The Thessaly maneuver consists of the patient, using monopodal support and knee flexion of 5º and then 20º, performing internal and external rotations of the leg. In case this reproduces the pain that the patient refers, the test will be considered as positive. It is a test used for the diagnosis of meniscal pathology (sensitivity greater than 90% and specificity greater than 95%) (Answer 1 correct).

The Thessaly maneuver consists of the patient, using monopodal support and knee flexion of 5º and then 20º, performing internal and external rotations of the leg. In case this reproduces the pain that the patient refers, the test will be considered as positive. It is a test used for the diagnosis of meniscal pathology (sensitivity greater than 90% and specificity greater than 95%) ([HIDDEN]).

A 41-year-old male consults for gonalgia of several days' evolution. During the examination, the Thessaly test (pain with internal and external rotation movements with the knee flexed) is positive. Which of the following lesions is most likely to occur?

Injury by rupture of the anterior cruciate ligament.

Injury by rupture of the posterior cruciate ligament.

Injuries to the posterior cruciate ligament of the knee.

The posterior cruciate ligament (PCL) is the strongest ligament about the knee and is approximately twice as strong as the anterior cruciate ligament. Its main function is to prevent the posterior dislocation of the tibia in relation to the femur, providing 95% of the strength to resist the tibial posterior displacement. Along with the anterior cruciate ligament (ACL) the PCL controls the passive 'screw home' mechanism of the knee in terminal knee extension. It also provides mechanical support for the collateral ligaments during valgus or varus stress of the knee. PCL ruptures are uncommon apparently due to its strong fibre structure. The most frequent injury mechanism in isolated PCL tears is a direct blow on the anterior tibia with the knee flexed thus driving the tibia posteriorly. Automobile accidents (in which the knee hits the dashboard) and soccer injuries (in which an athlete receives a blow to the anterior surface of the tibia during knee flexion) characteristically produce this type of injury. In other PCL injury mechanisms (hyperextension, hyperflexion or rotational injuries with associated valgum/varum stress), other knee structures are also often damaged. The most characteristic diagnostic finding in a knee with a PCL rupture is the 'posterior sag sign' meaning the apparent disappearance of the tibial tubercle in lateral inspection when the knee is flexed 90 degrees. This is due to gravity-assisted posterior displacement of the tibia in relation to the femur. A positive posterior drawer test performed at 90 degrees of flexion and a knee hyperextension sign are sensitive but nonspecific tests. False negative findings are frequent, especially in acute cases. If necessary, the clinical diagnosis of the PCL tear can be verified by magnetic resonance imaging, examination under anaesthesia, arthroscopy, or a combination of these modalities. If a PCL avulsion fragment has been dislocated, surgical treatment is recommended. In isolated, complete midsubstance tears of the PCL the majority of the recent studies recommend conservative treatment, since abnormal residual posterior laxity1 in most of these knees is consistent with functional stability and minimal symptoms. This has been the case even in athletes. In isolated PCL tears, the outcome seems to depend more on the muscular (quadriceps) status of the knee than on the amount of residual posterior laxity. Therefore, the conservative treatment protocol emphasises intensive quadriceps exercises, and only a short (under 2 weeks) immobilisation period followed by early controlled activities and early weightbearing.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical treatment of multiple knee ligament injuries in 44 patients: 2-8 years follow-up results.

The purpose of the study was to evaluate the mid-term results of surgical treatment in different groups of patients with multiple knee ligament injuries. Review of our patients' records revealed that 48 acute and chronic patients were surgically treated for combined knee injury. Due to severe capsular damage in these injuries, open techniques were used. In our treatment protocol, avulsed ligaments and tears of the posterolateral and posteromedial corner were repaired if possible, whereas midsubstance tears of cruciate ligaments and chronic cases were reconstructed with autografts. Postoperatively, an accelerated program of rehabilitation was introduced, aiming to progressively mobilize the joint and improve muscle endurance. For the follow-up evaluation we designed a protocol composed of two parts. In the first part, anatomical lesions were recorded and in the second part, clinical evaluation was performed using the Lysholm score, the Tegner rating system, the IKDC evaluation form, and the KT1000. Student's t tests and chi-square tests were used for data analysis. Forty-eight patients (mean age 28.6+/-11.9 years; 41 males) were classified according to the specific anatomical structures involved. Group A included 12 anterior cruciate ligament (ACL) and medial structure injuries, group B included 11 ACL or posterior cruciate ligament (PCL) ruptures combined with posterolateral injuries, and group C consisted of 25 knee dislocations (ACL and PCL ruptures which might be combined with damage of the collateral ligaments). Thirty-eight patients were surgically treated during the acute phase and ten patients were treated chronically. Forty-four patients (91.6%) were followed up at a mean of 51.3+/-29.9 months. Average Lysholm score was 87+/-12.3; average Tegner score was 5.09+/-2.19 before accident and 4.34+/-2.12 in re-examination; IKDC score was A in 10 cases, B in 22, C in 6, and D in 6. The mean range of motion was 129.9 degrees +/-12.5 degrees . The average loss of extension and flexion were 1.6 degrees +/-2.5 degrees and 7.6 degrees +/-7.9 degrees , respectively. The side-to-side difference in corrected anterior and posterior translation in quadriceps neutral angle and in anterior translation in 30 degrees angle was <3 mm for about 65% of our patients. Surgical treatment of multiple knee ligament injuries, using autografts, provided satisfactory stability, range of motion, and subjective functional results. However, despite the improvement of the quality of life, the preinjury patients' activity level was not fully obtained in re-examination. Patients underwent surgical treatment during the acute phase had better scores in several points, but finally there was no statistical significance between acute and chronic patients. Moreover, no statistically significant differences were observed among the groups with specific damaged anatomical structures.

Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for "isolated" anterior cruciate ligament tear.

Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries. To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft. Case series; Level of evidence, 4. Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment. Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle <17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age <18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C). Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization.

[Examination of the knee joint. The value of clinical findings in arthroscopic control].

Purely clinical examination of the knee joint can, at best, only be regarded as a "screening procedure". Diagnosis with the aid of apparatus (sonography, arthrography, CT, NMR) produces better results. However, arthroscopy performed by an experienced examiner confirms the diagnosis in cases of suspected meniscus injury or isolated lesions of the cruciate ligaments and leads to early and therefore optimal therapy. In a retrospective study 300 arthroscopies performed in 1985 were selected and evaluated. In 1986/87, a further 300 patients were clinically examined prospectively, according to the same criteria, and findings were compared with the arthroscopy performed the following day. Clinically, in 287 patients with multiple diagnoses, internal meniscus lesions were diagnosed in 162 cases (54%), external meniscus lesions in 38 (13%), chondropathia patellae in 54 (18%), and old ruptures of the cruciate ligaments in 46 (15%). In 13 patients no diagnosis could be established. Arthroscopically, pathology of the internal meniscus was found in 98 (33%) of the 300 patients, of the external meniscus in 40 (13%), cartilage damage in 103 (34%), old cruciate ligament ruptures in 51 (17%), and recent anterior cruciate ligament ruptures in 156 (52%); in 40 cases findings were normal. At 78%, the highest positive predictive value (proportion of tentative clinical diagnoses confirmed by arthroscopy) was found in cases of old ruptures of the anterior cruciate ligament, followed by external meniscus lesions (61%) and internal meniscus lesions (55%); i.e., only 55 out of 100 clinically suspected internal meniscus lesions are diagnosed by arthroscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior cruciate ligament injury

Most ACL injuries can be diagnosed by examining the knee and comparing it to the other, non-injured knee. When a doctor suspects ACL injury in a person who reports a popping sound in the knee followed by swelling, pain, and instability of the knee joint, they can perform several tests to evaluate the damage to the knee. These tests include the pivot-shift test, anterior drawer test, and Lachman test. The pivot-shift test involves flexing the knee while holding onto the ankle and slightly rotating the tibia inwards. In the anterior drawer test, the examiner flexes the knees to 90 degrees, sits on the person's feet, and gently pulls the tibia towards him or herself. The Lachman test is performed by placing one hand on the person's thigh and the other on the tibia and pulling the tibia forward. These tests are meant to test whether the ACL is intact and therefore able to limit the forward motion of the tibia. The Lachman test is recognized by most authorities as the most reliable and

[Surgical treatment of posteromedial corner injury combined with cruciate ligament rupture of knee].

To investigate the methods and effectiveness of surgical treatment for posteromedial corner (PMC) injury combined with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) ruptures. Between February 2009 and February 2012, 15 patients (15 knees) with PMC injury combined with ACL and PCL ruptures underwent PMC repair with suture anchor and ACL and PCL reconstruction. There were 7 males and 8 females with an average age of 39 years (range, 15-59 years). The causes of injury were traffic accident injury in 6 cases, sport injury in 7 cases, and sprain injury in 2 cases. The disease duration was 3-15 days with an average of 7 days. All patients presented positive results of anterior drawer test, posterior drawer test and valgus stress test, and dysfunction of knee joint. Of 15 cases, 3 had ACL and PCL ruptures, 5 had ACL rupture, 3 had ACL injury at the attachment point of the condyles crest, and 4 had PCL rupture; 9 had PMC tear at the femur insertion, 5 had PMC tear at the tibia insertion, and 1had PMC tear in the body area. All incisions healed by first intention with no complication of infection or stiffness of knee. All cases were followed up 18.4 months on average (range, 10-36 months). At last follow-up, 14 cases had normal knee flexion and extension ranges, but 1 case had 10 degree limitation of the knee extension. Except 1 case which had weakly positive valgus stress test, the other patients showed negative results of anterior drawer test, posterior drawer test, and valgus stress test. Based on the improved Lysholm classification standard, the results were excellent in 8 cases, good in 5 cases, and fair in 2 cases; the excellent and good rate was 86.7%. Early repair of the PMC and reasonable reconstruction of cruciate ligament can effectively restore the knee stability for patients with PMC injury combined with ACL and PCL ruptures.

[Anatomical reconstruction of posterolateral complex in treatment of multi-ligament injury of knees].

To evaluate the short-term effectiveness after static anatomical reconstruction of posterolateral complex (PLC) in the treatment of traumatic multi-ligament injury of the knee. Between June 2007 and July 2011, 23 cases of multi-ligament injury of the knee were treated. There were 15 males and 8 females with an average age of 41 years (range, 19-56 years). The injury was caused by traffic accident in 9 cases, sprain in 7 cases, bruise in 3 cases, and falling from height in 4 cases. The time between injury and operation was 13-78 days (mean, 32 days). The results of posterior drawer test and Lachman test were positive, and all cases complicated by varus and external rotation instability. The Lysholm score of the knee was 43.4 +/- 5.7. According to International Knee Documentation Committee (IKDC) scoring, all were rated as grade D. According to Fanelli typing, all were classified as type C. The X-ray films showed that load-induced posterior motion of the knee was (13.3 +/- 4.2) mm; the lateral joint space was (15.1 +/- 2.4) mm. Anterior cruciate ligament/posterior cruciate ligament and PLC were reconstructed simultaneously with auto-semitendinosus, gracilis tendon, and allogeneic tendon. All incisions healed by first intention, and no complication occurred. All patients were followed up 12-56 months (mean, 28 months). At last follow-up, the results of posterior drawer test and Lachman test were negative; 3 cases had varus instability, and 2 cases had external rotation instability. The Lysholm score of the knee was 85.6 +/- 16.7, showing significant difference when compared with preoperative score (t=-11.469, P=0.000). According to IKDC scoring, 7 cases were rated as grade A, 12 as grade B, and 4 as grade C; significant difference was found when compared with preoperative value (Z=4.285, P=0.000). The load-induced posterior motion of the knee was (5.1 +/- 4.4) mm, the lateral joint space was (3.2 +/- 2.8) mm, showing significant differences when compared with preoperative ones (P < 0.05). In the treatment of traumatic multi-ligament injury of the knee, the anatomical reconstruction of the PLC using auto-semitendinosus, gracilis tendon, or allogeneic tendon can obtain good short-term effectiveness.

Primary repair plus intra-articular iliotibial band augmentation in the treatment of an acute anterior cruciate ligament rupture. A follow-up study of 70 patients.

Between September 1987 and November 1989, we treated 90 consecutive patients with an acute anterior cruciate ligament (ACL) rupture with the multiple suture technique and iliotibial band augmentation. Seventy of these patients were re-examined 2 to 5 years after the operation (mean 3.5 years), the examination consisting of a questionnaire, clinical examination, laxity tests with the KSS machine (Acufex), radiological examination and isokinetic muscle strength testing (Cybex 6000). There were 32 men and 38 women (mean age 34 years). The injury was sustained in sports in 44 (63%) cases, and the sports most frequently involved were downhill skiing (18 cases), soccer (9 cases) and volleyball (5 cases). Of the injuries, 38 were isolated ACL ruptures and 31, ACL ruptures combined with a medial CL rupture. In 9 cases, an additional meniscus injury and in one case an additional posterior CL - lateral CL rupture was found. At the follow-up, 55 patients (79%) were satisfied with the end result, and according to our objective functional criteria 55 (79%) had an excellent or good outcome. According to the Lysholm score, 53 (76%) patients were excellent or good (> or = 82 points). In the Lachman test, 29 knees (41%) were completely stable. The Lachman test was mildy positive in 40 knees (57%) (36 had 1+ laxity and 4, 2+ laxity), and one patient had 3+ laxity with a hard end-point. Similarly, the anterior drawer test was negative in 53 knees (76%), and the other 17 (24%) had mild laxity (16 had 1+ laxity and 1, 2+ laxity). The total anterior-posterior laxity measured with the KSS averaged 9.7 +/- 3.5 mm in the injured knee and 7.3 + 3.0 mm in the uninjured knee (the laxity measured at a knee angle of 20 degrees of flexion). Corresponding values at a knee angle of 90 degrees of flexion were 6.1 +/- 2.4 mm and 4.7 +/- 1.9 mm, respectively. The pivot shift test was negative in 62 patients (89%) and 1+ positive in the remaining 8 patients (11%). Fifty-eight patients (83%) had full knee extension and 40 patients (57%), full knee flexion. Compared with the uninjured knee, the operated knees showed an average 14% strength deficit in isokinetic knee extension and 6% deficit in flexion at the speed of 60 degrees/s. At the speed of 180 degrees/s, the corresponding deficits were 8% and 4%, respectively. Of the 44 patients who were active in sport before the injury, 40 (91%) were able to return to sports. A flexion deficit of 5 degrees or more was associated with thigh muscle atrophy (P < 0.05) and quadriceps weakness, both at the slow speed (P < 0.05) and high speed (P < 0.001) of the isokinetic movement. In conclusion, in an acute rupture of the ACL, primary repair of the ligament with intraarticular iliotibial band augmentation seems to be a good method to restore the functional capacity of the injured knee.

Knee examination

cause medial collateral ligament rupture, meanwhile a varus force can cause lateral collateral ligament rupture. When a person suddenly slows down during running, twisting, or pivoting with valgus force applying on the knee, the anterior cruciate ligament can rupture. Posterior dislocation of the tibia can cause posterior cruciate ligament injury. Twisting and pivoting while bearing weight can cause tearing of the meniscus. Fractures of the knee are less common but should be considered if direct trauma to the knee has occurred such as during a fall. Examples of fractures involving knee joints are: tibial plateau fractures, fractures of the lateral condyle of femur, medial condyle of femur, and patellar fractures.

Posterior cruciate ligament

An additional test of posterior cruciate ligament injury is the posterior sag test, where, in contrast to the drawer test, no active force is applied. Rather, the person lies supine with the leg held by another person so that the hip is flexed to 90 degrees and the knee 90 degrees. The main parameter in this test is step-off, which is the shortest distance from the femur to a hypothetical line that tangents the surface of the tibia from the tibial tuberosity and upwards. Normally, the step-off is approximately 1 cm, but is decreased (Grade I) or even absent (Grade II) or inverse (Grade III) in injuries to the posterior cruciate ligament. The posterior drawer test is one of the tests used by doctors and physiotherapists to detect injury to the PCL. Patients who are suspected to have a posterior cruciate ligament injury should always be evaluated for other knee injuries that often occur in combination with an PCL injuries. These include cartilage/meniscus injuries, bone bruises, ACL

[Knee injuries in general practice].

Careful technique of examination of the knee joint allows to establish the diagnosis of the most frequent knee joint injuries already through simple clinical and radiological evaluation: Recurrent dislocation of the patella with the Apprehension sign; meniscal injuries with the test of McMurray, pain on the joint line and pain on passive hyperextension; the anterior cruciate ligament tear with Lachman's sign and the Pivot Shift test and posterior cruciate injury with the Sag sign. Further imaging techniques allow to establish a definite diagnosis, which has replaced in many cases the classical, purely diagnostic arthroscopy. Thanks to careful aspiration of the knee joint the patient can be referred with a more precise diagnosis to the traumatologist and orthopaedic surgeon. Meniscal lesions don't have to be treated as emergencies with exception of the locked knee. Equally, in presence of a fresh tear of the anterior cruciate ligament a delay of surgery for eight weeks may be beneficial, be it only to rehab and prepare the knee joint for surgery. Posterior cruciate ligament tears should only be treated by a few centers, since they demand a high degree of experience. The same accounts for the new techniques for the treatment of cartilage lesions like the mosaicplasty or the autologous chondrocyte implantation.

[Primary clinical results of double-bundle anterior cruciate ligament reconstruction with semitendinosus allografts].

To evaluate the primary clinical results of double-bundle anterior cruciate ligament reconstruction (ACLR) with semitendinosus allografts. From March 2006 to October 2006, 33 patients underwent double-bundle ACLR with semitendinosus allografts. The complete followed-up data of 31 patients was analyzed retrospectively. There were 24 males and 7 females aged 18-35 years old (average 25 years old). The injury was caused by sports accidents in 23 cases and traffic accidents in 8 cases, involving the left knee in 18 cases and the right knee in 13 cases. Anterior cruciate ligament rupture were confirmed by MRI and arthroscopy in all the patients, without lateral collateral ligaments injuries and posterior cruciate ligament injuries. The time from injury to operation was 1-43 months (average 11 months). The knee was fixed at 0 degree position after operation for 2 weeks and got knee joint rehabilitation exercises gradually. The incision of 2 patients showed effusion 4 and 7 days after operation, respectively, and healed after symptomatic treatment. The incision of 29 patients healed by first intention. There were no complications such as stiffness of knee joint, neurovascular injuries and joint infections. All the patients were followed up for 24-29 months (average 26 months). MRI displayed the anterior cruciate ligament grafts presented with good connection and signal similar to the normal 2 years after operation. There was significant difference between the preoperational value and the final follow-up value in terms of bilateral knee joint difference of prior laxity, Lachman test, and pivot shift test (P < 0.05 ). The circumference difference between the injured and the normal was (11.6 +/- 7.9) mm before operation and (5.0 +/- 3.1) mm at the final follow-up (P < 0.05). The Tegner score, Lysholm score, and International Knee Documentation Committee score was 3.83 +/- 1.15, 64.38 +/- 6.81, and 41.42 +/- 6.30, respectively, before operation, and 6.29 +/- 0.64, 94.45 +/- 3.03, and 95.72 +/- 3.10, respectively, at the final follow-up. There was a significant difference between before and after operation (P < 0.05). The primary clinical results of double-bundle ACLR with semitendinosus allografts are satisfactory and the allogeneic semitendinosus are good grafts for double-bundle ACLR.

Gravity-assisted pivot-shift test for anterior cruciate ligament injury: a new procedure to detect anterolateral rotatory instability of the knee joint.

The denominated gravity-assisted pivot-shift test was introduced as a new procedure to detect anterolateral rotatory instability of the knee joint. The patient lies in the supine position or slightly rotated onto the affected side. The affected knee flexed approximately 60 degrees and the ipsilateral hip flexed, abducted and externally rotated so that the plane of the knee motion runs parallel to the floor. The examiner instructs the patient to raise the affected leg off the examining table and to extend the affected knee gradually. If the lower leg is internally rotated suddenly, with the knee subluxated at an angle of approximately 20 degrees , followed by the reduction in flexion, this test is regarded as positive. This test was investigated on 51 anterior cruciate ligament (ACL) deficient knees, being positive in 30 knees (Group P) and negative in 21 (Group N) with the positive rate of 59%. There was no significant correlation between the result of this test and the clinical features, but Group N included relatively small number of females and recurrent injuries tended to occur more frequently in Group P. Thirty-six knees received ACL reconstruction subsequently. There was no statistically significant difference between the groups in the side-to-side difference in anterior knee laxity at one year postoperatively. However, three patients with the side-to side difference of more than 3 mm belonged to Group P. Relatively low positive rate in ACL deficient knees suggests that it may not be used as a diagnostic procedure for ACL injury. It is possibly used for the prediction of high risk patients for symptomatic giving-way and/or patients with poor prognosis after ACL reconstruction.

Cruciate ligament

In animals the two cruciate ligaments that cross the inside of the knee joint are referred to as the cranial cruciate (equivalent to anterior in humans) and the caudal cruciate (equivalent to the posterior in humans). The cranial cruciate ligament prevents the tibia from slipping forward out from under the femur. Stifle injuries are one of the most common causes of lameness in rear limbs in dogs, and cruciate ligament injuries are the most common lesion in the stifle joint. A rupture of the cruciate ligament usually involves a rear leg to suddenly become so sore that the dog can barely bear weight on it. How a rupture can occur: There are several ways a dog can tear or rupture the cruciate ligament. Young athletic dogs can be seen with this rupture if they take a bad step while playing too rough and injure their knee. Older dogs, especially if overweight, can have weakened ligaments that can be stretched or torn by simply stepping down off the bed or jumping.

[Effect of external extra-articular ligament plasty on the results of anterior cruciate ligament reconstruction with patellar tendon, a 4 years follow-up].

The purpose of this study was to compare the functional results obtained when an external extra-articular plasty was added to an anterior cruciate ligament (ACL) reconstruction using an autologous bone tendon-bone patellar tendon graft. The authors analyzed two consecutive series of 60 and 50 patients operated by the same surgeon for a chronic rupture of the anterior cruciate ligament, one by reconstruction of the cruciate ligament with a free graft of the patellar tendon supplemented by an external extra-articular plasty made with a quadriceps tendon graft and the second with an isolated free patellar tendon graft. Anterior laxity was measured before and after surgery, by dynamic X-rays and by the Medmetric KT-1000 arthrometer. Functional results were evaluated four years after operation, with the French A.R.P.E.GE score based on sport activity level and intensity. Anterior laxity was not different before operation in both groups and there was no difference between males and females. Medmetric KT-1000 arthrometer showed the same negative differential laxity immediately after surgery in both groups and the same evolution during the first 4 years, without any significant difference on laxity on the middle aspect of the knee. Radiological results were different. After a 4 years follow-up, anterior laxity did not show significant difference on the medial compartment of the knee (5.3 +/- 2.3 mm and 5.5 +/- 1.7 mm), but there was a significant minor laxity in the lateral compartment for the lateral extra-articular plasty group (11.0 +/- 2.3 mm against 14.8 +/- 3.8 mm)(p = 0.002). Functional results and sport activity were similar in both groups. Examination showed 4 positive pivot shift tests (2 "sliding" and 2 positive) in the group with extra-articular plasty, even though 8 positive pivot shift tests in the isolated ACL group (5 "sliding" and 3 positive) were found. This study, as well as five others studies found in literature, was not randomized. In all these series, the surgical techniques, the rehabilitation programs and the functional score evaluation were too different to allow any pertinent comparison. Extra-articular plasty helps to control the laxity of the lateral compartment of the knee which is incompletely controlled by ACL reconstruction, particularly in chronic cases. This is proved by radiological measurements and pivot shift tests. Jensen in 1983, about 205 patients with a 4 year follow-up and Noyes, which used an allograft patellar tendon, found an advantage to do extra-articular plasty. But Strum (in 1989), as O'Brien (in 1991) and Roth (in 1987), did not found any advantage with extra-articular plasty. It is therefore obvious, after a four-year follow-up, that extra-articular supplementation presents an advantage for reconstruction of the ACL. by a free graft of the patellar tendon in chronic cases. Further randomized study will confirm that isolated ACL reconstruction is possible in some well defined categories of anterior laxity.

Anterior cruciate ligament reconstruction

The Anterior Cruciate Ligament is the ligament that keeps the knee stable. Anterior Cruciate Ligament damage is a very common injury, especially among athletes. Anterior Cruciate Ligament Reconstruction (ACL) surgery is a common intervention. 1 in every 3,000 American suffers from a ruptured ACL and between 100,000 and 300,000 reconstruction surgeries will be performed each year in the United States. Around $500 million health care dollar will come from ACL injuries. ACL injuries can be categorized into groups- contact and non-contact based on the nature of the injury Contact injuries occur when a person or object come into contact with the knee causing the ligament to tear. However, non-contact tears typically occur during the following movements: decelerating, cutting, or landing from a jump. ACL injury is 4-6 times higher in females than in males. ACL injuries account for a quarter of all knee injuries in the high school population.</ref> An increased Q angle and hormonal

[The ACL tear from the pre-operative analysis to a 2-year follow-up, influence of the graft choice on the subjective and objective evaluation].

This study is a synthesis of three series. The first study was prospective on 418 patients with an anterior cruciate ligament (ACL) tear (group I). Two population of ACL ruptures were identified. One population with a postero-lateral bundle preserved in 16%, the mean medial anterior tibial translation side to side was 4.97 mm, the Lachman test was delayed in 40% with no or glide pivot shift in 73%. The second population with a complete ACL tear had a mean medial anterior tibial translation side to side of 7.93 mm, the Lachman test was soft in 98% with gross pivot shift in 80%. The second study was a retrospective study on 258 patients (group II) at 26 months follow-up, it correlated the impact of the type of graft on the clinical objective and subjective results. Twenty-eight percent had anterior knee pain, 33% for the patellar tendon and 25% for the hamstrings, the subjective IKDC was significantly lower for the painful knees, and 68% of the patellar tendon had a hypoesthesia and only 32% for the hamstrings. The ability to walk on the knee was 68% for the hamstrings and 35% for the patellar tendon. The third study was retrospective on 127 patients, 24 months after ACL reconstruction (group III), all were tested on a isokinetic machine for the extensor, the flexor and the internal rotator. In the total population, a 10% extensor and flexor deficit and a 5% rotator deficit was noted. A significant difference between patellar tendon and hamstrings in terms of muscular recovery was found. It pointed out that a more specific rehabilitation should be done on the hamstring group. The muscular recovery was correlated to the highest subjective score. This study allowed the surgeon to be more specific in the ACL tear definition, to adapt the graft choice to the type of sport activity but also to the type of work the patient does and finally to modify the rehabilitation protocol for the hamstring technique.

Meniscus tear

A meniscus can tear due to an internally or externally rotated knee in a flexed position, with the foot in a flexed position. It is not uncommon for a meniscal tear to occur along with injuries to the anterior cruciate ligament ACL and the medial collateral ligament MCL — these three problems occurring together are known as the "unhappy triad," which is seen in sports such as football when the player is hit on the outside of the knee. Individuals who experience a meniscal tear usually experience pain and swelling as their primary symptoms. Another common complaint is joint locking, or the inability to completely straighten the joint. This is due to a piece of the torn cartilage preventing the normal functioning of the knee joint.

[Ligamentoplasty of the anterior cruciate ligament after 40 years: a series of 41 patients].

Ligamentoplasty for tears of the anterior cruciate ligament (ACL) is generally thought to be unreliable after the age of 40 years. The purpose of this retrospective analysis was to assess the five-year outcome after ACL plasty in patients aged over 40 at the time of surgery. Between 1990 and 1997, 41 patients aged 44.5 +/- 4.5 years (28 men, 25 right side) underwent intra-articular reconstruction of the ACL. Clinical and radiological assessment using the IKDC criteria was obtained at a mean 62 months postoperatively using manual instrumental measurements with KT-1000. The indication for reconstruction was instability in daily life activities for 40 patients and difficulties encountered in sports activities in one; there were three cases of remodeling. Arthroscopy was used in all cases to perform a patellar tendon graft (bone-tendon-bone in 30 cases associated with extra-articular lateral reinforcement in eleven). There were no significant complications. Among 12 patients who initially participated in competition sports, seven were able to resume their activity at their former level. At last follow-up, global IKDC score was A for 12, B for 25, and C for three and D for one. All patients scored C or D had a poor IKDC symptom score, basically because of pain. Motion was not modified. The IKDC radiology score was A for 25, B for 15 and C for one, but the three cases of remodeling did not progress. Prognostic factors for overall IKDC result were: age of the patient at the time of reconstruction (under 45 years), and the delay to surgery for accident victims (less than one year). The following criteria had no effect at last follow-up: gender, sport practiced, type of initial laxity (anterior alone or global anterior), presence of meniscal damage, preservation of the medial and/or lateral meniscus, chondral injury observed peroperatively, and use of a lateral reinforcement. Radiographic remodeling observed in this group of 41 patients was related to delay from accident to surgery (p=0.0007) and preservation of the medial meniscus (p=0.03). Age, gender, type of activity before surgery, degree of initial and residual laxity had no statistically significant effect on remodeling. Age over 40 years is not a contraindication for arthroscopic free patellar tendon graft for the treatment of chronic anterior laxity. Using rigorous preoperative assessment criteria (delay from accident to surgery, absence of joint space narrowing on the AP and lateral view before intervention, symptomatic instability in daily life activities and motivated patient) this type of procedure can be performed safely and provides good functional outcome at five years. The current follow-up is insufficient to judge potential joint degradation. Age is not a contraindication if certain precautions are taken.

Drawer test

The drawer test is used in the initial clinical assessment of suspected rupture of the cruciate ligaments in the knee. The patient should be supine with the hips flexed to 45 degrees, the knees flexed to 90 degrees and the feet flat on table. The examiner positions himself by sitting on the examination table in front of the involved knee and grasping the tibia just below the joint line of the knee. The thumbs are placed along the joint line on either side of the patellar tendon. The tibia is then drawn forward anteriorly. An increased amount of anterior tibial translation compared with the opposite limb or lack of a firm end-point may indicate either a sprain of the anteromedial bundle or complete tear of the ACL. If the tibia pulls forward or backward more than normal, the test is considered positive. Excessive displacement of the tibia anteriorly suggests that the anterior cruciate ligament is injured, whereas excessive posterior displacement of the tibia may indicate injury of

[Diagnosis of anterior cruciate ligament injury of the knee joint].

From January, 1979 to May, 1989, 107 patients with problems related to anterior cruciate ligament (ACL) were treated in our hospital. 100 of the patients had anterior cruciate ligament injury confirmed by arthrotomy or arthroscopy. The remaining 7 patients were found to be normal either by arthroscopy or arthrotomy. 29 patients had fresh ACL injury and 71 old. All the patients had history of trauma of the knee joint. Swelling and pain in the affected knee joint took place in fresh cases and few of them complained of instability or deformity of the knee. On examination, floating patella test was positive in the majority of the fresh cases. It was shown that accurate diagnosis could be made by Lachman test rather than by conventional anterior drawer test in dealing with fresh injury, but with old ones, Lachman test didn't show the advantages. Examination under anesthesia or arthroscopy helped a lot in diagnosing fresh ACL injury. Anterior drawer test (ADT) was significant in determining the existence of ACL injury. When ADT was positive, ACL injury was found in the majority of the cases, however, injured ACL couldn't be ruled out by negative ADT only. Positive valgus stress test on 0 degrees position suggests possibility of ACL injury, even ADT was negative. Despite the negative anterior drawer test positive posterior drawer test on three directions indicated the injury of the posterior cruciate ligament and the anterior cruciate ligament. The positive rate of ADT was higher than that of pivot shift test in dealing with anterior cruciate ligament injury. Positive pivot shift test suggests ACL injury.

[Repair of old injury of knee medial collateral ligament by a combination of dynamic and static stability].

To observe the effectiveness of the combination of dynamic and static stability in the treatment of old knee medial collateral ligament injury. Between March 2004 and June 2008, 26 cases of old knee medial collateral ligament injury were treated, including 19 males and 7 females with a mean age of 38 years (range, 21-48 years). Injury was caused by traffic accident in 6 cases, by sprains in 12 cases, by falling from height in 8 cases. The location was left knee in 15 cases and right knee in 11 cases. Of them, 24 patients showed the positive result of knee valgus test, 2 cases showed slightly relaxed knee tendon. The knee X-ray films of valgus stress position showed that the medial joint space differences between both knees were 3-5 mm in 2 cases and 5-12 mm in 24 cases. The injuries included avulsion of the medial femoral condyle starting point in 19 cases, central laceration in 6 cases, and tibial point laceration concomitant meniscus injury in 1 case. The time from injury to hospitalization was 3-14 months (mean, 6.4 months). Gracilis muscle was used to repair knee medial collateral ligament and the sartorius muscle transfer to reconstruct the medial rotation of knee stability function. All incisions healed by first intention. No joint infection, deep vein thrombosis, or other postoperative complications occurred. Twenty-six cases were followed up 12-58 months with an average of 30 months. The results of knee valgus stress test were negative with no joint tenderness. At 3 months after operation, the knee X-ray films of valgus stress position showed the medial joint space differences between both knees were less than 1 mm. According to the modified Lysholm-Scale score, the results were excellent in 18 cases, good in 7 cases, and fair in 1 case with an excellent and good rate of 96% at last follow-up. A combination of dynamic and static stability in repairing old knee medial collateral ligament injury is easy-to-operate and has the advantages to perform the operation in the same incision, so it can avoid the shortcomings of single repair method and achieve better effectiveness.

[Intrafix fixation and remnants preservation in single-tunnel double-bundle reconstruction of anterior cruciate ligament with anatomical placement of hamstring tendons].

To study the feasibility and short-term effects of Intrafix fixation and remnants preservation in single -tunnel double-bundle reconstruction of anterior cruciate ligament (ACL) with anatomical placement of hamstring tendons. From August 2011 to November 2011, 25 patients with ACL injuries were treated with arthroscopic reconstruction of ACL using hamstring tendon. There were 19 males and 6 females, with a mean age of (26.26 +/- 9.53) years (ranged, 16 to 50 years). Fifteen patients had injuries in left knees, and 10 patients had injuries in right knees. The duration of the disease ranged from 1 to 60 d, with a mean of 9.6 d. All patients with acute injuries had swelling and pain on the knee, and anterior drawer test showed positive results in 14 cases, Lachman test showed positive results in 17 cases. Among patients with old injuries, 5 patients had knee joint pain, 5 patients had unstability of knee joint, 5 patients had positive results of anterior drawer test, and 5 patients had positive results of Lachman test. The diagnosis of ACL injury was determined by the anterior drawer test and Lachman test. There were 20 patients with acute injuries and 5 patients with old injuries. MRI was performed in all patients to confirm the diagnosis of ACL injuries and provide additional information on meniscal and other ligament injuries. Preservation of the remnants was through patellar tendon portal using meniscus suture guide. The femoral tunnel was placed at lateral femoral condyle at 2:00 or 10:00 position through the anteromedial (AM) portal with the knee flexed to 120 degree using an offset guide (DePuy Mitek). The tibia tunnel was placed at the center of the ACL remnant through the AM portal using a tibia guide set 45 degree. The AM and PL bundles were rotated by rotating the positioning tool to achieve the desired positions of the bundles and were fixed by femoral Intrafix and tibia Bio-Intrafix fixation. The anterior drawer test, Lachman test and Lysholm scores were observed to determinate the function of the knee and the activity of the patients. All the patients were followed up, and the duration ranged from 12 to 18 months. The Lysholm scores improved from preoperative 34.08 +/- 7.60 (25 to 49 scores) to 94.52 +/- 2.86 (89 to 98 scores) at the follow-up time (t = 21.29, P < 0.01). No postoperative complications such as synovitis, ligament rupture and movement restriction occurred. Intrafix fixation and remnants preservation in single-tunnel double-bundle reconstruction of ACL with anatomical placement of hamstring tendons is simple, effective, useful, reproducible, and gives a satisfactory short-term results.

[Evaluation of the clinical results in patients with symptomatic partial tears of the anterior cruciate ligament diagnosed arthroscopically].

The study presents a retrospective evaluation of clinical data and arthroscopic findings in a group of our patients with symptomatic knee instability due to a partial tear of the anterior cruciate ligament (ACL). The group included 31 patients diagnosed with symptomatic partial ACL tears, i.e. an isolated tear of the posterolateral (PL) or the anteromedial (AM) bundle. The patients' average age was 26.5 years. A side-to-side difference in ventral knee laxity was assessed using the anterior drawer test and the Lachman test under general anaesthesia before arthroscopy was commenced; rotational knee laxity was evaluated by the pivot shift test. An objective evaluation of side-to-side ventral laxity differences in both knees was performed on the GNRB® arthrometer with an applied pressure of 134 N and 250 N in the conscious patient. During arthroscopic examination, findings on the two ACL bundles were recorded. All 31 patients were diagnosed with symptomatic partial ACL tears, of them 22 had a PL bundle lesion and nine had an AM bundle tear. All patients with PL bundle lesions only reported problems in association with pivot sports, and all patients with AM bundle tears had problems regardless of any sports activities. In all patients with isolated AM bundle tears, the lesion was located close to its femoral attachment. In the patients with PL bundle tears, femoral location was found in 68% and tibial location in 32% of the patients. In the patients with partial PL bundle lesions, + and ++ results in the pivot shift test were recorded in 32% and 68% of the treated patients, respectively. The Lachman test showed + and ++ results in 71% and 9% of the patients, respectively. The anterior drawer test had negative results in 87% and positive + results in 13% of the patients. The side-to-side difference on the GNRB arthrometer ranged from 0.4 to 2.3 mm at a pressure of 134 N and from 1.2 to 4.2 mm at 250 N in the patients with isolated PL bundle lesions. In the patients with AM bundle lesions, the results were as follows: pivot shift test, 89% negative. 11% positive +; Lachman test, 56% negative, 44% positive +; anterior drawer test, 89% +, 11% ++; GNRB test, 2.2 to 4.4 mm at 134 N, and 4.3 to 7.1 at 250 N. The diagnosis of partial ACL lesions, i.e., isolated tears of the AM or the PL bundle, requires accurate knowledge of knee anatomy and its biomechanics. In accordance with other authors our results showed that an arthroscopic examination of both bundles of the ligament as well as knee laxity evaluation under general anaesthesia are most essential for making the definite diagnosis in partial ACL tears. They also confirmed that, in isolated AM bundle lesions, ventral laxity is present more often particularly at a higher degree of knee flexion while, in PL bundle lesions, rotational laxity is more frequent and ranges from 0 to 30 degrees of knee flexion. To make the definite diagnosis of partial ACL tears, patient medical history, clinical knee examination including instability type and degree assessment under general anaesthesia and, most importantly, arthroscopic findings on both ACL bundles are necessary.

[Meniscus lesions after isolated anterior cruciate ligament rupture].

In this retrospective study the meniscal status of 34 patients with untreated complete anterior cruciate ligament (ACL) tears is reported. The anterior cruciate ligament injury was initially documented by examination under anesthesia and arthroscopy. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. The mean follow-up was 7.3 years. Twenty-two (65%) patients showed signs of meniscal pathology at an average of 2.5 years after the ACL injury during the follow-up period. Rearthroscopy was performed and showed a higher incidence of medial meniscus tears (53%) than lesions of the lateral meniscus (41%). The most common tear of the medial meniscus was the bucket-handle type, followed by the flap tear and the single longitudinal split of the posterior horn. Secondary reconstruction of the ACL was necessary in 18 patients (82%) complaining of symptoms indicative of permanent anterior instability of the knee. The remaining 4 patients had rearthroscopy 3.5 years after the ACL injury and a partial meniscectomy and ACL reconstruction was performed. 12 patients (35%) had no symptoms or signs of joint instability or meniscal pathology during the follow-up period, but discontinued their sporting activities. This study indicates the increasing incidence of meniscal tears during ACL insufficiency. We recommend that patients with ruptures of the anterior cruciate ligament should be investigated for meniscal tears and that early ligament reconstruction of the knee and meniscal repair or partial meniscectomy should be considered simultaneously.

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).

Shelbourne's update of the O'Donoghue knee triad in a 17-year-old male Rugby player.

Acute athletic knee injuries are often caused by a combination of valgus impact with external rotation of the tibia leading to a triad of injuries involving medial collateral and anterior cruciate ligament disruption with associated meniscal damage. This injury pattern has been greatly discussed in the literature with conflicts of opinion and evidence as to whether medial or lateral meniscal pathology has a higher incidence. This case report introduces a 17-year-old male athlete with this unhappy triad It will evaluate the clinical assessment which suggested a medial meniscal lesion follow the patient through arthroscopy revealing a lateral meniscal tear in addition to complete anterior cruciate ligament rupture and grade 2 medial collateral ligament tear. It will go on to look at the evidence base for the relative incidence of lateral and medial meniscal injuries and will evaluate the role of MRI in assessing acute athletic knee injuries.

[Early Operative Treatment of Anterior Cruciate Ligament Lesions: 3-Year Experience].

PURPOSE OF THE STUDY The aim of this study is to show new possibilities for the treatment of anterior cruciate ligament injuries. For many years, the long-established rules have been followed. However, throughout history, treatment strategies have been gradually modified. The advent of new modern technologies now makes it possible to perform reconstructive procedures already in the acute phase, and thus shorten the treatment time significantly. MATERIAL AND METHODS 85 patients were followed after an acute knee injury with an isolated anterior cruciate ligament (ACL) lesion. There were 51 men and 34 women with the average age of 32 years. All patients underwent an acute knee arthroscopy with subsequent ACL reconstruction according to the type of lesion. The results were evaluated according to the clinical examination, Lysholm and Tegner activity scores. We compared 2 surgical techniques (Internal Brace, All-Inside ACL reconstruction) and assessed the possible occurrence of complications. RESULTS The injury was most often observed in patients aged 20-40 years, when mainly sports activities put a major strain on the knee joint. After performing ACL reconstruction, all patients reported a subjective improvement in the overall condition. The number of complications was very low - only in connection with a slower warm-up of the knee joint after surgery. DISCUSSION All patients achieved full stabilization of the knee joint, which is objectified by an increase in the Lysholm score. The improvement in patient's subjective feelings is also confirmed by the increase in Tegner activity scores. Only a few patients experienced a slight restriction of movement in the 8th week after surgery, but thanks to intensive rehabilitation the function of the knee joint was completely restored within 3 months of the operation. CONCLUSIONS Our study proves that if the set rules are followed, it is possible to perform the ACL reconstruction already in the acute phase. However, in order to choose this approach, the patient's motivation, gently performed procedure and early intensive rehabilitation are necessary. When meeting these criteria, the patient is able to return to normal life, including sports activities, quite early and there is no increased risk of complications. Key words: Internal Brace, ACL reconstruction, arthroscopy, early, rehabilitation, All-Inside.

Drawer test

See also Anterior cruciate ligament injury Posterior cruciate ligament injury Lachman test References Examination of the knee

Arthroscopic prevalence of ramp lesion in 868 patients with anterior cruciate ligament injury.

A special type of repairable meniscal lesion involving the peripheral attachment of the posterior horn of the medial meniscus is commonly associated with anterior cruciate ligament deficiency and is termed a "ramp lesion." However, there are no previously published articles reporting the epidemiologic characteristics of ramp lesions. The ramp lesion is a special type of medial meniscal tear with high prevalence associated with anterior cruciate ligament rupture; the prevalence increases with time from anterior cruciate ligament injury. Age and gender are risk factors affecting the prevalence of the ramp lesion. Cross-sectional study; Level of evidence, 3. From April 2002 to October 2007, 868 consecutive knees were diagnosed as having an anterior cruciate ligament injury and received arthroscopic surgery for anterior cruciate ligament reconstruction. All the patients had verified tears of the ramp area under arthroscopy. The prevalence of the ramp lesion was evaluated retrospectively. Then, all cases were divided into different groups depending on the time interval from anterior cruciate ligament injury to anterior cruciate ligament reconstruction and other relevant risk factors such as age and gender. The effects of age, gender, and time from injury on the prevalence of ramp lesions were analyzed. Among 868 knees that underwent surgery for anterior cruciate ligament reconstruction, 144 knees were diagnosed as having a ramp lesion. The mean age was 24.7 years; there were 113 male and 31 female patients. The mean time from injury to anterior cruciate ligament reconstruction was 27.2 months. The prevalence of ramp lesions was 16.6%, which was analyzed as a logarithmic correlation with time from injury. Patients younger than 30 years of age and male patients had a significantly higher prevalence of ramp lesions. The ramp lesion is a common meniscal injury that can occur at the time of anterior cruciate ligament rupture or as a result of knee laxity associated with anterior cruciate ligament insufficiency. The prevalence of ramp lesion in this patient group was 16.6%, which increased with time until 24 months after initial injury. Patients younger than 30 years of age and male patients had a higher prevalence of ramp lesions.

[Mid-term results of 173 cases of surgery of the anterior cruciate ligament using the Mac Intosh procedure, reinforced by the Kennedy Ligament Augmentation Device].

This is a retrospective study of 173 chronic laxities of the knee operated on between May 1985 and December 1988 using the Mac Intosh procedure, reinforced by the Kennedy L.A.D. Follow-up was between 4-8 years and the same surgeon operated on all the knees. 171 patients were operated on (113 men and 58 women) aged between 15-49 years (average age 26.5 years). The vast majority were sportsmen both at competition level (51 cases) and at recreational level (119 cases). The average time-span between accident and intervention was 15 months (1-240 months). In the pre-operative assessment, 80 cases (46.2 per cent) were found to have a grade II Lachman test and 91 cases (52.6 per cent), a grade III Lachman test; a positive pivot shift was found in more than 95 per cent of cases. There were lesions of the medial meniscus in 101 cases (58.4 per cent), of the lateral meniscus in 94 cases (54.4 per cent) and there was no meniscal lesion in only 41 cases (23.8 per cent). Finally there were 22 chondral lesions of the medial femoral condyle (12.7 per cent) and 7 of the lateral condyle (4.1 per cent). These were based on 159 cases (14 lost to follow-up before the third post-operative month), but only 107 (61.8 per cent) were reviewed by one of us (i.e. not the original surgeon). Tolerance of the L.A.D. was excellent. There was no sign of synovitis or joint effusion persisting beyond 1 year. Furthermore, there were no serious complications (no sepsis, only 4 cases (2.3 per cent) of joint stiffness, 2 cases of reflex sympathetic dystrophy and 5 cases of sural phlebitis (2.9 per cent). Moreover, the few minor complications that arose resolved with the appropriate treatment. Anatomical results, evaluated using. Lachmans test (maximum manual Lachman measured with the Bercovy Laximeter) showed 24 cases (22.4 per cent) with zero differential residual laxity, 54 cases (50.5 per cent) with a differential laxity of between 0-2 mm; 20 cases (18.7 per cent) with a laxity of between 2-4 mm and in 9 cases (8.4 per cent) a laxity of greater than 4 mm. Functional results, using the Arpège C.L.A.S. system showed good results in 83 per cent (score > and unsatisfactory results in 17 per cent of cases. The long time-span between intervention and subsequent review with the C.L.A.S. system should be taken into account. However, the proportion of competitive sportsmen to recreational sportsmen was practically identical when comparing pre-traumatic figures (C = 29.5 per cent, R = 68.8 per cent) to figures at the time of follow-up (C = 21 per cent, R = 69.5 per cent). Radiological results (A.P. and Schuss films) showed 63 knees (58.9%) with no signs of either medial or lateral, preliminary or full-blown, femoro-tibial osteo-arthritis. With an average follow-up of > 5 years (4-8 years), it is possible to say that ligamentoplasty of the anterior cruciate ligament using the Mac Intosh procedure reinforced with the Kennedy L.A.D. is not causative of any iatrogenic problems. The anatomical results were totally satisfactory (almost normal) in 72.9 per cent of cases; the radiological results showed ""normal'' knees in 58.9 per cent of cases and functional results were identical to results obtained using many other techniques.

A modified repair for the anterior cruciate ligament deficient knee.

A retrospective analysis of 48 sportsmen and women from an original series of 76 consecutive patients who had undergone a modified McIntosh repair was carried out to establish whether or not the procedure could provide a satisfactory recovery and return to previous ability. The type and level of sport before injury was compared with that after operation. Symptoms of pain and giving way, and examination findings of pivot shift, and Lachman's test were compared before and after operation. Of the 48 patients assessed, 28 (58%) returned to full sporting capacity; 17 (35%) patients were participating in different sports or lower levels of their previous sports, and three patients did not participate in any sport. The more severely symptomatic knees did not perform so well after operation. The degree of preoperative anterior draw and Lachman's test did not influence the final result and the pivot shift, present in all before operation, was abolished in all but one case, which remained badly symptomatic. Concurrent meniscal injury or medial or lateral laxity did not influence return to sport once a full postoperative recovery was made. No deterioration was noticed in the level of sporting ability achieved thereafter. In this study it has been shown that the modified McIntosh repair is a swift extra-articular reconstruction for the anterior cruciate ligament deficient knee, which is less elaborate than previously described Ellison and McIntosh procedures, and which has produced a comparable result.