Answer 1 correct: The Thessaly test is a meniscal exploration maneuver. The statement focuses exclusively on this part of the examination and also explains that it is indeed positive, which leads to the suspicion of a meniscal lesion. "The Thessaly test is a dynamic reproduction of load transmission in the knee joint and is performed at 5° and 20° of flexion. The examiner supports the patient by holding his or her outstretched hands while the patient stands flatfooted on the floor. The patient then rotates his or her knee and body, internally and externally, three times, keeping the knee in slight flexion (5°). Then the same procedure is carried out with the knee flexed at 20°. Patients with suspected meniscal tears experience medial or lateral joint-line discomfort and may have a sense of locking or catching. The theory behind the test is that, with this maneuver, the knee with a meniscal tear is subjected to excessive loading conditions and almost certainly will have the same symptoms that the patient reported. The test is always performed first on the normal knee so that the patient may be trained, especially with regard to how to keep the knee in 5° and then in 20° of flexion and how to recognize, by comparison, a possible positive result in the symptomatic knee." Answer 2 incorrect: At no time do they describe any exploration maneuvers of the anterior cruciate ligament, nor do they mention any trauma that may have injured it. Answer 3 incorrect: At no time do they describe any exploration maneuvers of the posterior cruciate ligament, nor do they mention any trauma that could have injured it. Wrong answer 4: Although it could occur, it is not to be expected in a 41 year old person with an acutely established clinical condition.

[HIDDEN]: The Thessaly test is a meniscal exploration maneuver. The statement focuses exclusively on this part of the examination and also explains that it is indeed positive, which leads to the suspicion of a meniscal lesion. "The Thessaly test is a dynamic reproduction of load transmission in the knee joint and is performed at 5° and 20° of flexion. The examiner supports the patient by holding his or her outstretched hands while the patient stands flatfooted on the floor. The patient then rotates his or her knee and body, internally and externally, three times, keeping the knee in slight flexion (5°). Then the same procedure is carried out with the knee flexed at 20°. Patients with suspected meniscal tears experience medial or lateral joint-line discomfort and may have a sense of locking or catching. The theory behind the test is that, with this maneuver, the knee with a meniscal tear is subjected to excessive loading conditions and almost certainly will have the same symptoms that the patient reported. The test is always performed first on the normal knee so that the patient may be trained, especially with regard to how to keep the knee in 5° and then in 20° of flexion and how to recognize, by comparison, a possible positive result in the symptomatic knee." [HIDDEN]: At no time do they describe any exploration maneuvers of the anterior cruciate ligament, nor do they mention any trauma that may have injured it. [HIDDEN]: At no time do they describe any exploration maneuvers of the posterior cruciate ligament, nor do they mention any trauma that could have injured it. [HIDDEN]: Although it could occur, it is not to be expected in a 41 year old person with an acutely established clinical condition.

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

Injury due to rupture of the anterior cruciate ligament.

Injury due to rupture of the posterior cruciate ligament.

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.

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)

[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.

[Mid-term effectiveness of arthroscopic anterior cruciate ligament reconstruction combined with meniscus allograft transplantation].

To summarize the mid-term effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction combined with meniscus allograft transplantation. A clinical data of 21 patients treated with arthroscopic ACL reconstruction and meniscus allograft transplantation and followed up more than 5 years between February 2007 and December 2014 was retrospectively analyzed. There were 12 males and 9 females, aged from 18 to 45 years, with an average age of 23.5 years. The cause of injury was sport sprain in 15 cases, falling in 4 cases, and traffic accident in 2 cases. The time from injury to operation ranged from 2 to 36 months, with an average of 12 months. Among them, 15 patients underwent previous meniscectomy, with an average interval of 1.6 years (range, 3 months to 6.5 years). All patients were primary ACL reconstruction. Preoperative anterior drawer test, Lachman test, and pivot shift test were positive. Lysholm score was 43.6±10.2. International Knee Documentation Committee (IKDC) score was 60.50±14.06. Of the 21 patients, 10 were gradeⅠ-Ⅱcartilage injuries and 11 were grade Ⅲ cartilage injuries according to MRI. All patients were followed up 5.1-7.8 years, with an average of 5.5 years. There were 2 cases of numbness of lower extremity, 3 cases of slight exudation of incision, 2 cases of articular movement bounce, 5 cases of mild joint swelling and pain after exercise. At last follow-up, Lachman tests were negative in 18 cases and positive in 3 cases; anterior drawer tests were negative in 19 cases and positive in 2 cases; pivot shift tests were negative in all cases. Lysholm score was 84.5±16.5 and IKDC score was 85.25±4.60, which were significantly higher than those before operation ( <iP</i<0.01). The flexion and extension of the affected knee joint were (128±13) and (3±7)°, respectively, which were smaller than those of the healthy knee joint [(133±15), (0±5)°] ( <iP</i<0.01). The results of KT-1000 test showed that when knee flexion was 30 and 90°, tibial anterior displacement of affected side [(2.35±1.20), (1.60±1.15) mm] were not significantly different from those of healthy side [(1.20±1.10), (1.10±1.03) mm] ( <iP</i>0.01). MRI showed that the ACL graft was in normal position and meniscus survived well. Cartilage injuries were gradeⅠ-Ⅱ in 18 cases and grade Ⅲ in 3 cases. For patients with severe meniscus injury and ACL rupture, ACL reconstruction combined with meniscus allograft transplantation can restore the stability of the joint, recover the meniscus function which is conducive to the protection of articular cartilage and obtain satisfactory mid-term effectiveness.

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

[CLINICAL OBSERVATION OF ONE-STAGE ARTHROSCOPIC RECONSTRUCTION AND STRICT IMMOBILIZATION FOR TREATMENT OF KNEE DISLOCATION].

To investigate the effectiveness of one-stage arthroscopic reconstruction and strict immobilization for 6 weeks for treatment of knee dislocation. Between August 2010 and May 2013, 22 cases (22 knees) of knee dislocation were treated with one-stage reconstruction and strict immobilization for 6 weeks. There were 15 males and 7 females, aged 21-54 years (mean, 31.5 years). The left knee and right knee were involved in 8 cases and 14 cases respectively. The disease causes were traffic accident in 12 cases, falling from height in 6 cases, and sports injury in 4 cases. The time between injury and operation was less than 2 weeks in 6 cases, 2-3 weeks in 10 cases, and more than 3 weeks in 6 cases. The results of anterior drawer test, posterior drawer test, and Lachman test were positive in all patients. The posterior displacement of the tibia was more than 10 mm. The results of valgus stress test and varus stress test were positive in 13 cases and 11 cases respectively. The preoperative knee range of motion was (58.2 ± 28.4)°, Lysholm score was 39.7 ± 4.6. All patients had anterior cruciate ligament rupture and posterior cruciate ligament rupture; combined injuries included medial collateral ligament rupture in 11 cases, lateral collateral ligament rupture in 9 cases, both medial and lateral collateral ligament rupture in 2 cases, femoral condylar avulsion fracture in 2 cases, and meniscus injury in 7 cases. No nerve or blood vessel injury was observed. All cases obtained primary healing of incision without infection. All the patients were followed up 12-48 months (mean, 27.8 months). At 12 months after operation, the results of the anterior drawer test, posterior drawer test, Lachman test, valgus stress test, and varus stress test were all negative; the knee range of motion increased was significantly to (121.3 ± 7.9)° (t = 30.061, P = 0.000); Lysholm score was 87.2 ± 6.1, showing significant difference when compared with preoperative score (t = 24.642, P = 0.000). A combination oathogopi osta ge reconstruction and strict immobilization for treatment of knee dislocation is a safe and effective method, good stability and joint function can be achieved.

[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.

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

[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.

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.

[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.

[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.

[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.

Open knee dislocation with a patellar tendon rupture: Result of staged surgical repair.

Knee dislocation with concomitant multiligament injury is a rare and devastating injury. We report the successful repair of a rare case of open knee dislocation with concomitant multiligament injury and patellar tendon rupture of an 18-year-old male due to a motorcycle accident. The patient presented with an open wound running parallel to the knee joint line and patellar tendon rupture with full exposure of the cartilage of the distal femur. Staged surgical management including the application of a ring-type external fixator with a hinged joint, lateral collateral ligament repair, medial collateral ligament reconstruction using autogenous hamstring tendon, and joint release was performed. Range of movement was recovered to 0 degrees of knee extension and 80 degrees of knee flexion, and extension lag was negative. The Lysholm score of the patient was recovered to 92. The patient was able to return to work in the construction field 2 years after sustaining the injury. The patient had no complaint of pain and was able to resume construction work, even though reconstruction of the anterior cruciate ligament and posterior cruciate ligament was not performed. The application of a hinged ring-type external fixation device might play a key role in early range of movement restoration and to maintain the reduced position and acceptable recovery of the posterior cruciate ligament injury without the need for reconstructive surgery. This report is the first to describe the safety and effectiveness of staged surgical management for the repair of open knee dislocation with concomitant multiligament injury and patellar tendon rupture. However, further studies with longer follow-up periods will be needed to observe the development of osteoarthritis or weakness of the knee. Staged surgical management is a safe and effective procedure for repairing an open knee dislocation with concomitant multiligament injury and patellar tendon rupture.

[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.

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

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).

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.

[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.

Diagnosis of ACL and meniscal injuries: MR imaging of knee flexion versus extension compared to arthroscopy.

The aim of the study was to evaluate whether MR Imaging of the knee at 30° and 55° of flexion can improve the diagnosis of anterior cruciate ligament and menisci injuries compared to arthroscopy and imaging during extension of the knee joint. Knee joints from 40 patients with clinical suspicion of an anterior cruciate ligament (ACL) rupture were examined using MRI while the knee joint was either extended or flexed at 30° and 55° of knee flexion. A standard MR knee coil was used at extension, whereas at 30° and 55° of flexion a non-metallic positioning device and a flexible surface coil was placed ventral to the patella. Sagittal T2-weighted TSE sequences were acquired. In 29 of 40 patients, arthroscopy results were compared to the MRI examinations. Image quality of MRI examinations was evaluated using a three-point rating scale in a blinded fashion. Images were compared between groups and rated as better quality, same quality, or worse quality. Additionally, each angle MRI was compared to arthroscopy results. Partial ACL ruptures were diagnosed with 63% accuracy using MR imaging at 30° and 55° of knee flexion compared to 50% accuracy during knee extension. MRI imaging of complete ACL ruptures resulted in 83% accuracy of diagnosis when imaged at 30° flexion, 93% accuracy at 55° flexion, and 83% accuracy at extension. The accuracy of diagnosing medial meniscus lesions was 73% at extension, 64% at 30° flexion and 73% at 55° of flexion. MR imaging was only able to diagnose lateral meniscus tears with 55% accuracy in all three knee positions. The diagnosis of meniscal tears was more difficult due to small peripheral tears. The improved results in the diagnosis of ACL tears in response to 30° flexion and in particular in response to 55° flexion were based on the fact that the anterior cruciate ligament moved further away from the intercondylar roof with increased knee flexion. During flexion the ligament tension decreased, which causes the anterior cruciate ligament to have cylindrical shape and therefore made visualization of the injury easier. In conclusion, MR Imaging of the knee at 55° of flexion and less at 30° of flexion allows an improved diagnosis of injuries to the anterior cruciate ligament as compared to MRI examinations at extension. The diagnosis of meniscal injuries, however, was not superior at both flexion positions compared to commonly performed examinations at knee extension.

[Results of follow-up of conservatively treated isolated fresh anterior cruciate ligament rupture].

35 patients with an arthroscopically confirmed isolated fresh anterior cruciate ligament rupture were subjected to follow-up examination after an average period of four years. In all the 35 patients a conservative treatment schedule had been followed post-arthroscopically, with a physiotherapy on a neurophysiological basis. Of the 35 isolated anterior cruciate ligament ruptures, 24 were complete and 11 partial ruptures. The follow-up examination results are based on subjective scores (O'Donoghue Score, Lysholm Score) and on one objective score (objective ODonaghue Score), as well as on the Lachman Test and the Pivot Shift Sign. In the partial anterior cruciate ligament ruptures we obtained mostly good to satisfactory results with the subjective and objective scores and a lower incidence of surgery; the original performance ratings at sports were largely maintained. On the other hand, the complete isolated anterior cruciate ligament ruptures yielded mainly satisfactory to poor results with the objective scores and a high rate of repeat surgery especially in the case of meniscus tears, and a major setback in the original sports performance ratings.

Drawer test

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

[Rupture of the pes anserinus superficialis and partial rupture of the patellar ligament. Rare concomitant injures in complex knee injuries].

We present a rare case of combined knee joint lesions in a 25 year old patient. Besides the commonly reported injuries of the knee joint due to directly applied valgus force, forceful quadriceps muscle contraction, external rotation at flexed knee causing combined lesions such as rupture of the anterior cruciate ligament, rupture of the posterior cruciate ligament and rupture of the medial collateral ligament, a rare combination of the above mentioned lesions and a rupture of the lateral meniscus, an osteochondral fracture of the lateral femur condylus, a rupture of the medial patellofemoral retinacula as well as a complete rupture of the superficial pes anserinus and a partial rupture of the patellar ligament was encountered.

[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.

Acute combined posterior cruciate and posterolateral instability of the knee.

This report concerns 13 consecutive patients (13 knees) who underwent operative treatment for acute combined posterior cruciate and posterolateral instability due to combined injury to the posterior cruciate ligament and the arcuate ligament complex. Our purpose was to examine the method of diagnosis and the results in these patients. There were 12 males and 1 female (average age, 26 years). Five patients were injured in a motor vehicle accident, four in sports activities, and four in nonsports activities. The mechanism of injury was an anteromedial blow to the flexed knee in six patients, a fall onto the knee in two, and unknown in five patients. Eleven patients were available for follow-up evaluation (average, 56 months), and in each the result was rated as good, fair, or poor. In 10 patients (90%) the results were rated as good subjectively, in 11 (100%) as good functionally, and in 8 (73%) as good objectively. Injury to both the posterior cruciate ligament and the arcuate ligament complex can result from rotational force that can be due to a blow to the anteromedial aspect of the knee. Diagnosis can be made by a combined positive response to the posterior drawer test, the anterior drawer test performed with the tibia in internal rotation, the abduction and adduction stress tests performed with the knee in full extension, the posterolateral drawer test, and the external rotation-recurvatum test. In a knee with concomitant injury to the posterior cruciate ligament and the arcuate ligament complex that requires surgical repair, all injured structures should be explored and repaired to ensure a subjectively, objectively, and functionally good result.

An extra-articular procedure improves the clinical outcome in anterior cruciate ligament reconstruction with hamstrings in female athletes.

A positive glide is a common finding after ACL reconstructions, especially in women. The aim of this study was to prospectively evaluate the role of Cocker-Arnold's extra-articular procedure in reducing the incidence of a residual postoperative rotational knee laxity. Sixty patients affected by an ACL injury with a +2 (clunk) or +3 (gross shift) pivot-shift test entered this prospective study; they were randomly assigned to group A (control group, hamstrings) or group B (study group, hamstrings plus Cocker-Arnold). Thirty-two patients entered group A and 28 group B. At follow-up, patients underwent clinical evaluation, KT-1000 arthrometer and Lysholm, Tegner, VAS and subjective and objective IKDC form. At a mean follow-up of 44.6 months, the same expert surgeon reviewed 55 patients (28 group A and 27 group B). The comparison of the results of the evaluation scales used and of the KT-1000 arthrometer did not show statistically significant differences (p>0.05). Lachman test was negative (S/S) in all the patients of both groups (100 %). A residual positive pivot-shift (glide) was found in 16 patients (57.1 %) of group A and in five patients (18.6 %) of group B (p<0.05). The extra-articular MacIntosh procedure modified by Cocker-Arnold in combination with ACL reconstruction significantly reduces the rotational instability of the knee.

[Biomechanical correlations of lesions associated with traumatic diseases of the anterior cruciate ligament. Analysis with magnetic resonance].

To investigate the correlations between traumatic injuries of the anterior cruciate ligament and other ligamentous, meniscal and bone traumatic injuries, a series of 193 patients with anterior cruciate ligament injuries studied with MRI between January 1992 and December 1994, was retrospectively reviewed. MR results were compared with arthroscopic and/or surgical findings in most (181) patients; in the remaining 12 patients, clinical follow-up was performed. We used two 0.5 superconductive MR units, with dedicated coils and T1-weighted spin-echo and T2*-weighted gradient-echo sequences on the axial, sagittal and coronal planes. Anterior cruciate ligament injuries were associated with other ligamentous, meniscal and bone injuries in 78% of patients. The patients were classified in 5 groups depending on biomechanics and the association of injuries: -group I: isolated injury of the anterior cruciate ligament (41 patients), most frequently caused by forced extension stress associated with "kissing contusions" of the anterior portion of the lateral femoral condyle and of the lateral tibial plateau; this type of injury is less frequently caused by forced flexion stress associated with avulsion fracture of the tibial eminence; -group II: associated injury of the anterior cruciate ligament and medial compartment (62 patients), caused by forced flexion-external rotation stress (abduction, valgism and external rotation). The classic association of this mechanism was the injury of the anterior cruciate ligament, medial collateral ligament and medial meniscus (O'Donoghue triad) (9 patients). Valgus stress and the pivot-shift phenomenon can impact the tibial and femoral articular surfaces, with consequent osteochondral contusion; -group III: associated injury of the anterior cruciate ligament and lateral compartment (26 patients), caused by forced flexion-internal rotation stress (adduction, varism and internal rotation). This mechanism can cause, as a typical bone lesion, Segond fractures; -group IV: associated injury of the anterior cruciate ligament, lateral and medial compartments observed in 52 patients with different associations of varus-valgus and rotatory stress; -group V: in 5 patients, anterior cruciate ligament injury was associated with traumatic injury of the posterior cruciate ligament; in this case, posterior displacement of the tibia and knee hyperextension were the most common mechanisms of injury. In conclusion, our results demonstrate that anterior cruciate ligament injuries due to traumatic sprains of the knee are rarely isolated (21%). Thus, it is important to know the biomechanics of knee trauma to read MR images in order to detect possibly associated injuries. The final goal is to assess the actual extent of the traumatic damage for best subsequent clinical-therapeutic management.

[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.

The influence of a meniscal bucket handle tear on the Posterior Cruciate Ligament Angle in Anterior Cruciate Ligament Rupture - A case report.

Chronic anterior cruciate ligament (ACL) tear might be difficult to diagnose on MRI. Indirect signs might be a typical meniscal or cartilage lesion, or a spontaneous anterior drawer visualized by a decreased angle of the posterior cruciate ligament (PCL). A 27-year-old former ballet dancer was admitted to the emergency department for a locked left knee, without never having experienced previous symptoms of giving way or locking. The MRI performed revealed a medial meniscus bucket handle tear, without traumatic bone marrow oedema or ligament injury. The PCL angle was 130°. A former MRI of her left knee performed 1 year previously to investigate on the recurrent catching of her left knee showed a grade III medial meniscal tear of the posterior horn, and buckling of the PCL angle of 100°, as a sign of chronic ACL rupture. During arthroscopy and medial meniscal repair, the ACL showed complete loss of tension, and was therefore reconstructed simultaneously to enable proper meniscal healing. Chronic ACL insuffiency is a major risk factor for subsequent medial meniscus tear, especially bucket handle tear. The locked knee might unable proper pre-operative clinical examination. The preoperative MRI therefore being the only possibility to diagnose concomitant ligamentous injury. This is the first case reported in literature showing, that a positive PCL angle sign might be falsely negative due to a locked medial meniscus bucket handle tear.

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.