The American Journal of Sports Medicine

We sought to determine prospectively the natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries in athletically active patients. The study population consisted of 133 patients (average age, 25.2 years at time of injury). All patients completed a subjective questionnaire each year for an average of 5.4 years (range, 2.3 to 11.4). Sixty-eight of the 133 patients returned to the clinic for long-term follow-up evaluation. Objectively, physical examination revealed no change in laxity from initial injury to followup. No correlation was found between radiographic joint space narrowing and grade of laxity. The mean modified Noyes knee score was 84.2 points, the mean Lysholm score was 83.4, and the mean Tegner activity score was 5.7. Patients with greater laxity did not have worse subjective scores. No correlation was found between subjective knee scores and time from injury. Regardless of the amount of laxity, half of the patients returned to the same sport at the same or higher level, one-third returned to the same sport at a lower level, and one-sixth did not return to the same sport. Results of this study suggest that athletically active patients with acute isolated posterior cruciate ligament tears treated nonoperatively achieved a level of objective and subjective knee function that was independent of the grade of laxity.

The tension in an anterior cruciate ligament graft may not be normal when the femoral tunnel is placed using the single-incision arthroscopic technique because the femoral tunnel is drilled through the tibial tunnel. We hypothesized that the in vivo tensile behavior of the double-looped semitendinosus and gracilis tendon graft can be normal or abnormal compared with the native anterior cruciate ligament, that the placement and angle of the tibial tunnel can predict the tensile behavior of the graft, that the graft with abnormal tensile behavior is associated with a nonanatomically placed tibial tunnel, and that the tensile behavior of the graft determines the stability of the reconstructed knee at 1 year. Total tension in the graft and knee flexion angle were measured in 14 subjects as the knee was flexed from 0° to 90°. A graft force greater than 40 N at 80° of flexion was considered abnormal. One year after surgery, the angle and position of the tibial tunnel were determined from roentgenograms, and knee stability was measured with a KT-1000 arthrometer. The criteria for anatomic tibial tunnel placement in the sagittal and coronal planes were derived from magnetic resonance images of uninjured knees. The tensile graft behavior was either normal (4 of 14) or abnormal (10 of 14) with the single-incision arthrosopic technique. The angle of the tibial tunnel in the coronal plane was predictive of abnormal tensile behavior. Abnormal tensile behavior occurred in anatomically placed tibial tunnels and was compatible with a stable and functional reconstructed knee at 1 year.

Recent publications have reported differences in the incidence, rate, risk, and type of sports injury among men and women. We undertook a prospective study to determine the incidence of injury among high school basketball players and to examine the differences in injury type, incidence, rate, and risk between male and female athletes. During a single basketball season, an injury survey of girls' varsity teams at 100 class 4A and 5A high schools in Texas was conducted. These data were previously reported. We surveyed the same 100 high schools during a subsequent season to gather injury data from the boys' varsity teams. The athletic trainer collected data on each reportable injury and reported the data weekly to the University Interscholastic League. A reportable injury was defined as one that occurred during a practice or a game, resulted in missed practice or game time, required physician consultation, or involved the head or the face. The boys' and girls' data were compared and statistically analyzed. The rate of injury was 0.56 among the boys and 0.49 among the girls. The risk of injury per hour of exposure was not significantly different between the two groups. In both groups, the most common injuries were sprains, and the most commonly injured area was the ankle, followed by the knee. Female athletes had a significantly higher rate of knee injuries including a 3.79 times greater risk of anterior cruciate ligament injuries. For both sexes, the risk of injury during a game was significantly higher than during practice.

We describe the biceps load test for evaluating the integrity of the superior glenoid labrum in shoulders with recurrent anterior dislocations. With the shoulder in an abducted, externally rotated position and the forearm supinated, active flexion of the elbow against resistance relieves the discomfort of a standard apprehension test for anterior shoulder instability. A group of 75 patients with proven unilateral anterior shoulder dislocations were prospectively examined in a double-blind fashion with arthroscopic examination and the biceps load test. Sixty-three patients had a negative test and 62 of these had an intact biceps tendon-superior labrum complex; the remaining patient had a type II superior labral anterior and posterior lesion. Twelve patients had positive tests, and 10 had superior labral lesions; the other 2 patients had intact superior labra. Therefore, the biceps load test revealed a sensitivity of 90.9%, a specificity of 96.9%, a positive predictive value of 83%, a negative predictive value of 98%, and a kappa coefficient of 0.846.

Repair of patellar tendon ruptures has often relied on cerclage augmentation and prolonged immobilization in extension. We are reporting our experience with avulsion injuries as well as midsubstance ruptures, both treated with primary repair without augmentation, allowing early mobilization in the athlete less than 40 years of age. Repairs were performed to allow knee flexion to more than 60°. Rehabilitation was performed with heel slides, allowing flexion to 45° for the first 3 weeks, increasing to 90° at 3 to 6 weeks, and thereafter without restriction. An accelerated weightbearing and muscle strengthening program was adopted. At a mean follow-up of 2.6 years (range, 20 to 61 months), 12 patients had returned to their previous levels of activity. No loss of extension or extensor lag was noted; mean flexion loss was 5°. Patellofemoral symptoms and signs were present in five patients, but activity was limited in only two. Mean peak torque at 60 deg/sec was 92% (range, 73% to 105%). Mean Lysholm score was 94 2.5 points. Primary repair with immediate, protected range of motion resulted in uniformly excellent results and obviated the need for manipulation or subsequent hardware removal.

The results of treatment after closed reduction of elbow dislocation vary. Twenty consecutive patients with closed posterior elbow dislocations were treated prospectively on a rapid motion, nonimmobilized functional regimen. This treatment protocol emphasizes immediate active range of motion under close supervision. No slings or splints were employed. Final range of motion averaged 4° to 139°. All patients attained final extension within 5° of the contralateral side. Each patient achieved his final range of motion within an average of 19 days after reduction of the dislocation. Arm circumference returned to normal at an average of 6.5 days. There was one redislocation. After treatment, all patients met qualification for graduation from the U.S. Naval Academy and were able to pursue unrestricted athletic and career options. Our findings suggest that an aggressive immediate motion rehabilitation allows nearly full final elbow motion and an excellent functional outcome.

Anterior cruciate ligament injuries are occurring at a higher rate in female athletes compared with their male counterparts. Research in the area of anterior cruciate ligament injury has increasingly focused on the role of joint proprioception and muscle activity in promoting knee joint stability. We measured knee joint laxity, joint kinesthesia, lower extremity balance, the amount of time required to generate peak torque of the knee flexor and extensor musculature, and electromyographically assessed muscle activity in 34 healthy, collegiate-level athletes (average age, 19.6 1.5 years) who played soccer or basketball or both. Independent t-tests were used to determine significant sex differences. Results revealed that women inherently possess significantly greater knee joint laxity values, demonstrate a significantly longer time to detect the knee joint motion moving into extension, possess significantly superior single-legged balance ability, and produce significantly greater electromyographic peak amplitude and area of the lateral hamstring muscle subsequent to landing a jump. The excessive joint laxity of women appears to contribute to diminished joint proprioception, rendering the knee less sensitive to potentially damaging forces and possibly at risk for injury. Unable to rely on ligamentous structures, healthy female athletes appear to have adopted compensatory mechanisms of increased hamstring activity to achieve functional joint stabilization.

We evaluated three methods for fixing a medial meniscal autograft to determine which method restored tibial contact mechanics closest to normal. The contact mechanics (maximum pressure, mean pressure, contact area, and location of the center of maximum pressure) of the medial tibial articular surface were determined using pressure-sensitive film while knee specimens were loaded in compression to 1000 N at 0°, 15°, 30°, and 45° of flexion. Pressure was measured for the intact knee, the knee after meniscectomy, and the knee with the original meniscus removed and reimplanted as an autograft using three different fixation methods. The contact mechanics of the autograft reinserted with bone plug fixation were closest to normal; however, the maximum pressure was significantly greater than in the intact knee. Adding peripheral sutures neither improved nor worsened the contact mechanics. Fixation with sutures only did not restore normal contact mechanics. We concluded that medial meniscal transplantation requires anatomic fixation of bone plugs attached to the anterior and posterior horns to restore contact mechanics closest to normal. Fixation of the meniscal horns with sutures alone cannot be recommended.

In the past, there has been a plausible hypothesis that anterior cruciate ligament graft placement at isometric sites, such that the tibial and femoral attachment sites remain equidistant from each other throughout knee range of motion, would increase the likelihood of a satisfactory outcome. For a given tibial placement we wanted to determine whether placing the graft on the average of the most isometric femoral line, a fixed distance from the outlet of the intercondylar notch, would return normal laxity to all knees. The three-dimensional kinematics of seven cadaveric knees were measured for angles from full extension to 90° of flexion at 15° increments. Physiologic levels of quadriceps muscle forces were applied to the intact knee, after transection of the anterior cruciate ligament, and after ligament reconstruction with a patellar tendon graft. On average, the reconstruction was found to return anterior-posterior translation, internal-external rotation, and varus-valgus rotation to levels not significantly different from those of the intact knee. However, the ranges of the translation and rotations were large. Placing the graft on the average most isometric femoral line did not restore knee laxity to normal in all knees. This supports the need to customize graft placement in each knee at the time of surgery.

The purpose of this study was to make a direct comparison between lumbar spine radiographs of incoming college football players and of an age-matched control group to determine whether there is a higher prevalence of lumbar spine abnormalities in football players before competing at the Division I level. We reviewed 187 lumbar spine radiographs. Of these, 104 were taken as a standard part of the preparticipation physical examination for incoming college football players. The remaining 83 radiographs were taken during routine preemployment physicals at a local factory. Each radiograph was read independently by three separate orthopaedic radiologists in a blinded fashion. Data were collected and statistically evaluated for 13 variables. The rate of spondylolysis was only 4.8% in our group of athletes and 6.0% in the control group (not significantly different). Only in the category of degenerative changes was a significant difference found. The control group had a 16.9% incidence of disk space narrowing and spurring and the football players had a 6.7% incidence. The remainder of the variables were not significantly different between the two groups. Our findings differ from previously published reports and indicate that football players entering college at the Division I level may have a similar prevalence of radiographic lumbar spine abnormalities, including spondylolysis and spondylolisthesis, as age-matched controls.

The specific aim of this study was to quantify glenohumeral translations in cadaveric shoulders after repair of the superior and middle regions of a surgically created Bankart lesion and after repair of the superior, middle, and inferior regions of the same lesion. Anterior-posterior, superior-inferior, and medial-lateral translations in nine cadaveric specimens were tested with shoulders in 0°, 45°, and 90° of humeral abduction and varying degrees of humeral rotation. There was statistically significantly less anterior and inferior translation after three-site labral repair compared with after two-site labral repair, and this effect was greatest at 90° of glenohumeral abduction. The decreased translations demonstrated with three-site repair emphasized the importance of careful repair of the labrum to the inferior glenoid rim during a Bankart reconstruction and suggested that failure to do so may be a contributing factor to recurrent instability after anterior shoulder reconstruction.

We evaluated the significance of magnetic resonance imaging findings in patients with patellar tendinitis. Midline sagittal magnetic resonance images were taken of 12 knees from 10 patients and of 17 knees from 15 age- and activity-matched subjects who underwent imaging for reasons other than patellar tendinitis. Of the 12 magnetic resonance imaging scans of knees with clinical patellar tendinitis, 3 (25%) exhibited no defect and only 7 (58%) had unequivocal intratendinous lesions. Among the 17 scans of subjects without clinical patellar tendinitis, 5 (34%) showed no defect and 4 (24%) had unequivocal intratendinous lesions. Proximal tendon width was significantly larger for the tendinitis patient group (5.0 1.7 mm versus 3.9 1.0 mm), although considerable overlap was present. All subjects with unequivocal intratendinous signal changes had a significantly longer nonarticular inferior patellar pole and were significantly older (38.1 years versus 26.8 years). Only Blazina stage III lesions were associated with abnormal findings on magnetic resonance imaging. As a whole, the sensitivity and specificity of magnetic resonance imaging was 75% and 29%, respectively. In younger patients with relatively mild symptoms, magnetic resonance imaging did not show significant changes; in older, active patients changes may be present in asymptomatic knees.

The object of this study was to evaluate the effect of a patellar realignment brace on patients with patellar subluxation or dislocation. Twenty-one patients (24 patellofemoral joints) with clinical evidence of patellar subluxation (N 16) or dislocation (N 5) were examined with the joint inside a positioning device to allow active-motion, kinematic magnetic resonance imaging. To analyze the patellar tracking pattern, the same imaging parameters (patellar tilt angle, bisect offset, and lateral patellar displacement) and section locations were used before and after application of a patellar realignment brace. No statistically significant differences were found in any of the three parameters for the patellofemoral relationships before or after wearing the patellar brace. The results indicated no stabilizing effect of the tested brace in patients with patellar subluxation or dislocation during active joint motion.

A prospective, randomized, double-blinded study was performed to determine whether dilute epinephrine saline irrigation (1 mg/l) delivered by gravity flow would significantly reduce the need for tourniquet use during routine arthroscopic surgery. One hundred five patients requiring straightforward arthroscopic knee surgery were randomly assigned to either an epinephrine group that received dilute epinephrine irrigation by gravity flow or to a placebo group that received normal saline irrigation by gravity flow. The need for tourniquet use and the tourniquet time, total operative time, and volume of irrigation fluid used were documented and compared between the two groups. A tourniquet was required 50% less often in the epinephrine group than in the placebo group. This difference was found to be statistically significant using the Student's t-test (P< 0.008, α ≤ 0.05). If a tourniquet was required, the presence of dilute epinephrine in the irrigation fluid did not affect the overall tourniquet time or the ratio of tourniquet time to total operative time. We believe this study proved that dilute epinephrine irrigation is effective in decreasing the need for tourniquet use during routine arthroscopic knee surgery.

The objective of this study was to elucidate how cryotherapy after anterior cruciate ligament reconstruction affects intraarticular temperature and clinical results. A prospective and randomized study was performed on 21 knees of 21 patients. The ligament reconstruction was performed by single-incision arthroscopy using autogenous ham-string tendon. On completion of the surgery, thermosensors were implanted in the suprapatellar pouch and the intracondylar notch, and the intraarticular temperature was monitored while the joint was cooled. Cooling was performed in one group at 5°C (N 7) and in another at 10°C (N 7), for 48 hours. A control group (N 7) did not undergo cryotherapy. The cooled groups showed three temperature phases: a low-temperature phase immediately after the ligament reconstruction, followed by a temperature-rising phase and a thermostatic phase. The control group had no low-temperature phase and immediately entered a thermostatic phase. During the low-temperature phase in the treated groups, the temperature of the suprapatellar pouch and of the intercondylar notch were significantly lower than the body temperature. The pain score and the number of times an analgesic had to be administered were both significantly lower in the 10°C group than in the control group. Blood loss was significantly less in the 5°C group than in the control group.

We studied the effects of insulin-like growth factor I on Achilles tendon healing in a rat model. Rats were randomized into groups of six each: sham surgery, transection alone, and transection plus growth factor. Postoperatively, rats treated with growth factor had a significantly smaller maximum functional deficit and a decreased time to functional recovery than rats in the untreated groups. Biomechanical testing revealed no significant differences in the measured parameters between the treated and the untreated groups after transection. To study the mechanism of action, six additional animals received an Achilles tendon injection of the inflammatory agent carrageenan alone and six received carrageenan plus growth factor. Rats treated with growth factor did not show the inflammation-induced functional deficit experienced by the control rats. Spectrometric myeloperoxidase assays on the remaining eight rats after Achilles tendon transection demonstrated no significant difference between the untreated and the growth factor-treated groups, indicating a mechanism other than neutrophil recruitment by which the growth factor limits inflammation. Histologic studies were performed on carrageenan-injected rats at postinjection day 2 and on surgically treated rats at postoperative day 15. No gross histologic differences were seen between untreated and growth factor-treated groups. This study demonstrated that via a possible antiinflammatory mechanism, insulin-like growth factor I reduces maximum functional deficit and accelerates recovery after Achilles tendon injury.