Infrapatellar contracture syndrome. Diagnosis, treatment, and long-term followup

Infrapatellar contracture syndrome is an uncommon but recalcitrant cause of reduced range of motion after knee surgery or injury. The results and conclusions presented here are based on a retrospective clinical study evaluating the long-term outcome in 75 patients who developed infrapatellar contracture syndrome. These 75 patients (76 knees) were evaluated at an average followup of 53 months after the index (inciting) procedure or injury. Comparing subgroups within the study population, factors that correlated with poorer results or more severe infrapatellar contracture syndrome were found to be acute anterior cruciate ligament repair or reconstruction, the use of patellar tendon autograft for anterior cruciate ligament reconstruction, nonisometric graft placement, multiple surgical procedures, use of closed manipulation, and the development of patella infera. We concluded that appropriate procedures can substantially increase the range of motion in patients with infrapatellar contracture syndrome. However, residual functional morbidity persists in many patients, and the outcome, as determined by subjective knee function scores, is only fair. The natural history of an anterior cruciate ligament-deficient knee appears to be more benign than the natural history of a knee that develops infrapatellar contracture syndrome.     

What would you do? Acute extension block caused by anterior cruciate ligament tear: a case report

Acute knee locking is usually attributed to a displaced meniscus tear. This case involved late diagnosis of mechanical extension block caused by anterior displacement of a torn anterior cruciate ligament (ACL) with impingement in extension. Definitive reconstruction was delayed after debridement of the ACL stump to improve preoperative range of motion. Despite this, the patient still had difficulty regaining extension after surgery. Early treatment of mechanical extension block may facilitate motion recovery after ACL reconstruction.     

Treatment of seasonal affective disorder with a high-output negative ionizer

A retrospective analysis was performed to explain the decreasing incidence of postoperative arthrofibrosis of the knee in 191 consecutive patients who had anterior cruciate ligament reconstruction using the central third patellar tendon from 1987 through 1991. Follow-up data were available on 188 patients (98%). Age, sex, time interval from injury, preoperative motion, and concomitant meniscal repair or partial meniscectomy were evaluated for their significance as risk factors. Twenty-two of 188 patients (12%) developed arthrofibrosis; the incidence was lower when the acute anterior cruciate ligament reconstruction was delayed at least 3 weeks from the injury, and when preoperative extension was 10 degrees or better. Age, sex, preoperative flexion, and need for concomitant meniscal surgery were not risk factors. The postoperative motion protocol evolved during the study period. Group 1 patients were braced in 45 degrees of flexion for 1 week before passive extension was allowed. In Group 2, motion was started after 48 hours. Group 3 patients were braced in full extension, with motion starting with 24 hours. With these changes, the incidence dropped from 23% to 3%. Decreases in the incidence of arthrofibrosis with modifications in operative technique and postoperative analgesia were not statistically significant.     

The effect of exercise and rehabilitation on anterior-posterior knee displacements after anterior cruciate ligament autograft reconstruction

We studied the effect of rehabilitation strength training and return to activities on anterior-posterior knee displacements after patellar tendon autogenous anterior cruciate ligament reconstruction. A total of 938 measurements were sequentially collected for 142 patients with the KT-2000 arthrometer. Rehabilitation included immediate knee motion and early weightbearing, light sports at 6 months, and competitive sports at 8 months or later. At a minimum of 2 years after surgery, 121 patients (85%) had normal displacements (less than 3 mm of increase at 134 N), 14 (10%) had 3 to 5.5 mm of increase (partial function), and 7 (5%) had more than 5.5 mm of increase (failed). There was no association found between the initial onset of the abnormal displacements in the 21 knees and either the amount of time after surgery or the rehabilitation program. Six of the seven grafts that failed did so in the 1st postoperative year. Serial displacement measurements allow early detection of graft stretching and subsequent modification of rehabilitation or delay in return to strenuous activities. These measurements showed that the rehabilitation program used in this study was not itself injurious and resulted in an acceptable failure rate of 5%.     

Acute repair of injury to the anterior cruciate ligament. A long-term followup

We reviewed 30 patients at an average of 7.4 years after acute repair of the anterior cruciate ligament augmented with a loop of iliotibial tract. A noncontact twisting had been the mechanism of injury in 18 of these patients, with 28 having been injured in sports. At followup, 25 patients had not experienced symptoms of instability and 23 were able to return to unrestricted athletic activity; only 5 had been unable or unwilling to return to sporting activity at all. There had been no swelling in 23 patients; however, 17 suffered from pain on exertion. The average Lysholm score was 93.2. Joint laxity was assessed and anteroposterior tibial translation quantified with a KT-1000 arthrometer. Eighteen patients had a normal or 1+ Lachman test and 27 had an absent or 1+ pivot shift. When compared with the results of a similar study performed on this group of patients at 2 years after surgery, there had been little subjective change in knee function. However, objectively there had been significant deterioration of the anteroposterior stability of the knees at 7 years, suggesting failure of the integrity of the repaired ligament with time. An associated medial collateral ligament injury had a significant adverse effect both on the integrity of the anterior cruciate ligament repair and the incidence of postoperative stiffness.     

Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients with articular cartilage damage

To test if anterior cruciate ligament reconstruction with autogenous patellar tendon can alleviate symptoms and functional limitations and increase activity levels in patients with advanced articular cartilage damage, we looked at 53 patients with arthroscopically documented cartilage damage. In this group, a mean of 7.5 years had elapsed between the original injury and the reconstruction, and 90 prior operative procedures had been done. Postoperatively, all patients had immediate motion and early functional rehabilitation. The results were assessed with the Cincinnati Knee Rating System. At followup (mean, 27 months), significant improvements were found for pain, swelling, giving way, functional limitations with daily and sports activities, and the overall rating score. Forty-two patients (79%) had returned to some type of athletic activity. Only three patients (6%) had failed results. In the patients' own ratings of the overall knee condition, 8 of 51 (16%) rated their knees as normal, 28 (55%) as very good, 7 (14%) as good, 5 (10%) as fair, and 3 (6%) as poor. We concluded that the majority of patients benefited from the arthroscopically assisted anterior cruciate ligament reconstruction because it decreased episodes of giving way with daily activities and increased activity without aggravating the preexisting arthrosis.     

A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction

We conducted a prospective study of 94 consecutive patients who received a patellar tendon autograft for anterior cruciate ligament rupture. Eighty-seven patients (93%) returned for followup a mean of 28 months postoperatively; 57 had chronic and 30 had acute or subacute ruptures. There were no significant differences between the subgroups for age, sex, articular cartilage lesions, or months of followup. Forty-six meniscal tears were repaired; 27 of these extended into the central avascular region. Rehabilitation emphasized immediate knee motion, but strenuous activity was delayed for at least 4 months. Only one patient had a knee motion complication, and stability (<3 mm, KT-2000 arthrometer, 134 N) was restored in 85% of knees with chronic ruptures and 92% of knees with acute ruptures. Earlier reconstruction should be considered in active persons as symptoms and limitations continued postoperatively in knees with chronic ruptures, leading to overall less satisfactory results. In patient rating of the overall knee condition, 69% of knees with chronic ruptures and 100% of knees with acute ruptures scored in the normal or very good range. Repair of meniscal tears that extend into the central avascular region should be considered, as 24 of the 27 (89%) menisci repaired showed clinical evidence of healing and did not require reoperation.     

The effects of knee reconstruction on combined anterior cruciate ligament and anterolateral capsular deficiencies

We tested the effect of intraarticular reconstructions of the anterior cruciate ligament alone and in combination with extraarticular reconstructions in 10 cadaveric knees. These knees had anterior cruciate ligament deficiency alone or in combination with anterolateral capsuloligamentous deficiencies. In the knees with combined injury, intraarticular reconstruction returned anterior stability to levels not significantly different from levels found for the knees deficient in the anterior cruciate ligament alone and treated with this procedure. After intraarticular reconstruction, rotational stability of the knee with combined injuries failed to return to the levels seen in the knee with isolated anterior cruciate ligament deficiencies that underwent the same treatment. When a tenodesis with either 0 N or 22 N of tension was added to the intraarticular reconstruction in the knee with combined injuries, we found that excessive internal rotation significantly decreased at all angles of flexion, except at full extension with 0 N of tension. In addition, the extraarticular reconstruction with 22 N of tension in the tenodesis overconstrained the knee in internal rotation between 30 degrees and 90 degrees of knee flexion. The tenodesis with 0 N of tension overconstrained the knee at only 60 degrees and 90 degrees of flexion. These results suggest extraarticular reconstruction as an adjunct to the intraarticular operation for the knee with anterior cruciate ligament and anterolateral structural injuries. The results also suggest that the surgeon can affect anterior and rotational laxity by adjusting the tension in the tenodesis.     

Meniscal allograft transplantation for unicompartmental arthritis of the knee

Sixty-seven meniscal allografts were transplanted in the knees of 63 patients between 1988 and 1994. Before surgery, all patients experienced refractory disabling knee pain secondary to a prior total meniscectomy with advanced unicompartmental osteoarthritic changes as verified by arthroscopy. At a mean followup of 31 months (range, 1.0-5.5 years), 58 knees (86.6%) attained a good to excellent results-Twenty-one knees received isolated meniscal allografts, with 19 achieving good to excellent results (90.5%). Five knees received a medial or lateral meniscal allograft with an anterior cruciate ligament reconstruction, and 4 (80.0%) obtained good to excellent results. Thirty-four knees received a meniscal allograft in combination with either a valgus high tibial osteotomy, varus high tibial osteotomy, or varus distal femoral osteotomy to correct for preoperative varus or valgus deformities, with 29 (85.3%) attaining good to excellent results. The remaining 7 knees underwent a combined medial meniscal allograft, valgus high tibial osteotomy, and anterior cruciate ligament reconstruction with 6 (85.7%) attaining good to excellent results. The most frequent complication was a traumatic posterior horn tear in 6 knees at a mean of 21 months after surgery (range, 9-43 months), most likely the consequence of unsuccessful healing of the posterior horn of the graft.     

The use of cold therapy after anterior cruciate ligament reconstruction. A prospective, randomized study and literature review

We performed a randomized, prospective study to assess the effectiveness of postoperative cold therapy in patients who had anterior cruciate ligament reconstructions. Drain output, length of hospital stay, range of motion, and use of pain medication were all assessed. Patients were randomized into one of four groups after surgery. Group 1 patients had a cooling pad applied to the knee postoperatively and set at a temperature of 40 degrees to 50 degrees F, Group 2 had the cooling pad set at 70 degrees to 80 degrees F, Group 3 received ice packs, and Group 4 received no cold therapy of any kind. The skin temperatures in Groups 1 and 3 were significantly lower than the skin temperatures in Groups 2 and 4 (P < 0.001). The length of hospital stay, range of motion at discharge, use of oral and intramuscular pain medicine, and drain output were not significantly different between groups. No complications related to the type of cold therapy were seen in any group. Thus, both ice packs and cooling pads significantly decreased knee temperature, but we found no objective benefits in the early postoperative course due to this decrease in temperature.     

Anterior cruciate ligament reconstruction. Bone-patella tendon-bone versus semitendinosus anatomic reconstruction

In this article, the long term (2-10 years; mean, 4.8 years) followup results of two reconstructive procedures for the anterior cruciate ligament are compared. The bone-patella tendon-bone (with interference fit fixation) was performed on 69 knees, and the semitendinosus anatomic reconstruction was performed on 68 knees, in a population of 76 men and 52 women (age range, 15-60 years; average, 31 years). The patients in the two groups showed no difference in subjective results or activity level and no significant difference to manual testing. The semitendinosus procedure group had a slightly higher KT manual maximum failure rate than the patella tendon group (17% versus 11%). Arthrometric stability did not show deterioration, but patient satisfaction decreased in those patients who had meniscectomies. Both procedures showed satisfactory results during the long term followup. However, if the secondary restraints are compromised, the stiffer bone-patella tendon-bone construct is preferred for reconstruction of the chronic anterior cruciate ligament deficient knee.     

The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea

To determine the effect of anterior cruciate ligament (ACL) reconstruction on symptoms of pain and instability in patients with chronic ACL insufficiency who had previously undergone meniscectomy, we reviewed a series of 21 symptomatic, previously meniscectomized patients with chronic ACL deficiency (average age, 31 years). Arthroscopically assisted intra-articular ACL reconstruction using a middle, one-third patella-tendon autograft was performed in all cases. All patients had radiographic evidence of degenerative changes before ACL reconstruction. The average time from meniscectomy to ACL reconstruction was 6.6 years. Preoperative and postoperative range of motion, stability, and subjective evaluations were compared. Follow-up averaged 37.4 months (range, 24 to 67 months). Physical examination and postoperative KT-1000 side-to-side measurements revealed three patients (14%) with pathological ligament laxity. One patient had a 2+ Lachman, a 2+ pivot shift, and > 5 mm difference on KT-1000 maximum manual test, and two patients had a 1+ Lachman and a 1+ pivot shift. Range of motion measurements taken at follow-up were not significantly different from preoperative measurements (extension, P = .14; flexion, P = .46). Subjectively, all items on a panel of 15 visual analog scales were improved, but intensity of pain and instability were significantly improved after statistical analysis (P < .05). This review suggests that symptoms of pain and instability in patients with chronic ACL deficiency who have previously undergone meniscectomy can be improved by ACL reconstruction if objective stability is obtained.     

Knee joint proprioception in normal volunteers and patients with anterior cruciate ligament tears, taking special account of the effect of a knee bandage

Proprioception of the knee joint was tested in 30 healthy volunteers with clinically inconspicuous knee joints. To examine proprioception, an angle reproduction test was performed. We could not document any differences between the left and the right knee joint or between men and women. At the mid-range, proprioception was worse compared with the end range of motion. In addition, 25 patients with an isolated rupture of the anterior cruciate ligament were evaluated, 14 before and 11 after operative anterior cruciate ligament (ACL) reconstruction. Preoperatively, there was a significant deterioration of proprioception compared with the control group. We were able to show a positive influence of a knee bandage on the proprioception of the injured knee. Patients after ACL reconstruction showed no significantly better proprioception compared with the preoperative group.     

Postoperative pain after anterior cruciate ligament reconstruction using a transligamentous approach

Anterior cruciate ligament reconstruction by free patellar tendon graft was performed using 2 different surgical approaches to the intercondylar notch in 67 consecutive patients with chronic anterior cruciate ligament insufficiency. In the first 30 patients (Group A), the traditional medial parapatellar arthrotomy with lateral luxation of the patella was done, whereas in the last 37 patients (Group B) a transpatellar tendon approach was used. Postoperative pain was managed by analgesics and, in patients who had epidural anesthesia, by administration of bupivacaine in indwelling catheters. Generally, the analgesics and bupivacaine were given immediately on request to establish comfort at rest and to permit range of motion exercises without severe pain. Compared with those in Group A, the patients of Group B had a significantly longer period from the first dose of analgesic or bupivacaine to the second, and the total number of doses of analgesic or bupivacaine was significantly lower. In the subgroup of patients with epidural anesthesia (21 in Group A and 32 in Group B), the Group B patients required significantly less analgesics, as doses equivalent to 10 mg of morphine, compared with that of Group A.     

Proprioceptive capacity of the knee joint area in patients after rupture of the anterior cruciate ligament]

In 30 healthy volunteers with clinically inconspicuous knee joints the proprioception of the knee joint was evaluated by an angle reproduction test. With the same set-up we documented the effect of an elastic knee bandage. We could not document any differences between the left and the right knee joint or between men and women, but at the mid-range of motion, proprioception was worse compared to the end range of motion. The applied elastic knee bandage significantly improved the position sense. Additionally 25 patients with an isolated rupture of the anterior cruciate ligament were evaluated. Fourteen patients were examined preoperatively 11 after operative ACL reconstruction. Preoperatively proprioception was significantly poorer than in the control group. We were able to show a positive influence of a knee bandage on the proprioception of the injured knee as well. Patients after ACL reconstruction showed no significantly better proprioception than the preoperative group.     

Midline osteotomy with lag screw stabilization for mandibular swing

Fifteen patients with recurrent inversion ankle sprains and documented lateral ankle instability were treated with an anatomically oriented ligament reconstruction using a split peroneus brevis tendon graft. This reconstruction is designed to augment repair of the anterior talofibular and calcaneofibular ligaments without restricting subtalar motion. Of the 12 patients available for long-term followup, all were functionally improved, with no recurrences of instability. Stress radiographic examination at followup confirmed that mechanical stability had been restored in all ankles. Eversion strength and subtalar joint motion were maintained after surgery. We recommend this procedure in patients who require augmented reconstruction of the lateral ankle ligaments.     

Comparison of arthroscopic and open reconstruction of the anterior cruciate ligament. Early results

The purpose of this study was to determine in a prospective, randomized, blinded design whether arthroscopically assisted anterior cruciate ligament reconstruction offered any significant immediate or short-term advantages over traditional open reconstruction through a limited arthrotomy. Patients with a diagnosis of deficiency of the anterior cruciate ligament were randomly assigned to one of two treatment groups: the open group (limited open reconstruction) or the arthroscopic group (fully arthroscopic reconstruction). Postoperatively, both groups were treated identically. Intra- and postoperative observations included length of surgery, duration of hospitalization, and amount of pain medication. Follow-up evaluations were performed at 1, 6, 12, 16, 20, and 24 weeks to record crepitus, swelling, range of motion, ligament laxity, and thigh atrophy. Lysholm scores were obtained at the 16 and 24 week follow-ups. At 24 weeks, 86% of the open group and 89% of the arthroscopic group had good-to-excellent results. Intraoperative, postoperative, and follow-up findings indicated no statistically significant differences or relationships between the two groups in any of the variables measured, except that operative time was 13 minutes longer in the arthroscopic group (P < 0.001). The results do not substantiate a clinical advantage for either technique.     

Flexion instability after primary posterior cruciate retaining total knee arthroplasty

Between 1990 and 1995, 25 painful primary posterior cruciate ligament retaining total knee arthroplasties were revised for flexion instability. These patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90 degrees flexion, and above average motion of their total knee arthroplasty. The primary total knee arthroplasty was performed for osteoarthritis in 23 patients and rheumatoid arthritis in two patients. There were 13 male and 12 female patients and their mean age was 65 years (range, 35-77 years). Before the revision operation, Knee Society knee scores averaged 45 points (range, 17-68 points) and function scores averaged 42 points (range, 0-60 points). Twenty-two of the knee replacements were revised to posterior stabilized implants and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant were improved markedly after the revision surgery. Only one of three knee replacements that underwent tibial polyethylene exchange was improved. After the revision for flexion instability, Knee Society knee scores averaged 90 points (range, 82-99 points) and function scores averaged 75 points (range, 45-100 points) for the 20 knees with a successful outcome. This study suggests that flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate ligament retaining total knee arthroplasty. A revision operation that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate retaining total knee arthroplasty.     

Anterior knee laxity and loss of extension after anterior cruciate ligament injury

This study was performed to examine the relationship between knee extension loss and the length of time after injury. We also wanted to compare anterior laxity in anterior cruciate ligament-injured knees in the early and late stages of injury. Loss of knee extension was measured in 81 patients with anterior cruciate ligament injury using lateral radiography with the injured leg relaxed and elevated. Extension loss was defined as the difference in maximal extension angle between the injured and uninjured knees. Average loss of extension was 3.6 degrees in the 17 knees in which the anterior cruciate ligament had been torn 3 weeks or less before examination (the acute injury group) and 0.6 degree in the 64 knees in which the anterior cruciate ligament had been torn more than 3 weeks before examination (the chronic injury group). The extension loss in the acutely injured knees was significantly greater compared with that in the uninjured knees and in the chronically injured knees. Arthrometric measurements using the KT-1000 arthrometer were reliable to diagnose an acute tear. There was no correlation between the degree of extension loss and arthrometric anterior knee laxity measurements. In 12 patients, the initial extension deficit in the early stage of injury significantly resolved with time, and manual maximum arthrometric measurements of anterior knee laxity improved spontaneously with time.     

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.