K. Donald Shelbourne

The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia

This study presents eight patients with stress fracture of the anterolateral cortex of the midshaft of the tibia. All of the patients, ranging in age from 14 to 23 years, were competitive basketball players who experienced pain while running or jumping for an average of 4.4 months before the diagnosis was made. Eight patients were treated with rest and/or pulsing electromagnetic field therapy. Although one of the pa tients required bone grafting procedure, all eight of these patients showed complete healing and were able to return to full activity after an average of 8.7 months of treatment. They have remained asymptomatic for an average of 14.7 months. The overall time from initial symptoms to return to competition averaged 12.5 months in this group of athletes. The results presented in this paper suggest that rest and pulsing electromagnetic field therapy may result in healing in some patients with delayed union stress fractures of the anterolateral cortex of the midshaft of the tibia. Although this injury is associated with a pro longed healing period, seven of eight patients with adequate followup in our study were able to return to competition without complications following treatment. One patient was asymptomatic for 33 months before experiencing a reinjury. In conclusion, we feel that diagnosis of stress fracture should be a primary consideration in basketball players presenting with a prolonged history of pain on the anterolateral aspect of the midthird of the tibia. Once the diagnosis is made we recommend initial treatment consist of rest and external electrical stimulation for a minimum time of 3 to 6 months prior to considering surgical intervention.

What I have learned about the ACL : utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction

Anterior cruciate ligament surgery and rehabilitation have changed drastically during the past 30 years. The patellar tendon autograft fixed with buttons provides tight bone-to-bone placement of the graft and quick bony healing, which allows accelerated rehabilitation to obtain full range of motion and strength. Although surgical stability is easily reproducible, long-term patient satisfaction is difficult to guarantee. Full knee range of motion should be compared to that of the contralateral normal knee, including full hyperextension. We followed the progress of all patients to gauge the utility of our rehabilitation program. In order of importance, the lack of normal knee range of motion (within 2° extension and 5° of flexion compared with that of the normal knee), partial or total medial meniscectomy, partial or total lateral meniscectomy, and articular cartilage damage were related to lower subjective scores. Rehabilitation after ACL reconstruction must first strive to achieve full symmetrical knee range of motion before aggressive strengthening can begin. Our current perioperative rehabilitation starts at the time of injury and preoperatively includes aggressive swelling reduction, hyperextension exercises, gait training, and mental preparation. Goals after surgery are to control swelling while regaining full knee range of motion. After quadriceps strengthening goals are reached, patients can shift to sport-specific exercises. When using a graft from the contralateral knee, the conflicting goals of strengthening the donor site and achieving full knee range of motion are divided between the knees. Thus, normal range of motion and strength can be achieved more easily and more quickly than when using an ipsilateral graft. Regardless of the graft source, a systematic rehabilitation program that emphasizes the return to symmetrical knee motion, including hyperextension, is necessary to achieve the optimum result.

Results of Transphyseal Anterior Cruciate Ligament Reconstruction Using Patellar Tendon Autograft in Tanner Stage 3 or 4 Adolescents with Clearly Open Growth Plates

Background Drilling across the physes for intra-articular anterior cruciate ligament reconstruction is considered risky for skeletally immature patients. Hypothesis Skeletally immature patients with clearly open growth plates can safely undergo intra-articular anterior cruciate ligament reconstruction with patellar tendon autograft without suffering growth plate disturbance. Study Design Retrospective review of prospectively collected data. Methods Surgery involved drilling tunnels through the tibial and femoral physes, the bone plugs were placed proximal to the physes, and button fixation was placed on the cortex. Of 272 skeletally immature patients, 16 had clearly open growth plates. Tanner stage of physical development was evaluated. Follow-up evaluation included objective and subjective data. Results At the time of surgery, 7 patients were Tanner stage 3 and 9 were Tanner stage 4. Clinical follow-up (mean, 3.4 years after surgery) showed that the mean growth after surgery was 11.7 ± 4.2 cm for boys and 6.6 ± 2.3 cm for girls. No patients had growth plate disturbances, gross leg deformities, or gross leg-length discrepancies. Subjective results (mean, 5.6 years after surgery) showed a mean total score of 97.6 ± 2.9 for the modified Noyes survey and 95.4 ± 6.9 for the International Knee Documentation Committee survey. All patients returned to competitive sports after surgery. Conclusion In 16 skeletally immature patients with clearly open growth plates who were Tanner stage 3 or 4, an intra-articular anterior cruciate ligament reconstruction was performed using a patellar tendon autograft with no gross growth disturbance; however, the surgical technique was meticulous for placing the bone plugs proximal to the physes, and the graft was not overtensioned.

Knee Dislocation With Lateral Side Injury Results of an En Masse Surgical Repair Technique of the Lateral Side

Background Knee dislocations with lateral side injury are rare and disabling if not treated. Hypothesis An en masse surgical technique to repair the lateral side will provide good stability, and the posterior cruciate ligament will heal when left in situ. Study Design Case series; Level of evidence, 4. Methods Twenty-three patients underwent an en masse lateral side repair after knee dislocation injury; all but 1 patient had anterior cruciate ligament reconstruction. Physical examination included the International Knee Documentation Committee score, isokinetic strength testing, KT-2000 arthrometer testing, radiography (including varus stress), and magnetic resonance imaging scan. Patients were evaluated subjectively with several surveys. Results Mean objective evaluation occurred for 17 patients at 4.6 years postoperatively, and 21 subjective evaluations occurred for 21 patients at 5.6 years postoperatively. The objective overall grade was normal for 10 patients and nearly normal for 7 patients. Lateral laxity was graded as normal in 15 patients and 1+ in 2 patients. The posterior drawer was normal in all but 3 patients, who had 1+ posterior laxity. The postoperative varus stress radiography demonstrated a mean increase of 1.1 ± 1.7 mm (range, —1.2-4.7) between knees. Magnetic resonance scans showed that the lateral side was thickened but intact in all patients. The posterior cruciate ligament was viewed as healed or intact in all patients but was sometimes seen as elongated or buckled. The mean subjective total scores were 91.3 points for the IKDC survey, 93.0 for the modified Noyes survey, and 8.0 for an activity score, but scores were higher for patients who underwent surgery within 4 weeks from the injury. Conclusions The en masse surgical technique to repair the lateral side combined with an anterior cruciate ligament reconstruction after knee dislocation provides excellent long-term stability. The repaired lateral side and untreated posterior cruciate ligament heal with continuity. Patients can return to high levels of activity.

Digital Radiographic Evaluation of Medial Joint Space Narrowing After Partial Meniscectomy of Bucket-Handle Medial Meniscus Tears in Anterior Cruciate Ligament–Intact Knees

Background Few studies exist that evaluate the effect of partial medial meniscectomy in knees with intact anterior cruciate ligaments. Hypothesis Partial meniscectomy of bucket-handle medial meniscus tears will cause joint space narrowing. Study Design Case series; Level of evidence, 4. Methods Between 1982 and 2001, 135 patients met the study criteria of a partial medial meniscectomy, intact ligaments, no surgery to the contralateral knee, and no chondromalacia greater than grade II. Seventy-nine patients living within 150 miles of the clinic were asked to return for physical examination. Joint space narrowing was measured from the middle of the femoral condyle to the middle of the tibial plateau using digitally magnified weightbearing 45° flexed posteroanterior and full-extension anteroposterior radiographs. Measurements were performed twice with the observer blinded to the previous measurements. Subjective follow-up was obtained prospectively on an annual basis with International Knee Documentation Committee and modified Noyes knee questionnaires. Results Forty-nine patients were examined at a mean of 11.8 years postoperatively. Mean medial joint space narrowing was 1.2 ± 0.5 mm on 45° flexed posteroanterior radiograph and 0.2 ± 0.9 mm on full-extension anteroposterior radiographs (P <. 001). Four patients had 2 mm or more of joint space narrowing. Subjective surveys obtained from 95 patients showed a mean subjective score of 89.9 points. Subjective scores did not decrease through time, and there was no correlation of joint space narrowing to lower subjective scores. Conclusion Partial medial meniscectomy in stable knees causes only mild joint space narrowing (mean, 1.2 mm) at a mean 12-year follow-up. Digitally magnified 45° flexed posteroanterior radiographs are more likely to demonstrate joint space narrowing than are full-extension anteroposterior radiographs.

Recalcitrant Patellar Tendinosis in Elite Athletes Surgical Treatment in Conjunction With Aggressive Postoperative Rehabilitation

Background Recalcitrant patellar tendinosis is difficult to treat, and results are varied. Hypothesis Surgical removal of necrotic tissue, surgical stimulation of remaining tendon, and aggressive and specific rehabilitation after patellar tendonectomy will allow athletes to return to sports. Study Design Case series; Level of evidence, 4. Methods From December 1996 to July 2002, 16 high-level athletes (4 professional, 2 Olympic, 9 collegiate, 1 preparatory), aged 16 to 25 years (mean, 19.7 years), with 22 symptomatic patellar tendons had failed nonoperative care of their patellar tendinosis symptoms and were unable to compete effectively in their sports. Magnetic resonance imaging showed confirmation of disease, with typical findings being necrosis in the posterior half of an abnormally thick patellar tendon, often in conjunction with partial tearing of the posterior half with a compensatory enlargement of the anterior half. Each patient then underwent tendonectomy of the necrotic portion in conjunction with stimulation of the remaining tendon by making multiple longitudinal cuts in the tendon. Patients participated in a postoperative rehabilitation protocol that included immediate range of motion, full flexion, and immediate high-repetition, low-resistance quadriceps muscle exercise. Results Subjective improvement was noted in all athletes. Return to the same sport at prior level of intensity was accomplished by 14 of 16 patients (87.5%) at a mean of 8.1 months (range, 3-12 months). Conclusion Overall, tendonectomy, surgical tendon stimulation, and aggressive postoperative rehabilitation were found to be a safe, effective way to return high-level athletes to their sports.

Intercondylar Notch Width Measurement Differences Between African American and White Men and Women With Intact Anterior Cruciate Ligament Knees

Background A recent report of professional womens basketball found that white European American female players were 6.5 times more likely to tear their anterior cruciate ligament than their nonwhite European American counterparts. African Americans accounted for 95% of the nonwhite European American group. Hypothesis African American men and women have wider intercondylar notches than white men and women. Study Design Cohort study (prevalence); Level of evidence, 2. Methods We obtained 45° flexed weightbearing posteroanterior radiographs on 517 patients who had knee problems other than an anterior cruciate ligament injury or arthrosis. One experienced observer measured the intercondylar notch width with no knowledge of race or gender, and the measurements were analyzed based on race and gender. Results The mean intercondylar notch width was 15.5 mm (SD = 2.8; range, 9-22) for African American women and 14.1 mm (SD = 2.5; range, 8-21) for white women; this difference was statistically significant (P = .009). Similarly, the mean intercondylar notch width was 18.0 mm (SD = 3.6; range, 10-27) for African American men and 16.9 mm (SD = 3.1; range, 9-27) for white men; these values were statistically significantly different (P = .003). Conclusion We conclude that African Americans have statistically significantly wider intercondylar notch widths on 45° flexed weightbearing posteroanterior radiographs than whites of the same gender. This relationship may offer an explanation for the difference between races with regard to risk of anterior cruciate ligament tears.

Preventing complications and minimizing morbidity after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction

In this article we offer our approach to potential problems of anterior cruciate ligament (ACL) reconstruction and provide suggestions on how to minimize, prevent, or avoid them. Graft harvest, particularly with the patellar tendon graft, has concerned surgeons. Range of motion, quadriceps strength (if the patellar tendon is harvested from the ipsilateral knee) anterior knee (patellofemoral) pain, patellar tendinitis, and patellar contracture/baja are included in the spectrum of potential problems associated with ACL reconstruction when the autogeneous patellar tendon graft is chosen as the ligament substitute. The suggestions we offer are (1) patient selection (with consideration of age, demands, and desires), (2) preoperative rehabilitation to attain range of motion and quadriceps strength, (3) delay of surgery until the patient is physically and mentally ready, (4) regular visits to monitor rehabilitation after the surgical procedure so that if problems are developing they will be detected early and corrected, and (5) long-term follow-up. When the goals of full knee extension, minimal swelling, leg control (active control by quadriceps), and 90° of flexion are attained by 2 weeks postoperatively, we know that the common postoperative complications after ACL reconstruction are essentially prevented. With our total program patients are able to return to a functional state and full activity without compromising long-term knee stability.

Joint Space Narrowing After Partial Medial Meniscectomy in the Anterior Cruciate Ligament-Intact Knee

Abstract Osteoarthritis of the knee is common after total medial meniscectomy. In anterior cruciate ligament‐intact knees, the reported outcomes of partial medial meniscectomy are variable. Radiographic assessment using a posteroanterior weight‐bearing view is a reliable tool for detecting minor medial joint space narrowing, which may be an early sign of osteoarthritis. Studies that assessed the effect of partial medial meniscectomy found a low percentage of patients with >50% joint narrowing at 10 to 15 years after surgery. Digital radiography, using a posteroanterior weightbearing view, is a highly sensitive method for observing minor joint space narrowing in the involved knee. A recent study showed that 88% of patients who underwent partial medial meniscectomy had joint space narrowing of <2 mm, and none had narrowing ≥2 mm, at a mean follow‐up of 12 years. Subjective results after partial medial meniscectomy are favorable, with 88% to 95% of patients reporting good to excellent results.

Graft selection, placement, fixation, and tensioning for anterior cruciate ligament reconstruction

The ideal graft for replacement of the anterior cruciate ligament (ACL) is one that retains at least an equivalent level of normal ACL strength, allows for secure fixation, enables unrestricted rehabilitation, and has no graft harvest morbidity. The choices for ACL grafts are both biologic and synthetic. Among the biologic choices are autografts and allografts. One must decide on the type of biologic tissue, whether patellar tendon, hamstring tendon, iliotibial band, or Achilles tendon. In addition to selecting a graft, the ACL substitute must be correctly placed with secure fixation and under appropriate tension. Correct placement of a graft requires an accurate understanding of the normal anatomic attachment sites of the ACL, both on the tibia and the femur. Ideal fixation will allow secure initial fixation and sufficient stability until the native bone and/or tissue heals. This fixation must also be strong enough to allow the recommended postoperative rehabilitation. The tension of the graft must be sufficient to achieve stability but not so excessive that it captures the joint. ACL reconstruction depends on the surgeon understanding these options and possessing the necessary skills to perform the procedure. The goals of the surgery—restoring normal knee stability and allowing expedient recovery—depend on the surgeon knowing the ACL graft choices, the proper placement within the joint, the ideal fixation, and the proper tension.