Infrapatellar contracture syndrome. An unrecognized cause of knee stiffness with patella entrapment and patella infera

A new surgical procedure for the treatment of patella infera

A new method for the treatment of patella infera is presented. This technique is based on the previously described procedure for treatment of old ruptures of the patellar ligament. The main advantage of this technique is the achievement of a normal patellar position without the adverse effects on the knee extensor mechanism found with other techniques, such as patellectomy or elevation of the tibial tubercle. The main surgical steps of this technique are outlined and the preliminary results reported.

Anterior Cruciate Ligament Insufficiency: Principles of Treatment

Anterior cruciate ligament (ACL) injuries often result in functional disability, particularly in jumping, cutting, and deceleration activities. Some patients can accommodate to this functional loss, while others require surgical reconstruction of the ligament to provide stability and to protect the meniscus from further injury. Nonoperative management involves an intensive rehabilitation program, patient counseling about high-risk activities, and measures to prevent recurrent injuries. Surgical reconstruction of the ACL involves the technical factors of graft selection, positioning, fixation, and tensioning and the avoidance of stress risers. A supervised and intensive rehabilitation program is necessary to achieve optimal results.

Arthroscopic lysis in knee arthrofibrosis

Arthrofibrosis continues to be a difficult complication in articular surgery on the knee. We present our experience in 21 cases of arthroscopic lysis as an alternative to mobilization under anesthesia. The technique begins with the liberation of the adhesions of the suprapatellar pouch, continues down both gutters, and ends with a cleaning of the notch where necessary. When a restriction of patellar mobility persists, we make a retinacular release. The results obtained are very satisfactory, with an average increase in the arc of mobility of 68 degrees. The average gain in mobility at 6 months is significantly greater than that achieved in the immediate postoperative period. Longer follow-up showed no improvement in range of motion after 6 months.

Locked bucket-handle meniscal tears in knees with chronic anterior cruciate ligament deficiency

Because we noticed patients had difficulty regaining full range of motion after surgery for a locked bucket-handle meniscal tear with simultaneous reconstruction for a chronic anterior cruciate ligament tear, we adopted a two-stage procedure for this group of patients. We evaluated the results of a two-stage procedure in the knees of 16 athletes (Group 1) and compared their outcome with the outcome of 16 matched athletes who had been treated with simultaneous repair or removal of the displaced bucket-handle meniscal tear and autogenous patellar tendon anterior cruciate ligament reconstruction (Group 2). Four patients in Group 2 required a second procedure or casting to regain full extension. No patient in Group 1 required a second procedure. One meniscal retear was detected in Group 1. The two-stage procedure also appears to have a number of theoretical advantages: 1) more aggressive use of repair rather than removal of a displaced torn meniscus, 2) prevention of problems in regaining range of motion, 3) allows a second look to judge the success of meniscal repair, and 4) allows time for the patient to prepare for anterior cruciate ligament reconstruction physically, mentally, academically, and socially.

Comparison of perioperative morbidity of anterior cruciate ligament autografts versus allografts

We present a retrospective report of 50 patients (31 autograft and 19 allograft patients) who underwent arthroscopic bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstructions between August 1988 and September 1990. All patients were followed for a minimum of 2 years. The purpose of this study was to analyze each group regarding hospital stay, swelling, thigh atrophy, laxity, strength, endurance, range of motion, patellofemoral symptoms, and complications. We found no statistical difference between autograft or allograft ACL reconstructions with regard to perioperative morbidity.

Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months

The results of the first sixty-nine consecutive patients who had had seventy arthroscopically assisted reconstructions of the anterior cruciate ligament with use of an autogenous patellar-ligament graft at our institution were reviewed retrospectively. Sixty-seven patients (sixty-eight knees) were available for evaluation after a minimum of two years. All patients had been managed with early, postoperative range-of-motion exercises and a standardized program of physical therapy. At the time of the most recent follow-up evaluation, the median ligament score, according to the rating system of The Hospital for Special Surgery, was 93 of a possible 100 points. Of the sixty-eight knees, forty-four were rated excellent; fifteen, good; six, fair; and three, poor. Eighteen knees had symptoms related to the patellofemoral joint and sixty-three had a full range of motion; two knees had had manipulation for loss of flexion. At the follow-up evaluation, KT-1000 arthrometric measurements were obtained for both knees of fifty-six patients. Eighty-four per cent of the patients had an increase of three millimeters or less in anterior-posterior displacement of the tibia on the reconstructed side compared with the normal side, while 93 per cent had an increase of four millimeters or less. Postoperatively, there was no apparent association between changes in the Insall-Salvati patellar ligament-to-patella ratios and pain in the patellofemoral joint. The results of the arthroscopically assisted reconstructions combined with use of early range-of-motion exercises were comparable with those reported after open reconstruction and immobilization of the limb in a plaster cast. The frequency of pain in the patellofemoral joint and the need for manipulation because of loss of motion were decreased after the arthroscopically assisted procedures.

Quadriceps strength and functional capacity after anterior cruciate ligament reconstruction. Patellar tendon autograft versus allograft

Harvesting the central third of the patellar tendon for autograft anterior cruciate ligament reconstruction is thought to compromise quadriceps strength and functional capacity. We compared objective measurements of quadriceps strength and functional capacity in athletes after patellar tendon autograft or allograft anterior cruciate ligament reconstruction. We looked at 33 active male patients (mean age, 24.3 years) who had anterior cruciate ligament reconstructions 12 to 24 months earlier using patellar tendon autograft (N = 15) or allograft (N = 18) techniques. All patients underwent an intensive rehabilitation program. Quadriceps strength and power were assessed by measuring peak torque at 60 and 240 deg/sec, torque acceleration energy at 240 deg/sec, and the quadriceps index using a Cybex II isokinetic testing device. Functional capacity was evaluated based on the results of 3 specially designed functional performance tests and the hop test. Results revealed no significant difference between autograft and allograft groups with respect to any of these parameters. These findings indicate that harvesting the central third of the patellar tendon for autograft anterior cruciate ligament reconstruction does not diminish quadriceps strength or functional capacity in highly active patients who have intensive rehabilitation. Thus, the recommendation to avoid patellar tendon autograft anterior cruciate ligament reconstruction to preserve quadriceps strength and functional capacity may be unnecessary.

Effects of Continuous Passive Motion on Anterior Laxity Following ACL Reconstruction with Autogenous Patellar Tendon Grafts

Continuous passive motion (CPM) is a modality used in the treatment, management, and rehabilitation of a variety of orthopedic problems. Recently, CPM devices have been therapeutically employed immediately after autogenous patellar tendon reconstruction of the anterior cruciate ligament (ACL). Whereas the concept of early motion is indicated, there is a concomitant concern that the implementation of immediate passive motion may stretch or rupture the graft. Twenty subjects scheduled to undergo ACL reconstruction were randomized into two groups (10 CPM and 10 non-CPM). All subjects performed the same postoperative rehabilitation with the exception of the CPM. Objective anterior tibial translation measurements were recorded with a KT-1000 for a 30-1b (133.5-N) Lachman test at 1 year postreconstruction. The results of this study indicated that the implementation of immediate continuous passive motion did not have any deleterious effects on the stability of the ligament reconstruction.

Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction

We evaluated the remodeling process of autogenous patellar tendon graft for anterior cruciate ligament (ACL) reconstruction by means of light microscopic (LM) and electron microscopic (EM) examinations from the biopsy specimens obtained at the time of second-look arthroscopy. Twenty-one patients were examined at various times postoperatively (from 6 weeks to 15 months, mean 9.5 months), and the results were correlated with the morphology of normal patellar tendon and normal ACL. Our study showed that the graft was revascularized in the early postoperative period, fibroblastic remodeling took place, and the graft obtained gross similarity to the original ACL on their arthroscopic and LM appearances at approximately 1 year postoperatively. However, EM study showed that at both approximately 6 months and 1 year postoperatively the grafts consisted equally of active fibroblasts with a higher cytoplasm-to-nucleus ratio compared with normal ACL. Collagen fibrils of these grafts were of uniformly small diameter compared with normal patellar tendon and ACL. Our results with ultrastructural study suggest that the grafts were still immature even at 1 year postoperatively.

Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction

Arthrofibrosis resulting in loss of knee extension compromises the results of anterior cruciate ligament reconstructions. We designed a study to clarify the symptoms and to evaluate the results of arthroscopic treatment of this complication. Forty-two patients in a series of 959 consecutive open anterior cruciate ligament reconstructions required further surgical treatment for relief of symptoms related to loss of extension. Arthroscopic examination of these knees confirmed the presence of an extension block caused by hypertrophy of the ligament or abundant tissue formation in the anterior tibiofemoral joint an average of 9 months after anterior cruciate ligament reconstruction. The offending tissues were excised arthroscopically and the patients were followed with an aggressive rehabilitation program. Thirty-five patients were available for followup an average of 28 months after excision of the tissue. Subjective functional status and symptomatic status were scored numerically using identical, patient-completed questionnaires before and after the excision procedure. Range of motion, Cybex, and KT-1000 arthrometer results were also recorded. The results were statistically compared with results from a control group demographically matched and selected at random from the 959 patients. Before excision of the offending tissue, the knee scores of the study group differed significantly from those of the control group. However, after the excision procedure, the knee scores of the 2 groups were nearly identical. Marked improvements in function and symptoms (most notably, activity-related anterior knee pain, crepitus at terminal extension, and knee stiffness) were noted in all patients in the study group after removal of the extension block and resumption of an accelerated rehabilitation program.(ABSTRACT TRUNCATED AT 250 WORDS)

Simultaneous high tibial osteotomy and ACL reconstruction for combined genu varum and symptomatic ACL tear

This article reviews the subjective, objective, functional, and radiographic results of five patients with symptomatic anterior cruciate instability, genu varum, and varus rotational instability treated by sequential high tibial osteotomy and anterior cruciate ligament reconstruction at one operative procedure. The average patient age was 27 years (range: 21 to 35), and the average follow up was 2.5 years (range: 2 to 3). All patients had symptomatic instability with anterior tibia subluxation, which was documented by KT-1000 testing. All patients also had a varus alignment clinically and radiographically with medial compartment pain. Postoperatively, the medial compartment pain was improved, and instability episodes were eliminated. Side to side differences (KT-1000--manual maximum) were reduced to 3.1 mm. There were no complications. The instability episodes were eliminated, and functional levels were improved in all patients. We concluded that, for this select group of patients, simultaneous extremity realignment and ligament stabilization will effectively manage both conditions without compromising the results of either procedure.

Patellar tendon length change after anterior cruciate ligament reconstruction using the midthird patellar tendon

The purpose of this study was to determine if use of the midthird patellar tendon autograft contributes to or causes patellar tendon shortening or patella baja in anterior cruciate ligament reconstruction. Thirty-six patients undergoing arthroscopically assisted midthird patellar tendon autograft anterior cruciate ligament reconstruction were studied prospectively. Intraoperative patellar tendon length changes were measured. Half of the patients had the tendon defect closed and half had it left open (closing peritenon only). Radiographic tendon length changes and patella baja were assessed using Insall-Salvati and Blackburne-Peel ratios measured on 45 degrees lateral knee radiographs using an adjustable polypropylene jig. Bilateral films were obtained preoperatively and at 2 weeks, 3 months, and 6 months postoperatively. No patients demonstrated evidence of patellar tendon shortening greater than the 5.5% measurement error. Tendon defect closure resulted in negligible tendon shortening intraoperatively, averaging 2.28% (1.11 mm). Of the 18 patients whose defects were closed, 5 showed no shortening. The remaining 13 patients had measurable tendon shortening less than 4% (2 mm). No patients developed patella baja.

Anterior cruciate ligament reconstruction. The effect of tibial tunnel placement on range of motion

In 111 patients who had anterior cruciate ligament reconstructions, postoperative radiographic measurements of anterior to posterior and medial to lateral location of the tibial tunnels were correlated with the final range of motion achieved. In the 25 patients with extension deficits of 10 degrees or more, placement of the tibial tunnel was more anterior (average, anterior 23% of the tibia) than in the remaining 86 patients with extension deficits of < 10 degrees (average, anterior 29% of tibia). This difference was statistically significant with P < 0.001. Logistic regression analysis revealed that the more anterior the placement of the tibial tunnel, the greater the loss of both flexion (P = 0.01) and extension (P = 0.002). In the 21 patients with full extension but flexion < 130 degrees, placement of the tibial tunnel tended to be more medial (average, medial 40% of the tibia) than in the 65 patients without flexion deficit (average, medial 45% of the tibia). We conclude that placement of the tibial tunnel in the "eccentric," anteromedial position may contribute to the development of flexion and extension deficits after anterior cruciate ligament reconstruction.

Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee

We performed an anatomical dissection of the medial soft-tissue retinacular fibers that restrain lateral patellar displacement and found that the medial patellofemoral ligament inserts not only on the patella but also on the undersurface of the distal aspect of the quadriceps mechanism. The deep capsular layer contained substantial retinacular fibers that were associated with the medial patellomeniscal ligament. Functional studies of the relative contributions of the medial soft-tissue restraints in the prevention of lateral patellar displacement were also performed. Twenty-five fresh-frozen specimens of the knee, obtained after amputations (nineteen specimens) or from cadavera (six specimens) were tested biomechanically on a universal testing instrument. We ranked the soft-tissue restraints, in order of their relative contributions to the restraining force, on the basis of the percentage of force provided by the retinacular and ligamentous tissue that resisted the lateral displacement of the patella. The medial patellofemoral ligament, although varying in size and importance, was found to be the major medial soft-tissue restraint that prevented lateral displacement of the distal knee-extensor mechanism, contributing an average of 53 per cent of the total force. The patellomeniscal ligament and associated retinacular fibers in the deep capsular layer of the knee, which were previously thought to be functionally unimportant in the stabilization of the patella, contributed an average of 22 per cent of the total force. The previously described retinacular fibers (the patellotibial band) were functionally unimportant in the prevention of lateral displacement.

Reconstruction of old anterior cruciate ligament tears with a Dacron prosthesis. A prospective study

Seventy patients with chronic anterior instability underwent anterior cruciate ligament reconstruction with a Dacron prosthesis pretensioned to 60 N. Of these patients, 49% (34%) had combined medial instability, 32% (22) had failed previous anterior cruciate ligament surgery, and 37% (26) had previous meniscectomy. At reconstruction, 12 patients had their medial instability treated; 22 did not. Follow-up intervals were 3, 6, and 12 months and then each year to 5 years. The 5-year followup included 69 patients; the other 1 had the ligament removed because of a synovial fistula at 8 months. Results were 23% prosthesis ruptures, 3% poor, 17% fair, 16% good, and 39% excellent. The 2-year results showed the same distribution, but a lower rupture rate, which was affected by placement of the tibial tunnel within the anterior one-third of the tibia (9 times increase) and coexisting nonrepaired medial instability (5 times increase). Those patients with perfect placement of the ligament who also had good medial stability and no previous ligament surgery had no rupture at 5 years. The stability that was gained at surgery was gradually lost (-11.2% per year). At 5 years, the uninjured knee also had lost 41% of the preoperative stability; the mean laxity difference was within +/- 2 mm. The mean improvement in subjective knee function (Lysholm score 74.5 to 91.9) was maintained during the followup. The mean preoperative activity level improved significantly, but did not reach the preinjury level. These results show that the Dacron prosthesis will not give acceptable results in salvage cases where other instabilities are left untreated.

Deterioration of patellofemoral articular surfaces after anterior cruciate ligament reconstruction

One hundred eighty-seven patients who had undergone intraarticular anterior cruciate ligament reconstruction using either a fresh-frozen allogeneic tendon or central third autogenous pateller tendon 3 to 89 months previously were arthroscopically evaluated. The focus was on secondary changes of the patellofemoral joint at the time of second-look arthroscopy. Overall, 93 knees deteriorated, 74 knees remained unchanged, and 14 improved. The deteriorative changes were predominantly located around the central ridge of the patellae, although all but two knees remained free from anterior knee pain. Statistical multivariate analysis showed surgical approach by conventional medial parapatellar incision and use of the central one-third of the autogenous patellar tendon graft as possible risk factors for the deterioration, although chi-square analysis failed to demonstrate statistical significance for the latter.

An in vitro analysis of patellofemoral contact areas and pressures following procurement of the central one-third patellar tendon

Patients have complained of pain after the use of the central one-third patellar tendon for reconstruction of the anterior cruciate ligament-deficient knee. This study investigated the effect on patellofemoral contact areas and pressures of harvesting the central 10 mm of the patellar tendon in five cadaveric knees. Isometric quadriceps forces were applied to produce approximately 30% of reported maximum voluntary extension moments at the knee. Using Fuji pressure-sensitive film, measurements were recorded for three states: the normal knee, after the graft removal, and after the tendon was closed. Contact areas and pressures were measured at 20 degrees, 30 degrees, 60 degrees, and 80 degrees of knee flexion in each specimen. Tests of the reproducibility of our methods were performed. Average patellofemoral contact areas for three states ranged from 1.6 cm2 at 20 degrees of knee flexion to 3.0 cm2 at 60 degrees. The average patellofemoral contact pressures ranged from 1.9 MPa at 20 degrees of knee flexion to 3.0 MPa at 30 degrees. At each flexion angle there were no significant differences in average patellar contact area or pressure for the three states (P < 0.05). These results suggest that neither harvesting the central 10 mm of the patellar tendon, nor closing the gap, significantly alters patellofemoral contact area or pressure.

Arthroscopically assisted anterior cruciate ligament reconstruction with the pes anserine tendons. Comparison of results in acute and chronic ligament deficiency

Fifty anterior cruciate ligament-deficient knees treated consecutively with arthroscopically assisted reconstruction using a pes anserine tendon autograft were retrospectively studied. The mean followup was 36.7 months (range, 26 to 58). All patients had reconstruction with a double-stranded graft. The mean injury to surgery interval was 9.6 days in 22 patients (acute group) and 22.5 months in 28 patients (chronic group). Objective outcome, which was noted to be more optimal in the acute group, was better than subjective outcome in either group. Examination revealed 95% of patients treated acutely and 82% of those treated later to have 1+ or less Lachman test result (P < 0.036) and 96% of the acute group and 82% of the chronic group to have an absent pivot shift (P < 0.036). Eighty-eight percent of acutely treated patients had a KT-1000 result of < or = 3 mm, as compared to 61% of chronically treated patients (P < 0.001). Loss of range of motion was significantly greater in the acute group (P < 0.018). Using a strict overall rating system, patients reconstructed earlier were noted to have a better outcome compared to those after delayed reconstruction (P < 0.021). Cumulative meniscal injury appears to be the most significant contributing factor.

Arthroscopic treatment of flexion deformity after ACL reconstruction

After anterior cruciate ligament (ACL) reconstruction, one frequent complication is the restriction of the range of motion and loss of extension. In addition to the presence of adhesions in the suprapatellar pouch, it is possible to detect two different pathological findings in the intercondylar notch: a misplacement of graft causing an intercondylar impingement, or the presence of hypertrophic tissue originating from the graft that blocks the last degrees of extension, causing an "anterior impingement." We reviewed 18 consecutive cases treated by arthroscopic release. All patients had knee range-of-motion restriction after an ACL procedure. The follow-up at 1 and at 6 months shows that good results have been obtained in cases of anterior impingement, whereas in cases of intercondylar impingement a restricted range of motion, especially of flexion, did remain. In all cases, after arthroscopic treatment the postoperative extension was between 5 and 10 degrees, but this deficit regressed after 6 months in 12 patients, whereas a dropout case was necessary in the remaining 6 patients.

Loss of motion after anterior cruciate ligament reconstruction

We did a retrospective review and follow-up examination to investigate the incidence, risk factors, and outcome of patients who developed loss of motion after arthroscopic anterior cruciate ligament reconstruction. Two hundred forty-four patients with a minimum followup of 1 year were reviewed. Loss of motion (defined as a loss of extension of more than 10 degrees or flexion of less than 125 degrees) was identified in 27 patients for an overall incidence of 11.1%. Factors associated with loss of motion included acute reconstruction (less than 1 month from initial injury), male sex, and concomitant medial collateral ligament repair or posterior oblique ligament reefing or both. Twenty-one patients required surgery to regain their motion; three patients required a second procedure. Twenty-one of 27 patients with loss of motion underwent a detailed followup and were compared with 24 randomly chosen controls who had a normal range of motion after anterior cruciate ligament reconstruction. At followup, patients who experienced loss of motion had a significant decrease in noninvolved to involved knee extension and flexion compared to the control patients. There was no difference between our patients and the controls regarding patellofemoral problems, anterior knee laxity, and functional strength. Sixty-seven percent of patients with loss of motion had a good or excellent result in comparison to 80% of the controls.

Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction

We evaluated extensor mechanism function in 10 patients after they had arthroscopically assisted ACL reconstruction using the central third of the patellar tendon. The patients were randomly selected 12 to 24 months after reconstruction. All had rehabilitation where range of motion was initiated within the 1st postoperative week. All patients stated that they were satisfied and considered their knee to be stable. The KT-1000 maximum measurements (30 to 40 pounds) averaged an increase of 1.7 mm when compared with the opposite knee. Subjective complaints, such as anterior knee pain, grating, and weakness, were common and only 3 of 10 patients returned to all of their preinjury sports. Persistent radiographic abnormalities were common. Physical examination and functional testing also revealed persistent dysfunction of the extensor mechanism in patients with radiographic abnormalities. Isokinetic testing at 60 deg/sec showed an average quadriceps deficit of 18% compared to the normal extremity. Axial computed tomography scans revealed significant decrease in quadriceps cross-sectional area. Magnetic resonance imaging and computed tomography confirmed persistent defects at the harvest site; there was significant anterior knee scar formation in these patients. Despite achieving ligamentous stability, patients still experienced permanent weakness, functional deficits, patellar chondrosis, and pain after ACL reconstruction using the central one-third of the patellar tendon.

The clinical use of continuous passive motion in physical therapy

Continuous passive motion (CPM) has become a common rehabilitation modality for athletes with orthopaedic problems. The purpose of this review is to examine the current literature on the historical perspective of motion, physiological effects of immobilization on bone and soft tissue, clinical CPM studies, animal CPM studies, descriptions of the CPM device, and clinical uses of CPM in physical therapy. The authors conclude that there is little clinical research evaluating the efficacy of protocols for CPM usage in numerous applications for orthopaedic problems. They recommend that further studies regarding the efficacy of CPM treatment be initiated. J Orthop Sports Phys Ther 1992;15(3):132-140.

Long-term study of anterior cruciate ligament reconstruction for chronic instability using the central one-third patellar tendon and a lateral extraarticular tenodesis

Forty-four patients with symptomatic chronic anterior cruciate ligament instabilities that had been reconstructed with the central one-third patellar tendon and a lateral extraarticular iliotibial band tenodesis were studied at an average followup of 7 years (range, 4 to 10). The cases with associated medial, lateral, or posterior laxity were not included, nor were the cases with more than minimal preoperative degenerative changes. The average age at surgery was 21 years (range, 16 to 33). A postoperative cast was used for 4 weeks. Satisfactory objective stability, which was defined as a KT-1000 side-to-side difference of up to 5 mm at the manual maximum test, was obtained in 37 (84%) of the patients. In 25 patients (57%), stability was restored within normal limits (less than or equal to 3 mm). No deterioration of the KT-1000 stability was noted at two follow-up visits performed by the same examiner (at an average of 4 and 7 years). A return to high-risk sports was possible in 27 (62%) of the patients. Difficulties in regaining a complete range of motion were recorded in 5 (11%) of the patients. A flexion contracture of 5 degrees to 7 degrees was also found in 5 patients. Significant patellofemoral symptoms were present in 4 patients (9%). A 5% to 11% shortening of the patella tendon was observed in 14 (32%) of the knees, but did not correlate with patellar problems. Moderate radiographic changes were noted in eight patients (18%) at followup and correlated with meniscectomy and pain. Overall satisfactory results were obtained in this initial experience in 29 (66%) of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Update on accelerated rehabilitation after anterior cruciate ligament reconstruction

Rehabilitation of the anterior cruciate ligament (ACL) reconstructed knee continues to be a topic of intense interest among surgeons and therapists. Since 1987, over 880 patients who have undergone ACL reconstruction using the central one-third of the bone patellar tendon bone graft have followed our accelerated rehabilitation protocol. Follow-up of the patients reveals early return to athletic activity and maintenance of long-term stability. Our 1987 accelerated rehabilitation program continues to be modified, with less constraints placed on the postoperative patient in our present rehabilitation protocol. These recent changes are once again prompted by noncompliant patients who, with close follow-up evaluation, continue to yield excellent results. Our present accelerated rehabilitation protocol is divided into four phases. The initial phase encompasses the preoperative period. The second phase involves the initial 2 weeks post ACL reconstruction. The third phase dates from 2-5 weeks postoperation, and the final phase (greater than 5 weeks) involves a safe return to athletic play. Our goal with the accelerated rehabilitation protocol remains to decrease postoperative complications without jeopardizing the long term stability of the ACL reconstructed knee. J Orthop Sports Phys Ther 1992;15(6):303-308.

Current concepts in the treatment of anterior cruciate ligament disruption

Treatment of anterior cruciate ligament injuries has changed considerably in recent years. The purpose of this paper is to discuss the past and present treatment for anterior cruciate ligament (ACL) disruptions in athletic individuals. In addition, this paper will discuss current trends in rehabilitation, such as immediate motion, weight bearing, and close kinetic chain exercises, and provide the scientific rationale for these rehabilitation principles. The treatment of individuals who have suffered an ACL disruption has changed dramatically over the years. The treatment of ACL ruptures has made a full circle. The first reconstructive procedure described used a patellar tendon graft. Then primary ACL repairs were advocated. With the limited success of that procedure, the nonoperative treatment was popularized, with reconstruction performed only after the conservative program failed. With this treatment plan, clinicians noted early degenerative joint changes and an increase in meniscus tears in the ACL deficient knee. Thus, reconstructive surgery using a patellar tendon graft was again advocated. Today, the current trend in the treatment of ACL tears is an arthroscopically assisted procedure to reconstruct the ACL using a bone-tendon-bone graft, such as a patellar tendon. The surgery employs accurate graft placement, tensioning, and fixation, which allows the therapist the opportunity to utilize immediate motion and weight bearing, in addition to strengthening exercises. This paper attempts to explain the rehabilitation process following ACL reconstruction using current scientific and clinical research. The program is based on the anatomy, biomechanics, and healing process of the knee, joint, and ACL. The clinical implications of this paper are numerous. First, we believe the information will assist clinicians in developing their own programs. Second, the data will assist the reader in understanding the sequential healing process. Finally, this paper documents that immediate aggressive rehabilitation is not deleterious to the ACL graft, and early therapy improves the functional outcome. J Orthop Sports Phys Ther 1992;15(6):279-293.

A new technique of harvesting patellar tendon autografts for anterior cruciate ligament reconstruction

A new surgical technique to uniformly harvest the middle one-third of the patellar tendon for anterior cruciate ligament reconstruction is described. The technique uses a guide system of 8 templates of varying widths to guide the saw cuts and "collared," depth-controlled saw blades and drill bits to produce a standard cutting and drilling depth. This kind of template system lessens the risks of graft harvesting complications such as patella fracture, bone graft fragmentation, suture pull out, and judgment errors pertaining to graft depth, length, or width. The Patellar Tendon Graft Guide was used to obtain a patellar tendon graft in 65 patients. Fifty-nine arthroscopic-assisted and 6 open anterior cruciate ligament reconstructions were performed. Of the 65 grafts harvested, 63 consistently demonstrated bone portions 20 mm in length, 7 mm in depth, and a width corresponding to the template chosen (usually 10 mm). Two grafts supposed to be 10 mm in width turned out to be 9 mm in width because of a technique related problem.

The role of arthroscopic debridement after anterior cruciate ligament reconstruction

This retrospective study included 55 patients who had prior anterior cruciate ligament (ACL) reconstruction; 30 made up the experimental group who had arthroscopic debridement of impinging soft tissue and 25, who did not have a second-look arthroscopy, were used as controls. Impinging tissue was not necessarily the primary reason for arthroscopy in the experimental group. Only nine patients (30%) were debrided solely because of anterior symptoms suggestive of soft tissue impingement; 16 (53%) underwent arthroscopy primarily to assess meniscal repairs; five (17%) were done in conjunction with hardware removal. Both groups were evaluated for pain, crepitation, and anterior laxity at three specific times. Debridement reduced crepitation from 35% to 8% in patients with moderate crepitus, and from 50% to 38% in patients with mild symptoms. The percentage of patients without crepitation increased from 15% to 54% by final follow-up. Predebridement, 14% of patients had moderate pain, and 53% mild pain. By final follow-up, 38% had mild pain and 62% were pain free. Patients benefitted from debridement regardless of method of ACL reconstruction. Arthroscopic debridement did not increase anterior knee translation. Both groups gained extension and had improved activity levels with the passage of time from ACL surgery.

Anterior cruciate ligament reconstruction without drill holes

Anterior cruciate ligament (ACL) reconstruction in adolescents with open physes remains a difficult problem for the orthopedic surgeon, especially in view of growing teenage participation in contact sports. Traditionally, treatment of ACL tears in adolescents has been conservative; the patient is advised to delay surgery up to several years for fear of damaging physes by drilling holes across them. Unfortunately, this waiting period may inflict irreparable knee damage. This paper suggests an ACL reconstruction technique that utilizes no drill holes, thus causing no harm to physes or other essential knee structures. A graft consisting of semitendinosus and gracilis (SG) tendons is passed under the anterior horn of the medial meniscus through the knee joint, then brought out through the posterior capsule and secured to the lateral femoral metaphysis. The graft is augmented with an iliotibial band tenodesis. Designed primarily but not exclusively for teenagers with open physes, the procedure has produced encouraging results thus far in a small series.

Limitation of motion following anterior cruciate ligament reconstruction. A case-control study

Limitation of motion following ACL reconstruction is a well-recognized and disturbing complication. The purposes of this study were to identify and characterize those patients who developed this complication from a series of 527 ACL reconstructions, determine etiologic factors, and make recommendations regarding prevention and management. The case group included 37 patients who required a manipulation under anesthesia because of failure to gain a satisfactory range of motion after an ACL reconstruction. Unsatisfactory motion was defined as a flexion deformity of 10 degrees or more and/or limitation of flexion to less than 120 degrees by 3 months following ACL reconstruction. The control group of patients were selected randomly from the overall series and all had a satisfactory range of motion. The cases and controls were then compared by analyzing these variables: age, sex, knee, time from injury to reconstruction, type of tissue used, meniscal abnormalities or surgery, repair of the medical collateral ligament, and postoperative immobilization and rehabilitation. The cases were followed up to assess the range of motion compared to the opposite knee at an average of 26 months postmanipulation. Thirty-seven patients (7%) underwent a manipulation under anesthesia, 9 of these (24.3%) also had an arthroscopic arthrolysis. Reconstructions done less than 2 weeks postinjury showed a statistically significant higher rate of knee stiffness. The same trend was also present for those reconstructed 2 to 6 weeks postinjury. All other variables failed to show a significant statistical difference. At followup, the average loss of extension was 4 degrees and loss of flexion 5 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons

Eighty consecutive patients with chronic laxity due to a torn ACL underwent arthroscopically assisted reconstruction with either autogenous patellar tendon or doubled semitendinosus and gracilis tendons. Reconstructions were performed on a one-to-one alternating basis. Preoperatively, no significant differences between the two groups were noted with respect to age, sex, level of activity, and degree of laxity (chi square analysis). A standard rehabilitation regimen was used for all patients after surgery including immediate passive knee extension, early stationary cycling, protected weightbearing for 6 weeks, avoidance of resisted terminal knee extension until 6 months, and return to activity at 10 to 12 months postoperatively. Seventy-two patients were evaluated at a minimum of 24 months postoperatively (range, 24 to 40 months). No significant differences were noted between groups with respect to subjective complaints, functional level, or objective laxity evaluation, including KT-1000 measurements. Seventeen of 72 patients (24%) experienced anterior knee pain after ACL reconstruction. Overall, 46 of 72 patients (64%) returned to their preinjury level of activity. Mean KT-1000 scores were 1.6 +/- 1.4 mm for the patellar tendon group and 1.9 +/- 1.3 mm for the semitendinosus and gracilis tendons group. This study did find a statistically significant weakness in peak hamstrings torque at 60 deg/sec when reconstruction was performed with double-looped semitendinosus and gracilis tendons.

Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation

Arthrofibrosis is a potential complication of acute ACL reconstruction. Arthrofibrosis prevents the patient from regaining full range of motion, particularly the terminal 5 degrees of full extension, postoperatively. We did a retrospective study of 169 acute ACL reconstructions in a population of young athletes (average age, 22 years). We sought to determine the optimal time to perform acute ACL reconstruction with respect to arthrofibrosis and the effects of an accelerated versus conventional rehabilitation program. The short-term results were evaluated by range of motion measurements and 13 week Cybex scores. Patients whose ligaments were reconstructed within the 1st week after injury (Group I) had a statistically significant (P less than 0.05) increased incidence of arthrofibrosis (limited extension, scar tissue) over patients who had ACL reconstruction delayed 21 days or more (Group III). At 13 weeks after the reconstruction procedure, Group III patients scored an average of 70% (compared to 51% for Group I, P less than 0.05) on the Cybex evaluation. They also showed a trend toward more flexion of the knee as well as near full extension. Patients who had an ACL reconstruction between 8 and 21 days after injury (Group II) had a similar incidence of arthrofibrosis as Group I when they followed a conventional rehabilitation program postoperatively. However, only a small number of cases (approximately 4%) of Group II patients who followed an accelerated postoperative rehabilitation program had any arthrofibrosis--an observation we also made in the Group III patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic management of arthrofibrosis of the knee, including infrapatellar contraction syndrome

Infrapatellar contracture syndrome (IPCS) has been defined as a subcategory of arthrofibrosis of the knee following surgery. We present a systematic, wholly arthroscopic surgical approach to this difficult problem. The technique includes assessment of patellar mobility, resection of intraarticular adhesions, release of possible extracapsular bands, resection of fibrotic fat pad, and lateral and medial releases if indicated. We obtained satisfactory results with increased total range of motion of 45 degrees in 12 patients with IPCS. This is comparable to the results in routine arthrofibrosis of the knee, where the mean increase in total range of motion was 50 degrees for the seven patients in this series.

Results of knee manipulations after anterior cruciate ligament reconstructions

We analyzed the results of knee manipulations in 42 knees that had persistent flexion or extension deficits after intraarticular ACL reconstructions. All manipulations were done under a spinal or general anesthetic and, in 10 cases, arthroscopic debridement of adhesions also was performed. The average time from reconstruction to manipulation was 7 months (range, 3 to 14 months) and the average followup was 26 months (range, 6 to 56 months). At manipulation, average flexion was increased from 95 degrees to 136 degrees and average extension from 11 degrees to 3 degrees. In no case was motion gained at the expense of joint stability and, at final followup, average flexion and extension were 127 degrees and 4 degrees, respectively. The final range of motion achieved was not affected by the time to manipulation, severity of premanipulation flexion deficit, or concomitant arthroscopic debridement of adhesions. However, knees with premanipulation extension deficits of greater than or equal to 15 degrees achieved significantly less final extension than knees with lesser premanipulation deficits. Overall, manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstructions.

Innervation of the human knee joint by substance-P fibers

Anterior knee pain is a frequent musculoskeletal complaint affecting all ages, both sexes, athletes, and nonathletes alike. Numerous theories have been proposed regarding its etiology including patellar malalignment, quadriceps insufficiency, subluxation, quadriceps muscle tightness, and chondral defects. However, the mechanism by which these factors produce this pain is not clear. Knowledge of the distribution of nociceptive nerve fibers around the knee would seem to provide insight in treating these painful conditions. Eleven human patellae--eight specimens from patients with degenerative patellofemoral disease and three normals--were evaluated. Immunohistochemical techniques using monoclonal antibody to substance-P were employed to identify nociceptive fibers. Substance-P is a nociceptive neurotransmitter found in afferent nerve fibers. Substance-P fibers were isolated in the retinaculum, fat pad, periosteum, and subchondral plate of patellae affected with degenerative disease. This study demonstrates that selective tracting of nociceptive pain fibers is possible around the knee both in soft tissue and, in some circumstances, bone. The subchondral plate of normal patellae did not demonstrate erosion channels, but those with chondral defects from degenerative disease did. Nociceptive fibers found in these defects may explain the origin of symptoms in some patients. The distribution of substance-P nerve fibers in the soft tissues around the knee suggests that denervation may be the mechanism by which surgical procedures for anterior knee pain produce favorable results.

Cyclops syndrome: loss of extension following intra-articular anterior cruciate ligament reconstruction

Arthrofibrosis is one of the recognized complications following traditional anterior cruciate ligament (ACL) reconstruction. With the advent of arthroscopic assisted ACL reconstructions, the extent of potential arthrofibrosis appeared to be less. However, 13 patients after intra-articular ACL reconstruction using a patella tendon autograft developed a similar symptom complex. In addition to postoperative loss of full extension, there was an audible and palpable clunk with terminal extension. These patients had similar arthroscopic findings of a nodule that formed anterolateral to the tibial tunnel placement of the graft. The arthroscopic appearance of the soft tissue mass with its surface vessels was reminiscent of a "cyclops." After arthroscopy with debridement and manipulation of the knee, extension was improved in all cases. The average range of motion immediately after the procedure was 6.0-130 degrees, compared with 16-103 degrees preoperatively. The range of motion at last follow-up averaged 3.8 degrees of extension and 138 degrees of flexion. All patients had greater than 130 degrees of flexion. There were no complications attributed to the manipulation and arthroscopic lysis of adhesions, and no patient experienced loss of graft integrity or knee stability. The "cyclops" nodule was examined grossly and microscopically and demonstrated peripheral fibrous tissue with a central region of granulation tissue in all specimens. In addition, two specimens were noted to include bony fragments and three specimens contained cartilaginous tissue.

Lateral release of the patella: indications and contraindications

Charts were reviewed on patients at the Salt Lake Knee and Sports Medicine Clinic who had had a lateral release of the patella. Patients were divided into two groups. Group I contained patients who were entirely satisfied with the procedure, and Group II included patients who were complete failures (defined as a need for further surgical procedures). In Group I, 74 patients were included in the subjective followup. Forty of the 74 patients also had an objective followup, including roentgenograms and a physical examination. Group II contained 43 patients. Results indicated that the most predictable criterion for success was a negative passive patellar tilt. Secondary criteria included a medial and lateral patellar glide of two quadrants or less and a normal tubercle-sulcus angle at 90 degrees of flexion. Patients had less predictable results after an isolated lateral release with a positive (greater than 5 degrees) passive patellar tilt and a three quadrant or greater medial and lateral patellar glide or an abnormal tubercle-sulcus angle at 90 degrees of flexion.

Accelerated rehabilitation after anterior cruciate ligament reconstruction

To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient's tolerance. Of 800 patients who underwent intraarticular ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100 degree range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from frequent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Biomechanical and histological observations of the dog patellar tendon after removal of its central one-third

The use of a central one-third patellar tendon as an autograft for surgical reconstruction of a damaged cruciate ligament is common. Few complications of its use have been reported. However, recent clinical studies indicate that decreased quadriceps strength, decreased range of motion, decreased thigh circumference, and patellofemoral problems can be associated with this procedure. Some of these complications may result from alterations in the biomechanical properties of the remaining patellar tendon. The objective of this study was to examine biomechanically and histologically the fate of the remaining patellar tendon after removal of its central one-third. Three groups of dogs were used for this study. On one knee the central third of the patellar tendon was removed, while the contralateral side was used as a control. One group was immediately euthanized, while the other two groups were euthanized at 3 and 6 months. Control and operated patella-patellar tendon-tibia preparations were harvested and stretched to failure at 100% strain per second. The 3 and 6 month groups had a 10% decrease in length of the operated patellar tendon versus the contralateral control. There was a very significant increase in cross-sectional area of the patellar tendon at 3 months, and a further increase at 6 months. The failure load was 70% of the controls at 3 months and 60% of the controls at 6 months. The stiffness and modulus of the operated tendon within the physiologic range were dramatically reduced to 70% and 33% of controls at 6 months, respectively. These overall results were observed with the central one-third defect closed or left open in surgery.(ABSTRACT TRUNCATED AT 250 WORDS)