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Document Title: Noyes-AJSM-Jul97.shtml
Article Title: A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction
Authors: Frank R. Noyes, MD, and Sue D. Barber-Westin, BSc
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: July-August 1997
Volume 25, Number 4, pages 460-471
Keywords: ACL reconstruction, patellar-tendon autografting, PT autograft, acute versus chronic ACL tearing, articular-cartilage abnormalities, degeneration.
(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)
Comments: This superbly done and profoundly insightful study demonstrates the viability of using the patellar-tendon autograft for ACL reconstruction, for both acute knee injuries and chronic ones. For knees with chronic ACL tears, the rehabilitation was more difficult, but the results were still well worthwhile. Note that any knee that is allowed to remain ACL-deficient for extended periods of time will accumulate additional pernicious damage in the form of meniscal erosion and accelerated wear of components, and also gradual stretching-out of secondary restraints; these concerns are present even if the ACL-deficient knee does not actually give way after the initial injury. Clearly, prompt reconstruction of complete or near-complete ACL tears (and in any case, ACL tears of sufficient severity to render the knee unstable) is always best. The success rate for patellar-tendon autografting, for first-time ACL reconstruction, is about 95%; in this study, it was 93% overall (i.e. including both the knees with acute and chronic ACL tearing). Patellar-tendon autografting remains the gold standard today, especially given its unique advantage of secure healing due to bone plugs at both ends. The authors additionally note the importance of meniscal repair; even tears to the central avascular zone of the meniscus are amenable to repair. The best method for meniscal repair involves meticulous suturing. Although this is time-consuming for the surgeon to perform, it brings long-term benefits for the patient. As for articular-cartilage condition, the authors note that articular-cartilage damage was observed in 42% of the patients in the chronic subgroup and in 33% of the patients in the acute subgroup, at time of ACL reconstruction. This is not surprising, because ACL tears are very often accompanied by bone-bruising (in addition to meniscal tearing); articular-cartilage damage tends to worsen the longer an ACL-deficient knee is left unstable. Fortunately, even in unstable knees harbouring considering articular-cartilage abnormalities, ACL reconstruction is still well worthwhile. (Studies focusing specifically on ACL reconstruction in the arthritic knee can be found here: Noyes-AJARS-Feb97.shtml, Noyes-AJSM-Sep97.shtml, Shelbourne-KSSTA-Sep97.shtml.)
ABSTRACT
We conducted a prospective study of 94 consecutive patients who received a patellar tendon autograft for anterior cruciate ligament rupture. Eighty-seven patients (93%) returned for followup a mean of 28 months postoperatively; 57 had chronic and 30 had acute or subacute ruptures. There were no significant differences between the subgroups for age, sex, articular cartilage lesions, or months of followup. Forty-six meniscal tears were repaired; 27 of these extended into the central avascular region. Rehabilitation emphasized immediate knee motion, but strenuous activity was delayed for at least 4 months. Only one patient had a knee motion complication, and stability (<3 mm, KT-2000 arthrometer, 134 N) was restored in 85% of knees with chronic ruptures and 92% of knees with acute ruptures. Earlier reconstruction should be considered in active persons as symptoms and limitations continued postoperatively in knees with chronic ruptures, leading to overall less satisfactory results. In patient rating of the overall knee condition, 69% of knees with chronic ruptures and 100% of knees with acute ruptures scored in the normal or very good range. Repair of meniscal tears that extend into the central avascular region should be considered, as 24 of the 27 (89%) menisci repaired showed clinical evidence of healing and did not require reoperation.
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