The American Journal of Sports Medicine

We wanted to use biomechanical testing in a cadaveric model to compare the Broström repair, the Watson- Jones reconstruction, and a new anatomic reconstruc tion method. Eight specimens were held in a specially designed testing apparatus in which the ankle position (dorsiflexion-plantar flexion and supination-pronation) could be varied in a controlled manner. Testing was done with intact ligaments and was repeated after sectioning of the anterior talofibular ligament and the calcaneofibular ligament and after a Broström repair, a Watson-Jones reconstruction, and a new anatomic re construction were performed. An anterior drawer test was performed using an anterior translating force of 10 to 50 N, and a talar tilt test was performed using a supination torque of 1.1 to 3.4 N-m. The forces in the anterior talofibular ligament and calcaneofibular liga ment were measured with buckle transducers, and tibiotalar motion and total ankle joint motion were meas ured with an instrumented spatial linkage. The in crease in ankle joint laxity observed after sectioning of both the anterior talofibular and calcaneofibular liga ments was significantly reduced by the three recon structive techniques, although not always to the level of the intact ankle. Joint motion was restricted after the Watson-Jones procedure compared with that in the intact ankle. Unlike the Watson-Jones procedure, the ligament or graft force patterns observed during load ing after the Broström repair and the new anatomic technique resembled those observed in the intact ankle.

Seventy-one consecutive patients with posterolateral knee injuries had clinical stability testing abnormalities documented prospectively. We compared these find ings with the incidence and patterns of their injuries documented at surgery. An abnormal reverse pivot shift test was associated with injury to the fibular col lateral ligament (P = 0.01), popliteal components (P = 0.01), and midthird lateral capsular ligament (P = 0.02). An abnormal posterolateral external-rotation test at 30° of flexion was associated with injury to the fibular collateral ligament (P = 0.0001 ) and lateral gastrocne mius tendon (P = 0.01). An abnormal adduction test at 30° of flexion was associated with injury to the poste rior arcuate ligament (P = 0.02). The results of this study should alert the clinician to the possibility of injury to a specific anatomic structure when the correspond ing clinical stability test is abnormal. Because the fib ular collateral ligament was injured in only 23% of the knees in this large series of patients, we recommend that an injury to the fibular collateral ligament not be the sole determining factor in making the diagnosis of pos terolateral injuries. The wide array of injuries to many individual anatomic components that we found indi cates the complexity of injuries to the posterolateral aspect of the knee.

The anatomy of the fibular collateral ligament-biceps femoris bursa is described. The bursa is located lateral to the distal quarter of the fibular collateral ligament and forms an inverted "J" shape around the anterior and anteromedial portions of the ligament. Its most distal margin is just proximal to the fibular head where the fibular collateral ligament inserts, and its more proximal aspect is at the superior edge of the anterior arm of the long head of the biceps femoris muscle. We found this structure in all 50 knees dissected; there was a constant anatomic location of the fibular collat eral ligament-biceps femoris bursa in all specimens. Measurement of the anatomic dimensions of the bursa revealed a mean width of 8.4 mm and a mean height of 18 mm. Knowing the prevalence, shape, size, and anatomic location of this bursa may aid the clinician in the differential diagnosis of lateral knee pain.

Clinical evaluation of posterolateral complex injuries of the knee can be difficult. To determine if magnetic resonance imaging can assist in decision-making in the treatment of posterolateral complex injuries, six consecutive patients with acute posterolateral knee trauma were imaged preoperatively with standard magnetic resonance imaging sequences. Magnetic resonance imaging findings were then correlated with results of examination under anesthesia or open lateral reconstruction. There were five complete lateral com plex injuries (grade III) and one partial tear. Magnetic resonance imaging was able to accurately depict the extent of injury preoperatively in each case. All patients had concomitant anterior cruciate ligament tears. There was one partial posterior cruciate ligament tear. Visualization of the arcuate complex, biceps femoris tendon, lateral capsule, iliotibial band, popliteal tendon, and lateral collateral ligament was possible. A charac teristic bone contusion on the anteromedial femoral condyle was present in all patients with complete pos terolateral disruptions. Lateral complex injuries of the knee can be very accurately demonstrated on mag netic resonance imaging, and this imaging technique can be used to clarify the exact nature of the injury to allow better surgical planning.

The Bankart procedure is a commonly performed an terior shoulder reconstruction that may shorten the anterior capsule. In this study, biomechanical testing was performed to evaluate the effect of the classic Bankart reconstruction on external rotation of the shoulder. The procedure was performed on six fresh- frozen cadaveric specimens that were free of intraar ticular pathologic changes. With the arm in 0° of ab duction, resisting torques about the vertical axis were measured while the humerus was externally rotated. The intact specimens demonstrated a nonlinear load displacement behavior in which little resisting torque was measured until a moderate amount of external rotation was applied. Shortening the capsule by 2 mm resulted in a 40% decrease in the low-tension zone of external rotation, and shortening the capsule an addi tional 5 mm resulted in a 67% decrease in the low- tension zone. This study demonstrates that the normal shoulder capsule is quite sensitive to anterior capsular shortening and suggests that care must be exercised when performing a Bankart reconstruction to avoid overtightening this structure.

To evaluate differences in shoulder strength and range of motion between painful and pain-free shoulders we examined two matched groups of athletes. Fifteen competitive swimmers were allocated to two groups. Group 1 consisted of seven swimmers with unilateral shoulder pain related to swimming (Neer and Welsh phase I to II). The control group (Group 2) consisted of eight swimmers with no present or previous history of shoulder pain. Concentric and eccentric internal rota tional torques were reduced in painful shoulders in between-group comparisons as well as in side-to-side comparisons. The decrease in internal rotational torque resulted in significantly greater concentric and eccentric external-to-internal rotational strength ratios of the painful shoulder in Group 1 swimmers compared with the controls. Furthermore, the functional ratio (ec centric external rotation:concentric internal rotation) was significantly greater in the painful shoulder in both between-group and side-to-side comparisons. Both groups of swimmers exhibited increased external range of motion and reduced internal range of motion compared with normalized data, but no between-group or side-to-side differences were detected. Our findings suggest that prevention or rehabilitation of swimmer's shoulder might not solely involve strengthening of the external rotators of the shoulder joint. Attention might also be drawn toward correction of a possible deficit in internal rotational strength. Changes in shoulder range of motion seem unrelated to the occurrence of shoul der pain.

We conducted a prospective study of 94 consecutive patients who received a patellar tendon autograft for anterior cruciate ligament rupture. Eighty-seven pa tients (93%) returned for followup a mean of 28 months postoperatively; 57 had chronic and 30 had acute or subacute ruptures. There were no significant differ ences between the subgroups for age, sex, articular cartilage lesions, or months of followup. Forty-six me niscal tears were repaired; 27 of these extended into the central avascular region. Rehabilitation empha sized 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 con sidered in active persons as symptoms and limitations continued postoperatively in knees with chronic rup tures, 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 evi dence of healing and did not require reoperation.

The initial biomechanical properties of semitendinosus and patellar tendon autografts and their fixation strengths were investigated. Twenty fresh cadaveric knees from donors under 42 years of age were used in the study. After removing all soft tissues other than the anterior cruciate ligament, we determined the ultimate tensile strength (2195 ± 427 N) and stiffness (306 ± 80 N/mm) of the anterior cruciate ligament in nine knees. In six knees, anterior cruciate ligaments were reconstructed using an autologous patellar tendon graft with proximal and distal interference fit screws; this resulted in an ultimate tensile strength of 416 ± 66 N. Five knees were reconstructed with quadruple- stranded (double-looped) semitendinosus tendons fixed proximally by a titanium button and braided tape and distally by tibial post screw. This resulted in an ultimate tensile strength of 612 ± 73 N, which was significantly higher than the strength in the patellar tendon group. Graft stiffness did not differ between the groups and was 47 ± 19 N/mm (N = 11). This study demonstrates that the reconstructed knees had only 20% to 30% of the ultimate tensile strength of the normal anterior cruciate ligament. In summary, the semitendinosus reconstruction using a button for prox imal fixation is, at the time of surgery, approximately 50% stronger than patellar tendon reconstructions with similar stiffness.

We measured tibial translation in the knees of 22 sub jects with posterior cruciate ligament tears or recon structions by using the KT-1000 arthrometer. To as sess the reliability of the device, two testers made measurements. One tester was a novice and the sec ond tester had substantial clinical experience with the KT-1000 arthrometer. The quadriceps neutral angle was found for the uninvolved knee. Anterior and pos terior translation and total anterior-posterior excursion were then measured. The quadriceps neutral angle was then reproduced in the involved knee and the same measurements were taken. Each subject was tested twice by each tester. The intraclass correlation coefficient values for the novice, experienced, and in tertester reliability were 0.67, 0.79, and 0.62, respec tively, for corrected posterior translation; 0.59, 0.68, and 0.64, respectively, for corrected anterior transla tion; 0.70, 0.74, and 0.29, respectively, for quadriceps neutral angle; and 0.84, 0.83, and 0.62, respectively, for total anterior-posterior excursion. Ninety-five per cent confidence intervals for the novice, experienced, and intertester reliability were ±2.95, ±2.53, and ±3.27 mm, respectively, for corrected posterior trans lation; ±3.99, ±3.89, and ±3.74 mm, respectively, for corrected anterior translation; and ± 10.70°, ± 11.73°, and ± 16.25°, respectively, for quadriceps neutral an gle. The KT-1000 arthrometer was found to be a mod erately reliable tool for the measurement of tibial trans lation in patients with posterior cruciate ligament tears and reconstructions.

The frequency of concomitant meniscal and articular cartilage lesions in the femorotibial joint was analyzed in a retrospective study of 1740 knee joints examined arthroscopically with the objective of determining pos sible correlations between the two knee joint abnormal ities. Articular cartilage lesions were found in 81.4% (N = 1416) of femorotibial joints examined and menis cal derangements were noted in 72.8% (N = 1268). In the medial compartment, concomitance was noted in 76.3% (821 of 1076) on the femoral condyles and in 48.6% (523 of 1076) on the tibial plateau. In the lateral compartment, 43.1 % (212 of 492) of the knees with deranged menisci had femoral and 55.1 % (271 of 492) had tibial articular lesions. Medial meniscal lesions were more frequently associated with femoral and tibial chondral degeneration than lateral meniscal derange ments (P < 0.001). Longitudinal, bucket-handle, and complex tears of the medial meniscus were signifi cantly more often associated with articular cartilage damage than horizontal cleavage, flap, or radial tears. Degeneration of the meniscus was highly correlated with chondral destruction in both compartments. No cause-and-effect relationship could be established, but practical implications of these findings are discussed.

In this prospective study of ice hockey injuries in Fin land we have investigated the incidence of injury at two playing levels and the causal factors, mechanisms, types, and consequences of the injuries. Seven Finn ish ice hockey teams were observed during the 1988 to 1989 season. There were a total of 189 injuries. There were 134 injuries in 4 teams of the highest level, the Finnish National League, and 55 injuries in 3 teams of the second highest level, Division I. The incidence of injuries during games was 66 per 1000 player-game hours in the National League and 36 per 1000 player- game hours in Division I. As for severity, 10 (5%) injuries were classified as major. Of all injuries, 15 (8%) were fractures and 34 (18%) were to the head or face. The most severe injuries were tears of a knee ligament or fractures of an upper extremity. Ongoing surveil lance and an exact reporting system are needed for establishing the trends in the number and severity of the injuries.

Eighty-six male high school ice hockey players partic ipated in this prospective study to determine both the incidence of injury in high school ice hockey and the influence of physical, situational, and psychosocial fac tors. Physical factors included height, weight, vision, previous injuries, musculoskeletal abnormalities, and injuries present at the time of screening evaluations. Situational factors examined were level of participa tion, playing time, player position, and games versus practices. Psychosocial factors such as confidence, stress, social support, positive states of mind, and mood states were also examined to determine their influences on injury. Twenty-seven injuries occurred during the 1994 to 1995 season. As hypothesized, the overall incidence of injury in high school hockey games (34.4 per 1000 player-game hours) was less than the incidence of injury in Junior A hockey (96.1 per 1000 player-game hours) and was more than previously re ported for Bantam youth hockey (10.9 per 1000 player- game hours). Injuries occurred more often in games than in practices, usually as a result of collisions. Phys ical factors such as player position and previous inju ries did not significantly predict injuries, but players in the high playing time group were more likely to be injured. Psychosocial factors of low vigor and high fatigue as measured by the Incredibly Short Profile of Mood States (ISPOMS) significantly predicted high school ice hockey injuries.

We undertook this study to determine the types and frequency of injuries sustained in the sport of luge. Before this study, no data were available in the medical literature on luge injuries. We performed a retrospec tive analysis between the years 1985 and 1992 using data obtained from the athlete injury and illness report forms at the US Training Center Sports Medicine Clinic in Lake Placid, New York. During the 7 years exam ined, 1043 athletes took 57, 244 track runs and sus tained 407 injuries. The risk of sustaining an injury was 0.39 per person per year, and the risk of an injury causing the loss of more than 1 day of practice was 0.04 per person per year. Contusions were the major injury (51%), followed by strains (27%). Strains of the neck muscles and contusions of extremities, especially the hands, were characteristic injuries sustained by athletes. The most serious injuries were concussions (2%) and fractures (3%). Crashes were responsible for 64% of injuries. Luge appears to be a relatively safe sport with injury rates comparable with recreational alpine skiing.

Although there is a higher relative incidence of anterior cruciate ligament injuries in female than in comparable male athletes according to the literature, the majority of populations studied after reconstruction are male-dom inated. We wished to determine whether a selection bias for reconstruction based on sex is warranted ac cording to complications and outcome. Ninety-four pa tients (47 of each sex) were matched for chronicity of injury, age, preoperative sports activity levels, articular cartilage condition, and months of followup. All had patellar tendon autogenous reconstruction and a sim ilar program of immediate knee motion and early return to function. The results were rated with the Cincinnati Knee Rating System. At a mean of 26 months postop eratively, there were no significant differences for com plications or outcome between men and women. Women required an average of six more rehabilitation visits than men; however, none required additional surgery for knee motion complications and the rate of patellofemoral crepitus conversion was only 7%, lower than that found for men (15%). The overall failure rate was low, only 6% for women and 4% for men. We concluded that the functional rehabilitation program was effective, postoperative complications were few, and no scientific basis exists to use sex alone as a selection criteria for anterior cruciate ligament reconstruction.

The purpose of this study was to evaluate the results and complications of anterior cruciate ligament surgery in middle-aged patients. Forty-five consecutive pa tients over 40 years old (average age, 44.6 years) who had arthroscopically assisted anterior cruciate liga ment reconstructions with midthird patellar tendon au tografts were evaluated. The patients returned for in terviews, physical examinations, radiographs, Biodex dynamometer strength testing, and KT-1000 arthrom eter testing at an average of 37 months after their surgeries (range, 24 to 96 months). The mean Lysholm and Gillquist score was 91, which corresponds to symptoms only with vigorous activity. The overall scores from the International Knee Documentation Committee form were 29 (64%) normal or nearly nor mal and 2 (4%) severely abnormal. Side-to-side differ ences as determined by the KT-1 000 arthrometer were ≤3 mm in 31 of 40 patients (78%), between 3 and 5 mm in 4 patients (10%), and >5 mm in 5 patients at 30 pounds of anterior displacement. Seventy-six percent of the patients (N = 34) returned to their preoperative activity levels. Three patients required repeat arthro scopic surgery for persistent knee pain and two pa tients had graft ruptures. This study shows that when middle-aged patients undergo surgery, their results can be successful and satisfying to a degree similar to those of younger patients.

This retrospective study determined that the outcome from anteromedialization of the tibial tubercle corre lates well with the location of patellar articular lesions. Detailed descriptions of patellar articular cartilage le sions were obtained from the operative reports of 36 patients who had anteromedialization performed be tween February 1984 and March 1994. The patterns fell into four distinct groups. Ten patients with type I (distal) patellar lesions and 13 patients with type II (lateral facet) patellar lesions had 87% good to excel lent subjective results, and 100% of these patients said they would have the procedure done again. Nine pa tients with type III (medial facet) lesions had 55% good to excellent results, and 5 patients with type IV (prox imal or diffuse) lesions had only 20% good to excellent results. Patients with type I or II lesions were signifi cantly more likely to have good or excellent results than those with type III or IV lesions. Central trochlear lesions were associated with medial patellar lesions and all patients with central trochlear lesions had poor results. There was no significant correlation between the Outerbridge grading of the patellar lesion and the overall results. Workers' compensation issues dimin ished the likelihood of a satisfactory outcome by 19%; however, this was not statistically significant. This is the first study to correlate the patellar articular cartilage lesion with outcome after tibial tubercle transfer.

Ankle disk training has been used as an exercise in sports medicine clinics to help protect against ankle sprains. This study investigated the effects of ankle disk training on the contraction pattern of the anterior tibialis, posterior tibialis, peroneus longus, and flexor digitorum longus muscles in a simulated ankle sprain. Twenty adults were recruited and divided into a control group and an experimental group. A platform with a trapdoor was used to simulate a lateral ankle sprain. Electromyographic data were recorded from each sub ject in pretraining and posttraining tests. The experi mental group underwent ankle disk training for 8 weeks between the pretraining and posttraining tests. In the pretraining test, the four muscles started to contract simultaneously; in the posttraining test, the contrac tions of the anterior and posterior tibialis muscles were delayed. This delay favors the correction of excessive ankle inversion. This study examined the effects of one form of proprioceptive training on muscle reaction times, and its results may explain why such training can help protect against ankle sprains.

Three hundred sixty-four Australian Regular Army re cruits with acute ankle sprains sustained during train ing were randomized to treatment with either piroxicam or placebo. Compared with the placebo group, sub jects treated with piroxicam had less pain, were able to resume training more rapidly, were treated at lower cost, and were found to have increased exercise en durance on resumption of activity. Nausea was the only side effect reported significantly more often in the treatment group than in the placebo group (6.8% ver sus 0.3%). Interestingly, subjects treated with piroxi cam showed some evidence of local abnormalities such as instability and reduced range of movement. We conclude that nonsteroidal antiinflammatory agents should form an integral part of the treatment of acute ankle sprains.

The purpose of this study was to evaluate the histo logic and biomechanical changes that occur between 12 and 52 weeks in an intraarticular, semitendinosus autograft placed through tibial and femoral drill holes in a rabbit model. The results of this study show that, in this rabbit model, the soft tissue graft maintained its biologic fixation in the osseous tunnel when stressed to failure at 1 year. The bony fixation occurred by the formation of an indirect tendon insertion, and this for mation was complete by 26 weeks. At 52 weeks, large differences persisted in the strength and stiffness of the graft compared with the normal semitendinosus tendon and anterior cruciate ligament. Based on the results of this study, we support a cautious approach in returning patients to early full activity, including sports, after anterior cruciate ligament reconstruction with a semitendinosus autograft.

The goal of this study was to evaluate, histologically and biochemically, repair of the articular cartilage in a rabbit joint after the use of the holmium:yttrium-alumi num-garnet laser in a cartilage chondroplasty model. In 30 New Zealand White rabbits, chondroplasty was per formed with the laser at an intensity of 0.8 J at a rate of 10 Hz. The animals were sacrificed 12 weeks after surgery. Histologically, the safranin O staining index of proteoglycan correlated well with the biochemical re sults, illustrating a decrease of proteoglycan in the repaired articular cartilage after laser articular cartilage chondroplasty. The damaged articular cartilage sur face after the laser application was extensive. The damaged area observed was gradually distributed along the radius from the central point of the laser beam application. Biochemically, the amount of glycos aminoglycan in the repaired tissue (8 ± 2 mg of hex osamine per gram of dry cartilage) was statistically less when compared with that in the sham-treated tissue (40 ± 5 mg). The amount of sulfate incorporated into proteoglycans was 8 to 10 times less in the chondro plasty model compared with the control, suggesting that cell viability was greatly reduced in the treated tissues or expression of proteoglycans was greatly reduced. In the subchondral area, histologic evaluation showed the lack of osteocytes in lacunae of the bone tissue after use of laser energy. The architecture of the subchondral bone in the chondroplasty area was dam aged, with damage also seen in the membranes of the blood vessels.

The records of 234 people who had anteromedializa tion of the tibial tubercle with oblique osteotomy be tween 1983 and 1994 at two separate institutions were reviewed retrospectively. Six patients (2.6%) had frac tures of the proximal tibia postoperatively, within 13 weeks of the Fulkerson osteotomy. All fractures oc curred after a change in the postoperative physical therapy regimen from partial weightbearing to immedi ate full weightbearing. All fractures healed with accept able alignment of less than 5° of varus-valgus or an teroposterior angulation. Given this increase in fracture incidence, a more conservative postoperative physical therapy regimen is recommended. All patients should be nonweightbearing initially, advanced gradually to partial weightbearing, and allowed full weightbearing only after the osteotomy has radiographic evidence of complete healing.

I used a computer simulation model of aerial move ment to investigate the techniques for producing and controlling rotations of the human body during free flight. I found that the rotational motion can change from a twisting somersault to a nontwisting somersault by flexing at the hips at a suitable time. Twist may be produced in the aerial phase by means of asymmetri cal movements of arms or hips, which result in a tilting of the longitudinal axis away from the plane perpendic ular to the angular momentum vector. Asymmetrical movements may also remove the tilt and stop the twist. Elite performances of twisting somersaults are charac terized by a large contribution from aerial twisting tech niques. A progression of movements is presented for learning a double somersault with one and a half twists in the second somersault.

The recent description of exercise-induced intimal fi brosis affecting mainly the iliac artery (and therefore usually described as external iliac artery endofibrosis) has dramatically changed the diagnostic approach of unexplained recurrent lower limb exercise pain, espe cially in cyclists. Because arterial disease is often as sociated with the aftereffect of various concomitant musculotendinous lesions, several months may pass before an arterial origin is suspected. The arterial origin of the pain must not be eliminated on normal ankle-to- arm index or normal Doppler velocity profiles at rest. Ultrasound examinations taken at rest may show the lesions in 80% of endofibrotic patients and allow for the diagnosis of popliteal entrapment syndrome during dorsiflexion of the foot. However, the hemodynamic consequences of a stenosis on the aortoiliofemoral axis can only be proved by measurement of the ankle- to-arm index after exercise. A cutoff of this index <0.5 provides an 85% sensitivity in the detection of endofi brosis. Invasive investigations (arteriography or an gioscopy) will confirm the diagnosis before surgery is discussed. Although long-term results in endofibrosis are unknown, most of the surgically treated patients return to competition.