Orthopaedic and trauma surgery

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7000.331 (Published 29 July 1995) Cite this as: BMJ 1995;311:331
  1. D S Johnson,
  2. R B Smith
  1. Research registrar Consultant orthopaedic surgeon Department of Orthopaedic Surgery, Royal Preston Hospital, Preston PR2 4HT

    Best method of anterior cruciate ligament reconstruction is debated

    EDITOR,--Christopher J K Bulstrode's article on recent advances in orthopaedic and trauma surgery suggests that long term research into the treatment of injuries to the anterior cruciate is not being undertaken.1 Many of these injuries improve with conservative treatment, with only 21-43% of patients (18-36 out of 84) in one study ultimately requiring reconstruction.2 Reconstruction is now widely accepted to be the best treatment in patients in whom conservative treatment has failed. There is much debate, however, about the best method of reconstruction. Synthetic materials have fallen out of favour with some surgeons following the failure of carbon fibre and Dacron grafts. Polyester now seems to be the preferred material for synthetic grafts, good results having been reported in 80% (20/25) of patients at five years of follow up.3 Autografts of patella tendon are becoming increasingly popular, with good results having been reported in 92% (68/74) of patients at six years, although loss of extension was present in 23% (17/74) of patients.4 One prospective randomised trial comparing polyester and patella tendon grafts in 60 patients has reported results at two years.5 No difference in symptom scores or functional scores was found. The group given polyester grafts, however, showed greater laxity on Lachman's test, and a greater proportion of this group had a positive result of a pivot shift test; the group given patella tendon grafts had an increased incidence of extension lag. A similar long term randomised controlled trial is being undertaken at Royal Preston Hospital.

    The debate over the best method of reconstruction in patients in whom conservative treatment has failed is likely to continue. It has not been helped by the plethora of procedures available and the wide variety of methods used to evaluate patients. These problems are being addressed and trials are under way, but the long term results of these will not be available for many years.


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