The relationship between the intercondylar roof and the tibial plateau with the knee in extension: relevance for tibial tunnel placement in anterior cruciate ligament reconstruction.

The relationship between the intercondylar roof and the tibial plateau with the knee in full extension was studied in 100 patients with a unilateral anterior cruciate ligament (ACL) lesion. A lateral view of both knees in full extension with superimposition of the femoral condyles was obtained with the fluoroscope. We found that, in the normal knee, the roof line intersects the tibial plateau (roof-plateau intersection ratio) at 31.5% (SD +/- 5%) of its width and at 33.9% (+/- 5.4%) in the ACL deficient knee (P < .001). The difference was attributable to a subtle anterior tibial displacement in the ACL-deficient knee. Multiple regression analysis showed a direct relationship between roof-plateau intersection ratio and the angle between roof line and tibial plateau (P = .0006). A direct relationship of borderline significance (P = .06) was present with the knee recurvatum measured clinically. In conclusion, the roof-plateau intersection ratio has a wide range of variability (22% to 41%). The larger the roof-plateau angle the more posterior the roof-plateau intersection ratio.

Anatomic versus non-anatomic tibial fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft.

We prospectively compared two series of 30 anterior cruciate ligament (ACL) reconstructions each where the bone-patellar tendon-bone graft was alternately fixed at the level of the tibial plateau (group A; anatomic fixation) or distal to the plateau level (group B; non-anatomic fixation). In group A, a 35-mm-long tibial tuberosity bone block was harvested. The distal 10-15 mm were resected and fixed proximally to the undersurface of the tendon to shorten it. After an average 18 months' follow-up, there were no significant differences between the two groups concerning subjective evaluation, symptoms, range of motion and objective stability. Tibial tuberosity pain was more frequent in group A (53% vs 17%, P = 0.01). Radiographic evaluation showed that tibial tunnel enlargement was less frequent in group A (23% vs 43%, P = 0.02). There was no correlation between tunnel enlargement and objective stability. In conclusion, fixation of the graft at the tibial plateau level did not improve objective stability in this study. Because of the greater technical difficulty and occurrence of tibial tuberosity pain, this technique is not recommended.

Arthroscopic-assisted anterior cruciate ligament reconstruction with the central third patellar tendon. A 5-8-year follow-up.

We reviewed 89 arthroscopically assisted patellar tendon anterior cruciate ligament (ACL) reconstructions for chronic isolated injuries with an average follow-up of 7 years (range 5.4 to 8.6 years). Pain was present in 7 knees (8%). Giving-way symptoms were reported by 7 patients (8%). A KT-2000 side-to-side difference over 5 mm at 30 lbs was recorded in 12 cases (16%). The pivot shift was glide in 17 cases (19%) and clunk in 10 (11%). A 3 degrees-5 degrees extension loss compared with the normal side was present in 20 knees (22%) and 6 degrees-10 degrees in 4 knees (4%). The intra-articular exit of the femoral tunnel was misplaced in the anterior 50% of the condyles along the roof of the notch in 10% of the knees. This positioning significantly (P = 0.003) increased the frequency of graft failure (62.5%) compared with the cases with a more posterior placement (graft failure 12%). An anterior position of the intra-articular exit of the tibial tunnel (in the anterior 15% of the sagittal width of the tibia) significantly (P = 0.01) increased the frequency of extension loss > 5 degrees. Medial meniscectomy was associated with a 35% incidence of narrowing of the medial joint space, which was significantly higher compared with knees with normal menisci (9%; P = 0.04) or with medial meniscal repair (7%; P = 0.05). In conclusion this study showed satisfactory anterior stability (KT-2000 side-to-side difference up to 5 mm and pivot absent or glide) in 83% of the knees. This percentage increases to 88% in the knees with a correct posterior and proximal femoral tunnel placement. Accuracy in tunnel positioning is essential for the success of ACL surgery. Meniscal repair was effective in decreasing joint space narrowing and should be attempted when possible.

The Insall-Burstein posterior stabilized total knee replacement in the valgus knee.

Sixty-seven Insall-Burstein (Zimmer Inc, Warsaw, Indiana) posteriorly stabilized total knee replacements were implanted in knees with a preoperative alignment > 10 degrees of valgus (average: 19.5 degrees). An anteromedial approach with release of the lateral ligaments of the femur was used. A lateral patellar release was necessary in 49% of cases. Fifty-one knees (76%) were reviewed with an average follow-up of 6 years. Pain at follow-up was absent or mild in all of the knees except one with aseptic loosening of the tibial and patellar components. The average flexion was 105 degrees. The results according to the Knee Society Rating System were excellent in 53%, good in 39%, fair in 6%, and poor in 2%. A patellofemoral "clunk" was present in three knees (6%), and one knee required arthroscopic debridment. The mechanical axis was within 5 degrees of neutral in 88%. A survivorship analysis was performed using failure requiring reoperation as the end point. There were four failures due to aseptic loosening, symptomatic lateral ligamentous instability, deep infection, and recurrent patellar dislocation. The patellar component had not been implanted in the knee with recurrent patellar dislocation due to severe bony erosion. The cumulative success rate was 95% at 10 years. These results indicate that release of the contracted lateral structures and implantation of a posteriorly stabilized prosthesis achieve a stable and well-aligned knee in 66 out of 67 knees. Attention must be paid to patellar tracking and realignment of the extensor mechanism.

Neural system of the human posterior cruciate ligament in osteoarthritis.

The purpose of this study was to quantify the neural elements in a group of posterior cruciate ligaments from osteoarthritic patients in comparison with normal subjects. Nine ligaments obtained from total knee arthroplasty procedures and five control ligaments from amputated limbs or fresh cadavers were stained with gold chloride. The percentage area occupied by the receptors and the neural network was determined by means of a computer-assisted image analyzer. A significant reduction of the neural elements was observed in the group of ligaments from osteoarthritic patients (0.44 +/- 0.132 SEM vs 0.958 +/- 0.13 SEM, P = .001). The loss of mechanoceptors and the consequent reduction of neural afferences may reduce the functional stability of the joint, participating in the osteoarthritic degenerative process.

Insall-Burstein posterior-stabilized knee prosthesis in rheumatoid arthritis.

The authors reviewed 65 Insall-Burstein (Zimmer, Warsaw, IN) total condylar posterior-stabilized knee prostheses in 50 patients with rheumatoid arthritis with a follow-up period of at least 5 years (range, 5-13 years). Forty-two knees in 31 patients were evaluated using the Knee Society knee and functional rating scores. Radiographic assessment was performed using standing long radiographs (hip to ankle). Radiolucent lines were studied using fluoroscopic-centered views. Excellent or good clinical results were obtained in 95% of the cases, and the average knee score improved from 22.5 to 90 points. No cases of radiologic loosening were observed. Incomplete radiolucent lines around the tibial component were detected in only 17% and were nonprogressive. Two patients developed hematogenous late deep infection, which required removal of the prosthesis in both, followed, at a second stage, by arthrodesis in one and prosthesis reimplantation in the other. Three knees (7%) had a painful impingement of the patella. Two of these were successfully reoperated with arthroscopic debridement of the peripatellar synovial tissues. Survivorship analysis, based on endpoints such as prosthesis removal for any cause or radiologic loosening (complete radiolucent line thicker than 1 mm, tilt, or subsidence of the component), showed a cumulative success rate of 96.2% at 13 years.

A comparison of clinical and radiological parameters with two arthroscopic techniques for anterior cruciate ligament reconstruction.

We performed a comparative study of two series of 25 patellar tendon arthroscopic reconstructions of isolated chronic anterior cruciate ligament injuries, alternating between a double-incision (using a rear-entry guide) or single-incision technique (using a transtibial approach). The patients were reviewed to assess the clinical, KT-2000 and radiological differences at an average follow-up of 14 months (range 8-18 months). For the clinical evaluation the International Knee Documentation Committee Form was used. The following radiographic parameters were measured: (1) the direction of the femoral and tibial tunnels in the antero-posterior (AP) and lateral (LL) views; (2) the location of the anterior border of the intra-articular exit hole of the femoral tunnel in the LL radiologic view; (3) femoral interference screw divergence with the bone block. An extension loss < or = 5 degrees was detected in 40% of the double-incision and 36% of the single-incision patients (NS). A flexion loss < or = 10 degrees was present in 8% of the double-incision and 16% of single-incision group (NS). There were no differences in terms of pivot shift test between the two groups (pivot glide in 12% of both groups). The average side-to-side KT-2000 differences at the manual maximum test were 1.98 mm in the double-incision and 2.64 mm in the single-incision group. With the double-incision technique the femoral and tibial tunnels were divergent in the AP plane and crossed the joint at an angle of 37 degrees and 72 degrees, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of surgical treatment of arthrofibrosis after ACL reconstruction.

We prospectively studied 31 knee arthrolyses performed for loss of motion after intra-articular anterior cruciate ligament (ACL) reconstruction. The arthrolysis was performed on average 10.6 months after the reconstruction (range 4-25). Seven knees were localized forms. They were treated with arthroscopic removal of a fibrous nodule and scar tissue anterior to the ACL, which was preserved. Twenty-four knees were global forms and treated arthroscopically (14) or in open procedure (10). Suprapatellar, medial, and lateral gutter adhesions were sectioned, and fibrous tissue was removed from the anterior compartment. A posteromedial and/or posterolateral capsulotomy was necessary in 7 knees. The ACL graft was nonfunctional and/or malpositioned in 19 knees. The results were evaluated with the IKDC form with an average follow-up of 3.5 years (range 1.5-7). Preoperatively the localized forms had an average extension loss of 11 degrees and an average flexion loss of 14 degrees compared to the opposite knee. At follow-up all the knees were satisfactory for symptoms. All except one achieved a satisfactory motion (within 5 degrees of extension loss and 15 degrees of flexion loss) and a satisfactory final result. Global forms had a greater preoperative flexion loss (average 34 degrees) and extension loss (average 17 degrees). At follow-up 58% were satisfactory for symptoms and 71% for arc of motion. However, the final result was satisfactory in only 37%. In conclusion, local forms have a good prognosis. In global forms motion may be improved by surgery, but the final result is downgraded by symptoms. Arthrolyses performed within 8 months from index operation had a better outcome.

A comparison between medial meniscus repair, partial meniscectomy, and normal meniscus in anterior cruciate ligament reconstructed knees.

A clinical, radiographic, and scintigraphic comparative study was performed on 57 consecutive successful patellar tendon anterior cruciate ligament reconstructions for chronic laxity. Patients were divided into 3 matched groups according to the medial meniscal treatment. Group A included 18 patients with medial meniscal repairs; Group B, 19 patients with partial medial meniscectomies; and Group C, 20 patients with normal menisci (controls). The average followup was 55 months. At clinical examination, patients in Group B had more activity-related pain than those in Group C (p = 0.04). The anteroposterior weight-bearing views in extension showed more degenerative changes in the medial compartment in Group B than in the other 2 groups (Group A versus B, p = 0.01; Group C versus B, p < 0.001). Scintigraphy showed an increased uptake in the operated knee as compared with the normal side (11%), but no differences among the 3 study groups. The patients with partial meniscectomies had more pain and degenerative radiographically evident changes than the control group. Medial meniscal repair offers a better chance than partial meniscectomy to preserve the articular cartilage of the medial compartment. Bone homeostasis, as detected by bone scanning, remains slightly altered in successful reconstructions as compared with the opposite normal side.

Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction.

The results of intraarticular anterior cruciate ligament reconstruction with either the patellar tendon or the semitendinosus and gracilis tendons (four strands) were prospectively compared in a consecutive series of 60 patients with chronic injuries. A single surgeon performed arthroscopically assisted reconstructions in an alternating sequence. Preoperative and operative data revealed no significant differences between the two groups. After 28 months of followup there were no significant differences in the incidence of symptoms, and recurrent giving way was present in only one knee with semitendinosus and gracilis tendon graft. Return to sport participation was more frequent in the patellar tendon group (80% versus 43%, P < 0.01). A minor extension loss (< or = 3 degrees) was more frequent in the patellar tendon group (47% versus 3%, P < 0.001). Other differences between the two groups were not significant. KT-2000 arthrometer side-to-side difference of anterior displacement > 5 mm at 30 pounds was present in 13% of the knees with patellar tendon grafts and in 20% of those with semitendinosus and gracilis; a patellofemoral crepitation developed in 17% and 3% of the two groups, respectively. Based on these data we routinely use patellar tendon grafts. Semitendinosus and gracilis tendons are preferred in selected cases: older patients, patients with preexisting patellofemoral problems, and those with failed patellar tendon grafts.

Patellofemoral problems after intraarticular anterior cruciate ligament reconstruction.

A series of 226 anterior cruciate ligament (ACL) reconstructions were reviewed to determine the incidence of patellofemoral (PF) problems and the associated prognostic factors. Patients were divided into four groups according to the type of injury (acute or chronic) and operation (through an arthrotomy or arthroscopic assisted). The average follow-up period was 39 months. Overall there was a 5% incidence of PF crepitus with pain and/or swelling, and a further 20% of clear PF crepitus without pain. The change from open surgery and cast to arthroscopic surgery and early motion allowed a decrease of PF problems from 40% to 21% in acute injuries, but the difference was less marked in chronic knees. A deficit greater than 10% at the one-leg hop test was present in 75% of the knees with PF crepitus and pain. The height of the patella was increased in 5% and decreased in 17% of the knees. Patients with rehabilitation difficulties had the largest decrease in patella height, whereas a patella alta was more frequent after patellar tendon reconstruction. A significant correlation was found between PF problems and female gender, positive congruence angle, preoperative PF crepitation, rehabilitation difficulties, flexion loss greater than 10 degrees, extension loss greater than 5 degrees, and variation in the height of the patella. The importance of avoiding immobilization, rehabilitation difficulties, and permanent flexion or extension loss is emphasized.

Arthroscopic anterior cruciate ligament reconstruction with patellar tendon.

Anterior cruciate ligament reconstruction using a bone-patella tendon-bone free autologous graft was performed with an arthroscopic technique in 73 patients with chronic insufficiency. Sixty-nine (94.5%) were available for personal follow-up 3-5 years after the operation. Six patients (8%) had had postoperative difficulties in regaining a complete range of motion. Symptoms of giving-way were cured in 97% of the cases, and 89% had returned to vigorous activities. Residual anterior laxity (defined as pivot shift 2+, and/or Lachman 2+, and/or KT-1000 > 5 mm at the manual maximum) was found in 13% and was more frequent in patients with an uncorrected varus laxity. Patellofemoral crepitus was present in 17% of the knees and was associated with pain and/or swelling in a further 4%; it correlated with radiographic evidence of patellofemoral incongruence (p = 0.009). Comparison of the results with those of a previous series performed by arthrotomy revealed a decreased incidence of limited range of motion, severe patellar symptoms, and changes in patellar height. Stability was the same.

Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis.

Forty-four patients with symptomatic chronic anterior cruciate ligament instabilities that had been reconstructed with the central one-third patellar tendon and a lateral extraarticular iliotibial band tenodesis were studied at an average followup of 7 years (range, 4 to 10). The cases with associated medial, lateral, or posterior laxity were not included, nor were the cases with more than minimal preoperative degenerative changes. The average age at surgery was 21 years (range, 16 to 33). A postoperative cast was used for 4 weeks. Satisfactory objective stability, which was defined as a KT-1000 side-to-side difference of up to 5 mm at the manual maximum test, was obtained in 37 (84%) of the patients. In 25 patients (57%), stability was restored within normal limits (less than or equal to 3 mm). No deterioration of the KT-1000 stability was noted at two follow-up visits performed by the same examiner (at an average of 4 and 7 years). A return to high-risk sports was possible in 27 (62%) of the patients. Difficulties in regaining a complete range of motion were recorded in 5 (11%) of the patients. A flexion contracture of 5 degrees to 7 degrees was also found in 5 patients. Significant patellofemoral symptoms were present in 4 patients (9%). A 5% to 11% shortening of the patella tendon was observed in 14 (32%) of the knees, but did not correlate with patellar problems. Moderate radiographic changes were noted in eight patients (18%) at followup and correlated with meniscectomy and pain. Overall satisfactory results were obtained in this initial experience in 29 (66%) of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the chronically lax anterior cruciate ligament using the middle third of the patellar tendon. A 3-9 year follow-up.

After an average of 5 years, the authors reviewed 76 cases of anterior cruciate ligament reconstruction in which the middle third of the patellar tendon had been used as a free autogenous graft. A lateral Lemaire operation had been used in 85% of the cases and postoperative cast immobilization in 72%. Functional knee instability was eliminated in 96% of the patients. Pain was present at the follow-up in 14.5% of the patients and correlated with both meniscectomy (p = 0.03) and the presence of degenerative changes on the radiographs (p = 0.002). The pivot-shift was eliminated in 93% of the cases and the maximum manual test performed with the KT-1000 arthrometer was less than or equal to 5 mm in 83%. Lateral compartment laxity which was not corrected at operation was frequently associated with graft failure (p = 0.01). Seven patients had difficulty in rehabilitation, and in 6 of these the final result was unsatisfactory. Pain and swelling in the femoropatellar joint were present in 8% of the cases. Slight and moderate degenerative changes were shown on the radiographs in 48% and 10% of the patients, respectively, at follow-up; these findings correlated with meniscectomy (p less than 0.001) and rehabilitation problems (p = 0.03). This procedure achieved lasting, satisfactory results in 70% of the cases. Additional advances include greater care in positioning the graft, use of arthroscopy, and early mobilization. Further studies are needed to verify the advantages of these new techniques.

[Epidemiologic and diagnostic observations on hemorrhage of the upper gastroenteric tract]. / Osservazioni epidemiologiche e diagnostiche sulle emorragie del tratto gastroenterico superiore.

Acute upper gastrointestinal (GI) bleeding causes, according to the authors' experience, 1.65% of all annual hospitalizations. Mortality rate among high risk patients is about 20% and cirrhotic patients have a particularly poor outcome (70% of deaths caused by gastrointestinal hemorrhage). Endoscopy has been performed in 329 cases to identify the active site of bleeding (7.22% of 4791 "EGDS" performed from 1984 to 1988). In this retrospective study gastric and duodenal peptic diseases, have been observed more frequently than esophageal varices ruptures (11.8%) and in 25% of patients Gl bleeding was associated with the use of potentially dangerous drugs (NSAID and/or Steroids). A prompt endoscopy is fundamental to recognize the etiology and for a better management of the patient; unfortunately, even if improvements have been obtained in the diagnosis and therapy, the mortality caused by gastrointestinal hemorrhage is not significantly reduced.