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ACL-reconstruction aims to restore joint stability and prevent osteoarthritis; however, malfunction and osteoarthritis are often the sequelae. Our study asks whether ACL-reconstruction or conservative treatment lead to better long-term results. In this retrospective cohort study, 136 patients with isolated ACL-rupture who had been treated by bone-ligament-bone transplant or conservatively were identified. Twenty-seven of these were excluded because of a revision operation in the 11.1 years follow-up period, leaving 109 patients (60 reconstructions and 49 conservatively treated) for evaluation based on clinical, radiological and internationally accepted knee-scores (Tegner, IKDC, Kellgren and Lawrence). An individual cohort study is classified as EBM level 2b according to the Oxford Centre of EBM. We observed significantly better knee-stability (P = 0.008) but more osteoarthritis (Grade II or higher) after ACL-reconstruction (42% vs. 25%). Physical activity levels were similar in both groups during the follow-up period (P = 0.16). Eleven years after ACL-rupture the physical activity levels are similar for both groups. After ACL-reconstruction, stability is higher as is osteoarthritis, whereby the result is not necessarily perceived as better subjectively. Specifically, this retrospective study yielded a 24% incidence of oseoarthrits 11 years after conservative management of ACL-rupture in patients not needing secondary surgery. The risk of secondary meniscal tears is reduced after ACL reconstruction, which reduces the negative effects of OA after surgery. The ultimate objective would be to achieve a good subjective outcome by conservative treatment followed by a rehabilitation program designed to keep secondary meniscus tears at a low level.

Correct placement of the femoral and tibial bone tunnels is decisive for a successful anterior cruciate ligament (ACL) reconstruction. Our method of tunnel placement was evaluated as part of quality control at a teaching hospital. The emphasis was placed mainly on investigating the influence of surgical experience on tunnel placement, and the effect of tunnel position on the clinical outcome. Seventeen surgeons with different levels of experience (between 0 and >150 ACL reconstructions) performed endoscopic ACL repair in uniform technique from August 2000 to August 2003 on 50 patients (18 women, 32 men, age range 18-43 years). The patients were available to clinical and radiological follow-up after an average of 19 months. The clinical outcome was classified according to the International Knee Documentation Committee (IKDC) standard evaluation form. The femoral tunnel was evaluated according to the quadrant method of Bernard and Hertel; the position of the tibial bone tunnel was assessed according to the criteria of Stäubli and Rauschnig. The IKDC score revealed 47 (94%) patients with a normal (A) or nearly normal (B) knee joint at follow-up. According to the quadrant method, the femoral canal was situated on average at 29% in the saggital plane. The tibial tunnel was situated on average at 43% of the a.p. diameter of the tibial condyle. Statistical analysis of our data showed no significant correlation between tunnel placement and surgical expertise. However, a highly significant correlation was found (alpha<0.01) between the femoral position of the tunnel in the sagittal plane and the IKDC score. The more anterior the femoral canal, the poorer the IKDC score. The method of tunnel placement in ACL reconstruction being investigated here only showed slight dependence on surgical experience, whereby good short-term clinical outcomes were achieved. Therefore, the method is suitable for application at a teaching hospital. A far too anterior femoral tunnel placement will probably lead to a decline in the clinical result.

Seventy-six patients with septic arthritis (78 affected joints) were treated with a combination of arthroscopic irrigation, debridement, and antibiotic therapy according to the tested bacterial sensitivity. There were 62 knee, 10 shoulder, 5 ankle joints, and 1 hip joint. No antibiotics were added to the irrigating solution. The arthroscopic and radiological stage of infection, treatment, and outcome in these patients was analyzed. The patients were classified into three groups according to initial stage of joint infection (stage I: 21 patients, 22 joints; stage II: 43 patients, 44 joints; stage III: 12 patients, 12 joints). Causes of infection were: hematogenous dissemination in 54%, postoperative wound infection in 28% (17% after open, 11% after arthroscopic procedures). Other causes were: 10% intra-articular steroid injections, 3% diagnostic punctures, and 3% open traumatic injury of the joint. In 78% of the infected joints the causative organism could be identified: Staphylococcus aureus was the most common organism found (42%), followed by streptococci (15%), pneumococci (6%), Escherichia coli (4%), Staphylococcus epidermidis (3%), Borrelia burgdorferi (3%), and others in 5%. In the stage I group only one patient needed repeated arthroscopic irrigation, in the stage II group 52%, and in the stage III group 75%. Open revision for eradication of the infection was necessary in one joint with stage II and in two joints with stage III infection (3%). Two joints of the stage III group needed additional surgery after successful treatment of the infection. The combination of arthroscopic irrigation and systemic antibiotic therapy was able to cure 91% of the affected joints. Open revision was necessary in 4% of joints. The number of arthroscopic procedures and the efficacy of treatment depended on the initial stage of the infection. It is concluded that an arthroscopic staging of the initial joint infection has prognostic and therapeutic consequences.

In a follow-up study 27 patients were evaluated after anterior cruciate ligament (ACL-)reconstruction combined with high tibial osteotomy because of chronic rupture of the ACL, cartilaginous lesions of the medial compartment and varus malalignment. They were divided into two groups. In 14 patients (non-LAD group) ACL reconstruction was performed using the central third of the autologous patellar tendon modified according to Eriksson-Trillat. Thirteen patients (LAD group) underwent repair with the same technique, but a Kennedy ligament augmentation device (LAD) in "hot dog' technique and fixed over the top was added. The postoperative treatment was the same in both groups. All patients were examined according to IKDC criteria. KT-1000 arthrometer testing at maximum manual traction was performed. Although the mean follow-up interval was more than double in the non-LAD group (non-LAD: 127 months vs LAD: 58 months), the subjective and clinical results, IKDC evaluation and KT-1000 arthrometer testing results were similar, showing no statistically significant difference. Further, no complications due to the use of LAD occurred. In this study no evident functional or clinical advantage from the augmentation performed could be shown.

We assessed the patients who were operated on in a combined procedure from 1980 to 1992 with anterior cruciate ligament (ACL) insufficiency, cartilaginous lesions of the medial compartment, lesion of medial meniscus and varus malalignment. The combined operative procedure was autologous intra-articular ACL reconstruction with the middle third of the patellar ligament--partially augmented with Kennedy-ligament augmentation device (LAD) in hot dog technique--and high tibial osteotomy. The patients were examined according to the criteria of IKDC including testing of anterior stability with the KT-1000 arthrometer. Radiographically we checked axis and arthritis according to a modified score of Kannus. Twenty-seven of 34 patients who fulfilled the inclusion criteria could be followed up in three categories (2-5 years post-operatively, 5-10 years postoperatively, over 10 years post-operatively). Total qualification was good in 37%; there were no perioperative complications. Rehabilitation was not prolonged. Eighty-nine percent practised their preoperative job, over 50% had a higher level of sports activities than preoperatively, and more than 25% regained their pretraumatic sports capacity. Two-thirds had no giving way and less than 3 mm translation difference in comparison to the contralateral knee. Seventy-five percent of patients would accept the operation again. Radiological findings had no correlation to overall qualification. The encouraging results with respect to many of the criteria suggest using the combined procedure in a young patient with ACL insufficiency, varus malalignment and medial compartment damage including medial meniscus lesion.