Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. Results after long-term follow-up.

We retrospectively reviewed the records of fifty-two patients who had had a rupture of the anterior cruciate ligament between the ages of forty and sixty years, to determine the results of aggressive non-operative treatment. We were able to locate and re-examine thirty of these patients (mean age, forty-six years) after a mean duration of follow-up of seven years (range, five to thirteen years), and to assess the clinical, radiographic, and functional results. The mean score, according to the scale of Lysholm and Gillquist, was 82 points; eight of the eleven patients who had combined ligamentous injuries had a score of less than 84 points (symptoms with daily activities). Thirteen substantial reinjuries had occurred in eleven patients (37 per cent) during the follow-up period. Twenty-nine patients (97 per cent) had a grade-2 or 3 Lachman test, and a positive pivot-shift test was elicited in twenty-five patients (83 per cent). Plain radiographs revealed minimum or no changes in twenty-six patients (87 per cent). Magnetic resonance imaging in nine patients revealed scarring of the remnant of the anterior cruciate ligament to the posterior cruciate ligament in six. The mean difference in anterior-posterior laxity between the injured knee and the normal, contralateral knee, as measured with the KT-1000 arthrometer, was five millimeters at twenty pounds (eighty-nine newtons). Twenty-five (83 per cent) of these thirty middle-aged patients, who had had guided rehabilitation and had modified activity, had a satisfactory outcome without an operation. However, a few patients, who had combined instabilities and who wished to resume competitive sports activity that required pivoting, were dissatisfied. Such patients may need operative reconstruction to achieve their goals.

Electromyographic and cinematographic analysis of elbow function in tennis players with lateral epicondylitis.

Lateral epicondylitis occurs frequently in tennis players and appears to be caused by tears in the extensor aponeurosis. The purpose of this study was to compare the electromyographic activities of 5 muscles in players with lateral epicondylitis with those of injury-free players during the single-handed backhand tennis stroke. Finewire electrodes were placed into the extensor digitorum communis, extensor carpi radialis longus and brevis, pronator teres, and flexor carpi radialis muscles in competitive tennis players; 8 players had lateral epicondylitis and 14 had normal upper extremities. The backhand stroke then was recorded on high-speed film and synchronized with the electromyographic signal. The injured players had significantly greater activity for the wrist extensors and pronator teres muscles during ball impact and early follow-through. This activity increase may have been caused by the abnormal mechanics evident on film, including a "leading elbow," wrist extension and an open racquet face near the time of ball impact, and ball contact in the lower half of the strings. These mechanics not only result in a lower level of play but also leave the wrist extensors and the pronator teres muscles vulnerable to injury. This is the first study that documents increased activity in muscles that have been previously injured.

Rehabilitation of the knee after anterior cruciate ligament reconstruction.

From the Kerlan-Jobe Orthopaedic Clinic, 501 E. Hardy Street, Suite 200, Inglewood, CA 90301. New information regarding the isometric placement of the anterior cruciate ligament (ACL) substitute, revascularization process, and biomechanical stresses have all contributed to and been incorporated in the rehabilitation program after ACL reconstruction. Treatment protocols specifically designed for the patient following ACL reconstruction are imperative to return the individual to his or her preinjury status. Care is taken to limit the amount of stress placed on the ligament substitute especially at end of range extension. A program incorporating techniques for developing range of motion and strength while still preserving stability at the knee joint is still of the utmost importance. This program is a revision of a previously reported regimen from this facility (Brewster, Moynes, Jobe, J Orthop Sports Phys Ther 5:121-126, 1983) and is based upon clinical experience and research information. J Orthop Sports Phys Ther 1989;11(1):8-18.

Reconstruction of the ulnar collateral ligament in athletes.

Reconstruction of the ulnar collateral ligament using a free tendon graft was performed on sixteen athletes. All participated in sports that involved throwing (mostly professional baseball), and all had valgus instability of the elbow. After reconstruction and rehabilitation, ten of the sixteen patients returned to their previous level of participation in sports, one returned to a lower level of participation, and five retired from professional athletics. Despite precautions, there was a high incidence of complications related to the ulnar nerve. Two patients had postoperative ulnar neuropathy (one late and one early) that required a secondary operation, but they eventually recovered completely. Three others reported some transient postoperative hypoesthesia along the ulnar aspect of the forearm that resolved after a few weeks or months.

Surgical treatment of tears of the rotator cuff in athletes.

Forty-five athletes with either a partial or a complete tear of the rotator cuff were treated with anterior acromioplasty and repair of the tear. The minimum duration of follow-up was twenty-four months (average, forty-two months). Thirty patients had an incomplete tear and fifteen had a complete tear. Postoperatively, thirty-nine (87 per cent) of the patients stated that they were improved compared with their preoperative status, although only thirty-four patients (76 per cent) felt that they had a significant reduction of pain postoperatively. Objectively, twenty-five (56 per cent) of the patients were rated as having a good result, which allowed them to return to their former competitive level without significant pain. Twelve (41 per cent) of the twenty-nine athletes who had been involved in pitching and throwing returned to their former competitive status. Seven (32 per cent) of the twenty-two pitchers and throwers who had been active at a professional or collegiate level returned to the same competitive level. In our experience, a repair of the rotator cuff combined with an acromioplasty in a young athletic population provides satisfactory relief of pain but does not guarantee that the patient will be able to return to his or her former competitive status in all sports.

Shoulder impingement syndrome in athletes treated by an anterior acromioplasty.

Shoulder pain caused by a impingement syndrome commonly affects an athlete's performance. Thirty-five shoulders in 33 athletes had an impingement syndrome treated by an anterior acromioplasty after failure of conservative treatment. Thirty-one of 35 shoulders (89%) were subjectively judged improved by the patients from their preoperative status. The moderate and severe pain was reduced from 97% of the shoulders preoperation to 20% postoperation. The pain at rest and with activities of daily living was reduced from 71% of the shoulders preoperation to 9% postoperation. However, only 15 of 35 operated shoulders (43%) allowed return to the same preinjury level of competitive athletics, and only four of 18 athletes involved in pitching and throwing returned to their former preinjury status. This operation is satisfactory for pain relief but does not allow an athlete to return to his former competitive status. A prolonged rehabilitation program may improve the results.

The coracoid transfer for recurrent anterior instability of the shoulder in adolescents.

Thirty-six shoulders with recurrent anterior dislocation or subluxation in thirty-four adolescent patients were treated with a modified Bristow procedure. The average length of follow-up was five years and ten months. Postoperatively, two patients had recurrent anterior subluxation on one occasion and none had recurrent anterior dislocation. The average loss of external rotation was 10 degrees. Despite the fact that young patients have a high rate of recurrence after anterior dislocation or subluxation of the shoulder, the modified Bristow procedure is an effective method of treating recurrent anterior instability of the shoulder in adolescents.

Clinical presentation of osgood- schlatter disease in the adolescent population.

Osgood-Schlatter disease is a condition affecting knees of adolescents. Males are affected more frequently than females, and unilateral involvement is more common than bilateral. In the 75 cases seen in our clinic in 4l/3 years, participation in basketball was twice as common among our patients as was any other sport. With the addition of our clinical cases to those documented in the literature, the left knee is significantly more involved than the right (P < 0.05). Relationship to hand dominance is discussed as a possible explanation for the unusual prevalence for left knee involvement. J Orthop Sports Phys Ther 1985;7(1):1-4.

Arthroscopy of the shoulder.

The operative technique and indications for shoulder arthroscopy have been reviewed, with a description of proper technique and instrumentation. Visualization within the joint is usually superior to visualization with arthrotomy. With the refinement of techniques and equipment, it is expected that the frequency of transarthroscopic procedures will increase in the near future.

Radiographic abnormalities of the iliac apophysis in adolescent athletes.

Nine of thirteen adolescent patients with a diagnosis of a so-called hip-pointer injury demonstrated a discontinuity of the anterior part of the iliac apophysis on radiographs. Eight of the nine patients improved with conservative treatment and there was total resolution of symptoms in one to eight months. The remaining patient, who was skeletally mature at the time of writing, continued to have recurrent symptoms of discomfort over the iliac crest during athletic activity. Other reports have described the discontinuity as a stress fracture, but the natural history in our patients did not reveal evidence of fracture-healing. However, the discontinuity disappeared at skeletal maturity in all patients. The radiographic discontinuity may be an anatomical anomaly, since it was present bilaterally in all nine patients although only two had symptoms on both sides.

Stress fractures of the femur in runners.

Early diagnosis, followed by conservative management, permitted five of six long-distance runners to return to running after they had suffered stress fractures of the femur. The sixth patient developed a displaced fracture of the femoral neck which was openly reduced and internally fixated at surgery: this athlete returned to marathoning one year later. In the series there were two fractures of the femoral neck and four of the proximal medical shaft of the femur. Although early diagnosis depends upon a complete history, physical examination and x-ray film results, bone scanning is a further aid when x-ray films still do not confirm the presumptive diagnosis.

The modification Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations.

A review of 107 cases in which the Bristow-Helfet procedure was done for recurrent anterior shoulder subluxation and dislocation is presented. The redislocation rate was 2% with very few complications. Eighty-nine percent of the patients were satisfied with the procedure. Mean loss of external rotation was 12.6 degrees. Six of the 41 patients with dominant shoulder surgery were capable of throwing in the same manner as they did prior to injury. Five of 24 patients (21%) with a diagnosis of recurrent anterior subluxation continued to have symptoms of instability following surgery. Associated symptoms of posterior or voluntary subluxation may preclude a satisfactory result.

Staple capsulorrhaphy for recurrent posterior shoulder dislocation.

Recurrent posterior shoulder dislocation or subluxation is uncommon but occurs occasionally in athletes. Ten patients were treated with a posterior shoulder staple capsulorrhaphy. A posterior Bankhart-type-lesion was found in all cases. Eight of the 10 patients had pain relief. The range of motion was usually maintained postoperatively, but no patient returned to his former throwing status. Four patients also had anterior instability. Three patients (30%) had postoperative recurrence of their posterior instability. The two "ligamentous lax" conditions in the series both recurred. The procedure should be supplemented in the "lax" individual. Complications in 4 patients included a painful staple, postoperative adhesions, and symptomatic ectopic bone formation in two patients. Recurrent posterior shoulder dislocation is not a definite indication for operative repair; patients must be carefully selected.

Pes anserinus transplantation without a routine medial meniscectomy: a review of twenty-two cases.

Of 549 pes anserinus transplantations performed at the National Athletic Health Institute, Inglewood, California from 1971 through 1977, only 27 involved the transfer for anteromedial rotational instability in the presence of an intact medial meniscus. The 22 patients reviewed were evaluated with a questionnaire, physical and roentgenogram examinations, and hamstring and quadriceps muscle testing with Cybex II isokinetic dynamometer. Average length of follow-up was one year, four months. Acute anteromedial rotational instability was seen in 16 patients while six had chronic instability. All had an injury to the anterior cruciate ligament, and 12 had associated medial collateral ligament tears. One year postoperatively, 93% of the patients were participating in athletics and 70% rated their knee as above 90% of normal. The Cybex evaluation, however, revealed only 50% of the patients had 90% of normal strength in hamstrings and quadriceps. One patient developed anteromedial rotational instability, and one a torn medial meniscus, two years postsurgery. It was concluded that: I) Routine medial meniscectomy is not necessary with pes anserinus transplantation; 2) Anterolateral rotary instability does not routinely develop after pes anserinus transplantation done without medial meniscectomy; and 3) Hamstring and quadricep muscle strength below 90% of the normal extremity is not indicative of a subjective unsatisfactory functional result.Indexing terms: pes anserinus transplant; medial meniscectomy; anteromedial rotational instability; anterior cruciate ligament; and medial collateral ligament.

Isolated lateral meniscectomy. A study of twenty-six patients with isolated tears.

To better define the role that the lateral meniscus plays in stabilizing the knee, a study was made of twenty-six patients who had an uncomplicated lateral meniscectomy between 1972 and 1977. Patients with any degree of ligament instability, cruciate or collateral, prior to lateral meniscectomy were eliminated from the study. Also eliminated were any patients with roentgenographic evidence of degenerative arthrits, osteochondritis dissecans, or loose bodies. Only patients whose operative reports stated that the articular cartilage of the lateral compartment was either grossly normal or showed Grade-1 chondromalacia (less than one centimeter in diameter and only softening of the cartilage) at the time of surgery were included in the review. The meniscal lesions included bucket-handle tears, horizontal cleavage tears, and multiple linear defects. No grossly cystic menisci were included in the study. Two menisci demonstrated cystic degenerative changes on histological section. In sixteen patients some degree of ligament instability developed. The longer the interval between injury to the meniscus and its excision, the less satisfactory the result. Only fifteen (54 per cent) of the patients reported satisfactory results, and twenty lost some motion of the knee. We concluded that stability of the knee joint is a multifactorial problem, in which the lateral meniscus certainly plays an important part.