The Course of Knee-Ligament Injuries

Combined Anterior Cruciate Ligament Reconstruction and High Tibial Osteotomy in Anterior Cruciate Ligament-Deficient Varus Knees

Background

The presence of varus deformity in anterior cruciate ligament (ACL)-deficient knees can be a source of persistent knee pain owing to medial compartment overload. This deformity may threaten the outcome of ACL reconstruction because of increased tension on the graft.

Methods

In the period between June 2006 to January 2013, 12 patients with ACL deficiency and genu varus were treated by anatomical single bundle ACL reconstruction and open medial wedge high tibial osteotomy. The selected patients had manifestations of ACL deficiency in association with medial joint line pain with or without lateral thrust.

Results

Prospective evaluation using the International Knee Documentation Committee (IKDC) score was performed. The mean follow-up period was 56 months (range, 26–74 months). This technique achieved knee stability and realignment to normal values. The IKDC score has significantly improved from 37 (pre-operation) to 78 (post-operation) ( p<0.05).

Conclusion

The combined procedure of ACL reconstruction and high tibial osteotomy restored knee stability and reduced pain over the medial compartment. Although the combined procedure has a longer period of rehabilitation than an isolated ACL reconstruction, the elimination of lateral thrust and preservation of articular cartilage of the medial compartment are of paramount importance to the future of these knees.

Anterior Cruciate Ligament Reconstruction with Bone Patellar Tendon Bone Graft through a Mini Arthrotomy

Instability after rupture of anterior cruciate ligament (ACL) may lead to recurrent episodes of giving way, an increased risk of meniscal injury and premature degenerative changes. A total of 25 cases with ACL injuries were evaluated after reconstruction with bone patellar tendon bone graft through a mini-arthrotomy. All patients were male. Maximum number of patients were between 25-30 years of age (40%). The most common modality of injury was contact sports (44%). Most common complaint was instability of knee (100%). Average Lysholm score increased from pre-operative of 47 (27-75) to post-operative of 87 (68-95). Two patients (8%) had retropatellar pain. Moderate to severe graft site tenderness was present in 4 (21%). After an average follow up of one year three months, the results were comparable with the results of arthroscopic reconstruction.

The clinical diagnosis and results of conservative treatment of knee distortion injury

Distortion of the knee joint is a considerable trauma even when the knee is primarily stable. Of 50 patients, 30% displayed symptoms or signs 2 months after the injury and 36% on subsequent examination an average of 5.6 years later. In a repeat clinical examination one anterior cruciate ligament rupture was not confirmed at the primary stage (2%). For assessment of stability and extent of injury, the repeat clinical examination proved reliable. Ruptures of the meniscus were noted in 18% of the patients in connection with the primary injury. Of those who underwent a meniscus operation, 27% had further operations and, four patients of 50 had another operation as a result of a new trauma. Thus, a total of 25% of the patients required surgery. The material is biased as I sought to exclude ligament ruptures in the first instance. No patient was permanently incapacitated from work. A large portion of the later symptoms were connected with the patellofemoral joint or with the postoperative condition. Bandaging did not affect the resulting recovery rate. Regular exercise of the thigh muscles prevented the onset of quadriceps atrophy, but there was a clear deterioration in the condition of the muscles in the early stages.

Long-term prognosis of isolated partial medial collateral ligament ruptures. A ten-year clinical and radiographic evaluation of a prospectively observed group of patients

We prospectively observed 38 patients with nonoperatively treated isolated partial ruptures of the knee medial collateral ligament at 3 months, 4 years, and 10 years after the initial trauma using clinical and radiographic examinations. The initial diagnoses were based on clinical and arthroscopic examinations. Three months after injury, 28 patients (74%) had regained nearly normal knee function and muscle strength, and 75% of these patients could perform at their preinjury activity level (competitive team sports). Five patients (13%) had increased valgus laxity (grade 1) in the injured knee. After 4 years, the patients had a median Lysholm score of 100 (range, 64 to 100). Thirty-three patients (87%) had normal knee function during strenuous activities. Repeat injuries to the medial collateral ligament occurred in two patients (5%), and another two patients sustained cruciate ligament injuries during the follow-up period. After 10 years, the Lysholm score (median, 95; range, 73 to 100) was lower compared with the 4-year score (P < 0.03), but the patients still performed on a similarly high activity level. Five patients (13%) had distinct signs of beginning osteoarthritis (Fairbank's signs) on radiographs, but none had joint space reduction.

Soccer after anterior cruciate ligament injury--an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players

All players in Swedish soccer teams are required to have insurance in the same company. From the archives of the insurance company, all 3,735 injuries reported in 1986 in 188,152 Swedish soccer players were reviewed. Of these, 937 were knee injuries. All players were asked by mail to fill in a questionnaire and 83 percent replied. The patient records from the different hospitals were requested. The anterior cruciate injuries represented one third of the reported knee injuries. The relative risk of sustaining an anterior cruciate ligament injury was increased in female players, in elite players, and in players in the forward position. The odds ratios were 1.6 (1.3-2.1), 3.3 (1.7-6.1) and 1.8 (1.4-2.5), respectively. The injuries occurred at a younger age in females than in males. 50 percent of the injured players were treated with anterior cruciate ligament surgery, predominantly as a reconstructive procedure, with use of a patellar tendon transplant. 30 (20) percent of the players with anterior cruciate ligament injury were active in soccer after 3 (7) years, compared to 80 (50) percent of an injured control population of soccer players. None of the elite players was active at the same level after 7 years. A comparison of anterior cruciate ligament-injured players, whether treated by surgical reconstruction or not, revealed no difference with regard to the proportion of players still playing soccer after 7 years.

Function of the quadriceps and hamstrings muscles in knees with chronic partial deficiency of the anterior cruciate ligament. Isometric and isokinetic evaluation

We assessed the isokinetic and isometric strength and power profile of the knees of 37 patients who had a previous grade II sprain (partial tear) of the anterior cruciate ligament. Of the 37 knees, 11 had an isolated partial anterior cruciate ligament rupture and 26 had a partial anterior cruciate ligament rupture combined with a partial medial collateral ligament rupture. The Cybex II isokinetic dynamometer was used in the measurements. Eight years after the injury, the mean strength deficit of the injured knees was minimal when compared with the uninjured side. In the hamstrings of both groups, the relative strength deficit increased significantly with a higher speed of isokinetic movement (P less than 0.05). Compared with the strength parameters (peak torques), the other functional parameters (total work, average power, and peak angular impulse) of the injured knees showed some, but not significantly greater, deficits (hamstrings, 7% to 10%; quadriceps, 4% to 10%). We found that the general thigh muscle function in knees with old grade II sprains of the anterior cruciate ligament appears adequate except in flexion where the strength deficits are significantly greater in higher speeds of isokinetic movement. Therefore, rehabilitation using high-speed flexion (and extension) exercises is recommended.

Treatment of acute isolated and combined ruptures of the anterior cruciate ligament. A long-term follow-up study

From a total of 293 patients who had an acute, complete anterior cruciate ligament rupture, we selected all patients (N = 55) who had an anterior cruciate ligament rupture without associated meniscal or ligamentous injuries, and all patients (N = 52) who had an anterior cruciate ligament rupture combined with a rupture, and subsequent primary repair, of the medial collateral ligament. Initially, all patients were assigned to one of two groups: conservative treatment of the anterior cruciate ligament or augmented anterior cruciate ligament repair with the iliotibial band. In the 52 patients who had an anterior cruciate ligament rupture combined with a medial collateral ligament rupture, the associated injuries to the medial collateral ligament and sometimes the posterior oblique ligament, meniscus, and arcuate ligament complex were treated in a similar fashion, without regard to the treatment of the anterior cruciate ligament. Ninety-nine patients (93%) were reexamined 35 to 74 months after the injury, and knee function was evaluated with subjective and objective criteria, including functional tests. Patients who had been treated with augmented anterior cruciate ligament repair had superior stability with better subjective results and returned to strenuous activities more frequently than patients who had undergone conservative treatment. In those patients who had augmented repair, the prognosis did not differ between those who had isolated lesions and those who had combined lesions. Conservative treatment of the anterior cruciate ligament with repair of the medial collateral ligament and other associated injuries, when present, resulted in an almost equally unfavorable outcome for patients with combined and isolated anterior cruciate ligament lesions.

The long-term course after treatment of acute anterior cruciate ligament ruptures. A 9 to 16 year followup

Acute total ACL (N = 60) and concomitant medial collateral ligament (N = 46) ruptures were repaired in 60 patients (mean age, 28 years) without augmentation. Menisci were removed in 23 knees. Fifty-three (88%) of the patients were reexamined 9 to 16 years later with special emphasis on manual and instrumented stability testing (Stryker, Genucom), knee function score (Lysholm), and activity level (Tegner). Standing roentgenograms (30 degrees of knee flexion) were taken in 69% of the patients. At followup, an ACL reconstruction had been performed in seven patients (12%) due to symptomatic instability. Sixty-four percent of the knees had a positive Lachman sign and 40% a positive pivot shift. Sagittal laxity difference was +3 mm or more in 57%. Knee function score was a mean of 86 +/- 12 points. The mean activity level had changed from recreational team sports (Level 7) to recreational individual sports (Level 5). Only patients with good knee stability were able to perform demanding sports and could continue at their desired activity level. Osteoarthritis of slight to moderate degree (Fairbank I/II) was found in 58% of the patients younger than 35 years of age at the time of trauma and in 87% of the older patients. Knees with intact menisci had less osteoarthritis than knees with removed menisci (P less than 0.05).

Anterior cruciate ligament repair with and without augmentation. A prospective 7-year study of 51 patients

A prospective comparison was made of the 7-year results of repair of the acutely ruptured anterior cruciate ligament with and without augmentation using the longitudinal patellar retinaculum. The knee stability was evaluated by clinical tests and by a specially constructed testing device. In the repair group, 6/22 had unchanged activity and intensity levels compared with 24/29 in the augmentation group. Lysholm's functional score was higher in the augmentation group. All the clinical tests and all the objective measurements except Lachman's test showed better stability in the augmentation group.

The importance of the meniscus in unstable knees. A comparative study

This study analyzes differences in knee function in ACL deficient knees with different meniscus status. Eighty patients, 12 women and 68 men, were matched in four groups according to sex, age, knee injuries, and follow-up time. Group I had two intact menisci; Group II, one meniscus successfully repaired; Group III, one meniscus removed; and Group IV, both menisci removed. The ACL was repaired acutely or reconstructed later in most cases and other significant ligament injuries were treated. All patients were reexamined clinically 6 to 8 years after injury. Knee function was recorded using the Lysholm knee function score. Activity level before injury and at followup was rated with the Tegner scale. Stability was tested and weightbearing roentgenograms were taken. There was a higher frequency of ACL reconstructions in Groups I and II, but instability was the same in all groups. No difference was found in Lysholm score (range, 86 to 92). The activity level was higher in Group IV at followup. A lower frequency of motion impairment was found in Group III, (20% versus 50%). Subjective evaluation was similar and positive in all groups. Group I had six meniscus ruptures during the follow-up period. In Group II three of the repaired menisci were removed, as were two of the contralateral menisci in Group III. Roentgenograms, available in 55 of 80 cases, showed osteoarthritis in 65%. There were no differences in the frequency of osteoarthritis among the first three groups, but Group IV had a higher incidence of osteoarthritic changes. Osteoarthritis did not result in lower knee function, poorer subjective evaluation, or increased impairment of motion.(ABSTRACT TRUNCATED AT 250 WORDS)

Augmentation with the longitudinal patellar retinaculum in the repair of an anterior cruciate ligament rupture

Most authors advocate repair of the acutely ruptured ACL by augmentation or some form of primary reconstruction. Strong autogenous tissues like the patellar and semitendinosus tendons and the iliotibial band are often used when augmentation is the surgical choice. This paper describes a surgical procedure using a strip of the longitudinal patellar retinaculum as an augmentation of the repaired ACL. The retinaculum adds stability and strength to the repaired ACL during the healing period. Moreover, the retinaculum may enhance the healing process of the ruptured ACL by revascularization. It may also increase the stimulation of synovial tissue proliferation over the repaired ACL. Twenty-eight patients have been clinically and objectively evaluated at a mean follow-up time of 78 months (range, 63 to 94 months). The patients' own evaluation of their knee function was excellent or good in 86% (24 patients). Eighty-two percent (23 patients) could return to their preinjury activities at the same intensity level as before injury, whereas at an intermediate followup at 18 months only 64% (18 patients) had done so. Anterior tibial displacement was objectively evaluated at both followups by means of the anterior drawer test, with 20 degrees to 30 degrees and 90 degrees of knee flexion, in a testing device. The operated knee usually showed a tendency to a slightly increased anterior displacement when compared with the uninjured knee. The repair of a ruptured ACL with an augmentation using the longitudinal patellar retinaculum has been shown to give good results after more than 5 years.

Temporal biomechanics of posterior cervical spine injuries in vivo in a rabbit model

There are numerous clinical and biomechanical criteria for determination of acute spinal instability. No data, however, exist on the biomechanical behavior of the injured, untreated spine during the healing period. Using a rabbit model, this study was designed to quantify changes in the mechanical properties of the injured spine over time. Sixteen rabbits were assigned to four injury groups: Injury 1 (C4-5 supra/intraspinous ligament transection), Injury 2 (C4 laminectomy), or Injury 3 (C4 laminectomy, plus bilateral facet capsular ligament transection). The fourth injury group was Sham (posterior exposure of C4-5, no spinal injury). Preinjury range of motion was determined by standardized flexion-extension radiographs on all animals. Postinjury flexion-extension radiographs were taken at 4, 8, and 12 weeks. At the end of 12 weeks, animals were killed. Mean range of motion at C4-5 for all injury groups decreased from preinjury values. The greatest decrease was for the most severe injury. At 8 weeks, the range of motion for this injury was less than half of the preinjury level and increased to 62% of the preinjury level at 12 weeks.

The durability of anterior cruciate ligament reconstruction with the patellar tendon

Thirty patients operated on because of insufficiency of the ACL were objectively evaluated twice, 2 and 5 years after operation. The results were mostly good with regard to knee stability and function. No change in the outcome could be seen over the years.

[The radiologic Lachman test--a simple and sure method for the detection of damage to the cruciate ligament]

The Lachman test, a method allowing to verify a lesion of the anterior cruciate ligament, is not yet generally known, but it is considered to be the only test which provides clear evidence. A radiological check of this test performed by us with a special holding device proved its high qualitative and quantitative value. The possibility to diagnose also lesions of the posterior cruciate ligament could be demonstrated. A special template has been developed for a rapid reading of the test results. The test is particularly suited for the examination of fresh lesions of the knee joint without anesthesia, for the follow-up of surgical transposition of ligaments, and for the elaboration of medical expert opinions.

Clinical and radiological long-term results after primary knee ligament surgery

A total of 77 patients were reviewed 2 to 7 years (average 40 months) after primary operative treatment of an acute knee ligament injury. Fifty percent of the injuries occurred during sports events, the other causes were traffic in 29% of cases and accidents at work, home etc. in 21% of the cases. Cross-country skiing was the cause in half of the sports accidents. There were two annual peaks in the distribution of the injuries: January-March (40% of the cases) and August-October (29%). The total number of operations increased steeply during our observation period; 57% of the operations were performed from 1980 to 1981. The most common types of injury were a combination rupture of the anterior cruciate and the medial collateral ligaments (36% of the cases) and a medial collateral ligament rupture alone (31%). According to the follow-up study, excellent or good results were obtained in 59% of the cases and fair or poor in 41%. The pathological clinical and radiological changes after knee ligament injury accumulated markedly under some specific findings. Characteristic of the patients with excellent healing results was that they were younger, received isolated ligament injury and played a great amount of sport, and of the patients with fair or poor results that they were older, received combined ligament injury, suffered quadriceps muscle atrophy and had diminished sporting activity.

Prospective stress radiography in 38 old injuries of the ligaments of the knee joint

In a prospective clinical and stress radiographic study comprising 38 patients, the course of chronic ligament injuries in the knee joint was evaluated. All but five patients had isolated ligament injuries, 16 of which affected the anterior cruciate ligament. The operations were performed from 18 days to 20 years after the injury had occurred. In 13 patients primary suture could be carried out, 12 patients underwent exploratory arthrotomy, and the remainder had relevant ligament repair. After a follow-up period of 7 years the instability had been cured in all patients with medial laxity and in one of two patients with lateral laxity. Nineteen patients had a drawer sign preoperatively. The anterior drawer sign disappeared in practically all patients, while a posterior drawer sign was a constant sequel to injury affecting the posterior cruciate ligament. It was difficult to prevent the development of rotatory instability--which was present in six preoperatively and in 14 at follow-up--and the rotatory instabilities were predominantly marked (greater than 6 mm). Nevertheless, only a few patients had an annoying sensation of instability. By means of ligament reconstruction, it was possible to reduce the preoperative instability appreciably. Passive instability had completely subsided in 40 per cent (15/38). The subjective result was good, only 16 per cent (6/38) having troublesome loss of function.