Five-year results of conservatively treated tears of the anterior cruciate ligament

Follow-up examinations of 35 patients with an arthroscopically confirmed isolated fresh tear of the anterior cruciate ligament were conducted after an average period of 5 years. After arthroscopy and immobilization of the knee in a plaster cast for 2 weeks, all 35 patients had been conservatively treated with neurophysiological physical therapy. Twenty-four of the tears were complete; the remaining 11 were partial. The results of the follow-up examination are based on subjective scores (O'Donoghue score, Lysholm score), an objective score (objective O'Donoghue score) and clinical examination. With the partial tears, good to satisfactory results were achieved, and surgery was needed less often. In these patients, it was largely possible to maintain the original level of athletic performance. Those patients with complete, isolated tears generally had satisfactory to poor results on the objective scores. There was a high rate of revision surgery, especially in the case of meniscus tears, and they were largely unable to regain their original level of athletic performance.     

Patterns of meniscal tears associated with anterior cruciate ligament lesions in athletes

In this study, 400 clinically anterior cruciate ligament (ACL) deficient knees were arthroscoped and studied prospectively in the period January 1986 to April 1992. An ACL tear was always confirmed, and 41 per cent of these patients did not have an associated meniscal tear. In 30.25 per cent the lateral meniscus was torn; in 21.25 per cent the ACL tear was associated with a medial meniscus tear, and in the remaining 7 per cent both menisci were torn. The most frequently associated meniscal injury was the bucket handle tear of the medial meniscus (9 per cent), followed by the posterior horn tear of the lateral meniscus, which showed the same frequency as the ragged (or degenerated) tear of the lateral meniscus (6 per cent). The horizontal tear of the posterior part of the lateral meniscus showed a prevalence of 4.3 per cent. This picture is probably dependent on a secondary referral nature of the centre surveyed, in which the average time between injury and arthroscopy was 23.3 months.     

Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers

We reviewed the records of 315 patients receiving an arthroscopically assisted stabilizing procedure for an acute anterior cruciate ligament injury incurred while alpine skiing to evaluate associated meniscal injuries. Meniscal injuries were classified by type, location, and treatment of the tear. Of the 317 knees operated on, all demonstrated an anterior cruciate ligament tear at arthroscopy. Ninety-eight percent of the injuries (310) were diagnosed within 3 days of injury, and 97% (307) were reconstructed within 28 days of injury. All tears occurred in the intrasubstance of the ligament; 32% were isolated injuries and 68% were combined with other injuries. In 159 patients with 170 meniscal tears 141 of the tears (83%) were lateral and 29 (17%) were medial. The injury triad of anterior cruciate ligament-medial collateral ligament-lateral meniscus was seen nine times as often as the anterior cruciate ligament-medial collateral ligament-medial mensicus combination.     

The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients

We describe the results of conservative treatment for complete midsubstance tears of the anterior cruciate ligament (ACL) in 18 skeletally immature patients, followed for a minimum of 36 months. Six patients had an ACL reconstruction during the follow-up period and were assessed immediately before their operation. The average time from initial injury to evaluation was 51 months. All patients had symptoms when reviewed. The modified Lysholm knee score showed one excellent result, one good, eight fair, and eight poor with a mean score of 64.3. Only one patient had returned to her preinjury level of athletics. Secondary meniscal tears were confirmed in six patients, and three more had the clinical signs of a tear at follow-up. Radiological evidence of degenerative changes was found in 11 of the 18 patients. We conclude that the results of non-operative treatment for ACL injuries in this age group are poor and not acceptable.     

Value of posterior cruciate ligament index in the diagnosis of anterior cruciate ligament injuries

Several EF-hand recoverin mutants were obtained and their abilities to bind to photoreceptor membranes and to inhibit rhodopsin kinase were determined. The mutants with the 'spoiled' 2nd, 3rd or (2nd+3rd) EF-hand structures did not act upon the kinase activity in the microM range of Ca2+ concentrations. Mutations of the 4th EF hand, which 'repaired' its Ca2+-binding activity, resulted in recoverin with three 'working' Ca2+-binding sites. The latter mutant inhibited rhodopsin kinase even more effectively than the wild-type recoverin, containing two working Ca2+-binding structures.     

The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion

OBJECTIVE: To assess the outcome of 31 patients treated in a day and semi-residential psychotherapy setting. METHOD: Patients had moderate to severe personality difficulties and were referred when current therapy was insufficient or because of the severity of their problems. Eighty-one percent had a Cluster C and 19% a Cluster B (Borderline) Personality Disorder diagnosis (DSM-III-R). Therapy was psychodynamically and feministin-formed and included a sociopolitical dimension. Rating scales used were the Symptom Checklist 90, Goal Attainment Scale, Global Assessment Scale and measures of health resource usage, which were completed pre-treatment, post-treatment and at 4-, 12- and 24-month follow-up. RESULTS: Mean duration of therapy was 4 months (68 therapy days). All clinical rating scales demonstrated marked improvements following treatment (p < 0.0001) which were sustained at 2-year follow-up. There were also improvements of health resource usage. CONCLUSIONS: The results document the clinical efficacy of psychotherapy in this setting, provide support for the philosophy of practice, and suggest that psychotherapy outcome can be evaluated at reasonable financial cost in many settings.     

Day case arthroscopic anterior cruciate ligament reconstruction

Renal abscess, a very uncommon renal disease in the pediatric patient is often complicated by irrelevant antibiotics treated urinary tract infection or due to other unknown reasons. In this paper, two cases of renal abscess were reported though they had been treated with antibiotics. The diagnosis had been made soon by sonography and computed tomography (CT). In addition, during the period of treatment, a series of sonography were performed to monitor resolution of abscess. In one, the lesion was resolved by antibiotics alone for 2 months duration, the other nearly disappeared 3 weeks later after antibiotics treatment combined with tube-drainage. These imaging techniques permit a prompt diagnosis as well as percutaneous drainage performed if antibiotic treatment dose not lead to resolution of the abscess.     

Prosthetic replacement of the anterior cruciate ligament in dogs

Prosthetic cruciate ligaments are now used clinically. Long-term results are not yet available and for that reason an attempt has been made to reproduce the clnical situation in dogs. Post-traumatic osteoarthritis was inevitably noted following simple excision of the anterior cruciate ligament in a control group of 10 animals. Different prosthetic materials were used and their breaking point was compared with that of normal anterior cruciate ligaments. The longest follow-up period was 6 months. Although some animals had no clinically demonstrable instability, at autopsy all prosthetic ligaments were noted to have failed. The degree of post-traumatic osteoarthritis was directly related to the duration of follow-up. The causes of failure of the prosthetic ligament do not appear to be related to the method of anchorage to bone but rather to the type of prosthetic material used. Although the tensile strength may occasionally have been sufficient, the materials did not have the required elastic characteristics to meet the physiologic demands of a normal cruciate ligament.     

Revision of failed prosthetic anterior cruciate ligament reconstruction

Revision of failed prosthetic anterior cruciate ligament reconstructions will continue to be necessary as previously placed prosthetic devices fail with time. These patients often present with recurrent instability, pain, swelling, or effusions. Graft rupture and the generation of particulate debris are common causes of these symptoms. To effectively treat these patients requires careful preoperative evaluation and planning. Operative treatment includes removing the prosthesis and metal fixation devices, evaluating femoral and tibial bone stock, and determining adequacy of previous tunnel position. Staging of the operation may be a necessity if significant bone loss or poor tunnel position on either the femoral or tibial side requires bone grafting. The use of an autogenous bone-patellar tendon-bone graft is suggested and has proven to be effective in restoring knee stability in these revision cases. The ultimate outcome following revision of failed prosthetic ligaments may be limited by associated intraarticular pathology often seen in this patient population.     

Mechanisms of anterior cruciate ligament neovascularization and ligamentization

Columbia-Rambouillet cross-bred sheep were used to study the revascularization and ligamentization process of anterior cruciate ligament (ACL) reconstruction over a 6-month period using basic histology, immunohistochemistry, and electron microscopy. The reconstruction technique studied was a quadruple-hamstring, interference screw fixation technique. Further, these specimens, after retrieval at 6, 12, and 26 weeks, were compared with human arthroscopic 'second looks' and with 10 en bloc specimens obtained when a cruciate-sacrificing total knee replacement was performed. The study showed that, with this reconstruction technique, Sharpey's fibers were seen at 6 weeks in both sheep and human specimens. The intratunnel specimens showed proliferative chondrification, then ossification of the matrix. Intra-articular neovascularization, ligamentization, and junction ossification occurred. Myoblasts or smooth muscle cells appear to mediate the ligamentization as evidenced in electron microscopy by proliferate collagen manufacture. These myoblasts were seen in both the healing sheep and human second looks, but not seen in mature ACL grafts or in normal ACLs. At 6 months postoperatively, the sheep ACL reconstruction appeared clinically, histologically, and immunohistochemically indistinguishable from the normal sheep ACL. A correlation of this work with published animal studies in which biomechanical testing was performed and with human 'second looks' would imply that an ACL reconstruction may be vulnerable during this period of neovascularization and ligamentization.     

Tensile load and the metabolism of anterior cruciate ligament cells

It generally is recognized that tensile load plays a major role in maintaining the homeostasis of the anterior cruciate ligament fibers, but its detailed mechanism remains a matter of controversy. The effect of cyclic tensile load on the metabolism of the anterior cruciate ligament were investigated experimentally using cultured cells from the anterior cruciate ligament of rabbits. Using culture plates with flexible rubber bases, a cyclic tensile load was applied to the cultured cells for 24 hours, and the changes in shape, alignment, and metabolism of the cells were analyzed. Under the cyclic tensile load, the shape of the cells from the anterior cruciate ligament changed to spindle and aligned perpendicularly to the direction of the tensile load. The cyclic tensile load also caused an increase in collagen synthesis by the cells from the anterior cruciate ligament, which was predominant in Type I. The cells from the synovium showed similar changes in shape and alignment under the cyclic tensile load, but no significant change was observed in cell metabolism. These observations suggest that the application of cyclic tensile load on the anterior cruciate ligament cells is an important factor in the regulation of collagen synthesis in the anterior cruciate ligament.     

Displaced bucket handle tears of the medial meniscus masking anterior cruciate deficiency

Traditionally, anterior cruciate ligament (ACL) injuries have been difficult to diagnose in the Casualty Department. Studies have shown that the anterior drawer test has a poor sensitivity both in acute and chronic ACL deficient knees [4, 6, 9]; thus, more emphasis has been placed on the pivot shift and Lachman tests [3]. We report four cases of proven ACL rupture where clinical examination revealed an absent pivot shift and a near normal Lachman test following a displaced bucket handle tear of the medial meniscus. This finding has been reproduced in cadaver studies, and we conclude that if the history strongly suggests an ACL injury and examination reveals a stable knee, then the dual pathology of medial meniscus tear and ACL rupture should be suspected.     

Avulsion fracture of the anteromedial bundle of the anterior cruciate ligament

The avulsion fracture of the tibial attachment site of the anterior cruciate ligament is relatively rare among adults. Although partial avulsion fracture of this site is very rare, complex forces exerted on the knee joint could produce this type of fracture. We report on an adult patient with an avulsion fracture of the attachment site of anteromedial bundle of the anterior cruciate ligament associated with injuries of lateral and medial collateral ligament and fibular fracture. We speculate varus stress in a flexed knee coupled with rotation between the femur and tibia caused this type of injury.     

The semitendinosus tendon as replacement for the anterior cruciate ligament

This article describes the history, advantages, biomechanical properties, operative technique, and results of replacement of the anterior cruciate ligament using the semitendinosus tendon. After arthroscopic ACL replacement using the doubled semitendinosus tendon in combination with an extraarticular lateral repair in 65 consecutive patients (20 acute, 45 chronic instabilities) we found after 2 years in 51 patients (78%) an excellent or good result with less than 3 mm difference in the Lachman test measured with the KT-1000 arthrometer (MMD). After 6 years 40 out of the 45 patients with chronic instabilities could be examined again. Only 28 patients (70%) showed a difference in anterior translation of less than 3 mm. A positive pivot shift sign could be seen in 11% of the patients after 2 years and in 20% after 6 years. The Tegner score increased from 6.0 after 2 years to 6.2 after 6 years, the Lysholm score decreased from 93 to 91 in the same interval. 89% of the patients had a free range of knee motion after 2 years and 92.5% after 6 years. There were 10% normal, 50% nearly normal, 25% abnormal, and 15% severely abnormal knees in the IKDC evaluation after 6 years. In the last 4 years we are using the quadrupled semitendinosus tendon in an arthroscopic single incision technique for ACL replacement with femoral Endobutton fixation, because the doubled semitendinosus tendon seems to elongate over time. After 23 months on average (12-36 months) the preoperative anterior translation of 7.5 mm could be decreased to 1.9 mm in 35 patients.     

Mechanisms of injury of the anterior cruciate ligament in soccer players

Despite the great amount of research that has been focused on the anterior cruciate ligament in recent years, relatively little is known about the exact mechanisms that cause these injuries. By defining the factors that contribute to these injury mechanisms in soccer players, the authors hope to facilitate appropriate training methods and work at preventing these serious injuries.     

Radionuclide imaging of the knee with chronic anterior cruciate ligament tear

We studied the results of bone scans in 50 consecutive patients with symptomatic, unilateral, chronic anterior cruciate ligament (ACL) tears. All patients had failed conservative therapy and underwent radionuclide imaging of the knee prior to arthroscopic ACL reconstruction. The scintigraphic activity in each of the three knee compartments was quantitatively scaled from 1 (normal scintigraphic activity) to 4 (marked activity). Quantitative activity in each of the three compartments was correlated with plain radiographic, arthroscopic, and clinical findings. All but four of the scans (92%) showed abnormal scintigraphic activity. The quantitative activity was highest overall in the medial compartment (2.9), followed by the lateral (2.4) and patellofemoral compartments (1.9). In the subgroup of patients with normal menisci (10 patients), most of the abnormal activity was in the lateral compartment (2.9), implying that when the medial meniscus remains competent in the presence of a torn ACL, there is increased stress on the lateral compartment. There was little correlation with scintigraphy and roentgenographic changes, except in the presence of moderate or severe radiographic degenerative arthritis. Similarly, there was little correlation between increased scintigraphic activity and chondromalacia. These results provide a baseline for future studies that use scintigraphic imaging in monitoring restoration of bone homeostasis following ACL reconstruction.