John C. Kennedy

Nerve supply of the human knee and its functional importance

This investigation utilized gross dissections, histolog ical preparations, and neurophysiologic experiments to gain an improved understanding of the innervation of the human knee. Anatomical illustrations represent the findings of dissections of 15 fresh amputation specimens. Neurohistologic preparations using silver staining techniques demonstrate the rich innervation of the soft tissues of the knee, and a variety of spe cialized receptors are identified. In 10 subjects with normal knees, an experimentally produced knee ef fusion of 60 cc was found to result in profound inhi bition of reflexly evoked quadriceps contraction. Clin ical implications of the anatomical and physiologic data are discussed.

The Anatomy and Function of the Anterior Cruciate Ligament: As Determined By Clinical And Morphological Studies

In a biomechanical and morphological study of cadaver knees and a clinical end-result study of fifty patients with tears of the anterior cruciate ligament, the structure and function of the ligament, the mechanism of injury, and the results of various forms of therapy were analyzed. It was concluded that tension of the anterior cruciate ligament varies during knee motion, being least at from 40 to 50 degrees of flexion; that there are adequate intraligamentous blood vessels and nerves for healing to occur; that isolated tears of the anterior cruciate ligament do occur (probably as the result of internal-rotation displacement of the tibia with respect to the femur); that such tears are frequently associated with meniscal tears; and that early results of operative or non-operative treatment of the anterior cruciate ligament are acceptable although late instability may occur.

Medial and Anterior Instability of the Knee: An Anatomical And Clinical Study Using Stress Machines

Our clinical stress machine serves as an additional aid in the detection of isolated or combined damage to ligamentous structures about the knee. The machine has greatly assisted in the classification of chronic ligamentous damage. In the questionable gray area of medial instability, machine evaluation has been a great asset in making critical therapeutic decisions.

Presidential address. Intraarticular replacement in the anterior cruciate ligament-deficient knee.

For years there has been a struggle for a satisfactory intraar ticular replacement in the anterior cruciate-deficient knee. This paper summarizes our basic and clinical research over the last decade and presents a potential solution to the problem. Instron testing reveals that the anterior cruciate ligament fails at 51.2 kg. Scanning electron microscopy demonstrates that there is little difference whether the ligament is tested just to the point of failure or taken to visible rupture. The technique of the MacIntosh quadriceps-patellar tendon transfer is outlined. Two modifications in the form of a new approach through the defect in the quadriceps mechanism, as well as a new instrument to aid in the passage of the transfer are described. The strength of the tissues about the knee that have been used to substitute for the anterior cruciate ligament are pre sented. Only the distal iliotibial band seems suitable on strength characteristics alone. Intraarticular semitendinosus transfers in rabbits revealed degeneration and a marked decrease in tensile strength at 6 months. We conclude from this experiment and the data from Instron testing on autopsy specimens, substantiated by our clinical impressions, that the long-term success of autogenous intraarticular transfers seems unlikely. We introduce the ligament augmentation device (LAD) as a possible answer. A polypropylene, diamond-braided device is sutured to the prepatellar tissue in the MacIntosh repair to increase its tensile strength. It will sustain the host tissue during the period of degeneration and weakening, and thus allow eventual collagenization. We present our animal work with regard to the LAD and early human clinical application.

Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction

The purpose of this clinical retrospective study is to determine whether a polypropylene braid (PB) used to augment an intraarticular autograft to reconstruct the anterior cruciate ligament (ACL) is safe and to deter mine whether the PB improves the efficacy of the procedure. A simultaneous review was performed of patients who had undergone an intraarticular ACL reconstruc tion using an autograft composed of the central quad riceps tendon, prepatellar periosteum, and patellar ten don left attached distally to the tibial tubercle and of patients who had undergone the same procedure with PB augmentation of the autograft. Preoperatively, all patients had chronic ACL insufficiency and were expe riencing symptomatic giving way. A subjective questionnaire and a physician exami nation (JHR) were completed on each patient. Objective laxity and functional testing, including KT 1000 arthro meter measurement, Cybex isokinetic strength analy sis, and one leg horizontal hop for distance, were performed. Six radiographs of each operated knee were obtained. Results were statistically analyzed. Thirty-eight of 43 (88%) nonaugmented procedures performed were reviewed, with a mean followup of 64 months. Forty-five of 48 (94%) PB augmented recon structions with a minimum followup of 42 months (max imum 57 months, mean 50 months), were reviewed. On objective laxity and function testing, the PB aug mented patients had better results than the nonaug mented patients. On subjective questioning, physicians examination, and radiographic analysis, the PB aug mented results were significantly better. There were 12 (32%) knees with recurrent symptomatic giving way in the nonaugmented group and 5 (11 %) in the PB aug mented group. Chrondromalacia patellae and arthrofi brosis were seen in both groups. No adverse reaction to the PB was seen. We conclude that the PB is safe and that PB aug mentation improves the efficacy of the intraarticular autograft to reconstruct the ACL.

Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by transfer of the biceps femoris tendon.

In a retrospective study to determine whether the efficacy of intra-articular reconstruction of the anterior cruciate ligament is improved by an extra-articular transfer of the biceps femoris tendon, we compared the results in a group of forty-three patients in whom the advancement procedure had been done with those in a group of fifty patients in whom it had not. The minimum length of follow-up was twenty-four months. There was no significant difference between the two groups, and we concluded that advancement of the biceps femoris tendon does not improve the efficacy of an intra-articular reconstruction of the anterior cruciate ligament.

COMPLETE DISLOCATION OF THE ACROMIO-CLAVICULAR JOINT

1. Screw fixation of clavicle to coracoid process, with subsequent calcification and ossification along the conoid and trapezoid ligaments, creates an extra-articular fusion of the acromio-clavicular joint. 2. Though the follow-up is admittedly early, excellent results can be obtained in the young healthy adult. It is possible to return an athlete to competitive sports and a heavy labourer to full work in a surprisingly short time. 3. The operation is of doubtful value in older patients. 4. A precise operative technique is most important in producing a successful result. 5. Screw fixation introduces a new movement into the abduction mechanism of the shoulder: synchronous scapulo-clavicular rotation.

OSTEOCHONDRAL FRACTURES OF THE FEMORAL CONDYLES

1. The importance of recognising osteochondral fractures of the femoral condyle in the adolescent knee joint is emphasised. 2. The mechanism of the formation of the fractures is discussed. Essentially, a powerful rotary and compressive force shears off cartilage and subchondral bone. The absence of lateral condylar lesions in the experimental group lends support to the theory that the patella may cause the fracture by impingement. 3. On the basis of the mechanism a clinical classification of osteochondral fractures of the femoral condyles is presented. 4. Early surgery is recommended. The arguments for removal or replacement of the fragment are discussed.

The use of the medial head of the gastrocnemius muscle in the posterior cruciate-deficient knee: Indications-technique-results

This review retrospectively analyzes a group of pa tients with chronic posterior cruciate insufficiency who were treated surgically with transfer of the medial head of the gastrocnemius muscle. Our indications, technique, and the results of this surgery are presented. Twenty-one patients (21 knees) over the last 3½ years, from January 1977 to June 1980, were treated by this procedure. Eighteen patients were followed up for more than 8 months after surgery and are included in the review. Subjectively, pain, swelling, reduction of activity, and functional instability were assessed and graded from 0+ to 3+. Postoperative examination showed improvement of these parameters in most patients. Objectively, assessment of effusion, patellofemoral joint symptoms, stability, and recurvatum were tabu lated and compared to preoperative information. Of greatest significance was improvement of the patients overall functional classification in most cases. The posterior sag or drawer sign and patellofemoral com plaints were not altered by the operation. Gait analysis and isokinetic testing were performed as part of the followup on 50% of the patients. We advocate this as a safe, effective reconstructive procedure for the posterior cruciate deficient knee with significant advantages over alternative tech niques.

Arthrodesis of the ankle with particular reference to the Gallie procedure; a review of fifty cases.

Ankle fusion may be accomplished in a satisfactory fashion by a number of standard techniques. There is still a place for the choice of technique, depending on the situation. The Gallie ankle fusion with or without modifications is a useful addition and yielded a minimum of complications in twenty patients. An analysis of fifty ankle fusions revealed sufficient postoperative complaints to emphasize the need for careful patient selection.