A variety of graft sources have been used for ACL reconstruction to improve functions and kinematics in ACL deficient knees. The two most commonly used autogenous grafts are the central third of the patellar tendon and the hamstring tendon constructs. The choice of different grafts and different construct influence the final clinical outcome of ACL reconstruction. The 3 groups, of 25 patients each, were generated by choosing the technique (PT tendon, 4 strand hamstring, and single hamstring plus extraarticular plasty) to utilize and followed for 5 years, with an alternate systematic sampling. Our comparison has shown significant kneeling pain in the patellar tendon with respect to the groups with hamstrings techniques. Single hamstring plus extraarticular plasty achieved subjective score significantly higher with respect to the other two groups as well as for the time to resume sport. The study confirms that patellar tendon and hamstring can be equivalent options for ACL reconstruction. This study demonstrated that a superior outcome as far as subjective clinical findings were concerned, was obtained in group III. Patients in the latter group were also able to return to sports sooner than those in the bone-patellar tendon graft group and the four-strand hamstring group.

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Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy's tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years' follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3-4 months and 27.5% in 4-6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this technique and the possibility of guaranteeing functional behaviour in the knee.

Meniscal substitution is a fundamental procedure to prevent osteoarthritis of the knee after massive meniscectomy. Stone, Steadman and Rodkey have developed a bioreadsorbable collagen matrix (CMI) which acts as a scaffold to restore the original medial meniscal. The objective of this study was to prospectively evaluate the results of CMI implantation at a follow up from a minimum of 6 to a maximum of 8 years. Eight patients (mean age 25) were evaluated at a final observation point from 6 to 8 years after CMI implantation. Inclusion criteria were an irreparable meniscal tear or a previous meniscectomy involving the medial meniscus. Follow up evaluation included Cincinnati Knee Rating Scale (CKRS), IKDC, subjective evaluation and X-ray and MRI control. There were no complications related to the device. All patients were able to return to day activities without limitations 3 months after surgery. Both subjective CKRS score and objective IKDC score showed improvement in all cases except one patient with an ACL re-injury. In two cases scores were slightly worse from 2 years after surgery to the final observation point. The other five cases obtained maximum score at final follow-up. In four cases the absence of pain remained until the final observation point, while in four cases a low entity of pain was described at long term follow-up. MRI showed in five cases mixoid degeneration signal, two had normal signal with reduced size, while one patient had no recognizable implant. Six patients had preserved cartilage and articular space, with no changes respect to pre-op control. Arthroscopic second look evaluation has been performed in three cases, revealing in two cases the presence of the implant, although with a reduced size respect to the original one, while in one case the CMI was almost disappeared. Our small series of eight patients prospectively followed from 6 to 8 years of follow-up has shown highly satisfactory results. Although the aspect of the implant was mostly abnormal, the implant may have helped reduce the deterioration of the knee joint at final observation time.

Revision ACL reconstruction restored similar anterior-posterior knee laxity compared with primary ACL reconstruction. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores, had inferior clinician-reported knee function and more radiographic signs of tibiofemoral osteoarthritis compared with patients with primary ACL reconstruction.