Daniel M. Veltri

The Role of the Cruciate and Posterolateral Ligaments in Stability of the Knee A Biomechanical Study

The role of the posterolateral and cruciate ligaments in restraining knee motion was studied in 11 human ca daveric knees. The posterolateral ligaments sectioned included the lateral collateral and arcuate ligaments, the popliteofibular ligament, and the popliteal tendon at tachment to the tibia. Combined sectioning of the an terior cruciate and posterolateral ligaments resulted in maximal increases in primary anterior and posterior translations at 30° of knee flexion. Primary varus, pri mary internal, and coupled external rotation also in creased and were maximal at 30° of knee flexion. Com bined sectioning of the posterior cruciate and posterolateral ligaments resulted in increased primary posterior translation, primary varus and external rota tion, and coupled external rotation at all angles of knee flexion. Examination of the knee at 30° and 90° of knee flexion can discriminate between combined posterior cruciate ligament and posterolateral injury and isolated posterolateral injury. The standard external rotation test performed at 30° of knee flexion may not be routinely reliable for detecting combined anterior cruciate and posterolateral ligament injury. However, measurements of primary anterior-posterior translation, primary varus rotation, and coupled external rotation may be used to detect combined anterior cruciate and posterolateral ligament injury.

Traumatic Tears of the Subscapularis Tendon Clinical Diagnosis, Magnetic Resonance Imaging Findings, and Operative Treatment

The study population consisted of 14 shoulders in 13 consecutive patients with surgically confirmed isolated subscapularis tendon tears. In all but three patients, the mechanism of injury was traumatic hyperextension or external rotation of the abducted arm. All patients reported pain and weakness in the affected shoulder. Physical findings revealed limited passive range of motion at maximal internal and external rotation due to pain, weakness of internal rotation of the shoulder, and tenderness in the region of the intertubercular groove. However, these findings did not conclusively point to the subscapularis tendon as the site of injury. Preop erative interpretation of magnetic resonance imaging studies was used to diagnose tears of the subscapu laris tendon in 14 shoulders and biceps tendon sublux ation or dislocation in 6 shoulders. On arthroscopic examination, one patient was found to have a partial- thickness tear that was treated with arthroscopic de bridement. Six shoulders had full-thickness tears of the subscapularis tendon, and seven shoulders had full- thickness tears associated with concomitant biceps tendon pathologic conditions, including subluxation, dislocation, or rupture. The full-thickness subscapu laris tendon tears were repaired via an open anterior approach to the shoulder through the deltopectoral groove. Associated biceps tendon injuries were treated with tenodesis of the tendon to the intertubercular groove. Our early followup results have shown that, with proper diagnoses and surgical treatments, pa tients have greatly decreased pain and marked im provement in shoulder function.

The role of the popliteofibular ligament in stability of the human knee. A biomechanical study

The popliteal tendon has a significant attachment to the fibula, the popliteofibular ligament. The role of this ligament in knee stability has not been determined. In this study we used selective cutting techniques to measure the static contribution of the popliteal tendon attachments to the tibia and the popliteofibular liga ment for stability of the knee. Sectioning of all the posterolateral structures except the popliteal tendon attachments to the tibia or the popliteofibular ligament resulted in increased primary posterior translation, va rus rotation, external rotation, and coupled external rotation. Although statistically significant, these in creases were small. Sectioning of all the posterolateral structures resulted in larger increases in primary pos terior translation, varus rotation, external rotation, and coupled external rotation. Our data indicate that the popliteal tendon attachments to the tibia and the pop liteofibular ligament are important in resisting posterior translation and varus and external rotation. If an iso lated injury to the posterolateral structures occurs, an atomic reconstruction of the major ligaments that re strain posterior translation and varus and external rotation may provide the best functional result. Recon struction for isolated posterolateral instability should include anatomic attachment of the popliteal tendon to the tibia and the popliteofibular ligament.

Current status of allograft meniscal transplantation.

The meniscus has several roles that contribute to knee function. Many clinical studies have documented the detrimental effects of loss of meniscus function. Meniscal repair is recommended when technically and anatomically feasible to preserve meniscal function. Techniques for meniscal repair can be used to transplant meniscal allografts. Animal studies have documented that meniscal allografts can heal in the recipient. There are few clinical studies of meniscal allograft transplantation in humans. Indications, techniques, results, and complications of meniscal allograft transplantation in humans are described.

Isolated and Combined Posterior Cruciate Ligament Injuries

&NA; Posterior cruciate ligament (PCL) injuries represent 3% to 20% of all knee ligamentous injuries, but the diagnosis often is missed at initial evaluation. Diagnostic acumen is increased by knowledge of knee biomechanics and selective ligament‐cutting studies. The examiner must differentiate the isolated PCL injury from combined ligamentous injury to determine appropriate treatment. Isolated acute PCL tears with less than 10 mm of posterior laxity at 90 degrees of flexion should be treated with an aggressive rehabilitative program. This amount of laxity is found in the majority of isolated acute PCL tears. Isolated acute PCL tears with more than 10 to 15 mm of posterior laxity and PCL tears with combined ligamentous injuries should be reconstructed. Large PCL bony avulsions should be fixed internally. Small PCL bony avulsions with more than 10 mm of posterior laxity should be reconstructed. Chronic PCL injuries initially should be treated with an aggressive rehabilitation program. If such a program is not successful in a patient with more than 10 to 15 mm of posterior laxity and no significant radiographic evidence of degenerative changes, the PCL should be reconstructed.

Symptomatic intraarticular ganglia of the cruciate ligaments of the knee

This case report draws attention to the clinical presentation, differential diagnosis, and recommended diagnostic modality and treatment of symptomatic ganglia of the anterior and posterior cruciate ligaments. One patient presented with a recurrent inability to fully extend the left knee. Another patient presented with pain and soreness over the lateral aspect of the knee, including the lateral joint line. The diagnosis of ganglia of the cruciate ligaments was made after clinical, radiographic, and magnetic resonance examination. Both patients were treated successfully with resection of their ganglia using arthroscopic techniques.

Symptomatic ossification of the tibiofibular syndesmosis in professional football players: a sequela of the syndesmotic ankle sprain.

Ankle syndesmosis sprains are common injuries in collegiate and professional football. Several reports have documented that patients with syndesmosis injuries require a longer time to return to full athletic participation than patients with lateral ankle sprains. Here we present the cases of two professional football players with ankle pain secondary to syndesmosis ossification following documented syndesmosis ankle sprains. Both patients eventually required resection of the heterotopic ossification to allow a pain-free return to football. We conclude that syndesmosis ossification may be symptomatic in some patients, and surgical excision of the ossification may be required to allow an asymptomatic return to sports.

Arthroscopically assisted posterior cruciate ligament reconstruction

Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure. However, not all patients with PCL injury require reconstruction. We reconstruct the PCL when there is significant posterior instability or associated ligamentous injury. Bone-patellar tendon-bone autograft or allograft or Achilles tendon allograft can be used for PCL reconstruction. Here we outline our arthroscopic technique for reconstruction. Posterior cruciate ligament-specific drill guides and the use of accessory arthroscopy portals assist in reconstruction. Fluoroscopic guidance is useful in tibial tunnel placement. An isometer is used to determine correct femoral tunnel placement. The graft passage is eased by the use of a Steinman pin as a pulley. Finally, the graft is fixed in full extension. Attention to the technical surgical details of PCL reconstruction will increase the probability of success.

Complications in posterior cruciate ligament surgery

Posterior cruciate ligament (PCL) injuries are less common than anterior cruciate ligament injuries. Consequently there are fewer reported series of PCL reconstructions. These PCL reconstructions are technically demanding. There are several complications inherent to the technical aspects of PCL reconstruction. Improper graft placement can lead to limited postoperative knee flexion and extension or even graft failure. Selection of poor graft materials such as the medial gastrocnemius and iliotibial band will result in reconstructions that fail to achieve objective stability. Neurovascular injury can occur during preparation of the tibial tunnel. Direct femoral articular injury or avascular necrosis can occur secondary to femoral tunnel placement. Proper selection of graft tissues, proper graft placement, and excellent surgical exposure is necessary to avoid complications and achieve objective and functional success in PCL reconstruction.

Treatment of acute and chronic injuries to the posterolateral and lateral knee

Abstract Acute and chronic posterolateral injury is often associated with cruciate injury. Surgical reconstructions for acuteposterolateral instability achieve better results than reconstructions for chronic posterolateral instability, and whenever possible, we perform acute reconstruction of posterolateral injury. First, any associated cruciate injury is reconstructed. Then the posterolateral corner is exposed through an open lateral incision. We attempt to anatomically repair or reconstruct the major supporting structures of the posterolateral corner. They are the lateral collateral ligament, the popliteus, and the popliteofibular ligament. In acute injury we first attempt direct repair, advancement and recession, or augmentation. Occasionally, reconstruction with patellar tendon autografts or allografts or with achilles allografts is required. In the patient with chronic posterolateral instability and varus alignment, a proximal valgus tibial osteotomy is performed. If required, additional posterolateral reconstruction is performed on a staged basis. In the patient with chronic posterolateral instability and valgus alignment, reconstruction with patellar tendon or Achilles allograft is performed. This article reviews the techniques for reconstruction of acute and chronic injuries to the popliteofibular ligament, and popliteal attachment to the tibia and the lateral collateral ligament.