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The Inter-rater and Intrarater Reliability of the Femoral Tunnel O'Clock Grading System During ACL Reconstruction (SS-63)
ABSTRACTS height, weight, BMI, meniscus injury, and time of return to pre-injury sports. Chi-square and independent t-tests were used to identify differences between subjects that failed and those who did not fail. Results: 206 subjects were included in this study, 168 double-bundle and 38 single-bundle reconstructions, 80% were available for ⱖ 9 month follow-up. Fifty percent of the subjects were female, the average (standard deviation) age was 24 (10) years, BMI was 24.5 (4.6) and time to return to sports was 263(68) days. Twenty-nine percent had a medial meniscus tear and 37% a lateral meniscus tear. Overall, 26 (13%) subjects had a failed graft. Of the subjects undergoing anatomic double-bundle ACL reconstruction, 22 (13%) failed. Double-bundle subjects who failed were younger (19 vs. 25 year, p ⬍0.001) and returned to sports earlier (at 222 vs. 267 days, p ⫽ 0.007). There were no differences in sex, height, weight, BMI, and meniscus status. Four (11%) of the single-bundle subjects failed. Single-bundle subjects who failed were younger (19 vs. 24 year, p ⫽ 0.049) and heavier (83 vs. 65 kg, p ⫽ 0.031). There were no differences in sex, height, BMI, meniscus status, and time to return to sports. Conclusion: The overall failure rate after anatomic ACL reconstruction with allograft was 13%. Younger age, earlier return to sports, and a higher body weight were associated with failure. The increased failure following ACL reconstruction with allograft reported in the literature combined with the failure rate presented in this study suggests that the use of allograft should be reconsidered in young people involved in competitive sports. Additionally, modifications in postoperative rehabilitation and return to sports may be necessary when the ACL is anatomically reconstructed. Arthroscopic Suture Fixation for Avulsion Fracture of the Tibial Attachment of the Posterior Cruciate Ligament (SS-62) Shih-Sheng Chang, M.D. Introduction: The clinical results of a procedure for 36 patients with posterior cruciate ligament (PCL) avulsion fracture with various tibial fragmentation size treated with arthroscopically assisted reduction and suture fixation with multiple No. 5 Ethibond sutures (Ethicon, Somerville, NJ) are presented in this study. Methods: This prospective study analyzed 36 patients (24 male, and 12 female) who underwent arthroscopic reduction and suture fixation for image-proven PCL avulsion fractures from tibia. The mean follow-up period was 36 months (range, 24 to 45). Follow-up assessment included Lysholm knee score, Tegner activity score,
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International Knee Documentation Committee (IKDC) score, and KT-1000 arthrometer and radiographic evaluations. Results: The mean preoperative Lysholm score in the 36 knees was 8.4 (range, 0 to 17); the mean postoperative Lysholm score was 87.5 (range, 43 to 100). The mean preoperative and postoperative Tegner scores in the 36 knees were 0.5 (range, 0 to 2) and 4.8 (range, 2 to 7), respectively. According to our modified Meyers and McKeever classification, completely displaced fragmentation (Type III) is the most common type. Four (11.7%) of seventeen patients were diagnosed to have type II fractures in this study, 25 (70.6%) were type III fractures, and 7 (17.6%) were type IV fractures. At final follow-up, 33 patients (91.6%) were classified by IKDC score as normal or nearly normal (grade A or B). The IKDC classification was abnormal (grade C) in 3 patients (8.3%). All 36 fractures achieved osseous union or stable fibrous union at final follow-up visits. No significant complications, such as arthrofibrosis, loss of initial fixation, or wound infection, were noted in this series. Conclusion: Treating PCL avulsion fracture with different tibial fragmentation size by arthroscopic reduction and suture fixation by use of multiple No. 5 Ethibond sutures can reduce osseous fragments, restore joint stability, promote early motion, and minimize morbidity. The Inter-rater and Intrarater Reliability of the Femoral Tunnel O’Clock Grading System During ACL Reconstruction (SS-63) Vishal M. Mehta, M.D., Ashish Rawal, M.D., Timothy S. Petsche, M.D. Introduction: While the o’clock grading system is widely used to describe the placement of femoral tunnels during anterior cruciate ligament (ACL) reconstruction, the inter-rater and intrarater reliability of the system remains unknown. The purpose of this study is to determine the inter-rater and intrarater reliability of the o’clock grading system as used by 3 fellowship trained sports medicine surgeons. Methods: Arthroscopic video was taken of the femoral tunnel placement during 20 consecutive ACL reconstructions performed by 2 different surgeons. All femoral tunnels were created using a medial portal technique. Video was taken using a 30 degree arthroscope placed in the lateral portal and demonstrated the femoral tunnel as well as the remainder of the femoral notch, the posterior cruciate ligament and the menisci for orientation. Three fellowship trained sports medicine surgeons were asked to review the videos and assign an o’clock position to the femoral tunnel from the 9 to the 3 o’clock position in
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“half-hour” increments. They were also asked to review the videos again 6 months later to determine the intrarater reliability. Inter-rater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (rs) was applied to evaluate intrarater reliability. Results: The inter-rater reliability as measured by the intraclass correlation coefficient (ICC) demonstrated poor agreement between the three surgeons (ICC ⫽ .204; 95% confidence interval, –.015 to .491; F ⫽ 2.8; P ⫽ .004). The intrarater reliability at a 6-month interval was found to be moderate (rs ⫽ .43, P ⫽ .004). Conclusion: The inter-rater reliability of the o’clock femoral tunnel grading system was found to be poor among fellowship trained sports medicine surgeons while the intrarater reliability was found to be moderate. The utility of the femoral tunnel o’clock grading system may be compromised by suboptimal inter-rater and intrarater reliability making it less useful as a tool of communication between surgeons. Effect of Donor Age on Patellar Tendon Allograft Anterior Cruciate Ligament Reconstruction (SS-64) Daniel Hampton, M.D., Joshua Lamb, M.D., John Klimkiewicz, M.D. Introduction: ACL reconstruction with patellar tendon allograft tissue is a common orthopaedic procedure. It is unknown what effect, if any, the age of the donor has on clinical outcomes. It has been postulated that increasing the donor age would have negative effects on outcome. Biomechanical studies have shown strength of cadaveric patellar tendon to be independent of age, but no clinical studies have evaluated patient outcomes related to this variable. Methods: Case logs were reviewed to identify primary ACL reconstruction with allograft patellar tendon by a single surgeon using a standard endoscopic transtibial technique with interference screw fixation. Revision and multi-ligamentous surgeries were excluded. 83 patients were identified meeting this criteria. Allografts were fresh frozen, aseptically harvested patellar tendons from a single tissue bank. The age of the donor was obtained from the tissue bank. Clinical outcomes were obtained by contacting patients by telephone and retrospective chart review. Pre- and postoperative Lysholm scores as well as activity levels were utilized for comparison. Results: Data from 75 patients was obtained with an average follow-up of 24 months. The average donor age was 44 years with a range of 14-65 and the average age
of the patient was 37 years. Statistical analysis of pre and postoperative Lysholm scores demonstrated improvement that was statistically significant (p⬍0.001). Using donor age as a continuous variable, there was no effect on either postoperative Lysholm score (p⫽0.5) or the postoperative Tegner score (p⫽0.6). Conclusion: ACL reconstruction with patellar tendon allograft has a high success rate that is independent of the age of donor tissue utilized for reconstruction with standard technique. Femoral Tunnel “Blowout” During ACL Reconstruction: A Biomechanical Analysis (SS-65) Kyle E. Hammond, M.D., Vishnu Potini, B.S., Brian D. Dierckman, M.D., John W. Xerogeanes, M.D., Sameh A. Labib, M.D. Introduction: Suspensory femoral fixation is commonly used for soft-tissue graft ACL reconstruction. For this fixation to be utilized, it is considered imperative that the lateral femoral cortex is not violated. Anatomic, single and double-bundle femoral tunnel techniques lead to shorter tunnels and, thus, are susceptible to an increased incidence of cortical breaching, or “blowout.” When this occurs, it is assumed a secondary type of fixation is needed. The purpose of our study was to determine if secondary fixation is needed when femoral “blowout” occurs, and whether the diameter of the femoral tunnel affects the cyclical and ultimate load to failure of three different suspensory fixation devices. Methods: Sixty fresh-frozen porcine femora were dissected to isolate the ACL footprint. Femoral ACL tunnels were then drilled at 7-, 8-, 9-, and 10-mm diameters. Biomechanical testing, both cyclical and load to failure, were undertaken utilizing an MTS machine. Five separate trials at each tunnel diameter were conducted for three different cortical suspension devices. Statistical analysis was then performed to compare the methods of failures and forces to failure across the four tunnel diameters, as well as the three devices. Results: Mean load-to-failure decreased as the tunnel size enlarged for all three devices. In 7-mm tunnels, mean load-to-failure ranged from 1163.7 to 1455.0 N; in 8-mm tunnels, 1154.7 to 1643.2 N; in 9-mm tunnels, 820.8 to 1125.21 N; and in 10-mm tunnels, 314.7 to 917.8 N, across the three devices. No significant difference was seen with the mean load-to-failure between the three devices (p⬍0.52). Methods of failure also varied as the tunnel sizes enlarged. In the 7- and 8-mm tunnels there were no failures across the three devices during cyclical testing, or with the devices being pulled into the tunnel; all the failures were due to the devices either
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International Knee Documentation Committee (IKDC) score, and KT-1000 arthrometer and radiographic evaluations. Results: The mean preoperative Lysholm score in the 36 knees was 8.4 (range, 0 to 17); the mean postoperative Lysholm score was 87.5 (range, 43 to 100). The mean preoperative and postoperative Tegner scores in the 36 knees were 0.5 (range, 0 to 2) and 4.8 (range, 2 to 7), respectively. According to our modified Meyers and McKeever classification, completely displaced fragmentation (Type III) is the most common type. Four (11.7%) of seventeen patients were diagnosed to have type II fractures in this study, 25 (70.6%) were type III fractures, and 7 (17.6%) were type IV fractures. At final follow-up, 33 patients (91.6%) were classified by IKDC score as normal or nearly normal (grade A or B). The IKDC classification was abnormal (grade C) in 3 patients (8.3%). All 36 fractures achieved osseous union or stable fibrous union at final follow-up visits. No significant complications, such as arthrofibrosis, loss of initial fixation, or wound infection, were noted in this series. Conclusion: Treating PCL avulsion fracture with different tibial fragmentation size by arthroscopic reduction and suture fixation by use of multiple No. 5 Ethibond sutures can reduce osseous fragments, restore joint stability, promote early motion, and minimize morbidity. The Inter-rater and Intrarater Reliability of the Femoral Tunnel O’Clock Grading System During ACL Reconstruction (SS-63) Vishal M. Mehta, M.D., Ashish Rawal, M.D., Timothy S. Petsche, M.D. Introduction: While the o’clock grading system is widely used to describe the placement of femoral tunnels during anterior cruciate ligament (ACL) reconstruction, the inter-rater and intrarater reliability of the system remains unknown. The purpose of this study is to determine the inter-rater and intrarater reliability of the o’clock grading system as used by 3 fellowship trained sports medicine surgeons. Methods: Arthroscopic video was taken of the femoral tunnel placement during 20 consecutive ACL reconstructions performed by 2 different surgeons. All femoral tunnels were created using a medial portal technique. Video was taken using a 30 degree arthroscope placed in the lateral portal and demonstrated the femoral tunnel as well as the remainder of the femoral notch, the posterior cruciate ligament and the menisci for orientation. Three fellowship trained sports medicine surgeons were asked to review the videos and assign an o’clock position to the femoral tunnel from the 9 to the 3 o’clock position in
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“half-hour” increments. They were also asked to review the videos again 6 months later to determine the intrarater reliability. Inter-rater reliability was evaluated using the intraclass correlation coefficient (ICC) 2-way mixed effect model with absolute agreement. The Spearman rank-order correlation coefficient (rs) was applied to evaluate intrarater reliability. Results: The inter-rater reliability as measured by the intraclass correlation coefficient (ICC) demonstrated poor agreement between the three surgeons (ICC ⫽ .204; 95% confidence interval, –.015 to .491; F ⫽ 2.8; P ⫽ .004). The intrarater reliability at a 6-month interval was found to be moderate (rs ⫽ .43, P ⫽ .004). Conclusion: The inter-rater reliability of the o’clock femoral tunnel grading system was found to be poor among fellowship trained sports medicine surgeons while the intrarater reliability was found to be moderate. The utility of the femoral tunnel o’clock grading system may be compromised by suboptimal inter-rater and intrarater reliability making it less useful as a tool of communication between surgeons. Effect of Donor Age on Patellar Tendon Allograft Anterior Cruciate Ligament Reconstruction (SS-64) Daniel Hampton, M.D., Joshua Lamb, M.D., John Klimkiewicz, M.D. Introduction: ACL reconstruction with patellar tendon allograft tissue is a common orthopaedic procedure. It is unknown what effect, if any, the age of the donor has on clinical outcomes. It has been postulated that increasing the donor age would have negative effects on outcome. Biomechanical studies have shown strength of cadaveric patellar tendon to be independent of age, but no clinical studies have evaluated patient outcomes related to this variable. Methods: Case logs were reviewed to identify primary ACL reconstruction with allograft patellar tendon by a single surgeon using a standard endoscopic transtibial technique with interference screw fixation. Revision and multi-ligamentous surgeries were excluded. 83 patients were identified meeting this criteria. Allografts were fresh frozen, aseptically harvested patellar tendons from a single tissue bank. The age of the donor was obtained from the tissue bank. Clinical outcomes were obtained by contacting patients by telephone and retrospective chart review. Pre- and postoperative Lysholm scores as well as activity levels were utilized for comparison. Results: Data from 75 patients was obtained with an average follow-up of 24 months. The average donor age was 44 years with a range of 14-65 and the average age
of the patient was 37 years. Statistical analysis of pre and postoperative Lysholm scores demonstrated improvement that was statistically significant (p⬍0.001). Using donor age as a continuous variable, there was no effect on either postoperative Lysholm score (p⫽0.5) or the postoperative Tegner score (p⫽0.6). Conclusion: ACL reconstruction with patellar tendon allograft has a high success rate that is independent of the age of donor tissue utilized for reconstruction with standard technique. Femoral Tunnel “Blowout” During ACL Reconstruction: A Biomechanical Analysis (SS-65) Kyle E. Hammond, M.D., Vishnu Potini, B.S., Brian D. Dierckman, M.D., John W. Xerogeanes, M.D., Sameh A. Labib, M.D. Introduction: Suspensory femoral fixation is commonly used for soft-tissue graft ACL reconstruction. For this fixation to be utilized, it is considered imperative that the lateral femoral cortex is not violated. Anatomic, single and double-bundle femoral tunnel techniques lead to shorter tunnels and, thus, are susceptible to an increased incidence of cortical breaching, or “blowout.” When this occurs, it is assumed a secondary type of fixation is needed. The purpose of our study was to determine if secondary fixation is needed when femoral “blowout” occurs, and whether the diameter of the femoral tunnel affects the cyclical and ultimate load to failure of three different suspensory fixation devices. Methods: Sixty fresh-frozen porcine femora were dissected to isolate the ACL footprint. Femoral ACL tunnels were then drilled at 7-, 8-, 9-, and 10-mm diameters. Biomechanical testing, both cyclical and load to failure, were undertaken utilizing an MTS machine. Five separate trials at each tunnel diameter were conducted for three different cortical suspension devices. Statistical analysis was then performed to compare the methods of failures and forces to failure across the four tunnel diameters, as well as the three devices. Results: Mean load-to-failure decreased as the tunnel size enlarged for all three devices. In 7-mm tunnels, mean load-to-failure ranged from 1163.7 to 1455.0 N; in 8-mm tunnels, 1154.7 to 1643.2 N; in 9-mm tunnels, 820.8 to 1125.21 N; and in 10-mm tunnels, 314.7 to 917.8 N, across the three devices. No significant difference was seen with the mean load-to-failure between the three devices (p⬍0.52). Methods of failure also varied as the tunnel sizes enlarged. In the 7- and 8-mm tunnels there were no failures across the three devices during cyclical testing, or with the devices being pulled into the tunnel; all the failures were due to the devices either