Bruce Reider

The anterior cruciate ligament-a technique of repair and reconstruction

Both primary repair and late substitution of anterior cruciate ligaments can be accomplished by intra-articular methods. This principle is to provide temporary struts that are initially avascular but can later undergo revascularization and metaplasia to form a new ligament. The graft does afford initial support, however. An understanding of anatomic principles, suture placement, freedom of graft from impingement, avoidance of acute angular deviation of the graft, solid static stability, anatomic attachment points, and blood supply, is absolutely essential for success in this field of surgery.

Treatment of isolated medial collateral ligament injuries in athletes with early functional rehabilitation: a five-year follow-up study

A prospective study was designed to provide 5-year fol lowup of the treatment of isolated grade I I I sprains of the medial collateral ligament with early functional rehabili tation in 35 athletes. After injury, patients were placed in lateral hinged braces to provide valgus support with out restricting flexion or extension of the knee. Treat ment was initiated with range of motion exercises per formed in a whirlpool or swimming pool. Patients were then started on quadriceps setting and leg raises. When 90° of flexion was present, resistive exercises were added. Upon recovery, patients were allowed to return to unrestricted sports. Followup consisted of both ques tionnaires and physical examination and was graded on the 50-point Hospital for Special Surgery scale. Mean followup was 5.3 years (range, 2.5 to 8); mean Hospital for Special Surgery knee rating score was 45.9 points (range, 41 to 50). These results are comparable with those achieved with surgery or immobilization by earlier investigators. Thus, early functional rehabilitation treat ment of complete medial collateral ligament sprains pro duces results comparable with those achieved with sur gery or immobilization while minimizing treatment- related morbidity and allowing more rapid return to sports participation.

The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee.

We report the effects of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee. An isometric femoral tunnel site was located using a specially de signed alignment jig. Additional femoral tunnel positions were located 5 mm proximal and distal to the isometric femoral tunnel. With the graft in the proximal femoral tunnel, graft tension decreased as the knee flexed; with the graft in the distal femoral tunnel, graft tension in creased as the knee flexed. When the graft was placed in the isometric femoral tunnel, a nearly isometric graft tension was maintained between 0° and 90° of knee flexion. One technique tested was tensioning the graft at 90° of knee flexion while applying an anterior drawer force of 156 N to the tibia. This technique restored sta tistically normal posterior stability to the posterior cru ciate ligament-deficient knee between 0° and 90° for the distal femoral tunnel position, between 0° and 75° for the isometric tunnel position, and between 0° and 45° for the proximal tunnel position. When the graft was tensioned with the knee in full extension and without the application of an anterior drawer force, posterior trans lation of the reconstructed knee was significantly dif ferent from that of the intact knee between 15° and 90° for all femoral tunnel positions.

The effects of arthroscopic partial lateral meniscectomy in an otherwise normal knee: a retrospective review of functional, clinical, and radiographic results

A retrospective review of patients who underwent arthroscopic partial lateral meniscectomy for lateral meniscus tears in otherwise normal knees was conducted to review the long-term functional, clinical, and radiographic results. Twenty-six patients (27 knees) were evaluated by questionnaire; 20 patients (21 knees) also underwent physical examination and radiographic analysis. Minimum follow-up was 5 years and mean follow-up was 8 years. Patient data were obtained from detailed questionnaires, knee examinations, and radiographs. Excellent or good results decreased from 92% at the time of maximal improvement to 62% at the most recent follow-up: 85% of patients were initially able to return to their preinjury activity level; however, only 48% were able to maintain this level of activity at the most recent follow-up. Seventy-two percent of patients had either one or no Fairbank changes and there was no statistical difference when comparing radiographic criteria in the operated and nonoperated knee. Early results for partial lateral meniscectomy can be quite good; however, significant deterioration of functional results and decreased activity level can occur. Radiographic changes did not correlate with subjective symptoms and functional outcome in our patient population. Our findings suggest that the functional outcome for patients undergoing partial lateral meniscectomy may deteriorate with time and it may be helpful to counsel patients concerning long-term expectations.

An in vitro study of an intraarticular and extraarticular reconstruction in the anterior cruciate ligament deficient knee

The biomechanical effectiveness of an extraarticular ACL reconstruction, an intraarticular ACL reconstruc tion, and the combination of these on both anterior stability and internal rotational stability of the ACL de ficient knee was investigated in six cadaver knees. The extraarticular reconstruction consisted of the Müller anterolateral femorotibial ligament iliotibial band teno desis, and the intraarticular reconstruction used the middle third of the patellar tendon in the manner of Clancy. The extraarticular reconstruction was found to over- constrain internal tibial rotation of the ACL excised knee between 30° and 90° ( P < 0.05). While the isolated extraarticular reconstruction did not return normal an terior stability to the ACL deficient knee (P < 0.05), it did significantly reduce the anterior laxity of the ACL deficient knee between 30° and 90° of knee flexion (P < 0.05). For the combined reconstruction, the intraarticular procedure was performed and then only enough ten sion was applied to the extraarticular reconstruction to take up slack in the tenodesis without shifting the rotatory position of the tibia from that produced by the intraarticular procedure alone. Neither the intraarticular reconstruction nor the combined procedure resulted in any significant shifts from normal (P < 0.05) in the rotatory position of the unloaded tibia; during loading neither resulted in rotational displacements significantly different from normal; and both of these procedures reduced the increased anterior laxity of the ACL defi cient knee to a level not statistically different from normal. Because the extraarticular reconstruction shared the load when performed with the intraarticular reconstruc tion as part of a combined procedure, we concluded that it would be useful as an adjunctive procedure in appropriate clinical situations.

A Comparison of Intraarticular Morphine and Bupivacaine for Pain Control After Outpatient Knee Arthroscopy A Prospective, Randomized, Double-Blinded Study

To determine the duration of pain relief and efficacy of intraarticular morphine compared with bupivacaine after outpatient knee arthroscopy under local anesthe sia, we gave patients one of three postoperative intraar ticular injections: 4 mg morphine, 0.25% bupivacaine, or 0.9% saline. Visual analog scale scores and supple mental pain medication use were recorded at 0 to 30 minutes, 2, 4, 6, 8 to 12, and 24 hours after surgery. The score on the visual analog scale at 24 hours was sig nificantly lower in the morphine group than in the bupi vacaine or control groups. The cumulative amount of pain medication used was significantly lower in the mor phine and bupivacaine groups at 2 to 6 hours after sur gery than in the saline control group. The morphine group used the least supplemental pain medication dur ing the 12 to 24 hour interval (P = 0.06). We found that the use of intraarticular morphine or bupivacaine after outpatient knee arthroscopy will de crease the amount of narcotic medication needed for pain relief during the early postoperative period. In ad dition, morphine provided prolonged pain relief up to 24 hours when compared with bupivacaine or placebo, and the patients in the morphine group tended to take less supplemental pain medication during the first postop erative day.

The Effects of Removal and Reconstruction of the Anterior Cruciate Ligament on the Contact Characteristics of the Patellofemoral Joint

Seven cadaveric knees were used to investigate the effects of removal and reconstruction of the anterior cruciate ligament with a bone-patellar tendon-bone graft on contact characteristics of the patellofemoral joint during physiologic levels of quadriceps muscle loads at 30°, 60°, and 90° of knee flexion. Loads were applied to the quadriceps tendon to equilibrate externally applied flexion moments equivalent to one-third of values for maximum isometric extension moments. Patellofemoral contact areas and pressures were measured using pressure-sensitive film. Excision of the anterior cruciate ligament resulted in significant decreases in the total patellofemoral contact area by as much as 94 mm2 (68%), the medial facet contact area by as much as 55 mm2 (93%), the combined average contact pressure by 0.7 MPa (21%), the medial facet average contact pressure by 2.3 MPa (70%), the combined peak contact pressure by 3.0 MPa (38%), and the medial facet peak contact pressure by 5.4 MPa (76%), all at 30° of knee flexion. Excision of the anterior cruciate ligament also resulted in significant decreases in total, medial facet, and lateral facet patellofemoral contact areas at 60° and 90° of knee flexion. Intraarticular reconstruction returned these to levels not significantly different from those of the intact knee.

Results of Isolated Patellar Debridement for Patellofemoral Pain in Patients with Normal Patellar Alignment

We reviewed the records of 36 patients who underwent arthroscopic patellar debridement for patellofemoral pain. All patients had isolated chondromalacia patellae noted during arthroscopic examination. No patient had a history of patellar instability or physical or radio graphic signs of patellar malalignment. The chondro malacia patellae was classified as traumatic or atrau matic in origin. All patients had failed results after a minimum of 4 months of physical therapy before sur gery, and all patients had grade 2 or worse chondro malacia patellae at the time of debridement. At the time of followup, patients were evaluated by questionnaire, Fulkerson-Shea Patellofemoral Joint Evaluation score, independent physical examination, and radiographs. Patients were also asked to subjectively score their knees preoperatively, at the time of maximal improve ment postoperatively, and at the time of followup for comparison. Preoperative examinations and radio graphs were compared with examinations at the time of followup. The most significant finding was the im provement in the overall joint evaluation score. The score for the entire group improved from a mean of 51.9 preoperatively to 78.8 at the time of maximal improvement and 75.3 at the time of followup. All but four patients subjectively thought that surgery had a beneficial effect. There were no observed changes in the preoperative and postoperative radiographs. Pa tients with traumatic chondromalacia patellae had 57.9% good or excellent results with surgery, and the patients with atraumatic cases had 41.1 % good or excellent results with surgery, indicating that many patients who were improved by the surgery still had functional limitations.

Comparison of Various Icing Times in Decreasing Bone Metabolism and Blood Flow in the Knee

In a previous study we used technetium-99m bone scans to show that cooling a knee for 20 minutes with a standard ice wrap will decrease soft tissue blood flow by a mean of 26%, and skeletal blood flow and me tabolism by 19%. The present study examined the ef fects of shorter and longer icing periods to determine minimum cooling time for a measurable and consistent decrease, and time to produce maximal decrease within a safe period of icing (<30 minutes). Thirty-eight sub jects were studied. An ice wrap was applied to one knee for an assigned time (5, 10, 15, 20, or 25 minutes). Triple-phase bone scans of knees were obtained; mean percentages of decrease in the iced knee for each of the five time groups at each of the three phases of the bone scan were calculated and compared. Mean decreases of 11.1 % in soft tissue blood flow, and 5.1% in skeletal metabolism and blood flow were measured at 5 min utes ; maximums of 29.5% and 20.9%, respectively, were obtained at 25 minutes. A small but consistent decrease in soft tissue blood flow and skeletal blood flow and metabolism in a knee appear to be obtained with as little as 5 minutes of ice application. This effect is time-dependent and can be enhanced three- to four fold by increasing the ice application time to 25 minutes.

The Effects of Knee Reconstruction on Combined Anterior Cruciate Ligament and Anterolateral Capsular Deficiencies

We tested the effect of intraarticular reconstructions of the anterior cruciate ligament alone and in combination with extraarticular reconstructions in 10 cadaveric knees. These knees had anterior cruciate ligament deficiency alone or in combination with anterolateral capsuloligamentous deficiencies. In the knees with combined injury, intraarticular reconstruction returned anterior stability to levels not significantly different from levels found for the knees deficient in the anterior cruciate ligament alone and treated with this proce dure. After intraarticular reconstruction, rotational sta bility of the knee with combined injuries failed to return to the levels seen in the knee with isolated anterior cruciate ligament deficiencies that underwent the same treatment. When a tenodesis with either 0 N or 22 N of tension was added to the intraarticular reconstruction in the knee with combined injuries, we found that ex cessive internal rotation significantly decreased at all angles of flexion, except at full extension with 0 N of tension. In addition, the extraarticular reconstruction with 22 N of tension in the tenodesis overconstrained the knee in internal rotation between 30° and 90° of knee flexion. The tenodesis with 0 N of tension over constrained the knee at only 60° and 90° of flexion. These results suggest extraarticular reconstruction as an adjunct to the intraarticular operation for the knee with anterior cruciate ligament and anterolateral struc tural injuries. The results also suggest that the surgeon can affect anterior and rotational laxity by adjusting the tension in the tenodesis.