Biomechanical evaluation of two reconstruction techniques for posterolateral instability of the knee.

We evaluated two reconstruction techniques for a simulated posterolateral corner injury on ten pairs of cadaver knees. Specimens were mounted at 30° and 90° of knee flexion to record external rotation and varus movement. Instability was created by transversely sectioning the lateral collateral ligament at its midpoint and the popliteus tendon was released at the lateral femoral condyle. The left knee was randomly assigned for reconstruction using either a combined or fibula-based treatment with the right knee receiving the other. After sectioning, laxity increased in all the specimens. Each technique restored external rotatory and varus stability at both flexion angles to levels similar to the intact condition. For the fibula-based reconstruction method, varus laxity at 30° of knee flexion did not differ from the intact state, but was significantly less than after the combined method. Both the fibula-based and combined posterolateral reconstruction techniques are equally effective in restoring stability following the simulated injury.

Treatment algorithm for osteochondral injuries of the knee.

The treatment of osteochondral fractures and OCD lesions in the knee is controversial. Many new procedures and techniques have been developed recently to address osteochondral lesions, indicating that no single procedure is accepted universally. Our treatment algorithm is based on the age of the patient, skeletal maturity, and the presence of adequate subchondral bone attached to the chondral lesion. Most nondisplaced lesions in the patient with open physes will heal with conservative treatment. The onset of skeletal maturity indicates a need for a more aggressive treatment approach. If adequate cortical bone is attached to the fragment, drilling of stable lesions, or drilling with fixation of unstable or loose fragments is appropriate. Autologous bone graft can be necessary to stimulate healing and properly reconstruct the subchondral bony contour. For failed fixation attempts or lesions not amenable to fixation, each treating surgeon must be proficient and comfortable with an articular surface reconstruction technique. The goal for the reconstructive procedure, to produce a smooth gliding articular surface of hyaline or hyaline-like cartilage, is possible using current techniques including mosaicplasty, osteochondral allograft transplantation, and autologous chondrocyte transplantation. Débridement, drilling, microfracture, and abrasion chondroplasty have been shown to result in fibrocartilage with inferior mechanical properties when compared with hyaline cartilage. No long-term studies have been published, however, to confirm the benefits of replacing osteochondral defects with hyaline cartilage rather than fibrocartilage. Although the results of many reconstructive procedures are quite encouraging with early follow up, the ultimate goal is to prevent long-term degenerative arthritis. Only well-designed prospective studies with long-term follow up will determine the adequacy of these procedures in reaching the ultimate goal. This treatment algorithm is based on the senior author's (WGC) experience with the complex dilemma of osteochondral lesions of the knee.

Rehabilitation after anterior cruciate ligament reconstruction in the female athlete.

OBJECTIVE: To discuss the rehabilitation program after anterior cruciate ligament (ACL) reconstruction in the female athlete. In addition, we will discuss 8 unique characteristics identified in the female athlete and specific training drills to address and correct the potentially deleterious effects of these unique characteristics. BACKGROUND: The female athlete appears to be more susceptible to noncontact ACL injuries than the male athlete. There seem to be many differences between the female and male athlete that may contribute to the increased injury rate in the female athlete. These variations include anatomical and neuromuscular considerations and differences. DESCRIPTION: Based on the unique characteristics of the female athlete and the anatomical and neuromuscular dissimilarities, a specially designed rehabilitation program has been established for the female athlete after ACL surgery. CLINICAL ADVANTAGES: The rehabilitation drills discussed in this article challenge the neuromuscular system through proprioception, kinesthesia, dynamic joint stability, neuromuscular control, and perturbation training activities. Improving the female athlete's neuromuscular system will, we believe, expedite the injured athlete's recovery after ACL injury or surgery. Although the concepts discussed are part of a postoperative rehabilitation program after ACL surgery, these concepts may also be implemented as a preventive program to assist in reducing the incidence of ACL injuries in the female athlete.

Clinical classification of patellofemoral pain and dysfunction.

The patellofemoral joint is a complex articulation based on its dependence on both dynamic and static restraints for stability. Classification of patellofemoral disorders has been frought with confusion. However, progress has been made in the classification and understanding of these disorders by improved understanding of the biomechanics of the joint and by clarification of the terminology to describe patellofemoral pathology. The term chondromalacia patella, although once used as an all-inclusive term for anterior knee pain, is now widely accepted as a term used to describe pathologic lesions of the patellar articular cartilage found at arthroscopy or arthrotomy. An adequate classification system should aid in proper diagnosis and treatment of specific problems. If properly devised, it should also aid in the comparison of results between different treatment centers. In addition, it should be a system that is simple and useful in the clinical setting with minimal use of complicated imaging techniques. From a clinical perspective, patellofemoral problems in the skeletally mature patient fall into three broad categories: 1) patellofemoral instability, i.e., subluxation or dislocation; 2) patellofemoral pain with malalignment but no episodes of instability; and 3) patellofemoral pain without malalignment. The myriad of patellofemoral disorders then fall into subclassifications of these categories. Treatment algorithms can be broadly developed based on the general category, with specific treatments based on the subclassification. In this paper, the authors will present a review of the pertinent literature documenting patellofemoral classification systems and develop concepts of clinical classification of patellofemoral disorders based on the three categories described above.

Tendinitis in golf.

The term tendinitis has been used in a universal fashion to describe a variety of pathologic conditions. This article examines the pathology of tendon failure. The anatomy of the tendon and the spectrum of tendon injuries are discussed. Histologic evaluation of injured tendons usually reveals areas of tendinosis, or tendon degeneration, with an occasional inflammatory infiltration the paratenon, the outer connective tissue lining layer. A variety of treatment options are presented.

Alabama sports medicine experience with isolated and combined posterior cruciate ligament injuries.

Injuries to the posterior cruciate ligament (PCL) are an uncommon but significant instability pattern that eventually deteriorates the articular surface of the PLC-deficient knee. Although controversy persists regarding the appropriate treatment for the isolated PCL tear, patients with combined ligament injuries are best served by reconstruction of the PCL and surgical correction of the other injured tissues. The authors outline their experience with these complex ligamentous derangements.

Posterior cruciate ligament reconstruction with patellar tendon autograft.

Although the management of the PCL-injured knee remains controversial, there is a group of patients who will develop accelerated traumatic arthritis in whom surgical intervention is warranted. PCL reconstruction with a patellar tendon graft can reliably restore objective stability in over 90% of patients. Strict attention to detail, however, especially with respect to tunnel placement, is necessary to insure success.

Combined posterior cruciate ligament injuries.

Management of posterior cruciate ligament injuries combined with other ligamentous knee injuries must begin with an understanding of the normal anatomy and biomechanics of the knee. Careful physical examinations and judicious use of ancillary tests allow delineation of the extent of knee injury. Each combined injury can then be approached with an organized and specific plan for reconstruction, optimizing knee stability and function.

Cervical spine injury, hockey helmets, and face masks.

Over the past 30 years hockey players began wearing helmets and face masks. Cervical spine injury, with an incidence of 15 cases per year, began to be reported in the 1980s. Cervical spine trauma had not been reported before then. After review of the literature, there seems to be a consensus of opinion that the style of play that is allowed a player with head protection may actually increase the chances of cervical spinal trauma.

Quadriceps muscular strength after removal of the central third patellar tendon for contralateral anterior cruciate ligament reconstruction surgery: a case study.

Surgical reconstruction of the anterior cruciate ligament (ACL) using a patellar tendon autograft is a common orthopaedic procedure. Complications such as arthrofibrosis, patellar fracture, significant donor site pain, and quadriceps muscle weakness can occur from this procedure. Previous studies have not documented the effects of isolated graft procurement without concomitant ligamentous reconstruction on the donor extremity. This case study documents the clinical outcome results of an individual who underwent a central one-third graft harvest from his contralateral uninjured knee for an ACL graft of his injured ACL-deficient knee. The results indicate that at 4 months following graft procurement, the knee extensors were equal to the preoperative isokinetic test results of that leg. In addition, the patient exhibited full range of motion and no patellofemoral complaints of dysfunction. At 12 months postsurgery, the graft donor leg was 5-9% stronger than the preoperative test results. The results of this case study suggest that isolated harvesting of a 10-mm central patellar tendon free graft may not result in significant quadriceps muscle weakness or contribute to donor site pain.

Back injuries in college athletes.

Frequency and types of back injuries sustained by intercollegiate athletes were determined by examining medical records of 4,790 athletes that competed in 17 varsity sports over a 10-year period. These athletes sustained 333 back injuries, an injury rate of 7 per 100 participants. Injury rates were significantly higher in football and gymnastics, and 80% of the injuries occurred in practice, 6% in competition, and 14% during preseason conditioning. Muscle strains occurred with much greater frequency than other types of injuries, and acute back injuries were much more prevalent (59%) than overuse injuries (12%) or injuries associated with pre-existing conditions (29%).

Acute tears of the anterior cruciate ligament. Surgical versus conservative treatment.

In a prospective eight-year study comparing surgical and conservative treatment of acute tears of the anterior cruciate ligament, ninety-two patients in whom a tear had been confirmed either by arthroscopy or by arthrotomy were treated and could be followed. The choice of treatment was determined entirely by whether the result of a pivot-shift test was graded as absent, trace, or mild (non-operative treatment) or as moderate or severe (surgical treatment). Surgical treatment consisted of primary repair of the torn ligament and augmentation with a patellar tendon graft. Twenty-two patients were treated non-operatively, and the results were evaluated after twenty-four to eighty-two months (average, forty-eight months). Seventy patients were treated surgically, and fifty-two of them (approximately 70 per cent) returned for follow-up after twenty-four to 100 months (average, forty-eight months); an additional eighteen patients answered a questionnaire. In the non-operative group, about half of the results were graded as excellent or good and half, as fair or a failure. In the surgical group, all but two of the patients had an excellent or a good result; two patients had a fair result. No result was graded as a failure. The results of this study suggest that when the pivot-shift test is not strongly positive, half of the patients will do reasonably well after treatment with a non-operative program of functional rehabilitation. The patients in this study who had a more unstable knee had far better results after a repair and augmentation procedure than have been previously reported after primary repair alone.

Diagnosis of acute and chronic anterior cruciate ligament tears.

The diagnosis of acute and chronic injuries of the ACL has been reviewed. Attention has been given to the history, physical examination, and other diagnostic tools available for evaluation of the ligamentous injury. Clinical correlations have been highlighted. Finally, our recommendations for surgical intervention have been presented.

Semimembranosus tendinitis: an overlooked cause of medial knee pain.

A significant number of patients presenting with nontraumatic chronic medial knee pain have been found, after careful examination, to have chronic semimembranosus tendinitis. Of 115 patients diagnosed and treated for semimembranosus tendinitis over a 5 year period, 10 patients were refractory to conservative treatment. The purpose of this paper is to discuss the symptomatology and diagnosis of semi-membranous tendinitis, and to relate the treatment that these 10 patients underwent, i.e., surgical exploration, drilling of the insertion site, and semitendinosus tendon transfer. Most cases of semitendinosus tendinitis respond to conservative therapy; however, if surgical treatment is considered, arthroscopy should probably be performed at the time of surgery. In this way, it is possible to determine the presence of significant intraarticular abnormalities that may have a causal relationship with the onset of semimembranosus tendinitis.