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A total of sixty consecutive cases of anterior chronic laxity of the knee the pre- and intraoperative features of which corresponded to the criteria of inclusion considered, hospitalized in our institute between September and December 1998 and submitted to reconstruction of the ACL were reviewed at a follow-up of 74 months. The series was made up of two groups that were homogeneous in terms of sex, age, degree of preoperative laxity and number and type of associated meniscal lesions; in the first group (20 cases) reconstruction was carried out using the patellar tendon (BPTB) and in the other (40 cases) the doubled semitendinosus and gracilis tendons (DGST) were used with the association in cases with greater rotatory laxity (20 cases) of peripheral reinforcement reconstruction. An accelerated rehabilitation protocol was used in the first group, a more prudent one with immobilization in extension for two weeks was used in the second group. The results, evaluated based on the IKDC form, appeared to be better in the DGST group, with a statistically significant difference; joint stability, evaluated at follow-up with a KT1000 arthrometer also proved to be better in the DGST group, with a difference that was not statistically significant. The present study seems to show that reconstruction of the ACL with DGST, a prudent rehabilitation protocol and peripheral reinforcement reconstruction in selected cases is capable of providing better long-term results as compared to standard reconstruction with the patellar tendon and accelerated rehabilitation protocol. Among methods used to reconstruct the anterior cruciate ligament (ACL), those that utilize the central third of the patellar tendon (BPTB) or the semitendinosus and gracilis tendons (DGST) continue to be those used most frequently. Although the debate between orthopedics is still going on as to which of the two methods is to be preferred, studies that compare the two methods do not seem to report essential differences in medium-term results. In a recent meta-analysis of the most important international literature, to this regard Freedman et al. concluded that despite a significant major presence of anterior pain reconstruction with BPTB is capable of guaranteeing better joint stability and patient satisfaction, with a minor incidence of transplant failure. Nonetheless, if methods of reconstruction with BPTB seem to be rather standardized in terms of the method used to obtain the specimen and that used for stabilization (with very few differences between interference screws and transverse stabilization), and in postoperative rehabilitation (so-called accelerated), when DGST is used there are many technical variables capable of influencing the final results (choice of methods of stabilization, postoperative rehabilitation in particular). For this reason we still cannot obtain an absolute comparison of the two methods, but can only compare reconstruction with BPTB and a particular method used with DGST. It is the purpose of this study to present the medium-term results not so much of ACL reconstruction with the semitendinosus and gracilis doubled, but as a more articulate approach to the pathology of the ACL, so that DGST is only one phase, even if it is the most important one. Because we wished to verify whether it is possible, even in terms of joint stability and patient satisfaction, to improve the results of the so-called gold standard for reconstruction of the ACL, reconstruction by BPTB with transverse femoral reconstruction and accelerated postoperative rehabilitation protocol was chosen as a term of paragon.

To investigate the correlations between traumatic injuries of the anterior cruciate ligament and other ligamentous, meniscal and bone traumatic injuries, a series of 193 patients with anterior cruciate ligament injuries studied with MRI between January 1992 and December 1994, was retrospectively reviewed. MR results were compared with arthroscopic and/or surgical findings in most (181) patients; in the remaining 12 patients, clinical follow-up was performed. We used two 0.5 superconductive MR units, with dedicated coils and T1-weighted spin-echo and T2*-weighted gradient-echo sequences on the axial, sagittal and coronal planes. Anterior cruciate ligament injuries were associated with other ligamentous, meniscal and bone injuries in 78% of patients. The patients were classified in 5 groups depending on biomechanics and the association of injuries: -group I: isolated injury of the anterior cruciate ligament (41 patients), most frequently caused by forced extension stress associated with "kissing contusions" of the anterior portion of the lateral femoral condyle and of the lateral tibial plateau; this type of injury is less frequently caused by forced flexion stress associated with avulsion fracture of the tibial eminence; -group II: associated injury of the anterior cruciate ligament and medial compartment (62 patients), caused by forced flexion-external rotation stress (abduction, valgism and external rotation). The classic association of this mechanism was the injury of the anterior cruciate ligament, medial collateral ligament and medial meniscus (O'Donoghue triad) (9 patients). Valgus stress and the pivot-shift phenomenon can impact the tibial and femoral articular surfaces, with consequent osteochondral contusion; -group III: associated injury of the anterior cruciate ligament and lateral compartment (26 patients), caused by forced flexion-internal rotation stress (adduction, varism and internal rotation). This mechanism can cause, as a typical bone lesion, Segond fractures; -group IV: associated injury of the anterior cruciate ligament, lateral and medial compartments observed in 52 patients with different associations of varus-valgus and rotatory stress; -group V: in 5 patients, anterior cruciate ligament injury was associated with traumatic injury of the posterior cruciate ligament; in this case, posterior displacement of the tibia and knee hyperextension were the most common mechanisms of injury. In conclusion, our results demonstrate that anterior cruciate ligament injuries due to traumatic sprains of the knee are rarely isolated (21%). Thus, it is important to know the biomechanics of knee trauma to read MR images in order to detect possibly associated injuries. The final goal is to assess the actual extent of the traumatic damage for best subsequent clinical-therapeutic management.