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PubMed1987

Operative versus non-operative treatment of recent injuries to the ligaments of the knee. A prospective randomized study.

Two hundred consecutively seen patients who had an injury to either the anterior cruciate ligament or the medial collateral ligament, or both, were randomly allocated to treatment by either conservative or a surgical regimen. Injuries to the medial collateral ligament could not be demonstrated to benefit from surgical treatment in any respect--with or without surgery the results were excellent. With injuries to the anterior cruciate ligament, recovery was more rapid without surgery but otherwise the results differed between the groups in only one respect: the pivot-shift test was more often positive after conservative treatment. The results were good in both treatment groups even though most of the patients who had an injury of the anterior cruciate ligament were somewhat less pleased with the outcome after a period of time.

Adolescent↗
PubMed1995

Adhesiveness of human ligament fibroblasts to laminin.

The adhesiveness of fibroblasts from the human anterior cruciate and medial collateral ligaments to the laminin molecule was studied, with particular emphasis on the intrinsic differences between fibroblasts from the two ligaments. Cellular adhesion strength, adhesion area, laminin concentration, and seeding time were examined. Cell adhesion to laminin anchored with poly-D-lysine to a cleaned cover glass was measured with a micropipette micromanipulation system after seeding. The adhesion strength of fibroblasts from the anterior cruciate ligament to laminin was greater than and significantly different from that of fibroblasts from the medial collateral ligament, depending on the laminin concentration. Fibroblasts from the anterior cruciate ligament also exhibited an increase in adhesion strength, dependent on laminin concentration of as much as 30 micrograms/ml, at which the laminin receptors were thought to be saturated. Fibroblasts from the medial collateral ligament did not show such an increase except at laminin concentrations of 5-10 micrograms/ml. There was no significant difference in adhesion area between fibroblasts from the two ligaments except after 45 minutes at a laminin concentration of 40 micrograms/ml. For both, the adhesion to laminin showed little correlation to seeding time during periods of as long as 60 minutes. Measurements of adhesion area also failed to show a significant correlation to seeding time for fibroblasts from either ligament at laminin concentrations of 20 and 40 micrograms/ml. Adhesion strength normalized by adhesion area had no correlation to seeding time.(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior Cruciate Ligament↗
PubMedDate not supplied

Outcome of elbow surgery in professional baseball players.

We reviewed the records of 72 professional baseball players who underwent arthroscopic or open elbow surgery. The most common diagnoses were posteromedial olecranon osteophyte (65%), ulnar collateral ligament injury (25%), and ulnar neuritis (15%). Intraarticular loose bodies were found in 39% of the patients. Fifty-nine patients (82%) were observed for a minimum of 24 months, with an average of 42 months' followup. Forty-seven players (80%) returned to play for a minimum of one season (73% at the same or higher level of play), and 17% of the players retired initially because of their elbow injury. One third of the players required two or more surgical procedures, with 25% of these patients requiring an ulnar collateral ligament reconstruction after removal of a posteromedial olecranon osteophyte. The patients with posteromedial olecranon osteophytes had the highest rate of reoperation, and patients who underwent ulnar collateral ligament reconstruction had a higher rate of return to play. The incidence of ulnar collateral ligament injuries was most likely underestimated in this group of athletes, with initial treatment directed at the secondary injuries instead of the primary ulnar collateral ligament injury.

Adult↗
PubMed1994

The effects of nerve injury on ligament healing in a rat model.

The presence of an intact nerve supply is important in the regeneration of injured tissue in some animals. It has not been determined whether an intact nerve supply is important in ligamentous healing. The authors hypothesize that the nerve supply of a ligament might have a significant effect on its healing. The purpose of this paper was to determine whether injury to the nerve supply of the medial collateral ligament in a rat model results in poor ligament healing (which would suggest that intact nerve supply enhances ligament repair). Clinically, such a finding would demonstrate the importance of avoiding injury to nerve-ligament systems in reparative ligament surgery. Twenty three rats underwent complete bilateral dissection of the major nerves supplying the medial collateral ligament, and each ligament was transected at the level of the tibial tuberosity. The major nerve supplies of the experimental ligaments were destroyed by segmental excision, either distally at the medial articular nerves or proximally at the saphenous nerve, while the control ligament's nerve supplies were left intact. The rats were euthanized at 12 days, and each medial collateral ligament was tested biomechanically using a hydraulic materials testing machine. This time point was chosen because the rat ligament transection site heals rapidly, causing the ligament to avulse from its tibial insertion instead of rupturing at the transection site at later time points. This rat medial collateral ligament injury model has shown statistically significant differences in healing at this time point in numerous experiments evaluating the effects of other variables on ligament healing.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1991

The effect of continuous passive motion on knee ligament reconstruction with carbon fibre. An experimental investigation.

Our purpose was to determine whether continuous passive motion enhanced the quality of knee ligament reconstruction using carbon fibre. In 46 rabbits the medial collateral ligaments were excised and replaced with carbon fibre prostheses. The animals were treated postoperatively by either continuous passive motion, cast immobilisation or cage activity, termed intermittent active motion. At six weeks, the ligaments were compared histologically and biomechanically with normal (control) medial collateral ligaments and with sham-operated controls. The ligaments treated with continuous passive motion were superior to those in the other two treatment groups. There were no ligament failures in any of the groups. This study suggests that continuous passive motion, initiated immediately postoperatively, enhances the biomechanical properties of carbon fibre ligament replacement of the medial collateral ligament while preventing the harmful effects of joint immobilisation.

Animals↗
PubMed2002

Posterior cruciate ligament reconstruction with the quadriceps tendon in chronic injuries.

We reviewed 18 patients (knees) operated on because of chronic PCL insufficiency. Preoperatively all the patients were severely disabled and showed a posterior drawer of 10 mm or more. A quadriceps tendon autograft was implanted using an open technique, direct posterior approach, and fixation to the tibia. A free semitendinosus graft was used to reconstruct the lateral collateral ligament in six knees and the medial collateral ligament in two. The patients were reviewed with a mean follow-up of 3.5 years (range 2-5.5) using the IKDC form. Stability was evaluated by stress radiography using the Telos device. The mean side-to-side difference in posterior tibial displacement at 70 degrees of knee flexion at follow-up was 4.8 mm; the side-to-side difference was less than 5 mm in 77% of cases. A side-to-side difference less than 2 mm in lateral joint line opening was found in five of six knees with a lateral collateral ligament reconstruction. Posterior tibial translation was similar in the knees with and those without collateral ligament reconstruction. Only one patient complained of significant pain and giving-way at follow-up. Patellofemoral crepitation was present in nine knees at follow-up although it was symptomatic only in one. The results of this series suggest that posterior cruciate ligament reconstruction using an autologous quadriceps tendon is a valuable option to reconstruct these severe injuries.

Adolescent↗
PubMed1997

Development of the human knee joint ligaments.

BACKGROUND: Many studies have been published on the development of the human knee joint, but scant attention has been given to the development of the knee joint ligaments. The only elements that have received much attention are the cruciate ligaments and their relationships with the synovial membrane. METHODS: We summarize our observations on the development of the knee joint ligaments in 50 serially sectioned human embryonic and fetal lower limbs (26 embryos and 24 fetuses). RESULTS: The patellar ligament begins to form in O'Rahilly stage 20, with the muscle fibers of the quadriceps muscle being attached inferiorly to the tibial tuberosity. The cruciate ligaments (beginning with the posterior) arise from the articular interzone in O'Rahilly stage 21. Subsequently, with the organization of the Wrisberg's meniscofemoral ligament, in week 10 of development, the cruciate ligament system is completed. The lateral collateral ligament begins to form in O'Rahilly stage 23, and from its first appearance it is independent of the knee joint capsule. At this time, development of the tendon of the popliteus muscle begins. The medial collateral ligament begins to develop in week 9 of development as a condensation of the joint capsule. Two weeks later, the intra-articular pad of fat begins to form from mesenchymal tissue below the patella and between the cruciate and the patellar ligaments. With the organization of the suprapatellar bursa in week 14 of development, knee joint development is complete. CONCLUSIONS: The morphogenetic time table of the knee joint ligaments was established.

Anterior Cruciate Ligament↗
PubMed2000

Lateral stabilizing structures of the knee: functional anatomy and injuries assessed with MR imaging.

The lateral aspect of the knee is stabilized by a complex arrangement of ligaments, tendons, and muscles. These structures can be demonstrated with routine spin-echo magnetic resonance (MR) imaging sequences performed in the sagittal, coronal, and axial planes. Anterolateral stabilization is provided by the capsule and iliotibial tract. Posterolateral stabilization is provided by the arcuate ligament complex, which comprises the lateral collateral ligament; biceps femoris tendon; popliteus muscle and tendon; popliteal meniscal and popliteal fibular ligaments; oblique popliteal, arcuate, and fabellofibular ligaments; and lateral gastrocnemius muscle. Injuries to lateral knee structures are less common than injuries to medial knee structures but may be more disabling. Most lateral compartment injuries are associated with damage to the cruciate ligaments and medial knee structures. Moreover, such injuries are frequently overlooked at clinical examination. Structures of the anterolateral quadrant are the most frequently injured; posterolateral instability is considerably less common. Practically all tears of the lateral collateral ligament are associated with damage to posterolateral knee structures. Most injuries of the popliteus muscle and tendon are associated with damage to other knee structures. MR imaging can demonstrate these injuries. Familiarity with the musculotendinous anatomy of the knee will facilitate accurate diagnosis with MR imaging.

Anterior Cruciate Ligament↗
PubMedDate not supplied

Acute skier's thumb repaired with a proximal phalanx suture anchor.

The purpose of this study was to determine the functional outcome of a surgical technique for the repair of injuries of the ulnar collateral ligament of the thumb. A 14-point questionnaire was developed to determine functional outcome after surgical repair of acute ulnar collateral ligament rupture. Early ulnar collateral ligament repair was performed on 58 patients with grade III sprains (complete rupture) of the ligament using a new technique that employs a suture anchor for fixation. Forty-five patients were interviewed at a minimum postoperative interval of 12 months and were included in this study. Forty-four patients (98%) believed they had a stable repair, were satisfied with their surgery, and would have it again if necessary. Forty-four patients (98%) were not hindered in their day-to-day activities and had a functional range of motion. Mild discomfort was felt by eight of our patients (17%), but only three patients (7%) had pain with activities. The average time to return to skiing was 1.7 days. The use of a suture anchor provided a strong and stable repair if the surgery was performed early.

Activities of Daily Living↗
PubMedDate not supplied

Impact biomechanics of lateral knee bracing. The anterior cruciate ligament.

We evaluated the effects of six different prophylactic braces on ACL ligament strain under dynamic valgus loads using a mechanical surrogate limb validated against human cadaveric specimens. Medical collateral ligament and anterior cruciate ligament peak forces, medial collateral ligament and anterior cruciate ligament tension initiation times, and impact safety factors were calculated for both braced and unbraced conditions. These tests were conducted to determine whether or not application of a prophylactic brace might provide protection to the anterior cruciate ligament under valgus loading conditions. The results of this study indicate that those braces that increased impact duration appear to differentially protect the anterior cruciate ligament more than the medial collateral ligament, and that most of the braces tested appear to provide some degree of protection to the anterior cruciate ligament under direct lateral impacts. These findings should be confirmed clinically.

Anterior Cruciate Ligament↗
PubMed1985

In vivo and in vitro investigation of the long-term behavior and fatigue strength of carbon fiber ligament replacement.

The long-term behavior of carbon fiber ligament replacements was evaluated in sheep. In vitro assessments of both isolated carbon fiber prostheses and resected animal ligaments were performed. The right knee in 45 sheep was reconstructed. In 30 animals, only the medical collateral ligaments were replaced, but with different systems of anchorage to bone. In 15 animals, a combined replacement of medial collateral ligament and anterior cruciate ligament was performed. In the first group the animals were sacrificed three months postoperation, while in the latter group evaluation was performed one year after surgery. After one year the strength of the medial collateral ligament complex was higher than that of the normal sheep ligaments. The elasticity and extensibility were similar to those of the normal ligaments. No case of partial rupture or rupture of the medial collateral ligament replacements was seen, but four of 12 anterior cruciate replacements showed signs of partial rupture. In vitro testing showed that rupture is more likely to occur where movement occurs around a small radius of bending, and this may be a factor in these cases where the anterior cruciate ligament enters a bony tunnel at an acute angle. Histologic assessment showed good biocompatibility, similar to that reported by other authors. With an operative technique designed to increase the radius of bending where the carbon fiber enters bone, these ligament replacements have a fatigue strength and elasticity adequate for long-term survival.

Animals↗
PubMed1996

Coloured microsphere assessment of blood flow to knee ligaments in adult rabbits: effects of injury.

Coloured microspheres were used to determine standardized blood flow in an established model of medial collateral ligament injury in the adult rabbit knee. Resting blood flow in the ligament was ascertained to be on the order of 0.68 +/- 0.08 ml/min/100 g (mean +/- SEM) in normal rabbit knees, although errors in flow estimates of this magnitude may be quite high. In healing medial collateral ligament, however, flow had increased markedly 3 weeks after injury (21.45 +/- 5.48 ml/min/100 g). Flows in sham-operated control medial collateral ligaments were not significantly increased compared with those in control normal ligaments. Six weeks after injury, blood flow in the ligament remained elevated (16.90 +/- 3.20 ml/min/100 g) and was similarly elevated in other neighbouring joint tissues (i.e., ipsilateral synovial fat pad). The increase in flow to ipsilateral noninjured articular tissues did not persist beyond 6 weeks, but flow in the healing medial collateral ligament scar tended to remain elevated after 17 weeks (4.20 +/- 1.79 ml/min/100 g), although this did not achieve statistical significance. We conclude from these data that it is possible to measure the increase in blood flow in injured and healing articular tissues using the coloured microspheres technique and that ligament injury is a potent stimulus for increasing blood flow. Coloured microsphere measurements of blood flow to joint connective tissues may offer a valuable approach to future investigations of joint injury and arthritis.

Animals↗
PubMedDate not supplied

Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability.

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

Acute Disease↗
PubMed1991

How to treat knee ligament injuries?

Indications for conservative treatment of knee ligament injuries can be established for all grade I or II sprains (partial tears), as well as isolated grade III sprains (complete tears) of the posterior cruciate ligament (PCL) and medial collateral ligament (MCL). These injuries should be treated with immediate mobilization. Only in isolated partial anterior cruciate ligament (ACL) tears without a positive pivot shift phenomenon is conservative treatment justified. However, many of these injuries may require operative reconstruction later. In complete ACL tears the surgical treatment consists of primary reconstruction or augmented primary repair. Today, the middle third of the patella tendon with the bone blocks is regarded as the "gold standard" for augmented repairs and late reconstructions. For the present, there is no place for synthetic prostheses in the treatment of an acute ACL rupture. Allograft replacement of the ACL must now be considered an experimental procedure. In the reconstruction of the PCL the above mentioned patella tendon graft is also preferable. Lateral collateral ligament (LCL) tears, especially if they are combined with ruptures of posterolateral ligament complex, should be repaired immediately after the injury. In these injuries late reconstructions are difficult and the results are poor. Conservative treatment of partial tears and postoperative treatment of reconstructed ligaments is twofold: on the one hand, the healing tissue should be protected and on the other hand, atrophy and wasting of uninjured tissue should be avoided. Overload and stretching of the injured ligaments should be eliminated with the aid of a suitable knee brace, but early range of motion exercises of the knee are allowed immediately.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1997

Gene transfer to the patellar tendon.

Growth factors have the potential to enhance native repair responses in ligamentous lesions. However, methods for applying these cytokines to sites of injury for extended periods are lacking. We suggest that local transfer of genes which encode the relevant healing factors merits investigation as a potential solution to this problem. In the present study, the retroviral vectors MFG lacZ and BAG lacZ neo(r) and adenovirus LacZ were evaluated for their ability to deliver genes to cells of ligamentous origin. The posterior and anterior cruciate ligaments, medial collateral ligament, semitendinosus tendon and patellar tendon were harvested from New Zealand white rabbits. Cells grown from these tissues were then investigated for their susceptibility to genetic alteration by these vectors in vitro. Based upon their ability to convert cells in culture to a lacZ(+) phenotype, adenovirus was the most effective vector in short-term experiments. However, expression was transient. Although retrovirus gave lower initial transduction efficiencies, the percentage of transduced cells could be increased by the use of the selectable marker gene neo(r). In an in vivo marker study, we injected adenovirus into the rabbit patellar tendon. Transduced cells could be observed preferentially in the subsynovial layer at a declining frequency over a 6-week period. The allogeneic transplantation of in vitro retrovirally transduced fibroblasts into the patellar tendon resulted in a greater number of transduced cells. Although the number of lacZ(+) cells declined with time, positive cells were still present 6 weeks after transplantation. Furthermore, the transplanted cells, unlike cells transduced in situ with adenovirus, migrated from the injection site and integrated into the crimp of the tendon.

Adenoviridae↗
PubMed2004

The evaluation of the proximal tibiofibular joint for patients with lateral knee pain.

In contrast to important functions of the proximal tibiofibular joint (PTFJ), there appear a few clinical and radiological studies concerning the PTFJ pathologies. Although almost all of the joints have been investigated in detail by MRI, review of the literature reveals none on the pathologies of PTFJ. Thirty-eight knees of 32 patients with lateral knee pain were evaluated clinically and radiologically. All had tenderness over the PTFJ and lateral hamstring tightness. MRI examination revealed effusion of the PTFJ in 22 knees and partial ruptures of anterior or posterior tibiofibular ligament, lateral collateral ligament or biceps femoris tendon in 25 knees. All patients were treated by manipulative physiotherapy of the PTFJ and strengthening and stretching exercises of the surrounding structures. All patients were followed-up 12-36 months (mean 28 months) after the treatment protocol, and complete relief of the symptoms was recorded in 28 of the 38 knees. Although spontaneous pain was not present in five patients, there was tenderness over the PTFJ by palpation. No change in the symptoms was recorded in five patients. These results suggest that PTFJ pathologies should be kept in mind in the evaluation of lateral knee pain and MRI examination provides useful information.

Adolescent↗
PubMed1997

Dependence of cruciate-ligament loading on muscle forces and external load.

A sagittal-plane model of the knee is used to predict and explain the relationships between the forces developed by the muscles, the external loads applied to the leg, and the forces induced in the cruciate ligaments during isometric exercises. The geometry of the model bones is adapted from cadaver data. Eleven elastic elements describe the geometric and mechanical properties of the cruciate ligaments, the collateral ligaments, and the posterior capsule. The model is actuated by 11 musculotendinous units, each unit represented as a three-element muscle in series with tendon. For isolated contractions of the quadriceps, ACL force increases as quadriceps force increases for all flexion angles between 0 and 80 degrees; the ACL is unloaded at flexion angles greater than 80 degrees. When quadriceps force is held constant, ACL force decreases monotonically as knee-flexion angle increases. The relationship between ACL force, quadriceps force, and knee-flexion angle is explained by the geometry of the knee-extensor mechanism and by the changing orientation of the ACL in the sagittal plane. For isolated contractions of the hamstrings, PCL force increases as hamstrings force increases for all flexion angles greater than 10 degrees; the PCL is unloaded at flexion angles less than 10 degrees. When hamstrings force is held constant, PCL force increases monotonically with increasing knee flexion. The relationship between PCL force, hamstrings force, and knee-flexion angle is explained by the geometry of the hamstrings and by the changing orientation of the PCL in the sagittal plane. At nearly all knee-flexion angles, hamstrings co-contraction is an effective means of reducing ACL force. Hamstrings co-contraction cannot protect the ACL near full extension of the knee because these muscles meet the tibia at small angles near full extension, and so cannot apply a sufficiently large posterior shear force to the leg. Moving the restraining force closer to the knee-flexion axis decreases ACL force; varying the orientation of the restraining force has only a small effect on cruciate-ligament loading.

Anterior Cruciate Ligament↗
PubMed2002

Growth and maturational changes in dense fibrous connective tissue following 14 days of rhGH supplementation in the dwarf rat.

The purpose of this study was to investigate the impact of recombinant human growth hormone (rhGH) on patella tendon (PT), medial collateral ligament (MCL), and lateral collateral ligament (LCL) on collagen growth and maturational changes in dwarf GH-deficient rats. Twenty male Lewis mutant dwarf rats, 37 days of age, were randomly assigned to Dwarf + rhGH (n = 10) and Dwarf + vehicle (n = 10) groups. The GH group received 1.25 mg rhGH/kg body wt twice daily for 14 days. rhGH administration stimulated dense fibrous connective tissue growth, as demonstrated by significant increases in hydroxyproline specific activity and significant decreases in the non-reducible hydroxylysylpyridinoline (HP) collagen cross-link contents. The increase in the accumulation of newly accreted collagen was 114, 67, and 117% for PT, MCL, and LCL, respectively, in 72 h. These findings suggest that a short course rhGH treatment can affect the rate of new collagen production. However, the maturation of the tendon and ligament tissues decreased 18-25% during the rapid accumulation of de novo collagen. We conclude that acute rhGH administration in a dwarf rat can up-regulate new collagen accretion in dense fibrous connective tissues, while causing a reduction in collagen maturation.

Animals↗