The American Journal of Sports Medicine

From 1973 to 1987, 28 patients seen at our institution sustained isolated posterior cruciate ligament tears. Of these 28 patients, 25 were reevaluated at an average followup of 7 years and 1 month after secondary recon struction of the posterior cruciate ligament using the semitendinosus and gracilis tendons alone or with an extraarticular procedure.

Subjectively, 22 of 25 patients related no restrictions regarding activities of daily living, with 14 of 25 patients being able to return to their previous competitive level in sports. Objective evaluation after reconstruction re vealed no change in the preoperative and postoperative posterior drawer examination in 13 of 25 patients, a finding confirmed by KT-1000 arthrometer measure ments. Radiographic evaluation revealed degenerative changes predominantly involving the medial and patel lofemoral compartments in 15 of 25 patients.

Despite optimistic subjective reporting, this long-term retrospective study reveals that this procedure incon sistently limits posterior instability and therefore cannot be recommended.

This is a retrospective review of the presentation, di agnosis, treatment, and outcome of 19 patients who injured the tarsometatarsal joint of the foot during ath letic activity. Diagnosis by clinical and radiographic ex amination was supplemented by stress fluoroscopy of the articulation under anesthesia. Injuries were classi fied as either a first- or second-degree sprain of the tarsometatarsal joint, a third-degree sprain (with dias tasis between the metatarsals or cuneiforms), a frac ture, or frank dislocation. Poor functional results were seen in those for whom diagnosis was delayed and for whom the injury was not treated adequately. Three patients were unable to return to sports, one of whom eventually required fusion of the tarsometatarsal joint. The third-degree sprains were indistinguishable from fracture and fracture-dislocations in that good results were not reliably obtained by nonoperative treatment, and both classes of injury seem to require open reduc tion and internal fixation for optimal return to function. The delay in return to full activity is a marker of the severity of this injury despite an often benign appear ance on radiograph.

A prospective study was conducted to determine 10- day pain and analgesic use profiles of outpatients after arthroscopic surgery of the knee and to examine the effects of oral corticosteroid use on analgesic intake, perceived pain, and functional outcomes. Sixty-two patients who underwent a variety of arthroscopic pro cedures of the knee were matched on level of injury and surgical repair, and were assigned to two groups. The experimental group received a standard dosage of oral postoperative corticosteroids. The placebo group received the same dosage of a placebo (sugar pill). Both groups received the same prescription of an an algesic for pain relief after surgery. Results indicated that there were no significant differences for any de pendent variables between the experimental and pla cebo groups. There were significant (P < 0.001) de creases in analgesic use and perceived pain throughout the 10 days. Conclusions were that most patients who have undergone arthroscopic surgery of the knee per ceive pain at low levels, use limited amounts of anal gesics, and return to work within a week. The addition of oral corticosteroids does not influence this profile.

Anterior cruciate ligament reconstruction by free patel lar tendon graft was performed using 2 different surgical approaches to the intercondylar notch in 67 consecu tive patients with chronic anterior cruciate ligament insufficiency. In the first 30 patients (Group A), the traditional medial parapatellar arthrotomy with lateral luxation of the patella was done, whereas in the last 37 patients (Group B) a transpatellar tendon approach was used. Postoperative pain was managed by analgesics and, in patients who had epidural anesthesia, by ad ministration of bupivacaine in indwelling catheters. Gen erally, the analgesics and bupivacaine were given im mediately on request to establish comfort at rest and to permit range of motion exercises without severe pain. Compared with those in Group A, the patients of Group B had a significantly longer period from the first dose of analgesic or bupivacaine to the second, and the total number of doses of analgesic or bupivacaine was significantly lower. In the subgroup of patients with epidural anesthesia (21 in Group A and 32 in Group B), the Group B patients required significantly less anal gesics, as doses equivalent to 10 mg of morphine, compared with that of Group A.

The potential benefits of a nonsteroidal antiinflamma tory drug to 67 patients undergoing knee arthroscopy were evaluated in a prospective, randomized, placebo- controlled, double-blinded study. Group A received the drug (diclofenac, 75 mg twice daily) for 3 to 5 days before and for 7 days after surgery. Group B received a placebo preoperatively and the drug postoperatively. Group C received a placebo at both times. Codeine was available postoperatively for all patients if needed. Outcomes reported by the subjects included pain, crutch use, and return to activities. Outcomes assessed by physicians included knee effusion, range of motion, and gait. Knee flexion and extension strengths were measured isokinetically pre- and postoperatively.

Pain scores on the 1 st postoperative day were higher in Group C than in Group A. Pain scores at all other time points were not significantly different in the three treatment groups. Groups A and B required less co deine during the first 72 hours after surgery than Group C (mean, 2.9 ± 1.0 versus 6.8 ± 1.0 pills). Recovery of function, recovery of strength, and physical examina tion parameters were not significantly different in the three treatment groups.

Diclofenac was an effective analgesic in the immedi ate postoperative period. Recovery from arthroscopy, however, was not enhanced by taking the drug.

The effect of temperature on the mechanical failure properties of rabbit skeletal muscle (tibialis anterior and extensor digitorum longus) was examined. For all tests, one leg was maintained at 25°C and the contralateral leg at 40°C. Muscles were pulled to failure according to assignment into one of three groups: 1) passive failure at 10 cm/sec, 2) passive failure at 1 cm/sec, or 3) active (muscle is stimulated to contract as it is pulled) failure at 10 cm/sec. Load to failure was higher in the cold muscle for all groups tested. Total deformation was the same except in Group 1, when the warm muscle had a greater deformation. Energy absorbed before failure was greater in the cold muscle in Groups 2 and 3. Stiffness was higher in cold muscles for all muscles except the extensor digitorum longus in Group 1. In this study, temperature had a significant effect on the tensile properties; these thermal effects were de pendent on both loading rate and contractile state. Comparing loading rates, warm muscle tested at 10 cm/sec had higher failure loads than that tested at 1 cm/sec. Comparing stimulated versus unstimulated muscle (Group 1 versus Group 3), the stimulated tibialis anterior muscle absorbed more energy than unstimu lated ones. Stimulated extensor digitorum longus mus cles had higher failure loads, absorbed more energy, and were stiffer than nonstimulated muscles. This study offers experimental data to support the theory that warming muscles can aid in injury prevention and im provement in athletic performance.

Thirty-two patients who had arthroscopic anterior cru ciate ligament reconstruction using a bone-patellar ten don-bone autograft underwent subsequent magnetic resonance imaging of the knee. A total of 32 magnetic resonance imaging examinations were performed from 10 days to 39 months postoperatively. The anatomic plane of the autograft was determined by obtaining a coronal pilot scan of the graft fixation screws or screw and staple. T1-weighted, T2-weighted, proton density, and gradient-echo imaging sequences were then ob tained in the anatomic plane, as well as T1-weighted coronal images. The autograft was defined on the basis of visualization of fiber continuity on T2-weighted im ages as follows: 1) intact; 2) having a partial tear; or 3) having a complete tear. These results were then cor related with clinical examination and, in 10 cases, sub sequent arthroscopy. Magnetic resonance imaging cor related with clinical findings in 31 of 32 patients. In addition, of the 10 patients who underwent subsequent arthroscopy, magnetic resonance scanning correlated in all cases with arthroscopic findings. T2-weighted and, in some cases, proton density images were most useful in visualizing the autograft. T2-weighted magnetic res onance imaging in the anatomic plane of the anterior cruciate ligament autograft can be a useful diagnostic tool in the evaluation of patients with patellar tendon anterior cruciate ligament reconstructions when graft integrity is in question.

To establish the value of magnetic resonance imaging in determining which patients with ankle sprains will benefit from surgical treatment, 1 uninjured volunteer and 15 patients with acute, subacute, and chronic injuries of the lateral ankle ligaments were imaged at 1.0 tesla using a fast imaging with steady-state preci sion three-dimensional technique and 1.5-mm slice thickness. A dedicated knee coil was used to hold the foot in a neutral or plantar-flexed position. In cases of acute, low-grade injuries, fraying of the anterior talofib ular ligaments with intact calcaneofibular ligaments was observed in the presence of edema and hemorrhagic fluid. In cases of acute, high-grade sprains, the calca neofibular ligament appeared wavy or was visualized only partially or not at all. Subacute injuries showed ligament disruption; chronic lesions, on occasion, showed atrophy of the calcaneofibular ligament but no edema or hemorrhagic fluid. These findings showed a good qualitative correlation with the results of graded stress radiography.

Magnetic resonance imaging can definitely determine the ligaments involved in lateral ankle sprains and pro vide useful anatomic information in cases in which acute or reconstructive surgery is contemplated. However, the magnetic resonance imaging findings do not directly correlate with degree of instability and do not replace those of physical examination or routine radiographic studies.

Published reports agree that there is a strong associa tion between intercondylar notch stenosis and anterior cruciate ligament injuries. In a previously published retrospective study on bilateral anterior cruciate liga ment injuries and associated intercondylar notch ste nosis, we formulated the notch width index to measure and compare intercondylar notch width. The purpose of this prospective study was to establish a normal range for the notch width index and to correlate inter condylar notch size and anterior cruciate ligament in juries. We gathered data on 902 high school athletes, including range of motion, thigh girth, ligament stability and intercondylar notch width using the notch width index. The population was then followed prospectively and anterior cruciate ligament injuries were recorded and correlated with notch width index in a blind manner. Two-year results showed that the overall anterior cru ciate ligament injury rate was 3%. The normal intercon dylar notch ratio was 0.231 ± 0.044. Intercondylar notch width index for men was larger than that for women. Athletes sustaining noncontact anterior cru ciate ligament tears have statistically significant inter condylar notch stenosis (notch width index, 0.189). Ten of 14 athletes with noncontact anterior cruciate liga ment injuries had a notch width index that was at least 1 SD below the mean. Athletes with contact anterior cruciate ligament injuries had a mean of 0.233. We conclude that athletes with a stenotic intercondylar notch are at significantly greater risk for sustaining noncontact anterior cruciate ligament injury.

Fibrochondrocytes synthesize and maintain the extra cellular matrix responsible for the distinctive material and structural properties of a normal meniscus. Viable meniscal cells are believed to be necessary for the long- term maintenance of these properties in meniscal allo grafts. The purpose of this study was to determine if the donor cells (fibrochondrocytes) survive after a fresh meniscal allograft transplantation.

A DNA probe technique was used to clearly distin guish the DNA patterns in donor cells from the host cells in the Spanish goat. No remaining donor DNA could be demonstrated at 4 weeks in transplanted meniscal tissue; it was all of host origin. The host DNA content at 4 weeks approached or exceeded the amount present in the contralateral control meniscus.

Clinical significance: The results of this study dem onstrate that viable cells in medial meniscal allografts transplanted from one animal to another do not survive. Host cells rapidly repopulate the transplanted menis cus. There is no evidence these new cells will maintain on a long-term basis the extracellular matrix of the meniscus. The evidence in this paper, that the fibro chondrocytes do not survive transplantation, suggests further justification is necessary for using grafts with living cells. Allografts with living cells have an increased expense, more complicated surgical logistics, and have a higher potential risk of disease transmission.

Fifty-four patients with anterior cruciate ligament tears that were arthroscopically reconstructed within 3 months of initial injury were prospectively evaluated. Patients with grade 3 medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament tears were excluded. Eighty percent of our patients had a bone bruise present on the magnetic resonance image, with 68% in the lateral femoral condyle. Two of the latter findings—an abnormal articular cartilage signal (P = 0.02) and a thin and impacted subchondral bone (P = 0.03)—had a significant relationship with injury to the overlying articular cartilage. Meniscal tears were found in 56% of the lateral menisci and 37% of the medial menisci. A significant association was present between bone bruising on the lateral femoral condyle and the lateral tibial plateau (P = 0.02).

Results of our study support the concept that the common mechanism of injury to the anterior cruciate ligament involves severe anterior subluxation with im paction of the posterior tibia on the anterior femur. Determination of the significance of bone bruising, ar ticular cartilage injury, or meniscal tears will require a long-term followup that includes evaluation for arthritis, stability, and function. These 54 patients represent the first cohort evaluated in this ongoing prospective clinical study.

Arthrofibrosis resulting in loss of knee extension com promises the results of anterior cruciate ligament re constructions. We designed a study to clarify the symp toms and to evaluate the results of arthroscopic treat ment of this complication. Forty-two patients in a series of 959 consecutive open anterior cruciate ligament reconstructions required further surgical treatment for relief of symptoms related to loss of extension. Arthro scopic examination of these knees confirmed the pres ence of an extension block caused by hypertrophy of the ligament or abundant tissue formation in the anterior tibiofemoral joint an average of 9 months after anterior cruciate ligament reconstruction. The offending tissues were excised arthroscopically and the patients were followed with an aggressive rehabilitation program. Thirty-five patients were available for followup an av erage of 28 months after excision of the tissue. Subjec tive functional status and symptomatic status were scored numerically using identical, patient-completed questionnaires before and after the excision procedure. Range of motion, Cybex, and KT-1000 arthrometer results were also recorded. The results were statisti cally compared with results from a control group de mographically matched and selected at random from the 959 patients. Before excision of the offending tis sue, the knee scores of the study group differed signif icantly from those of the control group. However, after the excision procedure, the knee scores of the 2 groups were nearly identical. Marked improvements in function and symptoms (most notably, activity-related anterior knee pain, crepitus at terminal extension, and knee stiffness) were noted in all patients in the study group after removal of the extension block and resumption of an accelerated rehabilitation program. The evidence from this study indicates that an intraarticular block to full knee extension is associated with definite symp toms and disability. When this problem fails to respond to nonoperative treatment, significant improvement can be obtained by arthroscopic excision of the impinging tissue followed by an aggressive rehabilitation program.

Although the semitendinosus and gracilis tendons have long been used in ligamentous reconstruction proce dures of the knee, their anatomic relationships have not been explicitly detailed. Therefore, cadaveric dissec tions were performed on fresh-frozen adult knees to examine these relationships. Several key anatomic points are useful in the harvest of these tendons. Their conjoined insertion site is medial and distal to the tibial tubercle. They become distinct structures at a point that is farther medial and slightly proximal. Tendon harvest is facilitated by identifying the tendons proximal to this point. The superficial medial collateral ligament lies deep to the tendons in this area and should not be disturbed. The tendons are ensheathed in a dense fascial layer that may impede tendon stripping. The accessory insertion of the semitendinosus tendon (which was present in 77% of the knees dissected) should be identified and transected to avoid tendon damage at harvest. Knee flexion may reduce the risk of injury to the saphenous nerve as it crosses the gracilis tendon. Variation in tendon diameter affects graft strength.

The objective of this study was to determine the bio mechanical effect of graft tensioning during reconstruc tion of the anterior cruciate ligament. We evaluated the magnitude of the tensioning force (22 or 67 N), the flexion angle at which the tension was applied (exten sion or 30° of flexion), and the direction of application of the tensioning force (proximal, distal, or distal with a posterior force simultaneously applied to the tibia) on 10 fresh cadaveric knees. The anterior cruciate liga ment was reconstructed using a bone-patellar tendon- bone graft. The graft was then temporarily fixed during the application of each of 12 combinations of tensioning variables listed above. After each fixation, graft force and joint motion were measured during anterior tibial loads.

Tensioning direction and the flexion angle significantly affected graft force and joint motion, while the magni tude of the graft tensioning did not. Graft forces were greater when the tensioning was applied at 30° of flexion. Compared with distal tensioning with and with out posterior tibial force, graft forces with proximal tensioning were greater in extension and lower in flex ion. The position of the tibia relative to the femur was posterior and externally rotated, compared with normal, for all combinations of tensioning variables in both unloaded and anterior load states.

Using a prospective, randomized experimental design, 622 college intramural basketball players were stratified by a previous history of ankle sprains to wear a new pair of either high-top, high-top with inflatable air cham bers, or low-top basketball shoes during all games for a complete season. Subjects were asked to complete a history questionnaire and were given a complete ankle examination. They were allowed to wear these shoes only during basketball competition. Followed over the course of a 2-month intramural season, 15 ankle injuries occurred during 39,302 minutes of player-time: 7 in high-top shoes, 4 in low-top shoes, and 4 in high-top shoes with inflatable air chambers. The injury rates (injuries per player-minute) were 4.80 × 10^-4 in high-top shoes, 4.06 x 10^-4 in low-top shoes, and 2.69 x 10 ^-4 in high-top shoes with inflatable air chambers. There was no significant difference among these 3 groups, leading to the conclusion that there is no strong rela tionship between shoe type and ankle sprains.

The financial outcome and epidemiology of ballet dan cers' injuries were studied by examining workers' com pensation insurance records covering 3 seasons (3 years) of activity for a large professional ballet com pany. One hundred four dancers sustained 309 injuries that resulted in insurance payouts for medical costs of $398,396. The average cost per injury was $1289. Although only 4.2% of the injuries resulted in medical costs exceeding $5000, these represented 60.0% of the total medical costs. Nine injuries resulted in medical costs in excess of $10,000 each. Overall, there were 2.97 injuries per injured dancer. Twenty-four dancers (23.0% of the injured) sustained 5 or more injuries each and thus were responsible for 51.9% (161) of all injuries. The foot (74 injuries, 23.9%), lumbar spine (71, 23.0%), and ankle (41, 13.3%) were the most frequently injured anatomic regions. The experience of this ballet com pany is similar to that of a college athletic department or a professional sports team. All could employ similar strategies to reduce injuries and associated costs.

Performing classical ballet may cause major stress to the feet of the dancer. A variety of foot injuries have been described, with one such injury being an overuse syndrome involving the base of the second metatarsal and adjacent Lisfranc's joint. The diagnosis for this syndrome usually requires differentiating synovitis of Lisfranc's joint from a stress reaction of the base of the second metatarsal. Prompt diagnosis is important since the treatment for these two conditions differs signifi cantly and, in the case of bone stress reaction, delay can cause progression of the lesion. We report good clinical results in a group of eight ballerinas for whom we obtained early diagnosis and treatment of their injuries. This is in contrast to poor results reported in the literature if the diagnosis and management of these types of injuries are delayed. We developed a simple diagnostic protocol to enable diagnosis at presentation. When a bone stress reaction had progressed to a fracture line, a characteristic appearance was found on magnetic resonance imaging, suggesting a specific mechanism of injury. A possible mechanism for this injury is discussed.

Occult instability is recognized as a major cause of shoulder dysfunction in throwing athletes. Few studies have characterized the findings of occult instability in nonthrowers. The purpose of this study was to examine shoulder instability in a group of weight lifters. The symptoms, physical findings, and results of treatment for 23 shoulders in 20 athletes are presented. All ath letes presented with a complaint of progressive inability to perform exercises with the upper extremity in the abducted, externally rotated position (the "at-risk" po sition) because of pain. One hundred percent of the athletes experienced posterior shoulder pain when the shoulder was placed in forced abduction and external rotation. Thirteen shoulders in 10 patients responded to conservative management including aggressive re habilitation and modification of technique to avoid the at-risk position. The other 10 shoulders, which did not respond to conservative treatment, required surgical treatment to alleviate the symptoms. All 20 patients have successfully returned to their previous weight lifting activities.

The accuracy and interexaminer reliability of the Mc Murray test for the diagnosis of meniscal tears were compared with arthroscopic findings in a prospective study of 104 consecutive patients awaiting elective arthroscopy. The only significant McMurray sign found to correlate with meniscal injury was a "thud" elicited on the medial joint line with a medial meniscal tear (P = 0.05) that had a fair interexaminer reliability (kappa = 0.35). The sensitivity of a medial thud was 16%, and the specificity was 98% with a positive predictive value of 83%. Examiner experience had little effect on the accuracy of diagnosis of medial meniscal tears. This study supports the continued but limited emphasis on the McMurray test in the clinical diagnosis of meniscal tears.

We measured the anteroposterior ligamentous laxity and thigh muscle power in 92 subjects who were rated as successes after they had undergone arthroscopic anterior cruciate ligament reconstruction for unilateral anterior cruciate ligament insufficiency 18 to 36 months previously. The subjects were divided into 2 groups according to the type of graft: fresh-frozen allogenic tendon (N = 47) or central one third of the ipsilateral patellar tendon (N = 45). Instrumented drawer tests in the Lachman position were performed to measure an terior tibial displacement at 200 N (anterior laxity). Thigh muscle power was isokinetically measured with a Cy bex II dynamometer. Significantly more anterior laxity was found in the reconstructed knees than in the contralateral normal knees regardless of graft material (paired t-test, P < 0.01), except for the male allograft patients. Although the mean anterior laxity difference between sides for the allograft patients was less than that for the autogenous ones, analysis of variance failed to demonstrate a statistically significant difference be tween the 2 groups if the comparison was strictly made within the same sex. Thigh muscle tests revealed that extension torque in the reconstructed knees was sig nificantly less than that in the contralateral knees and analysis of variance showed that knee extension torque at 60 deg/sec for the allograft patients was significantly better than that of the autograft ones (P < 0.05). We concluded that the allograft procedure is advantageous over the patellar tendon autograft in terms of better restoration of anterior stability.