This study documents outcomes of athletically active, skeletally immature patients with proximal anterior cruciate ligament (ACL) tears treated with a non-reconstructive technique to promote healing ("healing response").Between 1992 and 1998, 13 skeletally immature athletes with proximal ACL tears underwent a healing response procedure. Patients with previous ACL injury, other concurrent ligament pathology, and/or complete mid-substance ACL tears were excluded. Average preoperative KT-1000 arthrometer manual maximum difference for all patients was 5 mm (range: 3-10 mm). Preoperatively, all patients had a 1ϩ or 2ϩ pivot shift, and all patients reported knee function as abnormal or severely abnormal. Patients were followed prospectively with clinical examinations, KT-1000 testing, and subjective questionnaires. Three (23%) patients had a re-injury 30 to 55 months after the healing response and underwent subsequent ACL reconstruction. Subjective follow-up on the remaining 10 patients at an average of 69 months (range: 26-113 months) postoperatively indicated no patients experienced pain or giving way, and all considered their knee function normal. Average Lysholm score was 96, Tegner score was 8.5 (range: 7-10), and patient satisfaction at follow-up was 9.9 (1ϭvery dissatisfi ed and 10ϭvery satisfi ed). Clinical examination at least one year postoperatively was performed on 7 of 10 patients at 35 months (range: 12-63 months). Five patients had a negative pivot shift and 2 had a 1ϩ pivot shift. KT-1000 measurements improved to 2 mm (range: 0-3 mm).In the athletically active, skeletally immature patient, the healing response procedure can restore stability and knee function, with proper patient selection. In this study group, patients were very satisfi ed with the procedure and returned to a high level of sports and activities.
Management of the patella during primary total knee arthroplasty remains an unanswered question. Internationally, there is significant variation in the approach to resurfacing with some geographic regions resurfacing almost universally, and other regions rarely resurfacing. This difference in preference is a result of the different geographic locations, and is influenced by where the surgeons were trained, what was taught during their training, their patients' patellae profiles, financial condition and hospital policy where the surgeons practise. In this current concepts review, we investigate where we are now with patellar resurfacing during total knee arthroplasty from an international perspective, and the differences in outcomes between resurfaced and non-resurfaced patellae. In the end, the decision to resurface or not to resurface remains at the surgeon's discretion and is highly influenced by both medical and non-medical reasons. This review includes an alternative method to address anterior knee pain, which can be an additional management option apart from resurfacing or non-resurfacing for patients where patellar resurfacing is not a viable option, such as in very thin patellae. Moreover, we will also describe other variables that may play a role in causing persistent anterior knee pain, for instance soft tissue imbalance around the patella or improper positioning of the components. It may be important to address these factors to prevent undesirable postoperative outcomes.
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