Patellar tendon length after anterior cruciate ligament reconstruction.A prospective study.

Shortening of the patellar tendon after anterior cruciate ligament (ACL) reconstruction has been implicated as a cause of postoperative complications such as anterior knee pain, patella infera syndrome, and traumatic patellar tendon rupture. This prospective study was designed to asses whether closure of the patellar tendon defect during ACL reconstruction with mid-third bone-patellar tendon-bone autograft leads to radiographic evidence of patellar tendon shortening. One hundred fourteen patients underwent arthroscopically assisted ACL reconstruction using mid-third bone-patellar tendon-bone autograft. Group I (59 patients) had the patellar tendon defect left open. Group II (55 patients) had the defect sutured closed. The paratenon was approximated in all patients. Lateral knee radiographs were taken pre- and post-operatively. The pre- and postoperative patellar tendon lengths were measured and compared. Group I (defect left open) showed virtually no patellar tendon shortening (average 0.3%). Group II (defect closed) showed minimal but slightly more shortening (average: 0.51%). The maximum shortening was 2.3% in Group I and 4.3% in Group II. Therefore, closure of the patellar tendon defect does not significantly alter the length of the patellar tendon after ACL reconstruction.

Contemporary magnetic resonance imaging of the knee. The orthopedic surgeon's perspective.

This article discusses the current applications of MR imaging in the practice of orthopedic surgery and sports medicine. When is MR imaging helpful to the treating surgeon, and when is it not? In what specific areas will future improvements in technical acquisition and interpretation be helpful in determining appropriate treatment? This article explores these questions.

Distal humeral epiphyseal separation in a young athlete: a case report.

Elbow pain in the young throwing athlete can have numerous etiologies. Skeletally immature athletes commonly sustain epiphyseal injuries secondary to trauma and/or repetitive activity. The case of a 7-year-old Little League pitcher with the diagnosis of distal humeral epiphyseal separation is presented along with a review of the current literature.

Arthroscopic meniscectomy in patients over the age of 40.

One hundred eighteen patients, aged 40 or older, underwent partial meniscectomy and limited debridement of coexisting grade III or grade IV degenerative articular cartilage lesions. No curettage, abrasion arthroplasty, or subchondral drilling was performed. The average age of the patients was 57 years (range, 40 to 78). The mean followup was 3.3 years (range, 1 to 7). Sixty-three similar patients who also underwent partial meniscectomy but did not have the finding of significant coexisting articular surface erosion were studied for comparison. Of the 118 patients in the group with articular lesions (78 men and 40 women), 71 (60%) rated their improvement as significant, 22 (19%) as moderate, and 15 (13%) as mild; 10 (8%) noted no improvement. Although 98 (83%) were generally satisfied with their result, only 57 (48%) reported satisfaction for sports. However, 89 (75%) had resumed and continued recreational athletic activities. Results tended to be worse in women, in patients older than 60, in those with moderate or severe tibiofemoral radiographic changes, those who had a grade IV articular lesion, and those with longer followup time. Although results were poorer in patients with coexisting grade III or grade IV degenerative arthritis, arthroscopic partial meniscectomy and limited debridement was an acceptably effective procedure in patients over the age of 40.

The long-term followup of primary anterior cruciate ligament repair. Defining a rationale for augmentation.

Fifty primary ACL repairs using the Marshall multiple suture technique were analyzed. The average age at surgery was 23 years (range, 15 to 56), with 76% under the age of 30. The average followup was 61.3 months (range, 48 to 86). The average time from injury to surgery was 7 days (range, 1 to 18). Eighty percent of the injuries were sports-related with football and skiing predominating. Thirty-eight percent were "isolated" ACL tears, and 62% had associated injuries. There was a 46% incidence of meniscal tear with 59% of the meniscal tears being repaired. The postoperative evaluation included a multifactorial analysis correlating 43 variables including subjective, objective, radiographic, and KT-1000 data. The Hospital for Special Surgery Knee Diagnostic Score, a clinical objective score based on the postoperative Lachman and pivot shift examination, a KT-1000 arthrometer data score, and an overall combined assessment score were determined. The results showed 59% excellent, 18% good, 14% fair, and 8% poor. The Lachman test was diagnostic in all cases. The quality of ACL tissue at repair was rated excellent or good in 62% of the cases. Four patterns of ACL tears were distinguished by the location of the tear. Football injury, younger age, increased peroperative pivot shift, midsubstance Type IV tear, and return of full motion correlated with poor postoperative results. Increasing age, tight jointedness, Type I tears, and a 5 degrees flexion contracture correlated with good postoperative results.

Bilateral simultaneous rupture of the infrapatellar tendon in a recreational athlete. A case report.

Bilateral rupture of the infrapatellar tendons is a rare event in an otherwise healthy athletic individual. The event is usually quite severe and diagnosis can be readily made on a clinical examination. In the case presented here, predisposing factors consisted of an underlying patella alta and a long history of repetitive trauma to the knee. Prompt diagnosis and surgical repair will lead to a good functional result.

The conservative treatment of the anterior cruciate deficient knee.

Seventy-nine recreational athletes (average age, 26 years) with complete ACL tears were treated with nonligamentous arthroscopic surgery, monitored rehabilitation, functional bracing, and activity modification. The average followup was 52 months (range, 36 to 102 months). Six (8%) patients ultimately underwent ligament reconstruction and were considered failures of nonreconstructive treatment. The remaining 73 patients were the subject of detailed analysis. There were 9 (11%) excellent, 25 (32%) good, 17 (22%) fair, and 28 (35%) poor results. Although 71 patients (97%) were satisfied with their knee for activities of daily living, only 36 (49%) were satisfied with their knee for sports. Twenty-nine (40%) had significantly modified their athletic activities. Age, sex, interval from injury to treatment, associated meniscal tears (49 or 67%), and articular cartilage damage (21 or 29%) had no apparent effect on the outcome. Poor results were noted in 29 (40%) patients with significant pivot shifts. Multiple repeat injuries, repeat arthroscopy, isokinetic deficits, and increased length of followup were also associated with poor results.

Rationale and protocol for postoperative anterior cruciate ligament rehabilitation.

A rehabilitation program for postoperative anterior cruciate ligament (ACL) reconstruction permits adequate tissue healing time and allows early protected muscular conditioning. The program is based on kinematic, biomechanical, and kinesiologic factors as they pertain to ACL function. The program is divided into five phases. The early phases, zero to 12 weeks, are intended to control translational forces across the ACL and to allow necessary time for ligament revascularization and soft-tissue healing. During this period, isometric and isotonic training of the hamstrings and quadriceps muscle groups in a restricted active arc of motion is permitted. Passive motion is encouraged, and progressive weight bearing is allowed. Conditioning of the upper body as well as the nonsurgical lower limb is stressed. During the advanced phases, 12-31 weeks, isotonic muscle training continues throughout a full range of motion. Greater strength, coordination, and endurance to achieve dynamic stability of the knee, preparing the patient for unrestricted activity, are stressed. Approximately 52 weeks of active rehabilitation after ACL reconstruction surgery are usually required to return to a preinjury level of function.

Patterns of meniscal injury with acute anterior cruciate ligament tears.

One hundred two patients underwent an arthrotomy for the primary repair of an acute ACL tear with or without an associated collateral ligament injury. The mean age was 23 years. Forty-seven patients (46%) had meniscal injuries. Meniscal injuries were found in 41% of Group I patients (isolated ACL injuries) and in 54% of Group II patients (injured ACL/collateral ligaments). Twenty-eight medial and 22 lateral meniscal tears were noted. Twenty-six of the 50 meniscal tears (52%) were sutured in an attempt to repair the menisci. Of these, 20 of the medial (71%), and 6 of the lateral (27%) meniscal injuries were sutured. No patients in this series required a total meniscectomy. A thorough evaluation of the menisci is mandatory in knees with an acutely injured ACL.

Pregnancy after hemipelvectomy: a case report and review of the literature.

Hemipelvectomy is a most radical attempt at cure of malignant tumors of the pelvis and the upper portion of the femur. Pregnancy following this severely mutilating operation is rare. Despite the considerable loss of pelvic support patients do remarkably well. A case of pregnancy following hemipelvectomy is presented and represents the 16th report in the English literature. The anatomic consequences of hemipelvectomy are described and a review of the past 61 years experience with pregnancy following this operation is presented.

Primary repair of the anterior cruciate ligament.

The article reviews the clinical features of the acutely torn anterior cruciate ligament. The alternatives and techniques of repair are discussed. Results of primary repair are presented. A rationale for therapeutic options is presented.

Computed tomography (CT) arthrography of shoulder instabilities in athletes.

Sixty professional and recreational athletes underwent CT arthrography of the shoulder for evaluation of suspected shoulder joint derangement. These athletes, 46 males and 14 females ranging in age from 15 to 60 years (mean, 32 years), all had persistent pain that interfered with their sports activity and was resistant to conservative treatment. Seventeen patients had shoulder instability based on clinical manifestations and CT arthrographic findings. An additional five patients, also based on clinical manifestations and CT arthrographic findings, were considered to have an unobtrusive degree of anterior joint laxity. Patients with anterior instability (20 cases) all had an anteroinferior tear or detachment of the glenoid labrum, as well as some violation of the insertion of the joint capsule onto the scapula. Those with posterior instability (two cases) had a combination of labral and capsular tears. Two other major patterns of labral tears, both unaffiliated with shoulder instability, were identified. These included total or partial detachment of superior segments of the labrum, and anterior labral tears at the midglenoid level. Moreover, various degrees of labral attenuation (or, less often, enlargement), osteophyte formation, and alterations in articular cartilage were observed. Surgical correlation was obtained in 25 patients, with 95% accuracy of CT arthrographic findings. CT arthrography is a minimally invasive and highly accurate technique for investigation of glenohumeral derangement. Specifically, the extent of pathologic changes associated with instability can be determined and differentiated from other intraarticular causes of incapacity, such as labral tears caused by throwing, or degenerative changes.

Double contrast arthrography of the knee. A comparison to clinical diagnosis and arthroscopic findings.

The accuracy of pre-arthroscopic double contrast arthrography was evaluated in 100 consecutive patients. Meniscal tears were correctly diagnosed arthrographically in 76% of cases, and clinically in 85% of cases. Although reasonably accurate in determining the location of the meniscal tear, arthrography was significantly inaccurate in the evaluation of the type of tear. The status of the anterior cruciate ligament was correctly interpreted by arthrogram in 76% of cases; the integrity of the ligament was correctly assessed in 94% of cases by clinical examination without anesthesia. It appears, therefore, when compared to initial clinical examination, double contrast arthrography is of limited usefulness as a pre-surgical aid to the diagnosis of intra-articular knee pathology.

Athlete shoulder injuries: CT arthrographic findings.

Forty-three professional and amateur athletes with persistent shoulder pain that interfered with their sports activities were evaluated by computed tomographic (CT) arthrography. In 19 patients, glenohumeral instability (14 anterior, two posterior, three multidirectional) was diagnosed with CT arthrography based on the simultaneous presence of labral and capsular lesions. The findings were crucial in establishing the diagnosis of instability in six patients in whom the condition was not suggested or could not be confirmed clinically. Another significant injury consisted of labral lesions not associated with glenohumeral instability. These tears often involved the anterior and parasuperior segments of this structure. Other, less frequently detected lesions included segmental labral enlargement and several labra with abnormal orientation (everted labrum). Early onset of degenerative disease was present in many athletes, especially those with a long history of sports activity. CT arthrographic findings were correlated with arthroscopic or surgical results in 19 patients.

CT arthrography of capsular structures of the shoulder.

The capsular mechanism of the shoulder joint consists of the joint capsule, which is strengthened by the glenohumeral ligaments and the rotator cuff, the glenoid labrum, and a variable number of synovial recesses. Although the fibrous capsule is a lax structure, the normal function of the capsular mechanism makes it an effective barrier against anterior dislocation, particularly in external rotation. There has been a tendency in the past to overestimate the role of the glenoid labrum in stability of the shoulder joint. In patients with instability, the significance of the capsular attachment or its anomalous insertions to the glenoid has not been adequately recognized. Labral tears may develop as secondary lesions due to repeated dislocations and subluxations rather than representing the primary lesion responsible for instability. Operative visualization of capsular defects or detachments is often difficult. Prior knowledge of these lesions can effectively help the choice of an appropriate surgical procedure and reduce operating time. The results of computed tomographic (CT) arthrography of the shoulder joint in 45 patients are reported and the normal and pathologic variations of the joint capsule and particularly the capsular insertions are described. Configuration of the joint recesses and the glenoid labrum are also evaluated. These CT findings were correlated and verified by surgery or arthroscopy in 26 cases.

Computed tomography of tibial plateau fractures.

Open reduction with internal fixation of tibial plateau fractures in performed frequently. Factors that must be considered in planning treatment include the patient's age and physical condition, the presence and degree of plateau depression, the presence and degree of separation of split fragments, and the severity of fracture comminution. Twenty patients with tibial plateau fractures were studied by conventional tomography and computed tomography (CT) in order to determine the role and feasibility of CT in management of such patients. CT resulted in less discomfort to the patient and provided optimal visualization of the plateau defect and the split fragments. It proved more accurate than conventional tomography in assessing depressed and split fractures when they involved the anterior or posterior border of the plateau and in demonstrating the extent of fracture comminution. Split fragments with an oblique plane of fracture also were seen better by CT. The degree of fracture depression and separation as measured by the computerized technique was often more accurate than measurements obtained from conventional tomograms. In three patients, treatment was changed on the basis of the CT findings. In three other cases, the classification was altered without a change in treatment.

Treatment of intertrochanteric fractures with a sliding nail-plate.

Valgus closed reduction and internal fixation with a 150 degrees nail-plate produced favorable results in 55 stable and 45 unstable intertrochanteric fractures. The average axial collapse (impaction) was 14.9 mm in stable fractures and 19.6 mm in unstable fractures. Most (65%) of this spontaneous impaction occurred within the first week. There were six (6.0%) failures of fixation. The two failures (3.6%) among the stable fractures were the result of malpositioning of the internal fixation device. Four (8.8%) unstable fractures demonstrated loss of fixation related to failure to allow sufficient slide within the nail to accommodate the postoperative axial collapse of the fracture fragments. It is recommended that 20 to 25 mm of nail slide be made available in stable fractures and 25 to 30 mm in unstable fractures. This will increase stability by allowing the sliding nail to accommodate the complete post-fixation axial collapse of the fracture fragments.