The effect of meniscal status on knee stability and function after anterior cruciate ligament reconstruction

Arthroscopy: The Journal of Arthroscopic and Related Surgery 9(4):431--439 Published by Raven Press, Ltd. © 1993 Arthroscopy Association of North America

The Effect of Meniscal Status Function After Anterior Cruciate

on Knee Stability and Ligament Reconstruction

O w e n R. M c C o n v i l l e , M . D . , J a m e s M. Kipn i s , M . D . , J o h n C. R i c h m o n d , M . D . , S e a n E. R o c k e t t , M . D . , and M a r c J. M i c h a u d , M . D .

Summary: The purpose of this study was to examine the relationship of meniscal status at the time of anterior cruciate ligament (ACL) reconstruction with the ultimate function and stability of the knee joint. Seventy-one patients were studied prospectively following bone--patellar tendon-bone ACL reconstruction. Subjects were divided into six subgroups relative to the integrity (intact, partial meniscectomy, complete meniscectomy) of the two menisci. After a minimum of 2 years of follow-up (range 2-4.1 years), 56 subjects were available for subjective, objective, and radiographic assessment. Meniscal status at the time of ACL reconstruction proved to have no significant bearing on the ultimate stability of the knee. However, individuals who had undergone meniscal excision reported subjective complaints and activity limitations more commonly than those with intact menisci (p < 0.05). Radiographic changes also were more common in the meniscectomized subset. Key Words: Anterior cruciate ligament--Meniscus--Stability.

The benefits of reconstruction of the anterior cruciate deficient knee have become well established (1-6). Arthroscopically associated intraarticular anterior cruciate ligament (ACL) (4,7-10) reconstruction has developed as a means to restore stability (10- 12). Meniscal repair and limited resection attempt to maximize preservation of normal anatomy (13).

Evolution of surgical techniques, including ap- propriate graft selection (14) and fixation (15) has ledto improved results (6). The strength character- istics of the central third of the patellar tendon (14) make it a popular (though not universal) choice as a source of autograft. Furthermore, the presence of bony blocks makes rigid graft fixation with an endoscopic technique possible using interference screws (15). Advances in rehabilitation (16, I7) have complemented these improvements in technique.

From the Department of Orthopaedic Surgery, Tufts-New En- gland Medical Center, Boston, Massachusetts, U.S.A.

Address correspondence and reprint requests to John C. Richmond, M.D., Department of Orthopaedic Surgery, Tufts- New England Medical Center, Boston, MA 02111, U.S.A.

This article won the "Resident's Prize" at the Arthroscopy Association of North America's Annual Meeting, Boston, Mas- sachusetts, April 1992.

Despite these advances, some individuals still at- tain suboptimal functional results after ACL reconstruction (2). Henning (13,18,19) and others have recognized the negative effects of meniscectomy in the ACL-deficient knee. In the case of ACL rupture, both knee stability and the integrity of the articular cartilage are adversely affected by an associated meniscectomy (10,20-27). Degenerative joint disease has been associated with both ACL rupture and meniscectomy (28-32).

The consequences of meniscal pathology in the reconstructed knee have been less well evaluated. This report examines the effect of meniscal status at the time of ACL reconstruction on the ultimate stability and function of the knee. It represents a prospective evaluation of surgical reconstruction of both acute and chronic ACL-deficient knees using current operative and rehabilitative techniques.

MATERIALS AND METHODS

From 1987 to 1989, 71 patients with an ACL- deficient knee due to injury underwent arthroscopically assisted ACL reconstruction with anatomi-

431

432 O. R. McCONVILLE ET AL.

cally placed autogenous bone-patellar tendon-bone grafts. All surgeries were performed or directly su- pervised by the same surgeon (J.C.R.).

Subjects After a minimum of 2 years of follow-up (mean

3.2 years, range 2-4.5 years), 64 of 71 subjects (90%) were contacted for review. Seven were lost to follow-up. There were 40 male (63%) and 24 female patients (37%), with an average age at the time of surgery of 26.3 years (range 15-45). Demographic data are provided in Table 1.

Sixty-four subjects completed a health assessment questionnaire. This questionnaire was developed at The New England Medical Center to incor- porate the Lysholm (33) scoring scale and the In- ternat ional Knee Documen ta t ion Commit tee Evaluation Format into a patient-based form. Fifty- six individuals returned for a comprehensive objective evaluation, which included a detailed physical examination, functional performance tests, radio- logic assessment, Cybex data, and KT-2000 instrumented laxity measurements (34) (MEDmetric Cor- poration, San Diego, CA). Radiographs were evaluated for the presence of Fairbank's changes (35), and were scored independently for the presence of >50% joint space narrowing. Each portion of the evaluation was conducted by a different individual (independent of the chief investigator) in an effort to minimize bias (36).

The study population consisted of 19 acute injuries (surgery performed <4 months after injury) and 45 chronic injuries. The average interval between injury and reconstructive surgery was 25 months (range 3 days to 15.8 years). Sports-related injuries

T A B L E 1. Demographics o f study population

Sex Male n = 40 (63%) Female n = 24 (37%)

Age (yr) Mean 26.3 Range 15-45

Injuries Acute n = 19 Chronic n = 45

Interval to surgery Mean 25 mo Range 3 d to 15.8 yr

Follow-up (yr) Mean 3.2 Range 2-4.5

Involved knee Right n = 26 Left n = 38

accounted for 9I% of the ACL tears. The majority of injuries occurred while skiing. The predominant mechanism was valgus stress with associated rota- tional force. Thirty-eight left knees and 26 right knees were involved. Thirty-three patients (52%) heard an audible pop at the time of injury. Fifty-four (84%) experienced subsequent episodes of buck- ling.

Preoperative assessment Knee function was evaluated subjectively using a

patient questionnaire and a physician-administered Lysholm knee score (33). The average preoperative Lysholm knee score was 65. Tegner (37) activity grades were assigned to each individual. Preinjury Tegner scores averaged 7. I, corresponding to com- petitive tennis or recreational soccer. The mean preoperative score was 3.9 (e.g., recreational cycling or performing moderately heavy labor).

Objective assessment included both manual and instrumented tests of knee stability. The Lachman and anterior drawer tests were graded in comparison with the uninvolved knee; 0 = 0 mm of increased translation; 1 + = 1-5 mm of increased translation; 2+ = 6-10 mm of increased translation; 3 + = 11-15 mm of increased translation; and 4 + = >15 mm of increased translation.

Before surgery, five patients had a grade 1 Lach- man, 44 a grade 2, 12 a grade 3, and 1 a grade 4. Four patients were found to have an anterior drawer of grade 1, 44 a grade 2, 12 a grade 3, and 2 a grade 4. Preoperative instrumented laxity measurements averaged 5.6 mm at 15 lbs and 7.5 mm at 20 lbs.

All patients demonstrated a positive pivot shift. Seven patients had patellofemoral tenderness. Thir- teen patients displayed patellofemoral crepitus. Twenty-eight patients had greater than 1 cm difference in thigh sizes. Cybex strength measurements found the quadriceps muscles 21% deficient at 60°/s and 17% deficient at 180°/s.

Surgical technique A standard double-incision arthroscopically as-

sisted technique using a 10-mm bone-patellar tendon-bone autograft was used at the outset of this study. Subsequently, an endoscopic technique (12) was adopted. Meniscal repair was performed with an arthroscopic inside-out technique (13). Rigid graft fixation was achieved with interference screws or with three #5 sutures tied around an A-O bicor- tical screw with washer. The graft was tensioned with the joint in full extension at - 125 N.

Arthroscopy, Vol. 9, No. 4, 1993

EFFECT OF MENISCAL STATUS ON KNEE STABILITY 433

Surgical findings At surgery all subjects were found to have func-

tional or anatomic disruption of their ACLs. Seven individuals had undergone a prior ACL reconstruction. In addition, a total of 20 patients (31%) had had prior meniscal surgery on either the medial or lateral menisci or both (17 partial and six complete meniscectomies). A complete meniscectomy was considered any resection extending to the menisc- osynovial junction that disrupted the circumferen- tial continuity of the meniscus.

During ACL reconstructive surgery, one complete and 36 partial meniscectomies (33 patients) were performed. Including prior surgeries, 46 patients (72%) underwent meniscectomies on one or both menisci: 53 partial (20 medial and 33 lateral) and seven complete (six medial and one lateral) meniscectomies (Table 2). In addition, 17 menisci were repaired at the time of surgery, and 16 menisci had tears that were considered stable and were not repaired.

Of the 19 injuries treated acutely, 14 of 38 (38%) menisci (medial and lateral) were torn. Eleven of the 14 acutely injured menisci (92%) had lateral tears. Forty-six of 90 menisci (51%) were torn in the 45 patients with chronic injuries. Twenty-three (50%) of the chronic tears were medial and 23 (50%) were lateral.

Two patients underwent medial collateral ligament repair, and one underwent repair of the lateral collateral ligament. Pes anserinus advancement was performed in two subjects, medial reefing in one.

Outerbridge grade I patellofemoral changes were seen in 27 patients, grade II in one, and grade III in one. Fifteen patients had grade I medial compartment changes, two patients had grade II changes, and eight patients had grade III changes. In the lateral compartment, 10 patients had grade I changes and three had grade II findings.

Postoperative rehabilitation Immediately after surgery, the knee was immobi-

lized in a postoperative hinged brace set at 10 ° of

flexion. Continuous passive motion (CPM) and partial weight beating were initiated on the first postoperative day. If adequate strength, range of motion, and stability had been regained at 1 month, the hinged brace was discontinued. Stationary cycling and straight leg raises with ankle weights were be- gun at 6 weeks. At 2 months, patients progressed to aggressive quadriceps strengthening. Patients were allowed to return to athletics in a functional brace at 6 months if adequate strength had been attained (>90% at 60°/s).

Follow-up assessment Evaluations were performed on an annual basis.

At the time of each visit, a Lysholm knee score and Tegner activity level was recorded. A complete physical examination, including instrumented laxity testing and Cybex evaluation, was performed.

For purposes of this study, subjects were divided into six groups relative to the status of their menisci at the time of the index operation (intact, partial meniscectomy, or complete meniscectomy) (Table 3). Subjects with menisci that were repaired at surgery or with stable tears that were not repaired were considered to have intact menisci. It was the intent of this study to examine the effects of meniscal status at the time of reconstruction in a prospective fashion. Thus, those menisci that subsequently required partial meniscectomy because failure of repair or extension of a stable tear (see Failures) were coded according to their initial status (i.e., intact).

The groups were divided as follows: group I (intact/intact), group 2 (partial/intact), group 3 (partial/ partial), group 4 (complete/intact), group 5 (complete/partial), and group 6 (complete/complete). Further division into medial and lateral subgroups proved unnecessary due to an inadequate sample size needed to demonstrate statistical significance.

RESULTS

Data collected from all study subjects were stored in a relational database (Paradox, Ansa,

TABLE 2. M e n i s c e c t o m i e s

Previous 20 Patients (31%)

Performed 33 Patients (52%)

Total 46 Patients (72%)

Partial Complete Partial Complete Partial Complete

Medial 8 5 12 1 20 1 Lateral 9 1 24 0 33 6 Total 53 7


434 O. R. McCONV1LLE ET AL.

TABLE 3. Fina l men i sca l s ta tus

No. of Group Meniscal status patients

1 Intact/intact 18 2 Partial/intact 31 3 Partial]partial 8 4 Complete/intact 1 5 Complete/partial 6 6 Complete/complete 0

Inc., Scotts Valley, CA, U.S.A.). Statistical analysis was performed using GB-STAT software (Dy- namic Microsystems, Inc., Silver Spring, MD). Kendall -r and Pearson product-moment coefficients were calculated to examine correlation between the study variables. Paired t tests and X 2 analyses were used to evaluate differences between meniscal status subgroups and other recorded variables (7). To give a more accurate account of the impact of meniscectomy in the successfully reconstructed knee, analysis of data was also conducted after elimination of surgical failures. (Failures were determined by laxity >5 mm on KT-2000 testing with maximal manual force.)

Subjective Meniscal status was tested for correlation with

multiple subjective variables. Significant positive correlations were found with pain, swelling, partial giving way, full giving way, and reduced postsurgi- cal activity status (all p < 0.05).

Subjects having undergone any degree of meniscal surgery (groups 2-5, partial or complete meniscectomy) had more subjective complaints than those with normal menisci at the time of ACL reconstruction. Activity-related pain (Fig. 1) and swelling (Fig. 2) were statistically more common in the meniscectomized patients (p < 0.05). Thirty- eight percent experienced pain with moderate ac-

6 0 50

40 % 30 20 10

0

57

Intact (gp 1) Partial (gp 2-3) Complete (gp 4-5)

MENISCAL STATUS P<0.05

FIG. 1. Incidence of pain occurring with moderate activity relative to final meniscal status.

80

60 %

40

20

0 Intact (gp t) Partial (gp 2-3) Complete (gp 4-5)

MENISCAL STATUS P<0.05

FIG. 2. Incidence of swelling occurring with moderate activity relative to final meniscal status.

tivity (heavy manual labor, tennis, skiing). A similar proportion (36%) noted swelling with moderate activity.

In the entire study population, the sensation of full giving way was present with strenuous activity in 14 (22%), moderate activity in two (3%), and light activity in two (3%). An additional five patients (8%) noted partial giving way, one with strenuous activity and four with light activity. Both partial (Fig. 3) and full (Fig. 4) giving way were significantly more common in the meniscectomized groups (p < 0.05).

Overall, 83% rated their function "nearly normal" or better. There was a trend (though not statistically significant) of decreased functional status and history of a partial or complete meniscectomy.

Activity level was felt by patients to be "nearly normal" or better in 80% of cases. Patients having undergone any degree of meniscectomy showed compromise in their ability to perform strenuous activity (p < 0.05) (Fig. 5). Activity at lower levels was not significantly affected.

Lysholm scores for the entire patient population were 44.6% excellent (95-100 points), 39.3% good

/ 60" 50- 4 0 - % 30-

20-

10

Intact (gp 1)

57

Partial (gp 2-3) Complete (gp 4-5)

MENISCAL STATUS P<O.05

FIG. 3. Incidence of partial giving way occurring with moderate activity relative to final meniscal status.

Arthroscopy, Vol. 9, No. 4, •993


// 60- 50- 40- % 30" 20-

O Intact IgP 1)

P<O.05

5Z --~ Excellent (95-100)

Good (84-94)

Fair (65-83)

Poor (< 65)

Partial (gp 2-3) Complete (gp 4-5)

MENISCAL STATUS

FIG. 4. Incidence of full giving way occurring with moderate activity relative to final meniscal status.

(84-94 points), 14.3% fair (65-83 points), and 1.8% poor (<65 points) (Fig. 6). Average Lysholm score for the entire study population was 90. No difference was detected in Lysholm scoring between those with normal meniscal status and those having had partial or complete meniscectomy. This was true even when failures (those with >5 mm laxity) were eliminated from the data analysis. Mean Ly- sholm score by meniscal status is shown in Table 4.

Tegner activity level improved to a postoperative average of 5.6. Level 6 corresponds to participation in recreational tennis, downhill skiing, and jogging five times per week. Mean change in Tegner level was 1.8. There was no significant association of change in Tegner level with meniscal status.

Objective

Physical examination Pivot shift phenomenon, present in 100% of pa-

tients preoperatively, was absent in 89% at the time of review (Table 5). Four (7.1%) had a trace pivot, and two (3.6%) a positive shift. Nineteen patients (33.3%) demonstrated a negative Lachman test, 36

100

80

% 60

40

20

0 Intact (gp 1) Partial (gp 2-3)Complete (gp 4-5)

MENISCAL STATUS P<O.05

FIG. 5. Ability to perform strenuous activity relative to final meniscal status.

44.6

;~.3

0 10 20 30 40 50 60 %

FIG. 6. Distribution of Lysholm scores for entire patient population irrespective of meniscal status.

(63.2%) I + , and two (3.5%) 2 +. In no patients was the difference in anterior drawer at 90 ° of flexion > 1 + (Table 6). No association was uncovered between meniscal status and presence of a pivot shift sign, an abnormal Lachman test (2 + ), or an abnormal anterior drawer test after ACL reconstruction. A single knee was noted to have 1 + valgus laxity in 30 ° of flexion, and one other to have I + varus laxity.

Thigh circumference was within 1 cm of the con- tralateral limb in 44 individuals (79.6%). Twelve (21.4%) had 1-2 cm of atrophy. No relationship was found between meniscal status and degree of thigh atrophy.

Patellofemoral crepitus was found in nine individuals (16%), medial femoral-tibial crepitus in two (4%), and lateral femoral-tibial crepitus in one (2%). The presence of crepitus was unrelated to meniscal status.

Only a single patient had significant motion loss (>3 ° extension or >5 ° flexion) at follow-up. This individual, who had undergone a single partial meniscectomy, lacked 5 ° of extension. Ninety-eight percent of patients completing the one-legged hop test were able to perform at least to 90% of their uninvolved limb. A single patient who had undergone bilateral partial meniscectomy was unwilling to attempt this test. One-legged hop test (38) results were unrelated to meniscal status.

TABLE 4. Mean Lysholm scores by final meniscal status

Group n Mean

t 18 92 2 8 90 3 31 88 4 1 95 5 6 87

Total 64 90


436 O. R. McCONVILLE ET AL.

TABLE 5. Knee stability by instrumented laxity and pivot shift testing

Preoperative Postoperative

Instrumented laxity 20 pounds 7.5 mm 0.8 mm Maximum man. Not performed 1.6 mm

Pivot shift None 0 51 (89.5%) Trace 0 4 (7.0%) Positive 64 (100%) 2 (3.5%)

Stability Preoperatively, instrumented laxity differences

(between involved and uninvolved sides) averaged 7.5 mm at 20 lbs. Postreconstruction laxity differences at 20 lbs averaged 0.8 mm (Table 5). Maximal manual force measurements were not taken preoperatively.

Postoperatively, with maximal manual force ap- plied, instrumented laxity averaged 1.6 mm for the entire patient population. Ninety-five percent of knees demonstrated - 3 to 5 mm laxity compared with the uninjured limb. There was no statistically significant relationship between meniscal status and instrumented laxity measurement.

Radiographic analysis Eighteen percent of patients obtaining standing

radiographs demonstrated joint space narrowing in at least one joint compartment (patellofemoral, medial, or lateral). Preoperative radiographs were not available in many cases. This precluded determina- tion of preexisting degenerative changes. A statistically significant association (p < 0.05) was present between complete meniscectomy and radiographic changes of joint space narrowing.

The distribution of Fairbank's (39) changes ac-

TABLE 6. Knee stability by Lachman and anterior drawer testing

Preoperative Postoperative

Lachman 0 0 19 (33.3%) 1 + 5 (8.0%) 36 (63.2%) 2+ 44 (70.9%) 2 (3.5%) 3 + 12 (19.4%) 0 4 + 1 (1.7%) 0

Anterior drawer 0 0 54 (94.7%) 1 + 4 (6.5%) 3 (5.3%) 2 + 44 (70.9%) 0 3 + 12 (19.4%) 0 4 + 2 (3.2%) 0

cording to meniscal status is shown in Fig. 7. The average age of pat ients demonst ra t ing these changes was 31.4 years. The average time since the injuring event was 78 months. The presence of Fair- bank's changes was significantly more common in patients with partial or complete meniscectomy (p < 0.05).

Isokinetic testing Forty-seven patients (63.5%) underwent isokinet-

ic testing. Hamstring deficits averaged 6.0% at 60°/s and 7.2% at 180°/s. Quadriceps deficits averaged 10.1% at 60°/s and 11.4% at 180°/s. Isokinetic performance was not related to meniscal status.

Complications There were no perioperative complications. One

patient who lacked 5 ° of flexion underwent arthroscopic lysis of adhesions 17 months postoperatively. A painful neuroma of the infrapatellar branch of the saphenous nerve required resection in another individual. Painful hardware was removed from the proximal tibia in two patients.

Two patients who had undergone repair of medial meniscal tears at the time of the index operation subsequently experienced retears that required partial meniscectomy. One patient with a stable tear of the lateral meniscus at the time of surgery required a partial lateral meniscectomy I9 months later.

Failures Three patients were considered surgical failures.

Failure was defined as laxity >5 mm or the presence of a pivot shift. One patient had 9 mm of laxity and a positive pivot shift. This patient had failed a previous attempt at ACL reconstruction. He con- tinues to have difficulty with even light activity after his latest attempt at reconstruction. A second individual demonstrated an 8 mm laxity difference

oo/i 80 1 80 1

% 60- I

4 0 -

2 0 =

0~-- Intact (gp 1) Partial (gp 2-3)Complete (gp 4-5)

MENISCAL STATUS PcO.05

FIG. 7. Incidence of Fairbank's changes relative to final meniscal status.



and a trace pivot. Although she experienced giving way at times, she did not feel that this compromised her activity level. Finally, a woman with congenital insensitivity to pain developed a positive pivot shift postoperatively with a laxity difference of 5 mm. Although she felt no pain, she was somewhat limited by instability. Two of these surgical failures had undergone partial meniscectomy, and the third had had a complete meniscectomy. Data analysis was repeated with these subjects eliminated and showed no differences from that o f the entire study group reported above.

DISCUSSION

Cadaveric (20,21) and clinical (22) studies have documented that the menisci have a particularly important contr ibution to stability in the ACL- deficient knee. Meniscectomy, in combination with ACL rupture, leads to accelerated degeneration of the knee joint. Warren (25) has emphasized that the goal of ACL reconstruction must not be limited to restoration of stability and short-term function. Rather, prevention of osteoarthritis is a central is- sue in the predominantly young population that sus- tains this injury. Given the accelerated degeneration of the knee joint that follows meniscectomy, maximal preservation of meniscat tissue is war- ranted.

Although there is a good deal of evidence con- cerning the untoward effects of meniscectomy in the ACL-deficient knee, there are few studies in the literature that address the relationship between meniscal status and outcome in the ACL-reconstructed knee. Previous published reports generally have used outmoded surgical techniques and rehabilitation programs (33,40,41).

Using current techniques, including arthroscopically assisted graft placement and an aggressive rehabilitation protocol, we have shown meniscal integrity to be an important factor in determining subjective outcome and postoperative activity status. Arthroscopic meniscectomy of any degree corre- lated with poorer results. Complete meniscectomy further compromised the results.

Many individuals with subjective and functional deficits on our health questionnaire scored good to excellent on the Lysholm scoring scale. Lysholm scoring proved an insensitive indicator of suboptimal subjective outcome. Other studies have documented the inadequacies of knee scoring scales and the variability between different scales (42). Rather

than use a single knee score to evaluate our results, we chose to also examine patient responses independently. Although we found no correlation between meniscal status and overall (Lysholm) scores, there were significant associations between meniscal status and several independent subjective and functional variables.

Objective stability was reestablished regardless of meniscal status. No relationship was found between meniscal status and Lachman testing, pivot shift, or instrumented laxity measurements. The use of bone--patellar tendon-bone autograft accom- panied by rigid graft fixation allows for accelerated rehabilitation and maintenance of objective stability despite partial or complete absence of menisci. Me- niscal repair does not necessitate restrictions in an aggressive rehabilitation program (43).

Harter et al. (44) noted that patients' perception of postoperative knee status was independent of many commonly used clinical means of assessment. Our findings confirm this observation. In many meniscectomized patients, a subjective sensation of giving way existed despite the fact that clinical examination uncovered no discernable significant increase in laxity. This serves to emphasize that although surgery may restore clinical stability, true functional stability may, in large part, be determined by meniscal status at the time of reconstruction.

Kornblatt et al. (45) found a correlation between residual symptomatic instability after ACL reconstruction and the presence of a pivot shift. This correlation existed in our patient population as well. However, when our few patients with objective instability (positive pivot shifts) were eliminated, symptomatic instability (giving way) still showed a correlation with meniscal status. Thus, even in the apparently successfully reconstructed knee, the menisci contribute to functional stability.

Radiographic degeneration of meniscectomized knees has been recognized in the past. In this study, no degeneration was observed in knees with intact or repaired menisci. However, partial meniscectomy was shown to lead to a statistically significant increase in degenerative changes. This is consistent with other reports in the literature. Further progres- sion of degenerative changes should be expected with time.

The past decade has been marked by advances in the understanding of the biomechanics of the menisci and ACL. Improvements in the evaluation of knee injuries and the techniques of surgical care


438 O. R. M c C O N V I L L E E T A L .

h a v e b e e n p r o f o u n d . A r t h r o s c o p i c A C L r e c o n - s t r u c t i o n n o w a l l o w s fo r r e l i ab l e r e s t o r a t i o n o f k n e e s t ab i l i ty wi th a m i n i m u m o f m o r b i d i t y . P r e s e r v a t i o n o f m e n i s c a l t i s sue a t t he t ime o f A C L r e c o n s t r u c - t ion is n e c e s s a r y t o o p t i m i z e s u b j e c t i v e a n d func- t iona l o u t c o m e . M e n i s c a l s t a tus a l so s e r v e s as a p r o g n o s t i c d e t e r m i n a n t . T h e r e l a t i o n s h i p o f men i s - c e c t o m y a n d c o m p r o m i s e d o u t c o m e p r o v i d e s fur- t he r e v i d e n c e o f the bene f i t s o f a c u t e A C L r econ - s t ruc t ion . I n the a p p r o p r i a t e ind iv idua l , e a r l y re- c o n s t r u c t i o n m a y p r e v e n t the i r r e v o c a b l e u n t o w a r d s e q u e l a e o f m e n i s c a l i n ju ry a s s o c i a t e d w i th c h r o n i c ins tab i l i ty .

Acknowledgment: We thank Christine Robertson, Chris Chihlas, Wendy Harr is , Beth Kantz , Deborah Band- Entrup, and Judi Smith for their efforts in the coordina- tion of this study and in the preparation of the manu- script.

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The effect of meniscal status on knee stability and function after anterior cruciate ligament reconstruction