Late patellar tendon ruptures after removal of the central third for anterior cruciate ligament reconstruction. A report of two cases.

Patellar tendon rupture after removal of the central third for ACL reconstruction is a rare complication. Only nine cases have been previously reported, and all of these occurred within the first 10 months after surgery. We report two cases of late patellar tendon ruptures occurring at more than 3 and 6 years, respectively, after surgery. A review of the literature has suggested but not conclusively supported that devascularization, an alteration in tendon healing and remodeling, or injury to the remaining tendon at the time of graft harvest may be possible causes of this rare complication. Biopsy tissue from any future patellar tendon ruptures after removal of its central third could contribute to a better understanding of this anomaly.

Thromboembolism after hip surgery. Comparison of screening methods.

Venous thromboembolism is a serious and, often, asymptomatic complication of hip surgery. A reliable screening test is needed to detect thrombi early to prevent death from pulmonary emboli. Noninvasive screening tests were ineffective in our study of 453 patients. We recommend early use of ventilation/perfusion lung scanning in all patients after hip surgery. In those who have positive results, ascending venography can be used to localize the thrombus and anticoagulation therapy can be started early.

Thromboembolism following hip fracture.

Two hundred forty-eight patients following hip fracture were studied for deep venous thrombosis and pulmonary embolus. Ventilation-perfusion lung scans and contrast ascending venography were performed on the sixth to eighth postoperative days. Low-dose intravenous heparin (3,000-5,000 units every 6 hours) was followed by a decreased incidence of pulmonary embolism more than twofold. Although heparin administration was not associated with a significantly decreased incidence of deep venous thrombosis as assessed by venographic studies, thrombi in the nonheparin-treated patients were more likely to occur above the knee and were at higher risk for pulmonary embolus. Pneumatic and mechanical compression devices alone did not protect patients from deep venous thrombosis above the knee, but were associated with a decreased incidence of pulmonary embolus compared to control.

Popliteus tendon tenosynovitis.

This series of case suggests that the entity of tenosynovitis of the popliteus tendon is more common than once recognized. A high index of sucpicion and accurate palpation of the lateral aspect of the knee lead one to the diagnosis. Knowledge of this entity may prevent future misdiagnosis of tear of the lateral meniscus and unnecessary meniscectomy as experienced by Helfet, Holden, and myself. There is a definite correlation with activities requiring downhill walking or running. The runners invariably complained of the oneset of symptoms during downhill running rather than uphill running. Back packing enthusiastscomplained of no symptoms for several days after ascending into the mountains, only to experience the symptoms at the end of a long, rapid descent out of the mountains. The pathomechanics of this inflammation of the popliteus tendon is not fully understood. Preliminary analysis of gait movies suggests that in downhill running there is an increased vector to displace the weight-bearing femur forward on the relatively fixed tibia as the knee is increasingly flexed (Fig. 5). Previously mentioned EMG functional studies indicate that the popliteus muscle is active during this weight-bearing phase of gait and may act to retard the femur from forward displacement on the tibia in conjunction with the quadriceps. More specifically, it may help to retard the lateral femoral condyle from rotating forward off the lateral tibial plateau. Downhill running or walking therefore may cause increased stress on the popliteus muscle-tendon unit in an effort to decelerate the body weight against the altered angle of gravitational pull, with resultant tenosynovitis and symptoms. In this series there were no top flight competitive runners. The typical patient was a 31-year-old physician who was jogging 1 to 5 miles and decided to increase his pace and distance, particularly while jogging downhill. The average age of this series of patients (31 years) at the time of onset, coupled with the fact many of these persons were relatively sedentary until stressing the knee by increased activity, suggests that there will be an increasing number of these patients in the future as jogging and running are prescribed for cardiovascular system conditioning.

The functional treatment of pyogenic arthritis of the adult knee.

A method of treatment of pyogenic arthritis of the adult knee employing wide open arthrotomy and early active motion, as well as synovectomy in some knees, was used in thirty-four patients with pyogenic arthritis of the knee. Of these patients, sixteen had a good result, twelve had a fair result, and six had a poor result. This method of treatment was used as a salvage procedure in most of the patients, but may have more general application in the treatment of pyogenic arthritis of the knee.