Secondary damage to the knee after isolated injury of the anterior cruciate ligament A.
From the
FINSTERBUSH,* MD, U. FRANKL,* MD, Y. MATAN,* MD, AND G. MANN,†‡ *
Department of Orthopaedic Surgery, Hadassah University Hospital, Mount Scopus, Jerusalem, and the t Unit of Sports Medicine, Zinman College of Physical Education, Wingate Institute, Netanya, Israel It should be emphasized that the at times combined.
ABSTRACT
secondary damages
were
Between 1978 and 1984, we examined and performed arthroscopy on 1000 consecutive patients. Ninety-eight of the 1000 had isolated ACL damage. These cases do not include patients with initial ACL injuries combined with other intraarticular damage. Diagnosis was by physical and arthroscopic examination. Examination took place an average 13.6 months after injury. Of the 98 isolated ACL injuries, 56 were complete ruptures and 42 were partial ruptures. In most cases of partial rupture, the clinical diagnosis was wrong. "Meniscal damage" was the usual diagnosis in these cases; the true diagnosis was made only by arthroscopic examination. Thirty-four of the 98 patients with isolated ACL injuries (30 men and 4 women) developed further intraarticular damage. Of these 34, 20 had complete ACL rupture and 14 had partial ACL rupture. Treatment after primary injury included physiotherapy in all patients and bracing in those whose knee was unstable during daily activities. Reconstructive surgical
history of surgically untreated ACL tears may guideline in both preventive and curative treatment. The recent controversy concerning the functional disability and future prognosis of such patients’,&dquo; ~°°21~25,zs,3~,z~ is a result of multiple factors: patient populations differ widely among studies as far as the degree of their athletic participation, the magnitude of their ligamentous laxity, and their compliance with rehabilitation programs.~~9°~0~14,27,30 The natural
provide
a
Most reports deal with ACL combined injuries. The combination of ACL with meniscal damage or other ligamentous damage is most common.4 16,27,34 Reinjury data are not comparable for the same reason and also because existing reports do not specify whether certain physical activities were
avoided
or
permitted.
We reviewed a group of 98 patients who represented a cross-section of a young population, some involved in sports and others active only for leisure. Each of the 98 sustained a knee injury resulting in an isolated injury to the ACL. The final diagnosis was established in all patients upon arthroscopic examination. Since patients’ complaints and clinical findings do not always correspond to the the term &dquo;ACL insufficient knee,&dquo; we prefer not using this term in this
procedures were not performed in those patients. The time lapse from the primary to the secondary injury varied from 1 month to 20 years, with an average of 28 months. The secondary damage was caused by a secondary injury that was mild (22 cases) or developed
insidiously (12 cases). Five types of secondary damage were observed: partial ACL tears that became complete—11cases; meniscal tear— 8 cases; loosening and subluxation of
particular group. MATERIALS AND METHODS
the anterior horn of the medial meniscus—14 cases; and fracture or damage to the articular condylar cartilage, with or without bone involvement—11cases.
The patients in this study came from a general orthopaedic practice in Hadassah Mt. Scopus University Hospital, Jerusalem. Ninety-eight patients were found to have isolated ACL damage. This consecutive, unselected group of patients was obtained for study by a retrospective review of hospital
t Address correspondence and reprnt requests to G Mann, MD, Unit of Sports Medicme, Department of Orthopaedic Surgery, Hadassah Unnversity Hospital, Mount Scopus, P O Box 24035, Jerusalem 91240, Israel. 475
476
through Febpatients who underwent arthroscopic examination for a variety of knee problems, mostly after an injury. All patients who had additional articular knee injury, such as a meniscal or ligamentous tear other than ACL, were excluded from study. Examination under anesthesia included inspection of the medial and lateral collateral ligaments, so that cases in which there was major ligamentous and capsular damage could be excluded. Preoperative radiographs showed no calcifications of bony damage, specifically excluding PedegariStieda and Segond fractures. Of the 98 isolated ACL injuries, there were 56 complete ruptures and 42 partial ruptures. The preoperative diagnosis in the latter group almost always was a torn meniscus. There were 86 men and 12 women. The average age at injury was 26.2 years (range, 13 to 45 years). Most of the injuries occurred during sports (62) and army activities (26). Playing football (soccer) was the most frequent cause of sports-related knee injuries. The time from original injury to the first arthroscopic examination ranged from 3 weeks to 15 years. The average delay from injury to arthroscopy was 13.6 months, and the average age at arthroscopy was 27.6 years. After examination, patients were referred to physiotherapy for hamstring and quadriceps exercises. Bracing was recommended when episodes of giving way were frequent and interfered with daily activities, and for sports activity. Patients were instructed to minimize temporarily strenuous activities requiring jumping, sharp turning, and quick starts and stops. Patients who regained full muscle power and who did not have functional instability returned gradually to their previous activities. records
during the period from January
1978
ruary 1984. The review included 1000 consecutive
RESULTS
Follow-up examination Patients with isolated ACL tears were managed with early treatment of symptoms. Treatment consisted of antiinflam-
matory drugs, aspiration of the knee in cases of painful knee effusion, and the use of a Jones dressing. In initial, acute cases, cast immobilization for up to 8 weeks
was followed by physical therapy including hamstring and quadriceps exercises. Protective bracing was used only in cases where there was frequent giving way. Braces used ranged from a simple hinged support brace to a Lerman brace and a Lenox Hill (Lenox Hill Brace, Long Island City, NY) variable axis knee
orthosis. All of the patients were followed up periodically in our outpatient clinic. Subjective complaints and objective findings were recorded. Each of the patients had roentgenograms taken of the knee. The average length of followup from the injury was 5.4 years and from the arthroscopy, 4.2 years. The shortest follow-up time from the injury was 2.5 years. Thirty-four of 98 patients (30 men and 4 women) were readmitted to the hospital after reinjury of their affected knee (22 cases) or progressive deterioration of their knee (12
cases). These patients underwent a second examination under anesthesia and arthroscopy. The time from primary to secondary injury varied from 1 month to 16 years, with an average of 28 months. The incidence of secondary damage could not be directly linked with the time lapse from the initial injury or initial examination, although it was found to be probably related to intensity and duration of the patient’s physical activity. The remaining 64 patients were reevaluated clinically and reexamined. Forty-one of these 64 improved after the rehabilitation program, returning to their previous activities with minimal or no discomfort. The condition of the remaining 23 patients remained unchanged (Table 1). These 23 patients had, as before, episodes of pain, swelling, and instability, although the frequency of these complaints was limited, since they reduced their sport activities and were able to perform their work and other daily duties. There were no demands from the patients in this last group for further investigation or treatment. The clinical examination data from their medical files did not reveal any significant change in their condition.
Reinjury of the previously affected
knee
Clinical and arthroscopic findings in the patients whose previously injured knee had deteriorated or who had reinjured their knee was analyzed according to the clinical and arthroscopic findings (Table 2). Partial tear of the ACL to a complete tear. Eleven patients who had partial ACL tears found during primary arthroscopic examination developed ACL insufficiency and were later discovered to have a complete ACL tear or a complete
ACL tear combined with a tear of the lateral meniscus (two cases), or articular cartilage damage (four cases). The secondary knee damage occurred after a sports-related injury in nine patients (seven soccer injuries, one basketball injury, and one tennis injury). Two patients could not describe any acute traumatic event. The clinical symptoms of the patients with partial ACL tears in existence before the secondary injury were pain mostly in the anteromedial aspect of the knee and inability to extend the knee fully, which was interpreted as locking. There were mild objective findings TABLE 1 Condition at followup of 98 patients with ACL injury
TABLE 2
Complications in 34 cases of isolated ACL damage
477
of anteroposterior or rotational knee instability, although without a positive pivot shift sign (Table 3). The arthroscopic findings in cases of partial ACL tears varied from interstitial hemorrhages within the synovial lining of the ACL to partial detachment with or without the synovial lining while the other part of the ligament was still under tension when stretched under direct vision. In some cases, adhesions of the partially torn ACL or its synovial lining to the fat pad limited full extension of the knee; these cases were interpreted (clinically) as a locked knee. Meniscal tears. Eight patients were found to have meniscal tears: five of the posterior horn of the lateral meniscus, two bucket-handle tears of the medial meniscus, and one posteromedial tear of the medial meniscus combined with a tear of the anterior horn of the lateral meniscus. Six of these patients initially had a complete ACL tear and two initially had a partial ACL tear that became a complete tear. These last 2 patients were also included in the first group of 11 patients with partial ACL tears that developed into complete tears. In four patients, additional cartilage damage was noted. Loosening and forward dislocation of the anterior horn of the medial meniscus. Loosening and forward dislocation of the anterior horn of the medial meniscus was found on arthroscopy in 14 cases. Eleven of these cases involved a previous complete ACL tear with clinical evidence of insufficiency. An additional three patients had a partially torn ACL with a slight anteroposterior loosening of the knee, but with a negative pivot shift (Table 2). None of these patients had sustained acute trauma. All of these patients had the anterior horn of the medial meniscus detached from the tibia and displaced inferiorly. Their complaints were pain in the lower pole of the patella, mostly on extreme flexion or extension of the knee. Those complaints were, in addition to their previous symptoms, related to the ACL injury. Fracture of the articular cartilage. Articular cartilage fractures were found in 11 patients, with the medial condyle involved in 9 and the lateral in 2. All of these patients were discovered to have complete ACL tears on follow-up arthroscopy, but only seven had a complete ACL tear found on primary examination. Four of these seven patients had additional meniscal damage and are also included in the group of patients with meniscal injuries. The four patients whose original injury TABLE 3
Relationship between complications and type of ACL tear
°
Of these 11 patients, 4 originally had an incomplete ACL tear that was found to have transformed into a complete tear at the follow-up examination when the osteochondral fracture was observed.
was a
and
a
partial ACL tear developed both a complete ACL tear cartilaginous fracture.
Proliferative, chronic, subacute synovitis with joint effusion found at the primary arthroscopy in 10 cases (of 98) and at the repeated arthroscopy in 16 cases (of 34). Synovitis was found in all cases of meniscal and cartilaginous tears. was
Of 33
complications (excluding 11 cases of partial ACL complete ACL tears), 28 were seen in cases of complete ACL tear with major instability, and only 5 were observed in conjunction with partial ACL tears. Four of the 28 complications were originally partial tears; they were observed to be complete tears on followup when the complitear that became
cation
was
noted (Table 3).
DISCUSSION
Analysis of the knee injury and physical findings after the injury, followed by early arthroscopic examination combined with examination of the knee under anesthesia provides precise information regarding ACL injury. This early examination regimen demonstrated that isolated ACL damage does occur.6,17, 28, 31 Our follow-up study deals with patients who originally sustained an isolated ACL injury (as the exclusive primary finding). All patients with additional intraarticular injury at the time of the primary arthroscopy were excluded. The 98 patients with isolated ACL injury do not represent the exact number of isolated ACL tears at the time of the primary injury. The reason for this is that during the interval between initial injury and primary arthroscopy, additional intraarticular damage probably occurred in some patients, and these patients were excluded when seen at primary arthroscopy. Thus, the overall number of primary isolated ACL injuries is accordingly higher than documented. The 98 patients in this study were divided into two groups: 56 with a complete ACL tear and 42 with a partial ACL tear. Of the 56 patients with complete tears, 49 had knees that fit the term ACL insufficient. These patients were characterized by complaints of giving way and a positive drawer sign and Lachman test. Seven patients with complete ACL tears who were examined within 3 months of injury had only a slightly positive drawer sign and Lachman test; their knees were rather stable. This difference within the group with complete ACL tears is understandable when considering the chronic nature of injury of this major group, who developed laxity of secondary restraints. During the follow-up period, the condition of four of the seven deteriorated, and their knees became clinically unstable. The second group included 42 patients with partial ACL tears. These patients had a variety of complaints, mostly suggestive of meniscal damage (Table 4). In 31 cases (74%) there was a preoperative diagnosis of a torn medial meniscus. Knee locking as a symptom of a partially torn ACL has been reported by us previously.&dquo; None of the 42 patients presented with gross knee instability. On physical examination,
478
TABLE 4 Isolated tears of the ACL-patients’ complaints
We
currently treat patients with complete ACL tears, instability with positive drawer, Lachman and pivot shift tests, and repeated episodes of giving way with surgery. Recent experience in the diagnosis and evaluation of ACL injuries,’ awareness of possible consequences of nonsurgical treatment,l, 13, 15, 22, 23 and improved surgical techniques and gross
rehabilitation regimens,29 have clarified the treatment of these patients.
only half of this
group had
Lachman test. In
McMurray sign was
a slightly positive drawer or number of these patients a positive noted. The definite diagnosis of a partial
a
during arthroscopic examination. Diagnostic arthroscopy, used as the only diagnostic tool for detection of this clinically confusing injury, was reported by Noyes and McGinnis1° and was noted by Jackson and Dandy&dquo; and by Farquharson-Roberts and Osborne’ to presACL tear
ent with
was
some
made
clinical features of a torn meniscus.
Thirty-four of the 98 patients in this study developed, during a relatively short follow-up period [4.2 (mean) years], a secondary injury to their previously injured knee. Repeated arthroscopic examination revealed 44 structural injuries, some of them combined. Most of the reinjuries occurred when the patient, after prolonged physiotherapy, was symptom-free, self-confident in his physical ability, and participating in his or her previous sport activities. Sixty-four patients who maintained their original condition during the follow-up period, or whose condition improved, were examined clinically. Repeat arthroscopy was not performed in these 64, since there were no additional findings or positive diagnostic tests on repeat examinations, and we assumed that no changes had occurred within their knees. We cannot exclude conclusively the possibility of secondary damage within the joint in this asymptomatic group. One of the interesting findings of this study, not emphasized in the literature, was the finding of complete ACL tears in knees with clinical symptoms of ACL insufficiency and a previous diagnosis of partial ACL tear. Four of these patients sustained both meniscal and cartilage damage to their femoral condyle when reinjured. Another finding in this study was the forward dislocation of the anterior horn of the medial meniscus, which is occasionally observed during arthroscopy. This condition developed in 14 patients, all of whom had ACL insufficiency. This finding was not noted in the primary arthroscopic examination. It is an apparent possibility that the excessive anteroposterior and rotational knee movements in ACL insufficiency cause exaggerated meniscal mobility and stretching of the coronory and transverse ligaments, resulting in the forward displacement of the anterior horn of the medial meniscus. Our findings in this study caused us to make a significant change in the approach and treatment of these patients. Patients who are arthroscopically diagnosed shortly after injury with a partial ACL tear should immobilize the injured knee in a brace limiting extension to 30° for 8 weeks, followed by hamstring and quadriceps strengthening exercises. In addition, we recommend that the knee be protected during sports with a brace, up to 1 year after injury.
REFERENCES Amirault JD, Cameron JC, Maclntosh DL, et al. Chronic antenor cruciate ligament deficiency Long-term results of Macintosh’s lateral substitution reconstruction J Bone Joint Surg 70B. 622-624, 1988 2 Arnold JA, Coker TP, Heaton LM, et al. Natural history of antenor cruciate tears. Am J Sports Med 7 305-313, 1979 3. Bertoia JT, Urovitz EP, Richards RR, et al Anterior cruciate reconstruction using the Macintosh lateral-substitution over-the-top repair J Bone Joint 1
Surg 67A 1183-1188, 1985 4 Chick RR, Jackson DW. Tears of the antenor cruciate ligament in young athletes J Bone Joint Surg 60A 970-973, 1978 5 DeHaven KE. Arthroscopy in the diagnosis and management of the anterior cruciate ligament deficient knee Clin Orthop 172. 52-56, 1983 6 DeHaven KE Diagnosis of acute knee injuries with hemarthrosis Am J Sports Med 8 9-14, 1980 7 Editorial Routine arthroscopy for acute haemarthrosis of the knee Lancet 1 593-594,1989 8 Farquharson-Roberts MA, Osborne AH. Partial rupture of the anterior cruciate ligament of the knee J Bone Joint Surg 65B. 32-34, 1983 9 Feagin JA, Curl WW Isolated tear of the antenor cruciate ligament 5-year follow-up study Am J Sports Med 4 95-100, 1976 10 Fetto JF, Marshall JL The natural history and diagnosis of antenor cruciate ligament insufficiency Clin Orthop 147 29-38, 1980 11 Finsterbush A, Frankl U, Mann G Fat pad adhesion to partially torn anterior cruciate ligament A cause of knee locking. Am J Sports Med 17 92-95, 1989 12 Franke K Secondary reconstruction of the antenor cruciate ligament (ACL) in competitive athletes. Clin Orthop 198 81-86, 1985 13 Funk FJ Osteoarthritis of the knee following ligamentous injury Clin Orthop
172. 154-157, 1983 14 Giove TP, Miller SJ, Kent BE, et al Non-operative treatment of the torn antenor cruciate ligament. J Bone Joint Surg 65A. 184-192, 1983 15 Graham GP, Fairclourgh JA Early osteoarthritis in young sportsmen with severe anterolateral instability of the knee Injury 19 247-248, 1988 16 Hart JAL. Meniscal injury associated with acute and chronic ligamentous instability of the knee joint J Bone Joint Surg 64B: 119, 1982 17 Indelicato PA, Bittar ES. A perspective of lesions associated with ACL insufficiency of the knee A review of 100 cases Clin Orthop 198 77-80,
1985 18 Ireland J, Trickey EL Macintosh tenodesis for anterolateral instability of the knee. J Bone Joint Surg 62B . 340-345, 1980 19 Jackson RW, Dandy DJ. Arthroscopy of the knee (Modern Orthopedic Monographs) New York, Grune & Stratton, 1976, p 61 20 Jokl P, Kaplan N, Stovell P, et al Non-operative treatment of severe injuries to the medial and antenor cruciate ligaments of the knee J Bone Joint Surg 66A. 741-744, 1984 21 Kannus P, Jarvinen M. Conservatively treated tears of the antenor cruciate ligament Long-term results J Bone Joint Surg 69A. 1007-1012, 1987 22 Kannus P, Jarvinen M, Jozsa L Arthrosis in the unstable knee Acta Orthop Scand 59 476, 1988 23 Kennedy JC In Schulitz KP, Krahl H, Stein WH (eds) Late reconstruction of injured ligaments of the knee Berlin, Springer-Verlag, 1978 24 Kostuik JP Anterior cruciate reconstruction by the Maclntosh techniques J Bone Joint Surg 59B 511, 1977 25 Marshall JL, Warren RF, Wickiewicz TL, et al. The antenor cruciate ligament A technique of repair and reconstruction Clin Orthop 143 97-
106,1979 26. McDaniel WJ Jr, Dameron TB Jr The untreated antenor cruciate ligament rupture Clin Orthop 172. 158-163, 1983 27 McDaniel WJ Jr, Dameron TB Jr Untreated ruptures of the antenor cruciate ligament A follow-up study J Bone Joint Surg 62A 696-705, 1980 28. Noyes FR, Bassett RW, Grood ES, et al Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of antenor cruciate tears and other injuries J Bone Joint Surg 62A 687-695, 1980 29 Noyes FR, Butler DL, Paulos LE, et al Intra-articular cruciate reconstruc-
479 tion I
Perspectives on graft strength, vascularization, replacement Clin Orthop 172 71-77, 1983
and immediate
motion after
30
Noyes FR, McGinniss GH Controversy about treatment of the knee with antenor cruciate laxity Clin Orthop 198 61-76, 1985 31 Odensten M, Hamberg P, Nordin M, et al Surgical or conservative treatment of the acutely torn antenor cruciate ligament A randomized study with short-term follow-up observations Clin Orthop 198 87-93, 1985 32 Shields CL Jr, Silva I, Yee L, et al Evaluation of residual instability after
arthroscopic meniscectomy in antenor cruciate deficient knees Am J Sports Med 15 129-131, 1987 33 Tnckey EL In Jackson JP, Wough W (eds) Surgery of the Knee Joint London, Chapman and Hall, 1984, pp 178-183 34 Warren RF, Levy IM Meniscal lesions associated with anterior cruciate ligament injury Clin Orthop 172 32-37, 1983 35 Wirth CJ, Lobenhoffer P When is surgery indicated in antenor knee instability? Considerations on operative and functional treatment Arch Orthop Trauma Surg 105 232-234, 1986
From the
FINSTERBUSH,* MD, U. FRANKL,* MD, Y. MATAN,* MD, AND G. MANN,†‡ *
Department of Orthopaedic Surgery, Hadassah University Hospital, Mount Scopus, Jerusalem, and the t Unit of Sports Medicine, Zinman College of Physical Education, Wingate Institute, Netanya, Israel It should be emphasized that the at times combined.
ABSTRACT
secondary damages
were
Between 1978 and 1984, we examined and performed arthroscopy on 1000 consecutive patients. Ninety-eight of the 1000 had isolated ACL damage. These cases do not include patients with initial ACL injuries combined with other intraarticular damage. Diagnosis was by physical and arthroscopic examination. Examination took place an average 13.6 months after injury. Of the 98 isolated ACL injuries, 56 were complete ruptures and 42 were partial ruptures. In most cases of partial rupture, the clinical diagnosis was wrong. "Meniscal damage" was the usual diagnosis in these cases; the true diagnosis was made only by arthroscopic examination. Thirty-four of the 98 patients with isolated ACL injuries (30 men and 4 women) developed further intraarticular damage. Of these 34, 20 had complete ACL rupture and 14 had partial ACL rupture. Treatment after primary injury included physiotherapy in all patients and bracing in those whose knee was unstable during daily activities. Reconstructive surgical
history of surgically untreated ACL tears may guideline in both preventive and curative treatment. The recent controversy concerning the functional disability and future prognosis of such patients’,&dquo; ~°°21~25,zs,3~,z~ is a result of multiple factors: patient populations differ widely among studies as far as the degree of their athletic participation, the magnitude of their ligamentous laxity, and their compliance with rehabilitation programs.~~9°~0~14,27,30 The natural
provide
a
Most reports deal with ACL combined injuries. The combination of ACL with meniscal damage or other ligamentous damage is most common.4 16,27,34 Reinjury data are not comparable for the same reason and also because existing reports do not specify whether certain physical activities were
avoided
or
permitted.
We reviewed a group of 98 patients who represented a cross-section of a young population, some involved in sports and others active only for leisure. Each of the 98 sustained a knee injury resulting in an isolated injury to the ACL. The final diagnosis was established in all patients upon arthroscopic examination. Since patients’ complaints and clinical findings do not always correspond to the the term &dquo;ACL insufficient knee,&dquo; we prefer not using this term in this
procedures were not performed in those patients. The time lapse from the primary to the secondary injury varied from 1 month to 20 years, with an average of 28 months. The secondary damage was caused by a secondary injury that was mild (22 cases) or developed
insidiously (12 cases). Five types of secondary damage were observed: partial ACL tears that became complete—11cases; meniscal tear— 8 cases; loosening and subluxation of
particular group. MATERIALS AND METHODS
the anterior horn of the medial meniscus—14 cases; and fracture or damage to the articular condylar cartilage, with or without bone involvement—11cases.
The patients in this study came from a general orthopaedic practice in Hadassah Mt. Scopus University Hospital, Jerusalem. Ninety-eight patients were found to have isolated ACL damage. This consecutive, unselected group of patients was obtained for study by a retrospective review of hospital
t Address correspondence and reprnt requests to G Mann, MD, Unit of Sports Medicme, Department of Orthopaedic Surgery, Hadassah Unnversity Hospital, Mount Scopus, P O Box 24035, Jerusalem 91240, Israel. 475
476
through Febpatients who underwent arthroscopic examination for a variety of knee problems, mostly after an injury. All patients who had additional articular knee injury, such as a meniscal or ligamentous tear other than ACL, were excluded from study. Examination under anesthesia included inspection of the medial and lateral collateral ligaments, so that cases in which there was major ligamentous and capsular damage could be excluded. Preoperative radiographs showed no calcifications of bony damage, specifically excluding PedegariStieda and Segond fractures. Of the 98 isolated ACL injuries, there were 56 complete ruptures and 42 partial ruptures. The preoperative diagnosis in the latter group almost always was a torn meniscus. There were 86 men and 12 women. The average age at injury was 26.2 years (range, 13 to 45 years). Most of the injuries occurred during sports (62) and army activities (26). Playing football (soccer) was the most frequent cause of sports-related knee injuries. The time from original injury to the first arthroscopic examination ranged from 3 weeks to 15 years. The average delay from injury to arthroscopy was 13.6 months, and the average age at arthroscopy was 27.6 years. After examination, patients were referred to physiotherapy for hamstring and quadriceps exercises. Bracing was recommended when episodes of giving way were frequent and interfered with daily activities, and for sports activity. Patients were instructed to minimize temporarily strenuous activities requiring jumping, sharp turning, and quick starts and stops. Patients who regained full muscle power and who did not have functional instability returned gradually to their previous activities. records
during the period from January
1978
ruary 1984. The review included 1000 consecutive
RESULTS
Follow-up examination Patients with isolated ACL tears were managed with early treatment of symptoms. Treatment consisted of antiinflam-
matory drugs, aspiration of the knee in cases of painful knee effusion, and the use of a Jones dressing. In initial, acute cases, cast immobilization for up to 8 weeks
was followed by physical therapy including hamstring and quadriceps exercises. Protective bracing was used only in cases where there was frequent giving way. Braces used ranged from a simple hinged support brace to a Lerman brace and a Lenox Hill (Lenox Hill Brace, Long Island City, NY) variable axis knee
orthosis. All of the patients were followed up periodically in our outpatient clinic. Subjective complaints and objective findings were recorded. Each of the patients had roentgenograms taken of the knee. The average length of followup from the injury was 5.4 years and from the arthroscopy, 4.2 years. The shortest follow-up time from the injury was 2.5 years. Thirty-four of 98 patients (30 men and 4 women) were readmitted to the hospital after reinjury of their affected knee (22 cases) or progressive deterioration of their knee (12
cases). These patients underwent a second examination under anesthesia and arthroscopy. The time from primary to secondary injury varied from 1 month to 16 years, with an average of 28 months. The incidence of secondary damage could not be directly linked with the time lapse from the initial injury or initial examination, although it was found to be probably related to intensity and duration of the patient’s physical activity. The remaining 64 patients were reevaluated clinically and reexamined. Forty-one of these 64 improved after the rehabilitation program, returning to their previous activities with minimal or no discomfort. The condition of the remaining 23 patients remained unchanged (Table 1). These 23 patients had, as before, episodes of pain, swelling, and instability, although the frequency of these complaints was limited, since they reduced their sport activities and were able to perform their work and other daily duties. There were no demands from the patients in this last group for further investigation or treatment. The clinical examination data from their medical files did not reveal any significant change in their condition.
Reinjury of the previously affected
knee
Clinical and arthroscopic findings in the patients whose previously injured knee had deteriorated or who had reinjured their knee was analyzed according to the clinical and arthroscopic findings (Table 2). Partial tear of the ACL to a complete tear. Eleven patients who had partial ACL tears found during primary arthroscopic examination developed ACL insufficiency and were later discovered to have a complete ACL tear or a complete
ACL tear combined with a tear of the lateral meniscus (two cases), or articular cartilage damage (four cases). The secondary knee damage occurred after a sports-related injury in nine patients (seven soccer injuries, one basketball injury, and one tennis injury). Two patients could not describe any acute traumatic event. The clinical symptoms of the patients with partial ACL tears in existence before the secondary injury were pain mostly in the anteromedial aspect of the knee and inability to extend the knee fully, which was interpreted as locking. There were mild objective findings TABLE 1 Condition at followup of 98 patients with ACL injury
TABLE 2
Complications in 34 cases of isolated ACL damage
477
of anteroposterior or rotational knee instability, although without a positive pivot shift sign (Table 3). The arthroscopic findings in cases of partial ACL tears varied from interstitial hemorrhages within the synovial lining of the ACL to partial detachment with or without the synovial lining while the other part of the ligament was still under tension when stretched under direct vision. In some cases, adhesions of the partially torn ACL or its synovial lining to the fat pad limited full extension of the knee; these cases were interpreted (clinically) as a locked knee. Meniscal tears. Eight patients were found to have meniscal tears: five of the posterior horn of the lateral meniscus, two bucket-handle tears of the medial meniscus, and one posteromedial tear of the medial meniscus combined with a tear of the anterior horn of the lateral meniscus. Six of these patients initially had a complete ACL tear and two initially had a partial ACL tear that became a complete tear. These last 2 patients were also included in the first group of 11 patients with partial ACL tears that developed into complete tears. In four patients, additional cartilage damage was noted. Loosening and forward dislocation of the anterior horn of the medial meniscus. Loosening and forward dislocation of the anterior horn of the medial meniscus was found on arthroscopy in 14 cases. Eleven of these cases involved a previous complete ACL tear with clinical evidence of insufficiency. An additional three patients had a partially torn ACL with a slight anteroposterior loosening of the knee, but with a negative pivot shift (Table 2). None of these patients had sustained acute trauma. All of these patients had the anterior horn of the medial meniscus detached from the tibia and displaced inferiorly. Their complaints were pain in the lower pole of the patella, mostly on extreme flexion or extension of the knee. Those complaints were, in addition to their previous symptoms, related to the ACL injury. Fracture of the articular cartilage. Articular cartilage fractures were found in 11 patients, with the medial condyle involved in 9 and the lateral in 2. All of these patients were discovered to have complete ACL tears on follow-up arthroscopy, but only seven had a complete ACL tear found on primary examination. Four of these seven patients had additional meniscal damage and are also included in the group of patients with meniscal injuries. The four patients whose original injury TABLE 3
Relationship between complications and type of ACL tear
°
Of these 11 patients, 4 originally had an incomplete ACL tear that was found to have transformed into a complete tear at the follow-up examination when the osteochondral fracture was observed.
was a
and
a
partial ACL tear developed both a complete ACL tear cartilaginous fracture.
Proliferative, chronic, subacute synovitis with joint effusion found at the primary arthroscopy in 10 cases (of 98) and at the repeated arthroscopy in 16 cases (of 34). Synovitis was found in all cases of meniscal and cartilaginous tears. was
Of 33
complications (excluding 11 cases of partial ACL complete ACL tears), 28 were seen in cases of complete ACL tear with major instability, and only 5 were observed in conjunction with partial ACL tears. Four of the 28 complications were originally partial tears; they were observed to be complete tears on followup when the complitear that became
cation
was
noted (Table 3).
DISCUSSION
Analysis of the knee injury and physical findings after the injury, followed by early arthroscopic examination combined with examination of the knee under anesthesia provides precise information regarding ACL injury. This early examination regimen demonstrated that isolated ACL damage does occur.6,17, 28, 31 Our follow-up study deals with patients who originally sustained an isolated ACL injury (as the exclusive primary finding). All patients with additional intraarticular injury at the time of the primary arthroscopy were excluded. The 98 patients with isolated ACL injury do not represent the exact number of isolated ACL tears at the time of the primary injury. The reason for this is that during the interval between initial injury and primary arthroscopy, additional intraarticular damage probably occurred in some patients, and these patients were excluded when seen at primary arthroscopy. Thus, the overall number of primary isolated ACL injuries is accordingly higher than documented. The 98 patients in this study were divided into two groups: 56 with a complete ACL tear and 42 with a partial ACL tear. Of the 56 patients with complete tears, 49 had knees that fit the term ACL insufficient. These patients were characterized by complaints of giving way and a positive drawer sign and Lachman test. Seven patients with complete ACL tears who were examined within 3 months of injury had only a slightly positive drawer sign and Lachman test; their knees were rather stable. This difference within the group with complete ACL tears is understandable when considering the chronic nature of injury of this major group, who developed laxity of secondary restraints. During the follow-up period, the condition of four of the seven deteriorated, and their knees became clinically unstable. The second group included 42 patients with partial ACL tears. These patients had a variety of complaints, mostly suggestive of meniscal damage (Table 4). In 31 cases (74%) there was a preoperative diagnosis of a torn medial meniscus. Knee locking as a symptom of a partially torn ACL has been reported by us previously.&dquo; None of the 42 patients presented with gross knee instability. On physical examination,
478
TABLE 4 Isolated tears of the ACL-patients’ complaints
We
currently treat patients with complete ACL tears, instability with positive drawer, Lachman and pivot shift tests, and repeated episodes of giving way with surgery. Recent experience in the diagnosis and evaluation of ACL injuries,’ awareness of possible consequences of nonsurgical treatment,l, 13, 15, 22, 23 and improved surgical techniques and gross
rehabilitation regimens,29 have clarified the treatment of these patients.
only half of this
group had
Lachman test. In
McMurray sign was
a slightly positive drawer or number of these patients a positive noted. The definite diagnosis of a partial
a
during arthroscopic examination. Diagnostic arthroscopy, used as the only diagnostic tool for detection of this clinically confusing injury, was reported by Noyes and McGinnis1° and was noted by Jackson and Dandy&dquo; and by Farquharson-Roberts and Osborne’ to presACL tear
ent with
was
some
made
clinical features of a torn meniscus.
Thirty-four of the 98 patients in this study developed, during a relatively short follow-up period [4.2 (mean) years], a secondary injury to their previously injured knee. Repeated arthroscopic examination revealed 44 structural injuries, some of them combined. Most of the reinjuries occurred when the patient, after prolonged physiotherapy, was symptom-free, self-confident in his physical ability, and participating in his or her previous sport activities. Sixty-four patients who maintained their original condition during the follow-up period, or whose condition improved, were examined clinically. Repeat arthroscopy was not performed in these 64, since there were no additional findings or positive diagnostic tests on repeat examinations, and we assumed that no changes had occurred within their knees. We cannot exclude conclusively the possibility of secondary damage within the joint in this asymptomatic group. One of the interesting findings of this study, not emphasized in the literature, was the finding of complete ACL tears in knees with clinical symptoms of ACL insufficiency and a previous diagnosis of partial ACL tear. Four of these patients sustained both meniscal and cartilage damage to their femoral condyle when reinjured. Another finding in this study was the forward dislocation of the anterior horn of the medial meniscus, which is occasionally observed during arthroscopy. This condition developed in 14 patients, all of whom had ACL insufficiency. This finding was not noted in the primary arthroscopic examination. It is an apparent possibility that the excessive anteroposterior and rotational knee movements in ACL insufficiency cause exaggerated meniscal mobility and stretching of the coronory and transverse ligaments, resulting in the forward displacement of the anterior horn of the medial meniscus. Our findings in this study caused us to make a significant change in the approach and treatment of these patients. Patients who are arthroscopically diagnosed shortly after injury with a partial ACL tear should immobilize the injured knee in a brace limiting extension to 30° for 8 weeks, followed by hamstring and quadriceps strengthening exercises. In addition, we recommend that the knee be protected during sports with a brace, up to 1 year after injury.
REFERENCES Amirault JD, Cameron JC, Maclntosh DL, et al. Chronic antenor cruciate ligament deficiency Long-term results of Macintosh’s lateral substitution reconstruction J Bone Joint Surg 70B. 622-624, 1988 2 Arnold JA, Coker TP, Heaton LM, et al. Natural history of antenor cruciate tears. Am J Sports Med 7 305-313, 1979 3. Bertoia JT, Urovitz EP, Richards RR, et al Anterior cruciate reconstruction using the Macintosh lateral-substitution over-the-top repair J Bone Joint 1
Surg 67A 1183-1188, 1985 4 Chick RR, Jackson DW. Tears of the antenor cruciate ligament in young athletes J Bone Joint Surg 60A 970-973, 1978 5 DeHaven KE. Arthroscopy in the diagnosis and management of the anterior cruciate ligament deficient knee Clin Orthop 172. 52-56, 1983 6 DeHaven KE Diagnosis of acute knee injuries with hemarthrosis Am J Sports Med 8 9-14, 1980 7 Editorial Routine arthroscopy for acute haemarthrosis of the knee Lancet 1 593-594,1989 8 Farquharson-Roberts MA, Osborne AH. Partial rupture of the anterior cruciate ligament of the knee J Bone Joint Surg 65B. 32-34, 1983 9 Feagin JA, Curl WW Isolated tear of the antenor cruciate ligament 5-year follow-up study Am J Sports Med 4 95-100, 1976 10 Fetto JF, Marshall JL The natural history and diagnosis of antenor cruciate ligament insufficiency Clin Orthop 147 29-38, 1980 11 Finsterbush A, Frankl U, Mann G Fat pad adhesion to partially torn anterior cruciate ligament A cause of knee locking. Am J Sports Med 17 92-95, 1989 12 Franke K Secondary reconstruction of the antenor cruciate ligament (ACL) in competitive athletes. Clin Orthop 198 81-86, 1985 13 Funk FJ Osteoarthritis of the knee following ligamentous injury Clin Orthop
172. 154-157, 1983 14 Giove TP, Miller SJ, Kent BE, et al Non-operative treatment of the torn antenor cruciate ligament. J Bone Joint Surg 65A. 184-192, 1983 15 Graham GP, Fairclourgh JA Early osteoarthritis in young sportsmen with severe anterolateral instability of the knee Injury 19 247-248, 1988 16 Hart JAL. Meniscal injury associated with acute and chronic ligamentous instability of the knee joint J Bone Joint Surg 64B: 119, 1982 17 Indelicato PA, Bittar ES. A perspective of lesions associated with ACL insufficiency of the knee A review of 100 cases Clin Orthop 198 77-80,
1985 18 Ireland J, Trickey EL Macintosh tenodesis for anterolateral instability of the knee. J Bone Joint Surg 62B . 340-345, 1980 19 Jackson RW, Dandy DJ. Arthroscopy of the knee (Modern Orthopedic Monographs) New York, Grune & Stratton, 1976, p 61 20 Jokl P, Kaplan N, Stovell P, et al Non-operative treatment of severe injuries to the medial and antenor cruciate ligaments of the knee J Bone Joint Surg 66A. 741-744, 1984 21 Kannus P, Jarvinen M. Conservatively treated tears of the antenor cruciate ligament Long-term results J Bone Joint Surg 69A. 1007-1012, 1987 22 Kannus P, Jarvinen M, Jozsa L Arthrosis in the unstable knee Acta Orthop Scand 59 476, 1988 23 Kennedy JC In Schulitz KP, Krahl H, Stein WH (eds) Late reconstruction of injured ligaments of the knee Berlin, Springer-Verlag, 1978 24 Kostuik JP Anterior cruciate reconstruction by the Maclntosh techniques J Bone Joint Surg 59B 511, 1977 25 Marshall JL, Warren RF, Wickiewicz TL, et al. The antenor cruciate ligament A technique of repair and reconstruction Clin Orthop 143 97-
106,1979 26. McDaniel WJ Jr, Dameron TB Jr The untreated antenor cruciate ligament rupture Clin Orthop 172. 158-163, 1983 27 McDaniel WJ Jr, Dameron TB Jr Untreated ruptures of the antenor cruciate ligament A follow-up study J Bone Joint Surg 62A 696-705, 1980 28. Noyes FR, Bassett RW, Grood ES, et al Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of antenor cruciate tears and other injuries J Bone Joint Surg 62A 687-695, 1980 29 Noyes FR, Butler DL, Paulos LE, et al Intra-articular cruciate reconstruc-
479 tion I
Perspectives on graft strength, vascularization, replacement Clin Orthop 172 71-77, 1983
and immediate
motion after
30
Noyes FR, McGinniss GH Controversy about treatment of the knee with antenor cruciate laxity Clin Orthop 198 61-76, 1985 31 Odensten M, Hamberg P, Nordin M, et al Surgical or conservative treatment of the acutely torn antenor cruciate ligament A randomized study with short-term follow-up observations Clin Orthop 198 87-93, 1985 32 Shields CL Jr, Silva I, Yee L, et al Evaluation of residual instability after
arthroscopic meniscectomy in antenor cruciate deficient knees Am J Sports Med 15 129-131, 1987 33 Tnckey EL In Jackson JP, Wough W (eds) Surgery of the Knee Joint London, Chapman and Hall, 1984, pp 178-183 34 Warren RF, Levy IM Meniscal lesions associated with anterior cruciate ligament injury Clin Orthop 172 32-37, 1983 35 Wirth CJ, Lobenhoffer P When is surgery indicated in antenor knee instability? Considerations on operative and functional treatment Arch Orthop Trauma Surg 105 232-234, 1986
