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The anatomical and functional details of the cruciate ligamants of the knee were studied on 20 cadaver knees and 24 fresh knees. Each anterior cruciate ligament was found to consist of 2 parts: a distinct anteromedial band (AMB) and a main posterolateral part. The exact geometry of the ligaments and their relationship to bony landmarks were recorded in detail. The state of the cruciate ligaments, i.e. tightness or looseness was recorded in the various positions of the knee as the basis for classification of the function of the various anatomical components. Selective cutting of the anterior cruciate ligament resulted in an increase of anterior drawer flexion and extension. External and internal rotation were increased in both flexion and extionsion. Hyperextension also was increased. It is suggested that the AMB of the anterior cruciate is responsible for the in anteroposterior drawer with flexion. The selective cutting of the posterior cruciate ligament demonstrated that it is important in the flexed knee and produces an.increased posterior drawer sign. Rotational stability was unchanged in extension, but altered in flexion after cutting the posterior cruciate.

An analysis of the data with total scores in non-acute terms obtained from 280 patients suggests that knee injuries can be evaluated as: Good-Excellent=generally normal or near normal function, with few or no signs and minimal symptomatology, 41-50 points; Fair (+)=slight functional disability, with few signs and mild symptomatology, 36-40 points; Fair (-)=moderate functional disability, with significant clinical signs and moderate symptomatology, 31-35 points; Poor=severely disabled, with marked signs and symptoms of a compromised knee, less than 30 points. These gross categorizations correlate well with the patient's own evaluations of his condition and the physicians' clinical assessment of the status of a given knee. Although the majority of patients have been followed for four years or less with this method, it is felt that the method presented has provided: A consistency and organization of the workup, diagnosis, treatment, and study of knee ligament injuries, not previously available at our institution; an objective measure of individual patient response to treatment and eventual recovery; in general, more objective means of assessing modalities of therapy and modes of primary repair and reconstruction of ligaments; a tool facilitating communication both among physicians and between physicians and patient; a means by which the long term follow-up of an individual patient by more than one physician can become a more efficient undertaking; an increasing data bank of standardized observations from which many ideas are yet to evolve; and most importantly, an improvement and the means possible for further improvement in the care rendered patients with knee ligament injuries; also, the present computerized format has given rise to additional benefits not directly related to the immediate problem of knee ligament injury. One such benefit is the ability to request and receive rapidly, a concise, yet complete legal summary of a patient's hospital course.

Isolated MCL I and MCL II lesions evidence good recovery of integrity and function under non-operative modes of treatment. Isolated MCL III lesions may also be treated by non-operative management, but with the expectation of a slightly less successful result. However, there is an 80% incidence of concomitant ligament injury with this grade of lesion. The prognosis following injury to the MCL is significantly influenced by the presence of concurrent compromise of other ligaments, particularly that of the anterior cruciate ligament. Resolution of knee instability and dysfunction following a mixed MCL injury of any grade severity is best accomplished through operative intervention. Therefore, it is the authors' opinion that isolated MCL III and all mixed MCL lesions are best managed with operative treatment. Because of the apparent influence compromise of other ligament structures have on the recovery of MCL function, an attempt must be made to repair all acutely injured structures at the time of surgery. The keystones of a satisfactory result are early and accurate diagnosis, prompt treatment, and when indicated, complete surgical repair.

The knee is a complex joint and its stability depends upon many factors, but static stablizing structures are the most critical. The anatomic integrity of these structures correlates well with both their functional integrity and the instability observed during manual stress-testing of the knee. This makes accurate diagnosis possible. Stability of the knee is most easily defined in terms of straight planes, varus, valgus, anterior and posterior displacement. Rotory instabilities are syndromes which represent combinations of straight-plane instabilities. The stability in each plane is supplied by a primary static stabilizer and secondary and at times tertiary reinforcing structures. The information required to accurately interpret the pattern of injury is readily obtained by stressing the knee in the planes described.

In 233 knees with anterior cruciate ligament insufficiency the characteristic diagnostic signs and symptoms were: a specific mechanism of injury; an audible "pop" at the time of injury; a positive anterior drawer sign' "giving away"; functional disability; periarticular degenerative changes. Unresolved anterior cruciate ligament insufficiency follows a predictable natural history typified by a course of progressive knee dysfunction and deterioration. The progress of deterioration can be significantly modified or arrested by repair or reconstruction of the injured ligament.

Factors are examined which may be associated with chronic posterior heel pain of nonrheumatologic and nonmetabolic etiology. The charts of patients in whom Haglund's disease retrocalcaneal bursitis, or "pump bumps" was diagnosed during the period from 1963-1978 at The Hospital for Special Surgery, were reviewed. Nineteen patients met the criteria of symptomatic patients. The radiographs in 12 of these patients were available for review. These cases and 104 control cases were evaluated for the presence of calcaneal spurs, Achilles tendon calcifications and a posterior calcaneal step. In addition, Fowler-Philip measurements were obtained from the radiographs and compared with Fowler and Philip's results. Although the Fowler-Philip angles of the two groups were not significantly different (p greater than 0.05), the symptomatic heels had a significantly longer horizontal calcaneal length (p less than 0.05). The incidences of Achilles tendon calcification (p = 0.004) and of a posterior calcaneal step (p less than 0.001) were higher in patients who had chronic posterior heel pain as compared to a control population. An increased horizontal length of the calcaneus and the presence of a posterior calcaneal step appeared to cause chronic posterior heel pain and degenerative lesions of the Achilles tendon. Although a posterosuperior calcaneal prominence is theoretically important, it was not in this series. A posterior calcaneal step may alter the tension within the tendon, resulting in microscopic tendon injury, decreased vascularity and loss of strength, with subsequent calcification or rupture.

Patellar tracking patterns were studied in 20 cadaver knees. The predominant pattern (Type 1) found in 17 knees included medial shift and medial tilt of the patella with respect to the tibial tubercle during extension of the knee. The remaining three knees (Type 2) showed a tendency toward lateral shift and tilt. Release of the lateral retinaculum had no effect on patellar tracking in most knees, while release of the medial retinaculum produced abnormal tracking in many Type 1 knees and all Type 2 knees. The "proximal realignment" (medial imbrication-lateral release) procedure increased the tendency of the patella to tilt and shift medially during extension.

The difficulty in diagnosing and subsequently treating lesions of the anterior cruciate ligament (ACL) is demonstrated in a review of 136 cases. Twenty-one patients noted a "pop" at the time of injury and each had a lesion of the ACL. The mechanism of injury may be helpful. The commonly seen valgus external rotation injury was noted in 60% of the cases but internal rotation with hyperextension and/or hyperflexion were also reported. The anterior drawer sign, if present, increases the accuracy to 92.1%. Failure of early cast treatment occurred if the ACL was torn but not in lesions confined to the MCL. Early meniscectomy in the cruciate deficient patient did not alleviate the need for further surgery in this group. At surgery the medial meniscus was torn in 93/124 ligament injuries but in addition 14 tears of the lateral meniscus were found. Wound complications were frequent with infection (4.8%) always being associated with hematoma formation (9.5%).

Both primary repair and late substitution of anterior cruciate ligaments can be accomplished by intra-articular methods. This principle is to provide temporary struts that are initially avascular but can later undergo revascularization and metaplasia to form a new ligament. The graft does afford initial support, however. An understanding of anatomic principles, suture placement, freedom of graft from impingement, avoidance of acute angular deviation of the graft, solid static stability, anatomic attachment points, and blood supply, is absolutely essential for success in this field of surgery.

The progression from chronic anterior cruciate instability to degeneration of the knee has been well documented in animal studies. However, the literature is unclear as to the overall consequences with respect to the development of osteoarthritis. The long-term consequences of the anterior cruciate insufficient knee with or without associated medial collateral ligament insufficiency was investigated in 127 consecutive patients. The effects of meniscal injury and/or meniscectomy in the presence of ligamentous insufficiency was correlated with roentgenographic observations. A scoring system was devised and found to show that anterior cruciate insufficiency naturally progresses toward degenerative osteoarthritis. Meniscectomy with and without an associated medial collateral ligament insufficiency hastens the degenerative process. Progressive functional deterioration was shown to correlate with roentgenographic evidence of degenerative changes. The ultimate success of surgical repairs and reconstructions of the anterior cruciate ligament will not be based only upon functional return to activity or objective stability, but will also depend on the procedure's ability to prevent later development of degenerative osteoarthritis.