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Although many instruments are used to assess outcome after knee ligament reconstruction, their reliability, validity, and responsiveness have not been adequately proven. Our purpose was to assess these statistical measures in a commonly used instrument, the Cincinnati Knee Rating System. Reliability was determined from the responses of 100 subjects who completed the instrument twice, a mean of 7 days apart. Validity and responsiveness were assessed from 250 patients observed for at least 2 years after autogenous ACL reconstruction. Questionnaire items included symptoms, functional limitations with sports and daily activities, patient perception of the knee condition, and sports- and occupational-activity levels. The items demonstrated high test-retest reliability, supporting their use in evaluating groups of patients between two different treatment periods (all intraclass correlation coefficients > 0.70). In addition, the questionnaire demonstrated good content validity, construct validity, and item-discriminant validity. For the overall rating score, no "floor effects" (worst score possible) were found before or after surgery. No "ceiling effects" (best score possible) were found before surgery, and, at follow-up, these effects were calculated in only 22 patients (9%). The questions were found to be highly responsive to detecting changes between evaluations. The data demonstrated that this rating system has acceptable reliability, validity, and responsiveness for use in outcome studies after knee ligament reconstruction.

In a consecutive series, we treated 41 young patients who had anterior cruciate ligament deficiency, lower limb varus angulation, and varying amounts of posterolateral ligament deficiency. Seventy-three percent of the patients (N = 30) had lost the medial meniscus and 63% (N = 26) had marked articular cartilage damage in the medial compartment. All patients were treated with high tibial osteotomy and, in the majority (N = 34), anterior cruciate ligament reconstruction a mean of 8 months later. Posterolateral reconstructions were also required in 18 knees. A 100% follow-up was obtained at a mean of 4.5 years after osteotomy. Gait analysis testing was done in 17 knees before and after osteotomy. At follow-up, a reduction in pain was found in 71% (29 knees); elimination of giving way, in 85% (35 knees); and resumption of light recreational activities without symptoms, in 66% (27 knees). The patient rating of the knee condition was normal or very good in 37% (15 knees) and good in 34% (14 knees). The mean Cincinnati Knee Rating Score significantly improved from 63 to 82 points. The mean adduction moment, 35% higher than controls preoperatively, significantly decreased to below normal values postoperatively. Correction of varus alignment was maintained in 33 knees (80%). We recommend osteotomy in addition to ligament reconstructive procedures in these knees with complex injury patterns.

Few objective functional criteria are used to determine when patients return to unrestricted sports activities. Clinically feasible recommendations are made for measurement of muscle strength, lower limb symmetry, lower limb neuromuscular control, and ligament function in patients who desire to return to athletics after ACL reconstruction. Future studies are required to determine whether the demonstration of normal lower limb function before return to sports is effective in reducing reinjury rates.

We assessed the results of 198 meniscal tears that had a major segment in the central avascular region repaired with an arthroscopically assisted inside-out technique. There were 177 patients whose mean age was 28 years. Eighty-two percent were injured during sports, and 71% also required anterior cruciate ligament reconstruction. The menisci were evaluated by clinical examination (180 repairs) a mean of 42 months postoperatively, by follow-up arthroscopic evaluation (91 repairs) a mean of 18 months postoperatively, or both. At followup, 159 (80%) of the 198 tears were asymptomatic for tibiofemoral joint symptoms, and 39 (20%) required repeat arthroscopic surgery for these symptoms. Of the 91 repairs evaluated arthroscopically, 23 (25%) were classified as healed, 35 (38%) as partially healed, and 33 (36%) as failed. We recommend repair of meniscal tears that extend into the avascular region for select patients, including those in their 20s and 30s and highly competitive athletes. This study's reoperation rate of 20% should not be interpreted as the rate of meniscal healing, but as the incidence of tibiofemoral joint symptoms. Even though this is a higher rate than that reported for the repair of peripheral meniscal tears, we believe the benefits of a potentially functional meniscus outweigh the risks of reoperation.

The purpose of this study was to evaluate anterior cruciate ligament allograft reconstruction in skeletally immature athletes. Eight patients (mean age, 13 years, 6 months; range, 10 to 15 years) with radiographic documentation of open growth plates had anterior cruciate ligament repair and reconstruction with fascia lata or Achilles tendon allograft tissue. A 7-mm graft was centrally placed across the tibial physes and in an over-the-top position on the femur. All patients returned for followup a mean of 58 months (range, 22 to 94) postoperatively. All had an immediate knee motion and rehabilitation exercise program. The results were rated on a comprehensive rating system that assessed 20 variables. At followup, all patients showed closure of the growth plates. The difference in lower limb length, measured on scanograms, was not clinically significant. On KT-1000 arthrometer testing, 5 patients had less than 3 mm of increased anterior-posterior displacement (normal knee minus reconstructed knee) and 3 patients had between 3 and 5 mm. The final overall ratings were 6 excellent, 1 good, and 1 fair. The procedure is infrequently used, but appears to have merit in select, skeletally immature athletes who desire not to modify athletic activity or when associated meniscal repairs warrant consideration for reconstruction.

The short-term results of meniscal transplantation are encouraging in terms of reducing knee pain and increasing function; however, long-term transplant function and any chondroprotective effects remain unknown and require further investigation.