A. Herbert Alexander

Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study.

We conducted a prospective, randomized study of open and closed kinetic chain exercises during accelerated rehabilitation after anterior cruciate ligament recon struction to determine if closed kinetic chain exercises are safe and if they offer any advantages over conven tional rehabilitation. The closed kinetic chain group used a length of elastic tubing, the Sport Cord, to per form weightbearing exercises and the open kinetic chain group used conventional physical therapy equip ment. Results are reported with a minimum 1-year fol lowup (mean, 19 months). Pre- and postoperative evaluation included the Lysholm knee function scoring scale, Tegner activity rating scale and KT-1000 ar thrometer measurements. Overall, stability was re stored in over 90% of the knees. Preoperative patel lofemoral pain was reduced significantly; 95% of the patients had a full range of motion. The closed kinetic chain group had lower mean KT-1 000 arthrometer side- to-side differences, less patellofemoral pain, was gen erally more satisfied with the end result, and more often thought they returned to normal daily activities and sports sooner than expected. We concluded that closed kinetic chain exercises are safe and effective and offer some important advantages over open kinetic chain ex ercises. As a result of this study, we now use the closed kinetic chain protocol exclusively after anterior cruciate ligament reconstruction.

The Relationship Between Tunnel Placement and Clinical Results After Anterior Cruciate Ligament Reconstruction

To correlate clinical results after anterior cruciate liga ment reconstruction with tunnel placement measured radiographically, we prospectively studied 128 patients who had arthroscopically assisted bone-patellar ten don-bone reconstructions. Patients with bilateral ante rior cruciate ligament reconstructions, other significant knee ligament injuries, or those undergoing chondro plasty or meniscal repairs were excluded, leaving 42 patients. The relationship between radiographic tunnel position and clinical results was determined using the Lysholm score, KT-1000 arthrometer testing, the Teg ner activity level, and the pivot shift and Lachman tests. Clinical results correlated positively with posterior fem oral tunnel placement on lateral radiographs and neg atively with excessive anterior tibial tunnel placement. Specifically, when femoral tunnels were placed at least 60% posterior along Blumensaats line and tibial tun nels were at least 20% posterior along the tibial pla teau, 69% of patients had good or excellent Lysholm scores and 79% had KT-1000 arthrometer maximum manual side-to-side differences of 3 mm or less. When the above criteria were not met, 50% of patients had good or excellent Lysholm scores and 22% had KT- 1000 arthrometer maximum manual side-to-side differ ences of 3 mm or less. This close correlation indicates that satisfactory radiographic tunnel position influences outcome after anterior cruciate ligament reconstruc tion.

Arthroscopic treatment of transchondral talar dome fractures

Fifteen cases of transchondral talar dome fractures treated arthroscopically at the Naval Hospital in Oak land, California, were reviewed. Roentgenograms and results from clinical examination were assessed pre operatively and at regular intervals postoperatively. Clinical followup of 18 months was obtained in all cases (range, 18 to 36 months; mean, 26 months). All lesions were treated with arthroscopic excision of fragments with abrasion and/or drilling of the remaining crater. There were nine excellent results, four good, one fair, and one poor. There were no complications. Results of arthroscopic treatment compare favorably to those of open arthrotomy.

Kienböck's disease—Update on silicone replacement arthroplasty

In a previous paper, early lunate silicone replacement arthroplasty (SRA) for Kienbocks disease was advocated because of poor results obtained in stage III disease. Since then, an additional 16 patients have been operated on. Thirteen had stage III disease, and 12 underwent successful SRA. This result is attributed to the modification in anatomical configuration and the improvement in the physical characteristics of the new high-performance silicone lunate implant. Because SRA gives good results in a high percentage of patients in stage III disease, alternative modes of therapy may be considered in stage I or stage II disease without jeopardizing the ultimate result from SRA in stage III disease.

The Elmslie-Trillat procedure: Evaluation in patellar dislocation and subluxation

The Elmslie-Trillat procedure for correction of patello femoral malalignment was evaluated in 27 knees in 22 patients with an average followup of 42 months (mini mum of 24 months). Preoperative and postoperative pain and activity levels were recorded for all knees. The quadriceps angle was recorded in 22 knees preopera tively and in 19 knees postoperatively. Good or excel lent results were obtained in 81% overall and in 91 % of those knees with patella alta. The postoperative quadriceps angle (Q-angle) correlated with the result. Correction of 10° or less was always associated with a good or excellent result. In contrast, all patients with a fair or poor result had Q-angles of 15° or greater. The preoperative Q-angle did not correlate with the eventual result. We concluded that inadequate medial displacement of the anterior tibial tuberosity may lead to unsatisfac tory results and that this may be avoided by intraoper ative measurement of the Q-angle; that significant distal advancement of the tibial tuberosity is not required in patella alta; and that correction of the Q-angle to 10° or less correlates with a good or excellent result from the Elmslie-Trillat procedure for treatment of patella subluxation and dislocation.

The natural history of conservatively treated partial anterior cruciate ligament tears

Twenty-five patients with arthroscopically proven par tial ACL tears were reviewed. All patients underwent examination under anesthesia and arthroscopy follow ing an acute injury to a previously normal knee. The percentage of tear was estimated during arthroscopy. Postoperatively, patients were treated with early motion and hamstring strengthening. Weightbearing and quad riceps rehabilitation were delayed. A detailed rating of symptoms and function was performed at a minimum of 18 months after injury, using a modification of the AOSSM ACL follow-up form. Neither the estimated percentage of ligament tear, length of followup, nor age at time of injury significantly correlated with clinical score at followup. Thirteen patients underwent partial meniscectomy at the time of original arthroscopy. Their clinical outcome was not different from those without meniscectomy. Two patients (8%) underwent ACL re construction 8 and 64 months after injury, respectively. Overall results were judged as excellent (28%), good (32%), fair (24%), and poor (16%). Only 44% were able to resume sports at their preinjury level, and 72% had activity-related symptoms.

Multidirectional shoulder instability Clinical results of inferior capsular shift in an active-duty population

We reviewed the results of a capsular shift procedure performed on 10 active-duty patients with an average of 28 months followup. improvement in pain, function, and stability occurred postoperatively in nearly all pa tients. Loss of total elevation and external rotation were minimal and an average of three spinal segments of internal rotation were lost. Only one patient required further surgery for recurrent instability and all patients except two reported over-all improvement. Dominant shoulders made greater improvements in pain, stability, and functional capacity than nondominant shoulders. Patients with generalized ligamentous laxity had less pain and more posterior instability than those without laxity. A history of an acute traumatic event was pre dictive of greater improvement in pain and stability. A previous instability repair was indicative of the most postoperative instability and least functional improve ment.

Arthroscopic treatment of symptomatic synovial plica of the knee Long-term followup

We studied all patients undergoing arthroscopic resec tion of symptomatic plica without other intraarticular abnormality at our institution from October 1981 to March 1987. To be considered abnormal, plicae had to be thickened and/or fibrotic when viewed arthroscopi cally. Seventy-six of nearly 2000 patients (4%) who underwent diagnostic arthroscopies met our inclusion criteria. Clinical response after arthroscopic resection was evaluated in 51 patients at an average of 47 months (range, 15 to 77).

Lunate silicone replacement arthroplasty in Kienböck's disease: A long-term follow-up☆☆☆

We report a long-term follow-up (average, 5 years) of 10 patients who had lunate silicone replacement arthroplasty for treatment of Kienböcks disease. Clinical results were assessed on relief of pain, return to normal occupation, and range of motion. At 18- to 20-months follow-up, eight patients had satisfactory results, whereas at final follow-up only five of the patients had satisfactory results. Three of five patients with radiographs averaging 57 months after operation had evidence of particulate synovitis. Contrary to our previous publications on silicone replacement arthroplasty, it was concluded that the success rate for silicone replacement arthroplasty and the incidence of particulate synovitis do not warrant the continued use of silicone replacement arthroplasty as a primary treatment modality for Kienböcks disease.

Fracture of the femur after anterior cruciate ligament reconstruction with a GORE-TEX prosthetic graft A case report

Intraarticular reconstruction of the ACL-deficient knee in the amateur athlete has become more frequent. With more primary reconstructions being done, salvage procedures for their failures are also becoming more common. One such salvage procedure, still in development, is the replacement of the biologic ACL by a prosthetic graft. A complication that is of concern, but which has not yet been reported, is the incidental fracture of the femur through the large drill hole required to place the graft. We report a supracondylar femur fracture at the site of the drill hole used to place a GORE-TEX (WL Gore & Associates, Flagstaff, AZ) prosthetic ACL 8 weeks after surgery.