Current practices and opinions in ACL reconstruction and rehabilitation: results of a survey of the American Orthopaedic Society for Sports Medicine.

Many different surgical techniques and rehabilitation protocols have evolved for the treatment of anterior cruciate ligament (ACL) injuries, and there is a lack of agreement as to which approach results in the best outcome. Members of the American Orthopaedic Society for Sports Medicine (AOSSM) were surveyed to determine their current ACL reconstruction technique and opinions regarding preoperative and postoperative management. In 1999, members of the AOSSM were mailed surveys asking about their current treatment of ACL injuries. Approximately 76% of the active members responded to the survey, of which a large percentage (92%) currently performs ACL reconstructions. Both the experience of the surgeon and annual number of ACL reconstructions performed were recorded. Most responding surgeons routinely perform ACL reconstructions 3-6 weeks following an acute ACL injury using an endoscopic technique. Bone-patellar tendon-bone (BPTB) with interference screw fixation was the technique of choice for most respondents, with the majority performed on an outpatient basis. Rehabilitation protocols showed more variation regarding postoperative weight bearing, immobilization and bracing, length of physical therapy, and return to sport. Most surgeons prefer early postoperative full weight bearing with an average of 3.8 weeks of postoperative bracing. Physical therapy typically ranged from 1-4 months with return to sport at 6-7 months, generally with a functional brace. Patients with BPTB reconstruction were allowed the earliest return to full activity. Although previous clinical and biomechanical studies show good-excellent results with different ACL reconstruction and rehabilitation techniques, currently most surgeons practicing as members of the AOSSM continue to prefer BPTB grafts with metal interference screw fixation. However, there is less consensus regarding the specific postoperative rehabilitation protocol.

Double-stranded hamstring tendons for anterior cruciate ligament reconstruction.

Bone-patellar tendon-bone autograft is the most commonly used tissue for ACL reconstruction; however, the harvesting of patellar tendon as a free graft can lead to significant morbidity. Alternate grafts may lower morbidity, yet the most commonly used alternate grafts including the double-stranded semi-tendinosus or gracilis have not been studied biomechanically. This study investigated the morphometric and biomechanical properties of double-stranded semi-tendinosus and gracilis tendons separately along with the patellar and quadriceps tendons obtained bilaterally from six fresh, 77-year-old cadaveric specimens. The quadriceps tendon was the thickest and therefore had the largest cross-sectional area, whereas double-stranded semitendinosus had the highest mean peak load to failure (1029+/-158.4 N), 11.5% and 10.3% stronger than patellar tendon and quadriceps tendons, respectively. Midsubstance rupture occurred in the hamstring tendons, whereas the patellar and quadriceps tendons failed at the bone-tendon junctions. Semitendinosus tendons with higher cross-sectional area had higher peak loads to failure. This linear relationship between cross-sectional area and the peak load to rupture also was observed in the other tendon groups (except gracilis). These results indicate that despite a lower cross-sectional area of the double-stranded semitendinosus, this tendon demonstrated a comparable mean peak load to rupture and stress compared with patellar and quadriceps tendons. It also was demonstrated that combined double-stranded semitendinosus and gracilis tendons produce a stronger graft with initial strength twice that of the patellar tendon, but requires further testing.

Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center. With a modification to increase specificity for identifying malleolar fractures.

In a sports medicine center, we prospectively evaluated the Ottawa Ankle Rules over 1 year for their ability to identify clinically significant ankle and midfoot fractures and to reduce the need for radiography. We also developed a modification to improve specificity for malleolar fracture identification. Patients with acute ankle injuries (< or = 10 days old) had the rules applied and then had radiographs taken. Sensitivity, specificity, and the potential reduction in the use of radiography were calculated for the Ottawa Ankle Rules in 132 patients and for the new "Buffalo" rule in 78 of these patients. There were 11 clinically significant fractures (fracture rate, 8.3% per year). In these 132 patients, the Ottawa Ankle Rules would have reduced the need for radiography by 34%, without any fractures being missed (sensitivity 100%, specificity 37%). In 78 patients, the specificity for malleolar fracture for the new rule was significantly greater than that of the Ottawa Ankle Rules malleolar rule (59% versus 42%), sensitivity remained 100%, and the potential reduction in the need for radiography (54%) was significantly greater. The Ottawa Ankle Rules could significantly reduce the need for radiography in patients with acute ankle and midfoot injuries in this setting without missing clinically significant fractures. The Buffalo modification could improve specificity for malleolar fractures without sacrificing sensitivity and could significantly reduce the need for radiography.

Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation.

Patients with knee osteoarthritis (OA) have reduced functional capacity and muscle function that improves significantly after quantitative progressive exercise rehabilitation (QPER). The effects of these changes on the biomechanics of walking have not been quantified. Our goal was to quantify the effects of knee OA on gait before and after QPER. Bilateral kinematic and kinetic analyses were performed using a standard link-segment analysis on seven women (60.9 +/- 9.4 years) with knee OA. All functional capacity, muscle function and gait variables were initially reduced compared to age-matched controls. Muscle strength, endurance and contraction speed were significantly improved (55%, 42% and 34%, respectively) after 2 months of QPER (p < 0.05), as were function (13%), walking time (21%), difficulty (33%) and pain (13%). There were no significant changes in the gait variables after QPER. To use the QPER improvements to the best advantage, gait retraining may be necessary to "re-programme' the locomotor pattern.