The relationship of femoral intercondylar notch width to height, weight, and sex in patients with intact anterior cruciate ligaments.

Intercondylar notch width, femoral bicondylar width, height, and weight of patients with intact anterior cruciate ligaments were measured to determine whether intercondylar notch width was related to body size. A 45 degrees weight-bearing posteroanterior radiograph was obtained for 315 men and 163 women. Notch width and bicondylar width was measured at one-half notch height. Mean notch width for men was statistically significantly wider than for women (17.1 mm versus 14.7 mm, respectively; P<.01). There was no statistically significant correlation between height and notch width for men (r=-0.0019; P=.97) or women (r=0.1308; P=.10). No significant correlation existed between weight and notch width for men (r=-0.0311; P=.58) or women (r=0.0523; P=.51). Analysis of variance showed height and weight were not significant covariates in notch width for either men (P=.44) or women (P=.91). Women of the same height and weight as men had significantly narrower notches (P<.01). There was a statistically significant correlation between wider femoral bicondylar widths and higher weight for men (r=0.694; P<.01) and women (r=0.821; P<.01). Similarly, there was a statistically significant correlation between wider femoral bicondylar widths and increased height for men (r=0.670; P<.01) and women (r=0.785; P<.01). These data demonstrate height and weight are poor predictors of intercondylar notch width. Therefore, one cannot assume body size is a predictor of notch width. Furthermore, because mean notch width does not increase with increasing height and weight, the notch width index calculation cannot accurately reflect the size of the intercondylar notch.

Patellar tendon rupture repair using Dall-Miles cable.

Ten patients underwent patellar tendon repair with end-to-end suture technique and medial and lateral retinacular repair, as well as reinforcement with a Dall-Miles cable through the patella and tibial tubercle. The cable was tensioned at 60 degrees of flexion to allow immediate range of motion to at least 100 degrees of flexion and to protect the repair from undue tension while healing. Accurate tendon length was obtained from a lateral radiograph of the noninvolved knee in 60 degrees of flexion. Patients were allowed to bear full weight as tolerated postoperatively. A knee immobilizer was worn for approximately 2 weeks when adequate muscular control of the leg was attained. The cable was removed 6-8 weeks postoperatively, at which time range of motion equal to the opposite extremity was sought. Full extension was obtained by 1 week postoperatively. Average postoperative knee flexion was 88 degrees at 2 weeks, 112 degrees at 1 month, 133 at 3 months, and 138 degrees at 6 months compared to flexion of 141 degrees in the noninvolved knee. Mean quadriceps muscle strength 1 year postoperatively was 72%+/-11% of the noninvolved leg. No patient had patella infera or rerupture after surgery. Repair of a patellar tendon rupture with end-to-end techniques reinforced with a Dall-Miles cable allows immediate rehabilitation without the need for prolonged immobilization. This technique allows restoration of full range of motion early postoperatively and enables patients to regain adequate quadriceps strength.

Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon.

We studied patients who underwent primary anterior cruciate ligament reconstruction using either the contralateral (N = 434) or ipsilateral (N = 228) autogenous patellar tendon graft to determine the difference between groups for the return of range of motion, quadriceps muscle strength, and return to sports. The contralateral group had statistically significantly more flexion than the ipsilateral group at 1 week and 2 weeks postoperatively. The contralateral group had statistically significantly greater quadriceps muscle strength in the reconstructed knee at 1, 2, and 4 months postoperatively and in the donor knee at 1 and 2 months postoperatively. Mean KT-1000 arthrometer results were 1.9 +/- 1.3 mm for the contralateral group and 2.2 +/- 1.1 mm for the ipsilateral group. The mean time to return to sports at full capability in a competitive subgroup was 4.1 months for contralateral patients and 5.5 months for ipsilateral patients. Overall, 49% of patients in the contralateral group and 12% of patients in the ipsilateral group returned to their preinjury levels of activity by 4 months postoperatively. Our results indicate that the contralateral patellar tendon can be used to restore range of motion and strength sooner than an ipsilateral patellar tendon graft. Patients can also have a faster return to full capability in sports without compromising ultimate stability.

Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations.

We sought to determine how the status of the meniscus and articular cartilage observed at the time of anterior cruciate ligament reconstruction affects results at 5 to 15 years after surgery. Objective follow-up was obtained on 482 patients at a mean of 7.6 years after surgery. Subjective follow-up was obtained on 928 patients at a mean of 8.6 years after surgery. Patients with both menisci present had significantly better KT-1,000 arthrometer scores than did patients with any part of the medial or both menisci removed. Stepwise regression analyses determined that a partial or total medial or lateral meniscectomy and damaged articular cartilage significantly lowered the final subjective total score. Patients with both menisci present and normal articular cartilage had a mean subjective total score of 94, and 97% had normal or near normal radiographic ratings on a weightbearing 45 degrees posteroanterior radiographs. The overall International Knee Documentation Committee rating was normal or nearly normal for 204 of 235 patients (87%) with both menisci present, 52 of 74 patients (70%) with partial or total lateral meniscectomies, 71 of 113 patients (63%) with partial or total medial meniscectomies, and 36 of 60 patients (60%) with both menisci removed. We concluded that the long-term subjective and objective results of a successful anterior cruciate ligament reconstruction are affected by the status of the menisci and articular surface.

Low-velocity knee dislocation with sports injuries. Treatment principles.

Knowing that the injured MCL and PCL can heal and that the injured ACL and lateral side, predictably, will not heal are the bases for the treatment approach to these injuries. (1) Allow MCL healing nonoperatively. (2) Allow PCL healing to occur as long as PCL laxity is 2+ or less (reconstruct the PCL acutely if posterior drawer is > 2+ initially). (3) Initially delay ACL treatment and reconstruct later, if needed posterior drawer. (4) Perform acute lateral side repair to reattach structures to their distally torn site.

A perioperative rehabilitation program for anterior cruciate ligament surgery.

Rehabilitation programs have progressed alongside surgical advances in anterior cruciate ligament reconstruction. A perioperative program has been successfully used at our clinic for more than 10 years to reduce postoperative complications and return patients to activity safely and quickly. The four-phase program starts at the time of injury and preoperatively includes aggressive swelling reduction, hyperextension exercises, gait training, and mental preparation. Goals after surgery are to control swelling while regaining full knee range of motion. After quadriceps strengthening goals are reached, patients can shift to sport-specific exercises.

Correlation of the intercondylar notch width of the femur to the width of the anterior and posterior cruciate ligaments.

The purpose of this study was to determine if a correlation exists between the intercondylar notch width (NW) of the femur and the width of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). A study group of 124 consecutive patients (mean age 36.6 +/- 15.2 years; 67 men, 57 women) underwent a magnetic resonance imaging evaluation for knee pain but did not have an ACL or PCL tear or arthrosis. A T2 weighted coronal cut was identified and was located at the middle of the tibial spine, which represented the plane where the ACL and PCL cross each other when the knee is in 10 degrees of flexion. The NW and the width of the ACL and PCL were measured at the level of the middle of the popliteal hiatus on a physician-independent console that allowed for digital measurements in millimeters. Our results showed a statistically significant correlation between NW and ACL width (r = 0.87; P < 0.001) and between NW and PCL width (r = 0.75; P < 0.001). The mean ACL width was 6.4 +/- 1.4 mm (range 3-10 mm). The mean PCL width was 10.2 +/- 2.0 mm (range 6-17 mm). The mean ACL width was 5.7 +/- 1.1 mm for women and 7.1 +/- 1.2 mm for men (P < 0.001). The mean PCL width was 9.5 +/- 1.7 mm for women and 10.9 +/- 2.0 for men (P < 0.001). Our results indicate that NW correlates with ACL and PCL width. In addition, ACL and PCL widths are narrower in women than men.

The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study.

We sought to determine prospectively the natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries in athletically active patients. The study population consisted of 133 patients (average age, 25.2 years at time of injury). All patients completed a subjective questionnaire each year for an average of 5.4 years (range, 2.3 to 11.4). Sixty-eight of the 133 patients returned to the clinic for long-term follow-up evaluation. Objectively, physical examination revealed no change in laxity from initial injury to follow-up. No correlation was found between radiographic joint space narrowing and grade of laxity. The mean modified Noyes knee score was 84.2 points, the mean Lysholm score was 83.4, and the mean Tegner activity score was 5.7. Patients with greater laxity did not have worse subjective scores. No correlation was found between subjective knee scores and time from injury. Regardless of the amount of laxity, half of the patients returned to the same sport at the same or higher level, one-third returned to the same sport at a lower level, and one-sixth did not return to the same sport. Results of this study suggest that athletically active patients with acute isolated posterior cruciate ligament tears treated nonoperatively achieved a level of objective and subjective knee function that was independent of the grade of laxity.

ACL reconstruction using an abnormally thick autogenous patellar tendon graft.

This prospective study measured the patellar tendon thickness of 543 patients who underwent anterior cruciate ligament (ACL) reconstruction with an autogenous bone-patellar tendon-bone graft to document the normal range of patellar tendon thickness and to determine if using thicker than normal patellar tendons as an ACL graft source affected postoperative outcome. The postoperative results of 55 patients who underwent ACL reconstruction with a patellar tendon > or =7 mm thick (thick tendon group) were compared with those of 488 patients who underwent ACL reconstruction with a patellar tendon < or =6 mm thick (normal tendon group). 5 mm (4.5 mm in women and 5.3 mm in men) with a range of 3-11 mm (3-7 mm in women and 3-11 mm in men). There was no statistically significant difference in the postoperative KT-1000 arthrometer mean manual maximum difference (2.0 mm for grafts < or =6 mm thick and 1.9 mm for grafts > or =7 mm thick), postoperative quadriceps muscle strength scores, modified Noyes questionnaire subjective scores (mean of 91 points for grafts < or =6 mm thick and 92 points for grafts > or =7 mm thick), or postoperative stability and pain scores. These results indicate that an abnormally thick patellar tendon should not preclude the use of this involved tendon as a graft source for ACL reconstruction.

Rehabilitation program for both knees when the contralateral autogenous patellar tendon graft is used for primary anterior cruciate ligament reconstruction: a case study.

STUDY DESIGN: Case study of a basketball player who underwent an alternative surgical procedure for anterior (cruciate ligament (ACL) reconstruction and outline of the rehabilitation process designed for this procedure. OBJECTIVES: To describe the surgical procedure, detail the rehabilitation program, and report on this patient's clinical outcome. BACKGROUND: Anterior cruciate ligament injury, its treatment, and rehabilitation continue to be an area of interest to both clinicians and researchers. Surgical procedures have been refined and rehabilitation programs are constantly being evaluated and updated to allow the safest and most predictable return to activity. Currently, the autogenous bone-patellar tendon-bone graft is the graft of choice for ACL reconstruction. Typically the graft is taken from the ipsilateral knee. An alternative procedure is to take the graft from the contralateral, noninvolved knee, allowing 2 separate rehabilitation programs to take place. METHODS AND MEASURES: The patient was followed from the time of injury to 2 years postoperatively. Data collected included range of motion, isokinetic strength scores, ligament stability scores, subjective evaluation, and functional measures. RESULTS: At 3 weeks postoperative the patient had nearly full range of motion in both knees, normal gait, and was beginning sport-specific drills. He was shooting the basketball and jumping by 5 weeks and returned to competitive sports 6 weeks after surgery. He was able to play in all 32 games of the season, starting in 23 of them. CONCLUSIONS: Using the contralateral patellar tendon graft may be appropriate for primary ACL reconstruction of patients, particularly those desiring an early expedient return to athletic competition.

Treatment of limited motion after anterior cruciate ligament reconstruction.

Limited motion or arthrofibrosis after anterior cruciate ligament (ACL) reconstruction causes significant pain and functional impairment. Based on physical findings and loss of motion compared with the opposite normal knee, classification systems for the diagnosis and treatment of arthrofibrosis have been developed. The operative techniques and preoperative and postoperative rehabilitation and management are discussed. Range of motion (ROM) problems after ACL reconstruction have been minimized by improved surgical techniques and perioperative rehabilitation programs. The most effective treatment for arthrofibrosis is prevention by delaying ACL reconstruction until the patient has a normal gait and full ROM and minimal swelling in the injured knee and by appropriate ROM exercises after surgery.

Evaluation of knee stability before and after participation in a functional sports agility program during rehabilitation after anterior cruciate ligament reconstruction.

We sought to determine whether participation in a functional sports agility program as early as 4 weeks after anterior cruciate ligament reconstruction with autogenous patellar tendon graft would affect objective knee stability in 603 patients. The rehabilitation program prescribed a functional sports agility program at a mean of 5.1 +/- 1.0 weeks postoperatively when full knee hyperextension, knee flexion to 120 degrees, and quadriceps muscle strength of 60% of the normal leg had been achieved. The patients had KT-1000 arthrometer testing before beginning the program and at subsequent follow-up after they had performed the sport activity. The mean manual maximum KT-1000 arthrometer difference was 1.9 +/- 1.3 mm at initial testing and 1.9 +/- 1.2 mm at follow-up testing. The frequency distribution of the KT-1000 arthrometer scores revealed that 92.7% of patients at initial testing and 93.2% of patients at follow-up testing had displacement difference of 3 mm or less. The results of this study show that functional sports agility programs during the early rehabilitation period after anterior cruciate ligament reconstruction with a correctly placed autogenous patellar tendon graft do not cause a change in graft stability.

Early histologic appearance of human patellar tendon autografts used for anterior cruciate ligament reconstruction.

Nine patients underwent second-look arthroscopy and biopsy between 3 and 8 weeks after anterior cruciate ligament (ACL) reconstruction using autogenous patellar tendon. All nine biopsies were taken from the central region of the graft. Every biopsy revealed viable cells in two different patterns. As early as 3 weeks after ACL reconstruction, there were areas that were very similar to patellar tendon control specimens with low nuclear counts, mature collagen, and elongated, metabolically quiescent nuclear morphology. Other areas were hypercellular and associated intimately with neovascular invasion. Vascularity of the grafts was present as early as 3 weeks after reconstruction and increased in prevalence over the next 5 weeks. All specimens had areas of acellularity and degeneration. From these data, the authors conclude that the transplantation of nonvascularized, autogenous patellar tendon is characterized by early viability of the graft both from original fibroblasts and by new cells that arise from neovascularity that is present as early as 3 weeks after ACL reconstruction.

Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing.

This study evaluated posterior cruciate ligament (PCL) healing using magnetic resonance imaging (MRI). Forty knees with acute PCL injuries underwent acute and follow-up (>6 months) MRI examinations. Twenty-three knees had isolated injuries, and 17 knees had associated ligament damage. The initial MRI scans showed 22 high-grade injuries with complete disruption, 14 with midgrade injuries with extensive edema on T2 images with some bridging fibers present, and 4 patients had low-grade injuries. At a mean time of 3.2+/-1.3 years after the initial MRI, the follow-up MRIs revealed the PCL healed with continuity in all of the low-grade and mid-grade injuries, and in 19 of 22 high-grade injuries. Of the 19 high-grade PCL tears that healed, 4 healed with normal contour and 15 were continuous with altered morphology at follow-up. Of 11 high-grade PCL-injured knees with associated ligament damage, only 1 PCL failed to regain continuity. The 3 PCLs that did not regain continuity were in 2 patients with isolated injuries and 1 patient with associated anterior cruciate and medial collateral ligament injuries. These results demonstrate that most nonoperatively treated PCL injuries, even in association with other knee ligament damage, can heal with continuity.

The relationship between intercondylar notch width of the femur and the incidence of anterior cruciate ligament tears. A prospective study.

For 714 consecutive patients who underwent autogenous patellar tendon graft anterior cruciate ligament reconstructions we intraoperatively measured intercondylar notch width. We prospectively recorded height, weight, sex, and which patients subsequently tore their contralateral anterior cruciate ligament or the 10-mm autograft. The patients were divided into two groups based on notch width (group 1, < or = 15 mm; group 2, > or = 16mm. The mean notch width was 13.9 +/- 2.2 mm for women and 15.9 +/- 2.5 mm for men. There was no statistically significant difference in notch width between height groups for women or men. Analysis showed that, with height and weight as covariates, women had statistically significantly narrower notches than men. Twenty-three of 388 patients in group 1 and 4 of 326 patients in group 2 tore their contralateral anterior cruciate ligaments. Within groups, no statistically significant differences in contralateral tear rates existed between men and women. Once the men and women had reconstructions with equally sized 10-mm autografts, there was no difference in graft tear rate between groups or between men and women. Our results show that patients with narrower notches have a higher incidence of tearing their contralateral anterior cruciate ligament. After reconstruction with a 10-mm autograft, the incidence of graft rupture is the same for men and women.

Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup.

We sought to determine the long-term results of 1057 consecutive patients who underwent an anterior cruciate ligament reconstruction with an autogenous patellar tendon graft from 1987 through 1993 and who followed an accelerated rehabilitation program. The patients were followed prospectively and objective physical examination data were obtained on 806 patients at a mean of 4.0 years postoperatively. Subjective follow-up data were obtained on 948 patients at a mean of 4.4 years postoperatively. The mean final range of motion was 5 degree/0 degrees/140 degrees. The mean manual maximum KT-1000 arthrometer score was 2.0 +/- 1.5 mm. Isokinetic quadriceps muscle strength testing revealed a mean of 94% strength after acute reconstructions and 91% strength after chronic reconstructions. International Knee Documentation Committee evaluation after acute reconstruction rated 42% of knees as normal, 47% as near normal, 10% as abnormal, and 1% as severely abnormal. The same evaluation after chronic reconstruction rated 41% of knees as normal, 44% as near normal, 14% as abnormal, and 1% as severely abnormal. Radiographically, 94% of acute knees and 89% of chronic knees had no joint space narrowing. Subjective modified Noyes questionnaire results showed a mean score of 93.2 +/- 7.9 points. The mean time for patients to return to sport-specific activities was 6.2 weeks and to athletic competition at full capacity was 6.2 months postoperatively. In the long-term, patients exhibited full range of motion, excellent stability, good strength, and a return of full function in most cases.

Preventing anterior knee pain after anterior cruciate ligament reconstruction.

We studied a group of 602 patients who had anterior cruciate ligament reconstructions between 1987 and 1992. An autogenous patellar tendon graft was used, regardless of preexisting patellofemoral pain or chondromalacia. The surgeon and rehabilitation protocol were the same for all patients, with emphasis on obtaining full knee hyperextension postoperatively. All patients were evaluated by a questionnaire designed to determine the incidence and severity of anterior knee pain as it relates to sporting or daily living activities, prolonged sitting, stair climbing, and kneeling. Range of motion for the study group was recorded during physical examination. We compared the findings with those from a control group of 122 patients who had no previous knee injury. The study group reported a mean score of 89.5 +/- 12.5, compared with 90.2 +/- 12.3 in the control group. Both the operative and control groups reported little or no symptoms during sporting activities (94% and 92%, respectively). No differences were noted with respect to the other activities surveyed. These results demonstrate that anterior knee pain after anterior cruciate ligament reconstruction is not an inherent complication associated with patellar tendon harvesting. We suggest that the increased incidence of anterior knee pain with an autogenous patellar tendon graft can be prevented by obtaining full knee hyperextension postoperatively. This goal can be achieved through preoperative rehabilitation and a postoperative protocol emphasizing early restoration of full knee hyperextension.

Effects of finger and wrist taping on grip strength.

Taping of the fingers and wrists by professional and collegiate football players has become increasingly prevalent because many players believe taping provides them with increased grip strength. This study was conducted to determine whether taping of the fingers or wrists or both enhances grip strengths in football players. Twenty-five players who self-tape in game situations volunteered for the study. Grip strengths in both taped and untaped conditions (trials) were measured with a hand-held grip dynamometer. Each athlete completed five measurement trials. No statistically significant difference was found between the untaped dominant hand and the dominant hand with the fingers-only taped. There was no significant difference between the untaped nondominant hand and the nondominant hand with the wrist-only taped. The untaped dominant hand was significantly stronger than the taped dominant hand, with mean grip strengths of 142.7 versus 137.8 pounds. The results of these clinical measurements of grip strength showed that, contrary to the perceptions of professional and major college football players, taping of the fingers or wrists or both the fingers and wrists does not improve grip strength.