The correlation between anterior-posterior translation and cross-sectional area of anterior cruciate ligament reconstructions.

Total anterior-posterior translation is commonly used to assess the integrity of the cruciate ligaments and the success of reconstructive surgery. The purpose of this study was to determine, after surgical reconstruction of the anterior cruciate ligament with a biological graft, if total anterior-posterior translation correlated with graft length, cross-sectional area, or mechanical properties. These factors were investigated by analyzing data from three previous studies. These studies involved replacement of the anterior cruciate ligament in cynomolgus monkeys and goats, with free and vascularized patellar tendon autografts and both patellar tendon and anterior cruciate ligament allografts. Data were available at time periods of 6 and 12 months after surgery. We found statistically significant inverse correlations between the amount of anterior-posterior translation and cross-sectional area of a graft at the time of sacrifice. The Pearson correlation coefficients ranged from -0.966 (p < 0.002) to -0.830 (p < 0.05). We hypothesize that these correlations result from the following mechanism: the increased anterior translation reflects a slack graft; a slack graft is stress shielded by other structures about the knee; the reduced in vivo stresses on the graft modulate cellular metabolism in a way that over time produces a small cross-sectional area.

Lateral meniscal variant with absence of the posterior coronary ligament.

We reviewed the cases of 3468 patients who had had arthroscopy of the knee between January 1976 and December 1988. Twenty-six patients (0.8 per cent) had a partial or a complete discoid lateral meniscus, and seven (0.2 per cent) had the Wrisberg-variant-type lateral meniscus. Of the seven patients, six had operative stabilization of the meniscus and one had a partial lateral meniscectomy because of an irreparable complex tear. Subjective, objective, and radiographic evaluations were performed on the patients who had had stabilization of the meniscus. According to the scale of Tegner and Lysholm, the result was excellent in four patients, good in one, and fair in one. None of the six patients had a tear of the sutured meniscus after an average follow-up of thirty-two months (range, twenty-four to forty months). Two patients had progressive symptoms attributable to osteoarthrosis, but the changes in the articular cartilage had been present at the time of the index procedure. None of the seven Wrisberg-variant-type menisci demonstrated a true discoid shape of the meniscus. We therefore classified this lesion as a lateral meniscal variant with absence of the posterior coronary ligament.

Suprascapular neuropathy in the differential diagnosis of rotator cuff injuries.

Four cases of suprascapular neuropathy treated by nonoperative means have been presented. Complete recovery occurred in all four. The anatomy of the suprascapular nerve and probable mechanisms of injury secondary to traction have been discussed. The importance of electromyography in diagnosis has been stressed. Longer periods of nonoperative treatment are recommended here than by previous authors. Since the lesion is felt not to be an entrapment phenomenon but, rather, a traction injury, operative treatment should consist of release of the nerve at the notch to reduce the possibility of further traction injury, and a neurolysis should be done as well.

Operative treatment of posterior shoulder dislocations by posterior glenoidplasty, capsulorrhaphy, and infraspinatus advancement.

Posterior dislocations of the shoulder are rare, comprising only 4% of shoulder dislocations. Several operative procedures have been described in treating recurrent dislocations, and results have been varied. A retrospective review of eight shoulders in eight patients treated by posterior glenoidplasty with capsulorrhaphy and infraspinatus advancement revealed generally good results. Followup ranged from 10 to 114 months, with an average of 36 months. Seven patients were classified as recurrent traumatic dislocators and one as a recurrent atraumatic voluntary dislocator. Results graded as good, fair, and failure were based on pain, range of motion, return to activities, recurrence, and roentgenograms. Six patients had good results with return to full activity, full range of motion, no pain, no recurrence, and no degenerative changes of roentgenograms. One patient, who has not returned to athletic activities and has occasional pain and limited range of motion, was graded as a fair result. The patient classified as an atraumatic voluntary dislocator has occasional feelings of instability and slight pain with strenuous activity, but has not had a recurrence and has no difficulty with activities of daily living. She was also classified as a fair result. There have been no recurrences or degenerative changes on followup radiographs. Computerized tomography performed on two patients documented a definite change in orientation of the glenoid. We feel that glenoidplasty with capsular reefing and infraspinatus advancement, if performed carefully, provides an excellent operative treatment for recurrent posterior dislocations of the shoulder.

Ethyl chloride: an ineffective bacteriostatic or cidal agent for arthrocentesis.

The local and general anesthetic properties of ethyl chloride have been well delineated. The purpose of this study was to determine if ethyl chloride, when used as a local anesthetic, had any bacteriostatic or cidal effects on the normal array of skin flora. Fifteen different aerobic bacteria or fungi were collected from pure cultures. A total of 30 specimens were sprayed; 2 specimens of each of the 15 bacteria were sprayed with ethyl chloride for both 5 and 10 seconds. These specimens then were restreaked once the ethyl chloride had evaporated, and were incubated for 24 hours. At 24 hours the cultures were checked and found to have no significant growth inhibitions. It is thus concluded that ethyl chloride alone does not have any bacteriostatic or cidal effects on these commonly found skin flora.

Jejunal rupture in a football player.

An 18-year-old football player sustained a jejunal rupture when he was struck in the abdomen during a high school football game. Such abdominal injuries in contact sports are rare; however, it is imperative that team physicians, trainers, and coaches be aware of such injuries.

Cryotherapy and nerve palsy.

Ice application is one of the most extensively used treatments for athletic injuries. Frostbite is a recognized danger. Five cases of nerve palsy resulting from ice application are reported here. These palsies were temporary. They usually resolve spontaneously without any significant sequelae. This complication can be avoided by not using ice for more than 30 minutes and by guarding superficial nerves in the area.

Anterior cruciate ligament injuries in patients with open physes.

From July 1988 to August 1989, six children with open physes and injuries to the anterior cruciate ligament were treated operatively. All injuries involved twisting episodes during sports activities. All six patients had meniscal abnormalities, and, additionally, one patient sustained a Grade III medical ligament tear and had a lateral patellar dislocation. Operative reconstruction used hamstring tendons and place a groove over the front of the tibia and a groove over the top of the femur without violation of the growth plates. The anterior cruciate ligament was primarily repaired (three patients) at the time of reconstruction, if possible. At 3 months, one patient underwent arthroscopic resection of adhesions for arthrofibrosis. There were no other complications. Five patients were evaluated with clinical examination, radiographs, magnetic resonance imaging, and functional testing at an average followup of 33.2 months (range, 25 to 38). Four of the five had returned to their preinjury level of sports participation. Manual maximum KT-1000 arthrometer side-to-side differences averaged 3.6 +/- 1.9 mm. The average Lysholm knee score was 95.2 +/- 2.5; the average Hospital for Special Surgery knee score was 96.6 +/- 2.3. There were no growth plate injuries. Despite the overall clinical stability, magnetic resonance image scans of the five patients consistently demonstrated areas of increased signal in the anterior cruciate ligament grafts.

Isolated posterior shoulder dislocation in a child. A case report.

Posterior dislocations of the shoulder are rare, and even rarer in children. The outcome depends on early recognition and treatment if normal shoulder function is to be obtained.

Anterior cruciate ligament graft rotation. Reproduction of normal graft rotation.

The purpose of this study was to determine normal rotation of the anterior cruciate ligament and to provide a technique for reproduction of this rotation. Ten fresh-frozen knees were dissected of all soft tissue except for the anterior cruciate ligament. Specimens were secured in a vise in 60 degrees of flexion. Each tibia was allowed to spin freely on the femur, and rotation was recorded. Anterior cruciate ligament reconstructions, using bone-patellar tendon-bone grafts, were then performed on all specimens using four graft rotations. Each specimen was then tested to assess how the graft twist affected tibial rotation. The average tibial rotation of the normal anterior cruciate ligaments was 55 degrees internally. Previous descriptions of anterior cruciate ligament reconstructions have advocated medial or internal rotation of the graft to reproduce normal anatomic rotation of the anterior cruciate ligament. Our cadaveric dissections have demonstrated that the anterior cruciate ligament normally produces internal rotation of the tibia in relation to the femur. Reproduction of this anatomic rotation is accomplished with 90 degrees of lateral rotation of the tibial plug toward the fibula.

Metatarsal stress fractures.

We evaluated metatarsal lengths from roentgenograms in a group with metatarsal stress fractures and compared them with those of a control group having no foot symptoms to determine if a short first metatarsal could be implicated as a cause for metatarsal stress fractures. By statistical analysis we showed that the lengths of the first and second metatarsals in the group with stress fractures did not differ from those in a randomly selected control group. In addition, we determined that to be "short," the first metatarsal must be less than 73% of the length of the second metatarsal, and to be "long," the first metatarsal must be more than 94% of the length of the second metatarsal.

Nonoperative treatment of double lateral ligament tears of the ankle.

In this article the objective evaluation of 39 cases of double lateral ligament tears of the ankle treated by cast immobilization is described. Such treatment resulted in a 79.5% success rate as determined by repeat stress roentgenograms. In addition, a statistical method which may aid the orthopaedist in deciding whether to use nonoperative or operative treatment is presented.

In vivo measurement of anterior tibial translation using continuous passive motion devices.

Early motion protocols following anterior cruciate reconstruction often use continuous passive motion devices. There is concern that these devices may induce undesired anterior translation of the tibia and resulting graft stretching or rupture. This study measured the amount of anterior tibial translation that occurred during one cycle in 10 different brands of continuous passive motion devices. Five patients with ACL deficient knees participated in this study. Anterior translation was recorded by using an electrogoniometer with four degrees of freedom (Knee Signature System). Anterior translation measurements were also recorded for a 20 pound Lachman test in these same five patients using the Knee Signature System. Two of the devices showed anterior translation measurements that approached the recorded 20 pound Lachman values. These two devices had a high calf bar for the primary support of the leg. The results indicate that, when using a continuous passive motion device for early postoperative management of the reconstructed ACL in a patient, use of a calf-supporting type of continuous passive motion could induce an undesired strain of the healing graft.

Anterior cruciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Two year results in thirty-six patients.

Thirty-six of 44 patients (82%) who underwent ACL reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts were evaluated at least 2 years postoperatively. A detailed subjective evaluation using the Lysholm scale was recorded as well as a functional evaluation using the Tegner activity scale. All of the patients received a detailed physical examination that included testing with the KT-1000 ligament arthrometer and the Cybex dynamometer. Complete chart reviews and radiographic evaluations were also obtained. Only 17 patients were considered to be functionally successful and performing at their desired activity level. The average KT-1000 showed a side-to-side difference of 5.9 mm at 30 pounds for the successful group and 7.9 mm for those who had functional failure. The Lysholm scores were 91.6/100 versus 61.1/100 in the failures. Eight patients (22%) at repeat surgery were noted to have complete dissolution of the graft. Large femoral cysts were noted radiographically in all of these patients. It was concluded that freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts have a high failure rate and cannot be recommended for ACL reconstruction.

Reconstruction of the anterior cruciate ligament with freeze dried fascia lata allografts in dogs. A preliminary report.

In 16 adult dogs the anterior cruciate ligament (ACL) was transected and then reconstructed using freeze dried fascia lata allografts. Eight of the dogs had the intraarticular graft passed through drill holes in the tibia and femur, while in the other eight dogs the graft was passed through a drill hole in the tibia and routed "over-the-top" of the lateral femoral condyle. In all dogs the grafts were then passed deep to the lateral collateral ligament and secondarily secured to the tibia as an extraarticular reconstruction. Specimens from each group underwent histologic study and biomechanical testing on a mechanical testing system at 3, 6, 12, and 24 week intervals. All grafts were found to be intact at sacrifice with no overt evidence of biologic incompatibility. The knees displayed only mild instability to clinical testing without evidence of arthrosis. Histologically, the grafts appeared to function as a collagenous scaffolding for revascularization and fibrovascular creeping substitution. The mean maximum load at failure in the 24 week specimens reached 536.44 N, compared to values of 801.85 N in contralateral knees with an intact ACL.

Contaminated rabbit patellar tendon grafts. In vivo analysis of disinfecting methods.

In Part 1 of our study, 40 central-third bone-patellar tendon-bone grafts were harvested from 20 adult California White rabbits under strict sterile conditions. Ten grafts were placed directly into a thioglycolate broth, incubated, and subcultured; no growth was noted in any specimen. The next 6 grafts were contaminated 20 seconds each with 2 different species of coagulase-negative staphylococci. Organisms were grown with cultures obtained from an operating room floor during anterior cruciate ligament reconstruction. Marked growth of both species was noted in all 6 grafts within 24 hours. A subsequent 3 series of 8 grafts each were harvested sterilely, contaminated as described above, and soaked in 1 of 3 solutions 30 minutes before culture. Both 10% povidone-iodine and a triple-antibiotic solution (gentamicin, clindamycin, polymyxin) were 100% ineffective as both organisms grew; 4% chlorhexidine gluconate effectively decontaminated 8 grafts in all cases. Part 2 involved contamination of harvested grafts with 5 common, virulent organisms: Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterococcus faecalis. Elimination of all except Klebsiella pneumoniae was successful with 4% chlorhexidine gluconate alone for 8 grafts. Using a triple-antibiotic solution after chlorhexidine gluconate in 6 grafts eliminated this organism also.

Long-term followup of anterior cruciate ligament reconstruction using freeze-dried fascia lata allografts.

We identified 79 patients who underwent arthroscopically assisted intraarticular anterior cruciate ligament reconstruction with freeze-dried fascia lata allografts and an additional lateral extraarticular reconstruction. We were able to contact 62 patients (79%) for follow-up evaluation at an average of 134.5 months. Forty patients (51%) returned for objective evaluation. Lysholm scores at followup averaged 92.3 and Tegner activity scores averaged 5.1. Only four (6%) of the 62 patients contacted reported episodes of full giving way. Thirty (75%) of the 40 patients examined demonstrated 3 mm or less side-to-side difference on KT-1000 arthrometer manual maximum evaluation. Forty-eight (77%) of the 62 patients were participating in sporting activities at final followup. No patient had evidence of graft rejection.

Anterior cruciate ligament reconstruction using bone-patellar tendon-bone allografts. A biological and biomechanical evaluation in goats.

Twenty-eight goats underwent ACL reconstruction with freeze-dried bone-patellar tendon-bone allografts in one knee, the opposite knee serving as a control. One group of 16 knees was evaluated, in groups of four, at 6, 12, 26, and 52 weeks by histologic and vascular injection techniques. The other group of 12 knees was evaluated in two groups of six at 26 and 52 weeks by morphological and biomechanical techniques of analysis. Within the first 12 weeks these allografts were revascularized; in the first 26 weeks they had matured to resemble normal connective tissue. Graft stiffness was 29% of the control value and maximum force to failure was 43% of the control value. The results of this study indicated that freeze-dried bone-patellar tendon-bone allografts are biomechanically and biologically similar to patellar tendon autografts.

Instrumented testing of functional knee braces.

The ability of seven functional knee braces to control anterior tibial displacement in three severely lax ACL deficient knees using two instrumented testing devices was studied. Some braces were statistically shown to be much better in this regard than others, but not all data obtained was statistically significant. This material should aid one in determining which braces offer the greatest degree of control of anterior tibial displacement in patients with ACL insufficiency.

Biomechanical assessment of the healing response of the rabbit patellar tendon after removal of its central third.

The objective of this study was to determine the biomechanical properties of the healing patellar tendon after removal of its central third. This was accomplished by removing the central third of the patellar tendon from the right limb of 30 mature New Zealand White rabbits. The tendon of the contralateral normal limb served as the unoperated control. The rabbits were separated into five test groups according to healing time: time of surgery and 1, 2, 3, and 6 months after surgery. The ultimate failure strength of the patellar tendons with the central third removed was significantly less than the failure strength of the contralateral normal patellar tendons at all time intervals after surgery. At the time of surgery, the ultimate failure strength values of the operated patellar tendons were on average 53% of the normal patellar tendons, increasing to 72% of normal at 6 months. There was a significant correlation between the ultimate failure strength of the operated tendons and healing time. The positive slope for this regression indicated that the ultimate failure strength of the operated tendons converged toward normal as healing progressed. Failure mode of the operated tendon did not depend on healing time.