Anterior Cruciate-deficient Knee Research Articles

A Technique of Improved Medial Meniscus Visualization by Anterior Cruciate Ligament Graft Placement in Chronic Anterior Cruciate Deficient Knees

It is customary to perform medial meniscus repair before anterior cruciate ligament (ACL) graft placement when undertaken as a combined procedure. However, in chronic ACL-deficient knees, intraoperative anterior tibiofemoral translation can cause the medial meniscus repair to be more technically challenging. Intraoperative anterior tibiofemoral translation can both reduce the visualization of the medial meniscus and make its reduction unstable. An operative sequence alteration of ACL graft placement and tensioning before medial meniscal repair improves medial meniscus visualization in chronically ACL-deficient knees by using the ACL graft's ability to prevent anterior tibiofemoral translation. The technique sequence is as follows: (a) the medial meniscus is reduced, (b) ACL reconstruction is undertaken using a hamstring graft without final tibia fixation, (c) distal graft tension is manually applied to distal graft sutures by the surgeon to prevent tibiofemoral subluxation, (d) the medial meniscus is repaired while graft tension is applied, and (e) the graft is then fixed to the tibia using an interference screw or another device.

Sagittal kinematics of mobile unicompartmental knee replacement in anterior cruciate ligament deficient knees

BackgroundThere is a greater risk of tibial component loosening when mobile unicompartmental knee replacement is performed in anterior cruciate ligament deficient knees. We previously reported on a cohort of anterior cruciate ligament deficient patients (n=46) who had undergone surgery, but no difference was found in implant survivorship at a mean 5-year follow-up. The purpose of this study was to examine the kinematic behaviour of a subcohort of these patients. MethodsThe kinematic behaviour of anterior cruciate deficient knees (n=16) after mobile unicompartmental knee replacement was compared to matched intact knees (n=16). Sagittal plane knee fluoroscopy was taken while patients performed step-up and forward lunge exercises. The patellar tendon angle, knee flexion angle and implant position was calculated for each video frame. FindingsThe patellar tendon angle was 5° lower in the deficient group, indicating greater anterior tibial translation compared to the intact group between 30 and 40° of flexion. Large variability, particularly from 40–60° of flexion, was observed in the bearing position of the deficient group, which may represent different coping mechanisms. The deficient group took 38% longer to perform the exercises. InterpretationKinematic differences were found between the deficient and intact knees after mobile unicompartmental knee replacement; but these kinematic changes do not seem to affect the medium-term clinical outcome. Whether these altered knee kinematics will have a clinical impact is as yet undetermined, but more long-term outcome data is required before mobile unicompartmental knee replacement can be recommended for an anterior cruciate ligament deficient patient.

Electromyographic analysis of anterior cruciate deficient knees with and without functional bracing during lunge exercise.

The use of functional knee braces for returning to sports or during demanding activities following anterior cruciate ligament rupture is common; yet despite being commonly prescribed, its mechanism of action remains unknown. To examine the effect of functional knee braces on mean muscle activity when performing lunge exercises. Pre-/post-test (within-subject research design). A total of 10 male participants with unilateral isolated anterior cruciate ligament deficiency participated. Electromyographic activities of six muscles around the knee were recorded during lunge exercises, with and without wearing a custom functional knee brace. The lunge cycle movement was subdivided into three phases: eccentric, isometric, and concentric. The quadriceps and hamstrings were no different in the braced and unbraced conditions. When braced, the mean amplitude of the medial gastrocnemius was significantly lower throughout the whole movement (p = 0.01) and during the concentric (p = 0.006) and eccentric (p = 0.028) phases, but not within the isometric phase. The lateral gastrocnemius was found to have lower mean amplitude in the isometric phase (p = 0.044). With its origin on the medial femoral condyle, perhaps reduced medial gastrocnemius activity may better guide knee rotation and assist the joint achieving a healthier kinematic pattern. Lower medial gastrocnemius activity may facilitate lower medial compartment contact pressure, for which greater loading is known to increase the risk of osteoarthritis in anterior cruciate ligament-deficient (ACLD) knees. However, further research is needed.

Patterns of Meniscal Damage Associated with Acute ACL Rupture

Patterns of Meniscal Damage Associated with Acute ACL Rupture

Relationship of native tibial plateau anatomy with stability testing in the anterior cruciate ligament-deficient knee

Recent attention has been drawn to tibial plateau slope and depth with relation to both risk of anterior cruciate ligament (ACL) tear and kinematics in the cruciate-deficient knee. The purpose was to evaluate the relationship between native proximal tibial anatomy and knee kinematics in the anterior cruciate-deficient knee. Twenty-two cadaveric knees underwent CT scanning to measure proximal tibia anatomy. Translation was measured during Lachman and mechanized pivot-shift tests on the intact knee and then after resection of the ACL. Pearson's correlation was calculated to assess the relationship between tibial translation of the ACL-deficient knee and tibial plateau anatomic parameters. No significant correlation was found between ACL-deficient kinematic testing and tibial slope or depth (n.s.). Lateral compartment translation on Lachman and pivot-shift testing correlated with lateral compartment AP length (P=0.007 and P=0.033, respectively). The ratio of lateral AP length to medial AP length correlated with lateral compartment translation during the pivot shift (P=0.002). There was a poor correlation between native tibial slope and kinematic testing. There were, however, increases in translation during pivot-shift and Lachman testing with increased AP length of the lateral compartment. In addition, the finding of increased pivot-shift magnitude when the lateral compartment was relatively wide in the AP plane compared to the medial compartment suggests that patients with a "dominant" lateral compartment may be prone to a greater magnitude of instability after ACL injury.

Young, Unstable, and Arthritic: The Knee Surgeon’s Dilemma

The treatment of knee arthrosis in the young active patient poses a management dilemma for the orthopedic surgeon. This problem is further complicated when arthrosis is accompanied by symptomatic knee instability as a result of anterior cruciate ligament rupture. This article gives an overview of the physiological role of the anterior cruciate ligament, the mechanisms and diagnosis of ligament injury, the natural history after rupture, and the consequences of knee instability in relation to chondral damage and subsequent degenerative joint disease. We outline the management options and surgical guidelines for patients with unicompartmental arthritis in the anterior cruciate–deficient knee.

Decreased eccentric muscle endurance in the conservatively treated anterior cruciate-deficient knee

Concentric (CON) and eccentric (ECC) isokinetic knee extensor endurance, during 100 repetitive isokinetic contractions, were analysed in 32 consecutive patients with conservatively treated unilateral anterior cruciate ligament ruptured knees. There were 20 men and 12 women (mean age 34 years). The test was performed 6.8 years after the injury (range 4–14). The uninjured leg in each patient served as control. Lysholm subjective score, Tegner activity score and IKDC grading were used to relate the subjective knee function to muscle performance. Knee extensor endurance for concentric as well as for eccentric contractions were significantly lower in the injured side than the uninjured side. The magnitude of decrease in muscle performance was 7.6% for concentric (range-12 to 27%) and 15.3% for eccentric (range -9 to 50%) endurance. The eccentric injured/uninjured endurance ratio correlated significantly to the Lysholm subjective score. We conclude that the knee extensor endurance is decreased in patients with conservatively treated anterior cruciate ligament-ruptured knees. The eccentric endurance test seems to reflect the patients' subjective knee functioning.

Considerations for Osteotomy in the ACL Deficient Knee

Abstract: The natural history of the isolated ACL deficient knee with or without reconstruction remains unclear. Although multifactorial in nature, evidence demonstrates these knees gradually deteriorate over time. Mechanical overload from knee malalignment has been identified to contribute not only to early failure of ACL reconstruction, but also to more rapid deterioration of the joint. However, assessing limb alignment as a contributing factor still remains largely overlooked in the ligamentously unstable knee, and reconstruction has generally focused on the soft tissue constraints. Therefore, the emphasis of this paper is that mechanical axis deviation in the chronic ACL deficient knee needs to be addressed as a means of treating the instability and protecting the joint. Over time, untreated malalignment can worsen ligamentous laxity and lead to symptomatic chronic instability. On reviewing the literature regarding the ACL deficient knee, some emphasis has been placed on the varus knee in the coronal plane, however little exists on the effect of malalingment, particularly in the sagittal plane. Previous authors have identified the varus component and advocate early intervention for the varus, anterior cruciate deficient knee. Most of these studies examined the effect of a closing wedge osteotomy in the chronically ACL deficient knee. In this review, the authors discuss the indications for realignment and the surgical technique utilizing an opening wedge technique at the time of ACL reconstruction. In addition, the importance of this paper is to discuss coronal and sagittal plane alignment and the need to assess and correct alignment in the unstable ACL deficient knee.

Knee joint moments during stair climbing of patients with anterior cruciate ligament deficiency

Objective. To establish the gait adaptations of patients with anterior cruciate ligament deficiency during stair ascent. Design. Joint kinematics and kinetics during stair climbing were measured in both knees of normal subjects and unilateral anterior cruciate ligament deficient patients. Background. As there is limited research pertaining to activities other than level walking, the purpose of the current study was to elucidate the gait of patients with anterior cruciate ligament deficiency during stair climbing to determine the effects of the deficiency on knee joint motion and moments as compared with normal knee function. Methods. A motion analysis system was used to measure and calculate kinematic and kinetic data for six normal subjects and nine patients with unilateral anterior cruciate ligament deficiency during stair ascent on a specially constructed staircase. Left and right leg data were analysed to reveal between-limb differences for each subject. Results. Patients with anterior cruciate ligament deficiency displayed a significant ( P<0.05) reduction of up to 50% in peak knee flexion moments in their involved knee. In the present study where a step height of 15.5 cm was used, peak flexion moments in all subjects' limbs occurred at knee flexion angles of about 40° during single limb support. Conclusion. The current study showed that most patients with an anterior cruciate deficient knee adapted their gait during stair ascent. Relevance. As stair climbing is a common activity, its effect on gait is relevant to better understand appropriate treatment and management strategies of patients with anterior cruciate ligament deficient knees.

Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients. A Preliminary Report

To The Editor: We read the article, “Transepiphyseal Replacement of the Anterior Cruciate Ligament in Skeletally Immature Patients. A Preliminary Report” (2003;85:1255-63), by A.F. Anderson. Clearly, the author is attempting to address a difficult problem in relation to the anterior cruciate-deficient knee in early adolescence. The mean age in his series was 13.3 ± 1.4 years, which is three to four years prior to epiphyseal closure in the femur and tibia in boys. By the same token, the epiphysis also has the potential for growth during this period, and therefore, with time, the consequences for the graft will be either stretching or, if stretching is not encountered, gradual tunnel enlargement, particularly on the femoral side. Also, the need to avoid violation of the physis will make tunnel placement that avoids impingement on the tibial side and anatomic siting on the femoral side extremely difficult to perform and certainly, on the femoral side, it is unlikely that the tunnel siting will be reproducible. We noted with particular interest that the guide wire placement illustrated by a lateral view of the tibia (Fig. 2) in the article is only 25% of the anteroposterior diameter of the tibial plateau and therefore would be highly likely to produce an anterior tunnel placement, which would subsequently produce graft impingement. The opinion that isometric ligament placement either can be achieved or indeed is desirable is open to question, and, given that the over-the-top route has … Corresponding author: Christos K. Yiannakopoulos, MD Byzantiou 2 171 21 Nea Smyrni Athens Greece cky{at}ath.forthnet.gr

Current concepts in meniscus surgery: resection to replacement

More recently, increasing attention has been turned toward the preservation and restoration of the medial and lateral menisci of the knee. The literature is replete with studies that cite the important biomechanical roles that the menisci play in shock absorption and load distribution across the knee in addition to contributing to stability, joint congruence, articular cartilage nutrition, lubrication, and proprioception. 1 Kettlekamp D. Jacobs A. Tibiofemoral contact area Determination and implications. J Bone Joint Surg Am. 1972; 54: 349-356 PubMed Google Scholar , 2 Walker P. Erkman M. The role of the menisci in force transmission across the knee. Clin Orthop. 1975; 109: 184-192 Crossref PubMed Scopus (814) Google Scholar , 3 Levy M. Torzilli P. Warren R. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am. 1982; 64: 883-888 PubMed Google Scholar , 4 Radin E. de Lamotte F. Maquet P. The role of the menisci in the distribution of stress in the knee. Clin Orthop. 1984; 185: 290-294 PubMed Google Scholar , 5 Shoemaker S. Markolf K. The role of the meniscus in the anterior-posterior stability of the loaded anterior cruciate deficient knee Effects of partial versus total excision. J Bone Joint Surg Am. 1986; 68: 71-79 PubMed Google Scholar , 6 Beaupre A. Choukroun R. Guidouin R. Knee menisci Correlation between microstructure and biomechanics. Clin Orthop. 1986; 208: 72-75 PubMed Google Scholar , 7 Baratz M. Fu F. Mengato R. Meniscal tears The effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med. 1986; 14: 270-275 Crossref PubMed Scopus (647) Google Scholar Published data supports that meniscal attrition after subtotal meniscectomy could be associated with degenerative processes in adjacent articular cartilage surfaces. 7 Baratz M. Fu F. Mengato R. Meniscal tears The effect of meniscectomy and of repair on intraarticular contact areas and stress in the human knee. A preliminary report. Am J Sports Med. 1986; 14: 270-275 Crossref PubMed Scopus (647) Google Scholar , 8 Johnson R. Kettelkamp D. Clark W. Factors effecting late results after meniscectomy. J Bone Joint Surg Am. 1974; 56: 719-729 PubMed Google Scholar , 9 Jorgensen U. Holm S. Lauridsen F. Long term follow-up of meniscectomy in athletes A prospective longitudinal study. J Bone Joint Surg Br. 1987; 69: 80-83 PubMed Google Scholar , 10 Bolano L. Grana W. Isolated arthroscopic partial meniscectomy. Functional radiographic evaluation at five years. Am J Sports Med. 1993; 21: 432-437 Crossref PubMed Scopus (152) Google Scholar , 11 Osti L. Liu S. Raskin A. Merlo F. Bocchi L. Partial lateral meniscectomy in athletes. Arthroscopy. 1994; 10: 424-430 Abstract Full Text PDF PubMed Scopus (50) Google Scholar , 12 Hede A. Larsen E. Sandberg H. Partial versus total meniscectomy. J Bone Joint Surg Br. 1992; 74: 118-121 PubMed Google Scholar , 13 Anderson-Molina H. Karlsson H. Rockborn P. Arthroscopic partial and total meniscectomy Long-term follow-up study with matched controls. Arthroscopy. 2002; 18: 183-189 Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar , 14 Schimmer R. Brulhart K. Duff C. Glinz W. Arthroscopic partial meniscectomy A 12-year follow-up and two-step evaluation of the long-term course. Arthroscopy. 1998; 14: 136-142 Abstract Full Text PDF PubMed Scopus (118) Google Scholar Despite this body of work, arthroscopic meniscectomy remains one of the most commonly performed orthopaedic procedures. The development of an increasingly more sophisticated and scientific understanding and approach to knee problems and, in particular, the natural history of the meniscectomized knee has raised concern for the risk of late degenerative arthrosis. Multiple other factors have continued to heighten interest in meniscal surgery, including the trend in our society for all age groups to place greater emphasis on fitness and remaining active. This has raised the demand for normalizing knee function, not only after injury, but also at extended follow up. Patients, the media, and clinicians alike all focus more attention on the treatment as well as the prevention of osteoarthritis. Furthermore, as more advanced technical capability has evolved as far as knee surgery is concerned, there is an increasing tendency to carry out more comprehensive arthroscopic and reconstructive surgical methods. Expanding surgical indications and demand now exists for anterior cruciate ligament (ACL) reconstruction, articular cartilage biologic resurfacing, and correction of axial malalignment as well as meniscal preservation or replacement surgery. Interest in the meniscus continues to remain in the forefront of basic scientific work, clinical study, and novel technology development. The purpose of this publication is to review the current and potential future approaches to meniscal pathology, including decision-making and indications for meniscal resection versus repair, and to report on several of newest devices and methods for repairing meniscal tears and replacing and transplanting meniscal tissue.

Meniscal tears sustained awaiting anterior cruciate ligament reconstruction

We reviewed 68 patients who underwent anterior cruciate ligament (ACL) reconstruction after initial EUA & arthroscopy in the knee unit of a United Kingdom district general hospital. Mean time between injury and ACL reconstruction surgery was 23.3 months with the incidence of meniscal tear at reconstruction being 67.6%. In this series 10.3% of patients sustained a meniscal tear in the delay period between arthroscopy and reconstruction surgery. Meniscal tear is strongly associated with ACL rupture and also a poorer outcome following reconstruction surgery. The delay in diagnosis and wait for reconstruction surgery that patients experience are potentially worsening surgical outcomes in the anterior cruciate deficient knee.

Effect of hamstrings muscle action on stability of the ACL-deficient knee in isokinetic extension exercise

Objective. To quantify the effect of hamstrings muscle action on stability of the anterior cruciate ligament deficient knee during isokinetic exercise at various speeds. Design. Mathematical modeling and forward-dynamics computer simulation were used to study the interactions between knee-extension speed, hamstrings co-contraction activity, and anterior tibial translation in the intact and anterior cruciate deficient knee. Background. There is much experimental evidence available to believe that hamstrings co-contraction can reduce anterior tibial translation in the anterior cruciate deficient knee. Little is known, however, about the level of hamstrings activation needed to keep anterior tibial translation within normal limits during functional activity. Methods. Isokinetic knee-extension was simulated with a sagittal-plane model used previously to study load sharing between the muscles, ligaments, and bones during isometric knee-extension exercise, isokinetic exercise, and squatting exercise. Conclusions. Some amount of hamstrings activation is needed to stabilize an anterior cruciate deficient knee irrespective of how fast the knee extends. The level of hamstrings co-contraction needed to stabilize an anterior cruciate deficient knee is inversely related to extension speed. Hamstrings co-contraction is more effective in reducing anterior tibial translation than low-resistance extension exercise. Relevance Excessive anterior tibial translation during knee-extension exercise may lead to damage of the meniscus and other passive structures inside the knee. If anterior cruciate deficient patients can be trained to co-contract their hamstrings during isokinetic knee-extension, then this exercise is appropriate for maintaining strength of the thigh muscles without compromising the anterior stability of the knee.

Assessment of functional knee bracing: an in vivo three-dimensional kinematic analysis of the anterior cruciate deficient knee

Objective. To describe three-dimensional tibial and femoral movements in vivo and examine the effect of a brace on knee kinematics during moderate to intense activity. Design. Skeletal kinematics of anterior cruciate ligament deficient knees was measured with and without braces during moderate to intense activity. Background. Invasive markers implanted into the tibia and femur are the most accurate means to directly measure skeletal motion and may provide a more sensitive measure of the differences between brace conditions. Methods. Steinmann traction pins were implanted into the femur and tibia of four subjects having a partial or complete anterior cruciate ligament rupture. Non-braced and braced conditions were randomly assigned and subjects jumped for maximal horizontal distance to sufficiently stress the anterior cruciate ligament. Results. Intra-subject peak vertical force and posterior shear force were generally consistent between conditions. Intra-subject kinematics was repeatable but linear displacements between brace conditions were small. Differences in angular and linear skeletal motion were observed across subjects. Bracing the anterior cruciate ligament deficient knee resulted in only minor kinematic changes in tibiofemoral joint motion. Conclusion. In this study, no consistent reductions in anterior tibial translations were observed as a function of the knee brace tested. Relevance Investigations have reported that knee braces fail when high loads are encountered or when load is applied in an unpredictable manner. Questions remain regarding tibiofemoral joint motion, in particular linear displacements. The pin technique is a means for direct skeletal measurement and may provide a more sensitive measure of the differences between brace conditions.

Using instrumented gait analysis for identification and treatment planning of a “functional” gait impairment following trauma and knee arthroplasty

This paper describes a procedure to determine the progress of the gait rehabilitation in relation to a reference obtained from a normal population. This procedure includes three stages: (1) data standardization, to give time and space aspects comparable from one individual to another; (2) monovariate and multivariate distance computation, to assess the difference between a disabled patient at a given time in the rehabilitation and the reference computed from individuals with a `normal' gait; and (3) distance evolution. Since several variables are taken into account at the same time, the star view is proposed, each ray corresponding to the average distance between a given function of the patient undergoing rehabilitation and the corresponding reference function. Thus, as the rehabilitation process progresses, the distances are reduced and the star ray decreases. As a case study, the procedure is applied to the rehabilitation of a patient with an anterior cruciate deficient knee.

Multivariate graphical presentation for gait rehabilitation study.

This paper describes a procedure to determine the progress of the gait rehabilitation in relation to a reference obtained from a normal population. This procedure includes three stages: (1) data standardization, to give time and space aspects comparable from one individual to another; (2) monovariate and multivariate distance computation, to assess the difference between a disabled patient at a given time in the rehabilitation and the reference computed from individuals with a 'normal' gait; and (3) distance evolution. Since several variables are taken into account at the same time, the star view is proposed, each ray corresponding to the average distance between a given function of the patient undergoing rehabilitation and the corresponding reference function. Thus, as the rehabilitation process progresses, the distances are reduced and the star ray decreases. As a case study, the procedure is applied to the rehabilitation of a patient with an anterior cruciate deficient knee. Copyright 1998 Elsevier Science B.V.

The posterior cruciate ligament in total knee arthroplasty

The purpose of this study was to answer 2 questions: Does the posterior cruciate ligament (PCL) produce femoral rollback in a single-design, cruciate-sparing total knee arthroplasty (TKA)? Does the PCL prevent posterior tibial displacement when it is retained after a single-design, cruciate-sparing TKA? Knee kinematics and limits of motion were measured with the knees in the following states: (1) intact knee, (2) anterior cruciate-deficient knee, (3) PCL-retaining total knee of a single design (TKA), (4) PCL-retaining TKA with PCL cut, and (5) PCL-substituting TKA. Femoral rollback was then calculated from the above data. The results showed that the PCL was able to prevent posterior translation and maintain femoral rollback when it was preserved during TKA. Therefore, the PCL can be functional after TKA, in a single-design, cruciate-sparing TKA. When the PCL was cut, significant changes in knee kinematics were observed.

In vivo kinematics of cruciate-retaining and -substituting knee arthroplasties

A fluoroscopic measurement technique has been used to provide detailed three-dimensional kinematic assessment of knee arthroplasty function during a step-up activity. Three groups of knee arthroplasty subjects with excellent clinical outcomes and similar ranges of motion were evaluated. Each group received different prosthetic components and surgical treatments of the posterior cruciate ligament (PCL). Group 1 had relatively flat articular surfaces with retention of the bony insertion of the PCL, group 2 had similar articular geometry but recessed the PCL without retaining the bony insertion, and group 3 had prostheses with greater sagittal conformity and post/cam substitution of the sacrificed PCL. Although none of the knees exhibited normal knee kinematics, the ranges of axial rotation and condylar translation for group 1 were similar to ranges previously reported for normal and anterior cruciate-deficient knees. Axial rotations and condylar translations decreased when the PCL was surgically recessed or substituted. The smallest kinematic ranges were observed in group 3. The results indicate that both prosthetic component selection and surgical technique have a significant effect on prosthetic knee kinematics during functional activities.

Neural and muscular electric activity in the cat's knee. Changes when the anterior cruciate ligament is transected.

We studied the response of the normal and unstable knee to passive motion and anterior tibial displacement in the cat. 6 cats were anesthetized and the deep level of anesthesia was controlled by electroencephalograms. We recorded electric activity in the articular nerves (posterior PAN and medial MAN) and periarticular muscles (quadriceps and hamstring), while performing passive flexion, extension, internal and external rotation. We then produced anterior displacement of the tibia at 30 degrees and 90 degrees of flexion, as in the Lachman and the anterior drawer maneuvers. The anterior cruciate ligament was surgically sectioned and the same series of passive displacements was performed. We observed statistically significant increased activity in the MAN, the PAN and the quadriceps muscle during knee flexion, in the MAN during extension, and in the PAN and hamstring during external rotation with the knee 90 degrees flexed. Anterior cruciate transection caused anterior displacement of the tibia during stress. This produced a significant increase in the MAN activity and a significant decrease in the hamstring electric activity at 30 degrees and 90 degrees of flexion, as in Lachman and anterior drawer maneuvers. We conclude that electric activity in the articular nerves and periarticular muscles, in response to passive motion and anterior tibial displacement, is altered in the cat's knee after anterior cruciate transection. This suggests that various patterns of periarticular muscle reaction in the anterior cruciate-deficient knee may be related to the unconscious perception of abnormal motion.

Rupture of the anterior cruciate ligament — a quiet epidemic?

One hundred and seventeen consecutive patients with 119 anterior cruciate deficient knees presenting to a knee clinic were studied to analyse an apparent poor diagnosis rate by referring doctors. The diagnosis had been made by the original treating physician in only 9.8 per cent of cases. Thirty per cent of the patients had been seen by an orthopaedic consultant without the diagnosis being made. Thirty-six patients had undergone 51 invasive investigations, including arthroscopy, without the diagnosis being made. This was despite 90 per cent of patients having a typical history and all having unequivocal physical signs. The average delay in diagnosis was 21 months.