Tibial subluxation in anterior cruciate ligament-deficient knees: Implications for tibial tunnel placement.

PURPOSE: This study was performed to determine whether subtle anterior subluxation occurs in anterior cruciate ligament (ACL)-deficient knees with the knee in full extension. TYPE OF STUDY: Radiographic evaluation of tibial position in ACL-intact and ACL-deficient knees. METHODS: Twenty-four subjects with arthroscopically documented ACL-deficient knees were compared with 20 subjects with arthroscopically documented ACL-intact knees. A previously reported method was used to evaluate the tibial position relative to the femur. RESULTS: Measurements on standing lateral radiographs revealed asymptomatic but significant anterior subluxation of the tibia compared with the ACL-intact subjects. CONCLUSIONS: The possibility of anterior tibial subluxation with the knee in full extension should be taken into account when deciding on tibial tunnel placement or when evaluating for postoperative graft impingement by the intercondylar notch.

Impingement syndrome.

Pain from rotator cuff pathology is a common problem in upper extremity athletes. Impingement of the rotator cuff tendons on the subacromial arch is an important cause. Primary age-related degeneration and instability, however, should not be forgotten as causes for cuff pathology. Conservative treatment is successful in many athletes. Surgical subacromial decompression is reserved for resistant cases. Although often helpful, surgical treatment generally requires a long recovery for throwing athletes and can be associated with residual symptoms.

Fixed tibial subluxation after successful anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction results in improved function and stability in many patients. However, it is not known whether the improved stability is associated with an improved tibiofemoral relationship. We used stress radiographs to determine not only stability but also the tibiofemoral relationship in 15 patients who had a clinically successful anterior cruciate ligament reconstruction. Their results were compared with those of 14 volunteers with normal knees. The average Lysholm score for the patients was 94. None of the patients had more than 3 mm of side-to-side difference on KT-1000 arthrometer testing. Maximal anteroposterior tibial translation as measured by stress radiography was slightly increased in the reconstructed knees but was not statistically significantly different (6.6 +/- 3.2 mm versus 5.0 +/- 3.3 mm). However, with a posteriorly directed stress the tibia in the reconstructed knees did not translate posteriorly to the same extent as did the control knees, resulting in a significant difference in tibial position (-1.2 +/- 3.0 mm versus -4.0 +/- 3.3 mm). Surgical anterior cruciate ligament reconstruction may result in reduced anteroposterior tibial translation, accomplished, in part, through restraining posterior translation, leaving the tibia with persistent subluxation. Fibrosis and contracture of the posterior structures may explain this phenomenon.

Operative versus nonoperative treatment of knee dislocations: a meta-analysis.

Although several studies have investigated the optimal treatment of knee dislocations, all have been composed of a small number of patients and therefore have made it difficult to draw definitive conclusions. The literature on knee dislocation was reviewed to allow a meta-analysis and determine whether operative or nonoperative treatment had better outcomes. Range of motion, flexion contracture, Lysholm score, instability, ability to return to preinjury employment, and ability to return to preinjury athletic activities were compared using statistical methods. A total of 132 knee dislocations treated surgically and 74 treated nonoperatively were included. Average range of motion was 123 degrees in the surgical group and 108 degrees in the nonoperative group (P<.001). Flexion contracture averaged 0.5 degrees for the surgical group and 3.5 degrees for the nonoperative group (P<.05). A significant difference (P<.001) also was found in the Lysholm scores, with a surgical group mean of 85.2 and a nonoperative group mean of 66.5. There was no significant difference in the ability to return to preinjury employment or athletic activity or in the amount of instability between the two groups. Surgical treatment appears to be associated with improved outcomes, although significant disability is still possible after successful surgical treatment.

Outcomes of the operatively treated knee dislocation.

Despite being a serious injury with early complications associated with a high degree of morbidity, the outcomes of knee dislocations have improved dramatically since the days of Sir Astley Cooper. Currently, most authors favor early surgical reconstruction of the injured ligamentous structures. With modern surgical techniques and rehabilitation protocols, most patients are able to achieve functional range of motion and stability necessary for everyday life. Despite improvements in treatment, stiffness and pain, rather than instability, can be a problem. Patients continue to have difficulty returning to pre-injury levels of athletic competition and manual labor, although a significant number of patients have achieved these goals. As physicians, we must be knowledgeable in the current surgical techniques and rehabilitation protocols used in the treatment of knee dislocations, and the typical prognosis of the injury. By informing our patients of hurdles that they will be forced to overcome, in their path to recovery, before initiating treatment, patients will better understand the seriousness of the injury, which, it is hoped, will lead to compliance with their rehabilitation and thus better outcomes.

The effects of aging, antiinflammatory drugs, and ultrasound on the in vitro response of tendon tissue.

We investigated the effects of aging and various treatments on rat patellar tendon using an in vitro model. In the first part of the study, the 3H-thymidine and 3H-proline incorporation rates at 12 and 24 hours were determined in transected patellar tendon explants from young (21 days), intermediate age (8 to 10 weeks), and older (4 to 6 months) rats. In the second part, the same incorporation rates were measured in the older tendon explants in response to treatment with control medium, medium with a high and low concentration of indomethacin, and medium with a high and low concentration of dexamethasone. Finally, the effects of ultrasound treatment were measured and compared with a sham ultrasound treatment. The results indicated an age-dependent response of the tendon. The youngest specimens consistently showed the highest incorporation rates. The addition of a high concentration of dexamethasone resulted in a small negative effect on the 3H-thymidine incorporation. Ultrasound and indomethacin had no significant effects. This study indicates that aging is associated with a lower metabolic activity of tendon. In this model, currently used treatment methods failed to result in direct positive effects on tendon tissue, and a high concentration of dexamethasone appeared to have a small negative effect.

Patellar tendinitis: the significance of magnetic resonance imaging findings.

We evaluated the significance of magnetic resonance imaging findings in patients with patellar tendinitis. Midline sagittal magnetic resonance images were taken of 12 knees from 10 patients and of 17 knees from 15 age- and activity-matched subjects who underwent imaging for reasons other than patellar tendinitis. Of the 12 magnetic resonance imaging scans of knees with clinical patellar tendinitis, 3 (25%) exhibited no defect and only 7 (58%) had unequivocal intratendinous lesions. Among the 17 scans of subjects without clinical patellar tendinitis, 5 (34%) showed no defect and 4 (24%) had unequivocal intratendinous lesions. Proximal tendon width was significantly larger for the tendinitis patient group (5.0 +/- 1.7 mm versus 3.9 +/- 1.0 mm), although considerable overlap was present. All subjects with unequivocal intratendinous signal changes had a significantly longer nonarticular inferior patellar pole and were significantly older (38.1 years versus 26.8 years). Only Blazina stage III lesions were associated with abnormal findings on magnetic resonance imaging. As a whole, the sensitivity and specificity of magnetic resonance imaging was 75% and 29%, respectively. In younger patients with relatively mild symptoms, magnetic resonance imaging did not show significant changes; in older, active patients changes may be present in asymptomatic knees.

Anti-inflammatory treatment of muscular injuries in sport. An update of recent studies.

Stretch-induced muscle injuries or strains, muscle contusions and delayed-onset muscle soreness (DOMS) are common muscle problems in athletes. Anti-inflammatory treatment is often used for the pain and disability associated with these injuries. The most recent studies on nonsteroidal anti-inflammatory drugs (NSAIDs) in strains and contusions suggest that the use of NSAIDs can result in a modest inhibition of the initial inflammatory response and its symptoms. However, this may be associated with some small negative effects later in the healing phase. Corticosteroids have generally been shown to adversely affect the healing of these acute injuries. Animal studies have suggested that anabolic steroids may actually aid in the healing process, but clinical studies are not yet available and the exact role of these drugs has yet to be determined. Studies on anti-inflammatory treatment of DOMS have yielded conflicting results. However, the effect of NSAIDs on DOMS appears small at best. Future research may have to focus on different aspects of these injuries as the emphasis on anti-inflammatory treatment has yielded somewhat disappointing results.

Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature.

Tendonitis is a common diagnosis in sports medicine. The traditional view of tendonitis is a tendon injury resulting from repetitive mechanical load with a subsequent inflammatory response. The English literature from 1966 to the present on the etiology, diagnosis, and treatment of tendonitis was evaluated. There is some scientific support in the literature for the diagnosis of tenosynovitis and tendinosis as a pathologic entity. Actual inflammation of tendon tissue consistent with tendonitis has not been seen clearly in patho-anatomic studies. Conclusive evidence confirming that repetitive mechanical load is a major etiologic factor could not be found. Similarly, strength deficits, inflexibility, and improper equipment have not been studied in a controlled prospective manner. Other factors such as age and tendon vascularity have been consistently correlated with these injuries although their overall importance remains difficult to assess. There are no controlled studies on treatment through physical therapy aimed at flexibility and/or strengthening. Treatment with anti-inflammatory drugs has been studied extensively. However, only nine of 32 studies are prospective and placebo controlled. Some pain relief was found in five of the nine controlled studies, but healing of the tendon problem was not studied in these short follow-up studies. Twenty-three studies on steroid injections were found. Eight were prospective and placebo controlled studies, with three showing beneficial effects of the injection at follow-up. It was concluded that much of the pathology and etiology of tendonitis remains unclear. The possibility must be considered that current treatment methods may not significantly affect the natural history.

Tendinitis and other chronic tendinopathies.

Chronic tendon problems are common in orthopaedic patients. Relatively little is known about the etiology of these common problems and the efficacy of available treatments. It is believed that the cause of many injuries is repetitive mechanical trauma followed by an inflammatory response. Other factors, such as age-related degeneration and relative avascularity in the tendon, may play an important etiologic role as well. Histopathologic studies have generally revealed degenerative lesions consistent with tendinosis and/or inflammation of the peritendinous tissues consistent with peritendinitis. Initial treatment should focus on patient counseling and correction of associated mechanical factors, if present. Nonsteroidal anti-inflammatory drugs can give pain relief, but there is no convincing evidence that they alter the natural history. Corticosteroid injections can be used selectively in resistant cases, but recurrences are frequent. Surgery can be very successful when the affected tendon is treated directly.

Radiographic evaluation of anterior cruciate ligament graft failure with special reference to tibial tunnel placement.

Graft failure in anterior cruciate ligament (ACL) reconstruction can result from anterior placement of the tibial tunnel. Conventional radiographic evaluation of this problem does not take into account potential changes in tibio-femoral relationship caused by ACL instability. A retrospective radiographic evaluation of failed as well as successful ACL reconstructions was carried out. Both published radiographs as well as those obtained of patients treated by the authors were evaluated for tibial tunnel placement, roof impingement, and tibial position relative to the femur. In the second part of the study, the radiographs were obtained under standard conditions in both failed ACL reconstructions and normal knees. The results of both parts of the study indicate that lateral radiographs of the extended knee with ACL instability are likely to show subtle anterior tibial subluxation. The subluxation can give the impression of roof impingement on the graft. However, the majority of the failed knees had similar tibial tunnel placement compared with successful reconstructions and would appear unimpinged once corrected for subluxation. The diagnosis of graft impingement by the femoral intercondylar roof has to take into account potential tibial subluxation. Impingement as a cause graft failure may be less common than previously thought.

An in vitro investigation into the effects of repetitive motion and nonsteroidal antiinflammatory medication on human tendon fibroblasts.

Soft tissue injuries due to repetitive motion are common sports injuries and are often treated with antiinflammatory therapies. We investigated the in vitro effects of repetitive motion and nonsteroidal antiinflammatory medication on human tendon fibroblasts. In addition, we studied the effects related to the presence of inflammatory cells. Repetitive motion was associated with an increased release of prostaglandin E2 and increased deoxyribonucleic acid (DNA) and protein synthesis. The presence of nonsteroidal antiinflammatory medication decreased prostaglandin E2 release and DNA synthesis but increased protein synthesis. Contact with macrophages caused a marked additional increase in prostaglandin E2 and a concomitant increase in DNA synthesis. Release of interleukin-6 by the macrophages also suggested that this cytokine plays a role in the response to repetitive motion. Our results can aid in the search for a more scientific approach to the treatment of soft tissue injuries associated with repetitive motion. They suggest that nonsteroidal antiinflammatory medication may have potentially negative effects during the proliferative phase of a healing since it was associated with decreased DNA synthesis. However, it may be beneficial in the maturation and remodeling phase since it stimulated protein synthesis.

Post-operative problems following anterior cruciate ligament reconstruction.

Seventy adult patients were studied during the postoperative rehabilitation period following anterior cruciate ligament reconstruction in order to investigate the role of pre-, intra-, and postoperative factors in range of motion and graft problems. A standard bone-patellar tendon-bone autograft was used for the reconstruction. Pre- and intraoperative factors such as concomitant injuries, time from injury to surgery, age, sex, and tunnel placement were recorded. Tunnel placement was recorded on intraoperative radiographs of the final guide pin placement and compared to pin placement on cadaver knees. The results indicated a significant relation between early reconstruction (< 1 month) following the injury and range of motion problems during the early rehabilitation period (P < 0.001). This relation disappeared by the end of the first postoperative year. Prolonged surgery was also associated with early motion problems (P < 0.05). Graft laxity or failure was correlated with an earlier return of range of motion (P < 0.05). We hypothesized that graft failure can have a biologic cause rather than a mechanical one since intraoperative X-rays indicated a near-anatomic tunnel placement in this patient group when compared to ideal placement in the cadaver knees.

Outcome in the treatment of chronic overuse sports injuries: a retrospective study.

Overuse injuries due to repetitive motion are common in recreational and elite athletes. Some overuse injuries resolve quickly after activity modification, but others can persist, which often prompts the patient to seek medical attention. This study retrospectively reviewed outcome and compliance in the treatment of chronic overuse sports injuries. One hundred and two patients were contacted by telephone an average of 27 months following their initial visit for chronic overuse injury. A questionnaire regarding the treatment and outcome was completed. Of this group, 38 (37%) claimed to be completely better, 28 (28%) were improved, but 36 (35%) were not better or worse. Anterior knee pain had a significantly worse outcome than any other injury (p < 0.05). Excluding anterior knee pain, 71% were improved or completely better. Neither activity modification nor combination treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy through stretching and strengthening exercises was associated with a better result. Noncompliance rates were 9% for NSAID therapy and 13% for exercise treatment. These results indicate that chronic overuse injuries are not always self-limiting but can result in prolonged symptoms.

An evaluation of pre- and postoperative nonsteroidal antiinflammatory drugs in patients undergoing knee arthroscopy. A prospective, randomized, double-blinded study.

The potential benefits of a nonsteroidal antiinflammatory drug to 67 patients undergoing knee arthroscopy were evaluated in a prospective, randomized, placebo-controlled, double-blinded study. Group A received the drug (diclofenac, 75 mg twice daily) for 3 to 5 days before and for 7 days after surgery. Group B received a placebo preoperatively and the drug postoperatively. Group C received a placebo at both times. Codeine was available postoperatively for all patients if needed. Outcomes reported by the subjects included pain, crutch use, and return to activities. Outcomes assessed by physicians included knee effusion, range of motion, and gait. Knee flexion and extension strengths were measured isokinetically pre- and postoperatively. Pain scores on the 1st postoperative day were higher in Group C than in Group A. Pain scores at all other time points were not significantly different in the three treatment groups. Groups A and B required less codeine during the first 72 hours after surgery than Group C (mean, 2.9 +/- 1.0 versus 6.8 +/- 1.0 pills). Recovery of function, recovery of strength, and physical examination parameters were not significantly different in the three treatment groups. Diclofenac was an effective analgesic in the immediate postoperative period. Recovery from arthroscopy, however, was not enhanced by taking the drug.

Effects of repetitive motion on human fibroblasts.

Repetitive motion injuries such as tendonitis are common sports injuries. However, few scientific studies are available on the effects of repetitive motion on mesenchymal cells and the presumed inflammatory response. This study used a new in vitro model to study the effects of repetitive motion. Human tendon fibroblasts were subcultured and plated on culture wells with flexible bottoms. The cells were repetitively stretched using a micro-processor-controlled pressure unit that causes a cyclic deformation of the flexible bottom. The wells were divided in the following groups: group I controls without repetitive motion, group IIA repetitive motion with 0.25 strain at 0.17 Hz (10 cycles.min-1), group IIB repetitive motion with 0.25 strain and 0.17 Hz in presence of 25 microM indomethacin, and group III repetitive motion with 0.25 strain at 1 Hz (60 cycles.min-1). After 3 h of stimulation the supernatant fluids were harvested and evaluated for prostaglandin E2 (PGE2), leukotriene B4 (LTB4), and lactate dehydrogenase (LDH). The results showed significantly (P < 0.001) increased levels of PGE2 in groups IIA (46.9 +/- 4.7 pg.0.1 ml-1) and III (65.7 +/- 8.0 pg.0.1 ml-1). This represents a 1.3- and 1.8-fold increase, respectively, compared with the control group I (36.4 +/- 5.9 pg.0.1 ml-1). LTB4 was significantly (P < 0.001) elevated in the indomethacin-treated group IIB (45.0 +/- 11.0 pg.0.1 ml-1) compared with very low levels in all other groups. LDH was not significantly different in any of the experimental groups compared with the control group I. The results indicate that repetitive motion induces production of PGE2.(ABSTRACT TRUNCATED AT 250 WORDS)