Arthur C. Rettig

Nonoperatively treated isolated posterior cruciate ligament injuries

To evaluate the theory that isolated posterior cruciate ligament injuries do well when treated nonoperatively, we reviewed 40 patients (mean age, 33 years at fol lowup ; average interval from injury, 6 years) who com pleted a modified Noyes knee questionnaire and were reevaluated by physical examination, radiographs, and isokinetic testing. Thirty of the injuries to the posterior cruciate ligament were sports-related. On the question naire, 65% of the patients revealed that their activity level after injury was limited and 49% stated that the involved knee had not recovered fully despite rehabili tation. Ninety percent complained of knee pain with activity and 43% complained of problems with walking. The longer the interval between injury and this followup, the lower the knee questionnaire score and the greater the radiographic degenerative changes. The patients as a group exhibited excellent muscular strength with a mean isokinetic score of 99% of the contralateral extremity. There was no correlation between isokinetic testing and knee questionnaire score. Patients with greater posterior laxity, as measured by the posterior drawer examination, appeared to have greater subjec tive complaints. Our study suggests that patients with isolated posterior cruciate ligament injuries treated non operatively may maintain excellent muscle strength, but significant symptoms and degenerative changes in crease with increasing interval from injury.

Anterior cruciate ligament injuries in the young athlete with open physes

From 1980 to 1985, 40 patients under the age of 14 with open physes were treated for midsubstance tears of the ACL at the Methodist Sports Medicine Center. In this series, 16 were treated conservatively with re habilitation, bracing, and counseling on activity modifi cation. The remaining 24 patients underwent arthros copic examination and either an extraarticular or intra articular reconstruction based on growth potential. The average followup was 27 months for the con servative group and 26 months for the surgical group. In the conservative group, six patients underwent ar throscopy for meniscal tears, four medial and two lat eral. Only seven patients returned to sports, all experi encing recurrent episodes of giving way, effusions, and pain. In the surgical group, 12 medial and 6 lateral meniscal tears were found at arthroscopy. There were 10 ex traarticular reconstructions and 14 intraarticular recon structions. All 24 returned to sports activity, and 22 of the 24 are still competing. The two remaining patients both suffered reinjury 3 years after their surgery. We recommend arthroscopy and examination under anesthesia for the young patient with ACL tears. Based on the amount of instability, presence or absence of meniscal tears, and athletic desires of the patient and his or her family, a treatment plan can be undertaken.

Patellar Tendon Graft Reconstruction for Midsubstance Anterior Cruciate Ligament Rupture in Junior High School Athletes An Algorithm for Management

Between 1976 and 1988 we treated 75 junior high athletes who had midsubstance ruptures of the ante rior cruciate ligament and open physes. Thirty-eight children were initially treated conservatively and later had an intraarticular patellar tendon graft reconstruc tion, 2 patients underwent extraarticular reconstruc tion and then later had a patellar tendon graft intraar ticular reconstruction, and 20 children had a patellar tendon graft reconstruction initially. In all 60 pa tients the tibial and femoral tunnels were drilled through the open physes. Minimum followup was 2 years (mean, 4.2). Fifty-five of the 60 children were able to return to their original sports; 5 were active in less strenuous sports. No incidence of abnormal growth related to the intraarticular reconstructive surgery was recorded. Three children tore their an terior cruciate ligament grafts more than 2 years after surgery. Our records showed that conserva tive treatment of the active junior high athlete with an anterior cruciate ligament rupture failed in each case because of recurrent giving way or meniscal tears. Definitive treatment with an intraarticular au togenous patellar tendon graft reconstruction yielded good to excellent results and eliminated subsequent instability episodes and meniscal tears in our study group.

Anterior cruciate ligament injury: Evaluation of intraarticular reconstruction of acute tears without repair Two to seven year followup of 155 athletes

To evaluate the effectiveness of our treatment regimen, we retrospectively studied the surgically treated knees of 155 athletes, aged 15 to 42 years, who had sustained acute ACL tears. All were treated with ligament excision and intraarticular bone-patellar tendon-bone recon struction followed by early motion with emphasis on full extension. The follow-up period ranged from 2 to 7 years. Of the 155 patients, 140 were available for final followup at a minimum of 2 years after reconstruction. The patients were evaluated by objective measures (KT-1000, Cybex, Lachman test, range of motion, and postoperative competition level) and subjective assess ment scores (pain, swelling, stability, activity level, walk ing, stair climbing, running, jumping, or twisting). The subjective scores were tabulated for stability level, total score, and activity level. After the patients achieved full range of motion, the KT-1000 measurements at a 20 pound force revealed an average difference of 1.3 mm between the injured and noninjured knees. All but 3 of the 140 patients had a firm endpoint on the Lachman test, and the Cybex tests showed a mean hamstring strength of 98% and mean quadriceps strength of 90%. Sixty of the 69 varsity athletes who were eligible to play returned to preinjury competition level the following season. One had reconstruction failure and eight chose not to con tinue competition for academic reasons. The question naire score average was 92.7 (maximum, 100 points, normal athletic knee score 93.5). We concluded that the surgical procedure, with em phasis on early full extension postoperatively, achieved excellent results and provided a stable knee.

The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries.

Thirty-nine subjects volunteered for this blinded, ran domized, and controlled study to assess the clinical ex amination skills of orthopaedic surgeons with fellowship training in sports medicine. Eighteen of the patients had 19 chronic isolated posterior cruciate ligament tears. The controls were 9 patients with 9 anterior cruci ate ligament-deficient knees, 12 subjects with normal knees, and the contralateral normal knees of the ligament-deficient patients. To eliminate preexamina tion bias, all examiners were blinded from the examin ees history, identity, and diagnosis. The overall clinical examination accuracy for all orthopaedic surgeons was 96%. The accuracy for detecting a posterior cruciate ligament tear was 96%, with a 90% sensitivity and a 99% specificity. The examination accuracy was higher for grade II and III posterior laxity than for grade I laxity. Eighty-one percent of the time, the examiners agreed on the grade of the posterior cruciate ligament tear for any given patient. The posterior drawer test, which in cluded palpation of the tibia-femur step-off, was the most sensitive and specific clinical test. A thorough and precise physical examination, coupled with a patient history, can be considered diagnostic in the majority of isolated posterior cruciate ligament injuries. With this accuracy level known, the natural history of isolated posterior cruciate ligament tears can be reliably docu mented and studied.

Nonoperative Treatment of Ulnar Collateral Ligament Injuries in Throwing Athletes

Ulnar collateral ligament injury of the elbow in throwing athletes is a common occurrence, and either operative or nonoperative treatment is an option. The results of operative repairs and reconstructions have been well documented in the literature; however, little information has been reported on the outcome of nonoperative treatment. From 1994 to 1997, we evaluated 31 throwing athletes with ulnar collateral ligament injuries. The purpose of this study was to determine what percentage of athletes could return to their sport without surgical intervention and to identify factors that would predict return to full competition by an athlete treated nonoperatively. The factors studied included acute versus insidious onset of symptoms, the duration of symptoms before treatment, and age. Nonoperative treatment, which included a minimum of 3 months’ rest with rehabilitation exercises, allowed 42% of the athletes in our study (N 13) to return to their previous level of competition. Those who did return did so at an average of 24.5 weeks after diagnosis. No predictive findings obtained either through the patients history or physical examination were found that would assist the clinician or athlete in predicting the success of nonoperative treatment.

Athletic Injuries of the Wrist and Hand: Part II: Overuse Injuries of the Wrist and Traumatic Injuries to the Hand

Hand and wrist injuries in sports are some of the most common injuries reported. This review discusses common overuse injuries of the wrist including tendon injuries such as de Quervains syndrome, subluxation of the extensor carpi ulnaris, and the common dorsal carpal impingement syndrome. The main focus of this section is the discussion of traumatic injuries to the hand in the athlete. Included is a discussion and review of fractures of the phalanges and metacarpals, common proximal interphalangeal joint injuries, and thumb carpal metacarpal and metacarpophalangeal joint injuries. Emphasis is placed on more common injuries seen regarding diagnosis, indications for non-operative versus operative treatment, and time to return to athletic competition.

Isolated Autogenous Bone-Patellar Tendon-Bone Graft Site Morbidity

To distinguish between morbidity caused by the isolated patellar tendon graft harvest and morbidity associated with anterior cruciate ligament reconstruction when the graft is harvested from the involved knee, we studied 20 patients who had an isolated contralateral graft harvest for anterior cruciate ligament reconstruction in the op posite knee. We defined and quantitated the morbidity by evaluating the uninjured knee from preoperative studies to current followup (range, 0.5 to 5 years; av erage, 2 years). All graft harvest surgeries were per formed in an identical fashion. Rehabilitation of the har vest knee included immediate range of motion, weightbearing, and closed chain kinetic exercises with a emphasis on early strengthening. All patients re gained full knee range of motion by 3 weeks. At final followup, there was no clinical or radiographic evidence of patella contracture or baja. Quadriceps strength av eraged 69% at 6 weeks and returned to 93% at 1 year and 95% at 2 years. Activity-related soreness at the donor site (patellar tendinitis) was rarely restricting and resolved after the 1 st year. No patient complained of patellofemoral joint pain in the donor knee. The modified Noyes subjective questionnaire score averaged 97 of 100 at last followup. The morbidity of an isolated au togenous patellar tendon graft harvest appears to be of short duration and largely reversible.

Athletic Injuries of the Wrist and Hand Part I: Traumatic Injuries of the Wrist

Hand and wrist injuries in sports are some of the most common injuries reported. This review discusses briefly the causes of hand and wrist injuries in sports and discusses pertinent biomechanical findings regarding the range of motion required in different sports activities. The bulk of the review discusses specific traumatic and overuse injuries to the hand and wrist commonly seen in the athlete. Emphasis is placed on problematic traumatic injuries such as carpal scaphoid fractures and hook of the hamate fractures, as well as ligament injuries to the wrist with regard to diagnosis, treatment, and return to athletic competition.

Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients.

Background: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow. Purpose: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study. A successful outcome was defined as 25% or greater improvement on the visual analog scale for pain. Results: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .163). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .019). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .143). Success rates for patients at 12 weeks were 75.2% in the PRP group versus 65.9% in the control group (P = .104). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P = .009). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .037). No significant complications occurred in either group. Conclusion: No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.