John L. Marshall

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.

The Prime Static Stabilizer of the Medial Side of the Knee

The long fibers of the superficial medial collateral ligament are the primary stabilizers of the medial side of the knee against valgus and rotatory stress. The long fibers as a functional unit have a complex pattern in which the anteriormost fibers tighten as the knee flexes from the position of extension; simultaneously, the fibers just posterior to them slacken. The long fibers arise from a critical point on the medial femoral condyle relative to the instant centers of rotation such that the anterior border is kept under tension from full extension to 90 degrees of flexion. This may be of fundamental importance for surgical reconstruction of torn medial ligaments.

Instability of the Knee: A Long-term Experimental Study In Dogs

The anterior cruciate ligament was cut in ten dogs (unilaterally in nine, bilaterally in one). The dogs were killed in two groups, one at seven to nine months and the other at nineteen to twenty-three months. The dogs were clinically and roentgenographically examined at various intervals. At varying times before death they were given bone-seeking fluorochromes and necropsy was performed in all cases. Macroscopic, histological, and microroentgenographic examinations revealed proliferative and degenerative changes in the joints in which the anterior cruciate ligament was cut. These changes became increasingly severe for about a year. The osteophytes, which originated periarticularly, took part in remodeling of the condyles. The osteophytcs increased in size for about a year. There was persistent pain as long as marked instability remained. The knees became less unstable in time, apparently by means of an increase in the thickness of the joint capsule. Most of the clinical signs disappeared with decreasing instability. The conclusion was drawn that early stabilization is indicated in cases of rupture of the anterior cruciate ligament.

Primary surgical treatment of anterior cruciate ligament lesions.

Seventy patients who underwent primary repair of the anterior cruciate ligament are reviewed in follow-up. The surgical technique consisted of multiple loop- varying depth sutures in both cruciate stumps in 61 patients. Nine patients had additional fascial augmen tation done primarily. Follow-up was from 12 to 90 months, the average being 29 months. All patients were scored on a 50-point normal knee score sheet. Average score at follow-up was 42.7. No patient was bothered by giving way, which is defined as an unpre dictable instability. No patient has required subse quent meniscal surgery. Ninety-three percent of the patients were active in sports. Anterior drawer sign at 90° showed increased excursion compared to the unaffected leg in all patients. However, Lachmans test showed a firm end point to excursion in all knees tested, and, in addition, 52% were rated as normal compared to the unaffected knee. We conclude that primary repairs of mid-substance tears are technically possible and recommended in an athlete.

The Biceps Femoris Tendon and Its Functional Significance

Thirty-one knees were dissected to determine the detailed anatomy of the biceps tendon. Findings regarding the expansions of the superficial, middle, and deep layers of the tendon, and the insertions, differed from previous descriptions. The possible functional contributions of the biceps tendon to lateral knee stability were determined. The most important is the support furnished by the direct tibial attachment of the superficial and deep layers as the knee progresses in flexion.

Quadriceps atrophy in the anterior cruciate insufficient knee

Atrophy of the quadriceps musculature is frequently associated with chronic knee instability. This atrophy may persist despite the patients ability to return to athletic competition. When open biopsies of the quadriceps muscle from unstable knees were compared with those from normal acutely injured knees, it was found that clinical evidence of atrophy correlated with a relative decrease in the size of Type II or fast twitch muscle fibers. This sup ports the subjective, clinical impression that the unsta ble knee is less effective in explosive push-off. The findings also indicate the necessity of including exercise specific for the training of Type II fast twitch fibers in any program designed to rehabilitate the injured knee.

Joint looseness: a function of the person and the joint

In order to evaluate whether joint-looseness is a function of a particular joint and/or a characteristic of the person (a trait), 124 male and female subjects varying in age from 6 to 18 were tested. Evidence was found that joint-looseness is a trait. The validity of the trait measure was enhanced by finding significant negative correlations with age and performance. Although females were significantly looser on some joint-looseness tests, they were not looser on the trait indicator.

Synovial Chondromatosis of the Thumb: A Case Report And Review Of The Literature

Synovial Chondromatosis of the Thumb: A CASE REPORT AND REVIEW OF THE LITERATURE MICHAEL LEWIS;JOHN MARSHALL;JOSEPH MIRRA; The Journal of Bone & Joint Surgery

Microvasculature of the Cruciate Ligaments

Primary surgical repair of the cruciate ligaments should not only restore structural integrity, but also reestablish its vascular supply and maintain viability.

Extra-Abdominal Desmoid of the Hand

A twenty-eight-year-old Negro woman was seen with a painful, tender mass over the proximal border of the hypothenar muscles in the right hand. Both the mass and the tenderness had been present for two years without any antecedent history of trauma or infection. Up until six weeks before admission, neither the size of the mass nor the tenderness had shown any change. At that time, however, the patient began to feel “pins and needles” in both the ring and little fingers, which would frequently waken her at night; but she did not notice any sensory changes. She also became aware of the fact that the mass had grown in size. Examination of the right hand revealed a firm, slightly tender mass about two centimeters in