The American Journal of Sports Medicine

The diagnostic accuracy of the clinical examination for intraarticular injuries of the knee was documented by arthroscopy over a 6-month period. Two-hundred ninety patients (296 knees) were evaluated by history, physical examination, and standard radiographs. Supplemental diagnostic studies included 41 magnetic resonance images, 2 arthrograms, and 1 previous ar throscopy that had been recently performed.

Overall, the correct diagnosis was made in 165 knees (56%), an incomplete diagnosis in 92 (31%), and an incorrect diagnosis in 39 (13%). There were only 2 knees (0.07%) with no discernable lesions. When a single lesion was present in the knee, the diagnosis was made correctly in 72% of cases. When more than 2 were discovered, the diagnosis was correct in only 30%. However, all individual lesions were diagnosed with an accuracy of greater than 90%.

The lesions most difficult to diagnose were chondral fractures, fibrotic fat pads, tears in the anterior cruciate ligament, and loose bodies. Knees with acute lesions and those with a single diagnosis proved to be signifi cantly easier to diagnose (P < 0.01). The variables that proved to be insignificant were age, sex, magnetic resonance imaging, surgeon, workers' compensation, or pending litigation.

Because we noticed patients had difficulty regaining full range of motion after surgery for a locked bucket- handle meniscal tear with simultaneous reconstruction for a chronic anterior cruciate ligament tear, we adopted a two-stage procedure for this group of patients. We evaluated the results of a two-stage procedure in the knees of 16 athletes (Group 1) and compared their outcome with the outcome of 16 matched athletes who had been treated with simultaneous repair or removal of the displaced bucket-handle meniscal tear and au togenous patellar tendon anterior cruciate ligament re construction (Group 2). Four patients in Group 2 re quired a second procedure or casting to regain full extension. No patient in Group 1 required a second procedure. One meniscal retear was detected in Group 1. The two-stage procedure also appears to have a number of theoretical advantages: 1) more aggressive use of repair rather than removal of a displaced torn meniscus, 2) prevention of problems in regaining range of motion, 3) allows a second look to judge the success of meniscal repair, and 4) allows time for the patient to prepare for anterior cruciate ligament reconstruction physically, mentally, academically, and socially.

Twenty consecutive patients with superior labral ante rior and posterior lesions of the shoulder involving the biceps attachment to the labrum (Snyder types II and IV) were repaired arthroscopically and reviewed post operatively to evaluate the efficacy of the technique in the management of this recently described injury pat tern. Follow-up time averaged 21 months (range, 12 to 42). All patients were managed by an arthroscopic repair technique that included debridement of the frayed labrum and abrasion of the superior glenoid neck, fol lowed by the placement of multiple sutures into the torn labrum-biceps tendon complex using a Caspari suture punch. Patients were reexamined, and the results were quantitated with the shoulder evaluation form of the American Shoulder and Elbow Surgeons and with the Rowe rating scale. On evaluation, all patients obtained good or excellent results. This suture technique is recommended in the management of unstable superior labral detachment lesions of the shoulder.

One hundred eleven patients with acute rupture of the Achilles tendon were included in a prospective trial and randomly assigned to groups for operative (56 patients) or nonoperative (55 patients) treatment.

All of the patients were followed with clinic evalua tions at 4 months and 1 year after the rupture. The major complications in the operative treatment group were three reruptures and two deep infections as com pared with seven reruptures, one second rerupture, and one extreme residual lengthening of the tendon in the nonoperative group. There were fewer minor com plications in the nonoperative group than in the opera tive group.

The operatively treated patients had a significantly higher rate of resuming sports activities at the same level, a lesser degree of calf atrophy, better ankle movement, and fewer complaints 1 year after the ac cident.

The conclusion we reached through this randomized prospective study is that operative treatment of rup tured Achilles tendons is preferable, but nonoperative treatment is an acceptable alternative.

In a retrospective study to determine the anatomic nature of injuries in thumbs that were treated surgically for either fracture or instability, we reviewed 63 con secutive patients with acute skier's thumb injury. Of the 63 thumbs, 25 (40%) had a fracture. Surgical explo ration showed 2 fracture types: a fragment that was attached to the ulnar collateral ligament, and a fragment that was not attached to the ulnar collateral ligament. The 1 st type, corresponding to true avulsion fracture of the ulnar collaternal ligament, was found in 8 cases; the same fracture type was seen in another 7 cases, with an isolated fragment that was not attached to the ligament. Such an isolated fragment was observed in 10 other cases in which the ulnar collateral ligament was completely disrupted. This type of bony fragmen tation cannot be differentiated from a bony avulsion of the ulnar collateral ligament on routine films. Therefore, stress testing the injured thumb is mandatory even when bony avulsion fracture with minimal displacement is suspected from a radiograph, as indeed the fracture may not be a bony avulsion but may be a fragmentation of the ulnar volar aspect of the proximal phalanx as sociated with a complete disruption of the ulnar collat eral ligament.

The purpose of this study was to describe and compare the muscle firing patterns of the muscles controlling the ankle during running. Fine-wire electrodes monitored the activity of the gastrocnemius, soleus, peroneus brevis, tibialis posterior, and tibialis anterior muscles during 3 paces of running. High-speed film was used to synchronize the electromyographic data with the phases of running. The subjects were 15 recreational and competitive runners who were injury-free. There were 3 significant findings. First, the firing patterns of all of the posterior muscles demonstrated peak activity during midstance phase. Thus, these muscles were contracting in an eccentric fashion to control ankle dorsiflexion as the center of gravity passed over the ankle. Second, the tibialis anterior muscle fired above the fatigue threshold for 85% of the time. This may account for the high number of fatigue-related injuries to the tibialis anterior muscle seen in runners. Third, there was a significant increase of activity in the pero neus brevis muscle as the pace increased. This indi cates the importance of training this muscle when pace is increased. Using this information, a sport-specific effective and efficient exercise program for runners can be developed.

Forty-six limbs in 28 patients were surgically treated for exertional compartment syndrome. One group of 16 patients (26 limbs) underwent a fasciotomy for ex ertional anterior compartment syndrome (Group 1). A second group of 12 patients (20 limbs) underwent a fasciotomy for exertional deep posterior compartment syndrome (Group 2). Patients in Group 2 experienced symptoms for a significantly longer time than those in Group 1:16 versus 6.8 months (P < 0.01). All three of the pressure measurements used in this study (resting pressure, 1 minute after exercise, and 5 minutes after exercise) were significantly higher in both groups than in normal controls (P < 0.01). The 1 minute after exercise values were significantly higher in Group 1 (mean, 36.5) than in Group 2 (mean, 29.1) (P < 0.01). In Group 1, 25 of 26 limbs (96%) had excellent results. In Group 2,13 of 20 limbs (65%) had satisfactory results (5 excellent and 8 good) and 7 (35%) had unsatisfactory results (4 fair and 3 poor). Those patients who had an unsatisfactory outcome did so within 6 months. Pa tients in Group 1 had a significantly higher rate of satisfactory results than those in Group 2 (P < 0.05).

Thirty-seven bone-patellar tendon-bone composite grafts from the knees of 21 human cadavers were tested to failure. Average donor age was 28 years. The composites were divided into 4 groups: 3 groups with 10 grafts (5 pairs) and 1 group with 7 grafts from 6 donors. In Group 1 we tested 10- versus 15-mm wide grafts that were used without twisting; Group II, 10- mm wide grafts without twisting versus 10-mm wide grafts that were twisted 90°; Group III, 10-mm wide grafts twisted 90° versus 10-mm wide grafts twisted 180°; and Group IV, 10- versus 7-mm wide grafts that were not twisted. The tests were performed using a newly described potting technique and clamp system and a servohydraulic testing machine with an elongation rate of 5 cm/sec.

The results of this study suggest that the central third of the patellar tendon is stronger than previously re ported. The mean ultimate load of a 15-mm bone- patellar tendon-bone composite was 4389 N (±708); of the 10-mm wide composites, 2977 N (±516); and of the 7-mm composites, 2238 N (±316). Twisting the graft 90° increased the strength (P < 0.05). Further twisting to 180° had no significant effect compared with twisting 90°. This study supports the practice of using smaller (10 mm) bone-patellar tendon-bone grafts to avoid the potential complications of patellar fracture and graft impingement in the notch.

Thirty-five patients had reconstruction of the anterior cruciate ligament with intraarticular fresh-frozen Achilles tendon allograft and extraarticular tibial band tenodesis. Patients were followed 2 to 4 years (mean, 2.5). Evaluation included clinical and functional exami nations, measurement of tibiofemoral displacement, and anteroposterior and lateral radiographs. Clinical results were considered satisfactory in 85% of the patients; 16 had arthroscopic examination after the allograft; allograft biopsies in 9 at this time showed cellular and vascular tissue without evidence of immune reaction. Clinical, arthroscopic, and biopsy results were favorable, but radiologic results were not. In most pa tients there was a significant size increase in femoral and tibial bone tunnels, as measured from radiographs. In the 6 most extreme cases, bone tunnels measured 20 mm or more in diameter, twice the initial size. Etiology and clinical significance of these bone tunnel changes remain unknown. Enlargement appears to oc cur early after operation; it stabilizes within 2 years. No statistical correlation was seen between tunnel enlarge ment and results of clinical and functional examinations; nevertheless, unexplained tunnel enlargement is cause for concern, and allograft replacement of the anterior cruciate ligament with fresh-frozen Achilles tendon al lograft should be considered a salvage procedure.

Intraoperative isometry measurements are commonly performed before bone tunnel drilling during anterior cruciate ligament reconstruction. The relationship be tween initial isometer measurements and final graft isometry, however, is unclear. We tested 15 cadaveric knees to determine the relationship between isometer readings and final graft isometry. We found that isometer readings may vary widely from final graft isometry because of eccentric placement of the anterior cruciate ligament graft within bone tunnels. Isometer measurements may be used, however, to predict ac curate final graft isometry for specific graft positions within the bone tunnels.

To evaluate the effectiveness of subcutaneous subfas cial anterior transfer of the ulnar nerve in the surgical treatment of cubital tunnel syndrome in athletes, we retrospectively reviewed athletes undergoing subcuta neous anterior transfer of the ulnar nerve at the elbow. Criteria for inclusion in the study included active partic ipation in athletic activity, confirmed cubital tunnel syn drome, failure to respond to conservative treatment, and having an anterior subcutaneous subfascial trans fer as the only procedure performed. Twenty athletes underwent a total of 21 procedures. Results were evaluated by time to return to sport and a questionnaire developed to evaluate elbow function in the athlete.

The athletes returned to full activity at an average of 12.6 weeks. Average subjective postoperative scores were 84. Elbow rating scores averaged 9 (range, 0 to 10).

Anterior subcutaneous subfascial transfer of the ulnar nerve is a safe, effective means for treating cubital tunnel syndrome in athletes. The findings in this study are significant in that they confirm the effectiveness of the subcutaneous subfascial transfer procedure in re turning the athlete to competition. Of secondary impor tance is the development of an elbow rating question naire appropriate to the athlete.

In a radiologic study of the thoracolumbar spine in 143 athletes aged 14 to 25 years and 30 male nonathletes aged 19 to 25 years, abnormalities of the vertebral ring apophyses were analyzed. Abnormalities affecting the anterior part of the vertebral ring apophysis occurred exclusively in athletes and they were most common in wrestlers and female gymnasts. Different types of ab normalities were found and the type of abnormality was related to the spinal level. We propose that this is related to trauma of various types. Excavation of the anterior part of the vertebra, probably from compres sion forces, was mainly found in the thoracic and tho racolumbar junction of the spine. Persisting or enlarged apophysis, probably caused by avulsion of the anterior part of the vertebral ring apophysis, was only found in the lumbar spine.

The effect of an isolated injury of the posterior cruciate ligament on the articular cartilage and menisci has not been extensively studied. Intraarticular abnormalities in 88 arthroscopically proven posterior cruciate ligament tears in symptomatic patients with straight unidirec tional posterior instability were reviewed. There were 33 patients with acute injuries (range, 3 to 21 days; mean, 14) and 55 patients with chronic tears (range, 28 to 3650 days; mean, 786). Of the acute injuries, chondral defects occurred in 4 patients (12%) and meniscal tears in 9 patients (27%; 6 lateral and 3 medial). Chondral defects of both the lateral femoral condyles and patella were present in all 4 patients. Of the chronic injuries, chondral defects occurred in 27 (49%) and meniscal tears in 20 patients (36%) (7 lateral and 17 medial). Chondral defects of the medial femoral condyle were most common. The mechanism of injury resulting in an isolated injury of the posterior cruciate ligament is most likely to affect the lateral compartment or the articular cartilage of the patella. The incidence of articular defects and the incidence of meniscal tears increased in patients with chronic posterior cruciate ligament injuries; both lesions increased most in the medial compartment.

The associations between participation in several spe cific sports, use of free weights, and use of weight lifting equipment and herniated lumbar or cervical inter vertebral discs were examined in a case-control epi demiologic study. Specific sports considered were baseball or softball, golf, bowling, swimming, diving, jogging, aerobics, and racquet sports. Included in the final analysis were 287 patients with lumbar disc her niation and 63 patients with cervical disc herniation, each matched by sex, source of care, and decade of age to 1 control who was free of disc herniation and other conditions of the back or neck. Results indicated that most sports are not associated with an increased risk of herniation, and may be protective. Relative risk estimates for the association between individual sports and lumbar or cervical herniation were generally less than or close to 1.0. There was, however, a weak positive association between bowling and herniation at both the lumbar and cervical regions of the spine. Use of weight lifting equipment was not associated with herniated lumbar or cervical disc, but a possible asso ciation was indicated between use of free weights and risk of cervical herniation (relative risk, 1.87; 95% con fidence interval, 0.74 to 4.74).

Forty-eight cyclists were studied for suspected external iliac artery endofibrosis with ultrasound B-mode imag ing. In highly trained competition cyclists, symptoms of external iliac artery endofibrosis were characterized by lower limb claudication during maximal effort that was caused by fibrosis thickening of the intima of the exter nal iliac arterial wall. Typical ultrasound imaging aspects consisted of parietal thickening, enhanced echogenicity of the arterial wall, straightness of the abnormal arterial segment, and mild narrowing of the arterial diameter of the proximal or medial segment of the diseased external iliac artery. Although ultrasound B-mode imaging study seems to be useful in the diagnosis of external iliac artery endofibrosis, results with this technique must be compared with results of clinical examination, physio logic tests, and arteriography.

The results of 101 consecutive arthroscopic meniscal repairs were studied to determine the nature and fre quency of associated complications. All arthroscopic repairs were done by the senior author (OS) between November 1984 and June 1991. Our data include 65 patients with associated anterior cruciate ligament in juries, of which 49 underwent concurrent arthroscopic anterior cruciate ligament reconstruction. There was an overall complication rate of 18%.

There was a 20% risk of complication with meniscal repair when associated with anterior cruciate ligament injury and 14% without anterior cruciate ligament injury. There was a 10% incidence of arthrofibrosis when meniscal repair was performed with anterior cruciate ligament reconstruction and a 6% incidence when per formed in an anterior cruciate ligament-deficient, non- reconstructed knee. Overall, there was a 13% risk of complication with lateral repairs compared with 19% with medial repairs. In the subset of patients with intact anterior cruciate ligaments and isolated meniscal le sions, there were no complications associated with lateral repair and an 18% risk of complication with medial repair. Female patients demonstrated a higher likelihood of complication (29%) than male patients (13%). Excluding repair failures, there was an 8% re operation or rehospitalization rate.

Surgical reconstructions of anterior-inferior shoulder instabilities and rotator cuff injuries require secure fix ation of soft tissue to bone. Sutures are inserted directly through transosseous tunnels in current techniques, which are surgically complex and not always adequate for fixation strength. Using fresh-frozen cadaveric hu man specimens, our objectives were 1) to compare immediate pull-out strength of two versions of polyace tal suture anchors (wedge and rod) with conventional suture-only attachment techniques in Bankart lesion and rotator cuff repairs, and 2) to compare pull-out strength of the two polyacetal suture anchors with a metallic suture anchor. Our results indicate no signifi cant differences in fixation strength of Bankart lesions or rotator cuff repairs using sutures only, or using wedge or rod polyacetal suture anchors (P = 0.70). Pull-out force did not differ significantly (P = 0.37) between the two polyacetal anchors. Polyacetal an chors exhibited higher pull-out forces than metallic an chors when inserted into metaphyseal regions of the tibia and significantly higher pull-out forces (P < 0.001) when inserted into metaphyseal regions with thicker cortical walls. Our results indicate that both polyacetal suture anchors provide adequate immediate fixation for soft tissue repairs in the human shoulder.

Twenty-seven paired human cadaveric knee specimens were used to determine the effect of surgical technique and various interference screw parameters on the pullout strength of patellar tendon femoral bone blocks. The study compared the fixation strength of endoscop ically inserted and conventional "rear-entry" screws of different diameters and lengths. In all tests the most frequent mode of failure was bone block pullout from the interference screw. There was no significant differ ence in fixation strength between 9-mm diameter screws inserted through a conventional rear-entry tech nique and 7-mm diameter screws inserted through an endoscopic technique. There was no significant effect of screw length on fixation strength. The pullout force for 20-mm long screws increased on average 120% when 7-mm diameter screws were compared with 5.5- mm diameter screws. There was no significant effect of increased screw core diameter on fixation strength. There was a weak positive correlation (r² = 0.45) between screw insertion torque and pullout force. Our measured mean pullout force for the 7-mm endoscopi cally inserted screws of 362 ± 198 N represents 20.1 % of the failure load of the normal young adult anterior cruciate ligament. Our data indicate that properly in serted 7-mm diameter endoscopic interference screws can provide fixation strengths of patellar tendon ante rior cruciate ligament grafts equivalent to those of con ventional 9-mm diameter rear-entry, outside-in screws.

Individuals with anterior cruciate ligament deficiency typically do not have quadriceps activity during stance. This aberrant pattern has been termed "quadriceps avoidance" gait. We performed gait analysis during walking on 10 normal controls and 10 subjects 8 to 12 months after they had anterior cruciate ligament recon struction using autogenous middle third of the patellar tendon. All patients had good subjective and objective results at the time of analysis. Differences in gait be tween subjects and controls persisted up to 12 months after surgery. Specifically, subjects with anterior cru ciate ligament reconstructions demonstrated significant reductions in midstance knee flexion moments (P < 0.01) and tibially directed loading rates (P < 0.05) when compared with controls. However, the subjects had a net external flexion moment throughout most of the stance phase of gait, implying that quadriceps activity was present. After anterior cruciate ligament recon struction, there is a tendency toward gait normalization, and a quadriceps avoidance mechanism is no longer present.