William A. Grana

An Analysis of Autograft Fixation After Anterior Cruciate Ligament Reconstruction in a Rabbit Model

Fixation and incorporation of a tendon implanted within the bone pose theoretical as well as practical concerns for the surgeon who treats instability problems of the knee. Understanding the physiology involved in graft- bone incorporation is necessary for the appropriate re habilitation of patients who undergo anterior cruciate ligament surgery. The purpose of the study was to ex amine the histologic and biomechanical changes of a semitendinosus autograft reconstruction of the anterior cruciate ligament in a rabbit model at the graft-bone tunnel interface in the femur. The results indicate that by 3 weeks, failure of the bone-graft-bone or construction is through the intraarticular portion of the graft, not as a result of pullout from the bone tunnel. Graft fixation of the bone tunnel occurs by an intertwining of graft and connective tissue and anchoring of connective tis sue to bone by collagenous fibers and bone formation in the tunnels. The collagenous fibers have the appear ance of the Sharpeys fibers seen in an indirect tendon insertion.

Arthroscopic Bankart suture repair

The purpose of this paper was to report our experience with an arthroscopic technique of repair for the Bankart lesion following shoulder instability. Twenty-seven pa tients (average age, 21.7 years) were followed for an average of 36 months after arthroscopic suture stabili zation of anterior shoulder instability. Patients were excluded if instability was multidirectional or voluntary and if there was radiographic evidence of a significant loss of glenoid bone stock. Clinical evaluation using a functional grading system showed that 10 patients were rated as excellent, 5 good, and 12 poor. Fourteen patients returned to their previous level of activity. There were 12 patients rated as failed; all had recurrent instability of the shoulder. Success was associated with a period of immobilization of 3 weeks or longer and a history of acute injury, especially subluxation. Failures were associated with shorter immobilization periods after surgery and in patients who had recurrent dislo cations. The younger patient, who may not have com plied with the immobilization protocol, also seemed to be associated with failure. Contact sports seem to leave a patient at high risk for recurrence. We recommend caution in the use of arthroscopic procedures for the competitive athlete in whom a second surgery and rehabilitation might mean loss of more sports partici pation.

Isolated arthroscopic partial meniscectomy Functional radiographic evaluation at five years

Fifty patients who underwent isolated arthroscopic par tial meniscectomy with a minimum followup of 5 years were analyzed retrospectively. To analyze the factors associated with a satisfactory or an unsatisfactory clin ical result, we looked at the patients age, duration of symptoms, type of meniscal lesion, and articular carti lage abnormalities. The patients were graded with a functional knee score (Lysholm-Gillquist), and activity level before surgery and at followup was determined. The data also included radiographic evaluation of 29 of the 50 patients. Tibiofemoral alignment was measured, and osteoarthritic changes were graded and correlated with the type of meniscal abnormality and functional result. Eighty-two percent of our patients had satisfactory knee function, and the activity level was maintained. The factors associated with a satisfactory result after a partial meniscectomy included age less than 40 years, symptoms less than 12 months duration, type of tear, and chondromalacia less than grade II. Fairbanks changes were present in 50% of the patients, with significant grade III and IV changes identified in 30%. Although the radiographic changes did not necessarily correlate with the functional result, we felt that the changes were significant and indicative of abnormal stress transfer to articular cartilage and bone.

Evaluation of injuries in youth soccer

Soccer has rapidly gained in interest in the United States. A paucity of available data on soccer injuries led us to formulate this study to quantitate and categorize injuries acquired during a program of youth soccer (under age 19). A prospective study of 1,272 players showed an injury rate of 2.6 injuries per 100 participants. The injury rate for girls was twice as great as for boys. The under 10-age group was seldom injured (less than 1 injury per 100 participants), but the overall injury rate in the players of secondary school age was 7.7 injuries per 100 partic ipants. Most injuries were not serious. Soccer appears to be a safe activity for adolescents and children.

Natural History of a Hamstring Tendon Autograft Used for Anterior Cruciate Ligament Reconstruction in a Sheep Model

The purpose of this study was to describe the histologic structure of the intraarticular segment of a semitendinosus tendon autograft used for anterior cruciate ligament reconstruction over the first year after surgery. We performed an anterior cruciate ligament reconstruction in a single hindlimb of 11 sheep using a doubled semitendinosus tendon autograft secured to the femur with an endoscopic button and polyester tape and to the tibia with sutures tied around a screw. The histologic structure of the intraarticular segment of the graft at 4, 8, 12, 24, and 52 weeks after surgery was compared with that of the normal semitendinosus tendon and anterior cruciate ligament. The random collagen fiber orientation progressed to a longitudinal orientation from the peripheral to the central areas of the graft over the initial 12 weeks after surgery. A uniform sinusoidal crimp pattern similar to that seen in the normal anterior cruciate ligament was identified under polarized light in nearly one-half of each graft by 24 weeks. Further maturation was noted at 52 weeks. Graft necrosis was not evident at any time period. This study showed that semitendinosus tendon autografts transform into a histologic structure similar to that of the normal anterior cruciate ligament over the initial year after surgery, as has been described for patellar tendon grafts.

A Simple Distraction Technique for Ankle Arthroscopy

Arthroscopy of the ankle is now an established method for management of a wide variety of ankle disorders (1-4). Despite the relatively small size and intrinsic stability of the ankle joint, with adequate distraction and plantar flexion, a large portion of the joint can usually be visualized. Patient positioning and methods of distraction vary widely from surgeon to surgeon. Usually, an assistant is required to maintain constant distraction and positioning of the ankle. This may prevent the assistant from actually helping with the instrumentation and procedure and places him in a position that is awkward and detrimental to the surgeon. It is difficult to maintain constant positioning and distraction of the ankle by manual methods. Various distraction devices involving external fixators and transosseous pin fixation have been employed (2), but the iffcreased chance of complications with these invasive techniques is undesirable. We utilized a simple method of ankle distraction that frees the hands of the surgeon and assistant and presents no increased morbidity to the patient.

The effects of anabolic steroids on rat tendon. An ultrastructural, biomechanical, and biochemical analysis.

Forty-eight male rats were randomly separated into four groups: a control group, a group treated with anabolic steroids, a group treated with daily exercise, and a group treated with both steroids and exercise. At 6 weeks, biomechanical, ultrastructural, and biochemical testing was performed on the Achilles tendons of half of the rats in each group. The remaining rats continued in the experimental protocol, but steroid administration was discontinued. Similar testing was then performed on the remaining rats at 12 weeks. Testing showed ana bolic steroids produced a stiffer tendon that absorbs less energy and fails with less elongation; tendon strength was unaffected. Effects were entirely revers ible on discontinuation of the steroids. Light microscopic analysis revealed no changes in the appearance of the fibrils. No change in fibril diameter or shape was noted on electron microscopic analysis. Biochemical testing revealed no change in qualitative immunofluorescence staining with Type III collagen or fibronectin. Abuse of anabolic steroids is a widespread problem among com petitive athletes; consequently, complications after their use are seen with increasing frequency. Knowledge of the effects of these drugs on tendon and the muscu lotendinous unit may prove helpful in counseling ath letes who use anabolic steroids.

Evaluation and management of knee pain in the runner

Injury of the knee is one of the most common problems affecting the running athlete. The majority of symptoms result from overuse and are reversible with conservative care. Inciting factors include training errors, equipment change, and surface alterations. These must be sought after and aggressively corrected. In refractory cases the arthroscopic knee examination allows definition and correction of intra articular problems. Patience and persistence in managing these injuries allow most problems to be treated non operatively.