Intraarticular anterior cruciate ligament graft placement on the average most isometric line on the femur. Does it reproducibly restore knee kinematics?

In the past, there has been a plausible hypothesis that anterior cruciate ligament graft placement at isometric sites, such that the tibial and femoral attachment sites remain equidistant from each other throughout knee range of motion, would increase the likelihood of a satisfactory outcome. For a given tibial placement we wanted to determine whether placing the graft on the average of the most isometric femoral line, a fixed distance from the outlet of the intercondylar notch, would return normal laxity to all knees. The three-dimensional kinematics of seven cadaveric knees were measured for angles from full extension to 90 degrees of flexion at 15 degrees increments. Physiologic levels of quadriceps muscle forces were applied to the intact knee, after transection of the anterior cruciate ligament, and after ligament reconstruction with a patellar tendon graft. On average, the reconstruction was found to return anterior-posterior translation, internal-external rotation, and varus-valgus rotation to levels not significantly different from those of the intact knee. However, the ranges of the translation and rotations were large. Placing the graft on the average most isometric femoral line did not restore knee laxity to normal in all knees. This supports the need to customize graft placement in each knee at the time of surgery.

Results of isolated patellar debridement for patellofemoral pain in patients with normal patellar alignment.

We reviewed the records of 36 patients who underwent arthroscopic patellar debridement for patellofemoral pain. All patients had isolated chondromalacia patellae noted during arthroscopic examination. No patient had a history of patellar instability or physical or radiographic signs of patellar malalignment. The chondromalacia patellae was classified as traumatic or atraumatic in origin. All patients had failed results after a minimum of 4 months of physical therapy before surgery, and all patients had grade 2 or worse chondromalacia patellae at the time of debridement. At the time of followup, patients were evaluated by questionnaire, Fulkerson-Shea Patellofemoral Joint Evaluation score, independent physical examination, and radiographs. Patients were also asked to subjectively score their knees preoperatively, at the time of maximal improvement postoperatively, and at the time of followup for comparison. Preoperative examinations and radiographs were compared with examinations at the time of followup. The most significant finding was the improvement in the overall joint evaluation score. The score for the entire group improved from a mean of 51.9 preoperatively to 78.8 at the time of maximal improvement and 75.3 at the time of followup. All but four patients subjectively thought that surgery had a beneficial effect. There were no observed changes in the preoperative and postoperative radiographs. Patients with traumatic chondromalacia patellae had 57.9% good or excellent results with surgery, and the patients with atraumatic cases had 41.1% good or excellent results with surgery, indicating that many patients who were improved by the surgery still had functional limitations.

Arthroscopic arthrolysis for flexion contracture following intraarticular reconstruction of the anterior cruciate ligament.

This article describes the surgical technique and expected results for arthroscopic arthrolysis for the treatment of flexion contracture following anterior cruciate ligament (ACL) reconstruction. The technique emphasizes a systematic approach to the surgical procedure followed by an intensive rehabilitation program. The results in 11 patients treated with this technique are reviewed. They averaged 12.6 months from the index ACL reconstruction. Despite extensive physical therapy, their mean preoperative flexion contracture was 19 degrees, mean total range of motion was 94 degrees, and mean preoperative Lysholm score was 67. At a mean follow-up of 22 months following arthrolysis and physical therapy, mean flexion contracture improved to 2 degrees, total range of motion improved to 125 degrees, and mean Lysholm score improved to 94.

Grip lock injuries to the forearm in male gymnasts.

We performed an epidemiologic survey to estimate the number of grip lock injuries occurring among male high school and college gymnasts. These injuries occur when dowel grips used by the gymnast become locked on the bar as the gymnast's momentum carries him through the skill being performed. We also questioned injured gymnasts to obtain details of their injuries. Thirty-eight high school coaches reported 17 injuries and 32 college coaches reported 21 injuries for a 10-year period; 36% of the coaches responding reported at least one such injury in their program. Of the 23 injured gymnasts who returned detailed questionnaires, 20 had sustained fractures and 9 required surgery. The distal forearm or wrist were the areas injured most often. Fourteen gymnasts had residual pain, seven had functional limitations, and eight had limited motion in the wrist. Fifteen of the 23 athletes were using a cubital (hyperpronated) grip at the time of injury and 19 were using dowel grips. Among the reasons cited for the injury, 18 gymnasts thought that their grips were either too large, worn, or stretched; 8 said the grips slid up their wrists, and 7 cited technical errors.

A comparison of intraarticular morphine and bupivacaine for pain control after outpatient knee arthroscopy. A prospective, randomized, double-blinded study.

To determine the duration of pain relief and efficacy of intraarticular morphine compared with bupivacaine after outpatient knee arthroscopy under local anesthesia, we gave patients one of three postoperative intraarticular injections: 4 mg morphine, 0.25% bupivacaine, or 0.9% saline. Visual analog scale scores and supplemental pain medication use were recorded at 0 to 30 minutes, 2, 4, 6, 8 to 12, and 24 hours after surgery. The score on the visual analog scale at 24 hours was significantly lower in the morphine group than in the bupivacaine or control groups. The cumulative amount of pain medication used was significantly lower in the morphine and bupivacaine groups at 2 to 6 hours after surgery than in the saline control group. The morphine group used the least supplemental pain medication during the 12 to 24 hour interval (P = 0.06). We found that the use of intraarticular morphine or bupivacaine after outpatient knee arthroscopy will decrease the amount of narcotic medication needed for pain relief during the early postoperative period. In addition, morphine provided prolonged pain relief up to 24 hours when compared with bupivacaine or placebo, and the patients in the morphine group tended to take less supplemental pain medication during the first postoperative day.

The effects of arthroscopic partial lateral meniscectomy in an otherwise normal knee: a retrospective review of functional, clinical, and radiographic results.

A retrospective review of patients who underwent arthroscopic partial lateral meniscectomy for lateral meniscus tears in otherwise normal knees was conducted to review the long-term functional, clinical, and radiographic results. Twenty-six patients (27 knees) were evaluated by questionnaire; 20 patients (21 knees) also underwent physical examination and radiographic analysis. Minimum follow-up was 5 years and mean follow-up was 8 years. Patient data were obtained from detailed questionnaires, knee examinations, and radiographs. Excellent or good results decreased from 92% at the time of maximal improvement to 62% at the most recent follow-up: 85% of patients were initially able to return to their preinjury activity level; however, only 48% were able to maintain this level of activity at the most recent follow-up. Seventy-two percent of patients had either one or no Fairbank changes and there was no statistical difference when comparing radiographic criteria in the operated and nonoperated knee. Early results for partial lateral meniscectomy can be quite good; however, significant deterioration of functional results and decreased activity level can occur. Radiographic changes did not correlate with subjective symptoms and functional outcome in our patient population. Our findings suggest that the functional outcome for patients undergoing partial lateral meniscectomy may deteriorate with time and it may be helpful to counsel patients concerning long-term expectations.

Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation. A five-year follow-up study.

A prospective study was designed to provide 5-year followup of the treatment of isolated grade III sprains of the medial collateral ligament with early functional rehabilitation in 35 athletes. After injury, patients were placed in lateral hinged braces to provide valgus support without restricting flexion or extension of the knee. Treatment was initiated with range of motion exercises performed in a whirlpool or swimming pool. Patients were then started on quadriceps setting and leg raises. When 90 degrees of flexion was present, resistive exercises were added. Upon recovery, patients were allowed to return to unrestricted sports. Followup consisted of both questionnaires and physical examination and was graded on the 50-point Hospital for Special Surgery scale. Mean followup was 5.3 years (range, 2.5 to 8); mean Hospital for Special Surgery knee rating score was 45.9 points (range, 41 to 50). These results are comparable with those achieved with surgery or immobilization by earlier investigators. Thus, early functional rehabilitation treatment of complete medial collateral ligament sprains produces results comparable with those achieved with surgery or immobilization while minimizing treatment-related morbidity and allowing more rapid return to sports participation.

Gait adaptations by patients who have a deficient anterior cruciate ligament.

Sixteen patients who had unilateral deficiency of the anterior cruciate ligament and ten healthy control subjects were analyzed during level walking, jogging, and ascending and descending stairs. Kinematic and kinetic findings for the right and left hips, knees, and ankles of all of the patients and control subjects were recorded during each activity. Substantial differences from normal function were observed for both limbs of the patients during level walking and during jogging. The magnitude of the maximum moment that tended to flex the knee was reduced the most (140 per cent) during level walking. It was reduced less (30 per cent) during jogging, it was not changed while the patient descended stairs, and it was slightly increased while he or she ascended stairs. The reduction in the magnitude of the flexion moment about the knee was interpreted as the patient's effort to reduce or avoid contraction of the quadriceps. Reduction of the flexion moment reduces any contraction of the quadriceps because there must be a mechanical balance between the external moment (due to body weight and the weight and inertia of the segment of the limb) that tends to flex the knee and an internal moment (generated by contraction of the quadriceps) that tends to extend the knee. This so-called quadriceps-avoidance gait was related to the angle of flexion of the knee when the maximum flexion moment occurred during each activity. This angle of flexion was 20 degrees during walking, 40 degrees during jogging, and approximately 60 degrees during stair-climbing.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of cruciate ligament injury using single contrast arthrography.

To evaluate the accuracy of arthrography for assessing the status of the anterior cruciate ligament (ACL), 212 arthrograms from 212 knees in 205 consecutive patients undergoing single contrast arthrography and subsequent arthroscopy or arthrotomy were reviewed. Criteria for evaluation of the ACL included the clarity of its radiographic appearance as well as the anterior laxity of the knee as seen on manual stress views. Of the 111 knees having intact ACLs at surgery, 98 (88%) were evaluated correctly by arthrography. Of the 101 knees having a damaged ACL, 85 were read as torn or attenuated on the arthrogram. When the torn and attenuated ligaments were considered separately, accuracy was decreased. Of the 87 ligaments actually torn, 68 (78%) were read as torn and 9 (10%) as attenuated. Of the 14 actually attenuated, 5 (36%) were read as attenuated and 3 (21%) as torn. Of 114 arthrograms read as intact, 98 (86%) were correct. Of 77 arthrograms read as torn, 68 (88%), were correct. Of 21 arthrograms read as attenuated, 5 (24%) were correct. Of 114 torn medial menisci, 112 (98%) were correctly diagnosed, as were 38 (69%) of 55 torn lateral menisci. Sixteen of the 17 missed lateral meniscus tears were in knees with torn medial menisci. Single contrast arthrography is, therefore, highly accurate in distinguishing intact from damaged ACLs. The distinction between torn and attenuated ligaments, however, is not valuable.

Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure.

For the past five years we have attempted to correct knee instability due to rupture of the posterior cruciate ligament with a procedure that employs a free graft of one-third of the patellar tendon with its tibial and patellar attachments. This procedure was done for chronic instability in thirty-three patients and was combined with primary repair of an acute mid-substance tear of the posterior cruciate ligament in fifteen patients. Moderate to severe articular injury of the medial femoral condyle was found at operation in 48 per cent of the patients with chronic injury. Seventy-one per cent of the patients for whom the interval between injury and ligament reconstruction was two to four years, and 90 per cent of those for whom the interval was more than four years, showed articular injury of the medial femoral condyle. Only 31 per cent of the patients, however, had preoperative radiographic findings that indicated femoral articular damage. Twenty-three of the twenty-five patients with a minimum follow-up of two years returned for evaluation. All of the ten patients who had had a repair and reconstruction of an acute ligament injury (whose average follow-up was forty-one months) had a static and functional result that was graded as good or excellent. Of the thirteen patients for whom surgery was done for chronic instability (whose average follow-up was thirty-one months), the over-all static and functional result was graded as good or excellent in eleven. These results indicate that the use of one-third of the patellar tendon for reconstruction in patients with acute mid-substance tears as well as in patients with symptomatic chronic instability of the posterior cruciate ligament is an effective procedure for achieving static and functional stability of the knee.

Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers.

Eighty patients with persistent clinical and functional instability of the knee due to anterior cruciate ligament insufficiency underwent the operation reported, in which one-third of the patellar ligament substitutes for the cruciate ligament and extraarticular tendon transfers, medial and lateral, augment the substitution. The patients were followed for a minimum of two years, and fifty returned for personal evaluation. The average follow-up was thirty-three months, with a range of two to five years. There were thirty-five male and fifteen female patients. The average age was twenty-three years. The average interval from initial injury to the index operation was two years. Meniscal tears and articular changes were noted in most of the patients. Forty-three (86 per cent) of the fifty patients had at least one torn meniscus, twenty-seven patients (54 per cent) had significant degenerative articular changes, and fourteen (28 per cent) had patellar articular changes. In the procedure described, eccentric placement of the tibial and femoral tunnels for more accurate placement of the patellar ligament substitute is essential. The over-all results were graded as excellent in thirty knees, good in seventeen, fair in one, and a failure in two. One knee that was classified as a failure showed excellent stability, but the patient had significant pain from chondromalacia of the patella, while significant pain and hyperesthesia from a neuroma was the reason for failure in the second patient.

Clinical characteristics of patellar disorders in young athletes.

The clinical histories of 50 young athletes who complained of patellar instability or pain were analyzed, and their physical findings were compared to those of 50 controls. The patients were divided into three groups, based on their symptoms. Analysis of their physical findings confirmed the validity of these divisions. Those who complained of frank dislocation of the patella exhibited the most pronounced stigmata of quadriceps dysplasia, including vastus medialis deficiency and infrapatellar fat pad enlargement, and had increased general ligamentous laxity, increased mean patellar mobility, and out-facing patellae with concomitantly decreased Q angles in chronic, recurrent cases. Patients who complained of the classic patellar pain pattern, often called "chondromalacia patella," but who denied swelling were designated CMP. They had normal mean ligamentous laxity and mean patellar mobility, an increased incidence of in-facing patellae with concomitantly increased mean Q angle, and frequently palpable lateral patellofemoral bands. Patients who complained of pain and swelling had physical findings intermediate to the other two groups, and generally correspond to what is usually termed subluxation of the patella. They exhibited normal general laxity but increased mean patellar mobility, normal mean Q angle but an increased incidence of patellar infacing, and fat pad enlargement.

Patellar tracking.

Patellar tracking patterns were studied in 20 cadaver knees. The predominant pattern (Type 1) found in 17 knees included medial shift and medial tilt of the patella with respect to the tibial tubercle during extension of the knee. The remaining three knees (Type 2) showed a tendency toward lateral shift and tilt. Release of the lateral retinaculum had no effect on patellar tracking in most knees, while release of the medial retinaculum produced abnormal tracking in many Type 1 knees and all Type 2 knees. The "proximal realignment" (medial imbrication-lateral release) procedure increased the tendency of the patella to tilt and shift medially during extension.

The anterior aspect of the knee joint.

The anterior structures of forty-eight knees were dissected analyzed quantitatively. Correlations were established among the twelve measured parameters of the distal quadriceps complex. Patellar height, width, and thickness tended to correlate with the dimensions of the soft-tissue structures and not with each other. To a high degree of predictability, the shape of the patella correlated with several parameters of the quadriceps complex. The width of the lateral patellofemoral ligament was the parameter most closely related to patellar shape.

The anterior cruciate ligament: a technique of repair and reconstruction.

Both primary repair and late substitution of anterior cruciate ligaments can be accomplished by intra-articular methods. This principle is to provide temporary struts that are initially avascular but can later undergo revascularization and metaplasia to form a new ligament. The graft does afford initial support, however. An understanding of anatomic principles, suture placement, freedom of graft from impingement, avoidance of acute angular deviation of the graft, solid static stability, anatomic attachment points, and blood supply, is absolutely essential for success in this field of surgery.