Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Journal
Volume
of Surgery
and Joint
American
VOLUME
56-A,
No.
MARCH
1974
The
Anatomy Anterior
and Cruciate
Function Ligament
of the
As DETERMINED
BY JOHN C. KENNEDY, ANDREW From the Division ofOrthopaedic
BY CLINICAL
M.D., S. WILSON, Surgery F.R.C.S.(C)t, M.D., and
AND MORPHOLOGICAL
HOWARD LONDON, W.
STUDIES
M.D.t, AND
ONTARIO, ofAnatomv.
the Department
Ontario
of Western
Ontario,
London,
ABSTRACT:
In a biomechanical study of fifty function ofthe were varies during are adequate
morphological
study
of cadaver
knees
and
clinical end-result the structure and various cruciate fiexion; forms ligament that there
with tears of the anterior the mechanism ofinjury, It was concluded that
of therapy
tension
being least at from 40 to 50 degrees of blood vessels and nerves for healing
to occur; that isolated tears of the anterior cruciate ligament do occur (probably as the result of internal-rotation displacement of the tibia with respect to the femur); that such tears are frequently associated with meniscal tears; and that early results of operative although
There
of the anterior
cruciate
ligament
are acceptable
anatomy
and
function
of the
anterior
cruciate
ligament
that
and room
need when
further a torn
study. anterior
of uncertainty is unexpectedly
it
invariably discov-
pervades
authorities on the knee there is disagreement cruciate ligament can occur at all, and if There
and
a tear will affect knee function significantly 12.l4 tears located in the middle portion of the ligament.
We have been studying the pathomechanics
is also
morphology
no effective
of the
to repair
cruciate
ligament
provide
of years injury
guidelines
and, to this
for
more ligament.
the
recently, The
have basic
been purpose
investigating
the behavior
management
of patients
cruciate
Read in part
ligament.
We
also
hoped
to find
answers
to numerous
at the 5, 1973.
Annual
Meeting
of The
American
Academy
of Orthopaedic
Surgeons,
Las
Vegas,
111 Waterloo Street, London 72, Ontario, Canada. 1920 Weston Road, Weston, Ontario, Canada. Department of Anatomy, University of Western Ontario, London,
Ontario,
Canada. 223
224 1
cruciate
.
.
J. C.
KENNEDY,
H.
W.
WEINBERG,
AND
A.
S.
WILSON
How
does
are
tension the
cruciate
ligament that
motion
ofthe of the
knee? anterior
rupture
tear of this ligament in the anterior cruciate blood were knees who
are the late sequelae? and what levels are ligaand and as demsigns
occur
advantageous for repair? 5 . What is the intraligamentous to these studies of fifty questions
of the anterior
cruciate
sought
in two at autopsy
of cadaver patients
obtained
within
onstrated by arthrotomy. In the clinical study, and symptoms, operative machine and strength-testing ten years after The fifty treatment. patients were
to the mechanism
the results of tests made with our clinical stress and the functional result found from seven months to at random, the only requirements for inclusion in the
study being the presence of an anterior cruciate ligament tear accurately throtomy, and an adequate clinical follow-up in terms of duration and
evaluation. Three of the patients had been followed for less than one year, but their resuits were established (two, excellent and one, poor) at the time of the study. Of the fifty patients selected, twenty-four had isolated tears of the anterior cruciate ligament (ten with and fourteen tenor cruciate thirteen without without associated tears of a meniscus) ligament along with damage to other associated tears of a meniscus). Biomechanical Studies and twenty-six capsular ligaments had tears (thirteen of the anwith and
Dissections of one of the knees of ten adult cadavera (males and females included) obtained at autopsy revealed little individual variation in the length of the anterior cruciate ligament, the lengths ranging between 3.7 and 4. 1 centimeters (average, 3.9). In the same knees a central oblong block of bone was removed from the anterior aspect of the femur to
permit ten joints visualization in different of the entire positions
anterior
revealed
ligament
anterior
(Fig.
cruciate
1). Observations
ligament is taut
in these
when the
knee is in full extension and in 5 and 20 degrees of flexion, becomes most relaxed between 40 and 50 degrees of flexion, and then becomes increasingly taut as flexion is increased to from 70 to 90 degrees. These estimates of tension were made by inspection and palpation of the anterior cruciate ligament using a septal elevator and a small curved hook (Figs. 2-A through 2-E). In 1907 Pringle observed that tightening and slackening of the cruciate ligaments occurred in adult human knees as they were flexed results were recorded, however, and he simply relaxation of the ligaments was approximately tension of the knee joint. Little additional information relative and extended at autopsy. No quantitative estimated that the position of maximum halfway between full flexion and full exfunction of the intact cruciate anterior cruciate was
to the
of the anterior
ligament
also investigaged in our study. Internal rotation in all positions of flexion consistently increased tension, even with the knee flexed 40 degrees, the position in which the anterior cruciate ligament was most lax during flexion from full extension to 90 degrees (Figs. 3-A and 3-B). The effect of external rotation on the tension of the anterior cruciate ligament was not studied with the knee in different degrees of flexion. Our
ThE
previous
JOURNAL
studies
OF BONE
had showed
AND JOINT
that
SURGERY
ANATOMY
AND
FUNCTION
OF
THE
ANTERIOR
CRUCIATE
LIGAMENT
225
FIG.
Dissection to expose the entire anterior cruciate four centimeters of the ligament can be visualized.
ligament.
With
a large
central
notch
the
full
FIG.
2-A
FIG.
2-B
Figs. 2-A through 2-D: Photographs showing tautness of the anterior cruciate ligament with the knee in different positions from S to 90 degrees of flexion. Each pair of photographs shows the knee before (above) and after (below) a notch was cut in the femur to permit more accurate assessment of tension in the cruciate ligament.
In each position placed under the the same ligament. upward and anterior Note that the tautness force (judged subjectively) is less at 40 to 50 degrees. was being applied to the instrument
VOL.
56-A,
NO.
2. MARCH
1974
226
J.
C.
KENNEDY,
H.
W.
WEINBERG,
AND
A.
S.
WILSON
9O#{176}F]
FIG.
2-C
FIG.
2-D
tension
increased
as abduction
and
external-rotation
forces
were
applied
indicating
that
this ligament
Mechanisms
against
these
forces.
Cruciate Ligament
of the Anterior
Our
previous
cadaver
studies
showed
that
a tear
of the anterior
cruciate
ligament
and
FIG.
3-A
FIG.
Dissection showing effect of internal rotation of the tibia. With the knee in 40 degrees internally rotated on the femur to its fullest degree (Fig. 3-B), the increased tautness ligament (compare with Fig. 3-A) is readily visualized.
THE JOURNAL OF BONE
AND
JOINT
SURGERY
ANATOMY
AND
FUNCTION
OF
THE
ANTERIOR
CRUCIATE
LIGAMENT
227 and
8,10,
capsular forces
and
ligamentous directed
could applied
#{228}bas
in combination,
anterior
by hyperexten-
and abduction:
40 to 50 degrees
of exter-
of the tibia while the knee was held in 90 degrees was first stretched and then torn. If an abduction in addition to the rotation, tearing of the tibial forces studies were increased it was evident
of flexion, the medial capsuforce was then applied to the collateral ligament occurred. was disbe tensed
if both In these
further, the anterior cruciate ligament that the anterior cruciate ligament could
over the medial border external-rotation forces tenor cruciate ligament sufficiently taut to rupture Complete dislocation duced by hyperextension initially and then ruptured hyperextension, ment. After
of the lateral femoral condyle only when both abduction and were applied simultaneously. With external rotation alone, the anneither came in contact with the femoral condyle, nor became while other structures remained intact. of the knee joint: When complete anterior dislocation forces applied to cadaver knees 8, the posterior capsule at approximately 30 degrees of hyperextension. and then inspection the anterior of the joint With cruciate revealed of first the posterior had partially torn,
was
pro-
the posterior cruciate ligament was still intact, but accurate assessment of the integrity of the anterior cruciate ligament was not possible. With further hyperextension, rupture of both cruciate ligaments occurred, as well as an anterior dislocation of the knee. Direct posterior violence: In unpublished studies of cadaver limbs, an anteriorly directed force was applied to the posterior surface of the tibia, displacing it forward, while the knee was held in 90 degrees of flexion (a mechanism identical to that produced by clipping anterior damage that there structures. producing
Mechanism
in North American football). In fifteen consecutive cadaver limbs, tears of the cruciate ligament were produced, eight of them in the middle of the ligament. The seemed to be limited to the anterior cruciate ligament, but we could not be certain was neither an isolated
of Injury
damage
to the
posterior cruciate
Tears
nor
stretching violence
of other
important
we have
not classified
posterior
as a mechanism
of the Anterior
Cruciate
Ligament
Authorities
disagree
as to whether
12.14
there
is such
a clinical
entity
as an isolated
tear
of two as-
ligament rotation
and
sociated capsular and ligament injuries along with the tear of the anterior cruciate ligament. The third mechanism (posterior violence), on the other hand, caused no demonstrable damage to other structures, but it was impossible to be certain that stretching of other structures, either gross or microscopic, had not occurred. Another mechanism possibly causing isolated injury to the anterior cruciate ligament was suggested by the review of our fifty patients with proved tears of the anterior cruciate ligament. This mechanism was internal rotation of the tibia on the femur. Seven of the fifty patients gave a definite history of an injury causing internal rotation of the tibia with on the femur injury and at arthrotomy were found to have tear an anterior cruciate tear, capno associated in six and with an accompanying of the posterolateral
sule in one. However, laboratory using cadaver subjected ligament. either ligament
VOL.
five consecutive auempts knees which were placed force applied the ligament where
to reproduce this mechanism in the in from 15 to 20 degrees of flexion and to tear the anterior taut, but in every applied before rupture cruciate instance of the
or the tibia
fractured
56-A,
J.
C.
KENNEDY,
H.
W.
WEINBERG,
AND
A.
S.
WILSON
that internal
4). Her initial
a girl (Case 28), injured her right knee while skiing. An analysis of the injury described suggested rotation of the tibia on the femur had occurred while the knee was flexed from 15 to 20 degrees (Fig.
treatment included aspiration of blood from the knee and immobilization in a plaster cast for three
weeks. further
tive
Thereafter. evaluation
drawer
she had a persistent effusion, symptomatic instability was carried out, eighteen months after injury, clinical
sign with no medial or lateral opening of the joint
anterior
space
and increasing pain. When revealed a markedly posistress was applied. Evaluation
on the testing
Medial
Anterior Medial Lateral
machine
opening
tibial
revealed
(valgus
condyle
the following:
stress) 2.0 millimeters on the femur 18.5 millimeters
millimeters
(normal, (normal,
3.5) 5.0)
of the tibia
17.8 millimeters
stress) 2.7
(normal,
(normal,
5.0)
3.5)
Lateral
The
there was
opening
displacement
no abnormal
of the tibia
medial
forward ligament
was
almost
When
four
times
limit of normal
was performed,
while
a
or lateral opening
of the knee.
surgical
anterior
cruciate
but no other
abnormality
was noted.
Isolated
tear
Antertor
Cruciate
FIG.
Possible
mechanism
of injury
causing
an isolated
cruciate
ligament.
With
internal
rotation
of the tibia on the femur, femoral or tibial attachment, occurred in the mid-portion
as shown, or by
be disrupted by avulsion of bone from its 72 per cent of the ruptures in our series
of the ligament.
Morphological
Site of Anterior Cruciate
Studies
Tear
Avulsion of bone at one of the attachments of the anterior cruciate ligament is uncommon in our experience. It occurred twice in this series of fifty cases, both times at the tibial attachment. In several recent series the common site was described as the proximal end of the ligament near the femur, but with no bone avulsion. In our fifty patients, however, the mid-portion of the ligament was the most common site, as follows: upper end, nine patients (18 per cent); mid-substance, thirty-six (72 per cent); lower end, two (4 per cent); The confines and unknown, tear of the of the synovial three anterior (6 per cent). cruciate and ligament hence may be very be shredded difficult and hidden within the
to localize accurately. We have classified as mid-substance tears all those occurring in the middle two centimeters of the four-centimeter cruciate ligament, an area where reattachment of the ligament to its femoral origin is either technically impossible or impractical.
ThE JOURNAL OF BONE AND JOINT SURGERY
membrane,
ANATOMY
AND
FUNCTION
OF
THE
ANTERIOR
CRUCIATE
LIGAMENT
229
The Blood
and Nerve
Supply
ofthe
Anterior
Cruciate
Ligament
middle
cruciate ligament comes from branches of the to the ligament reaches it near its upper end and at a point as the tibial proximal to the tibial spine. This intercondylar artery, ultimately is structures autopsy of the knee joint, material by Gardneurovascu-
descends along its dorsal surface, bifurcating branch ofthe middle genicular artery, known distributed The as shown
ner
to both tibial condyles 17 rest of the blood and nerve supply of intra-articular in cats by Freeman and Wyke (1967) and in human
,
( 1948)
is derived
from
a much
more
extensive
projection
of periarticular
than earlier descriptions had suggested. The findings of these for the more recent detailed studies of Scapinelli ( 1968) and
(1968).
Methods of Tissue Preparation
present to age,
three One
adult cruciate
male
human
were and
without in 10 of
anterior
ligaments
formalin was
six specimens,
selected
at random
one week
to its longitudinal axis. Frozen sections, cut at a obtained from these slices and either impregnated of Schofield or stained by direct immersion in were used of each to prepare ligament. at five transverse The tissue micrometers, sections blocks so and
other
ligament middle,
and
the proximal,
with hematoxylin
dehydrated,
embedded
eosin.
in paraffin,
sectioned
The two remaining ligaments were bisected first longitudinally and then transversely to produce four portions of approximately equal size. Sections of these portions were then processed as described, the sections stained with hematoxylin and eosin being used to study blood vessels while the silver and methylene-blue preparations were used to identify nerve vidual ligament revealed contain revealed paravascular (Fig. 7).
of Morphological Findings
the
ligament
was
found either
variously
directed
loose connective tissue and tortuous blood vessels (Fig. nerve fibers in all regions of the anterior cruciate ligament in position but some ramifying freely among
the connective-tissue
Implications
The
structural
characteristics
of the anterior
cruciate
ligaments
indicate
their
suitabil-
ity to withstand
the multi-axial stresses of normal function. The irregular arrangement of the fasciculi provides interfascicular areolar spaces for the passage of neurovascular components from one region to another within the ligament. The tortuosity of the vessels is also in keeping with the demands of a joint movements. The vascular supply, although what with age, was by no means sparse even appeared The those tion. The impulses,
VOL.
mechanism characterized by very complex not profuse and presumably varying somewithin the deeper layers of the ligament, and to occur concerned vessels throughout its whole extent. with vasomotor control, but may serve some that other funcsuggestion accompanies they transmit injuries to the
which
at a distance
of these fibers was consistent with the rise to the slow pain which usually
1974
56-A, NO.2,
230
J. C.
KENNEDY,
H.
W.
WEINBERG,
AND
A.
S. WILSON
FIG. A neurovascular (N. F.) and a bundle vessel close are to the periphery of the
5
anterior cruciate ligament. A fasciculus of nerve fibers
(V.P.)
shown
in a longitudinal
section
of
the
ligament
(hematoxylin
and
eosin,
x 400).
FIG.
bundle in the more dense central portion of the anterior cruciate nerve bundle (N.F.) are seen between cords of dense connective
ligament.
A vessel
(V.P.)
tissue
(silver
impregnation
cruciate
ligaments.
There
is also a possibility the primary are believed of joints has not been Clinical
that these
fibers
first described
by Adrian in 1943. These fibers, rather than the cerebral cortex, Adrian exact demonstrated source of these that impulses
movements
in the cerebellum,
The to the
fifty
patients
with
tears
of the
anterior because
selected
according
previously
mentioned
criteria,
difficult,
if not
impossible,
to
ANATOMY
AND
FUNCTION
OF
THE
ANTERIOR
CRUCIATE
LIGAMENT
231
FIG.
7 within vessel an (silver interfascicular impregnation, space x in 1000). the depths of the
A myelinated
anteriorcruciate
fiber (NJ)
ligament.
in There
a longitudinal is no apparent
section companion
runs
a torn were
ligament (four
anterior treated,
by knees), repair
cruciate
that
ligament
is, an attempt tear
on clinical
was (five made knees),
grounds
to restore immediate
alone.
Of the fifty
of the knees); reconstruction
knees,
anterior of the
function (ten
and
pes anserinus
the torn and treated were examined anterior untreated and females. personally. thirty
transfer
cruciate groups years The
thirty-one
untreated. thirty-one excised was untreated in eleven. twenty-seven nineteen group were in both three
ligament
were in the
was
comparable. untreated
ignored
group.
in
The
age
and twenty-one
of the thirty-one
untreated
postoperative Forty-seven
patients
management had
were
All
patients
and forty-three were tested for muscle table. The average length of follow-up
to ten years), if the and years). patient had no limitation of the average age at final to sixty-one
The activity,
good
clinical
results
were
classified
as excellent
sional heavier
no discomfort, and no signs or symptoms that would identify the injured knee; as if the patient carried out normal activity and had returned to sports, but had occaor recurring mild episodes of discomfort or instability; and as poor if the patient discomfort which or instability received while doing normal work, or required a brace patients for (77
had persistent
no treatment,
twenty-four
of the thirty-one
or excellent result, while in the group which was treated, sixteen of (84 per cent) had similar results. It therefore appears that four or five knowledgeable in the management of knee-joint injuries, will at
by those
232
J. C.
KENNEDY,
H.
W.
WEINBERG,
AND
A.
S. WILSON
least
cruciate
temporarily
ligament
have
an acceptable
result
(excellent
or good)
whether
the
tear
in the
is meticulously
suring,
Functional
although
Result
our follow-up
in Relation tests, with
or totally
ignored.
This
observations
is reas-
In the strength
muscles developed were tested in a single used
90 degrees (Fig.
of flexion,
recorded
the maximum
by a cable
tension
tensiome-
maximum
developed
as a control.
in the
aircraft
industry
8).
In each
instance limb
In all patients,
strength
in the involved
Functional
Result
in Relation
Instahilit tested on our clinical stress machine I. From for anterior, these data, it is
valgus,
Forty-seven of the fifty and varus laxity The findings for anterior
instability
are summarized
in Table
evident that there was a definite correlation between the clinical result and the amount of anterior instability. The previously established amount of five millimeters was used as the upper limit of normal for anterior displacement Of the forty-seven patients tested, only eleven had normal anterior displacement six, laxity was either present right after injury at final evaluation. In the remaining thirtyor developed during the ensuing months or
THE JOURNAL OF BONE AND JOINT SURGERY
ANATOMY
AND
FUNCTION
OF
THE TABLE
ANTERIOR I
ON
CRUCIATE
LIGAMENT
233
RESULTS
IN
FORTY-SEVEN
KNEES
TESTED
CLINICAL
STRESS
MACHINE
Anterior
Result
Excellent
0 to
7
Instability 5.1 to 8
5
Expressed
in
Millimete
rs
11.1 or more 0
8.1 to 11 2
Good Poor
Total
4
0
11
12
3
20
6
3
11
2
3
5
No patient with from zero to five millimeters of anterior displacement and none with over eleven millimeters of displacement had an acceptable The presence of valgus or varus laxity in addition to anterior laxity with the functional outcome. Twenty patients had minor or moderate laxity (up to 8. 1 millimeters) and no varus or valgus laxity. results. Thirteen patients with a similar degree or valgus laxity had inconsistent results, ranging patients with greater than 8 1 millimeters It would therefore seem that the presence how a damaged well
is not
All twenty
had good
of anterior laxity also had inconor absence of varus or valgus cruciate provide result instability
Although
does
the
not determine
anterior instability
a knee
severe
with
(under
anterior ligament
will
perform
our early
8. 1 millimeters).
with
anterior instability
cruciate may
reason
for some
op-
anteroposterior
11.12#{149}
eventually
in disabling
osteo-
Tears
there
suggested
was ligament:
a high
that
incidence tears
presence
tears
of the
with
dam-
cruciate
been
nineteen
in the
ment excision of a meniscus with a minimum tear may remove a stabilizing factor 20#{149} Anteroposterior or rotatory instability is reported to have become evident as the meniscus was excised. On the other hand, there is the possibility that after surgery a knee with an isolated rupture of the anterior cruciate ligament and a meniscal tear (whether minimum or otherwise) may become symptomatic, necessitating a second operation, as instability an acute isolated to be indicated. increases with time. tear of the anterior In fourteen of the fifty knees in this series there was cruciate ligament but meniscectomy was not considered
Only two of these fourteen knees, both with high instability measurements, had poor results. In ten other knees there was also an acute tear of the anterior cruciate ligament, but a meniscectomy was performed at the time of arthrotomy. None of these knees had a poor result and none progressed to the point of having major instability. From follow-up, dial or lateral, the findings appear in this that group any of twenty-four hesitancy about tear knees, removing with an admittedly meniscus, ligament, tears
cruciate
it would
in the presence
of an isolated
grounds that removal may cause instability, is unwarranted. The high incidence of meniscal damage associated anterior cruciate ligament (fourteen of the twenty-four) should be performed to confirm the diagnosis, even ament is to be totally ignored. Discussion The fifty
VOL.
isolated
anterior
the thesis
that arthrotomy
biomechanical with
MARCH
and tears
data
from
this
study,
the early
results
in the ex-
patients
56-A,
NO.2,
proved
1974
cruciate
ligament,
J.
C.
KENNEDY,
H.
W.
WEINBERG,
AND
A.
S.
WILSON
for treatment
of injured
knees
in which
Ligament
If the anterior cruciate ligament primary repair should be attempted, be excised. If the tear collateral of the ligament the cruciate
is torn or avulsed at its femoral or tibial attachment a but if the tear is in the middle portion the ends should with substantial damage to the capsular One should and
is associated tear
ligaments,
importance.
proceed
immediately to repair of the latter structures. If at the time of arthrotomy external rotatory of the anterior cruciate ligament, a pes anserinus
one must be absolutely certain that no lateral instability exists. If there is lateral instability in the presence of a tear of the anterior cruciate ligament, a pes anserinus transfer may cause internal rotatory instability because structures. towards of underlying damage to the posterolateral repair capor sule and other reconstruction supporting lateral should be directed In this situation, attempts at surgical the weakened lateral structures. Cruciate Ligament
must
be examined
at regular
intervals,
much
as patients
with
scoliosis
are followed, since anterior sociated with pain, effusion, bracing or reconstruction. Patients with Chronic
laxity increases with time 12#{149} If such or subjective instability, then stability
Symptomatic reconstruction
Intra-articular
in our
hands.
both medial and lateral capsular Although our initial impression is premature.
of follow-up
Lenox Hill brace has been used on thirty-two of the knee. If a patient is middle-aged and or is a young competitive Hill brace is helpful. The athlete stability
experience and by actual testing using the clinical stress machine, tory. Nine of the thirty-two patients who had chronic instability showed marked improvement in stability when their knees were illustrated
CASE
has been very satisfacand wore the brace tested in the brace, as
by the following
case
reports:
retired football player, suffered from marked anteroposterior laxity of
2. A.P., a twenty-six-year-old
his knee. Testing anteroposterior stability on the clinical stress machine revealed that the medial tibial condyle came forward ten millimeters and the lateraltibialcondyle, ten millimeters. Repeating the test after application of the Lenox condyle was Hill brace with the knee flexed to 90 degrees revealed that anterior displacement of the medial tibial reduced to zero and anterior
displacement
of the lateral
tibial condyle,
to 0.5 millimeter.
CASE 3. W.M., a middle-aged farmer, had marked clinical anteroposterior instability of his knee joint. When anteroposterior stability was tested on the stress machine, anterior displacement of the medial tibial condyle was
15.4 millimeters, while that of the lateral tibial condyle was fourteen millimeters. Repeating the test with the knee flexed to 90 degrees and the Lenox Hill brace applied demonstrated marked reduction in anterior displacement, the medial tibial condyle coming forward three millimeters and the lateral tibial condyle, one millimeter.
greatly
JOURNAL
with
knee
flexion.
AND JOINT SURGERY
OF BONE
ANATOMY
AND
FUNCTION
OF
THE
ANTERIOR
CRUCIATE
LIGAMENT
235
2 Isolated tears of the anterior cruciate ligament do occur. 3 The anterior cruciate ligament contains both blood vessels sufficient to permit healing. 4. An acceptable result this specific ligament may result may be temporary.
cruciate
. .
and nerves
which
appear
following a tear ofthe anterior cruciate with or without repair of be anticipated in a high percentage of patients, although this injuries associated with isolated anterior
with
5. There is a high incidence of meniscal ligament damage. 6. Anterior instability in the presence ofa time. Continued observation is indicated, or bracing, or both, may
torn anterior cruciate ligament may increase and if symptoms develop an extra-articular
reconstruction
be necessary.
References
1. ABaorr,
ofthe L. C.; SAUNDERS, Knee Joint. J. Bone
E. D. : Afferent
J. B. DEC. and
Areas
M.; BOST,
C. E.: Injuries
Brain,
Joint Surg.,
in the
26: 503-521,
Connected
July 1944.
with the Limb.
2.
3.
4.
ADRIAN, ALLMAN,
BRANTIGAN,
Cerebellum
F. L.; DEHAVEN,
K. E.; EvARTs,
F.:
C. M.: Isolated
AnteriorCruciate
Tears
and Ligament.
at
The American
5.
Surgeons
The
Residents
Mechanics of the
Meeting,
of the Ligaments Cruciate
Duke University,
Menisci
1971.
of the Joint.
23:
44-66,
with
Jan.
Isolated
1941.
Tear Anterior
A Report
36 Cases.
D.C.
,
Meeting
ofThe
American
The
Academy
Innervation
of Orthopaedic
ofthe Anat. KneeJoint.
Surgeons,
An
Washington,
and
Feb.
MAR.,
ERNEST:
Study
7.
BARRY:
Anatomical
Histological
505-532,
1967.
KneeJoint.
8.
GARDNER, KENNEDY,
Thelnnervationofthe
J. C. : Complete
Dislocation
of the Knee
Joint.
Rec., J. Bone
101: 109-130,
and Joint
1948.
Surg., 45-A:
889-904,
July
1963. 9. KENNEDY, J. C.: Research on Patho Mechanics of the Knee. Spectator Correspondence Club Letter, March 1.1965. 10. KENNEDY, J. C., and FOWLER, P. J.: Medial and Anterior Instability of the Knee. An Anatomical and Clinical Study Using Stress Machines. J. Bone and Joint Surg., 53-A: 1257-1270, Oct. 1971. 11. MARSHALL, J. L., and OLssoN, S.-E.: Instability of the Knee. A Long-Term Experimental Study in Dogs. J. BoneandJointSurg., 53-A: 1561-1570, Dec. 1971. 12. ODONOGHUE, D. H.; FRANK, G. R.; JETER, 0. L.; JOHNSON, WILLIAM; ZEIDERS, J. W.; and KENYON, REX: Repair and Reconstruction of the Anterior Cruciate Ligament in Dogs. Factors Influencing Long-Term Results. J. Bone andJoint Surg., 53-A: 710-718, June 1971. 13. OUELLET, ROBERT; LEVESQUE, H. P.; and LAURIN, C. A.: The Ligamentous Stability of the Knee. An Experimental Investigation. Canadian Med. Assn. J., 100: 45-50, 1969.
14.
PALMER,
IvAR:
On
the
Injuries
to the Ligaments
of the Knee
Joint.
A Clinical
Study.
Acta Chir.
Scan-
dinavica, Supplementum 53, 1938. 15. PRINGLE,J. H.: Avulsion of the Spineof the Tibia. Ann. Surg.,46: 169-178, 1907. 16. ROBICHON, J., and ROMERO, C.: The Functional Anatomy of the Knee Joint with Special Reference to the Medial Collateral and Anterior Cruciate Ligaments. Canadian J. Surg., 11: 36-39, 1968. 17. SCAPINELLI, R.: Studies on the Vasculature of the Human Knee Joint. Acta Anat., 70: 305-331, 1968. 18. SCHOFIELD, G. C.: Experimental Studies on the Innervation of the Mucous Membrane of the Gut. Brain, 83:490-514, 1960. 19. SLOCUM, D. B., and LARSON, R. L.: Rotatory Instabilityof the Knee. Its Pathogenesis and a Clinical Test to Demonstrate its Presence. J. Bone and Joint Surg., 50-A: 211-225, Mar. 1968. 20. SLOCUM, D. B., and LARSON, R. L.: Pes Anserinus Transplantation. A Surgical Procedure for Control of Rotatory Instability of the Knee. J. Bone and Joint Surg., 50-A: 226-242, Mar. 1968. 21. SMILLIE, I. S.: Injuries of the Knee Joint. Ed. 4, p. 154. Edinburgh and London, E. and S. Livingstone, Ltd., 1970. 22. WLADMIROW, B.: Arterial Sources of Blood Supply of the Knee Joint in Man. Acta Med., 47: 1-10, 1968.
VOL. 56-A,NO.
2, MARCH
1974