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Preservation of meniscal tissue is paramount for long-term joint function, especially in younger patients who are athletically active. Many studies have reported encouraging results following repair of meniscus tears for both simple longitudinal tears located in the periphery and complex multiplanar tears that extend into the central third avascular region. This operation is usually indicated in active patients who have tibiofemoral joint line pain and are less than 50 years of age. However, not all meniscus tears are repairable, especially if considerable damage has occurred. In select patients, meniscus transplantation may restore partial load-bearing meniscus function, decrease symptoms, and provide chondroprotective effects. The initial postoperative goal after both meniscus repair and transplantation is to prevent excessive weight bearing, as high compressive and shear forces can disrupt healing meniscus repair sites and transplants. Immediate knee motion and muscle strengthening are initiated the day after surgery. Variations are built into the rehabilitation protocol according to the type, location, and size of the meniscus repair, if concomitant procedures are performed, and if articular cartilage damage is present. Meniscus repairs located in the periphery heal rapidly, whereas complex multiplanar repairs tend to heal more slowly and require greater caution. The authors have reported the efficacy of the rehabilitation programs and the results of meniscus repair and transplantation in many studies.

The purpose of this paper is to provide current knowledge regarding the indications, operative techniques, rehabilitation programs, and clinical outcomes of meniscus repair and transplantation procedures. Meniscus tears that occur in the periphery may be repaired using a variety of operative procedures with high success rates. Complex multiplanar tears that extend into the central one-third avascular zone can also be successfully repaired using a meticulous vertically divergent suture technique. The outcome of these repairs justifies preservation of meniscal tissue, especially in younger athletic individuals. Meniscal transplantation is a valid treatment option for patients who have undergone meniscectomy and have related tibiofemoral joint pain, or in whom articular cartilage deterioration in the meniscectomized compartment is present. Rehabilitation after these operations includes knee motion and quadriceps-strengthening exercises initiated the first day postoperatively. The initial goal is to prevent excessive weight bearing and joint compressive forces that could disrupt the healing meniscus repair or transplant. The protocol contains modifications according to the type of meniscal tear, if a concomitant procedure is done (such as a ligament reconstruction) or if noteworthy articular cartilage deterioration is present. Patients who have repairs of peripheral meniscus tears are generally progressed more rapidly than those who have repairs of tears extending in the central one-third region or those who undergo meniscal transplantation. The safety and effectiveness of the rehabilitation program has been demonstrated in several clinical studies. We recommend preservation of meniscal tissue, regardless of age, in active patients whenever possible.

A systematic approach to the clinical history, physical, and arthroscopic examination of patellofemoral disorders will lead to improved diagnostic accuracy and clinical treatment success. We review important aspects of physical and arthroscopic examination of patellofemoral disorders. Basic and advanced physical examination techniques are presented, and their clinical significance is reviewed. Arthroscopic examination of the patellofemoral joint is used as an adjunct to physical examination to evaluate chondral lesions of the patella and femoral sulcus and to visualize patellar tracking. Techniques to assess patellar tracking and the integrity of patellar restraints and to grade chondral lesions are outlined. Utilization of these techniques will improve clinical studies on the treatment of patellofemoral disorders.

Reprinted with permission from The American Journal of Sports Medicine 9:3 140-147, 1981. Presented at the Interim Conference of the American Orthopaedic Society for Sports Medicine, February 8, 1980, Atlanta, GA.Address correspondence to: Lonnie Paulos, MD, 2350 Auburn Ave., Cincinnati, OH 45219.The purpose of this paper is to present the specifics and rationale of our postoperative rehabilitation program after anterior cruciate ligament (ACL) reconstruction and compare it with an international survey of 50 knee experts. It is important to stress that what we present is opinion. This opinion, however, is based on principles, guidelines, and specifics which we believe are important.The early phases of our program are based upon time and control of forces, both of which are necessary for ligament healing. The classic parameters of return to play do not indicate healing of ligament tissue and must not be substituted for time restraints.After ACL repair and reconstruction, there are five phases of rehabilitation: maximum protection (12 weeks), moderate protection (24 weeks), minimum protection (48 weeks), return to activity (60 weeks), and activity and maintenance.The maximum protection phase consists of the early healing period and controlled motion period. The early healing period is governed by a principle which requires the absolute control of forces to prevent disruption of the suture line or attachment site. This time will vary according to the surgical technique. We do not allow motion during this period. During the controlled motion period, we allow motion but control external forces to protect ligament healing.The moderate protection phase consists of the crutch-weaning and walking periods. The major goal of the moderate protection phase is to prepare the patient for walking. The principles which govern Phase 2 are that walking activities create large anterior cruciate ligament forces and healing strength is still low. A balance of quadriceps and hamstring forces is necessary for proper knee kinematics. De-emphasis of quadriceps exercises and emphasis of hamstring muscles is appropriate; however, both muscle groups must be strengthened. The crutch-weaning period is designed to allow the gradual increase of motion and strength to sustain walking activities.A paradox of exercise exists for strength building. To push weight from 30 degrees of flexion into full extension will protect the patellofemoral joint but will create large forces on the ACL. Our compromise is to push low weight through a full range of motion. We begin full weightbearing no sooner than the 16th week.The final three phases of our program are designed to develop dynamic stability through strength, coordination, and endurance. Phase 3, the maximum protection phase, consists of the protected activity period from the 24th through the 36th week, and the light activity period from the 37th through the 48th week. Restrictions include no running, no jumping, and the use of a brace full-time. The light activity period allows further time to protect the slow healer. This may be shortened or lengthened, depending upon the patient's condition and goals.Phase 4, the return to activity phase, begins nine to 12 months after surgery. It consists of the advanced rehabilitation period and the running period. The advanced rehabilitation period is designed to achieve maximum strength and further enhance neuromuscular coordination and endurance. The running period begins when the operated leg has at least 75 percent of the strength and power of the normal leg.The activity and maintenance phase consists of the return to sport and maintenance periods. On return to sport, the patient must gradually resume full activity by advancing from skill drills. The maintenance program consists of triweekly strength-building sessions, brace protection during sporting, and avoidance of high-risk activities. J Orthop Sports Phys Ther 1991; 13(2):60-70.