The American Journal of Sports Medicine

This study was undertaken to determine the optimal time after injury for arthroscopically assisted anterior cruciate ligament reconstruction using a double semi tendinosus graft. We analyzed 87 patients. Time from injury to surgery was established as acute, subacute, or chronic; the three groups were matched. Meniscal damage and treatment were categorized. Chondral le sions were graded, postoperative parameters of mo tion, strength recovery, and stability were tabulated at 3, 6, 12, and 18 months. Complications were com pared.

Six percent of the patients with chronic knee injuries had two normal menisci at surgery, compared with 29% of the acute and subacute groups. Reparable tears were found in 37.8% of the knees. Chondral lesions were found in the tibiofemoral joint in 17% of acute, 7% of subacute, and 44% of the chronic knees. Postoperative motion recovery was significantly less at all time intervals for the acute group. Quadriceps strength recovery was slower in the acute knees. Sta bility was similar in all groups. Arthrofibrosis was found in 22% of acute, 0 subacute, and 12.5% of the chronic knees. Patellofemoral pain was noted in 17% of the acute, 0 of the subacute, and 9.3% of the chronic knees.

This study showed that surgery done within 6 months of injury does not jeopardize the knee. Recovery after acute anterior cruciate ligament reconstruction is sig nificantly slower than after subacute or chronic recon struction.

Arthrography was used for diagnosis of ruptures of lateral ligaments in 589 acutely injured ankles that were treated operatively. The accuracy of the method was tested comparing the findings of arthrography with those at operation. We found arthrography to be almost 100% reliable for diagnosing a fresh anterior talofibular ligament rupture. The best criterion for detecting cal caneofibular ligament rupture was filling of the peroneal tendon sheath with contrast medium. Leakage below and behind the lateral malleolus, when present with peroneal tendon sheath filling, confirms the diagnosis of calcaneofibular ligament rupture, but these findings without peroneal tendon sheath filling are too rare to base the diagnosis on them alone.

The purpose of this paper was to report our experience with an arthroscopic technique of repair for the Bankart lesion following shoulder instability. Twenty-seven pa tients (average age, 21.7 years) were followed for an average of 36 months after arthroscopic suture stabili zation of anterior shoulder instability. Patients were excluded if instability was multidirectional or voluntary and if there was radiographic evidence of a significant loss of glenoid bone stock. Clinical evaluation using a functional grading system showed that 10 patients were rated as excellent, 5 good, and 12 poor. Fourteen patients returned to their previous level of activity. There were 12 patients rated as failed; all had recurrent instability of the shoulder. Success was associated with a period of immobilization of 3 weeks or longer and a history of acute injury, especially subluxation. Failures were associated with shorter immobilization periods after surgery and in patients who had recurrent dislo cations. The younger patient, who may not have com plied with the immobilization protocol, also seemed to be associated with failure. Contact sports seem to leave a patient at high risk for recurrence. We recommend caution in the use of arthroscopic procedures for the competitive athlete in whom a second surgery and rehabilitation might mean loss of more sports partici pation.

To determine more precisely the injury mechanism of the peroneal tendon longitudinal tear, we studied 15 cadaveric lower extremities. Our study was motivated by our observation from a retrospective study of ath letes treated by one surgeon (FHB) over a 17-year period. Eight patients who sustained lateral ankle sprains by plantar flexion and inversion of the foot on the leg also had longitudinal tears (1 to 3 cm) of the peroneal tendon—five in the peroneus longus and three in the peroneus brevis. All of the lateral ankle sprains were successfully managed nonoperatively. However, even after a period of rehabilitation, when their ankles should have been asymptomatic, the patients continued to complain of persistent lateral ankle swelling, popping, and retrofibular pain. On physical examination, all ankles were clinically stable. Palpable retrofibular pop ping occurred with active foot rotation. There was no evidence of peroneal tendon instability. Radiographs were normal and tenograms were suggestive of pero neal tendon injury but did not have the specificity to reveal the rupture. Primary suture repair of this peroneal tendon split was performed and gave excellent long- term results. The cadaveric studies revealed that the tear of the tendon could occur in the 25° to 15° range of plantar flexion as the peroneus longus impinged against the tip of the fibula and as the peroneus brevis impinged against the lateral wall of the peroneal groove or against the longus tendon.

Seventy patients with chronic anterior instability under went anterior cruciate ligament reconstruction with a Dacron prosthesis pretensioned to 60 N. Of these patients, 49% (34) had combined medial instability, 32% (22) had failed previous anterior cruciate ligament sur gery, and 37% (26) had previous meniscectomy. At reconstruction, 12 patients had their medial instability treated; 22 did not. Follow-up intervals were 3, 6, and 12 months and then each year to 5 years.

The 5-year followup included 69 patients; the other 1 had the ligament removed because of a synovial fistula at 8 months. Results were 23% prosthesis ruptures, 3% poor, 17% fair, 16% good, and 39% excellent. The 2-year results showed the same distribution, but a lower rupture rate, which was affected by placement of the tibial tunnel within the anterior one-third of the tibia (9 times increase) and coexisting nonrepaired me dial instability (5 times increase). Those patients with perfect placement of the ligament who also had good medial stability and no previous ligament surgery had no rupture at 5 years. The stability that was gained at surgery was gradually lost (-11.2% per year). At 5 years, the uninjured knee also had lost 41% of the preoperative stability; the mean laxity difference was within ±2 mm. The mean improvement in subjective knee function (Lysholm score 74.5 to 91.9) was main tained during the followup. The mean preoperative ac tivity level improved significantly, but did not reach the preinjury level. These results show that the Dacron prosthesis will not give acceptable results in salvage cases where other instabilities are left untreated.

We studied 40 patients who underwent reconstruction for chronic anterior cruciate ligament deficiency with a Dacron ligament prosthesis using a modified MacIntosh over-the-top technique, augmented with iliotibial band. Thirty patients had undergone at least 1 prior surgical procedure on the affected knee, but only 7 patients had previous anterior cruciate ligament reconstruction.

All patients were followed for a mean of 47.5 months. The results at final followup demonstrated an average side-to-side arthrometer difference of 1.0 mm. The Lysholm score improved from 65 preoperatively to 89 at the end of the review; the Tegner activity level score improved from 3 to 5. Objectively, 75% of the patients had a negative Lachman test result and 95.1% of the subjects had negative or trace pivot shift results at review. Mild knee pain was still present with day-to-day activity in 87.7% of the patients.

Complications occurred in 27.5% of patients, includ ing five who had implant ruptures and two who had their grafts removed. Synovitis was a significant prob lem.

Based on our failure criteria, 47.5% (19) of the sub jects had failed results. In this study, radiologic evidence of tracer separation greater than 1 cm was a criterion of failure. With inclusion of tracer separation, the failure rate increased to 60.0% (24).

Multiple previous surgeries of any type had an ad verse effect on results. Damage to secondary stabiliz ers in these cases increased failure rate. Based on the high complication and failure rates, and relatively poor end result in this retrospective review, we cannot rec ommend this procedure.

We report the 5-year follow-up results of a prospective, multicenter study evaluating the use of a Dacron pros thetic ligament in reconstruction of anterior cruciate- deficient knees. The study group consisted of 84 pa tients, followed for at least 5 years. The patients were divided into 2 groups: 50 patients with isolated anterior cruciate ligament laxity (Group 1) and 34 patients with a failed previous anterior cruciate ligament surgery or combined laxities (Group 2). Two surgical techniques were employed: reconstruction through drill holes in the tibia and femur (30 patients) and reconstruction using the over-the-top position with the Dacron ligament wrapped in a strip of iliotibial band (54 patients).

The overall failure rate was 35.7% at 5 years. The failure rate at 2 years was 20%, illustrating a significant deterioration of results between the two follow-up in tervals. Evaluation of subjective criteria using the Lysh olm score showed an improvement from preoperative status at the 2-year followup; however, there was a slight decline when 5-year results were evaluated. Teg ner activity levels increased from a mean of 2.9 ± 2.1 at the preoperative visit, to a mean of 4.9 ± 2.0 at the 2-year followup and a mean of 5.0 ± 2.0 at the 5-year visit.

These results show that the Dacron ligament pros thesis achieves the short-term goal of restoring stability and improving function and may be sufficient to provide long-term stability for the anterior cruciate-deficient knee.

Ten patients with 11 cases of Freiberg's infraction were studied retrospectively. The patients had varying amounts of sports participation. All cases were treated surgically, most after some form of nonoperative inter vention. Surgery consisted of metatarsophalangeal joint debridement, except in 1 patient where the meta tarsal head was resected. All patients had improvement of their symptoms and 80% of normal joint range of motion was restored. No patient had joint space nar rowing or major arthritic changes on follow-up roent genographic studies.

Golf is a popular sport for both men and women. The trunk is the most common area of injury during the golf swing. The purpose of this study was to describe and compare the muscle firing patterns in the trunk during the golf swing. Twenty-three golfers with handicaps of five or below volunteered for this study. Surface elec tromyographic electrodes were placed on the abdomi nal oblique and erector spinae muscles bilaterally. High- speed cinematography was used in conjunction with the electromyographic electrodes. The results demon strated relatively low activity in all muscles during tak eaway (below 30% of maximal muscle test), and rela tively high and constant activity throughout the rest of the swing (above 30% maximal muscle test, with the exception of the contralateral erector spinae during late follow-through, which was 28% maximal muscle test). This high and constant activity demonstrated the im portance of the trunk muscles during a golf swing. These results indicate the need for an effective preven tive and rehabilitative exercise program for the golfer.

The sagittal anterior displacement of the tibia, induced by weightbearing, in chronic anterior cruciate ligament- insufficient knees was measured radiographically in 2 groups of patients. All patients in both groups had an increased laxity when assessed with the Lachman and flexion-rotation-drawer test. Sixteen patients were functionally improved and were relatively asymptomatic after a neuromuscular rehabilitation program, while the second group consisted of another 16 patients with persistent functional instability, despite the same reha bilitation program, who eventually had ligament recon struction. The mean radiographic anterior displacement during weightbearing in the nonsymptomatic group was 4.3 mm, and 8 patients had a displacement ≤ 2 mm. In the symptomatic group, the corresponding value was 8.1 mm (P < 0.05), and 3 patients had a displacement ≤ 2 mm. No correlations to meniscal injuries, age, or time from injury were found between the patients hav ing a displacement >2 mm and those with ≤ 2 mm. The findings should be explained by differences in neuro muscular control of the increased laxity in the injured knee.

It is generally believed that tennis players using a dou ble-handed backhand rarely develop lateral epicondyli tis since the helping arm appears to absorb more energy and changes the mechanics of the swing. The purpose of this paper was to compare muscle activity about the elbow in single- and double-handed backhand strokes in competitive tennis players. Muscle activity in 3 elbow extensors, a wrist flexor, and a forearm pron ator of the dominant arm was compared during the single-handed (N = 14) and double-handed (N = 13) backhand ground strokes using indwelling electro myography and high-speed cinematography. Signifi cantly higher activity was seen in the double-handed technique in the flexor carpi radialis muscle in the preparation phase and in the pronator teres muscle in the acceleration phase. Higher flexor carpi radialis mus cle activity in preparation of the double-handed stroke appeared to be a function of the double-handed grip used on the racquet, and the increased pronator teres muscle activity in acceleration indicated maintenance of greater pronation provided by the grip of the non- dominant hand. The decreased occurrence of lateral epicondylitis in players using a double-handed back hand may not be caused by decreased extensor activ ity, but rather by factors associated with flawed stroke mechanics more often seen in the single-handed tech nique.

The effects of biceps tendon tenodesis on internal- external and varus-valgus laxity were measured using fresh-frozen cadaveric specimens that had undergone sequential sectioning of the posterolateral structures and of the fibular collateral ligament. Tenodesis (using 89 N graft tension and a fixation point located 1 cm anterior to the fibular collateral ligament's insertion on the femur) was effective in restoring external rotation and varus laxity; the procedure actually overcon strained external tibial rotation at all flexion positions and varus angulation at 60° and 90° of flexion. Internal rotation and valgus laxity were unaffected by the teno desis procedure. The anterior fixation point was more effective in reducing laxity than a fixation point located 1 cm proximal to the fibular collateral ligament insertion. Tenodesis using the proximal fixation point, which was nonisometric, did not restore external rotation and varus laxities to intact values at 60° and 90° of knee flexion. Graft tension (45 or 89 N) had no measurable effect on the results of the tenodesis. This study has demonstrated that the biceps tenodesis procedure is effective for reducing static laxity in the knee with posterolateral instability.

We report for the first time the abnormal increases in posterior subluxation of the medial and lateral tibial plateaus after sectioning the posterolateral structures and posterior cruciate ligament. We applied specific forces and moments to the knees of seven cadaveric whole lower limbs and measured the position of the tibia at which the ligaments and the geometry of the joint limited motion.

Removal of only the posterolateral structures resulted in an average increase in posterior translation of the lateral tibial plateau of 8.0 mm (range, 5.7 to 10.6) at 30° of flexion over the intact state (P < 0.01), but no significant increase at 90° of flexion (mean, 2.7 mm). Knees with underlying physiologic cruciate ligament laxity (high anterior/posterior displacement in the intact knee) had the greatest lateral tibial plateau subluxation (P < 0.01). There was no abnormal posterior translation of the medial tibial plateau. After sectioning the poste rior cruciate ligament and the posterolateral structures, statistically significant increases in posterior translation of both the medial and lateral tibial plateaus occurred at 30° and 90° of flexion (P < 0.01). The increase in posterior translation of the lateral tibial plateau over the intact state averaged 17.8 and 23.5 mm at 30° and 90° of flexion, respectively; for the medial tibial plateau this increase averaged 7.6 and 12.3 mm at 30° and 90° of flexion, respectively.

The diagnosis of abnormal tibiofemoral rotatory sub luxations requires knowledge of the anteroposterior direction and magnitude of each tibial plateau under both low flexion and high flexion knee angle positions.

In 111 patients who had anterior cruciate ligament reconstructions, postoperative radiographic measure ments of anterior to posterior and medial to lateral location of the tibial tunnels were correlated with the final range of motion achieved. In the 25 patients with extension deficits of 10° or more, placement of the tibial tunnel was more anterior (average, anterior 23% of the tibia) than in the remaining 86 patients with extension deficits of <10° (average, anterior 29% of tibia). This difference was statistically significant with P < 0.001. Logistic regression analysis revealed that the more anterior the placement of the tibial tunnel, the greater the loss of both flexion (P = 0.01) and extension (P = 0.002). In the 21 patients with full extension but flexion <130°, placement of the tibial tunnel tended to be more medial (average, medial 40% of the tibia) than in the 65 patients without flexion deficit (average, medial 45% of the tibia). We conclude that placement of the tibial tunnel in the "eccentric," anteromedial position may contribute to the development of flexion and ex tension deficits after anterior cruciate ligament recon struction.

Iliotibial band syndrome is an overuse injury caused by repetitive friction of the iliotibial band across the lateral femoral epicondyle. Once considered an injury indige nous to runners, it is now frequently being seen in cyclists. The purpose of this paper is to identify iliotibial band syndrome as a significant problem in cyclists and to propose both operative and nonoperative measures for treating cyclists. Nonoperative measures specific to cyclists consist of bicycle adjustments and training modifications. These are adjunctive therapies to stretching, icing, rest, and oral nonsteroidal antiinflam matory drugs. For cyclists requiring operative interven tion, a new surgical technique for excising or releasing the distal iliotibial band is presented. This technique, used by the senior author (JCH) since 1984, involves excision of an elliptical piece of the distal posterior band off the lateral femoral epicondyle.

We reviewed 52 consecutive patients who had under gone arthroscopic labral debridement. The average age was 29 and there were 35 men and 17 women. At operation, 27 patients had superior labrum anterior and posterior (SLAP) lesions, 20 patients had anteroinferior labral lesions, and 5 patients had posterior labral le sions.

Despite the fact that, preoperatively, none of these patients had a history of dislocations or clinically evident instability, 70% of the patients with superior labral lesions, and all of those with anteroinferior and posterior lesions had instability on examination under anesthesia. The average followup was 36 months. At 1 year after arthroscopy, 78% of the patients with superior lesions had excellent relief compared with 30% of the patients in the anteroinferior group. At 2 years followup, these results decreased to 63% and 25%, respectively, and only 45% of the patients with superior labral lesions and 25% of those with anteroinferior lesions had re turned to their previous athletic performance level. Four patients required a reoperation: 2 for instability and 2 for impingement. We conclude that occult instability is frequently present in patients with glenoid labral tears. The overall results are not encouraging, but this pro cedure may have an indication for short-term goals in competitive athletes or those who are willing to accept some compromise in function.

Fifty patients who underwent isolated arthroscopic par tial meniscectomy with a minimum followup of 5 years were analyzed retrospectively. To analyze the factors associated with a satisfactory or an unsatisfactory clin ical result, we looked at the patient's age, duration of symptoms, type of meniscal lesion, and articular carti lage abnormalities. The patients were graded with a functional knee score (Lysholm-Gillquist), and activity level before surgery and at followup was determined. The data also included radiographic evaluation of 29 of the 50 patients. Tibiofemoral alignment was measured, and osteoarthritic changes were graded and correlated with the type of meniscal abnormality and functional result.

Eighty-two percent of our patients had satisfactory knee function, and the activity level was maintained. The factors associated with a satisfactory result after a partial meniscectomy included age less than 40 years, symptoms less than 12 months duration, type of tear, and chondromalacia less than grade II. Fairbank's changes were present in 50% of the patients, with significant grade III and IV changes identified in 30%. Although the radiographic changes did not necessarily correlate with the functional result, we felt that the changes were significant and indicative of abnormal stress transfer to articular cartilage and bone.

Patellofemoral joint biomechanics during leg press and leg extension exercises were compared in 20 normal subjects (10 men, 10 women) aged 18 to 45 years. Knee moment, patellofemoral joint reaction force, and patellofemoral joint stress were calculated for each subject at four knee flexion angles (0°, 30°, 60°, and 90°) during leg press and leg extension exercises.

All three parameters (knee moment, patellofemoral joint reaction force, and patellofemoral joint stress) were significantly greater in leg extension exercise than leg press exercise at 0° and 30° of knee flexion (P < 0.001). At 60° and 90° of knee flexion, all three param eters were significantly greater in leg press exercise than leg extension exercise (P < 0.001). Patellofemoral joint stresses for leg press and leg extension exercises intersected at 48° of knee flexion.

This study demonstrates that patients with patello femoral joint arthritis may tolerate rehabilitation with leg press exercise better than with leg extension exercise in functional ranges of motion because of lower patel lofemoral joint stresses.

The Strength Shoe is a modified athletic shoe with a 4- cm thick rubber platform attached to the front half of the sole. It is promoted as an effective method of increasing "speed, quickness, and explosive power," as well as ankle flexibility and calf circumference, when used in a plyometrics-based training regimen. This study evaluates, in a prospective, randomized trial, the efficacy and safety of the Strength Shoe training regi men for increasing lower leg flexibility and strength in intercollegiate track and field participants. No enhance ment of flexibility, strength, or performance was ob served for participants wearing the Strength Shoe at the end of an 8-week training program, following the suggested regimen of the manufacturer. The use of the Strength Shoe cannot be recommended as a safe, effective training method for development of lower leg strength and flexibility. However, the use of plyometrics in a properly supervised setting may improve athletic performance and merits further investigation.

The purpose of this study was to determine if use of the midthird patellar tendon autograft contributes to or causes patellar tendon shortening or patella baja in anterior cruciate ligament reconstruction. Thirty-six pa tients undergoing arthroscopically assisted midthird pa tellar tendon autograft anterior cruciate ligament recon struction were studied prospectively. Intraoperative pa tellar tendon length changes were measured. Half of the patients had the tendon defect closed and half had it left open (closing peritenon only). Radiographic ten don length changes and patella baja were assessed using Insall-Salvati and Blackburne-Peel ratios meas ured on 45° lateral knee radiographs using an adjust able polypropylene jig. Bilateral films were obtained preoperatively and at 2 weeks, 3 months, and 6 months postoperatively.

No patients demonstrated evidence of patellar tendon shortening greater than the 5.5% measurement error. Tendon defect closure resulted in negligible tendon shortening intraoperatively, averaging 2.28% (1.11 mm). Of the 18 patients whose defects were closed, 5 showed no shortening. The remaining 13 patients had measurable tendon shortening less than 4% (2 mm). No patients developed patella baja.

A retrospective review of 77 soccer players with 91 affected knees that had undergone the same operation, a rim-preserving meniscectomy, was made with a min imum followup of 20 years and an average followup of 27 years. The patients were divided into groups based on the presence of an intact (Group 1) or ruptured (Group 2) anterior cruciate ligament.

At 5 years after meniscectomy, 75% of Group 1 and 52% of Group 2 were still playing soccer, and 13% in Group 1 as opposed to 28% in Group 2 had given up sports. The sporting class assessment was good in 80% of the Group 1 knees and 62% in the Group 2 knees.

By followup, 5% of Group 1 and 32% of Group 2 required further meniscectomies, and 2% of Group 1 and 16% of Group 2 required operations for osteo arthritis. Radiologically diagnosed osteoarthritis was present in 24% of Group 1 knees compared with 77% of Group 2. Functionally, 60% of the Group 1 knees were excellent at followup as opposed to 9% in Group 2 knees. In Group 1, 49% were still involved in sports compared with 22% in Group 2. However, 97% of Group 1 were satisfied with their knees compared with 74% of Group 2. All of these differences were statisti cally significant.

Volunteers (986) from fitness clubs and studios were recruited and followed for a 3-month period to docu ment the injury consequences of adult recreational fitness participation. Participants were telephoned each week and their activities as well as any injuries that occurred were recorded.

Of the 525 injuries and complaints reported during 60,629 hours of activity, 475 occurred as a result of sports participation for an overall rate of 7.83 per 1000 hours of participation. Seventy-six percent of these episodes caused the patient to alter or miss 1 or more activities, while 9.5% involved a physician visit. The rate for time-loss injuries was less than 2 per person per year (1.76 per 298 hours) or 5.92 per 1000 hours. Running had a higher risk of injury compared with most other individual sports. Cardiovascular fitness activities had low to medium rates, as did weight work; compet itive sports were higher. For 6 of the most commonly injured areas, the reinjury rate was about twice that reported for those with no history of previous injury.

The risks of injury from most recreational fitness activities were relatively modest, particularly if the ac tivities were not competitive. Physicians might help patients reduce their risks of injury by encouraging suitable activities and by reducing the risks of reinjury by implementing appropriate rehabilitation programs.