The objective of this study was to assess knee function after anterior cruciate ligament reconstruction focusing on residual donor-site problems. Ninety consecutive patients with chronic unilateral anterior cruciate ligament rupture were operated on by the same surgeon using patellar tendon autografts, the all-inside arthroscopic technique, and interference screw fixation. At the follow-up examination 24 (range 22-32) months after the index operation, the median total anterior-posterior KT-1000 side-to-side difference was 2.5 (-7 to 11) mm. The median Lysholm score was 86 (range 37-100) points and the median Tegner activity level was 6 (range 1-9). Using the IKDC evaluation system, 62 of 90 (69%) were classified as normal or nearly normal. The median one-leg-hop quotient was 93 (range 0-167)% of the uninjured leg. Of 90 patients, 44 (49%) had minor or no discomfort when asked to walk on their knees (kneewalkers) and 46 of 90 (51%) patients had severe problems or found it impossible to perform the test (non-kneewalkers). The 'kneewalkers' had a median loss of anterior knee sensitivity of 10 (range 0-120) cm2. The corresponding value for the 'non-kneewalkers' was 25 (range 0-200) cm2 (P = 0.0001). Palpatory donor-site tenderness was registered in 19 of 44 (43%) of the 'kneewalkers' and 37 of 46 (80%) of the 'non-kneewalkers' (P < 0.001). Full hyperextension was not regained by 9 of 44 (20%) of the 'kneewalkers' and 19 of 46 (41%) of the 'non-kneewalkers' (P < 0.05). Additional surgery during the follow-up period was required by 6 of 44 (14%) of the 'kneewalkers' and 19 of 46 (41%) of the 'non-kneewalkers' (P < 0.01). Magnetic resonance imaging focusing on the donor site was performed on 31 randomly selected patients and revealed no difference between the 'kneewalkers' and the 'non-kneewalkers' in terms of patellar tendon width, thickness, length, and residual donor-site gap size. The kneewalking test was found to be a functional and reliable test for detecting donor-site morbidity. It appears that donor-site morbidity was related to problems requiring additional surgery during the follow-up period, such as extension deficit and pain near the metal implant on the tibial side, as well as the loss of anterior knee sensitivity. It appears to be important to attempt to preserve the sensitivity in the operated area during surgery and to regain full hyperextension in the postoperative period to minimize donor-site morbidity.
The variation in the dimensions of the lumbar spinal canal under both flexion-extension and axial compression-distraction was studied using computerized tomography (CT) scans in human cadaver lumbar spine specimens. In 3-mm-thick CT slices through the disk at L3-L4, the cross-sectional area of the spinal canal was reduced by around 40 mm2, corresponding to a 16% reduction of the initial area when the lumbar spines were moved both from flexion to extension and from distraction to compression. A corresponding reduction in the midsagittal diameter of the canal of 2 mm was found. During these motions, the ligamentum flavum did not appear to be a significant factor for the dynamic changes affecting the dimensions of the canal. This held true even after the disk had been excised in order to produce a total collapse of the disk space.
Nineteen consecutive patients undergoing anterior cruciate ligament reconstruction using the central third of the ipsilateral patellar tendon were included in the study. Serial magnetic resonance images revealed that the donor-site gap in the tendon decreased with time (mean follow-up, 26 months). The thickness was significantly increased compared with the intact contralateral patellar tendon, regardless of when the magnetic resonance imaging was performed. Ultrasonography showed the same findings at a mean follow-up of 26 months. Histologic evaluation of the repair tissue in the central part of the tendon, as well as the tissue in the peripheral part of the patellar tendon at the donor site, revealed a significant increase in cellularity and vascularity as compared with normal control tendons. Thus, 2 years after the harvesting procedure, the patellar tendon displayed significant radiographic and histologic abnormalities. On the basis of these findings, reharvest of the patellar tendon, at least up to 2 years after primary harvest, cannot be recommended.
Twenty-four patients who underwent anterior cruciate ligament revision surgery were studied postoperatively (12 with reharvested ipsilateral patellar tendon grafts and 12 with contralateral patellar tendon grafts). For comparison purposes, 12 matched patients with primary anterior cruciate ligament reconstruction, who had been operated on using the same technique by the same surgeons, were chosen. The median time since the first reconstruction was 57 months (range, 15 to 132) in the ipsilateral tendon group and 54 months (range, 20 to 108) in the contralateral tendon group. Follow-up examination showed that there were no significant differences in total KT-1000 arthrometer side-to-side measurements between the groups, but the Lysholm score was higher for patients with contralateral tendon grafts than for patients with ipsilateral grafts. Only two patients with ipsilateral grafts were classified as having excellent or good results. Functional testing outcomes were similar for all groups, and magnetic resonance imaging screening showed no differences between the reharvest and primary harvest groups in terms of length, width, thickness, or donor site gap of the patellar tendon. However, there were two major complications in the group with revision surgery with the ipsilateral reharvested patellar tendon. Reharvesting the ipsilateral patellar tendon resulted in lower functional scores and a higher rate of complications than revision with the contralateral patellar tendon or primary anterior cruciate ligament reconstruction.
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