Specialty Update of ACL & PCL

There is cumulative damage to cartilage with prolonged instability and that timely restoration of stability may prevent or delay the onset of arthritis.
A meta-analysis of four randomized controlled trials and five lower-level studies:
double-bundle Vs. normal knee: standardized laxity measurements an average of 0.52 mm closer double-bundle Vs. single-bundle: no significant differwenku.baidu.comnce in the odds of having a normal or nearly normal pivot shift
Rehabilitation
functional knee braces ? 127 reconstructed knees,1&2 years of follow-up functional knee brace Vs. simple neoprene sleeve no significant differences outcome measures laxity measurements functional tests graft rerupture rates
Revision surgery -- meticulous preoperative planning
63 revisions, follow-up of 72 months Restoration of knee stability with good or excellent results --- most patients Repeat revision --- 25% Return to sports activity --- much less predictable
ACL
The most extensively researched and frequently reconstructed ligament A major focus of research in sports medicine.
Graft options
Bone-patellar tendon-bone and hamstring autograft avoid harvest-site complications: anterior knee pain, pain with kneeling, loss of extension, poorer recovery of quadriceps strength. result in weakness of knee flexion and internal rotation --- certain athletes hamstring functions
decreased surgical time, smaller incisions & elimination of harvest-site morbidity
Vs.
disease transmission, slower graft incorporation & increased cost
Thanks for your attention~
Allograft
Allograft Vs. Autograft: Equivalent outcomes Increased laxity and more frequent graft failure Tensile strength similarily Biological differences : revascularization, cell viability, healing of allografts to host bone
A basic science study
sheep model delayed revascularization and recellularization decreased mechanical properties of fresh-frozen allograft A meta-analysis of patellar tendon autograft Vs. allograft: significantly better results: the rate of graft rupture the performance of a hop test
Specialty Update of ACL
Andrew C. Gerdeman, MaCalus V. Hogan and Mark D. Miller. What's New in Sports Medicine. J Bone Joint Surg Am. 2009;91:241-256.
Based on……
Graft tensioning --- no consensus
Overtensioning of ACL grafts
decreased motion poor graft vascularization increased femorotibial contact pressures long-term damage to cartilage
Double-bundle Vs. single-bundle
better rotational stability significant reductions in pivot shift
single-bundle reconstruction is sufficient to restore intact knee kinematics during pivotshift maneuvers and that overtensioning of the graft in double-bundle reconstructions can reduce the rotation to less than that of the intact knee
Tunnel placement
No significant differences in laxity, but the subjective stability score was significantly better for the more horizontal position Lowering the femoral tunnel in single-bundle reconstructions can improve clinical outcomes.
The concept of neuromuscular rehabilitation is important to protect the reconstruction as well as the health of the knee joint as a whole. Joint forces and kinematics are dependent on proprioception, balance, and compensation patterns, requiring a program that incorporates all of the components of neuromuscular control. Rather than a predetermined time to return to activity, monitored progression of functional tests allows safer return to sports.
Osteoarthritis
The protection of the meniscus ---YES Long-term studies on the development of arthritis --- NO
Previously: chronicity of instability development of arthritis patients without arthritic changes unstable knee 22 months patients with arthritic changes unstable knee 22 months
Failed ACL reconstruction
early postoperative period (<6 months) --- improper surgical technique late failures --- trauma Errors in tunnel placement failure of graft incorporation failure to recognize associated injuries
Sensory deficits --- injury to branches of the saphenous nerve during hamstring harvest Donor-site morbidity --- prevent performance deficits in the athletic population
The relationship between arthritis and anterior cruciate ligament injured knees remains unknown, and long-term, prospective, controlled studies are needed to clarify the issue.
Scientific publications and organizational proceedings from September 2007 to August 2008 The Journal of Bone and Joint Surgery The American Journal of Sports Medicine Arthroscopy the American Academy of Orthopaedic Surgeons (AAOS) the American Orthopaedic Society for Sports Medicine (AOSSM) the Arthroscopy Association of North America (AANA)