John R. McCarroll

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.

Posterior problems in the knee Posterior cruciate insufficiency and posterolateral rotatory insufficiency

During a recent three-year period, 39 patients under went surgical procedures for lesions of the posterior complex of the knee. The results in 28 followed for greater than six months (average followup, 16 months) are reported; eight are presently in the early rehabili tative phase and three have been lost to followup. In reconstruction for chronic laxity, a semitendino sus replacement of the posterior cruciate ligament with anterior advancement of the lateral arcuate com plex is recommended. Use of the medial gastroc nemius tendon is still advised in selected cases. Re construction for posterolateral rotatory laxity with an intact posterior cruciate is performed with anterior advancement of the popliteus tendon and the arcuate complex. Pes anserinus transfer, imbrication of the posterior oblique ligament, and biceps tenodesis may be performed as supplemental procedures.

Injuries in the Amateur Golfer.

In brief: To determine the types and frequency of injuries among amateurs, openended questionnaires were sent to 4,036 golfers; 1,144 responded (942 men and 202 women; average age, 52 years). The respondents played an average of two rounds per week; 708 (62%) had sustained one or more injuries. Among men, the most common injury site was the lower back; among women it was the elbow. Excessive practice and poor swing mechanics were the most common causes. Golf injuries perhaps could be prevented or reduced by proper technique, controlled practice routines, and physical conditioning.

Stress fractures of the medial malleolus

Six athletes, all engaged in running activities at the time of injury, presented with tenderness over the medial malleolus and ankle effusion. Three patients had a fracture line which could be seen on radiographs. These patients were treated by open reduction and internal fixation using two 4.0 cancellous screws. The other three patients had normal radiographs but bone scans showed increased uptake over the medial malleolus. These patients were treated with cast and immobiliza tion. We believe that each of these patients suffered a stress fracture of the medial malleolus. We suggest that the possibility of a stress fracture be considered in the differential diagnosis of patients who present with 1) chronic or subacute pain over the medial malleolus and ankle effusion, and 2) a history of running activity at the time of injury or running activities aggravating the pain. Bone scans appear to be more sensitive than radiographs in detecting a stress fracture of the medial malleolus. We propose that athletes with radiographic signs of a medial malleolar fracture who desire early return to full participation should be treated by open reduction and internal fixation. For these patients, early motion can be initiated. Other athletes whose fracture cannot be detected on radiographs but whose malleo lus shows increased uptake in the area on bone scans can be treated nonsurgically with immobilization and then progressive increase in activity. All of our patients returned to full activity between 6 and 8 weeks after treatment was initiated.

Peroneal tendon subluxation in athletes : Fibular groove deepening and retinacular reconstruction

Background: The purpose of this study was to evaluate the results of operative treatment of recurrent peroneal tendon dislocations followed by accelerated rehabilitation incorporating early range of motion and intermittent immobilization. Methods: Four female and nine male athletes with an average age of 24 years had objective clinical evidence of peroneal tendon dislocation (14 ankles). Operative treatment involved removing a bone flap from the distal posterior fibula, deepening the posterior fibular groove, and reattaching the bone flap within the deepened groove. The superior peroneal retinaculum also was reconstructed. Postoperatively, a removable boot was worn for approximately 4 weeks, when it was replaced with a stirrup brace. Results: At an average followup of 35 months, no recurrent subluxation or dislocation of the peroneal tendons had occurred. All patients were able to return to sports by 3 months after surgery. Nine of the 14 ankles regained normal range of motion, and the remaining five were within 5 degrees of the opposite side. Four patients were completely pain free, and nine patients had mild occasional pain that did not limit their activities. Eight patients returned to preinjury sports participation, and five patients elected to participate in sports at a level lower than they had before surgery for reasons not related to their ankle injury. Conclusions: This procedure was reliable for preventing recurrent peroneal tendon instability. Range of motion was nearly normal, immobilization time was minimal, and all patients returned to daily activities and sports within 3 months of surgery.

Effect on Knee Stability if Full Hyperextension is Restored Immediately After Autogenous Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction

We sought to determine if knee stability after autog enous bone-patellar tendon-bone anterior cruciate liga ment reconstruction was adversely affected by obtain ing immediate full hyperextension. We selected patients based on degree of knee hyperextension. Group 1 (46 men and 51 women), with an average of 10° (range, 8° to 15°) hyperextension, was compared with the ran domly selected control Group 2 (70 men and 27 women), which had an average of 2° (range, 0° to 5°) hyperextension. The operative knee in both groups, which underwent similar reconstruction of the injured knee, achieved full passive extension equal to the non- involved knee during the immediate postoperative course. The average KT-1000 arthrometer manual maximum side-to-side differences were 2.4 mm for Group 1 and 2.1 mm for Group 2 (P = 0.13). Seventy- nine patients in Group 1 had KT-1000 arthrometer dif ferences of ≤3 mm as compared with 85 patients in Group 2. Fourteen patients in Group 1 had KT-1000 arthrometer differences of 4 or 5 mm as compared with eight patients in Group 2. Four patients in each group had KT-1000 arthrometer differences >5 mm. Evidence suggests that restoring and maintaining immediate full knee hyperextension after this type of reconstruction does not adversely affect the ultimate stability of the knee.