty. We found no correlation to clinical outcome.

        Poster 242. Long-term evaluation of elmslie-trillat procedure for recurrent patellar dislocation

        Koichi Nakagawa, MD, Yuichi Wada, MD, Hiroshi Kitahara, MD, Hideshige Moriya, MD
        2001 ISAKOS Poster Abstracts
        Purpose: There were few reports demonstrated long-term results of Elmslie-Trillat procedure. The purpose of this study is to evaluate long-term results of this procedure and outline the factors that may affect the ultimate outcome. Methods: We evaluated 45 knees in 39 patents, 8 knees in 8 males and 37 knees in 31 females, ranged in age from 13 to 30 years at the time of operation. At a mean follow-up of 13.2 years (range 10 to 19.9 years), all patents completed postoperative surveys using Fulkerson’s score and physical examinations, which were compared with the findings in 1990. In addition, MRI was performed in 27 knees in 22 patents, and cartilage of patellofemoral joint was evaluated. Results: The mean of Fulkerson’s score was 89.4 points in 1990, and 85.5 points in 1999. Although the outcome seems to be satisfactory, the functions leveled down from good to fair in 12 knees mainly because of patellofemoral pain. In these cases, preoperative duration had a tendency to prolong, and degenerative change of patellofemoral joint was proved to be severe by MRI evaluation. Especially, the degeneration of lateral facet affects the ultimate outcome. Conclusions and Significance: It was reported that osteoarthritis did not progress so often after Elmslie-Trillat procedure different from Hauser procedure. However, this study showed that progression of patellofemoral degenerative changes was observed with long-term after Elmslie-Trillat procedure. Moreover, prolonged preoperative period with repeated dislocations was one of main factors to affect the ultimate outcome.

        Poster 243. Revascularization of ACL grafts reconstructed with hamstring tendons by single or bi-socket technique: Evaluation by Gd-enhanced MRI

        Ken Nakata, MD, PhD, Tatsuo Mae, Takahide Miyama, Hirotaka Shinjo
        2001 ISAKOS Poster Abstracts
        Purpose: To compare single and bi-socket ACL reconstruction using autogenous hamstring tendon graft in revascularization. Materials and Methods: Forty-five patients who had undergone the ACL reconstruction consented to have the follow-up MRI evaluation. The reconstruction was performed endoscopically using autogenous multi-stranded hamstring tendons with Endobutton® femoral and suture-post tibial fixations. Twenty patients underwent the single-socket procedure (SS), and the 25 were treated by the bi-socket one (BS). During postoperative period between 2 to 24 mos., the grafts were evaluated by both plain and intravenous Gd-enhanced MRI (table 1). Parasagittal and coronal MR images were analyzed. Results: In the tibial tunnel, Gd-enhancement within and around the graft was noted in both SS and BS as early as two months after surgery, and gradually diminished after 6 months. In the femoral sockets, the enhancement was first seen along the posterior graft-bone interface in both methods on the parasagittal images. However, the enhancement was detectable at 3 mos. in BS, while that was not observed until 4 mos. in SS on the coronal images. As for the core portion, the grafts were not enhanced in SS throughout postoperative period, whereas those via BS were entirely enhanced in the femoral sockets, followed by gradual subsidence over time after 8 mos. Conclusion: The hamstring ACL grafts anchored into two femoral sockets are revascularized earlier and more diffusely than those placed in a single socket.
        Table 1Time point for evaluation of Gd-enhancement of ACL grafts
        Mos. after surgery2m3m4m5m6m7m8-12m13-20m
        Single-socket (n=20)22423223
        Bi-socket (n=25)34543222

        Poster 244. Effect of knee flexion angle and sequence at graft fixation in two-bundle reconstruction of the anterior cruciate ligament

        Takashi Ogiuchi, Hisayo Orii, Takeshi Muneta, Kenichi Shinomiya
        2001 ISAKOS Poster Abstracts
        Purpose: To know how to get the most appropriate initial tension for the multi-strand graft, we inestigate the effect of knee flexion angle and sequence at graft fixation in two-bundle reconstruction of the anterior cruciate ligament (ACL). Method: We carry out two-bundle reconstruction of the ACL using multi-strand semitendinosus tendon fixed with Endobuttons for the purpose of getting better stability by putting the graft in the normal anatomy with minimized notch-plasty. We prospectively compared arthroscopic findings and clinical outcome 2 years postoperatively of two groups (A group: In 102 patients, PL-bundle was first fixed at 30° flexion, and AM-bundle was then fixed at 30° flexion. B group: In 73 patients, AM-bundle was first fixed at 0° and PL-bundle was then fixed at 30°). The clinical outcome was studied about range of motion, manual knee laxity tests (Lachman test, anterior drawer test, pivot-shift test), anterior knee laxity measurements with the KT-1000, and subjective evaluation (Lysholm knee score, subjective satisfaction). The arthroscopic findings were evaluated about its volume, roof and/or wall impingement, and synovial coverage at the hardware removal. Results: There was no statistically significant difference between the two groups with regard to Lachman test, pivot-shift test and KT-1000. With regard to anterior drawer test, A group was statistically better than B group in the restriction of abnormal anteroposterior laxity (p>0.05). But with regard to subjective evaluation, B group was better than A group (p>0.01). With regard to arthroscopic tension, volume, wall impingement, synovial coverage, there was no statistically significant difference between the two groups. But with regard to roof impingement the percentage of good case was higher in the B group than in the A group (p>0.001). Conclusion: In A group the AM-bundle might have been overconstraint and had the graft partial rupture, because it had been fixed later at 30° flexion. While in the B group the AM-bundle should have had more anterior loose leading to laxity because it had been fixed first at 0°. Significance: In two-bundle reconstruction of the ACL, we recommend to fix the AM-bundle first, and then fix the PL-bundle. The results also suggest fixation of AM-bundle first at flexion may reduce anteroposterior laxity as well as roof impingement.

        Poster 245. The value of the kneeling view to evaluate the direct posterior knee instability: A prospective randomised study

        Leonardo Osti, John Bartlett
        2001 ISAKOS Poster Abstracts
        Introduction: The radiographic evaluation of ligamentous instabilities as been investigated in the literature as a method to provide reliable and comparable information concerning the amount of tibio-femoral translation, with a minor number of studies focusing on PCL instability. Purpose of the study is to introduce and evaluate the kneeling view as a direct weight bearing method to measure the posterior tibial displacement. Materials and Methods: A specific but inexpensive apparatus has been designed and tested in order to obtain a reproducible positioning of the patient with exact 90 degrees of knee flexion during x-ray examination. The radiographic exams have been performed routinely in 29 patients undergoing total knee replacement. 10 of those patients underwent a previous unilateral PCA TKR by the same surgeon with total sacrifice of the PCL. A contralateral view (uninvolved knee) has been obtained routinely. On the x-rays the posterior tibial displacement has been measured as the distance between the projection of the line of the posterior tibial cortex and the end point of the Blumensaat’s line. Results: The mean value of the posterior tibial displacement measured was 0.92 mm in the control group (19 patients/38 knees) and 0.28 mm in the TKR group (10 patients /10 knees). Conclusions: A simple and reliable radiographic method to evaluate the direct posterior knee instability under weight bearing load has been introduced.

        Poster 246. Absorbable screw fixation in anterior cruciate ligament reconstruction – a clinical MRI and CT scan evaluation

        A. S. Panni, M. Tartarone, G. Milano, N. Maffulli
        2001 ISAKOS Poster Abstracts
        An anterior cruciate ligament reconstruction with autologous patellar tendon was performed in 21 patients, using absorbable interference screws (Poly L-Lactic Acid) for interference fixation of the bone plug. Clinical evaluation of results was performed by the IKDC form and through KT-1000 arthrometer. All patients were submitted to an examination by CT scan and MRI three, six, and twelve months after surgery. The overall results at a two-year follow-up were normal in 5 cases, nearly normal in 12 cases and abnormal in 4 cases. No cases of infection or clinically evident reactive synovitis were observed. CT scans showed that one year after surgery the bone plugs of the graft were completely incorporated within the bone tunnels. The gap between the screw and the bone plug was completely filled with bone. A reactive bone layer was observed around the screw. No changes were evident at the site of implantation of the absorbable material. The screws maintained their shape after one year and mild signs of resorption were observed along the outer and inner surfaces. MRI provided more significant information on the position of the bone tunnels and on the intraarticular part of the graft. Instead, CT scans proved to be superior because it better demonstrated the incorporation of the bone plugs, the bone-screw interface and the resorption of the screws.

        Poster 247. Does the technique make the difference? Osteoarthritis after open or arthroscopic anterior cruciate ligament reconstruction – a long-term follow-up

        Thomas W. Patt, MD, Niklaus F. Friederich, MD, PhD, Peter Burkart, MD
        2001 ISAKOS Poster Abstracts
        Objective: To evaluate the difference in osteoarthritis rate between open and arthroscopic ACL reconstruction. Methods: 174 consecutive patients with symptomatic ACL instability (87 open / 87 arthroscopic) were operated on by one surgeon between 1985-1994. The follow-up by an independent examiner was at an average of 56 mo. (open, range 34-80) vs. 92 mo. (arthroscopic, range 61-119). Evaluation included a thorough patient satisfaction evaluation (VAS), history (Tegner) and clinical examination (Lysholm score, KT-1000, OAK-evaluation, IKDC score). X-ray tests included standard lateral, full-length one leg pa in flexion (“Schuss,” Rosenberg) and patellar x-rays. Fairbanks classification completed the follow-up. Results: 7 patients (8%) in the open group had complications between surgery and follow-up (4 medial meniscus, 1 lateral meniscus, 1 recurrent swelling, 1 infection at tibial screw) vs. 5 patients (5.7%) in the arthroscopic group (1 medial meniscus, 4 x arthrofibrosis, 2 cartilage lesions, 1 parapatellar calcification). The VAS showed an average of 89.7 (open) vs. 92.3 (arthroscopic); OAK a mean of 91.4 (open) vs. 95 (arthroscopic).
        Tabled 1
        Radiographic changes (Fairbanks)pre-operativefollow-up
        open:080.5%37.9%
        119.5%52.1%
        28%
        31.1%
        arthroscopic:077%57.5%
        123%36.8%
        25.7%
        lKDC final resultABCD
        open:9%62%26%2%
        arthroscopic:16%71%11%
        Conclusions: Even though the arthroscopic follow-up time for the group was significantly higher (92 mo. vs. 56 mo.), the radiologic results at follow-up were much better. However the open group showed still acceptable results.

        Poster 248. Sport activity scores in patients after chronic anterior cruciate ligament deficiency – is the Tegner score a suitable tool?

        Thomas W. Patt, MD, Niklaus F. Friederich, MD, PhD, Peter Burkart, MD
        2001 ISAKOS Poster Abstracts
        Objective: Since returning to their previous sports activity level is of important interest, we evaluated the Tegner score (Clin Orthop 1985 Sep;(198):43-9) by assessing patients who underwent anterior cruciate ligament reconstruction. Methods: Between 1990 and 1984 87 patients with chronic anterior cruciate ligament deficiency were operated by arthroscopic means using the central third bone-patellar-bone as transplant and could be reached for follow-up. All patients were operated on by one surgeon. The follow-up was at an average of 92 months and was done by an independent examiner. Evaluation included a thorough patient satisfaction evaluation (VAS), and clinical examination (Lysholm score, KT-1000, OAK-evaluation, IKDC score). A score (“Innsbruck”) with 4 grades (high-pivoting, low-pivoting, non-pivoting, sedentary work), was compared at the time of trauma, surgery and follow-up with the Tegner score. Results: Preoperative Tegner score 6.67, postoperative 6.21. 20 patients (23%) decreased their level of activity, 67 (77%) patients reached the same level as prior to surgery. “Innsbruck”: Preoperatively 13 patients scored in group 1 (high pivoting sports), 73 patients in group 2 and 1 patient performed only non-pivoting sports before the operation. At the time of surgery all but 2 patients (98%) demonstrated a decrease in their sports level. 74 (85%) patients improved after the surgery and 10 patients (11.5%) were still able to practice on the level they were able to at surgery. Only 3 (3.5%) patients decreased after the surgery – due to non-knee- related reasons. Conclusions: Often patients with chronic knee instability are able to perform different levels of sport at time of injury/surgery/follow-up. In addition pivoting plays a role concerning the ACL. The new “Innsbruck” activity score differentiates pivoting and non-pivoting sport and thus is more distinctive.

        Poster 249. Femoral fixation in ACL reconstruction using a reverse thread interference screw

        Leo A. Pinczewski, MBBS, FRACS (a – Australian Institute of Musculoskeletal Research), Tim Musgrove, MBBS, FRACS, Lucy J. Salmon, BAppSc(Phty), Charles Burt, MD
        2001 ISAKOS Poster Abstracts2001 ISAKOS Poster Abstracts
        Aim: The aim of this study was to determine if a side to side difference in laxity occurs with anterior cruciate ligament reconstruction utilizing hamstring tendon and standard RCI (Smith and Nephew) interference screw fixation, and if this can be affected by the use of a reverse thread RCI screw in right knees. Method: A prospective study was performed on 80 patients undergoing right-sided ACL reconstruction with hamstring tendon autograft. Females were excluded in case of a sex difference in post operative laxity with HT graft. The study group comprised of 36 males utilizing standard RCI screw (STD), and 44 males utilizing reverse thread RCI screw (REV). The same technique was performed on all patients, and all procedures were by the same surgeon. Patients were evaluated at 6 and 12 months following surgery with KT-1000, IKDC assessment, and Lysholm Knee Score. Results: At 12 month follow-up, the average side to side differences using KT-1000 testing were 2.0 mm (STD) and 1.0 mm (REV) using manual maximum, and 1.7 (STD) and 1.0 (REV) using KT20. Both results were statistically significant. As well, 33% of the STD group had a manual maximum of >3 mm compared to 11% of the REV group (p<0.01). Accordingly there was a higher incidence of grade 1 Lachman in the STD group (23% of STD group; 8% of REV group; p=0.04). Conclusion: The use of a reverse thread interference (RCI) screw for femoral fixation in right-sided hamstring tendon ACL reconstructions in males significantly decreases laxity at 12 month review compared to standard RCI fixation.

        Poster 250. Treatment of bicruciate ruptures using synthetic allografts. Three years follow-up

        S. J. Plessas, Consultant, A.Th. Kouzelis, Registrar, P. Megas, Asst. Prof., E. Lambiris, Prof.
        2001 ISAKOS Poster Abstracts
        Purpose: To present the surgical outcome in complex knee injuries involving simultaneous rupture of both Cruciate Ligaments. Method: Eight patients, with simultaneous ruptures of both cruciates were treated surgically during the last three and a half years. Four of them had involvement of the posterolateral corner. Patients’ age ranged from 17 to 46 years (mean 26.5 y). All patients were operated 5 to 7 days after the initial injury by the same surgeon. All ruptured ligaments had been reconstructed at the same time, using LARS® synthetic ligament. The follow-up ranged from 9 to 41 months (mean 22 m). All patients were assessed with the Cybex Norm 770. The parameters assessed were the knee flexors and knee extensors peak Torque in 60 d/s and 180 d/s, the angle of the peak torque and the muscle endurance. All patients were assessed with the Lars laxiometer for evaluation of the tibial external rotation control. They also answered a modification of the Lysholm Knee Scoring Scale. Results: The peak torque deficit of the involved compared to the uninvolved knee was 13% for the flexors and 17.5% for the extensors. The difference in the muscle endurance was approximately 18% between the two sides. The difference of the tibial external rotation was less than 10 degrees between the two sides in all patients but one. The Lysholm Knee Score was 84-90 points. All patients returned to their pre-injury activities and they were happy with the result. Three of them returned to their previous level of sports activities. The commonest symptom was mild pain after increased activities. Conclusion-Significance: The reconstruction of all damaged ligaments after such complex knee injuries is mandatory. The use of synthetic allografts offers a good choice for reconstruction of such severely injured knees.

        Poster 251. Outcome of torn meniscal allograft transplantation

        Ehud Rath, MD, John C. Richmond, MD
        2001 ISAKOS Poster Abstracts
        Objectives: To identify the functional outcomes of torn meniscal allografts, and identify potential causes for failure. Methods: During the years 1991-1999, 30 consecutive patients underwent meniscal allograft transplantation (34 menisci) for compartmental pain. Of these, 9 patients tore the allograft. Patients who tore the allograft were reviewed prospectively for their symptoms, function and radiographic appearance of the involved knee. Follow-up included chart review, physical examination, IKDC 1999 Knee function evaluation preoperative and postoperative SF-36, weight-bearing flexed knee radiographs, and histologic analysis of all subsequently removed meniscal tissue, including quantitative cell counts, and selective cytokine assessment of selected specimens. Results: 2 patients had total removal of the allograft and reimplantation. 7 had partial allograft meniscectomy. Complete healing of the meniscus to the bed was evident in all cases. The SF-36 pain score improved significantly (p<0.0001) from pre-op to final follow-up in all patients except one. Quantitative histologic analysis revealed a greater than 50% reduction in the number of meniscal fibrochondrocytes in the tom allograft menisci, when compared to normal menisci or torn native menisci (p<0.05). Average Outerbride preimplantation score for articular surface damage in these patients was higher than asymptomatic patients but not significantly. Conclusions: Meniscal allograft tear is a common complication of meniscal allograft transplantation. The effective pain reduction and functional improvement is maintained in these patients. Hypocellularity and impaired chondrocyte function may explain the vulnerability of the allograft.

        Poster 252. The natural history of anterior cruciate ligament reconstruction graft tightness using central third patellar tendon

        Marc R. Safran, MD, Debra Schenk, MD, T. Ted Funahashi, MD
        2001 ISAKOS Poster Abstracts
        Introduction: The purpose of this study was to prospectively evaluate knee laxity following ACL reconstruction (ACLR) from the operating room until a follow-up of at least 2 years. Methods: 73 patients with isolated, unilateral ACL tears and > 2 year follow-up were studied. These patients underwent endoscopic ACLR by 1 surgeon with the same technique, graft, fixation and rehabilitation program. KT-1000 arthrometry was utilized under anesthesia pre-op and post-op, as well as at the 6 week, 3 month, 6 month, 1 year and subsequent annual visits. Statistical analysis included McNemar’s Test and Repeated Measures ANOVA. Results: These 47 males and 26 females averaged 26 years of age (14-48) and were followed for 39 months (24-63). There were 27 right and 46 left ACLRs. All patients had full extension. The manual maximum side to side differences are listed:
        Tabled 1
        Pre-Op KT-1000Post-Op KT-1000Change in KT-1000: OR-6wkChange in KT-1000: 6wk - 3moChange in KT-1000: 3mo - 6moChange in KT-1000: 6mo - 1 yrChange in KT-1000: 1 yr - Final
        8.4 mm-0.8 mm+1.2 mm+0.5 mm+0.2 mm+0.1 mm+0.2 mm
        (3-15)(-9-4)(p=0.0002)(p=0.670)(p=0.998)(p=1.00)(p=0.998)
        Meniscal surgery and chondral injury did not affect loosening. Discussion/conclusion: A patellar tendon graft fixed with interference screws loosens most in the first 6 weeks following ACLR. The graft does not stretch significantly after 3 months. This data may help guide rehabilitation of ACLR and return to sports.

        Poster 253. Modification of MRI to detect popliteomeniscal fasciculi

        Takahisa Sasho, MD, Yuichi Wada, MD
        2001 ISAKOS Poster Abstracts
        Objective: Popliteomeniscal fasciculi (PMF) are the stabilizer of lateral menisci. Recently, injury of PMF was reported to be one of the causes of hyper-mobile lateral meniscus and it was detectable with MRI. But identification of PMF with conventional MRI is controversial. So we tried to detect PMF by modification of MRI. Methods: 1) We tried to detect PMF more clearly by oblique coronal images that are inclined every 10 degrees from 0 (coronal) to 90 (sagittal). Three healthy males with no history of trauma or symptom of their right knee were examined and adequate obliquity and sequences were determined. 2) Twenty healthy knees were examined with adequate obliquity to examine the normal pattern of PMF. 3) MRI of two patients arthroscopically diagnosed hyper-mobile lateral meniscus due to PMF injury were studied and compared with that of intact images. MR arthrogram was also performed in these cases. Results: 1) Thirty to sixty degrees of oblique coronal images of proton-density were proper to examine the PMF. 2) Eighteen out of 20 antero-inferior fasciculi and all the 20 postero-superior fasciculi were detected in healthy knees. 3) Tear of PMF was clearly detected in 45 degrees oblique coronal images and MRA was superior to detect the PMF tear. Conclusions: Oblique coronal images of proton-density MRI are useful method to detect the injury of PMF and to diagnose the hyper-mobile lateral meniscus especially in cases with the symptom of catching or locking but have no findings in their lateral meniscus in conventional coronal and sagittal MRI.

        Poster 254. Arthroscopic ACL reconstruction with autogenous hamstring tendon fixed with biodegradable interference screw and bone block

        Seung-Suk Seo, MD, Jang-Seok Choi, MD, Young-Chang Kim, MD, Chang-Sup Lee, MD
        2001 ISAKOS Poster Abstracts
        Objective: The purpose of this study is to report the postoperative clinical results after arthroscopic ACL reconstruction with quadrupled hamstring autograft fixed with biodegradable interference screw and bone block in the femoral tunnel. Method: Between January and December 1997, we performed an endoscopic ACL reconstruction with a quadrupled hamstring autograft in twenty-one patients. To enhance the mechanical stability in the femoral tunnel the graft was fixed with a biodegradable interference screw and cortical bone block which was harvested from the proximal tibial metaphysis. The tibial side of graft was tied at the post of an A-O cortical screw. Postoperatively the patients were permitted an accelerated rehabilitation with motion limiting brace. The results were evaluated with lKDC form, complications, radiologic findings. The average follow-up was 36 months. Results: Patient subjective assessment was graded A in 4, B in 8, C in 7, D in 2 knees. Ligament evaluation was graded A in 16, B in 3, C in 1, D in 1 knees. Harvest sight pathology was graded A in 16, B in 4, C in 1 knees. Functional test was graded A in 6, B in 8, C in 4, D in 3 knees. Radiologic findings showed an average 22% increase in the tibial tunnel diameter. Postoperative complications were 1 recurrent patholaxity, 1 deep infection, 1 arthrofibrosis required operation. Conclusion: Arthroscopic ACL reconstruction with quadrupled hamstring autograft fixed with biodegradable interference screw and bone block in the femoral tunnel was provided with excellent ligament stability and was permitted the early accelerated rehabilitation. There was an increase in the tibial tunnel diameter but no effects on the clinical results.

        Poster 255. Magnetic resonance imaging study on reconstructed anterior cruciate ligament after renotchplasty

        Kojiro Shimada, Akihiro Tsuchiya, Masaki Sonoda, Satoru Nishikawa
        2001 ISAKOS Poster Abstracts
        Purpose: Renotchplasty is necessitated in some post anterior cruciate ligament (ACL) reconstructions with notchplasty, often due to notch regrowth. The purpose of this study was to evaluate the effects of renotchplasty by magnetic resonance imaging (MRI) and KT-2000 knee arthrometer. Method: MRI evaluations were performed on 114 cases of ACL reconstructions using semitendinosus and gracilis tendon with EndoButton technique between 1996 and 1999. On second-look arthroscopy, 18 cases necessitated renotchplasty due to notch impingement. MRI evaluations were performed before and after renotchplasty, and anterior knee instability was measured by a KT-2000 knee arthrometer. Results: Before renotchplasty, 4 cases indicated abnormal intensity (high) on MRI, 3 cases indicated abnormal pattern (curve), and 11 cases indicated both high intensity and curved pattern. After renotchplasty, all cases indicating abnormal pattern were improved to straight pattern on MRI. Ten cases which had indicated abnormal intensity were improved to low intensity. Seven cases showed improvement of anterior instability measured by KT-2000, although 11 cases were unchanged. Conclusion and Significance: Renotchplasty was found to improve curved patterns of reconstructed ACLs to straight in all cases. However, of the 15 high intensity cases, 10 improved to low and 5 were unchanged. Anterior knee instability were improved in 7 of 18 cases.

        Poster 256. Is joint line tenderness the most pathognomic finding of the meniscal tear of the knee?

        Dong-Bae Shin, MD, Young-Soo Lee, MD, Soo-Jin Park, MD
        2001 ISAKOS Poster Abstracts
        Objective: Joint line tenderness was known as a most diagnostic finding of meniscal tear of the knee. And many orthopaedic surgeons commonly decide to perform arthroscopic surgery if joint line tenderness combines with positive finding of tear on magnetic resonance imaging. The purpose of this study is to evaluate the correlation between preoperative findings of physical examinations and arthroscopic findings of meniscal tear and to determine what is the best diagnostic physical examination. Methods: One hundred and ninety-four patients underwent magnetic resonance imaging of the knee to detect the meniscal pathology from March 1997. Among them, 131 patients had arthroscopic surgery. Three physical examinations underwent preoperatively as follows: Joint line tenderness, hyperextension test and McMurray test. We investigated the efficacy of these three physical examinations and compare with arthroscopic findings and MR findings. Results: The sensitivity, specificity and positive predictive value for joint line tenderness were 100%, 12% and 82.8% respectively, while those of McMurray test were 74.5%, 60% and 92.9% respectively and those of hyperextension test were 74%, 80% and 94% respectively. The accuracy when three physical examinations were all positive was 100%, while the accuracy when two of three physical examinations were positive were 86.7% and 88.9% respectively. The accuracy when only joint line tenderness was positive was 21.1%. Conclusions: Among three physical examinations, joint line tenderness had a highest sensitivity. However, the specificity of joint line tenderness was worst than those of the other two physical examinations. This study showed that it was undesirable to perform arthroscopic surgery if only the joint line tenderness was positive. We concluded that it was desirable to perform arthroscopic surgery if two of three or all three physical examinations were positive.

        Poster 257. Sports activity level following ACL reconstruction with different grafts

        Rainer Siebold, MD, Jens-Ulrich Buelow, MD, Andree Ellermann, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study is to analyze differences in sports participation levels after ACL reconstruction with patellar tendon autograft, quadruple hamstring graft and allografts in patients with a high level of sports activity. Method: 450 patients after ACL reconstruction were evaluated according to the Cincinnati Sports Activity Scale (CSAS). KT-1000 side to side difference was measured. Minimum f/u was 2 years and average age was 35 years. Patients were divided into 3 groups: Group I: ACL reconstruction with autogenous patellar tendon (n=129), Group II: ACL reconstruction with autogenous quadruple hamstring graft (n=170) Group III: ACL reconstruction with allografts (patellar tendon and achilles tendon, n=151). Patients were matched for chronicity of Injury, age, gender, preoperative sports activity level and cartilage condition. An accelerated rehabilitation was performed in all patients. Statistical analysis was performed using the chi-square test. Significance was set at p<0.05. Results: At f/u the average manual max. KT-1000 side to side difference was 2 mm in group I and 2.2 mm in group II and III (pre-op: 6.2 vs. 6.4 vs. 6.2 mm). The level of sports activity at f/u (max. 100 pts.) was 85 pts. in group I, 77 pts. in group II and 80 pts. group Ill (pre-op: 90 vs. 84 vs. 86 pts.). 75% of patients in group I, 81% in group II and 81% in group Ill returned to their pre-op level of sports activity. At f/u 75% of patients in group I, 72% in group II and 70% in group Ill had no or only slight problems practicing sports, 11% of patients in each group were practicing sports with pain (“knee abuser”). The assessment of specific functions revealed 38 pts. in group I, 35 pts. in group II and 35 pts. in group Ill for daily activities (max. 40 pts.) and 91 pts. (group I), 86 pts. (group II) and 83 pts. (group III) for sports activities (max. 100 pts.). Discussion and significance: Our study indicates that ACL reconstruction with patellar tendon autograft, quadruple hamstring graft or with allograft achieve comparable results regarding the ability of sports participation. More than 70% of all patients had no or only slight problems practicing sports and nearly 80% returned to their pre-op sports activity level. On the other hand there were 11% of “knee abuser.” Allografts proved to be an alternative for patients with a high level of sports activity.

        Poster 258. Bone tunnel enlargement after anterior cruciate ligament reconstruction

        Olivier Siegrist, MD, Patrick Tomasetti, Brigitte Jolles
        2001 ISAKOS Poster Abstracts
        Introduction: Bone tunnel enlargement after anterior cruciate ligament is a misunderstood phenomenon which seems to be multifactorial. Biomechanically we observe less osteolysis with rigid fixation situated close to the joint line. While some consider this phenomenon as an early sign of graft failure, others estimate this as irrelevant. Material and Method: Forty-six patients sustained an ACL reconstruction using a double looped hamstring tendon by endoscopic single-incision arthroscopically assisted technique. We reviewed thirty of them (65%) with a follow-up of two years. Proximally, fixation was assured by endobutton ; distally, by suture on a screw. The rehabilitation went classically. Evaluation was done according to the IKDC rating score, all knees were radiologically controlled with an antero-posterior and a lateral view. Results: According to the IKDC rating score 23% of the patients are classified as grade A, 61% as grade B and 16% as grade C. The differential laxity between the reconstructed and normal sides was measured with the KT-1000. Average 3 mm (0-5). X-rays demonstrated bone tunnel enlargement in all cases. In comparison with the post-operative tunnel diameter, the average femoral tunnel increased from 44%, the tibial tunnel from 47%. Conclusion: In comparison with other techniques of fixation these clinical results are quiet similar. However it seems logical to suppose that bone tunnel enlargement doesn’t ensure a good graft incorporation and consequently a strong fixation. The rigid fixation close to the joint line of the graft seems to decrease the osteolysis; the fixation by sutures, proximally on endobutton, distally on a screw doesn’t allow to obtain this mechanical parameter.

        Poster 259. Morphological change after total meniscectomy for discoid lateral meniscus in children – an MRI study

        Takashi Soejima, MD, Shuji Horibe, MD, Yoshiki Shiozaki, MD, Konsei Shino, MD
        2001 ISAKOS Poster Abstracts
        Purpose: In order to elucidate intraarticular morphological changes after total meniscectomy for discoid lateral meniscus in children, we performed magnetic resonance (MR) evaluation on the bilateral knees after the growth period. Methods: Arthroscopic total meniscectomy was performed for symptomatic unilateral discoid lateral meniscal tears in eight children. Their average age at operation was 11 years, ranging from 9 to 13. All patients underwent MR evaluation (Hitachi Medical Co. 0.3 T AIRIS) for the bilateral knees with an average of five years after operation (range: 3 to 7 years). T1-weighted coronal/ sagittal images were taken to evaluate the morphological change around the knee joint. Results: At follow-up, all became asymptomatic except two cases with mild pain after sports activity. Signal intensity of the subchondral bone was normal except two cases with osteochondritis dissecans of the lateral femoral condyle. Lateral tibial plateau of the meniscectomized side became flat and wide compared to contralateral side, while no apparent osteoarthritic change was found. Although there were small pieces of meniscal remnants in two cases, meniscus regeneration was not found in any cases. Discussion & Conclusion: This MRI study demonstrated that adaptation of lateral femoro-tibial compartment occurred with growth and that osteoarthritic changes were less in children after meniscectomy. Such morphological changes may lead to a better outcome after total meniscectomy for discoid lateral meniscus in children.

        Poster 260. Quantitative analysis of reconstructed ACL and bone tunnels using magnetic resonance imaging

        Masaki Sonoda, MD, PhD, Yoshikuni Kawaguchi, MD, Akihiro Tsuchiya, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this study was to analyze reconstructed anterior cruciate ligament (ACL) and bone tunnels by axial images of MRI. Method: ACL reconstructions through use of hamstring tendons and endobutton technique were performed on 27 knees (17 male, 10 female, average age 23.4). Axial images (Gyroscan 1.5T, Philips) were taken 1 year following surgery and analyzed by NIH image. Analyses were performed to measure area of the reconstructed ACL, area of the tibial bone tunnel including the reconstructed ligament and area of the femoral bone tunnel including the ligament. Results: Reconstructed ACL area which was corrected by intraoperative bone tunnel area was 150.4±26.8% (%ACL). Tibial bone tunnel area (%TB) and tibial ligament area (%TL) were 188.4 ±36.3% and 123.1 ± 27.2%. Femoral bone tunnel area (%FB) and femoral ligament area (%FL) were 244.1±48.5% and 144.6±27.9%. Statistically %FB was significantly larger than %TB (p<0.05), %ACL and %FL were significantly larger than %TL (p<0.05). Further, %TB was strongly correlated with %TL (r>0.7) and %FB was strongly correlated with %FL (r>0.7). The anterior laxity side-to-side difference (KT-2000) was not correlated with %TB and %FB. Conclusion and Signficiance: In the present study, the femoral bone tunnel area was significantly larger than the tibial bone tunnel area. Enlargement of bone tunnels coupled with increase of ligament areas were not correlated with the anterior laxity. These results suggest that satisfactory bone-ligament healing may occur even when bone tunnels enlarge after ACL reconstruction using hamstring tendons.

        Poster 261. Cryotherapy decreases synovial temperature after ACL reconstruction

        Kurt P. Spindler, MD, Eric C. McCarty, MD, Todd A. Warren, A.C.N.P., Stephanie S. Martin, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Both the postoperative mechanism by which cryotherapy results in clinical benefits and whether synovial temperature declines in response to external application of ice remains unknown. We previously demonstrated significant global declines in intraarticular temperatures with cryotherapy after simple arthroscopic knee surgery (minimum bleeding). We investigated if cryotherapy results in similar synovial temperature declines after arthroscopic ACL reconstructions which results in increased intraarticular (IA) bleeding. Methods: Sixteen patients with IRB consent had IA temperatures measured 2 hours postoperatively by IT-18 thermocouple probes in the suprapatellar pouch (SP), lateral gutter (1-G), and skin. Each patient served as their own control. Half of the patients had ice applied the first hour, then had no ice the second hour. The other half of the patients had ice applied in the reverse order. Statistical analysis consisted of paired t-tests between initial and final temperatures for each site and application of ice. Results: Significant declines in synovial or IA temperature were observed in SP with either ice application time period (see table). However, unlike simple knee arthroscopy the LG did not decline in first hour and only trended in second (power = 0.88) (see table). Discussion: Why in setting of IA bleeding the LG temperature does not decline is unknown. We hypothesize either pooling of IA fluids and/or lack of conformity of cuff due to significant extraarticular swelling. Further investigation on the role pressure plays in temperature changes is warranted. Significance: Ice applied via Cryocuff® significantly reduces IA temperature only in SP with arthroscopic ACL reconstruction. Therefore, the effect on synovium must be considered in the beneficial clinical benefits. The magnitude of temperature difference between ice vs. no ice was >6.0°C, a clinically meaningful difference.
        Tabled 1
        SiteHour Ice AppliedAvg. Change °C +/- SDp
        SPFirst-2.7+/-2.60.02
        Second-2.7+/-1.80.004
        LGFirst0.0 +/- 2.8ns
        Second-1.4 +/- 1.80.06
        SkinFirst-12.3 +/- 2.6<0.001
        Second-11.4 +/- 1.6<0.001

        Poster 262. Evaluation of anterior cruciate ligament autografts in their femoral bone tunnels on MRI taken at 90 degrees of knee flexion

        Yoshio Sumen, MD, PhD, Mitsuo Ochi, MD, PhD, Masataka Deie, MD, PhD, Yoshikazu Ikuta, MD, PhD
        2001 ISAKOS Poster Abstracts
        Objective: The purpose of this study is to evaluate the anterior cruciate ligament (ACL) grafts in the femoral bone tunnel using magnetic resonance imagings (MRI) taken at 90 degrees of knee flexion. Methods: Fifty-seven knees were studied using MRI 1-50 months after arthroscopic ACL reconstruction with quadruple autogenous semitendinosus tendons. An endoscopic technique was used for all cases. MR examinations were performed at 90 degrees of knee flexion with T2-weighted sagittal images. MR findings were compared with anterior knee laxity measurement using a KT-2000 ligament arthrometer and the femoral tunnel expansion measured using a lateral radiograph. Results: Fifteen of 57 knees (26.3%) had a high signal intensity area between the anterior wall of the tunnel and the graft, which suggests possible infiltration of joint fluid into the tunnel. Out of 15 knees, 11 cases did not show the high signal in MRI on the extended knees. No high signal intensity was observed in the knees within six months after surgery. About 30% of the knees showed the high signal 12 months after surgery, and the high signal did not increase in number after 12 months. Neither ligament arthrometer measurement nor tunnel expansion showed a significant correlation with the high signal. Conclusions & Significance: The tendon-bone union is an important problem for the ACL reconstruction with hamstring tendons. It was demonstrated that MRI taken at 90 degrees of knee flexion could depict the gap between the graft and the bony wall. The gap might indicate the partial failure in tendon-bone union six months or more after surgery due to “bungee effect”’ or “windshield-wiper effect.”

        Poster 263. Long-term results of non-reconstructed ACL injuries. A clinical and radiographic evaluation

        Michele F. Surace, MD, A. Bini, MD, M. DePietri, MD
        2001 ISAKOS Poster Abstracts
        Aim of this study is to evaluate if the conservative treatment of an injured ACL could influence at more than ten years from injury, the status of the affected knee and the activity level of the individual. 17 patients were evaluated, 15 males (88.2%) and 2 females (11.8%), at a mean follow-up of 12.6 years (range, 10 to 26 years). Mean patient’s age was 37.1 years (range, 30 to 48 years). The ACL injury was diagnosed arthroscopically and a medial meniscectomy was performed in eleven patients (64.7%). Patient’s clinical evaluation was based on IKDC, Lysholm and Tegner scales. Stability tests were performed with a KT-2000 arthrometer. Bilateral standing AP and LL x-rays were obtained to evaluate the presence of arthritis, according to Sasaki and Fairbank classifications. Data were analyzed by means of independent and paired samples t-tests . The good clinical conditions observed (mean IKDC score 2.3 points; range, 1 to 3 points - mean Lysholm score 95.6 points; range, 78 to 100 points - mean Tegner score 6.3 points; range, 3 to 7 points) and the subjective satisfaction of the patients are in contrast with the poor x-rays conditions. All injured knees reported the radiographic evidence of arthritis (mean Sasaki value 2.3°; range 1° to 3° - mean Fairbank value 2.1°, range 1° to 3°) opposed to the significantly less arthritic counter-lateral knees (mean difference for both Sasaki and Fairbank scales 0.8°, p=0.049 and p=0.47 respectively), in asymptomatic patients whose quality of life was not compromised by the ACL injury.

        Poster 264. Clinical results and initial pull-out strength of anterior cruciate ligament reconstruction using modified bone-hamstrings-bone and bone-patella tendon-bone

        Ryohei Takeuchi, MD, PhD, Tomihisa Koshino, MD, PhD, Tomoyuki Saito, MD, PhD, Ikubumi Yamada, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Modified bone-hamstrings-bone (BHB) with interference screws fixation was developed for anterior cruciate ligament (ACL) reconstruction. Patients and Methods: We evaluated 50 knees with a minimal follow-up of 2 years after ACL reconstruction. Twenty knees with a mean age of 29 years were reconstructed using BHB, on the other hand thirty knees with a mean age of 27 years using bone-patella tendon-bone (BTB). Clinical assessment of 50 patients was performed according to Lysholm score, anterior laxity with KT-2000 and isokinetic strength with Cybex 6000. And biomechanical evaluation of these two methods were carried out with pull-out tests using 30 porcine knees. The initial ultimate pull-out strength and stiffness of the graft, reconstructed with BHB, was measured in 10 porcine knees, and the maximum strength and stiffness were compared with 10 knees reconstructed by BTB and also 10 normal porcine ACLs. Results: Clinically, total Lysholm score of BHB and BTB averaged to be 96 and 94 points respectively. The side-to-side differences of anterior laxity measured with KT-2000 at 30 lb averaged 1.2±2.8 mm and 1.7±0.9 mm, and knee extension muscle strength measured with Cybex averaged 83% and 81% at 60° per second, flexion strength averaged 92% and 86% at 60° per second compared with each of the uninjured knees, respectively. Patello-femoral (PF) pain was found 10 of 25 cases in BTB group, on the other hand there was no cases in BHB group. Biomechanical results showed the mean ultimate load to failure for the original ACL was 1455±275 N, for the BTB graft 777±108 N, and for the BHB graft 843±141 N. The mean stiffness was 1079±141 N/mm, 170±13.2 N/mm and 183±46.5 N/mm, in the original ACL, the BTB graft, and the BHB graft, respectively. There were no significant differences in ultimate load to failure and stiffness between BTB graft and BHB graft. Conclusion: Biomechanically, the initial fixation strength of the BHB graft was almost equal to the BTB graft. The fixation strength of our BHB procedure was considered to be suitable for clinical application and is recommended to result in better anterior stability without patello-femoral disorders.

        Poster 265. Utility of notch plasty in anterior cruciate ligament reconstruction

        Tomohiko Tateishi, Sadao Niga, Akiho Hoshino
        2001 ISAKOS Poster Abstracts
        Purpose: In Anterior Cruciate Ligament (ACL) reconstruction, tibial tunnel is placed behind Blumenstadt’s line to avoid impingement of notch. But anterior fiber rupture of reconstruction ligament was often seen in second look operation. So notch plasty was added now. The purpose of this study is to investigate the utility of notch plasty (two way: Conventional notch plasty and arthroscopically assisted notch plasty). Method: 281 patients who underwent ACL reconstruction with quadrupled semitendinosus tendon were evaluated in this study. Notch plasty was not performed in 110 cases (Group N). Conventional notch plasty was performed in 97 cases (Group C). Arthroscopically assisted notch plasty in 74 cases (Group A). Arthroscopically assisted notch plasty was underwent with stright scope from tibial tunnel to recognize lateral condyle. 3 groups were compared in stability, limitation of extension, enlargement of tunnel, arthroscopical result in second look. Result: Side-to-side difference of anterior laxity with KT-1000 was 1.2 ± 2.3 mm (Group N), 1.7 ± 2.0 mm (Group C), 1.8 ± 2.4 mm (Group A). There was no significant difference by Lachman test and pivot shift test. Patients who has limitation of extension (over 5 degrees) was 3% in Group N, 0% in Group C and Group A. Anterior fiber rupture of reconstruction ligament was 25% in Group N, 20% in Group C and 17% in Group A. Conclusion: There was possibility that notch plasty is useful in limitation of extension and anterior fiber rupture of reconstruction ligament. But there was no significant difference in conventional notch plasty and arthroscopically assisted notch plasty in this study.

        Poster 266. Update on anterior cruciate injury rate differences between female and male cadets at the United States Military Academy

        Dean C. Taylor, MD, Matthew Posner, BS, John F. Kragh, MD, John M. Uhorchak, MD
        2001 ISAKOS Poster Abstracts
        The purpose of this report is to provide prospective data on the incidence of ACL tears in an athletic college-aged population, and identify any gender differences. Methods: From 1990 to 1999, U.S. Military Academy cadets had their musculoskeletal injury data collected prospectively. The classes of 1994-99 were included in this study. Orthopaedic surgeons during daily clinic and training room evaluations evaluated all cadet knee injuries. Outpatient visits and admissions, and the activity during which the injury occurred were entered into a database. Complete ACL tears were identified by physical examination and subsequent confirmation at arthroscopy. Results: Patients injured ranged in age from 17 to 24. The average class size was 1089 (range: 1021 for ‘98 to 1190 for ‘94), with 955 (893-1045) males and 134 (114-151) females. There were 226 ACL injuries in the 6 classes (average 37.67 ACLs/class). The greatest number of injuries occurred during varsity football and intramural football, with 34 and 32, respectively. The average number of ACL injuries/class was 33.3 (24-42) for males and 4.3 (1-10) for females. Based on these four classes, the probability of sustaining a complete ACL tear during four years at this institution is 3.5%; 3.5% for males and 3.2% for females. Exclusion of football and rugby injuries and corresponding modification of the overall population reduces the overall injury risk to 2.2%; 2.1% for males and 3.2% for females. Discussion: These data suggest that in this population there is little difference in the incidence of complete ACL tears between men and women. Explanations for the discrepancy with other recent studies include the high injury rates seen with football, biased selection of athletes for this institution and similar physical training conditions and standards for men and women.

        Poster 268. Anatomical reconstruction procedure for posterolateral structures injury of the knee

        Akihiro Tsuchiya, MD, Masaki Sonoda, MD, Kojiro Shimada, MD, Takeshi Nagahara, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the results of new anatomical reconstruction procedures for chronic injuries of posterolateral structures (PLS). Method: Among PLS, LCL and popliteofibular ligament (PFL) were reconstructed anatomically. LCL reconstruction was performed by looped double-bundle autologus semitendinosus tendon which was passed through the bone tunnel of fibular head and proximally fixed with an EndoButton technique. PFL was reconstructed by autologus gracilis tendon which was proximally fixed by a figure eight loop suture to the popliteal tendon an anatomical position and distally fixed to the fibular head by the bone tunnel pull out method. Two cases were reconstructed in this method. The PCL was reconstructed simultaneously using autologus bone patellar tendon bone. The follow-up periods were 32 months and 14 months respectively. Results: Prior to surgery both patients complained of severe knee instability. The side to side difference of the lateral joint opening were 7 mm and 6 mm respectively. At follow-up, posterior drawer sign and reverse pivot sign were negative in both cases. The side to side difference of the lateral joint opening was 1 mm in each case. In both cases range of motion was full. The final evaluation of lKDC form was A and B. Conclusion: New anatomical reconstruction procedure were performed to combined injuries of PLS and PCL The clinical follow-up revealed good results. For combined injuries of PLS and PCL, our anatomical procedure succeeded in posterolateral rotatory instability decrease and improvement of symptoms. Significance: This is the first report of the anatomical reconstruction procedures for posterolateral structures of the knee.

        Poster 269. Long-term results of a ligament augmentation device in allograft reconstructions for chronic ruptures of the anterior cruciate ligament

        Franky Steenbrugge, MD, Peter Vorlat, MD,, M. R. Vandal, MD
        2001 ISAKOS Poster Abstracts
        Purpose: A prospective study was performed to determine the effect of a ligament augmentation device combined with a tendon allograft for the treatment of chronic rupture of the anterior cruciate ligament. Method: Fifty-four knees in 54 patients were divided into two groups. Group TA consisted of twenty-nine knees managed with a tibialis anterior allograft alone, and group TA-LAD consisted of twenty-five knees managed with both the allograft and a ligament augmentation device. Preoperatively, there were no statistically significant differences between the two groups with regard to fifteen variables. All patients were managed with the same postoperative program of immediate motion and rehabilitation of the knee. All patients returned for evaluation at a mean of eighty-four months (range, seventy-four to ninety-four months) postoperatively. Results: The results were evaluated with the International Knee Documentation Committee (lKDC) grading system, the Lysholm score, and the Tegner scale. Both procedures significantly decreased functional limitations and symptoms and improved the level of sports activity and the overall score. However, the use of the ligament augmentation device did not improve the efficacy of the reconstruction with regard to any of the assessed individual variables or in terms of the overall score. All patients regained an arc of 0 to 135 degrees of motion. Although the augmentation device reduced anterior-posterior displacement effectively for the first twenty weeks postoperatively, there was no difference between the groups in terms of the percentage of knees that had abnormal displacement at the latest follow-up. The overall rate of failure was twenty percent (eleven) of the fifty-four knees. The difference between the two groups was not statistically significant. Conclusion: The addition of the ligament augmentation device did not improve the results of allograft reconstruction in the treatment of chronic rupture of the anterior cruciate ligament. The use of either an allograft alone or an allograft combined with a ligament augmentation device did not satisfactorily reduce the amount of anterior-posterior displacement in all of the knees.

        Poster 270. Clinical results of fresh meniscal transplants in humans: Long-term follow-up

        René Verdonk, MD, PhD, K. F. Almqvist, MD, P. Verdonk, MD, Ph. Van Overschelde, MD, E. Witvrouw, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To assess the long-term clinical outcome of fresh, viable meniscal allograft transplantations in humans. Method: After harvesting and in vitro culture the meniscus was implanted in young patients with debilitating pain over the joint line and with a total meniscectomy in the past. If necessary, the meniscal transplantation was associated with an osteotomy. The patients were clinically evaluated with use of the Hospital for Special Surgery knee-rating scale. Pain was rated according to a Visual Analogue Scale. The return to previous work was included in the assessment. Results: Eighty patients were clinically evaluated, with a mean follow-up of 5 years and 4 months. Four of these patients were lost to follow-up and 4 had a total knee arthroplasty. The remaining 69 patients had an increase in the Hospital for Special Surgery score. The pain also decreased significantly after meniscal transplantation. There was no difference in the clinical outcome of lateral versus medial transplants, nor between medial transplants and medial transplants associated with a valgus osteotomy. Eighty-seven percent of the patients went back to their previous work. Conclusion: Fresh, viable meniscal allograft transplantation has a positive influence on the clinical outcome for a minimum of 10 years. Meniscal transplantation combined with an osteotomy does not affect the clinical outcome compared to pure allograft transplantation.

        Poster 271. Long-term results of tendon allograft replacement in ACL-deficient knees

        Peter Vorlat, MD, René Verdonk, MD, PhD, Guy Arnauw, MD, Koen Verstraete, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To assess the long-term validity of anterior cruciate ligament (ACL) reconstruction using tendon allografts. Method: Nineteen patients are presented who are followed for 8 years (mean 94 months) after tendon allograft replacement for ACL rupture. The evaluation was done using the form of the International Knee Documentation Committee (IKDC), the Lysholm score and the Tegner scale. Results: Two patients sustained a rerupture after a serious injury. Two others scored poorly because of associated proximal ipsilateral tibial and other fractures (IKDC grade D). Nine patients scored nearly normal (grade B), 6 patients abnormal (grade C). The Lysholm score showed 9 excellent (average 98), 5 good (average 87) and 1 fair result (70). Two of the excellent-rated patients were lKDC grade C, solely because the X-rays showed a slight (1 mm) narrowing of the medial cartilage. One patient had 0.5 mm narrowing. The X-ray findings might indeed indicate future problems. On the Tegner scale, the sports level decreased by an average of 2.1 points (from 6.87 to 4.73), and by 0.8 point compared to the level the patient actually desired to perform on. Conclusion: ACL repair using tendon allografts appears to provide satisfactory results on the Lysholm and Tegner scale. The IKDC scoring might suggest future cartilage degeneration.

        Poster 272. Long-term results of tendon allograft replacement with lad in ACL-deficient knees

        Peter Vorlat, MD, René Verdonk, MD, PhD, F. Steenbrugge, MD, F. Mortier, MD, K. Verstraete, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To assess the long-term validity of anterior cruciate ligament (ACL) reconstruction using tendon allografts with a ligament augmentation device (LAD). Method: Twenty-five patients are presented who are followed for 6 years (mean 74 months) after tendon allograft replacement with LAD for ACL rupture. The evaluation was done using the International Knee Documentation Committee (IKDC) form, the Lysholm score and the Tegner scale. Results: Three patients sustained a rerupture after a serious injury. Three others scored poorly because of associated injuries and fractures (polytraumatized patients) (IKDC grade D). Four patients scored normal (grade A), eleven patients scored nearly normal (grade B), seven patients abnormal (grade C). The Lysholm score showed 15 excellent (average 96), 5 good (average 86) and 5 fair results (average 76). Three of the excellent-rated patients were lKDC grade C, solely because the X-rays showed a slight narrowing of the medial cartilage. The X-ray findings might indeed indicate future problems. On the Tegner scale, the sports level decreased by an average of 1.4 points (from 7.25 to 5.83), and by 0.8 point compared to the level the patient actually desired to perform on. Conclusion: The LAD was devised to protect the biological graft during early phase of weakness after implantation. Only five patients showed an anteroposterior displacement of more then 3 mm, of which only one was in the grade C group.

        Poster 273. The efficacy of conventional magnetic resonance imaging in evaluating meniscal treatment

        Toshiyuki Wakabayashi, MD, Masashi Kimura, MD, Yasukazu Kobayashi, MD, Taisuke Tomatsu, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Magnetic Resonance Imaging (MRI) was shown to be almost equal in accuracy to arthroscopic evaluation for meniscal tears, however, some authors have recommended MR arthography or fat suppression technique for evaluation of the previously repaired meniscus because of the limitation of conventional MRI. The objective of this study was to investigate the efficacy of conventional MRI when we surgeon decide to operate being made. Methods: There were 454 meniscal tears noted in 444 patients studied during the last two years in our hospital. MRI was performed on a 0.3T machine (Hitachih, Japan). A Gradient echo 2DT2* sequence was employed. An arthroscopic examination was subsequently performed. Meniscal tears were characterized by each surgeon with respect to its reparability preoperatively. Results: Of the 454 meniscal tears, 247 (54%) were involving the medial meniscus and 167 (37%) were the lateral meniscus and 40 (9%) were both the medial and lateral meniscus. Eighty-six concomitant operative procedures were performed at the same operative setting. Sixty-two meniscal tears were predisposed as reparable before surgery. A meniscal repair was performed in twenty (4%), and twelve (3%) of the tears were treated with abrasion. No meniscal repair was performed among the cases we considered irreparable before surgery. Conventional MRI have sensitivity and specificity of 100% and 90%, respectively, for detection whether a meniscal tear is reparable. Discussion: Previous investigators stated MRI was reliable to detect the presence of a tear of meniscus with up to 95% accuracy, but its overall correlation between the examiner’s estimation of treatment and the actual surgical procedure performed. We recommend conventional MRI as a clarifying diagnostic tool to predict repairability.

        Poster 274. Surgical management for knees with combined posterior cruciate ligament and posterolateral instabilities

        Ching-Jen Wang, MD
        2001 ISAKOS Poster Abstracts
        A retrospective review was conducted in twenty-six knees in twenty-five patients undergoing surgical reconstructions for knees with combined posterior cruciate ligament and posterolateral instabilities with a follow-up of 18 to 46 months. The results showed a statistically significant improvement in pain relief and knee functions after surgery. The rate of satisfaction on the operation by patient’s subjective assessments was 85% and 7% by surgeon’s objective evaluations. The overall results were 23% excellent, 46% good, 23% fair and 8% poor. In spite of high rate of patient’s satisfaction, most patients recovered to gainful employment only at light and moderately heavy duties, and only one third of the patients could perform high level of activities including sports. Approximately one half of the knees showed one + (< 5 mm) instability of the knee and persistent quadriceps atrophy and deficits in muscle torque and endurance of both the quadriceps and hamstring which did not seem to affect the short-term result, but it might adversely impact on the long-term outcome. Therefore, appropriate rehabilitation from the onset of injury and early surgical intervention are strongly recommended in the management of knees with combined PCL and posterolateral instabilities.

        Poster 275. Comparison of tibial tunnel enlargement after anterior cruciate ligament reconstruction using patellar tendon autograft or allograft

        W. J. Willems, A. E.B. Kleipool, J. A.C. Zijl
        2001 ISAKOS Poster Abstracts
        Purpose: This retrospective study was designed to compare tibial tunnel enlargement in bone-patellar tendon-bone ACL autograft and allograft reconstructions and relate these radiographical changes to position of the tibial tunnel and clinical outcome. Materials and methods: Twenty-six autografts and 41 allografts were studied at a mean follow-up of 59 months (range 41 to 84 months). Changes in the diameter and position of the tibial tunnel were analysed radiographically. At follow-up the IKDC-score, Lachman and pivot shift test were performed and related to tunnel enlargement and position of the tunnel. Results: The average tunnel enlargement on the anteroposterior view was 2.2 mm (standard deviation 2.5 mm) in autografts and 2.8 mm (s.d. 2.1 mm) in allografts. On the lateral view the tunnel enlargement was 2.6 mm (s.d. 2.4 mm) and 3.4 mm (s.d. 2.6 mm) respectively. No significant differences were found between the autograft and allograft group. A trend was found in the correlation between the position of the tibial tunnel and the tunnel enlargement: More tunnel enlargement in more anteriorly placed tunnels. The changes in tunnel diameter did not relate to the IKDC-score, or knee laxity. There was a significant correlation between malposition of the tibial tunnel and poor clinical scores. A significant negative correlation was found between postoperative follow-up time and tunnel enlargement in both groups. Conclusion: We conclude that placement of the tibial tunnel is a determining factor in tibial tunnel enlargement and clinical knee scores after anterior cruciate ligament replacement in the autograft and allograft group. Tunnel enlargement tends to be less at a longer postoperative time interval.

        Poster 276. Collateral ligament reconstruction with a new technique, preliminary report

        D. B. Wouters
        2001 ISAKOS Poster Abstracts
        Introduction: No uniformity exists about the therapy of isolated grade 3 lesions of the collateral ligaments of the knee, but a tendency is found in the literature to recommend reconstruction. If also the anterior cruciate ligament is torn in the same knee in general, only this ligament will be reconstructed. The force on this ligament, however, if the insufficient collateral is left untreated, is 3-4 times higher than with an intact collateral ligament. The reconstruction is therefore at greater risk for failure. This has recently been affirmed by a biomechanical study. Method: From 1995 until 2000 10 medial- and 9 lateral reconstructions were performed in 14 patients, 11 males and 3 females. The average age was 33 years (range 23-49). The mean follow-up interval was 30 months (range 12-58). Ten times an ACL reconstruction was carried out combined with 1 collateral, 2 times with 2 collaterals and 2 times 1 collateral only. Twelve patients underwent several previous operations. The procedure consists of a trans-osseous fixation of an artificial ligament through femur and tibia of fibula along the original MCL or LCL. All patients except 1 approved at least 1 step on the IKDC scale (D to A). No side effects or permanent complications were encountered. Conclusion: This method seems promising though time will learn if the improvement will be permanent.

        Poster 277. MRI evaluation of bone tunnel enlargement after anterior cruciate ligament reconstruction utilizing the hamstring tendon graft

        Kazunori Yasuda, MD, PhD (a – Kyocera Co. Ltd.), Daisuke Kawamura, MD, Yoshie Tanabe, RPT, Harukazu Tohyama, MD, PhD, Akio Minami, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the femoral tunnel enlargement utilizing MRI after ACL reconstruction using the hamstring tendon graft. Method: A prospective study was conducted using 50 patients with unilateral ACL reconstruction. The femoral end of the hamstring tendon graft was fixed with a 10-mm polyester tape and an Endobutton. Then, the tibial end was secured with the same tape and 2 staples, applying an initial tension of 80N. Each patient was followed up twice, at 2 weeks and 2 years after surgery, using MRI, radiograms, KT-2000, and IKDC evaluation. Results: MRI clearly showed that the femoral tunnel was completely filled with tendon and granulation tissues in each patient. Tunnel Enlargement occurred only at the anterior edge of the tunnel entrance. Four percent of the knees showed a tunnel enlargement of more than 3 mm, 60% showed an enlargement of less than 2 mm, and 36% did not show any enlargement. The side-to-side anterior laxity difference was less than 3 mm in 81%, and more than 5 mm in 8%. No correlation was found between the degree of enlargement and possible factors including graft length, graft thickness, sex, age, IKDC score and residual joint laxity. Conclusions: It is difficult to precisely analyze femoral tunnel enlargement with radiograms. MRI was an effective tool to evaluate it. MRI demonstrated that the graft was not lacerated at the enlarged tunnel entrance, although the graft shifted anteriorly to some degree. Significance: The degree of femoral tunnel enlargement after ACL reconstruction using the hamstring tendons was less than that previously reported with radiography.

        Poster 278. Ligament endoflip: A new device for femoral fixation of the D-STG in ACL reconstruction

        G. Zaccherotti, A. C. Fisher, A. Castiglioni
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the mechanical properties of a new device for the femoral fixation of double-looped semitendinosus and gracilis tendons in ACL reconstruction.
        Figure thumbnail gr5a
        Figure thumbnail gr5b
        Method: Ligament Endoflip (Atlantech, UK) is a titanium (6ALGV) implant alloy. The device has been studied in three ways. Mathematical evaluation has been used to determine the failure load of each critic part and the overall stiffness. Finite element evaluation, using SAP90 (Algor, USA). has been done to design the maps of forces. The UTS laboratory test was used to verify the mode and the failure load. For the UTS test, the device was inserted through a hole in the mild steel plate mounted by means of 4 pillars to the fixed stage of a NENE tensile testing instrument. The hole of the device was lashed with 3 loops of braided polyester cord to a spigot-bar inserted through the fixing hole of a 5 kN load cell on the crosshead. The cord loops were pre-stressed to notionally 1 kN to tighten the knot. The failure load (in the range zero to <5kN) was determined at a crosshead speed of 5 mm per second. Results: Based on the mechanical properties of the material (Max normal force=980 N/mm2 and Max shear Force=566 N/mm2), the mathematical evaluation revealed that the ultimate load of each critic part of the device ranged from 6.490 N to 2.405 N. The weaker part was the flip (2.405 N). At the failure load, the stiffness has been calculated as 848 N/mm. Maps of forces confirmed that the weak part was the flip and that exposing the device at the load of 2.405 N, the stiffness was 2.428 N/mm (ΔL= 0.98 mm). UTS tests revealed that the ultimate load of the pieces tested ranged from 2.179 N to 2.330 N. The mode of failure was consistent: First one arm of the flip fractured in shear, marginally outside the projected axis of the flip’s stem, then the remaining contralateral arm fractured in a similar way. Conclusion: Ligament Endoflip has a very high mechanical performance in terms of ultimate failure load [2.405 (theoretically) and 2.330 N (experimentally)] and stiffness (2.428 N/mm; ΔL=0.98 mm). Significance: Ligament Endoflip allows one to obtain an increase in terms of primary femoral fixation of the doubled hamstring tendons in ACL reconstruction. It also offers an easier surgical technique using only one skin incision and imposes a very short learning curve to the surgeon.

        Poster 279. Chondrocalcinosis

        Mario Berenstein, MD, Tomas G. Czarnitzki, MD, Miguel A. Raijman, Fabio Goischain, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To examine the presence of uric acid crystals and calcium pyrophosphate crystals into the joint with; to correlate clinic, radiographic images, “TAC” and MRI with arthroscopy. Method: 1989-1998 46 cases of arthroscopic surgery. Age 39 to 81 years. Average 62. Men 24 (52%). Women 22 (48%). Right Knee 28 (61%), left knee 17 (37%). Bilateral 1 (2%). Results: The medial meniscus affectation was detected in 24 cases (52%), lateral meniscus 10 cases (22%), both 8 cases (17%); we observed condylar chondral diseases on 16 cases (35%), chondral disease of patellofemoral on 33 cases (73%), synovitis reaction on 41 cases (91%), crystals synovitis on 10 cases (22%), tophaceous gouty 4 cases (9%) and associated case to osteonecrosis (0.5%). Conclusion:
        • It generates degenerative lesions characterized by deposits of calcium crystals by uric acid or pyrophosphate in meniscus and articular cartilage destruction.
        • The uric acid crystals gather taking the shape of sheets, and the uric acid crystals feature like small foci.
        • Hemocromathosis, hyperparathyroidism and gout make it greater in a 30%.
        • The chondrocalcinosis is related to metabolic diseases, arthritis, previous meniscal surgery, genetic factors and traumatic antecedents.
        • It is something ordinary from the 6th decade of life on; with a prevalence of 20% between people older than 80 years.
        • It evolves in spite of the rectification the associated metabolic disease.
        Significance: The arthroscopy improves substantially the specific syntomatology resolving mechanical factors performing “menisectomias parciales, condroplastias” and extended synovectomy; although this does not constitute a definitive treatment to this disease.

        Poster 280. Avulsion fracture of the tibial tuberosity in adolescents. A report of 14 cases

        Xavier Juan, MD, Jaume Vilaró, MD, Pedro Alvarez, MD, Ramón Cugat, MD
        2001 ISAKOS Poster Abstracts
        The aim of this study is to do a clinical and a bibliographic review of avulsion fractures of the tibial tuberosity. This kind of injury is uncommon. We report 14 cases up to 12,700 soccer injuries (0.11%) during five years (from September 1994 to October 1999). The patients ranged in age from 12 to 18 years at the time of initial injury. One female and 13 males are reported. We’ve also reviewed the literature and we found only 150 fractures reported up to 1986. With surgical treatment in 12 cases and conservative treatment in 2 cases, we achieved excellent results in 100% of the patients. Two patients were not operated because of their type of injury according to Odgen’s, Ryu’s and Frankl’s classification. Excellent result was considered when the patient could play again at the same level, and no complications were seen. It is important to do an accurate clinical and roentgenographic exam to determine the type of injury, in order to perform surgical treatment or not. Also CT can be useful to measure fragment displacement. In conclusion, avulsion injuries of the tibial tuberosity are rare. The aim of treatment is to restore the extensor mechanism, and if necessary, a perfect articular surface. This can be done by many ways and with different kind of implants, depending on type of injury. It is also recommended to immobilize the knee for 4 to 6 weeks, and be sure of complete healing before return to sports.

        Poster 281. Indication, technique and results after ACT (autologous chondrocyte transplantation)

        J. Löhnert, Dr.Med
        2001 ISAKOS Poster Abstracts
        Since Sept. 1996 a total of 139 patients were treated with ACT at the St. Marien Hospital Gelsenkirchen Buer. The average age was 35, ranging from 13 to 68 years of age. The medial condyle was affected 87 times, followed by the lateral condyle (26), the patellar groove (9) and the patella (2). The average size of the defects measured 3.4 square centimeters, with the largest defect covering in area of 9 square centimeters. 52 patients were seen post op over a period of one to three years. Before ACT 25 patients underwent surgery at other hospitals one or more times. 30 patients had their cartilage defect caused by trauma, 14 patients showed an osteochondritis dissecans. 4 patients needed an ACL reconstruction with the ACT. Clinical evaluation was done using 5 different international scores. One to three years post op the rate of success according to the scores was 87%. MRI follow-ups were done on a regular basis. 92% showed sufficient results. 20 patients needed a second-look arthroscopy. Of those, ACT grafts were rated good to excellent in 17 cases. A biopsy was taken 9 times. Out of those, 8 specimen showed histological and immunohistochemical characteristics of hyaline cartilage. 90% of all patients questioned stated that they would undergo the same procedure again and/or recommend it to other patients.

        Poster 282. Synovial impingement as cause of anterior knee pain

        Paulo Roberto Rockett, Jaime Wageck
        2001 ISAKOS Poster Abstracts
        Objective: To describe the syndrome of the impingement of the anterior synovial in the knee based on clinical exam, arthroscopic findings and biopsies. Method: Between 1986 and 1998 we accomplished 36 resections of hypertrophic synovitis causing anterior impingement, of a total of 2032 knee arthroscopies. We excluded cases of systemic diseases, widespread synovitis and other concomitant intra-articular diseases. The clinical signs consisted of pain, pseudo-locking, especially in the extension, swelling and sensibility increase in the anterior area of the knee. Tests of strained hyperextension, causing pain, were accomplished and potentialized by the application of pressure above the anterosuperior border of the meniscus. The lesions were classified in: Type 1: Alterations restricted to the synovial tissue Type II: Lesions in the femoral joint cartilage Type III: Lesions in the anterior horn of the meniscus Type IV: Concomitant chondral and meniscal lesions. Results: The average age was 36 years and 52% had previous trauma, 24 presented lesions Type II, 1 had Type III and 11 had Type IV lesions. Biopsies confirmed synovial pathology in all cases. The average follow-up was 7 years and 10 months when all the patients presented pain recovery in the first 2 months of postoperative, 2 persisted with some limitation of the flexion and 3 had pain crisis after efforts. Conclusion: The synovial impingement caused anterior pain in the knee hurting mainly the cartilage and medial meniscus. The arthroscopic surgical treatment reached satisfactory clinical result, mainly, in the relief of the pain.

        Poster 290. Arthroscopic treatment of infrapatellar tendinitis

        Rene Abdalla, Moises Cohen, Benno Ejnisman
        2001 ISAKOS Poster Abstracts
        Purpose: To show the results of 15 patients treated from inferior pole patellar tendinitis through arthroscopic debridement of localized patellar chondromalacia. Method: 15 patients (18 knees) with patellar tendinitis justapatellar) treated by arthroscopic debridement of localized inferior patellar pole chondromalacia after failure of adequate conservative treatment. The average age was 28 (16-38), 12 (66.5%) in stage II and 6 (33.3%) in stage III (BLAZINA 1973). The procedure consisted of arthroscopic shaver of patellar inferior pole chondromalacia found in 100% of the cases. In 10 confirmed by MRI. The average follow-up was 24 months (18 to 36). Results: After post-op rehabilitation 11 patients (73%) could return to their previous sports activities in an average of 2 months post-op. In 3 (20%) were found symptoms improvement with no sports return and 1 (6%) remained unchanged. Conclusion: Inferior patellar pole debridement when appropriate led to sports activities return in 73% in average of 2 months. Significance: Patellar tendinitis seems to be increasing in incidence in both athletic and recreational activities. Treatment is still difficult. The inferior patellar pole arthroscopic shaver, when appropriate after others methods failure, showed to be 80% effective.

        Poster 291. Meniscal and ostheochondral lesions and their influence on ACL natural history

        Rene Abdalla, Moises Cohen, Antonio C. Souza, Benno Ejnisman
        2001 ISAKOS Poster Abstracts
        Objective: To evaluate associated lesions influence (meniscal and ostheochondral) on the ACL natural history on patients with post-traumatic hemarthrosis, first episode with no considerable laxity (grade I). Methods: 54 patients with post-traumatic knee hemarthrosis, grade I laxity, undergone to arthroscopy 7 days average after the lesion. All of them showed ACL lesion (30 total and 24 partial). In the partial group we considered the sheath integrity or not, classifying them in open (OS) or closed (CS) sheath which directly influenced the prognosis. They were followed up on average of 84 months and evaluated by IKDC score and grouped into normal/nearly normal and abnormal/severely abnormal. Results: In the total ACL lesion group (30) we found associated lesions in 18 (60%), meniscus 9, osteochondral fracture 5 and combined 4. In the normal/nearly normal group (8) we found 2 cases with associated lesions and in the abnormal/severely abnormal group (22) 16 (72%). In the partial lesions (24) normal/nearly normal (12) we found 04 associated lesions (03 0S and 01 CS) and in the abnormal/severely abnormal group (12) were found 12 (100%), 8 meniscal, 4 osteochondral, the majority in the OS group (9). Conclusion and Significance: There are few reports evaluating the ACL lesion natural evolution from the initial trauma. Our results showed that associated lesions indicated a worse prognosis. The differentiation between open and closed sheath in partial lesions, showed significant difference in the evolution. Our conclusion may be obvious, but proves that associated lesions should be approached with the same importance and care as the ACL during the reconstructive procedure.

        Poster 292. Treatment of chondral lesions with arthroscopic microfracture technique

        Cem Adabag, MD, Ümit Simsek, MD, Sükrü Solak, MD, Yalim Ates, MD
        2001 ISAKOS Poster Abstracts
        Purpose: We have retrospectively evaluated our patents who were treated for their Chondral lesions with the arthroscopic microfracture technique. Method: All patients who had Outerbridge Class IV chondral Lesions and treated with arthroscopic microfracture technique were called in for a last review of their status. Patients that had concomitant intervention for their ligamentous lesions were not included in this study. A total of 35 patents, 6 male and 29 female with an average age of 50.3 (range 40-69) were operated on between January 1996 and December 1998 formed the study group. 20 left 15 right knees were operated. 11 patients had degenerative tears of the rim of their menisci that were shaved off. All the chondral lesions were on average 2.1 cm2 (1-4 cm2) and were debrided and microfracture was performed with a surgical awl. All the patients were evaluated using the Lysholm Knee Score preoperatively and at the last follow-up. Average follow-up was 18 months (range 12-38). Results: Lysholm Score was 37.6 pre-operatively and 65.7 at the last follow-up. The differences were statistically significant with students T-test (P < 0.05). Three patients had postoperative effusions that required aspiration. Two patients had deep venous thrombosis and 2 patients underwent total knee replacement. Total knee replacements were done on patients whose lesions were greater than 3 cm2; these were the only patients that had lesions of this size. Conclusion: Treatment of chondral lesions with microfracture technique seems to be a good alternative in selected patients in the short term follow-up This technique cost-effective technically feasible and available to all surgeons who perform arthroscopy. Two patients who underwent total knee arthroplasty were 58 and 62 years old and their lesion was greater than 3 cm2, prognosis must be guarded when performing this treatment on lesions greater than 3 cm2.

        Poster 293. Arthroscopic realignment of patella for recurrent subluxation or dislocation (modified surgical technique)

        M. S. Ali, MD, FRCS Ed
        2001 ISAKOS Poster Abstracts
        Purpose: To present one- to five-year results of arthroscopic lateral release and medial plication for patients with anterior knee pain, recurrent subluxation or dislocation of patella. Method: Consecutive series of 22 patients were operated on between 1993 and 1998. They were 69% females and 31% males. The average age was 29.8 years (SD 6) with right 57% and left 43%. One patient was lost to follow-up. The range of follow-up was 1 to 5 years (mean 2.8 years, SD 1.26). The technique was totally arthroscopic through five portals and will be described. Results: Using a questionnaire based on Lysholm scoring system, 82% of patients had satisfactory, good or excellent results. 18% were considered poor, one of which developed RSD, one was arthroscopically revised and one failed where an open Hughston’s procedure was carried out. 75% did not require any painkillers, 20% required only occasional one or two tablets. 10% were unsatisfied on self-assessment, the rest were satisfactory. All patients went back to employment of which 16% were involved in heavy manual work. Conclusion: Minimally invasive surgical technique for patellar realignment as described which allows faster rehabilitation produces results as good as if not better than the conventional surgery with minimal complication. In this series the poor results were associated with a long history of symptoms, osteoarthritis and associated abnormalities like Charcot-Marie Tooth, etc.

        Poster 294. Meniscal suture using mitek stapling system: Preliminary results

        Pedro Alvarez, MD, Ramón Cugat, MD, Jaume Vilaro, MD, Xavier Juan, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Different type of meniscus suturing systems have been developed: Inside-out, outside-in and recently the all-inside type. The aim of this paper is to present the preliminary results of 34 consecutive meniscal ruptures treated with the Mitek stapling system. A prospective study will be presented. Material and Methods: From May 1999 to May 2000, 33 consecutive patients (34 meniscus) were treated. Average follow-up was 13.8 months. 28 patients were football players, 3 injuries were related to work and 2 to other physical activities. Clinical evaluation includes physical examination, simple x-ray study and MRI. Functional evaluation was based on the Lysholm and Tegner score. Lesion location and associated ligament injury were evaluated. The first series were sutured using Polypropylene staples. The others using PDS. Non weight bearing for four weeks. Isometric exercises and complete range of motion allowed. We performed 3 monthly controls (3, 6, 9 and 12 months postoperatively). Results: 19 cases presented ACL rupture associated. Seven cases involved the isolated internal meniscus and six the external. Most of the patients (>90%) scored good and excellent results. All patients came back to previous physical activities. MRI showed healing of the lesion in >80% of cases. We found one case of stapling failure and one of staples intolerance. Discussion: The development of all-inside suturing system allows great suturing precision with strong fixation, avoiding neurovascular problems, mainly in the posterior corner, and it is easy to perform. Despite the short follow-up, we found good functional results, confirmed with MRI. We hope these results will be confirmed in the future.

        Poster 295. Meniscus bucket handle fixation with meniscal arrow – a “no complication technique”

        Ron Arbel, MD, Moshe Yanku, Gavriel Mozes, Shmuel Dekel
        2001 ISAKOS Poster Abstracts
        The purpose of this study is to introduce the first 26 cases of meniscal tear, which were treated with all inside fixation technique with absorbable meniscal arrows. (Polylactic acid - Bionix). Various arthroscopic techniques for meniscus suturing have been introduced in the last several years. They are inside/outside as well as outside/inside and all inside techniques. These techniques are very well established. However serious complications may occur from this techniques especially when treating posterior Bucket handle tears on the lateral meniscus. New techniques have been introduced recently. This involves the use of arthroscopic meniscal arrows, which enables to fix all kind of Bucket handle tears including posterior meniscal lesions without any significant complications. In the last two and a half years 16 patients have been treated with this technique. Out of this 26 patients 16 had posterior horn lateral meniscal tear and 6 had posterior medial meniscal tear. In 16 of this patients only arrows have been used and in the other 11 in addition to the arrows an inside/outside techniques have been used. The postoperative treatment consisted of full weight bearing while the knee was kept in knee immobilizer in extension and 60° of flexion was allowed in the first 3 weeks. After 3 weeks the range of motion was increased to 90° and after 6 weeks a full range of movement and full weight bearing was allowed. Contact sport was allowed after 4 months. Two patients required additional arthroscopy as a second look, due to pain. In those 2, minimal finding were found, and they did not require any additional surgery. The meniscal was found to be well healed. The mean follow-up is around 14 months. All patients have no signs of meniscal damage and they are free of pain. The theoretical basis of meniscal preservation rather than excision is well documented in the literature. The possibility of using a new absorbable meniscal arrow increases the ability of meniscal repair especially in the area, which endangers the neurovascular elements. It is our belief that the meniscal arrow will increase the number of meniscal injuries, which are amenable to repair without complications.

        Poster 296. Articular cartilage change after ACL reconstruction evaluated by arthroscopy

        Hiroshi Asano, Takeshi Muneta, Hiroo Ikeda, Kenichi Shinomiya
        2001 ISAKOS Poster Abstracts
        Purpose: To make it clear the natural course of the articular cartilage change after ACL reconstruction, we evaluated the articular cartilage lesion at the reconstruction and second-look arthroscopy. Methods: 100 patients who underwent ACL reconstruction were evaluated about their change of articular cartilage by second look arthroscopy at a mean of fifteen months after ACL reconstruction. Articular lesions were evaluated at patella, femoral groove, medial and lateral femoral condyle, medial and lateral tibial plateau, and classified into four grades. (0. normal, 1. superficial damage, 2. cartilage defect without bone exposure, 3. cartilage defect with bone exposure). We compared the articular cartilage grades between at reconstruction and at second look arthroscopy, and evaluate the correlation with sex, age, KT-measurement, sports activity and meniscal injury. Results: Articular cartilage grades at second look arthroscopy got worse than the grades at reconstruction. There was no correlation between the change of articular cartilage and age, KT-measurement and meniscal injury. Females’ articular cartilage became worse than that of male. A postoperative higher sports activity significantly made worse the articular cartilage of females and had no effect on that of males. Discussion: It was speculated that the cartilage of females was more vulnerable than that of males. We have to take into consideration possible progression of osteoarthritic change in females who continue sports activity after ACL reconstruction.

        Poster 297. Radio frequency induced thermal modification for treatment of single bundle anterior cruciate ligament (ACL) rupture

        Wayne K. Augé II MD
        2001 ISAKOS Poster Abstracts
        Introduction: Partial ACL rupture has been more commonly recognized with the advance of MRI and arthroscopy techniques. Traditionally, operative treatment for these injuries has been limited to observation or full ACL reconstruction. The possibility of thermal modification to induce ligament changes that would promote stability and limit injury sequelae has been discussed. This study examines radio frequency induced thermal modification for treatment of single bundle ACL rupture when the remaining bundle exhibits evidence of intra-substance deformation without osseous detachment. Materials: 22 serial patients who demonstrated evidence of single bundle ACL disruption during arthroscopy were reviewed retrospectively. Two groups were fashioned without selection bias: Group I (N=9) underwent arthroscopy with debridement of the ruptured ACL bundle and Group II (N=13) underwent debridement of the ruptured ACL bundle with thermal modification of the remaining bundle. Bipolar radio frequency energy (20 Watts, 460 kHz + 1%, square wave, Crest factor < 1.3 @ 140 ohms) was applied in a limited fashion with the knee in 30° of flexion and until tension was fully developed within the remaining ligament bundle, avoiding excess thermal application after this tension was developed. Associated meniscal/chondral pathology was treated and the same standard post-operative protocol was followed for each subject. A single independent observer blinded to treatment group evaluated knee laxity during the study period. Results: Average follow-up for all subjects was 16 months (range 12-23). All single bundle ruptures occurred at the femoral attachment regardless of the bundle involved. Six of the seven complete meniscus tears noted at initial treatment were observed in subjects with anteromedial bundle (AMB) rupture. At follow-up, subjects that underwent radio frequency treatment demonstrated decreased side-side differences in knee laxity. Both meniscus tears in Group I at follow-up were in subjects with initial PLB ruptures that completed ACL rupture by injuring the residual AMB. Of the four complete ruptures evident at follow-up, three were initial PLB and one was an initial AMB rupture. Table 1:
        Figure thumbnail gr6a
        Figure thumbnail gr6b
        * values do not include data from subjects that sustained repeat injury completing ACL rupture Discussion: Thermal modification of the remaining tissue after single bundle ACL disruption appears to provide a distinct treatment benefit in this series. The decreased rate of complete ACL rupture and subsequent meniscus tearing after radio frequency thermal modification may be due to the decreased excursion evident in the remaining ACL bundle after this treatment protocol. In this series, the AMB rupture appears to be associated with a higher incidence of meniscal tearing and therefore represents a more severe injury pattern. This study does not allow the full evaluation that is necessary due the subject number and the intra-/inter-subject variability possible during knee laxity testing. Care should be taken to avoid excessive application of radio frequency energy when tensile properties are required early after thermal modification. Further study is required to more fully develop specific treatment protocols in this setting.

        Poster 298. Arthroscopic ACL reconstruction with single tibial incision using att allograft and endobutton

        Metin Lüfti Baydar, MD, Nevres H. Aydogan, MD, Servet Tunay, MD, Gökhan Maralcan, MD
        2001 ISAKOS Poster Abstracts
        Introduction: ACL lesions is an important problem mostly seen in the young and active population. Reconstruction of ACL is still discussed because of its placement and the characteristics of functions. There are many different surgical techniques to be used in ACL reconstruction. In recent years, arthroscopic ACL reconstruction has commonly been accepted but discussions about proximal and distal fixation are still continuing. Fixation materials differ according to graft and surgical techniques. Material & Method: Single incision arthroscopic ACL reconstruction which is a modification of Rosenberg’s technique are performed using ATT (Anterior Tibial Tendon) solvent-dehydrated allograft (Biodynamics Inc.) in 81 cases in GMMA, Department of Orthopaedic Surgery and Traumatology. We only included the results of 47 patients who had operation at least two years ago and were under regular control. Between September 1995 and November 1998, 81 patients were treated with this technique. 47 patients (46 male, 1 female) were controlled in the third, sixth and twelfth weeks and finally in November 1998 after the operation. The mean age was 21 and average follow-up period was 29 months. The functional results of the treatment were evaluated by the surgical team using physical examination, Lysholm score and Tegner activity scale. Results: Average Lysholm score was 94 (98-94). 47 patients were controlled and neither rerupture nor laxity was found, but 2 patients were operated arthroscopically because of arthrofibrosis. Compared to the old technique (two incision technique), it was found that objective and subjective data of the patients were better in this technique. Conclusions & Significance: The aim of the treatment of ACL is saving the anatomic structure of the knee joint by increasing its functional capacity, and regaining the functional stability. This one incision technique is less traumatic, and it allows the placement of graft in isometric position which prevents the rupture or insufficiency of the fixation, so it seems to be the ideal method in ACL reconstruction. When compared to the old technique, it is found that the muscle atrophy and postoperative pain is less and the stability of the graft is better. We believe that the best fixation can be obtained with this technique when the grafts that do not include bone block are used.

        Poster 299. Cryotherapy after arthroscopic surgery: Effect on joint temperature and postoperative care

        Bart Berghs, Bruno Vandekerckhove, An Ven
        2001 ISAKOS Poster Abstracts
        Purpose: To clarify the effect of various methods of cryotherapy on the intraarticular temperature of the knee and their clinical implications. Method: A prospective and randomized study was performed on 31 knees in 31 patients between 18 and 50 years, who underwent an arthroscopic meniscectomy or a diagnostic arthroscopy of the knee. A control group of 10 patients did not get any cryotherapy, a second group was cooled with a classic cryocuff (Aircast®), a third group was cooled with an ice-pack, and a fourth group was cooled with a Cryomanchet (lglotronics®). Each group with some form of cryotherapy consisted of 7 patients. Intraarticular temperature was measured in the immediate postoperative phase, the use of analgesic and antiinflammatory drugs was recorded, a visual pain score was performed, and clinical parameters of inflammation were followed. Results: We didn’t find any correlation between cryotherapy and pain relief, nor any clinical antiinflammatory effect. There was however a distinct effect on the intraarticular temperature with the use of a crushed ice pack and the Cryomanchet. Conclusion: We conclude that the inflammatory effect of an arthroscopy of the knee is not extensive enough to make an evaluation of the usefulness of cryotherapy. This study revealed, however, useful insights into the effect on the intraarticular temperature of the various cryotherapies. Significance: With these data, the physical effect of cryotherapy becomes predictable. The clinical effect needs further investigation in more invasive procedures.

        Poster 300. Arthroscopic surgery of discoid lateral meniscus: Type of discoid meniscus, tear pattern and extent of meniscal resection

        Seong-Il Bin, Ji-Chul Kim
        2001 ISAKOS Poster Abstracts
        The aim of this retrospective study was to analyze the relationship of type of discoid lateral meniscus, tear pattern, and extent of meniscal resection required. There were 109 consecutive cases (104 patients) with discoid lateral meniscal tear treated with an arthroscopic operation from September 1996 to August 1999. Of 109 cases, 9 cases with meniscal repair were excluded and remaining 100 cases were included in this study. Regarding type of discoid meniscus by Watanabe’s classification, 37 cases were classified as complete and 63 cases as incomplete. There was no Wrisberg type. Tear pattern according to the type of discoid meniscus showed striking difference. Simple horizontal tears were more prevalent in complete-type cases and radial, degenerative and complex tears were more prevalent in incomplete-type cases (p<0.001). Extent of meniscal resection showed significant difference according to tear pattern (p<0.001). Subtotal or total meniscectomy was required more frequently in longitudinal and complex tears. Partial meniscectomy was performed more frequently in simple horizontal, radial and degenerative tears. Extent of meniscal resection did not show significant correlation according to the type of discoid meniscus (p>0.05). In conclusion, tear pattern showed significant difference according to the type of discoid meniscus. Extent of meniscal resection depended on tear pattern, but not on the type of discoid meniscus. This knowledge would be helpful in therapeutic planning of the tear of discoid lateral meniscus.

        Poster 301. Arthroscopic partial meniscectomy for horizontal tear of lateral discoid meniscus – a new method

        Seong-Il Bin, Sang-Il Jeong, Hyun-Chul Shon
        2001 ISAKOS Poster Abstracts
        A new method of arthroscopic partial meniscectomy for horizontal tear of lateral discoid meniscus was devised to preserve as much meniscal tissue as possible. To evaluate the clinical result of this method for lateral discoid meniscus, 39 knees (37 patients) were reviewed at an average follow-up of 35 months (14-48). Horizontally torn lateral discoid menisci were classified as incomplete (12 cases) or complete (27 cases) by Watanabe classification; no Wrisberg-type was noted. Partial meniscectomy was performed in thirty-one cases and total or subtotal meniscectomy in eight cases which were excluded in this study. For the technique of a new method of partial meniscectomy, the unstable leaf of the horizontally torn meniscus was removed to the peripheral rim, but the stable one was preserved and reshaped to produce the similar appearance to the normal lateral meniscus in terms of width and thickness. It was trimmed to have a balanced rim of meniscal tissue about 8 mm in width. Meniscal repair was added to partial meniscectomy in one case. All the cases were rated using the Lysholm Knee Scoring Scale. The scores increased after partial meniscectomy by average 20.7 (73.0->93.7). Recurrence of tear or aggravation of symptom was not noticed at the final follow-up.

        Poster 302. Arthroscopic fixation of the intercondylar eminence fractures with a four portal technique

        Mehmet S. Binnet, Cengiz Yilmaz, Atac Karakas, Ilksen Gürkan
        2001 ISAKOS Poster Abstracts
        In spite of the well-described definition and classification of the intercondylar eminence fractures, debate goes on about the management of Type II and III fractures. Some controversy exists about the differences in the treatment and the results of surgical management between adolescent and adult patients. These fractures are the most popular group among the ones that can be treated by arthroscopic techniques. The study was carried on two groups of patients, adolescents and adults, with intercondylar eminence fractures who were treated arthroscopically. As internal fixation, sutures were used in 8 adolescents and screws were used in 13 adults. In the technique we describe, antero-medial superior and inferior, and anterolateral superior and inferior portals were used. Average follow-up period for the adolescents were 27.3 months (range, 11-57 months), and for the adults 19.6 months (range, 7-71 months). We did not encounter any non-union. There were only three complications, one with the established arthrofibrosis because of the delay of the rehabilitation due to a vascular compromise and two with the tenderness over the screw that responded well to its removal. Union occurred earlier in adolescents, but rehabilitation was easier in adults. Besides satisfactory results obtained by the arthroscopic treatment of the intercondylar eminence fractures the arthroscopy provides also the possibility to determine and treat associated pathologies. With the experience we gained, the procedure with the four-portal technique in treatment of these fractures became much easier as a routine approach.

        Poster 303. Cold irrigation in knee arthroscopy: Morbidity, pain and swelling. A comparison with standard techniques

        A. S. Boecksteiner, FRACS, L. Osti, FRACS, H. Morris, FRACS
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the use of cold irrigation in knee arthroscopy. Method: A randomised controlled study was performed looking at pain, swelling temperature and morbidity in day-case knee arthroscopy patients. Twenty-two patients were studied in each group. Randomisation was according to day of surgery. Groups were matched for age, and severity of knee problem by Lysholm score. Cold Ringers Lactate irrigation was use in the study group. Pre-operative features recorded included, age, Lysholm score, knee girth and core temperature. Intraoperative recordings included diagnosis, intra-articular temperature tourniquet time and core temperature at the end of the procedure. Post-operative features recorded were pain with a visual analogue scale, knee girth and analgesia use up to 10 days. Results: There was no significant difference in pain scores between the group. There was a slight trend to less pain on average at day 2. There was no significant difference in the swelling at the joint or above, between the groups. The analgesic use was similar. There was no infection or haemarthrosis requiring aspiration or reoperation. There were no other complications noted. The average core temperature drop was 0.5 degree Celsius in the study group, which was equal to the controls. The intra-articular temperatures recorded ranged from 4.5 degrees Celsius to 18 degrees. The tourniquet time reflecting the procedure time ranged from 10 to 30 minutes. Conclusion: We found no adverse effect on pain, body temperature, swelling or healing. Significance: The operative times in this study were very short. Therefore cold application was brief. This technique could be used in longer procedures such as ACL, PCL or synovectomy, and or combined with post-operative cold therapies to further investigate its value.

        Poster 304. Arthroscopic proximal realignment of the extensor mechanism in the treatment of recurrent dislocation of the patellofemoral joint

        Gilberto L. Camanho, MD, PhD, Marco Martins Amatuzzi, MD, PhD, Rogerio Olivi, MD, M.Sc., Márcia Uchôa de Rezende, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To describe and evaluate the technique of arthroscopic proximal realignment (APR) of the extensor mechanism in the treatment of the recurrent dislocation/ subluxation of the patella. Method: Between 1994 and 1997, 21 APR were performed in 12 women, 9 men with average age of 29 years (13 to 46). In cases of subluxation, only proximal realignment was performed. In cases with recurrent dislocation, a medial transfer of the tibial insertion of the patellar ligament was added (16 Elmslie-Trillat and 1 Goldthwait). In 2 cases of recurrent dislocation (age 16 and 46) only proximal realignment was performed. The APR technique is described by the section of the lateral retinaculum and of the insertion of the vastus medialis from medial surface of the patella re-inserting it more distally in respect to its original insertion. Postoperatively all patients remained with a long brace for 3 weeks with gentle manipulation every 3 to 4 days. After that period, rehabilitation protocol focused on gaining range of motion first, followed by gaining of muscle strength. Good results were defined by no subluxation or dislocation postoperatively and bad results subluxation episode or any other complication from the procedure. Results: After 2 years of follow-up there were 19 good results and 2 bad results. Of these two, both had recurrent dislocation and were females (ages 13 and 34). Conclusion: The APR proved to be a safe and effective technique in treating patella dislocation/subluxation. Significance: The APR reproduces the results of open proximal realignment with significant less morbidity.

        Poster 305. Day surgery ACL reconstruction with patellar tendon

        Gian Luigi Canata, MD
        2001 ISAKOS Poster Abstracts
        The reconstruction of the ACL in day surgery is becoming popular. The scope of this prospective work is to evaluate if day surgery influences post-operative rehabilitation time. Material and Methods. 131 young sportsmen underwent a reconstruction of the ACL with patellar tendon from July ‘96 to December ‘97. They were randomly divided up into two groups. Group A (62 patients, mean age 28 years) and Group B (60 patients, mean age 30 years) underwent day surgery staying one or two nights in the clinic. All surgery was performed using the same surgical technique by the same surgeon. Peripheral anaesthesia was used. 15% of the subjects in Group A and 17% of the subjects in Group B chose general anaesthetic. The same rehabilitation protocol was applied to all of the subjects. Results were evaluated with the lKDC form. Furthermore, the time crutches were used, the time needed in order to recover complete ROM and the time lapse from surgery to resuming running and sports activities were evaluated. The results were analysed statistically (paired Student’s t test). Results. The two groups were classified according to the lKDC form: Group A: 53 A, 6 B, 3 C. Group B: 44 A, 14 B, 2 C. The time crutches were used (mean 10 days in both groups) and the average time needed for the recovery of complete mobility was 88 days in Group A and 105 days in Group B. 8% of Group A and 3% of Group B did not recover flexion completely (<5°). Patients in Group A started running after an average time of 92 days, and in Group B after an average time of 110 days. 87% in Group A and 83% in Group B resumed sports activities after 161 and 179 days respectively. No statistical difference was evidenced in any parameter evaluated. 97% in group A declared that they were satisfied with the day surgery. Conclusions and Significance. ACL reconstruction day surgery does not jeopardize the rehabilitation time of sportsmen.

        Poster 306. Infrapatellar plica preservation in ACL surgery

        Gian Luigi Canata, MD
        2001 ISAKOS Poster Abstracts
        Purpose: This prospective study was aimed at evaluating if the presence of the infrapatellar plica could hasten the healing processes in ACL reconstruction. Material and Methods: ACL reconstruction with patellar tendon was performed in 135 subjects with isolated ACL lesions: 98 males and 37 females. The average age of the subjects was 28.8 years (14-64 years), and the average follow-up was 22 months (12-44 months). All subjects were operated on using the same technique by the same surgeon. Rehabilitation was the same for all the subjects. The subjects were divided up into two groups: Group A was composed of 70 subjects with infrapatellar plica and group B was composed of 65 subjects without infrapatellar plica. In no case was the infrapatellar plica excised. All subjects were evaluated using the IKDC form. The time lapse from surgery to resuming normal sports activities was recorded. The results were analysed statistically (paired Student’s t test). Results: Subjects in group A, rated A, were 81.42%; 15.71% were rated B, whereas those in group B, rated A, were 78.46% and 16.92% were rated B. These results are not statistically significant. Patients under 25 years with an intact infrapatellar plica could resume sports activities after 4.5 months. Those without after 5.94 months (p<0.005). In older patients the difference was not significant. Significance: Infrapatellar plica preservation hastens rehabilitation after ACL surgery in young patients.

        Poster 307. Arthroscopic arthrofibrolysis of knee: A review of 28 patients

        Rakesh C. Arya, MS(Ortho)
        2001 ISAKOS Poster Abstracts
        Purpose: To analyze the causes of Knee Stiffness over last 6 years (1994-1999) in patients seen at North Delhi Arthroscopy and Knee Clinic and present the results of Arthroscopic Arthrofibrolysis with our surgical technique. Method: Records of 28 patients of restricted range of motion were reviewed to study the causes of Arthrofibrosis. Patients with completely stiff knees with no range of motion were not included. All 28 patients had regular follow-up. All 28 patients underwent Arthroscopic Arthrofibrolysis followed by manipulation on the operating table. Postoperatively all patients underwent rigorous supervised physiotherapy, range of motion exercises including continuous passive motion machine. Results: Results of 28 patients treated by Arthroscopic Arthrofibrolysis of the Knee are reviewed. Despite prolonged physiotherapy to improve the range of motion, mean preoperative flexion contracture was 14 degrees. Mean preoperative range of motion was 81.4 degrees and mean preoperative Lysholm Knee score was 62. After average post-arthrolysis follow-up of 24 months mean flexion contracture improved to 4.8 degrees (gain of 9.2 degree). Total range of motion postoperatively improved to an average of 122 degree (average gain of 40.6 degrees) and mean Lysholm functional score improved to 90. Conclusion: Restricted range of motion in the knee joint is a disabling problem developing either as a result of immobilization of knee joint following either conservative management of knee injuries or a result of unsatisfactory surgical intervention requiring postoperative immobilization. Arthroscopic Arthrofibrolysis presents a technical challenge to surgeon as restricted range of motion provides very limited space to manipulate instruments. Final results are gratifying and worth the effort on the part of patient and surgeon! Regaining complete extension is more difficult than improving the range of flexion as shown by our results.

        Poster 308. Efficacy of changed indication for preservation of torn medial meniscus in ACL injured knees

        Sadahiro Cho, Sadao Niga, Takeshi Muneta, Akiho Hoshino
        2001 ISAKOS Poster Abstracts
        Purpose: To reduce number of patients who need a secondary procedure for medial meniscus (MM) after anterior cruciate ligament (ACL) reconstruction, we changed the indication for preservation of torn MM after 1996. This study reports efficacy of the changed indication on necessity of secondary procedures and healing rate of torn MM. Materials and Methods: Two-hundred and fifteen patients underwent ACI, reconstruction using medial hamstrings tendon were followed with a second-look arthroscopy from 1996 through 1998. Among the cases with torn MM doubted on preoperative MRI, only those which were stable by probing as well as asymptomatic were intentionally left nonoperatively, while before 1993 we tried to preserve torn MM without definite indication. One-hundred and twenty-three were doubted to have torn MM on preoperative MRI. In 83 out of the 123 cases were proved to have a tom MM arthroscopically and not stable with probing, meniscectomy or meniscal repair was performed. On the other hand, forty cases were stable arthroscopically, 18 of which were reaffirmed to have a torn MM, while the other 22 were not proved to have torn MM arthroscopically. The MM were left untouched in the 40 cases. Results: All of the 40 cases with untouched MM were asymptomatic through the follow-up period. In 12 cases out of 18 with a torn MM which was proved arthroscopically and left untouched, the MM was found healed by a second-look arthroscopy, while the other 6 showed the MM still unhealed. In 2 of the 6 cases, MM were not stable by probing, meniscectomy was performed. Four of the 6 cases were again left untouched because they were stable and asymptomatic. In the 22 cases in which the MM damage was doubted on MRI but any damage were not found arthroscopically, any case did not require an additional meniscal procedure. Overall rate of cases which needed a secondary procedure for torn MM after ACL reconstruction was 0.9% (2 out of 215). Conclusion: Definite indication for preserving torn MM showed apparent improvement for decreasing rate of secondary procedure from 8.2% (10 out of 122 cases before 1993) to 0.9%.

        Poster 309. Anterior medial impingement syndrome (?) of the knee

        James C.Y. Chow, MD
        2001 ISAKOS Poster Abstracts
        Objective: In >2000 knee arthroscopies, the author has observed a group of patients with anterior medial joint compartment pathologies including inflammation, polyp-type and loop appearance in the anterior medial joint compartment. Debridement significantly improved these patients’ symptoms in a very short period of time. This paper will report the author’s clinical findings of this group of patients. Methods: From 1989 to 1999, 266 patients were seen with anterior medial pathology, including inflammatory and hypertrophic changes with polyp or a loop appearance. All knees were evaluated pre- and post-operatively by physical and radiographic examination. Those patients with associated conditions such as meniscus injury, plica lesion, or significant chondromalacia changes that required debridement or osteochondral graft, were excluded from the study. Of the 266 cases, 21 had purely isolated anterior medial joint compartment pathology. The preoperative data, surgical video and arthroscopic pictures, and follow-up information were carefully reviewed. Results: 21 patients (3 male/18 female), age 11-68 yrs (mean - 29 yrs) for 8 right knees and 13 left knees with symptom duration ranging from 1 mo to 2 yrs were included. 19 of the 21 cases (91%) had a history of trauma to the involved knee. 7 of the 21 (34%) underwent MRI with 4 positive results, and 3 negative results. All cases were treated conservatively with NSAIDs, knee bracing, rest, and physical therapy for an average of 7 months prior to arthroscopic examination. Debridement of the anterior medial joint compartment, utilizing a laser, shaver, or thermal debrider, was the procedure performed in all cases. The post-op follow-up ranged from 3 mos to 10 yrs 7 mos (mean - 5 yrs, 1 mo). 17 of the 21 cases (81%) were pain-free within 1 wk following arthroscopic debridement, 19 of 21 (91%) within 2 wks, and all 21 (100%) within 3 wks. 14 of 21 (67%) returned to normal function/sports within 1 mo; all 21 cases within 2 mo. 1 patient with generalized chondromalacia changes and 1 patient with chondrocalcinosis of the knee presented with the symptoms of anterior medial joint pain but both cases were pain-free within 1 wk. Conclusion: Based on the clinical observations, further evaluation is necessary to determine if this indicates a possible impingement syndrome (?) of the knee following trauma that results in pathological changes in the anterior medial joint compartment. There is also a question as to whether this leads to chondromalacia changes of the medial femur condyle.

        Poster 310. MR imaging of the meniscocapsular tear of the knee

        Churl Hong Chun, MD, Jae Hyun Yang, MD, Seon Kwan Juhng, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The meniscus is very important structure for sports activity. Therefore, diagnostic accuracy is necessary for menisco-capsular separation of knee. The purpose of this study is to be valid MR imaging signs of menisco-capsular separation, define significant positive findings, and develop imaging criteria for the diagnosis of menisco-capsular separation by correlating findings on MR imaging performed preoperatively. Materials & Methods: For 2 years recently, total 46 patients with menisco-capsular separation were repaired by arthroscopy. We reviewed 31 patients except 15 cases which were not available MR imaging. The positive findings of MR imaging of menisco-capsular separation are (a) interposition of fluid between the meniscus and MCL or LCL, (b) increased distance between the posterior tibial rim and the outer meniscal border, (c) a peripheral meniscal corner tear, (d) displacement of the outer meniscal margin with respect to the outer edge of the tibia, (e) perimeniscal swelling, (f) menisco-femoral extension rupture and (g) menisco-tibial extension rupture. We investigated frequency of above each item on sagittal and coronal view of MR imaging at retrospective. Results: Medial menisco-capsular separation were 18 cases, on coronal, (a) was 12 cases (67%), (b) was 10 cases (56%), (f) was 7 cases (39%) and (c), (g) were 5 cases (28%) each. On sagittal, (c) 10 cases (56%), and (a), (d), (e), (h) 4 cases (23%) each. Lateral menisco-capsular separation were 13 cases, on sagittal, (b): 8 cases (44%), (e): 6 cases (33%), (a): 4 cases (23%). On coronal, we found (c): 10 cases (56%), (g): 8 cases (44%), (a), (b): 5 cases (28%) each. Conclusion: The significant MR findings of menisco-capsular separation of medial meniscus are increased distance or fluid. Also, at lateral meniscus, perimeniscal swelling, menisco-tibial extension rupture are more important for meniscocapsular tear. So, these findings are noted and then should be keep menisco-capsular separation in mind.

        Poster 311. Arthroscopic assisted simultaneous ACL and PCL reconstruction in knee dislocation

        Churl Hong Chun, Byoung Chang Lee, Jae Hyun Yang, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Combined ACL & PCL injuries after knee dislocation were reconstructed at once, using fresh-frozen achilles allograft under the arthroscopy. We analyzed prospectively clinical outcome and observed the recovery of sport activity. Materials and Methods: From Jan. 1996 to Mar. 1998, we performed arthroscopic assisted ACL & PCL reconstruction in 21 patients with knee dislocation. There were 4 acute, and 17 chronic knee injuries. Ligament injuries were 4 MCL (grade III), posterolateral instability 5 cases, 5 medial menisci and 4 lateral menisci. Fresh-frozen achilles allograft were adopted in reconstructive procedure, which were used one-tunnel method for ACL reconstruction and two-tunnel method for PCL reconstruction. Minimum follow-up periods were at least 2 years (range 24 to 49 months). Telos stress arthrometer, Lysholm knee score and Tegner activity scores were evaluated. Results: Telos stress arthrometer showed improved joint stability by means of decreased translation distance (average 4.5 mm). Under the Tegner activity score revealed 5 cases of grade VI, 8 cases of grade V and IV, 4 cases of grade III and II, and 4 cases of grade I. Lysholm knee score was 74 (42-90) points. Modified Feagin scoring system showed 8 cases of good and excellent. Conclusion: Conservative treatment could not gain knee joint activity, but also operative treatment is not yet standardized so as to its difficult technique. Considering the knee joint stability and activity, arthroscopic ACL & PCL simultaneous reconstruction is the best choice of operative technique.

        Poster 312. Partial lateral meniscectomy arthroscopy: Clinical and radiographic evolution

        Moises Cohen, Rene Jorge Abdalla, Benno Ejnisman, Joicemar T. Amaro
        2001 ISAKOS Poster Abstracts
        The authors followed 89 patients who have undergone partial lateral meniscectomy for an average of 139 months, between 1984 to 1993. All patients did not have any ligament tear, and no arthritic changes on x-ray. which were confirmed during the arthroscopy. They were evaluated according to clinical and radiological examination and correlated to their return to sports. Patients with lateral meniscus tear greater than one third, mainly in the posterior horn and popliteo hiatus, presented the poorest evolution. Athletes with chondral lesions showed worst results, such as longer recovery time and progressive arthritic radiological changes. The authors concluded that partial lateral meniscectomy associated with posterior horn lesions in highly demanded athletes decrease the chances of all excellent recovery.

        Poster 313. Outcomes following meniscal repair using the meniscal arrow

        David R. Diduch, MD, Sanjitpal S. Gill, MD
        2001 ISAKOS Poster Abstracts
        Objective: 1) Determine the healing rate of meniscal repair using the meniscal arrow in patients undergoing concurrent anterior cruciate ligament (ACL) reconstruction; 2) Evaluate patient outcomes with the IKDC and a visual analog scale (VAS). Materials and Methods: We retrospectively analyzed 41 patients with 42 meniscal tears in knees undergoing concurrent endoscopic ACL reconstruction whose menisci were repaired with the meniscal arrow system (Bionx, Blue Bell, PA). All meniscal tears were deemed amenable to repair according to length, stability, morphology, and zone of tear. There were 33 medial and 9 lateral meniscal tears, with an average tear length of 2.1 cm. An average of 2.5 arrows were used to repair each tear. All 42 tears were located in the posterior horn of the meniscus or extending into the body of the meniscus from the posterior horn. Follow-up was assessed by clinical examination, the knee disorders subjective history VAS, and the IKDC evaluation form. Reconstructed ACL laxity was assessed by KT-2000 arthrometry and clinical evaluation. Results: At an average follow-up of 2.4 years (range, 18-39 months), 33 patients have been surveyed to date. The success rate was 90.9% (30 of 33 patients) with three patients going on to arthroscopic partial meniscectomy. KT-2000 arthrometry showed that sagittal knee laxity was less than three millimeters in all reconstructed knees. Clinical criteria for success in the rest of the repaired menisci included (1) the absence of locking, catching, or giving way; (2) no history of recurrent effusions; (3) no joint line tenderness; (4) a negative McMurray’s exam; and (5) no subsequent surgical procedures on the repaired meniscus. Additionally, the VAS demonstrated the ability of these patients to return to a high level of activity, including competitive sports, without symptoms suggestive of a meniscal tear. The IKDC demonstrated “normal” or “nearly normal” function of all success knees except one patient who had residual MCL laxity. Conclusions: This study demonstrates that a high rate of meniscus healing can be achieved by the all-inside, bioabsorbable meniscal arrow system in conjunction with ACL reconstruction. Also, patients have excellent function of their knee and are able to return to a high level of activity. Significance: Our healing rates were comparable to those previously reported with the inside-out suture techniques without the need of an additional posterior incision that would increase operative time and risk to neurovascular structures.

        Poster 314. Cyclic testing of meniscal sutures after in vitro culture

        Michael Dienst, MD, Romain Seil, MD, Michael Kühne, MS, Dieter Kohn, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To compare different suture materials in medial porcine menisci under cyclic loading conditions after in vitro culture. Methods: 40 medial menisci were harvested from adult pigs under sterile conditions. The menisci were cut vertically with a scalpel 3 mm from the periphery creating a complete peripheral meniscus tear. Absorbable monofilament suture (PDS 2.0) and nonabsorbable braided suture (Ethibond=EB 2.0) were used for horizontal mattress sutures of the tears. The distance between the suture arms was 3 mm. The sutures were placed 3 to 4 mm from the peripheral edge of the tear. They were inserted from the articular, femoral side of the meniscus. In every case, a hand-tied square knot with 5 throws was tied on the capsular side. 5 menisci for each suture material were tested at the day of harvesting. 15 menisci for each suture material were cultured in vitro in standard culture medium (DMEM, 5% FCS + Pen/Strep + L-Glu).15 menisci each were tested after 2, 4 and 6 weeks of culture. Cyclic testing included a preloading of 5 N. Repetitive sequences of 50 vertical loadings were performed. In the first sequence, the upper cycle load was 10 N, which was increased after each sequence in steps of 10 N. The strain rate was 100 mm/minute for each suture. After cyclic loading to failure, the failure load was documented. Results: The ultimate failure strength of horizontal mattress sutures of nonabsorbable suture material (Ethibond 2.0) showed no significant decrease after 6 weeks of culture. Absorbable suture material (PDS 2.0) showed a significant decrease to about 70% after 4 weeks and 50% after 6 weeks of its initial ultimate failure strength.
        Figure thumbnail gr7a
        Figure thumbnail gr7b
        Conclusions: The use of absorbable suture material for repair of the meniscus could lead to healing problems of the repaired meniscus during repetitive loadings.

        Poster 315. Treatment of partial ruptures of ACL

        Mahmut Nedim Doral, O. Ahmet Atay, Gursel Leblebicioglu, Onur Tetik, Akin Uzumcugil
        2001 ISAKOS Poster Abstracts
        Purpose: To find out the functional outcomes of the partial ruptures of the ACL which were arthroscopically proven and compare the results of two groups, treated with only arthroscopic debridement and LASER shrinkage. Method: Between 1988 to 1998, 47 recreational athletes, who underwent arthroscopy and partial ACL tears were identified retrospectively included into the study. We performed debridement to the ruptures which 50% or more portion of the ligament was intact and not elongated. We performed LASER shrinkage if the ligament was elongated and more than half was intact. Intraoperative findings (such as Lachman and pivot-shift under anesthesia, associated injuries) and postoperative objective and subjective assessments at follow-up evaluation were made. Patients were evaluated according to the Lysholm knee scores, lKDC knee ligament standard evaluation form and Tegner activity level. Results: Mean age at the time of the surgery was 32 (14-49); there were 25 females and 22 males. Average follow-up time was 89 months (28-143). The mean Lysholm score was 87 (83-89); according to the IKDC evaluation system 32 (68%) patients were classified as normal, 13 (29%) as nearly normal and 2 (3%) as abnormal; according to Tegner activity level they were in group 7 (5-10). There was no statistical difference between the clinical results of arthroscopic debridement group (27) and LASER shrinkage group (20). Surgical procedures were performed to the associated meniscal and condral lesions. Conclusion: Patients with partial ACL ruptures could return to their previous sportive activity level without any functional instability. Significance: Low dose LASER shrinkage could be a preferable method for elongated partial ACL ruptures.

        Poster 316. No tourniquet use in routine knee arthroscopy

        Roberto Dórea, Cristiano Jodicke
        2001 ISAKOS Poster Abstracts
        Purpose: This presentation demonstrates a new method to control bleeding during the arthroscopic surgery, intending to diminish the risk of a development of a deep-vein thrombosis or of a lesion of the peripheral nervous system or muscle fibers. Method: The proceeding is performed with 0.5 ml of adrenaline diluted in 100 ml of isotonic solution, and we use 20 ml of this solution to inject into the entering portals. At the supero-medial portal 10 ml of the solution is injected and at the infero-lateral and infero-medial portals 5 ml are injected in each one. We wait 5 minutes making flexion-extension movements to spread the solution all over the knee articulation. Then, the knee is ready for the arthroscopy. Eventually, if a strong bleeding persists, one can inject 20-30 ml more of the solution, wait 5 minutes to let it take effect and afterwards, you will be able to visualize the structures with neatness. Results: During a period of 24 months, we have had 500 operative knee arthroscopies and no problems have occurred, with 0% of deep-vein thrombosis or lesion of the peripheral nervous system or muscle fibers. The age of the patients varied from 15 to 76 years. Conclusion: This procedure is technically easier and a more effective method to control bleeding during the arthroscopy, promoting an excellent image during the procedure and lowering the possibility of comorbidities.

        Poster 317. Causes & mechanisms of arthroscopically proven meniscal injuries in the adult population

        George Drossos, Louis Pozo
        2001 ISAKOS Poster Abstracts
        Aim: This study investigated the causes of meniscal tears in an unselected adult population. No epidemiological study of this type has been undertaken since the advent of arthroscopy & MRI. Method: 392 patients, 18-60 years old, with normal X-rays, no previous knee injury, surgery, or arthritis, and arthroscopically proven meniscal tears, were analysed. Results: Sports injuries occurred in 32.4% patients. Non-sporting injuries accounted for 38.8% patients, 71.9% of which happened in normal daily activities. Half occurred on rising from squatting position. No Injury was identified in 28.8% of patients. Average age of sports group was 33 years, non-sporting group 41 years & no injury group 43 years. Male:FEmale = 4:1. Age vs. cause: In group < 20 years meniscal tears occurred mainly in sports. In group 20-29 years, 64.5% were related to sports, 25% to non-sporting activities & 10.5% to no injury. Between 30-39 years, distribution was about equal in each group. In groups 40-49 & 50-59 years sports-related tears dropped below 20%, whilst non-sporting and no injury associated tears rose to 45% and 35% respectively. Analysis of tears in relation to different sports, the associated intra-articular injuries, the pathological types and distribution of tears will be presented. Conclusion 70% of meniscal tears in the general population occur during normal daily activities. Tears occur in the absence of definitive injuries even in early adulthood & middle years. Ascent from the squatting position is an important common mechanism of injury not generally described or emphasised.

        Poster 318. Arthroscopy alone or associated with open cystectomy: Treatment of lateral meniscal cysts

        Maher El-Assal, Maged Mostafa, Ahmed Abdel-Aal, Mohammed El-Shafee
        2001 ISAKOS Poster Abstracts
        From 1991 to 2000, 27 knees with the diagnosis of cysts of the lateral meniscus were retrospectively studied in 21 patients. Mean age was 29 years (range of 12 to 40 years). All patients had pain over the joint line with a palpable mass. All patients had a meniscal tear; 20 tears were horizontal and 7 were transverse. The pathology was in the middle or anterior one-third of the meniscus. The arhtroscopic surgery consisted of pential excision of meniscal tear, leaving a peripheral rim, coupled with debridement of the cyst in 22 knees. Open cystectomies were performed in the remaining 5 knees. Average follow-up was 54 months, with a range of 5-110. All patients but two were satisfied with the results.

        Poster 319. Computer guided ACL reconstruction (Navitrack)

        Andree Ellermann, Jens Buelow, Andrew Buchgraber
        2001 ISAKOS Poster Abstracts
        Objective: Computer-aided surgical systems are getting more and more attention in orthopaedic surgery. New software devices for the navigation system Navitrack, well known in spine surgery, allowed first clinical application in ACL-replacement. Our goal was to evaluate this system regarding precision, operation duration and clinical usefulness. Methods: We perform a preoperative MRI with a slice thickness of 1.5 mm. The data is transferred to an external unit where we create a 3-D-model which additionally allows real-time movement of surgical tools. While using a magnetic tracking system we adjust sensors to the instruments, the tibia and the femur. After a quick calibration of these sensors we are able to visualize the instruments in the model. Using a probe-like instrument and different 3-D-views of the knee joint, displaying among other structures especially Blumensaat’s line, we perform a precise placement of the insertion points. The virtual image of the reconstructed ligament undergoes a dynamic impingement and isometry testing, while the computer calculates the isometry as the difference between the shortest and the longest ligament elongation. Results and Conclusions: The preoperative planning and intraoperative control in the 3-D model leads to higher safety and precision. An intraoperative fluoroscopic control of the tunnels is obsolete. The preoperative reconstruction of the 3-D-model is rather time consuming whereas there is no major prolongation of anaesthesia and operation time. The surgeons choice of transplant and fixation technique is not influenced by the system.

        Poster 320. Soft tissue balancing in varus knee prosthesis implant

        Lamberto Felli, Romana Rainuzzi, Carlo Enrico Fiorentini, Francesco Pipino
        2001 ISAKOS Poster Abstracts
        Purpose: To assess the suitability of the implant of the Tack knee prosthesis in the case of osteoarthritic varus knee where a rebalancing of the peripheral capsuloligamentous structures is required. Method: At the Second Orthopaedic Clinic of the University of Genoa, the Tack (Total arthroplasty cementless knee) prosthesis has been implanted in 60 cases of osteoarthritic varus knee (with a deformity exceeding 8°). The Tack prosthesis is characterised by a highly congruent rotating platform, which allows a faithful duplication of normal articular kinematics. During the implantation stage, particular attention was drawn to the rebalancing of peripheral capsuloligamentous structures that, thanks to the characteristics of the surgical equipment used, can be balanced in a reliable way. The implantation has been carried out on 9 males and 48 females aged 70 on average, in 32 cases on the right-hand knee, in 28 cases on the left-hand knee and in 3 cases on both knees. The cases taken into examination showed a varus deformity between 8° and 15° and an unbalance of the peripheral capsuloligamentous structures. Rheumatoid deformities were not included. Implantations were performed according to a uniform protocol: Not prosthesized patella, cementless implantations, steady rehabilitation programme, same surgeon performing the implantations. In 64.2% of cases (45 cases) the posterior cruciate ligament was maintained, whereas in the remaining 35.8% of cases the PCL was sacrificed due to bone deformity and to the condition of the tissue. The follow-up period lasted 3 years on average (from a minimum of 12 months to a maximum of 60 months) and the assessment was performed on the basis of the HSS score card. Moreover, a postoperative evaluation of the varum valgum laxity was carried out, identifying total stability as degree 0, slight opening without metal-polyethylene contact noise as degree I, noisy elastic opening and return as degree II, residual unstable laxity as degree III. The residual laxity degrees were assessed on the basis of deterioration parameters (wear, radiolucent lines, loosening). Results: The assessment carried out on the basis of the HSS score card gave 35 excellent results, 15 good results, 10 satisfactory results. The varum valgum stability assessment revealed 40 knees with degree 0, 14 with degree I and 6 with degree II. No degree III laxity were reported. In the 6 cases with degree II the PCL had been sacrificed. Only one out of these 6 cases showed signs of radiolucent lines on the lateral plate and on the stem with a clinic reference of pain, after a period of 3 years. Conclusion: Thanks to its highly congruent design and to the implant method, allowing a rebalancing of the peripheral capsuloligamentous parts, the Tack prosthesis ensures the achievement of reassuring clinical results and reduced deterioration potentiality, as a result of a balanced implant, which minimizes stress and abnormal loads. The negligible wear incidence with mid-term f.u., confirms the effectiveness of such implantation. The PCL preservation affects latero-lateral stability. Significance: Thanks to its part congruence and to the implant method which ensures an accurate rebalancing of the capsuloligamentous structures, the Tack knee prosthesis allows an easy implant also in cases of knees presenting considerable axial deformation and soft tissue unbalances. An important role is indicated in PCL preservation.

        Poster 321. Arthroscopic diagnosis and treatment of symptomatic total knee arthroplasty

        Florian Fankhauser, MD, Jorg Michael Passler, MD, Franz Josef Seibert, MD, Christian Boldin, MD
        2001 ISAKOS Poster Abstracts
        Objective: With increasing numbers of total knee arthroplasty, there has been a resultant increase in postoperative complaints and problems. These range from restriction in range of motion, recurrent swelling, soft tissue impingement and ingrowth, to prosthesis failure with no obvious radiological abnormality. This study assesses the role of arthroscopy in the treatment and diagnosis of these conditions. Methods: During the last four years we performed 14 arthroscopies following total knee arthroplasty. Six of these cases presented with significant decreased range of motion, three had proximal medial joint line pain, three had pain with no obvious cause, one had a suspected patella incongruence with metal-metal contact and one case had a postoperative haemarthrosis. Results: Arthroscopy revealed that the main cause of the limitation of motion was adhesions and intraarticular fibrous bands resulting in incongruity of the patellofemoral joint. Medial compartment pain was due to a pseudomeniscal hypertrophic villous synovium or adhesions. In one case the pain was due to chronic infection and a synovectomy was undertaken. Also found was one case of a fracture of the polyethylene and the case of suspected patella malalignment with metal-metal contact was confirmed with arthroscopy. Conclusions: Arthroscopy of symptomatic total knee arthroplasties is reserved for selected cases after exhaustive noninvasive diagnostic investigation. Becasue of deceptions through reflection artefacts and the risk of iatrogenic lesions to the prosthesis, this procedure should be carried out by arthroscopic experienced surgeons, who also have the knowledge about the specific prosthetic design, the technique of prosthesis implantation and its possible complications. If soft tissue impingement or resultant maltracking of the patella is suspected and as a diagnostic aid in unclear symptomatic total knee arthroplasties, arthroscopy is a minimal invasive method which may aid in obtaining the diagnosis and assist in the managment of these problematic total knee arthroplasties.

        Poster 322. Tibial eminence displaced fractures reduction and fixation using arthroscopy: A personal method

        Danilo Gervasoni, Gianpaolo Chitoni, Antonio Medeghini
        2001 ISAKOS Poster Abstracts
        Purpose: Arthroscopic-assisted easy and quick reduction and fixation of tibial eminence displaced fractures in children, adolescent and adult. Method: In tibial eminence displaced fractures a perfect reduction is necessary in order to avoid an anterior laxity and defect of the knee extension. The arthroscopic techniques used up to now allow good results, but often the methods are lengthy and demanding. We have set up a technique employing 2 or 3 K-wires, 1 mm diameter, positioned by means of normal tibial guide for ACL repair, that holds the fracture in reduction. By means of a strong arthroscopic forceps said wires are then curved inside the articulation and drawn out of the skin. The p.o. management includes the use of a knee brace with R.O.M. between 5°-70° for 25 days and partial weight, then between 0° and 100° during other 15 days with total weight. Later on the K-wires are easily extracted in the outpatient’s department thanks to their elasticity. Results: In our two-years experience (five patients) results have been excellent with average surgical times of 15 minutes, complete recovery of the articular R.O.M. and with no residual laxity. Also, cosmetic results are excellent and radiographic follow-up demonstrated anatomic fracture healing. Discussion and conclusions: Open surgery has been abandoned in this type of fracture because of the articular rigidity and unsatisfactory cosmetic results, especially in female patients. We reviewed numerous arthroscopic methods described in literature, but they are often lengthy and demanding. Furthermore, many techniques may cause growth plate damage in children and adolescents. The advantages of this simple and quick technique are:
        • very short surgical time (average: 15 min.)
        • satisfactory reduction and fixation of fractures
        • K-wires easy removal after recovery
        • no growth plate damage in children and adolescents
        • excellent clinical, anatomical and cosmetic results.

        Poster 323. Treatment of full-thickness chondral lesion of the knee with microfracture technique

        Alberto Gobbi, MD, Stefano Santamaria, MD, Sanjeev Mahajan, MS
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the long-term results of the microfracture technique in a group of patients treated for full thickness chondral lesion of the knee. Methods: A group of 53 patients (26 sportsmen at different level) with chondral lesion grade IV were treated with arthroscopic shaving and microfracture and were prospectively evaluated. Patients’ average age was 38 years, and mean follow-up was 49 months (min. 24 - max 80). Femoral condyle was involved in 70% of these patients. Chondral lesion was due to macrotrauma in 8 patients, malalignment in 5, sport related microtrauma in 20 and 20 were idiopathic. 12 patients had undergone a previous open meniscectomy. Associated lesions were treated with ACL reconstruction in 11 patients, meniscal suturing in 3, tibial osteotomy in 3 and patellar realignment was done in 2 patients. We could perform a 2nd look arthroscopy in 10 patients. All the patients were evaluated with IKDC, Lysholm, Tegner and subjective evaluation. Results: IKDC: 6 normal, 30 nearly normal, 12 abnormal, 5 very abnormal. Lysholm: 16 excellent, 21 good, 11 fair, 5 poor. Tegner activity scale: 80% of these patients decreased their sport level (from 7 to 5). Average subjective evaluation scored 70/100. Conclusion: Microfracture technique is technically easy, with minimal morbidity and does not affect future procedures. We found an improvement in functional parameters of our patients, however long-term results are still unpredictable and degenerative changes may occur especially in active patients.

        Poster 324. Polyethylene mobility and short-term results after mobile bearing total knee arthroplasty

        Stefan Gödde, MD, Simone Burgard, Stefan Rupp, MD, Dieter Kohn, MD, PhD
        2001 ISAKOS Poster Abstracts
        Introduction: Purpose of this study was to evaluate the amplitude of the mobility of the polyethylene tibial insert of the INTERAX ISA knee prosthesis (Stryker Europe) in vitro and in vivo one year after surgery. Clinical results were compared with those of the standard fixed tibial component INTERAX knee prosthesis. Patients and Methods: In vitro maximum anterior and posterior tibial insert position and in vivo the amplitude of the insert mobility with the patient’s knee in extension and 90° of flexion in neutral and maximum internal/external rotation were measured fluoroscopically. Since 9/96 285 total knee arthroplasties INTERAX total knee system have been performed. 48 patients received an INTERAX ISA prosthesis with a mobile polyethylene meniscal platform. At one year follow-up 113 patients with a standard prosthesis (follow-up rate 86%) and 24 patients with a mobile bearing prosthesis (follow-up rate 87.5%) were evaluated. Results: In vitro tibial insert mobility was 10 mm in the sagittal plane. At one year follow-up in vivo average amplitude of mobility was 2 mm (range, 0 to 5 mm). Average functional and clinical Knee Society scores and HSS scores did not show significant differences: 88/83/84 points for patients with a mobile bearing prosthesis and 78/76/81 points for patients with a standard prosthesis. Differences in pain reduction and average range of flexion were not significant either. Conclusion: At one year follow-up in vivo amplitude of the polyethylene tibial insert mobility of the INTERAX ISA knee prosthesis is at 20% of in vitro mobility. The mobile bearing system does not lead to significantly better clinical or radiological short-term results compared with the standard fixed tibial component prosthesis.

        Poster 325. Complications in endoscopic fixation of a double-looped semitendinous and gracilis anterior cruciate ligament graft using bone mulch screw

        J. Eduardo Grandi Ribeiro, Dejair X. Cordeiro, Agostinho B. Figueiredo, José Gilson Feu, Rodrigo Rezende
        2001 ISAKOS Poster Abstracts
        Purpose: The objective of this paper was to evaluate the operative complications of endoscopic fixation of a double looped semitendinous (ST) and gracilis (GR) anterior cruciate ligament (ACL) graft using bone mulch screw fixation on femur and washer lock on tibia. Method: We reviewed the charts of 57 patients (52 male and 5 female) who were submitted to ACL reconstructions with double looped ST and GR with bone mulch screw from June 1999 to June 2000. The diagnostic of the ACL rupture was done the Lachmann test and confirmed by magnetic resonance image. 77.19% of the lesions were during soccer game. Results: We had 45.6% of associated medial meniscal tears, 17.52% of lateral meniscal tears and 7.01% of condral lesions. We had 8 (14.03%) complications, 1 (1.75%) case of popliteal artery injury and 7 (12.28%) of light complications (superficial infections, loose of GR tendon, loose of bone mulch screw, contralateral deep venous trombosis and loose of distal fixation). Conclusion: We considered it a good technique but with a great danger of popliteal artery near the way of the distal screw.

        Poster 326. Arthroscopic evaluation of meniscal injuries in the anterior knee instability

        Joáo Grangeiro Neto
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate arthroscopically the pattern meniscal injury in 100 patients with anterior insufficiency knee. Method: 100 patients with the anterior knee instability tested clinically were submitted to arthroscopic evaluation of the menisci prior to the main surgical procedure. The average age of 85 males and 15 females was 27 years (range, 19 to 36 years). All patients were examined in the out-patient clinic and under anesthesia for anterior knee instability. No one had any previous surgical treatment. Standing knee radiogram were done for all patients. 80 patients had ACL recontructed knees with central third of patellar tendon and meniscal tears were classified according with Weiss, de Haven and Gilquist (1989). Results: We found 40 (35%) incomplete meniscal tears and 74 (65%) complete lesions which were divided in: Stable longitudinal 10 (8.8%); bucket-handle 37 (32.5%); flap 18 (15.8%); complexes 9 (7.9%). 30 patients were presented with both menisci injured; 38 (45%) medial meniscus and 16 (19%) lateral meniscus. Anova test was applied with worse lesions seen on long term anterior instabilities and P < 0.05. Conclusion: In all 100 patients with ACL insufficiency, submitted to arthroscopic evaluation, 84% presented meniscal tears. Incomplete lesion were observed more frequently on the lateral meniscus, and in the medial meniscus the bucket-handle tear was predominantly seen. The incidence of lesion were superior in the medial meniscus and the most severe lesion were seen in those cases with long term insufficiency knee. Significance: The arthroscopic procedure showed us a good method in evaluating and staging menisci lesions in anterior knee disability.

        Poster 327. Modified technique of morgan’s all-inside repair of posterior horn of medial meniscus – using 2 posteromedial portals to ease the technical difficulties

        Jin Hwan Ahn, MD, Chul W. Ha, MD
        2001 ISAKOS Poster Abstracts
        Objective: The authors introduce a modified technique of all-inside repair of the peripheral or meniscocapsular junctional tears of the posterior horn of the medial menisci using 2 posteromedial portals. Technique: The arthroscope inserted through the anterolateral portal is advanced to the posteromedial compartment by transnotch technique. Two posteromedial portals are established. A universal cannula, is inserted through the upper posteromedial portal. A suture hook is inserted directly through the lower posteromedial portal. Meniscal suture is performed passing the suture hook through the tom portion. Both ends of the suture is retrieved through the universal cannula. The repair is secured with sliding knots and tightened with a knot pusher. A cutter is inserted through the lower posteromedial portal and makes the cut of the PDS suture over the knot. Usually 3-4 sutures are made for the posterior horn tears. Discussion & conclusion: The authors’ technique has the advantage of greatly increasing the working space of suture hook. The suture hook works through the lower posteromedial portal rather than working through the cannula. This greatly helps the arthroscopic surgeon handle the suture hook more easily and more widely. The probe inserted through the upper posteromedial portal can also helps the suture hook pass through the torn portion of the meniscus & avoid damage to the articular cartilage of the femoral condyle. We have done more than 70 repairs with this technique. The authors’ technique appears quite versatile and seems to help the arthroscopic surgeon get the most advantages of Morgan’s technique.

        Poster 328. The role of c-reactive protein in uncomplicated endoscopic ACL reconstruction compared to patients with infection after arthroscopy

        Wolfgang Hackl, Christian Fink, Karl Benedetto, Christian Hoser
        2001 ISAKOS Poster Abstracts
        Introduction: Before early detection is important Knee joint infection following ACL reconstruction is always of concern. Therefore early detection is important in order to start as soon as possible with adequate therapy to obtain a successful outcome. Because sometimes it is difficult to distinguish between normal postoperative reaction and infection certain blood variables can indicate for microbacterial infection. This study was designed to establish a baseline of C-reactive protein (CRP) levels following uncomplicated arthroscopic assisted ACL reconstruction using the middle third patellar tendon autograft. Materials and Methods: In forty patients (23 male, 17 female; mean age 26.3±2.3 years) blood samples were obtained preoperative and on postoperative days 1 to 5, 14 and 21. Those samples were analyzed for CRP and ESR. Patients showing a CRP level higher than 0.70 mg/dl preoperatively were excluded. These results were compared to the charts of 7 seven patients who developed postoperative infection following simple arthroscopy for meniscectomy and ACL reconstruction between 1990 and 1999. Results: No clinically signs of postoperative infection were observed in any of the 40 patients. Preoperative CRP level of 0.70 mg/dl increased to an average of 4.4 mg/dl on the second day (maximum) and decreased to 1.3 mg/dl on the post op day 5 but in 12.5% of patients the peak was on the third day. None of the patients had a higher CRP value than 4 mg/dl on day 4. CRP levels were back to normal on post op day 14. In contrast the peak of ESR level (first hour) was not reached before day 4 on average with a mean of 21.6 mm Hg. In the 7 patients developing infection after arthroscopy blood samples were taken and CRP levels were analyzed on the 4th postoperative day at the earliest. CRP values ranged from 25 mg/dl to 47 mg/dl and surgical intervention (arthroscopic debridement, removal of tendon graft, antibiotics, etc.) was implemented. Conclusion: In uncomplicated standardized ACL surgery CRP values follow a characteristic course with minimal variation. Clinical symptoms of infection and a CRP level much higher than 4 mg/dl on post op day 4 are highly suspective and further diagnosis and the immediate effective intervention should follow. Therefore the information provided by this study is a support to detect early joint infection after surgery.

        Poster 329. The influence of arthroscopic meniscectomy on lower limb alignment – a long-term follow-up study

        Hiroshi Higuchi, MD, Masanori Terauchi, MD, PhD, Masashi Kimura, MD, PhD, Kenji Shirakura, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the lower limb alignment in the long-term after arthroscopic meniscectomy. Material and Methods: Forty-five patients with isolated arthroscopic meniscectomy were examined. There were 22 men and 23 women. The age range at surgery was from 11 to 32 years (mean, 21.6 years). Twenty-seven patients were subjected to medial meniscectomy and 18 to lateral meniscectomy. Follow-up period ranged from 11 to 17 years (mean, 12 years). To analyze lower limb alignment, the femorotibial (FT) angle between the anatomical axis of the femur and that of tibia was measured from standing anteroposterior radiographs. Moreover, FT angle was divided into three components: Femoral condyle-femoral shaft (FC-FS) angle, femoral condyle-tibial plateau (FC-TP) angle, and tibial plateau-tibial shaft (TP-TS) angle. Results: After medial meniscectomy, FT angle was 177.5 ± 1.9° and 178.9 ± 2.1° in normal and treated limb, respectively. Moreover, TP-TS angle was 96.3 ± 1.9° and 97.6 ± 2.0° in intact and treated side, respectively. The lower limb alignment of treated side showed significant varus malalignment compared to normal side, especially at the upper medial tibial condyle. On the other hand, FT angle was not significantly different between normal and treated side after lateral meniscectomy. However, FC-TP angle was 1.3 ± 1.3° and 0.0 ± 2.5° in normal and treated side, respectively. After lateral meniscectomy, significant malalignment was found at the lateral joint. Conclusion: Varus malalignment was recognized at the upper medial tibial condyle after medial meniscectomy and valgus deformity was found at the lateral joint space after lateral meniscectomy. Arthroscopic meniscectomy affected the lower limb alignment in the long-term.

        Poster 330. Arthroscopic reconstruction of the posterior cruciate ligament: Experience with two graft methods

        Thomas Houe, MD, Frank Odgaard, MD, Uffe Jorgensen, MD
        2001 ISAKOS Poster Abstracts
        Objective: Although rarely, symptomatic knee instability after rupture of the posterior cruciate ligament (PCL) may persist in spite of rehabilitation. In such cases PCL reconstruction is an option. Although different procedures have been described, the relative efficacy of these methods remains to be elucidated. The purpose of this study was: 1. to investigate whether arthroscopic PCL reconstruction could relieve symptoms and increase the activity level in patients with “isolated” PCL instability. 2. to reveal any significant difference between using the patella bone-tendon-bone (pBTB) in one femoral tunnel or quadruple hamstrings in two femoral tunnels. Methods: Sixteen consecutive patients, 8 females and 8 males, with a median age of 31 years (19-46 years) were included. The median “age” of injury was 30 (20-72) months. A pBTB-graft was used in the first 6 patients and hamstrings were used in following 10 patients. Median follow-up was 24 (15-31) months. Patients were scored before and after operation and asked if they were very satisfied, satisfied, unsatisfied or very unsatisfied after reconstruction, and whether they would consent to surgical treatment, if they could decide again. Results: All patients improved after reconstruction and scores rose significantly (Lysholm: P<0.0001, Tegner: P<0.0005). Comparing the two graft-methods, no significant difference could be noted. All patients would consent to surgical treatment, if they could decide again. Conclusion: Arthroscopic reconstruction of isolated PCL rupture improves the patient activity level and relieves symptoms. No major differences were seen between pBTB or hamstrings / two or one tunnel techniques.

        Poster 331. The use of arthroscopic monopolar radiofrequency in the treatment of chronic anterior cruciate ligament instability: A preliminary report

        David J. Schurman, MD, Pier Francesco Indelli, MD
        2001 ISAKOS Poster Abstracts
        Objective: The treatment of Anterior Cruciate Ligament (ACL) instability resulting from incomplete tears or elongation in continuity has been historically treated either conservatively or by graft replacement. The literature is sparse with regard to alternative reparative surgical treatment of this condition. We report our early experience using a thermal shrinkage treatment on 11 consecutive knees suffering from this condition in patients experiencing continuing instability. Methods: Eleven patients underwent ACL electrothermal monopolar treatment at our institution between 1998 and 1999. All of these patients presented a difference of 6 mm or more when comparing the involved to the uninvolved side using KT-1000 evaluation. They showed ACL incomplete tears or elongation in continuity at the time of the arthroscopic evaluation. A single electrothermal device (Oratec, Oratec Interventions, Menlo Park, CA) was used in all of the cases. Rehabilitation protocol included immobilization and non-weight-bearing for 6 weeks. A one-year minimum follow-up study was conducted in all of the patients following the IKDC rating system. Results: The overall outcome at a one-year minimum F.U. was normal or nearly normal in all of the patients. They also showed a 30 pound side to side difference less than 5 mm. They were allowed to return to running 3 months after ACL shrinkage and to full unrestricted sports after 6 months. Conclusions: The thermal repair of ACL-insufficient knees represents an emerging alternative treatment to standard techniques. The primary contraindication for this technique is discontinuity of the ligament. Particular attention must be paid to patient compliance during ligament healing in its early stages.

        Poster 332. Arthroscopic experience in discoid meniscus tear surgery

        Carlos Infante, Jaime Hinzpeter, Jaime Catalan, Alejandro Orizola
        2001 ISAKOS Poster Abstracts
        We present the results of a study about the arthroscopic treatment in discoid meniscus tea r. Since 1995 to 1999, 22 patients were found with 26 discoid meniscus tears over a total of 550 arthroscopic meniscal procedures in this period doing. Two different age groups were operated , one with an average age of 11 and the other of 33 years. All of them had a lateral discoid meniscus. 68% had a traumatic event and the most frequent symptom was pain (82%) followed by recurrent locking (41%). Definitive discoid meniscus tear diagnosis was made intraoperative. Based on Watanabe classification we found 58% type I (incomplete), 31% type II (complete) and 11% type III (Wirberg). Meniscal tear was frequently central. Partial meniscectomy was done in 25 cases and we were able to keep more than two thirds of normal meniscus in 65%. One case had a meniscal suture. The short postoperative period allows return to normal activities early. No complications were seen. We had excellent and good clinical results in 100% cases at 15 months average follow-up period.

        Poster 333. A 10 year review comparing the clinical results of meniscal repair before and after the introduction of biodegradable implants

        Ari Pressman, FRCS, Don Johnson, FRCS, Moreno Morelli, MD, Ross Wilkinson, FRCS, Geoff Dervin, FRCS
        2001 ISAKOS Poster Abstracts
        Ongoing development of our understanding of meniscal function and the long-term consequences of meniscectomy have led to increased enthusiasm for meniscal preservation techniques for tears identified during anterior cruciate ligament reconstruction. Advances in technology have generated biodegradable implants, which have simplified repairs and yield success rates comparable to that of sutures. We performed the current study to determine the impact of the introduction of these devices on meniscal repair rates, mechanical failure and repeat surgery. For meniscal repair with concomitant anterior cruciate ligament reconstruction 2101 sequential patients treated from 1990-1999 were retrospectively reviewed. There were 274 meniscal repairs completed which were reviewed with an average repair rate of (13.0±6.4%). Patients were followed for a minimum of 1 year (min 1 year, max 10 years, average 5.24 years). The repair rate had a sharp increase from 1990-1995 (9.2±1.6%) to 1996-2000 (20.1±0.6%) with the introduction of biodegradable implants (p<0.01). Meniscal suture repairs were completed with vertical loop “inside-out” sutures from 1990-1995 and from 1996-2000 by a combination of biodegradable devices and sutures. There has not been a significant change in mechanical failure rates associated with the increased rate of repair from 1996-2000. Outcome measures included repeat surgery, mechanical symptoms, and subjective knee function questionnaires. Tegner scores, Lysholm evaluations and satisfaction were not significantly different between the two groups and were consistent with other published series. Given the long-term osteoarthritic changes, which are independently associated with anterior cruciate ligament injury and meniscectomy – we believe that this increased repair rate is justified.

        Poster 334. Laser-assisted fusion of meniscal tears

        Atsuo Kato, MD, Akiyoshi Saito, MD, PhD, Yusuke Morimoto, MD, Takeo Abe, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: We investigated the feasibility of laser-assisted meniscal repair by conducting a meniscal tear fusion study using Diode laser and Nd-YAG laser. Method: Materials were 12 menisci of mature pigs, and a GaAlAs Diode Laser (IHD Inc.) and an Nd-YAG Laser (SLT Japan Co. Ltd.) were utilized for irradiation. Each knee was surgically exposed under venous anesthesia, and an approximate 1 cm vertical tear was created 1 cm from the articular capsule attachment site. Four repair groups were established: Group D, the Diode laser was used for irradiation; Group N, the Nd-YAG laser was used for irradiation; Group F, fibrin glue only was applied; and Group C, no treatment of any kind was provided. Irradiation occurred at 1W for 20 seconds in Group D and for 30 seconds in Group N. Indocyanine green and India ink was used as a dye in Groups D and N, respectively, to enhance the fusion effect of the lasers. After four weeks, the menisci were excised, stained using H-E and Safranin O stains and then analyzed histologically. Results: Meniscal fusion was confirmed in Groups D and N, but not in Groups F or C. Conclusion: The successful fusion of meniscal tears using lasers suggests that laser-assisted meniscal fusion may be a potentially useful clinical tool for meniscal repair.

        Poster 335. Arthroscopic management in symptomatic knees after total knee replacement: A prospective study and meta-analysis. Of 357 cases

        H. Michael Klinger, Frank Lorenz, Thomas Haerer
        2001 ISAKOS Poster Abstracts
        Purpose: Problems and complications in total knee arthroplasty (TKA) have not been completely eliminated. However, they are sometimes amenable to arthroscopic treatment. The purpose of this study was to evaluate the role of arthroscopy in diagnosis and treatment of the problem TKA. In addition we performed a meta-analysis of 357 cases. Methods: Since October 1997 16 patients had arthroscopic evaluation after TKA. The study population included 13 women and 3 men with an average age of 69.1 years (range 42-81 years). 6 patients received a cemented condylar surface replacement, 5 patients an uncemented surface replacement and 5 a cemented hemi-replacement. Before the operation the patients had suffered symptoms for an average of 20.4 months (range 3-41 months). The mean follow-up time was 15.7 months (range 5-26 months). For a comparative evaluation the HSS (Hospital for Special Surgery) and Knee Society rating system were used. Results: All patients were available for follow-up and were examined clinically and radiographically. Operative diagnoses included arthrofibrosis, impinging hypertrophic synovitis, impinging PCL stump, prosthesis loosening or wear, symptomatic pseudomeniscus, an infrapatellar spur and meniscal rupture. The arthroscopy was successful in 11 patients. Postoperatively the average Knee Society score and HSS score were 83 and 79 and improved in all eleven patients after arthroscopic treatment. Four patients underwent total knee revision after arthroscopic diagnosis. There were no arthroscopy associated complications or infections. Conclusion and significance: Thus, arthroscopy is a safe, effective tool for managing certain problematic TKA and may help to avoid revision or arthrotomy in some cases. Our results are similar to those reported by most authors. Nevertheless, the indications for arthroscopic evaluation and treatment of painful knee prosthesis are limited.

        Poster 336. Arthroscopic shaving cystectomy of popliteal cyst

        Sang Hoon Ko, MD, Jin Hwan Ahn, MD, Sung Jae Kim, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the effectiveness of arthroscopic direct shaving cystectomy of the popliteal cyst. Materials and Methods: We treated 14 cases of popliteal cyst by arthroscopic shaving cystectomy from March 1998 to March 1999. We estimate operative time, interval of full ROM , pain free interval. And we check sonography after 6 months and 1 year. The pain, ROM and recurrence was checked for above 1 year. Results: The time duration was from 31 minutes to 58 minutes. The time to regain full pain free motion of knee was next day or second days after surgery. Sonography after 6 months and 1 year was no recurrence. No discomfort and no pain and all free ROM in all cases. Lauschning and Lindgren Criteria was all Grade 0 and Grade 1. Conclusion: An arthroscopic shaving cystectomy by motorized shaver was excellent result and effective alternative technique against the open technique of the popliteal cyst.

        Poster 337. Juxta-articular bone marrow signal changes of the knee on magnetic resonance imaging (MRI) following arthroscopic meniscectomy

        Masashi Kimura, Yasukazu Kobayashi, Hiroshi Higuchi, Kenji Takagishi
        2001 ISAKOS Poster Abstracts
        Purpose: Bone marrow signal changes on MRI could be early warning sign of osteonecrosis and it is still unknown whether meniscectomy procedures really cause osteonecrosis of the knee or not. The purpose of this study was to determine the incidence rate of bone marrow signal changes of the knee, the locations of these changes and the sizes of these changes after arthroscopic meniscectomy using MRI. Material and Methods: Ninety-three patients (51 men and 42 women) with isolated meniscal tears, who had no bone marrow signal changes on preoperative MRI, were examined. The age range was from 11 to 62 years (mean, 36.6 years). There were 57 partial meniscectomy (34 medial and 23 lateral meniscectomy) and the others (10 medial and 26 lateral meniscectomy) were total meniscectomy. MRI examination was performed independent from postoperative knee symptom to evaluate bone marrow changes. The examination range was from one to 24 months after surgery. Results: Thirty-two of 93 patients had bone marrow signal changes in femoral or tibial condyle on postoperative MRI. Age and gender were not a risk factor for these changes. Fifteen of 44 patients who underwent medial meniscectomy and 17 of 49 patients after lateral meniscectomy had these changes. Meniscectomy side did not affect the incidence rate of these changes. These changes were often recognized in both femoral and tibial condyle. No patients showed bone marrow changes in the opposite femoral or tibial condyle from the meniscectomy side. Majority of the sizes of these changes was less than half of each condyle. Moreover, the amount of meniscectomy affected the incidence rate of these changes. Conclusion: This study suggests a positive correlation between arthroscopic meniscectomy and postoperative MRI bone marrow signal changes of the knee.

        Poster 338. Arthroscopic treatment of osteochondritis dissecans in femoral condyle

        Hee-Soo Kyung, Sung-Jung Kim, Joo-Chul Ihn, Seong-Man Kim
        2001 ISAKOS Poster Abstracts
        Objective: We analyzed clinical and radiological results of the treatment of osteochondritis dissecans in the femoral condyle under arthroscopic guidance. Material and Method: The study group consists 19 knees of osteochondritis dissecans in 17 patients (15 males and 2 females). Average follow-up period was 34 months (range 14 - 57) and average age of the patients was 16 years (range 13 - 21). The average size of the lesions was 4.19 cm2 (range 2.04 cm2 - 8.75 cm2) . The patients mostly had pain & tenderness and locking, extension limit and the Wilson sign was found in some cases. Five cases of patients had definite trauma history and the others had only minor trauma history and insidious onset. There were 14 cases of medial condyle involvement and 5 cases of lateral condyle involvement. In MR staging of the lesion by the method of Desmet, 15 cases were stage 2 and 3, which means early separation and partially detached lesion. Also in arthroscopic classifications, early separation and partially detached lesions were most common. At the time of arthroscopic evaluation and treatment, the patients were classified by 4 different groups, using the following system: Group 1 - stable lesion and no specific treatment after arthroscopic examination; Group 2 - early separation and multiple drilling; Group 3 - unstable lesion and Herbert screw fixation; Group 4 - loose body and removal or crater curettage. The study group was consisted of 5 cases of Group 1, 4 cases of Group 2, 7 cases of Group 3 and 3 cases of Group 4. The results was analyzed by the criterion of Hughston which including clinical and radiologic outcomes. We analyzed statistical difference using Z-test (P < 0.05). Results: There were 14 (74%) cases of good and excellent results in 19 knees in which 80% (4/5) in Group 1, 75% (3/4) in Group 2, 86% (7/8) in Group 3 and 33% (1/3) in Group 4. The result of Herbert screw fixation group was better than that of other groups with statistically significant differences (P < 0.05). Conclusion: In the treatment of osteochondritis dissecans of young patients, arthroscopic finding was reliable guidance in decision of treatment method and active fixation was recommended in skeletally immature patients even with large, unstable lesion.

        Poster 339. Chondral lesions after arthroscopic meniscus repair with biodegradable arrows

        Jacques Menetrey, R. Seil, D. Kohn, D. Fritschy, J. L. Lerat, Prof
        2001 ISAKOS Poster Abstracts
        Introduction: Meniscus repair using absorbable devices has become popular in the last few years . Good clinical results have been reported and only a few complications have been published. We report 3 cases of chondral lesions following the implantation of meniscus Arrows (Bionx Implants Inc., Blue Bell, PA). Material and methods: 3 patients (male: 2; female: 1, mean age: 33 y; 2 sports accident: Soccer, marathon, 1 work accident) have undergone arthroscopic meniscus repair (2 medial, 1 lateral) using biodegradable Arrows. One patient underwent an ACL reconstruction at the same time. Post-operatively, all patients reported unusual pain, a knee effusion and limitation of function. All underwent a “second-look” arthroscopy at a mean follow-up of 7 (4-12) months. The arthroscopy showed “rail shaped” chondral lesions of the femoral condyle on the head of the Arrow. According to the Outerbridge classification, in two patients these lesions were grade 3 and in one grade 4. Our treatment consisted of an autologous osteo-chondral transplantation (mosaicplasty) in one patient, the retrieval of the head of the Arrow in another and the resection of a non-healed bucket-handle tear in the third. Discussion: To date, the reported complications of meniscus Arrows have included inflammatory foreign-body reaction, Arrow fracture, Arrow migration into the joint as well as extra-articular soft-tissue, irritation involving the infra-patellar branch of the saphenous nerve, the posterior capsule, the MCL and the semi-membranosus. Chondral damage secondary to meniscus repair with Arrows has not been previously reported. Conclusions: Based on these findings, we would recommend “second-look” arthroscopies in patients presenting prolonged and recurrent effusion, unusual pain and limitation over a period of three or more months after meniscus repair with biodegradable devices. Surgeons using the Arrows should be aware of potential post-operative chondral lesions.

        Poster 340. Delay in medical discharge of patients with working accidents: Comparison of three groups with the same pathology undergoing knee arthroscopy post operative

        Hernan Maiza
        2001 ISAKOS Poster Abstracts
        Introduction: This work tries to demonstrate the difference existing between this group of patients and two other groups in relation to their working activity. Material and method: A retrospective analysis of three groups, each with twelve patients, has been carried out. All these patients suffered from lesion of rear horn of internal meniscus as a unique pathology. All these cases had a surgical resolution by means of a partial internal meniscectomy (rear horn) via arthroscopy. All the patients belonging to the three different groups were selected according to their age (between twenty-five and thirty-five years old), sex (only male) and their activity at the moment of the lesion. The first group consisted of unemployed patients, the second one of men performing a stable job who practised a sport at weekends, and the third one comprised patients who had had labor accidents. Results: It has been observed that the patients belonging to the third group had a significantly increased time of recovery in order to go back to their previous tasks. This report shows that the group under study is not to be trusted statistically. Although there is no real for evaluation of the recovery time of patient after surgery, it is not uncommon to have a delay in the issuing of the certificate of discharge in the different patients, especially in those with some pathology related to their work. Conclusion: The comparison of patients belonging to the third group with respect to other groups of equal characteristics in not a reliable parameter for statistical purposes.

        Poster 341. Arthroscopic treatment of the discoid lateral meniscus

        Arturo Makino, MD, Miguel Puigdevall, MD, Esteban Garces, MD, Miguel Ayerza, MD, D. Luis Muscolo, MD
        2001 ISAKOS Poster Abstracts
        Objective: To determine the long term results of the arthroscopic treatment of symptomatic and isolated lesions of discoid lateral meniscus. Methods: We analyzed 25 patients who were treated arthroscopically for a symptomatic and isolated lesion of a discoid lateral meniscus. The average age at surgery was 25 years. According to Watanabe’s classification the type of meniscus found was complete in 21 cases and incomplete in 4. Eight patients were treated with a total meniscectomy and 17 with a partial meniscectomy. Outcomes were evaluated clinically with the lkeuchi knee rating scale and radiologically for assessing postmeniscectomy degenerative changes. The average follow-up was 9 years. Results: Ikeuchi knee rating scale: Partial meniscectomy (17 cases): - Excellent results: 15 cases. - Regular results: 2 cases. Total meniscectomy (8 cases): - Excellent results: 3 cases. - Good results: 3 cases. - Regular results: 2 cases. We did not observe degenerative changes (according to Ahlback’s radiological classification) in the external compartment of the operated knee in comparison with the contralateral knee. Conclusions: In our experience we had a better clinical result in patients treated with a partial meniscectomy in comparison with those treated with a total meniscectomy.

        Poster 342. Medial opening wedge proximal tibial osteotomy fixed with Puddu wedge plate: Presentation of the technique

        Luis R.S. Marczyk, MD, Joao L. Ellera Gomes, MD, Roberto P. Ruthner, MD
        2001 ISAKOS Poster Abstracts
        Objective: The objective of this work is to present the results obtained with a medial open wedge high tibial osteotomy fixed with a wedge plate, as described by “Giancarlo Puddu.” Method: We operated on 32 knees from 30 patients for correction of genu varum. In one patient, the bilateral procedure had prophylactic purposes; in all other patients, the procedure was performed for treatment of medial compartment osteoarthrosis. Follow-up was 9 to 39 months, with an average of 24 months. The surgical technique consists of an oblique osteotomy at the antero-posterior plane, starting at the insertion of the medial collateral ligament and moving towards Gerdy’s tubercle. This osteotomy was usually perpendicular to the longitudinal axis of the tibia, except in cases when an antecurvatum or recurvatum tibia was desirable to correct the structural deformity on this plane. The obtained correction was kept in place with the Puddu (Rome) wedge plate, fixed with two screws. The space obtained with the medial opening wedge osteotomy was filled with an autologous ilium graft. Patients were allowed to walk with partial weight bearing after 1 week, and immobilization was removed after two weeks. Full weight bearing was allowed 45 days after the surgery. Results: After 4 to 6 months there was a significant improvement in the symptoms that led to the surgical procedure. There was one case of infection, treated with debridement, with no need for plate and graft removal. In the final evaluation we found 30 satisfactory and 2 regular results. Conclusion and significance: The quality of the results obtained until this moment, together with the straightforwardness of the transoperative procedure and with the uneventful postoperative management, lead to the conclusion that the employed technique may rescue high tibial osteotomy from the exaggerated appeal of total knee prosthesis. With this technique, medial opening wedge osteotomy has again become an attractive alternative for the treatment of genu varum with medial unicompartmental osteoarthrosis.

        Poster 343. Outpatient arthroscopic knee surgery using remifentanil under monitored anesthesia care

        Matias Villalba, Eduardo Ruggieri, Nicolas Martinez, Alejandro Fazio
        2001 ISAKOS Poster Abstracts
        Objective: To evaluate the efficacy of Remifentanil to provide adequate analgesia and comfort in patients undergoing ambulatory knee arthroscopy. Methods: A prospective study consisted of 50 consecutive outpatient arthroscopies performed by the same surgical team during 1999. Demographics: 44 males, 6 females; aged 15-63 years, mean 36 years; all patients were ASA I-II. Sixty-five arthroscopic procedures were carried out (partial meniscal resection 52, osteochondral loose body resection 3, lateral meniscus cyst 1, drilling/micro fractures techniques 8, articular debridement 1). Arthroscopic technique: We use only two anterior portals and no pneumatic tourniquet. Anesthetic technique: Patients are premedicated with midazolam 2-3 mg to provide sedation; remifentanil (a new opioid with extremely rapid clearance, and therefore offset of effect) is administered in continuous IV infusion (0.25 ug/kg/min.) by an infusion pump or an IV drip; local infiltration at the sites of puncture is done with 10 cc of lidocaine; after the procedure 10 mg of morphine are injected intra-articularly. In a monitored anesthesia care (MAC) setting the anesthesiologist’s services are focused primarily on monitoring the vital signs and stability of the patient and anticipating any conditions that may require the administration of anesthetics or other medical care during the perioperative period. Evaluated outcomes included the surgeon’s opinion of the degree of patient comfort and the technical difficulty of the procedure; the patient’s subjective view of the procedure; and pain and any other adverse events associated with remifentanil. Results: The surgeon’s opinion was measured in a four-point scale (0=no difficulty at all); the average was 0.22 (range 0-2, only 4 patients with 2). The 10-point visual analog scale pain score during surgery was 0.54 (range 0-6), in the recovery room 4.6 (range 0-8), half of the patients require 30 mg IV ketorolac for pain relief; at discharge was 1.26 (range 0-7). All patients showed acceptance and satisfaction with the use of this anesthetic technique. Adverse events associated with remifentanil: Vomiting 2, respiratory depression 4. Conclusions: Knee arthroscopy using remifentanil under MAC is a reliable and practical procedure that provides adequate analgesia and patient comfort; the combination with midazolam serve effectively and safely to alleviate anxiety and provide desirable perioperative amnesia. Significance: The choice of anesthesia in routine knee arthroscopy varies considerably and local anesthesia is not a standard procedure in many hospitals. We think this technique may have a higher acceptance rate in young patients.

        Poster 344. The medial femoral condyle (MFC) cartilage surface morfology in patients after total or subtotal medial meniscectomy

        Andrzej Mioduszewski, MD, Robert Smigielski, MD, Robert Swierczynski, MD, Grzegorz Adamczyk, MD, PhD
        2001 ISAKOS Poster Abstracts
        Objective: We investigated effects of total or subtotal medial meniscectomy on the cartilage surface of the medial femoral condyle (MFC). Methods: Between July 1998 and 31 December 1999 we performed 445 knee arthroscopies. 28 patients had undergone total or subtotal medial meniscectomy in the past. There were 10 women and 18 men. Average age was 33.8 years. Mean observation time from the meniscectomy to our arthroscopy was 7 years. Results: In 19 patients (63%) we have found severe abnormalities of the MFC cartilage surface (III° and IV° Chondromalacia). Only 5 patients (17%) had no changes in the MFC. Conclusions and significance: We have found correlation between cartilage damage and time from the first and second surgical procedure.

        Poster 345. A new endoscopic PCL reconstruction: Minimization of graft angulation

        Yasumitsu Ohkoshi, MD, PhD, Shinya Nagasaki, MD, Ryosuke Ishida, PT, Shigeru Yamane, PhD
        2001 ISAKOS Poster Abstracts
        Introduction: The purpose of this study is to present a new surgical technique for endoscopic PCL reconstruction and to elucidate its short-term results. Methods: The concept of this surgical technique is to minimize the graft angulation at the inner edge of the bone tunnel. The tibial entry point of the guide pin is under the tibial lateral subcondylar flare approximately 1 cm anterior to the posterior cortex and 4 cm distal to the joint surface. This creates less graft angulation on the posterior aspect of the tibia. A new drill system has been devised to allow antegrade femoral drilling starting from inside the notch. This method also allows better femoral tunnel orientation. As a substitute graft material, we employ autogenous hamstring tendons, and we secure them with an Endobutton and Post-screw. Since 1995, 68 knees have undergone endoscopic PCL reconstruction. Twenty one patients were evaluated after a minimum follow-up of 2 years (27.3 ± 1.7 mos.). The clinical evaluation was performed using the International Knee Documentation Committee (IKDC) form. Results: The ROM was rated as A for 17 cases, B in 3 cases and C in one case. The mean side-to-side difference in the total AP translation (KT-1000, manual max.) was 2.8 mm (1.0-5.5 mm). The final evaluation showed a result of A (normal) in 3 knees, B (nearly normal) in 17 knees and C (abnormal) in one knee. Discussion & conclusion: A good clinical outcome was thus achieved with our endoscopic PCL reconstruction. The reduction of the graft angulation may contribute to the good results for PCL reconstruction.

        Poster 346. Prospective analysis of radiofrequency versus mechanical debridement of isolated patellar chondral lesions

        Brett Owens, MD, Beverly Stickles, MD, Philip Balihian, MD, Brian Busconi, MD
        2001 ISAKOS Poster Abstracts
        Objective: The mainstay of treatment for Outerbridge Grades 2 and 3 lesions mechanically aligned patellae is debridement to remove fissures and provide a stable rim of cartilage. Recent basic science reports suggest that radiofrequency probes are superior to mechanical shavers for articular cartilage debridement. The goal of this study was to determine the clinical outcomes after patellar chondral debridement using radiofrequency versus mechanical devices. Methods: Consecutive female patients undergoing arthroscopy for symptomatic, isolated patellar cartilage lesions without evidence of instability, malalignment, or patellar tracking disfunction were prospectively randomized into radiofrequency and mechanical debridement groups. All patients had failed a six month course of conservative treatement and had MRI-documented chondral pathology. Patients were assessed pre- and postoperatively with the Fulkerson-Shea Patellofemoral Joint Evaluation Score. Results: Nineteen female patients (mean age=37.5 years) underwent chondral debridement using a mechanical shaver, while twenty female patients (mean age=36.9 years) underwent chondral debridement using a bipolar radiofrequency probe using nonablative energy levels. The mechanical group had a mean preoperative score of 59.2, while the radiofrequency group had a mean preoperative score of 59.6. Postoperative scores at 12 months follow-up were 80.0 for the mechanical group and 87.9 for the radiofrequency group (p=0.0031). At 24 months, the mean score of the mechanical group was 77.5 and the mean of the radiofrequency group was 86.6 (p=0.0006). Conclusions: This study presents clear evidence of superior clinical outcome of debridement of patellar Grade 2 and 3 chondral lesions with the use of non-ablative bipolar radiofrequency energy versus mechanical shaver. Significance: This study represents superior clinical results with radiofrequency debridement of chondral lesions, supporting the use of this modality to address Grade 2 and 3 lesions.

        Poster 347. Arthroscopic treatment of tibial plateau fractures

        A. S. Panni, M. Tartarone, A Patricola, N. Maffulli
        2001 ISAKOS Poster Abstracts
        Between January 1994 and December 1995, 25 patients [13 women and 12 men; mean age 29.2 years (range, 20 to 42 years)] underwent arthroscopically and image intensifier assisted percutaneous fixation with cannulated screws for fractures of the tibial plateau (8 Schatzer’s type I, 7 Schatzer’s type II, 10 Schatzer’s type III). A lesion of the lateral meniscus which was treated with partial arthroscopic meniscectomy in 4 patients and with meniscal repair in 2 patients. When the tibial plateau fracture was depressed, we made a small incision medially to the tibial tuberosity, produced a tunnel using a corer, and elevated the fracture under direct arthroscopic viewing. There were no intra-operative or post-operative complications from arthroscopy. All the reduction remained roentgenographically anatomic with good to excellent clinical function. Full weight-bearing was permitted 2 months after the operation. The follow-up period averaged 48 months (range 36 to 60 months). Using the IKDC evaluation form, the long-term results were normal or nearly normal in all cases, with maintenance of the reduction obtained, early recovery of full range of motion and disappearance of painful symptoms. Arthroscopic evaluation at follow-up showed in 7 cases treated mild signs of degenerative changes of the articular cartilage of the tibial plateau in the zone of the previous fracture. We found that the advantages of the arthroscopically assisted technique are minimal surgical invasivity, complete articular inspection, direct control of the anatomical reduction of the fracture, possibility of treatment of the concomitant articular pathologies, earlier joint motion, and good cosmesis.

        Poster 348. The incidence of chondral damage in ACL deficient knees

        Vladimir Bobic, MD, Christos Patsalides, Mathias Stanislas
        2001 ISAKOS Poster Abstracts
        Objective: The main objective of this study was to establish the incidence of chondral damage in chronic ACL deficient knees, in the light of increased awareness and better diagnosis of chondral damage in recent years. The reported incidence of articular cartilage injury associated with acute or chronic ACL deficient knees varies from 20-46%. Methods: The majority of ACL deficient knees in our practice are chronic, with significant intra-articular damage. The average time in our practice from the time of injury to reconstruction is 5 years. Arthroscopy carried out in 148 chronic ACL deficient knees revealed only 25 knees (17%) with no evidence of chondral or meniscal injury. Chondral damage was seen in 108 knees (73%), using the Noyes point scaling system and the ICRS Standard Cartilage Evaluation Form for analysis of articular cartilage surfaces. Meniscal damage was noticed in 119 knees (80%). Results: The results of our study clearly demonstrate a very high incidence of chondral damage in chronic ACL deficient knees (73%), which is much higher than previously reported, including deep femoral and tibial fissures, semidetached chondral flaps and numerous chondral slivers floating about the joint. Most chondral defects were on the medial side of the joint (in the medial femoral condyle, in 62%). Conclusions and significance: Continuous chronic multiplanar instability, repetitive pivoting and chronic impingement of the tibial eminence on the femoral condyles, seem to be responsible for the progressive damage to the femoral and tibial articulating surfaces and menisci. This has significant negative impact on the successful long-term outcome of ACL reconstructions.

        Poster 349. 5-14 Year clinical follow-up results of meniscal replacement with a tendon autograft

        Gabriela Peters, MD, Carl J. Wirth, Prof. Dr., Dieter M. Kohn, Prof. Dr
        2001 ISAKOS Poster Abstracts
        Purpose: To present the clinical results of meniscal replacement with a tendon autograft in patients after total meniscectomy and anterior knee instability. Method: Between 1986 and 1995 23 meniscal replacements with an autograft of the quadriceps tendon had been performed in patients after medial meniscectomy and anterior knee instability. The ACL was reconstructed with a mid-third patellar tendon autograft. In a prospective study we examined the clinical outcome of these patients by clinical assessment with a subjective questionnaire (modified Lysholm-Score), arthroscopy, MRI and X-ray. Control groups were used. Results: Follow-up ranged between 5 and 14 years (mean 10.33 years). The subjective results showed a mean total score of 74.8 points in the Lysholm-Score. Postoperative MRI examination was performed in 18 patients. The structure of the meniscus revealed a triangular or cylindrical form. A subchondral sclerosis was described in the medial femorotibial joint in 4 patients. The arthroscopic assessment showed that all menisci still remained in place. In 2 cases a subtotal resection of the tendon tissue was necessary. A progress of chondromalacia was seen in 5 cases in comparison to the primary operation. In comparison to this the control group with the meniscectomized knee joint demonstrated an increase of degenerative changes of at least one degree according to the criteria of Fairbank. Conclusion: The tendon meniscus is not comparable with a perfect anatomical meniscus. Advantages concerning symptoms of chondromalacia and degenerative arthritis seem to appear in comparison to total meniscectomy. Furthermore all risk and reactions that are related to artificial and allogenous material can be excluded be taking the tendon autograft. Significance: The tendon meniscus replacement presents itself as a possibility for meniscal replacement. The tendon meniscus replacement allows a certain cartilage protection in comparison to total meniscectomy.

        Poster 350. Arthroscopic treatment of the first patella dislocation

        Luciano Quevedo, MD, Alberto Pienovi, MD
        2001 ISAKOS Poster Abstracts
        Introduction: Arthroscopic treatment of the first patella dislocation is still a controversial procedure. Several papers evaluate the results of nonoperative treatment and of different surgical techniques, reaching several conclusions. The purpose of this study is to present and analyze the results of the arthroscopic treatment using our technique described. Method: Nine patients were evaluated, without presenting previous patella dislocations or instability. The average age was 20.3 (range16 to 36), 6 were men and 3 women. All patients had a previous MRI and underwent a clinical and radiographic evaluation of the contralateral knee, looking for conditions that predispose this pathology. The period between the injury and the surgery was 15 days. The arthroscopic treatment consisted of the repair of the medial retinaculum with re-absorbable suture plus shrinkage with radiofrequency and lateral retinacular release using an electrocautery. In one case the anterior tibial tubercle was transferred as the patient presented a high patella. The knee was immobilized with a brace for 3 weeks, and afterwards rehabilitation started immediately. Results: From the 9 patients of this group, 56% presented conditions predisposing this pathology in the contralateral knee. The average follow-up was 28 months (8 to 34), obtaining 78% (7 cases) of excellent or very good results. No recurrent dislocations occurred in this group, 22% (2 cases) of the results were fair, corresponding to those cases presenting postoperative pain or feeling of instability. 56% of the patients returned to practice contact sports when authorized at 6 months postoperative. Discussion: Acute patella dislocation occurs mainly in young athletes, most of them presenting conditions predisposing this pathology. Arthroscopic treatment of the first patella dislocation presents low morbidity and allows an efficient and early recovery of its normal anatomy. We present a technique that repairs the injured tissues associated to an arthroscopic realignment of the patella, with predictable results.

        Poster 351. Osteonecrosis of the knee

        Miguel Raijman, MD, Mario Berenstein, MD, Tomas Czarnitzky, MD, Fabio Goischain, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The osteonecrosis premature treatment accomplishing its rapid diagnosis, avoiding the natural evolution of the disease. Method: 92 patients have been evaluated during 8 years, who fulfilled all the precise requirements for the job. These are based on age, sex, radiologic expression, previous pathology and loss of circulation of the limbs among others. From this selected group decompression cortical therapy were applied helping to pain relief medication, obtaining highly satisfactory results related to pain relief and osteonecrosis evolution. A distant following was accomplished with MRI, which shows the “necrosis” involution in a high percentage of cases, being the most propitious evolution according to the precious diagnosis and the bad prognostication when the pathology was not interpreted prematurely. Conclusion: Only after osteonecrotic pathology already placed have been discarded and only with preciously treated patients we can conclude that osteonecrosis is an orthopedic emergency and that its early acknowledgment will prevent future complications avoiding that the installed osteonecrosis can involve the biodynamic of the knee. Significance: The osteonecrosis of the knee is a frequent pathology, not often acknowledged, its early diagnosis and “descompresion” avoid to the patient the damage produced by the “necrosis” and the articular suffering.

        Poster 352. Knee arthroscopy in children and adolescents

        Valdet Saciri, MD, Oskar Zupanc, MD, Bostjan Baebler, MD, Vinko Pavlovcic, MD, PhD
        2001 ISAKOS Poster Abstracts
        Purpose: With increasing participation of children and adolescents in sports, paediatric knee arthroscopy is gaining in importance. The purpose of study was to assess the accuracy and value of arthroscopy. We also present our criteria and indications for the use of diagnostic and therapeutic knee arthroscopy in children and adolescents. Method: We report a series of 77 skeletally immature patients (41 children aged ≤13 yr and 36 adolescents aged 14-16 yr) who underwent knee arthroscopy over a period of 10 years. Indication for arthroscopy was clear history of trauma associated with a distinct clinical picture of an acute mechanical problem, or knee symptoms persisting over 2 months with unclear diagnosis. We compared each patient’s preoperative diagnosis with the diagnosis made on arthroscopy. The follow-up period ranged from one month to 7 years, on average 7 months. Results: Arthroscopy showed a pathological condition in 81 and a normal state in 6 (Table 1). Six patients required miniarthrotomy in addition to arthroscopy for the definitive treatment. Arthroscopy confirmed the prearthroscopic diagnosis in 41 (53%) of the 77 patients. The accuracy of clinical diagnosis in our patients aged 13 and less was 39%, while accuracy in patients aged 14-16 yr. was 67%. None of the patients experienced side effects, and no intra- or postoperative complications were encountered. Conclusion: Paediatric knee arthroscopy improves accuracy of clinical diagnosis. It is a safe procedure which allows definitive treatment of a variety of conditions and often prevents an unnecessary arthrotomy.
        Tabled 1Table 1:
        Medial meniscal tear1619.5%
        Lateral meniscal tear78.6%
        Lateral discoid meniscus44.9%
        Lateral meniscal cyst22.4%
        Partial ACL tear1113.5%
        Complete ACL tear89.8%
        Osteochondritis dissecans911.1%
        Osteochondral fracture22.5%
        Chondropathia patellae44.9%
        Plica syndrome56.2%
        Synovitis89.8%
        Empyema33.7%
        Avulsion fracture of tibial spine22.5%
        No pathology seen67.8%

        Poster 353. Aspergillus fumigatus infection of knee joint after arthroscopic ACL reconstruction in healthy young adult – a case report

        Seung-Suk Seo, MD, Young-Il Yang, MD, Jang-Seok Choi, MD
        2001 ISAKOS Poster Abstracts
        Objective: The purpose of this study is to report the rare case of articular aspergillosis in healthy young adult after arthroscopic ACL reconstruction with autogenous hamstring tendon fixed with biodegradable screw. Method and result: A 28-year-old male patient was admitted to the department of orthopaedics for anterior instability of left knee joint. He had a partial medial meniscectomy in the same knee in 1990. He had an arthroscopic ACL reconstruction with quadrupled hamstring autograft at 14th, April, 1997. The graft in the femoral side was fixed with a biodegradable screw (Bioscrew®, Linvatec) and a cortical bone block which was harvested from proximal tibial metaphysis. The graft in the tibial side was tied at the post of A-O cortical screw. Postoperative 14 days he complained a low grade fever, malaise, night sweat and persistent effusion of left knee. The clinical findings were fluctuated with time. Serum ESR and CRP were moderately elevated but bacteria was not found on bacteriological studies. Postoperatively 53 days an aggressively destroyed bone lesion was found at the posterolateral corner of the distal femoral condyle. He had open debridement and curettage. The specimen from infected necrotic tissue was showed a fungi with septation and acute angled branching. Fungal culture and PCR study revealed it as Aspergillus Fumigatus. He received amphotericin B. The surgical wound was uneventfully healed. The patient was followed 36 months. There was no evidence of recurrent infection. He had stable but stiff knee (0 to 90 degree range of motion). Conclusion: The author reports the rare case of articular aspergillosis after arthroscopic ACL reconstruction with autogenous hamstring tendon fixed with a biodegradable screw and a cortical bone block.

        Poster 354. Outcome following knee arthroscopy: A prospective study

        Sahir Shaikh, MB, D.Orth., MS, P. J. Dobson, FRACS, K. R. Angel, FRACS, P. L. Lewis, FRACS
        2001 ISAKOS Poster Abstracts
        Study Aims: To determine if the SF-12 is an appropriate instrument to detect an improvement in patients’ general health following arthroscopic knee surgery. We also wanted to define which patient factors were important in influencing outcome, such as the presence of significant intra-articular pathology, age and health insurance status. Methods: 235 consecutive patients undergoing arthroscopic knee surgery were entered into the study. SF-12 questionnaires were administered preoperatively and 12 weeks postoperatively. The age and insurance status for each patient was recorded. A statistical analysis of the data was performed. Results: The mean age of patients was 44 years with a range from 16 to 78 years. There were 116 right knees and 100 left knees. The mean pre-operative PCS-12 score was 37.1529 +/- 8.719. The mean post-operative score was 41.4912 +/- 10.150. This improvement was significant. Respondents also reported a small but statistically significant improvement in MCS-12 scores, with a preoperative score 51.5317 +/- 9.796 and post operative score of 53.9761 +/- 8.918. Conclusions: The SF-12 can detect an improvement in the general health status in patients following arthroscopic knee surgery. The presence of intra-articular pathology was not a significant factor in predicting improvement following arthroscopy. Insurance status had no significant effect on change in physical or mental health status. Younger patients had significantly greater improvements in physical and mental health status compared to older age groups following arthroscopic knee surgery.

        Poster 355. The effect of medial release on arthroscopic treatment for osteoarthritis of the knee

        Dong-Bae Shin, MD, Young- Soo Lee, MD, Soo-Jin Park, MD
        2001 ISAKOS Poster Abstracts
        Objective: Arthroscopic debridement is and effective procedure to relieve pain in patients with osteoarthritis of the knee. However, we often faced upon the technical difficulties because of the tight medial compartment. The purpose of this study was to evaluate the clinical outcome of our combined procedure including open release of medial capsule, arthroscopic joint debridement and notchplasty. Methods: Our combined procedure involved open subperiosteal release of the medial capsule by which the osteophytes can be removed after elevation of menisco-tibial ligament, arthroscopic debridement and notchplasty. We performed these combined procedure on the patients who have a mild to moderate osteoarthritis, normal mechanical axis on nonweight-bearing radiography and lateral decoaptation on monopodal weight-bearing radiography. Fifteen knees were followed up more than one year. The functional outcome was evaluated by HSS, IKDC scoring system and changes of lateral decoaptation was assessed. Results: The mean preoperative HSS score was 58.4 and improved to 80.7 at follow-up. The mean preoperative IKDC score of pain was 47.8 and improved to 65.6 at-follow up. The mean preoperative IKDC score of function was 43.3 and improved to 66 at follow-up. However, changes of lateral decoaptation were not regular. The degree of lateral decoaptation was decreases in 10 knees, however, increased in 4 knees and no change in one knee. There was one case of postoperative infection because of the synovial leakage which was controlled by arthroscopic lavage. The postoperative pain which had continued for two months in all cases decreased prominently at follow-up. Conclusions: Open release of the medial capsule enable surgeons to perform arthroscopic debridement of a medial compartment more easily and thoroughly. However, we could not obtain changes of lateral decoaptation that we had expected.

        Poster 356. Meniscal allograft with three-tunnel technique

        Kevin R. Stone, MD (a, b, d, e - Crosscart, Inc.; c - DePuy-Orthotec), Ann Walgenbach, RN, NP, MSN
        2001 ISAKOS Poster Abstracts
        Objectives: Meniscal cartilage replacement by allograft, prosthesis, and regeneration scaffolds has advanced from the laboratory to clinical practice. Since the first reported human meniscal allograft was performed by Michalowski in 1986, approximately 4,000 meniscal replacements have been performed in the United States. Most have be performed in knees without arthritis. We hypothesized that meniscal replacement could augment standard chondroplasties in arthritic knees. In order to overcome difficulties with arthritic knee deformities and the paucity of surgical instrumentation, the authors developed a technique to aid placement and fixation of the meniscal allografts. This study is the first of a series. This first study evaluates the technical difficulties and survivability of the implant in the arthritic knee. A second study will compare chondroplasty alone to chondroplasty plus meniscal allografting in the primarily unicompartmental arthritic knee. Methods: All patients signed informed consents, underwent pre-operative exams, X-rays, MRIs and completed pre- and post-operative Tegner, ADLS and WOMAC questions at sequential follow-up intervals. The arthroscopic surgical implant procedure implements a three-tunnel technique to secure the anterior and posterior meniscal horns and posterior corner of the allograft. Additional stabilization of the implant is achieved through an inside-out suture technique, shown in the following figures:
        Figure thumbnail gr8a
        Figure thumbnail gr8b
        Results: At an average follow-up of 1.2 years (range 0.5 to 2.7) preliminary results from a 47 patient prospective study of patients with Grade IV arthritis show reduction in pain scores pre to post-surgery of 6.2 to 4.6 (scale 1-10; 1 being no pain) (p ≤0.2), and increases in activity levels from 1.3 to 1.7 (scale 1-3) (p≤0.05), for 40 patients. WOMAC, Tegner, and ADLS scores also showed improvement. The re-tear rate was 6 of 47 implants. Conclusions: Meniscal allografting can be successfully performed in arthritic knees, although with a 13% re-tear rate. The specific cause of the pain relief cannot be pinpointed due to the multiple concomitant procedures performed in these complex knees as well as the patient’s participation in a defined rehabilitation program. It is the authors’ impression, however, that meniscal transplantation in arthritic knees augments standard care, and leads to favorable outcomes in this evaluation period. A controlled, comparative study will be required to prove this clinical impression. Further segmentation of these results over time will help clarify the role of meniscal allografting in arthritic knees.

        Poster 357. Arthroscopic diagnosis for tibiofibular syndesmosis disruption

        Masato Takao, MD, PhD, Mitsuo Ochi, MD, PhD, Kohei Naito, MD, PhD, Atsushi Iwata, MD
        2001 ISAKOS Poster Abstracts
        Purpose: The purpose of this report is to compare the accuracy of diagnosis for tibiofibular syndesmosis injury by ankle arthroscopy and plain radiographs. Method: Thirty-eight type-B (Weber system) distal fibular fractures in 38 patents undergoing surgery between March 1996 and April 1999 were diagnosed as to whether tibiofibular syndesmosis disruption was present. There were 26 male and 12 female patients. The mean age of the patients at the time of surgery was 40 years (range, 18 to 57 years). Sixteen patients had supination-external rotation fractures and 22 had pronation-abduction fractures in the Lauge-Hansen system. Standard non-weight bearing anteroposterior radiographs and mortise radiographs were evaluated. Furthermore, ankle arthroscopy was performed on all patients for the diagnosis of tibiofibular syndesmosis disruption. Results: Tibiofibular syndesmosis disruptions were diagnosed in 16 of the 38 patients (42%) by anteroposterior radiography, 21 of 38 patients (55%) by mortise radiography, and 33 of 38 patents (87%) by ankle arthroscopy. All of the patients who were diagnosed with tibiofibular syndesmosis disruption by anteroposterior radiography and mortise radiography were also confirmed to have injured their tibiofibular syndesmosis by ankle arthroscopy. In 12 patents, ankle arthroscopy was the only method used to diagnose the tibiofibular syndesmosis disruption. Conclusion: Ankle arthroscopy excels in term of the diagnosis ratio for tibiofibular syndesmosis disruption compared to both anteroposterior and mortise radiography. We therefore conclude that ankle arthroscopy is necessary for the accurate diagnosis for tibiofibular syndesmosis disruption.

        Poster 358. Treatment of the knee arthrofibrosis by arthroscopic arthrolysis: Difficulties and pathological features

        Ömer Taser, Prof. Dr., Isik Akgün, Prof. Dr., Ugur Haklar, Dr.
        2001 ISAKOS Poster Abstracts
        Purpose: To investigate the etiopathogenesis of knee arthrofibrosis and evaluate the difficulties/complications encountered during arthroscopic treatment. Method: We have operated 26 knees with arthrofibrosis of 26 patients (16 female and 10 male) ages ranging between 13 and 59 yrs (mean 32.6 yrs) from 1994 to 2000. At first all knees have been released by arthroscopic arthrolysis, but in 2 cases extra-articular release and in 4 patients open release were required. After operation, all knees were followed under intensive rehabilitation programme with CPM and epidural anesthesia was performed to 9 patients upon need. Before operation, mean arthrofibrotic period was 10.5 months and average follow-up period was 29.6 months. At 4 cases, biopsy material has been taken for pathological examination. Results: Knees with different degrees of restriction had a mean ROM of 42.1 degrees before operation which have increased to 118.1 degrees after operation. We have managed to gain at least 105 degrees of knee motion in 24 patients. In 2 knees we couldn’t restore knee motions. We have had complications in 3 of 26 knees (11.5%) which were patella fracture and refracture, and active extension loss because of quadriceps lengthening. The evaluation performed according to Lysholm scoring system have resulted in a mean gain of 43.7 points by this treatment. Pathological examination of biopsy samples revealed metaplasia, not fibrous hyperplasia, as it was suggested earlier. Conclusion: The success of operational treatment is highly related with timing of surgery, extra articular soft tissue adhesions and intra articular fixation materials. Owing to prolonged immobilization period, chondral tissue changes also may occur but motion of the joint is more important. An aggrevating mechanism should exist in arthrofibrosis pathogenesis and we have suggested that metaplasia could be an important candidate at this aspect. Significance: The success of operational treatment is highly related with timing of surgery. An aggrevating mechanism should exist in arthrofibrosis pathogenesis and we have suggested that metaplasia could be an important candidate at this aspect.

        Poster 359. Long-term assessment of arthroscopic meniscus repair: A 13-year follow-up study

        Franky Steenbrugge, MD, René Verdonk, MD, PhD, W. Huysse, MD, K. Verstraete, MD, PhD, M. R. Vandal, MD
        2001 ISAKOS Poster Abstracts
        Purpose: A prospective study was set up to evaluate meniscal sutures using an inside-out technique. Method: 13 of an initial group of 20 patients who underwent closed meniscus repair between 1985 and 1988 using an inside-out technique were studied. All patients underwent a clinical exam and an MRI investigation. These were compared with the MRI of their previous follow-up exam (1994). We used the Hospital for Special Surgery Sports Medicine Service knee injuries discharge summary follow-up score sheet (R.G. Stone et al., Arthroscopy, vol. 6, no. 2, 1990). The study included 7 males and 6 females. Their age averaged from 29 yrs. to 50 yrs. 2 mos. (mean age: 35 yrs. 6 mos.). Their mean follow-up was 13 yrs. 2 mos. (11 yrs. 11 mos. - 15 yrs. 4 mos.). There were 6 left and 7 right knees involved. Seven patients also had an ACL injury of which one was repaired 6 years post meniscal repair. Results: All patients had a score of more than 75% on HSS. One patient underwent arthroscopic repair of his chronic ACL lesion. MRI findings: In all patients the site of the previous suture could still be detected, mainly by small metal artifacts in the meniscus. In 1 patient a new or recurrent tear was found. In 1994, a new tear was found in a patient. This tear was not repaired. In 1999 there were no longer signs of this tear. Conclusion: Meniscal suturing gives good long-term clinical results. MRI proves to be a good tool for evaluating meniscal sutures. Although MRI may suggest a problem knee, the clinical results were good to excellent.

        Poster 360. Arthroscopically assisted reduction and fixation of intra-articular fractures of the knee

        Matjaz Veselko, MD, PhD, Valdet Saciri, MD
        2001 ISAKOS Poster Abstracts
        The purpose of the paper is to present our experience with arthroscopically assisted treatment of certain intraarticular fractures of the knee. Methods: During the period 1995-2000, arthroscopically assisted reduction and fixation of intra-articular fractures of the knee was done in 76 patients: 25 had arthroscopic reduction and fixation of fractures of the tibial plateau, 40 stable arthroscopic fixation of tibial avulsion fracture of the ACL with cannulated screws, and one arthroscopic retrograde fixation of the PCL avulsion fracture of the tibial spine with screws. Arthroscopic reduction and re-fixation of acute osteochondral fractures of the knee condyle with metal staples or resorbable pins was accomplished in 5 patients . Osteochondral fractures of the patella were arthroscopically reduced and re-fixed with resorbable pins in one patient and with staples in 4. We present several arthroscopic techniques for stable fixation of intra-articular fractures of the knee. Results: At an average follow-up of 2 years after surgery, all patients but two with ACL avulsion fracture reported stable knees and showed full range of motion. Anatomical reduction was obtained in 61 intra-articular fractures. In 5 patients the bone fragment was displaced by more than 2 mm. There was one case of aseptic synovitis. No other major complications were encountered. Conclusion: When properly indicated, arthroscopically assisted treatment of certain intra-articular fractures tends to yield better results than classical surgical techniques. Its advantages include less postoperative morbidity, shorter hospital stay and reduced rehabilitation time.

        Poster 361. Arthroscopic reconstruction for posterior cruciate deficient knees

        Ching-Jen Wang, MD
        2001 ISAKOS Poster Abstracts
        Purpose: Forty-two patients with 44 knees undergoing arthroscopic posterior cruciate ligament reconstruction for pain and instability of the knee with an average follow-up of 40 (24-108) months were retrospectively reviewed. There were 32 males and 10 females with an average age of 31 (16-57) years. One patient sustained bilateral PCL injuries from two unrelated accidents and one patient had repeated PCL surgery. The right knee was affected in 18 cases and the left knee in 26. The average duration from injury to surgery was 12.3 (1.0-50) months. The mechanisms of injury included 20 motorcycle accidents, 19 motor vehicle accidents and 5 sports related injuries. The associated injuries included 7 femur fractures, 7 tibial fractures, 5 other fractures, 7 meniscus tears and 3 medial collateral sprains. Arthroscopic single bundle PCL reconstruction was performed in 32 knees and arthroscopically assisted in 12 knees. The sources of tendon grafts included 29 autografts and 15 allografts. The concomitant surgeries included 6 meniscectomies, 1 meniscus repair and 2 bone grafting procedures. Method: The functional assessments included pain, givingway, swelling and locking, and Lysholm functional scores and Tegner activity scores. Physical examinations of the knee included the alignment and range of knee motion, the posterior instability by posterior sagging sign, posterior drawer test and reverse Lachman test and the posterolateral instability of the knee. The instrumental examinations included KT-1000 arthrometer and Kin-Com isokinetic evaluations. Radiographs of the knees were examined for evidence of degenerative changes. Results: The overall results were 32 (72.7%) good or excellent, 9 (20.5%) fair and 3 (6.8)% poor. The postoperative improvements in function and ligament stability of the knee and Lysholm scores were statistically significant (P<0.001). Approximately one third of the knees showed residual ligamentous laxity, 35% with 1+ (5 mm) and 7% with 2+ (5-10 mm) ligament laxity. Radiographs of the knee were positive for degenerative changes in 27 (61%) cases including 19 (70%) mild, 7 (26%) moderate and 1 (4%) severe and the severity of arthritic changes appeared proportional to the time and severity of PCL injury. The complications included 1 hematoma, 1 transient peroneal nerve palsy, 1 popliteal artery laceration, 1 recurrent PCL instability and 3 knees with donor site pain. Conclusion: In conclusion, the significance of PCL injury was overly simplified and the functional disability of the knee due to PCL injury was under-estimated. The incidence of degenerative changes of the knee joint after PCL injury is probably higher than it was believed and its onset is shorter than that reported in the literature. Arthroscopic PCL reconstruction significantly improved the function and stability of the knee in short and medium term follow-up. However, approximately one third of the knees showed residual ligamentous laxity which may adversely impact on the long-term results.

        Poster 362. Treatment of osteoarthritis of the knee with hylan G-F20 in patients who have undergone prior arthroscopic debridement

        Charles Weiss, MD (a, c, d, e - Biomatrix Inc, Genzyme Biosurgery; b - Wyeth-Ayerst Pharmaceutical Laboratories), Wolfgang Tillero, MD
        2001 ISAKOS Poster Abstracts
        Aim: To determine the safety and efficacy of intra-articular hylan G-F20 in patients with painful osteoarthritis of the knee who had prior arthroscopic debridement. Methods: 70 consecutive painful osteoarthritic knees that had previous arthroscopic debridement were treated with hylan G-F20 and were evaluated prospectively for one year. Global pain scores, efficacy, pain satisfaction, and safety were evaluated at 3, 6, 9 and 12 months. The mean age was 70 years with an average duration of symptomatic osteoarthritis of 10 years. 65% of knees had Grade IV osteoarthritis (x-ray and or full thickness defects at arthroscopy) with a median post arthroscopy time of 48 months. All patients failed counseling, exercises and analgesics. 94% failed NSAIDs and 78% failed steroid injections. Results: At 12 months, 7 knees were lost to follow-up. 2 knees underwent total knee arthroplasty, one underwent additional arthroscopy, 8 required repeat treatment and 50 knees were managed on a single course of treatment. At 3 months 77% of knees were better, 66% at 6 months and 49% at 12 months. Early effectiveness was predictive of long-term success: 57% of knees better at 3 months were better at 12 months and 70% of knees better at six months were better at 12 months. Of those knees that had no effusions prior to hylan G-F20 treatment, 84% were better at 3 months and 67% at 12 months compared to 73% and 38% respectively in those knees that had effusions prior to hylan G-F20 treatment. 8 knees underwent repeat treatment, 5 were better, 1 the same and 2 lost to follow-up. Three out of 70 knees (4.2%) experienced adverse events (increased pain, swelling and effusions). Two were treated with aspiration and intra-articular corticosteroids and one with aspiration alone. There were no systemic adverse events and all knees recovered uneventfully with no permanent sequelae. Conclusions: Treatment with intra-articular hylan G-F20 was effective and safe in patients with advanced painful osteoarthritis of the knee who had prior arthroscopic debridement, NSAIDs and corticosteroid injections.

        Poster 363. The meniscal flounce – a valuable arthroscopic sign: A prospective study of 1088 knee arthroscopies

        A. M. Williams, FRCS, P. T. Myers, FRACS, P. J. McMeniman, FRACS, J. White
        2001 ISAKOS Poster Abstracts
        Purpose: The meniscal flounce is the wavy region of the free inner margin of either meniscus that is seen at knee arthroscopy. The study aimed to establish the most common size/ position of medial and lateral meniscal flounces, and their relationships to pathology. Materials and Methods: A prospective study of consecutive knee arthroscopies was undertaken. Surgery was performed in a standardised manner and data recorded on a proforma. Results: 1088 knee arthroscopies were performed. 24 of the proformas were inadequate leaving 1064 for analysis. The mean age was 36 years. Both menisci, when intact, tended to have very characteristically sized and positioned flounces (p<0.01). The presence of meniscal pathology (e.g., tears) correlated closely with absence or abnormality of the ‘usual’ flounce (p<0.01). Conversely the presence of a ‘normal’ flounce was associated with an intact meniscus (p<0.01). Medial collateral ligament tears were associated with absence of the medial meniscal flounce. Conclusion: The significance or otherwise of the meniscal flounce has been hitherto unknown. The flounce represents an intra-articular clinical sign. The findings of this study are useful for arthroscopists especially when visualisation is difficult. The presence of a normal flounce is likely to signify no meniscal abnormality, whereas the presence of an absent, abnormally large or a ‘serpentine’ flounce may be the sign of a meniscal tear which is out of view thereby supporting the need for persistent meniscal examination.

        Poster 364. The correlation between clinical diagnosis and arthroscopic findings of knee pathologies

        Mustafa Yel, MD, Recep Memik, MD, M. I. Safa Kapicioglu, Mahmut Mutlu, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To compare the diagnostic value of clinical findings in the knee pathologies with arthroscopic findings. Method: In this prospective study, 666 knees of 666 patients were evaluated. By comparing the clinical findings with arthroscopic findings, the accuracy, sensitivity, specificity, and positive and negative estimated values of the clinical findings in diagnosis were calculated. Results: In the 934 knee pathologies diagnosed with arthroscopy, 617 (66.7%) of them had been determined clinically. High accuracy rates were obtained in meniscal and anterior cruciate ligament lesions with clinical examination (78.9 - 92.4%). However, the accuracy rates in chondral, plica, synovial lesions, and loose body were found low (77 - 84.6%). The sensitivity rates of meniscal and anterior cruciate ligament were found high (81.1 - 78.2%). On the contrary, chondral, plica, and synovial lesions and loose body sensitivity rates were found low (44.6 - 51.9%). Conclusion: These findings suggested that clinical examination of meniscal lesions and anterior cruciate ligament tears were more valuable than other knee pathologies such as chondral, plica, and synovial lesions and loose body. They also can be helpful for accurate diagnosis when they are used with other diagnostic tools.

        Poster 365. Ankle arthroscopy for occult injuries in the fresh ankle fractures

        Chong-Hyuk Choi, MD, Sung-Jin Park, MD, Ki-Hak Park, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To evaluate the effectiveness of ankle arthroscopy for the examination and treatment of occult injuries in the fresh ankle fractures. Method: Thirty-three patients, who were treated with ORIF for ankle fracture, were included. All fractures were simple without subluxation or dislocation. The average of age was 34.2 years. The fractures were classified with Lauge-Hansen method preoperatively. Prior to ORIF, the ankle arthroscopy was done for the investigation of occult injuries. The average of 15 minutes was required for the arthroscopic procedure. The minimal follow-up was 12 months (average of 2.1 yr.). Results: In seventeen ankles, the torn ligament (anterior talofibular, calcaneofibular or deltoid) and fracture (lateral or medial malleolus) were found at the same side simultaneously. The occult ligament injuries were found in 7 cases. The osteochondral fragments, which were displaced from the fracture site or floated in the joints, were removed. In 12 ankles, the cartilage damages in various locations were found. The free cartilage fragments were removed and the unstable margins were excised. The torn distal anterior tibiofibular ligaments were resected in 18 cases for the prevention of anterolateral impingement. At the final follow-up, there was no pain on the anterolateral aspect of ankle and there was no syndesmotic instability. Conclusion and Significance: After the ankle arthroscopy, the patterns of fracture and ligament injuries were consistent with Lauge-Hansen classification only in 10 ankles (30%). In 25 ankles (76%), various occult injuries were found. So, the evaluation and the treatment for occult injuries should be considered from the beginning of treatment. The ankle arthroscopy prior to ORIF was effective for those purposes. But it would be suggested that more studies will be necessary for the establishment of indication for the arthroscopy in the fresh ankle fracture.

        Poster 366. Dry arthroscopic ankle arthrodesis

        James K. Deorio, MD, Anthony W. Ware, MD
        2001 ISAKOS Poster Abstracts
        Question: Does a dry technique of ankle arthrodesis whereby the inflow is shut off prior to bone preparation and the ground up bone left in situ as graft and a three screw, 7.3 mm cannulated technique with a posterior percutaneous placed transachilles screw provide an anatomic ankle fusion with good results? Methods: 10 patients, average age 55, were fused using an arthroscopic technique. The follow-up averaged 1.5 years. The diagnoses were traumatic arthritis in nine and idiopathic arthritis in one. The surgery was accomplished in 90 minutes and all patients were casted the next day and discharged from the hospital. Patients were in a short leg cast for six weeks, nonweightbearing and then placed into a removable walker for four weeks. Results: All patients appeared fused by six weeks. The absence of any shortening gave the ankle a normal appearance and all patients were able to wear regular shoes. Nine patients were rated as excellent and one good. The one good patient is the only patient in whom the three screw was not employed. The dry technique was used in the last five patients and seemed to provide faster more complete healing. Conclusion: Removal of the fibula or large destruction of the bone in ankle arthrodesis is unnecessary. Although this series is small, the three screw technique using three cannulated 7.3 mm screws percutaneously and the dry preparation of the ankle joint which involves buffing and drilling of the bone with the graft left in situ provides patients with a solid fusion, normal anatomic appearance and the absence of pain.

        Poster 367. Effects of supine and lateral position, joint position, distension and traction for distraction of the hip in arthroscopy. An experimental study in cadavers

        Michael Dienst, MD, Romain Seil, MD, Michael Brang, MS, Dieter Kohn, MD
        2001 ISAKOS Poster Abstracts
        Purpose: To quantify the effects of traction alone and in combination with distension in different joint positions and to compare the effects of supine and lateral position on distraction in order to improve positioning in hip arthroscopy. Methods: 16 hip joints were studied in 16 fresh cadavers. In 8 hips, the effects of joint positions, distension and traction were studied in the supine position. In another 8 hips, the effects of lateral and supine position, joint positions and traction were investigated after distension of the joint. After rigor mortis was broken, the cadavers were placed supine or lateral on a standard fracture table. Traction was applied in 6 different joint positions (flexion/abduction 0/0°, 0/20°, 20/0°, 20/20°, 40/0°, 40/20°) alone or in combination with distension of air. 10 to 80 pounds of traction in steps of 10 were applied. Digital images were obtained by fluoroscopy and transferred to a PC. 4 distances between the femoral and acetabular subchondral bone were measured in standardized angles to the inclination of the acetabulum. Projection error was corrected. Results: For the supine position, the distraction effect was significantly better by the combination of traction and distension compared to traction alone for all distances. At a traction force of 25 kg which is used in vivo statistical analysis revealed p=0.012 for each of the 4 distances. Descriptive analysis showed that distraction was increased by the combination of traction and distension up to 4 times more within the weightbearing area compared to traction alone. At the acetabular fossa, increase was up to 3 times mo