Revision anterior cruciate ligament reconstruction using the lateral third of the ipsilateral patellar tendon after failure of a central-third graft: a preliminary report on 10 patients.

Long-term outcomes were reported for 10 (77%) of 13 cases of revision anterior cruciate ligament (ACL) reconstruction using the lateral third of the ipsilateral patellar tendon as a graft. All primary ACL reconstructions were ipsilateral central-third bone-patellar tendon-bone graft procedures. Mean age at follow-up was 30.7 years, and mean time from revision ACL surgery to follow-up was 42.9 months. At follow-up, average KT-1000 difference between knees was 2.4 mm. All patients had a negative pivot shift, extension within 5 degrees of the contralateral knee, and flexion within 15 degrees. Mean bilateral comparison ratios for isokinetic strength and hop testing were: extension, 83.5%; flexion, 96%; and single-leg hop 96.9%. No patella fractures or tendon ruptures had occurred. All patients had returned to their previous work level, and 8 of the 10 patients could participate in at least "moderate" sports activities (e.g., skiing and tennis). The results were comparable to published outcome reports for both primary and revision ACL reconstruction. The lateral third of the ipsilateral patellar tendon is a good graft option for revision ACL reconstruction.

Effect of ketorolac tromethamine (Toradol) on ecchymosis following anterior cruciate ligament reconstruction.

This article describes a study that assesses whether patients who received ketorolac tromethamine (Toradol; Syntex Research, Palo Alto, California) during knee surgery had an increased tendency to develop ecchymosis in the lower limb versus patients who did not receive ketorolac tromethamine. Sixty-four patients who underwent anterior cruciate ligament (ACL) surgery were divided randomly into three groups: patients who received Toradol at tourniquet inflation (TorTourn) at the end of surgery (TorEnd), or not at all (TorNone). None of the patients exhibited abnormal preoperative bleeding times. One week postsurgery, patients were evaluated photographically for ecchymosis between the hip and malleoli of the surgical limb. Ecchymotic areas between the hip and malleoli were traced around their borders with a black marker. Three photographs of each surgical knee were taken: posterior, anterolateral, and anteromedial views. Each patient's photos then were scanned into a computer and the amount of encircled (ecchymotic) surface area and the total surface area of the limb were calculated. For each view, the ecchymotic surface area was divided by the total surface area to obtain a percentage of ecchymosis on that view. The percentages for the three views were added to obtain a single score for each patient. The mean ecchymotic surface area score was 21.9 +/- 31% for the TorTourn group, 27.5 +/- 25.5% for the TorEnd group, and 30.3 +/- 36.4% for the TorNone group. There was no significant difference in the ecchymotic surface area among the groups. This study suggests that ketorolac tromethamine does not affect the amount of ecchymosis that occurs following knee surgery.

Sports medicine: anterior cruciate ligament injuries.

Newer techniques in anterior cruciate ligament surgery and accelerated rehabilitation has significantly altered the recovery process as well as the degree of functional recovery and the long-term prognosis. In most cases full recovery can be expected within 6 to 12 months following injury. Although great emphasis is placed on rapid progress in physical therapy and rehabilitation, it is also important to provide the necessary emotional support during this period of disability and altered functional state.

A biomechanical evaluation of the iliotibial tract screw tenodesis.

Biomechanical testing of the iliotibial tract screw tenodesis was performed in 10 cadaveric knees under forces approximating in vivo conditions. Force versus displacement curves at various flexion angles were generated with the anterior cruciate ligament intact, with the anterior cruciate ligament sectioned, and after the iliotibial tract screw tenodesis had been performed. Displacement force was measured to 5, 10, and 15 mm. The iliotibial tract screw tenodesis was ineffective in reducing anterior translation of the tibia in the anterior cruciate ligament-deficient knee at forces approximating in vivo conditions.

Anterolateral dislocation of the proximal tibiofibular joint: case report and literature review.

1. Dislocation of the proximal tibiofibular joint is a rare injury, probably less than 1% of all knee injuries. It is seen more frequently in athletes such as soccer players, ballet dancers, and equestrian jumpers. 2. Proximal tibiofibular dislocations are classified into four types: Type I, subluxations; Type II, anterolateral (the most common); Type III, posteromedial; and Type IV, superior. 3. Open reduction is preferred for acute instability or inability to achieve a closed reduction. Chronic instability may result in degeneration of the joint surfaces and is best treated by fibular head resection.

Evaluation of an electrogoniometric instrument for measurement of laxity of the knee.

Eight lower extremities from cadavera were tested for anterior-posterior laxity in two positions before and after transection of the anterior cruciate ligament. At critical points in the tests, electrogoniometric and radiographic measurements of tibiofemoral translation were compared. By direct measurement, we determined the accuracy of the radiographic method to +/- 0.4 millimeter (95 per cent) in measuring anterior-posterior translations of the tibia with respect to the femur. The electrogoniometer estimated displacement of the tibia with respect to the femur during the anterior drawer test to be 3.5 +/- 8.2 millimeters at 90 degrees of flexion of the knee and 11.1 +/- 16.1 millimeters at 30 degrees of flexion. Direct comparison of these measurements with those obtained by means of the radiographic technique showed that the electrogoniometer tended, on average, to overestimate the tibial translation. The amount of overestimation was 0.7 millimeter for intact knees and 1.9 millimeters after sacrifice of the anterior cruciate ligament. Despite this small average error in measurement of tibial translation, the difference between individual electrogoniometric and radiographic measurements varied greatly, with a 95 per cent confidence limit of +/- 5.5 millimeters. The error of the electrogoniometric measurements varied with the angle of flexion of the knee during testing, both the accuracy and the reliability of the electrogoniometric measurements being greatly diminished at 30 degrees of flexion. The electrogoniometric method also tended to overestimate tibial internal rotation (by an average of 10.5 degrees) and external rotation (by an average of 9.3 degrees); the reliability of these measurements was +/- 6.9 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)

Discoid meniscus.

The discoid meniscus is probably a congenital deviation that usually occurs laterally. The Watanabe classification consists of complete, incomplete, or Wrisburg ligament types. Complete and incomplete discoid menisci normally require treatment only when a tear occurs. The Wrisburg ligament type lacks a posterior capsular attachment. The preferred treatment is repair of the posterior capsular disruption with saucerization of the remaining meniscus.

External stabilization of the anterior cruciate ligament deficient knee during rehabilitation.

Using cadaveric specimens, we studied the effect of ACL deficiency upon anterior tibial translation during extension of the knee joint. Five knees were loaded via the quadriceps mechanism until flexion angles of 10 degrees, 25 degrees, 40 degrees, and 60 degrees were attained. At each angle, the anterior-posterior position of the tibia was documented with biplane radiography, both before and after division of the ACL. In every specimen, anterior tibial translation increased with loss of the ACL and was greatest at 25 degrees of flexion, where an average displacement of 3.3 mm was observed. Subluxation was not significant at flexion angles exceeding 60 degrees, regardless of ACL deficiency. We also examined the effect of an external restraining force on tibial subluxation in the ACL deficient knee. Posteriorly directed forces of 0 N, 45 N (10 pounds), 90 N (20 pounds), 135 N (30 pounds), and 225 N (50 pounds) were applied to the tibia at the level of the tibial tubercle. Anterior subluxation was eliminated through application of forces ranging from a maximum of 106 N (23.6 pounds) at 10 degrees to only 13 N (2.9 pounds) at 60 degrees.

Elbow arthroscopy.

Decreased surgical morbidity and rapid recovery time associated with arthroscopic surgery of the elbow justify its preference over more extensive open incisions in selected cases. Not all elbow conditions can be treated arthroscopically, however, and open incisions are still preferred in more extensive problems such as displaced fractures and olecranon impingement syndromes.

Arthroscopic management of lateral meniscal cysts.

This study presents seven cases of lateral meniscal cysts treated arthroscopically. All were noted to have meniscal lesions at the time of surgery; there were five flap tears and two radial tears. Partial arthroscopic meniscectomy was performed and the contents of the cysts were manipulated into the joint in six of seven cases. One patient underwent open cyst excision in addition to partial arthroscopic meniscectomy. Followup ranged from 18 months to 4 years with an average of 28 months. There were no cyst recurrences. The pathologic basis of the meniscal cyst is controversial, but recent work suggests the etiology is infiltration of joint fluid through micro and macro tears in the meniscus. Partial meniscectomy retains valuable meniscal function while minimizing the likelihood of cyst reformation. We found arthroscopic partial meniscectomy with manipulation of the contents of the cyst into the joint to be a successful alternative to complete open meniscectomy.

Synthetics in anterior cruciate ligament reconstruction: a review.

Because of a rapidly growing interest in synthetic ligaments, the American Academy of Orthopedic Surgeons Committee on the Knee sponsored a seminar in Atlanta, Georgia, in June 1983. Attending this seminar were Knee Committee Members, six invited guest consultants with expertise in collagen metabolism and healing and materials testings, and eight teams of investigators who presented data on eight different devices. In November 1983, the Federal Food and Drug Administration Advisory Panel for Orthopedics held an open meeting in Washington, D.C., on the subject of artificial ligaments. In February 1984, there was an hour and a half symposium on artificial ligaments at the Annual Meeting of the American Academy of Orthopedic Surgeons. Although there is widespread interest in this subject, it is evident that more scientific information and clinical experience must be accumulated. Uniform methods of evaluation, both biomechanical and clinical, are needed. At present, synthetic materials are being investigated under rigid controls, and none have been released for general clinical use. Indications are limited to cases of chronic instability in which autogenous tissues are insufficient or unusable.

Repairable posterior menisco-capsular disruption in anterior cruciate ligament injuries.

Two hundred thirty-four consecutive patients with a positive Lachman test underwent examination under anesthesia and diagnostic arthroscopy to include complete evaluation of both posterior menisco-capsular attachments. Knees which had had previous arthrotomy were excluded. Complete repairable posterior menisco-capsular disruptions occurred in 31 of 112 (27.7%) acute cases and 36 of 122 (29.5%) knees in the chronic group. These lesions are not predictable by physical examination or by routine clinical grading of instability. Thorough arthroscopic examination to include direct visualization of the posterior menisco-capsular junction is necessary for complete diagnosis in anterior cruciate ligament injuries.

Patellar pain and quadriceps rehabilitation. An EMG study.

Eighteen patients (26 knees) giving a history of patellar dislocation and/or subluxation and continued patellar symptoms underwent evaluation to determine the efficacy of their rehabilitation programs. Four-channel cine-electromyography was utilized to assess the relative muscular effort of the vastus medialis, vastus lateralis, vastus medialis obliquus, and rectus femoris in a series of exercises. Ten degrees of flexion of the knee reduced effective muscle effort in the vasti group to an average of 1/4 of the muscle effort demonstrated in full extension of the knee. No consistent pattern was noted by altering the rotation of the hip from neutral to external or internal rotation. The addition of weight (5 lb) to the ankle did not enhance the muscle effort with the knee in full extension. Quadsets and straight leg-raising exercises in full knee extension offer the best quadriceps rehabilitation program in the patient with a patellar malalignment syndrome and persistent symptoms.

Factors influencing elbow instability.

Stability or instability of the elbow is contingent upon three distinct but interrelated conditions: radiocapitellar articular continuity, coronoid process integrity and medial collateral ligament competency through an intact anterior oblique ligament. The latter, the anterior oblique ligament of the medial collateral ligament both in anatomic experimentation and clinical cases appears to be the most critical factor in elbow stability. The reconstruction of the unstable elbow must focus on this medial supporting ligament for a predictable result.