Background:The focus of most anterior cruciate ligament reconstructions has been on replacing the anteromedial bundle and not the posterolateral bundle.Hypothesis:Anatomic two-bundle reconstruction restores knee kinematics more closely to normal than does single-bundle reconstruction.Study Design:Controlled laboratory study.Methods:Ten cadaveric knees were subjected to external loading conditions: 1) a 134-N anterior tibial load and 2) a combined rotatory load of 5-N·m internal tibial torque and 10-N·m valgus torque. Resulting knee kinematics and in situ force in the anterior cruciate ligament or replacement graft were determined by using a robotic/universal force-moment sensor testing system for 1) intact, 2) anterior cruciate ligament deficient, 3) single-bundle reconstructed, and 4) anatomically reconstructed knees.Results:Anterior tibial translation for the anatomic reconstruction was significantly closer to that of the intact knee than was the single-bundle reconstruction. The in situ force normalize...

Biomechanical Analysis of an Anatomic Anterior Cruciate Ligament Reconstruction

Background: The effectiveness of anterior cruciate ligament reconstruction for restoring normal knee kinematics is largely unknown, particularly during sports movements generating large, rapidly applied forces.Hypothesis: Under dynamic in vivo loading, significant differences in 3-dimensional kinematics exist between anterior cruciate ligament-reconstructed knees and the contralateral, uninjured knees.Study Design: Prospective, in vivo laboratory study.Methods: Kinematics of anterior cruciate ligament-reconstructed and contralateral (uninjured) knees were evaluated for 6 subjects during downhill running 4 to 12 months after anterior cruciate ligament reconstruction, using a 250 frame/s stereoradiographic system. Anatomical reference axes were determined from computed tomography scans. Kinematic differences between the uninjured and reconstructed limbs were evaluated with a repeated-measures analysis of variance.Results: Anterior tibial translation was similar for the reconstructed and uninjured limbs. How...

Abnormal Rotational Knee Motion During Running After Anterior Cruciate Ligament Reconstruction

A prospective randomized study was performed to determine the differences in results between three methods of anterior cruciate ligament reconstruction: autogenous bone-patellar tendon-bone graft (group 1), semitendinosus and gracilis tendon graft reconstruction combined with an extraarticular procedure (group 2), and semitendinosus and gracilis tendon graft reconstruction alone (group 3). Preoperatively, there were no significant differences between groups. At a mean of 35.4±11.6 months postoperatively, 102 patients returned for evaluation. International Knee Documentation Committee knee evaluation revealed no significant differences in symptoms, function, return to pre-injury activity, harvest site abnormalities, or limitation of motion between groups 1 and 3. Patients in group 2 had a higher incidence of patellofemoral crepitation and loss of motion than did patients in group 3. The mean manual maximum KT-1000 arthrometer side-to-side difference was 2.1±2.0 mm in group 1, which was statistically signif...

Anterior Cruciate Ligament Reconstruction A Prospective Randomized Study of Three Surgical Methods

Two-thirds of Achilles tendon injuries in competitive athletes are paratenonitis and one-fifth are insertional complaints (bursitis and insertion tendinitis). The remaining afflictions consist of pain syndromes of the myotendineal junction and tendinopathies. The majority of Achilles tendon injuries from sport occur in males, mainly because of their higher rates of participation in sport, but also with tendinopathies a gender difference is probably indicated. Athletes in running sports have a high incidence of Achilles tendon overuse injuries. About 75% of total and the majority of partial tendon ruptures are related to sports activities usually involving abrupt repetitive jumping and sprinting movements. Mechanical factors and a sedentary lifestyle play a role in the pathology of these injuries. Achilles tendon overuse injuries occur at a higher rate in older athletes than most other typical overuse injuries. Recreational athletes with a complete Achilles tendon rupture are about 15 years younger than those with other spontaneous tendon ruptures. Following surgery, about 70 to 90% of athletes have a successful comeback after Achilles tendon injury. Surgery is required in about 25% of athletes with Achilles tendon overuse injuries and the frequency of surgery increases with patient age and duration of symptoms as well as occurrence of tendinopathic changes. However, about 20% of injured athletes require a re-operation for Achilles tendon overuse injuries, and about 3 to 5% are compelled to abandon their sports career because of these injuries. Myotendineal junction pain should be treated conservatively. Partial Achilles tendon ruptures are primarily treated conservatively, although the best treatment method of chronic partial rupture seems to be surgery. Complete Achilles tendon ruptures of athletes are treated surgically, because this increases the likelihood of athletes reaching preinjury activity levels and minimises the risk of re-ruptures. Marked forefoot varus is found in athletes with Achilles tendon overuse injuries, reflecting the predisposing role of ankle joint overpronation. Athletes with the major stress in lower extremities have often a limited range of motion in the passive dorsiflexion of the ankle joint and total subtalar joint mobility, which seems to be a predisposing factor for these injuries. Various predisposing transient factors are found in about one-third of athletes with Achilles tendon overuse injuries; of these, traumatic factors (mostly minor injuries) predominate. The typical histological features of chronically inflamed paratendineal tissue of the Achilles tendon are profound proliferation of loose, immature connective tissue and marked obliterative and degenerative alterations in the blood vessels. These changes cause continuing leakage of plasma proteins, which may have an important role in the pathophysiology of these injuries. The chronically inflamed paratendineal tissues of the Achilles tendon do not seem to have enough capacity to form mature connective tissue.

Achilles Tendon Injuries in Athletes

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.

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

Currently used measures of knee stability and function for ACL reconstructed knees have not gained universal acceptance. Clinical test results often are given more value than the patient's subjective evaluation of the surgical outcome. This study was designed to identify specific knee stability and function variables that were most predictive of the patient's rating of knee function following one of two types of combined (intraarticular and extraarticular) ACL reconstruction procedures. Individual measures of knee stability and function were also evaluated for differences between contralateral operated and nonoperated limbs. Postoperative and healthy contralateral knees of 51 male and female patients aged 18 to 49 years (mean, 23.7 years) were evaluated on a battery of tests at an average of 48.0 months after surgery (range, 24 to 101 months). All subjects possessed a normal contralateral knee for comparative purposes. The results of this retrospective study indicated that the variables selected were not highly correlated with, nor could they effectively predict, the patients' perceptions of postoperative knee status as measured by the Knee Function Rating Form (KFR). Statistically significant differences (P less than 0.001) between operated and nonoperated knees were found for 9 of 11 variables analyzed. The data suggest that patients' perceptions of postoperative knee status were independent of the results of static and dynamic clinical tests commonly used to assess knee stability and function. Postoperative deficits of up to 30% between the surgically reconstructed and normal contralateral knees on specific measures of knee stability and function did not greatly influence the patients' perceptions of knee function. Development of new, more specific dynamic tests may be necessary before stronger relationships between clinical test results and patients' perceptions of knee status in the ACL reconstructed knee can be realized.

Long-term evaluation of knee stability and function following surgical reconstruction for anterior cruciate ligament insufficiency

A long-term retrospective study (minimum 5 years) was done looking at three groups of anterior cruciate defi cient knee patients using both subjective and objective anterior cruciate tests. Twenty-seven chronic anterior cruciate ligament deficient knees reconstructed with the middle third of the patellar tendon and 28 chronic anterior cruciate ligament deficient knees reconstructed with the semitendinosus tendon were included in this consecutive group of patients and were felt to be directly comparable. It was found that the chronic an terior cruciate ligament deficient group reconstructed with the semitendinosus tendon had 4 excellent, 10 good, 7 poor, and 7 failures with an objective score averaging 4.5 of a possible 12, while the comparable group reconstructed with the middle third of the patellar tendon had 16 excellent, 7 good, 3 poor, and only 1 failure with a score of 10 of a possible 12 (P < 0.0032). For completeness sake, 20 anterior cruciate deficient knees from this group of consecutive patient...

Retrospective direct comparison of three intraarticular anterior cruciate ligament reconstructions.

Heel pain in runners is very common. Retrocalcaneal bursitis may be disabling to the competitive runner. When conservative treatment fails, surgery (partial calcaneal ostectomy) may be indicated. Ten patients underwent partial calcaneal ostectomies at our clinic and returned to their desired level of activity within 6 months. When the surgeon adheres to the surgical principles outlined in this article, the results are uniformly good.

Donald C. Jones

Papers

Long-term evaluation of knee stability and function following surgical reconstruction for anterior cruciate ligament insufficiency

Retrospective direct comparison of three intraarticular anterior cruciate ligament reconstructions.

Partial calcaneal ostectomy for retrocalcaneal bursitis